Tobacco Retail Licensing and Youth Product Use

Environmental influences on E-cigarette use among young people: A systematic review

E-cigarettes are a popular mode of delivery for nicotine, tobacco and cannabis. The prevalence of vaping among youth is increasing and this review aims to identify features of the neighbourhood environment, e.g., retailers, advertisements, and policies, that are associated with youth vaping. We included 48 studies. Of these, approximately 40% and 60% reported that presence of e-cigarette retailers, and advertisements, was associated with statistically higher odds of e-cigarette use in youth, respectively. Approximately 30% of studies reported that policies affecting e-cigarette availability were associated with statistically lower odds of vaping. Identifying these influential features of the neighbourhood environment will help formulate appropriate policies to reduce e-cigarette use among youth.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

INTRODUCTION

Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG.

METHODS

We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach.

RESULTS

We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice.

CONCLUSIONS

Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Perceptions of African American Youth and Adults Regarding Tobacco Use-Related Factors in Their Community: A Mixed-Methods Approach in Richmond, Virginia

INTRODUCTION

The US Food and Drug Administration is poised to restrict the availability of menthol cigarettes and flavored cigars, products disproportionately used by Black/African American (B/AA) individuals. We examined B/AA youth and adult perceptions regarding factors contributing to tobacco use, as well as prevention/cessation resources.

METHODS

In 2 mixed-methods studies in Richmond, Virginia, we conducted cross-sectional surveys among youth (n = 201) and adult (n = 212) individuals who were primarily B/AA and reported past 30-day cigar smoking or nontobacco use, followed by focus groups with a subset (youth: n = 30; adults: n = 24). Focus groups were analyzed using a thematic analysis framework, and descriptive survey data provided context to themes.

RESULTS

Among focus group participants, 20% of youth and 75% of adults reported current cigar smoking. Six themes emerged across the groups: advertising/brands, sensory experiences, costs, social factors, youth-related factors, and dependence/cessation. Youth and adults perceived cigars as popular; cigar use was attributed to targeted advertising, flavors, affordability, and accessibility. While adults expressed concern regarding youth tobacco use, youth did not perceive tobacco prevention programs as helpful. Adults and youth reported limited access to community tobacco prevention/cessation programs.

DISCUSSION

Expanded tobacco prevention and cessation resources for B/AA people who smoke could leverage federal regulatory actions to ban tobacco products targeted toward this group and decrease disparities in tobacco-related morbidity and mortality.

Assessing the profile of support for potential tobacco control policies targeting availability in Great Britain: a cross-sectional population survey

AIM

To examine the level of support for tobacco availability policies across Great Britain (GB) and associations between support for policy and sociodemographic, smoking and quitting characteristics.

METHODS

A cross-sectional representative survey (the Smoking Toolkit Study) of adults in GB (n=2197) during September 2021. Logistic regressions estimated the associations between support for each policy and sociodemographic and smoking characteristics.

FINDINGS

There was majority support for requiring retailers to have a license which can be removed if they sell to those under-age (89.6%) and for restrictions on the sale of cigarettes and tobacco near schools (69.9%). More supported than opposed raising the legal age of sale of cigarettes and tobacco to 21 (49.2% supported; 30.7% opposed; 20.1% unsure) and reducing the number of retailers selling tobacco in neighbourhoods with a high density of tobacco retailers (46.5% supported; 23.3% opposed; 30.2% unsure). More opposed than supported a ban on the sale of cigarettes and tobacco to everyone born after a certain year from 2030 onward (a 'tobacco-free generation') (41.3% opposed; 34.5% supported; 24.2% unsure). Age was positively associated with support for raising the age of sale and inversely associated with requiring tobacco retailer licenses. Women were more likely to support raising the age of sale and reducing the number of retailers.

CONCLUSIONS

Requiring tobacco retailer licensing and restrictions on sales near schools received majority support. Other tobacco availability policies received substantial support despite considerable opposition.

Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review

INTRODUCTION

Many jurisdictions have implemented different regulatory strategies to reduce vaping among youth. The objective of this systematic review is to synthesize the evidence of the effectiveness of different regulatory strategies for preventing and reducing nicotine vaping among youth.

METHODS

Five electronic databases were searched from January 1, 2004 to July 17, 2022 for primary studies examining state/provincial or national regulations targeting vaping among youth (aged 12-21 years) in high-income countries. The primary outcome was vaping prevalence. Included studies were qualitatively synthesized through systematic review.

RESULTS

The systematic review included 30 studies. There was insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping. Included studies had moderate-to-serious risks of bias.

DISCUSSION

Although several regulatory interventions have been shown to be effective at reducing vaping among youth, evidence is insufficient to recommend a specific type of regulation. Regulatory authorities could implement various regulations targeting the price, accessibility, and desirability (i.e., flavors and packaging) of E-cigarettes.

Tobacco 21 Laws and Youth Tobacco Use: The Role of Policy Attributes

Objectives. To estimate Tobacco-21 policies' relationships to 18- to 20 year-old youth cigarette, cigar, and electronic nicotine delivery system (ENDS) use, and to test for effect modification by policy attributes. Methods. In fall 2022, we used Tobacco 21 Population Coverage Database data to calculate the percentage of state residents covered by state or local Tobacco 21 (T21) laws monthly through June 2020. Matching T21 coverage to Population Assessment of Tobacco and Health and Behavioral Risk Factor Surveillance System data, we used 2-way fixed effect analyses to assess the relationship between T21 laws and 18- to 20-year-old youth cigarette, cigar, and ENDS use, and tested for differences by policy attributes: possession, use, or purchase (PUP) penalties, retailer noncompliance penalties, and compliance check requirements. Results. Increased T21 exposure yielded significant reductions in cigarette and cigar use, as well as in ENDS use, when accounting for policy attributes. These effects were dampened in T21 laws with PUP penalties relative to those without. Conclusions. Tobacco-21 laws yield reductions in 18- to 20-year-old youth cigarette, cigar, and ENDS use, with dampened effects when policies include PUP penalties. Public Health Implications. State policymakers should consider implementing T21 laws without PUP penalties to reduce underage nicotine and tobacco use. (Am J Public Health. 2024;114(1):90-97. https://doi.org/10.2105/AJPH.2023.307447).

E-commerce licensing loopholes: a case study of online shopping for tobacco products following a statewide sales restriction on flavoured tobacco in California

INTRODUCTION

Retailer licensing programmes can be an effective method of enforcing tobacco control laws, but most programmes do not require e-commerce retailers to obtain licenses. California's implementation of a statewide flavour restriction (Senate Bill 793 (SB-793)) in December 2022 enforced through its tobacco retailer licensing programme presented an opportunity to assess whether the exclusion of e-commerce in the definition of 'tobacco retailer' might have resulted in a shift in consumer behaviour towards e-commerce.

METHODS

To examine the association between SB-793 implementation and online shopping for tobacco, we collected weekly Google search rates related to online shopping for cigarettes and vaping products in California from January 2018 to May 2023. We compared observed rates of shopping queries after SB-793 implementation to counterfactual expected rates and prediction intervals (PI) calculated from autoregressive iterative moving average models fit to historical trends. Content analysis was performed on the search results to identify websites marketing flavoured vaping products and menthol cigarettes.

RESULTS

The week SB-793 was implemented, shopping queries were 194.4% (95% PI 100.8% to 451.5%) and 161.7% (95% PI 81.7% to 367.5%) higher than expected for cigarettes and vapes, respectively. Cigarette shopping queries remained elevated significantly for 11 weeks and vape shopping queries for 6 weeks. All search results contained links to websites that offered flavoured vaping products or menthol cigarettes to Californian consumers.

DISCUSSION

These findings raise concerns about potential loopholes in policy enforcement created by the absence of explicit regulations on e-commerce sales in retailer licensing programmes. Strengthening regulations to include e-commerce and monitoring e-commerce compliance are recommended to enhance the impact of laws enforced through retailer licensing programmes.

Normalization of Prevention Principles and Practices to Reduce Substance Use Disorders Through an Integrated Dissemination and Implementation Framework

Major research breakthroughs over the past 30 years in the field of substance use prevention have served to: (1) enhance understanding of pharmacological effects on the central and peripheral nervous systems and the health and social consequences of use of psychoactive substances, particularly for children and adolescents; (2) delineate the processes that increase vulnerability to or protect from initiation of substance use and progression to substance use disorders (SUDs) and, based on this understanding, (3) develop effective strategies and practices to prevent the initiation and escalation of substance use. The challenge we now face as a field is to "normalize" what we have learned from this research so that it is incorporated into the work of those involved in supporting, planning, and delivering prevention programming to populations around the world, is integrated into health and social service systems, and helps to shape public policies. But we wish to go further, to incorporate these effective prevention practices into everyday life and the mind-sets of the public, particularly parents and educators. This paper reviews the advances that have been made in the field of prevention and presents a framework and recommendations to achieve these objectives generated during several meetings of prevention and implementation science researchers sponsored by the International Consortium of Universities for Drug Demand Reduction (ICUDDR) that guides a roadmap to achieve "normalization."

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study

OBJECTIVE

This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation.

DESIGN

Qualitative semi-structured interviews.

SETTING

Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.

PARTICIPANTS

Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.

RESULTS

The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.

CONCLUSION

Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Strengthening Tobacco 21 implementation and enforcement to reduce tobacco-related health disparities: A stakeholder engagement project

INTRODUCTION

As a part of a priority-setting stakeholder engagement project to strengthen the impact of the federal Tobacco 21 (T21) law, we conducted a qualitative study to solicit input from a nationwide sample of tobacco control stakeholders regarding the implementation, enforcement, and equity implications of the T21 law.

METHODS

Following the T21 policy evaluation guidance developed by the Centers for Disease Control (CDC), we identified T21 experts in four domains: policy, evaluation, subject matter, and implementation from a national search of stakeholders (invitations, n=1279) to account for geographical variation. This study presents results from five focus groups conducted in December 2021 among stakeholders (n=31) with experience in T21 policy, evaluation, subject matter, and implementation.

RESULTS

Participating T21 stakeholders reported on eight themes from four main topic areas: 1) Implementation, 2) Enforcement, 3) Equity outcomes, and 4) Recommended changes from stakeholders. Stakeholders shared insights on both passive and active implementation methods used in their communities, and highlighted major barriers such as the absence of a standardized tobacco retail licensing mandate and insufficient resources. Regarding T21 enforcement, stakeholders believed that current deterrents for retail violations might not be effective. They noted that vape and tobacco shops and online sales of tobacco products are emerging major challenges in T21 enforcement. Stakeholders also discussed possible health inequities that may be exacerbated by heterogenous implementation of the T21 law.

CONCLUSIONS

To strengthen T21 and mitigate potential exacerbation of existing health inequities, greater alignment of federal, state, and local efforts to reduce heterogeneity of implementation and enforcement of the T21 law is recommended.

Adolescent use and co-use of tobacco and cannabis in California: The roles of local policy and density of tobacco, vape, and cannabis retailers around schools

Adolescent tobacco use (particularly vaping) and co-use of cannabis and tobacco have increased, leading some jurisdictions to implement policies intended to reduce youth access to these products; however, their impacts remain unclear. We examine associations between local policy, density of tobacco, vape, and cannabis retailers around schools, and adolescent use and co-use of tobacco/vape and cannabis. We combined 2018 statewide California (US) data on: (a) jurisdiction-level policies related to tobacco and cannabis retail environments, (b) jurisdiction-level sociodemographic composition, (c) retailer locations (tobacco, vape, and cannabis shops), and (d) survey data on 534,176 middle and high school students (California Healthy Kids Survey). Structural equation models examined how local policies and retailer density near schools are associated with frequency of past 30-day cigarette smoking or vaping, cannabis use, and co-use of tobacco/vape and cannabis, controlling for jurisdiction-, school-, and individual-level confounders. Stricter retail environment policies were associated with lower odds of past-month use of tobacco/vape, cannabis, and co-use of tobacco/vape and cannabis. Stronger tobacco/vape policies were associated with higher tobacco/vape retailer density near schools, while stronger cannabis policies and overall policy strength (tobacco/vape and cannabis combined) were associated with lower cannabis and combined retailer densities (summed tobacco/vape and cannabis), respectively. Tobacco/vape shop density near schools was positively associated with tobacco/vape use odds, as was summed retailer density near schools and co-use of tobacco, cannabis. Considering jurisdiction-level tobacco and cannabis control policies are associated with adolescent use of these substances, policymakers may proactively leverage such policies to curb youth tobacco and cannabis use.

Youth tobacco use before and after flavoured tobacco sales restrictions in Oakland, California and San Francisco, California

The tobacco industry has used recent findings from the Youth Risk Behavior Surveillance System Survey (YRBSS) to claim that a sales restriction on flavoured tobacco products might increase youth combustible cigarette use. In this special communication, we examined YRBSS data and reached the opposite conclusion. We observed the patterns in youth cigarette smoking in Oakland, California following its 2017 convenience store flavoured tobacco sales restriction. We also found that 2019 YRBSS data from San Francisco, California cannot be used to evaluate the effect of the sales restriction on all flavoured tobacco products in San Francisco as the YRBSS data for this city were collected prior to enforcement of the sales restriction. For future studies, we suggest triangulating with corroborating sales, behavioural and qualitative data over time to assess the effects of tobacco control policies on youth tobacco use. We recommend that policy enactment and enforcement dates, as well as the exact data collection periods for population health surveys, be published to facilitate more rigorous policy evaluation.

Underage E-Cigarette Purchasing and Vaping Progression Among Young Adults

PURPOSE

Despite laws prohibiting sale of e-cigarettes to individuals aged less than 21 years, many underage young adults purchase e-cigarettes from retail stores, which may increase likelihood of continued use due to a greater access to vaping products and exposure to point-of-sale marketing.

METHODS

Data are from a prospective cohort of young adults aged 18-20 years in Los Angeles who had ever used e-cigarettes at baseline (N = 1,029). We evaluated the association of underage e-cigarette purchasing behavior (owned and purchased vs. owned but never purchased vs. never owned an e-cigarette) with subsequent vaping frequency, intensity, and dependence symptoms one year later, adjusting for vaping behaviors prior to baseline; additional models evaluated whether associations differed by purchase location or product type.

RESULTS

At baseline, 332 (32%) had purchased e-cigarettes while underage, 227 (22%) owned but never purchased e-cigarettes themselves, and 470 (46%) never owned an e-cigarette. Compared to never owning e-cigarettes, those who had purchased their own e-cigarettes vaped more days in the past month (rate ratio [RR] = 2.97; 95% confidence interval [CI]: 2.15-4.09), had more vaping episodes per day (RR: 2.58; 95% CI: 2.12-3.14), vaped more puffs per vaping episode (RR: 1.90; 95% CI: 1.61-2.23), and had greater odds of dependence (odds ratio: 3.68; 95% CI: 2.51-5.40); elevated estimates were also observed for those who owned but never purchased e-cigarettes (vs. never owned). Vaping dependence was greatest among participants who purchased JUULs or other pod-mods.

DISCUSSION

Participants who purchased e-cigarettes underage subsequently vaped more intensely and had greater vaping dependence. Regulations that reduce underage retail access to e-cigarettes may help prevent vaping progression among those most at risk of dependence.

The association between local tobacco retail licensing and adult cigarette smoking by race/ethnicity, income, and education in California (2012-2019)

This study investigates the association between the strength of TRL ordinances and adult cigarette use, and differences in the relationship by sociodemographic characteristics, using California as a case study. We merged geocoded data from the California Health Interview Survey with the State of Tobacco Control Reports from the American Lung Association from 2012 to 2019. Each jurisdiction was graded (A-strongest to F-weakest) based on the strength of their TRL ordinance while current cigarette use was defined as respondents who had smoked 100 or more cigarettes in their lifetime and currently smoke cigarettes every day or some days. We estimated multilevel logistic regression models to test the relationship between the strength of the TRL ordinance and current cigarette use and tested for effect modification by including interaction terms for race/ethnicity, income, and education in separate models. 11.6 % of sample participants from all years (n = 132,209) were current cigarette smokers. Adults in jurisdictions with stronger grades (A-D) had lower odds of current cigarette use (OR = 0.89, 95 % CI: 0.79-1.01) compared to adults in jurisdictions with the weakest grade (F), but the association was not statistically significant (p < 0.07). We found no evidence of effect modification by race/ethnicity, income, or education. We found limited evidence that stronger TRL ordinances were associated with lower adult cigarette smoking in California. However, future studies testing the relationship between TRL ordinances and adult smoking outcomes should examine the role of TRL fees across jurisdictions and adult cigarette use.

Neighbourhood tobacco retail access and tobacco use susceptibility in young adolescents in urban India

BACKGROUND

Neighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence.

METHODS

In 2019-2020, a population-based sample (n=1759) of adolescents aged 13-15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco).

RESULTS

There was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access.

CONCLUSIONS

Efforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

Tobacco retail licencing systems in Europe

Tobacco retailer licencing has been recommended as an effective tobacco control strategy. In most European countries, however, retailers do not need a licence to sell tobacco products. We aimed to stimulate a discussion on the potential for tobacco retail licencing in Europe by describing (1) potential public health benefits, (2) licencing methods and (3) barriers and success factors in adoption of licencing systems. There is limited scientific evidence, but tobacco retail licencing may reduce smoking in three ways: (1) improved enforcement of and compliance to existing point-of-sale tobacco control policies (eg, minimum age of sale), (2) a reduction in the number and/or density of tobacco retail outlets and (3) denormalisation of tobacco. Licencing systems may take diverse forms. Systems may make licences expensive, and set criteria for purchasing a licence and retaining the licence after first purchase. In Europe, licencing systems have been implemented in Finland, Hungary, France, Italy and Spain. Licencing in Finland and Hungary was adopted for public health reasons; in Finland, with strong public support. In France, Italy and Spain, tobacco sales were state-monopolised, driven by economic motives. The cases of Norway and Scotland show that adoption of retail licencing may fail when political support is insufficient and tobacco retailers organise opposition with support from the tobacco industry. In conclusion, tobacco retailer licencing is a promising method to contribute to tobacco control efforts. Placing tobacco retailer licencing in a child protection framework may help generate the strong political and public support needed to effectively adopt licencing systems.

Cigarette availability and affordability among Chinese youth smokers: Findings from the 2019 China Youth Tobacco Survey

INTRODUCTION

Preventing youth from tobacco use is a priority for tobacco control in China, and the government has taken many measures such as introducing tobacco control in the health education curriculum, banning smoking in school, promoting smoke-free household, and advocacy campaigns. The objective of this study was to understand the availability and affordability of cigarettes for middle school (MS) and high school (HS) students in China.

METHODS

The data were extracted from the 2019 China National Youth Tobacco Survey, which was a school-based cross-sectional survey with a nationally representative sample of 288192 MS and HS students. The survey employed a randomized multistage stratified cluster sampling design with probability proportional to size sampling method and used an anonymous self-administrated questionnaire to collect data. The availability and affordability of cigarettes were analyzed, and all parameter estimates were weighted to account for the complex sampling design.

RESULTS

In 2019, an estimated 80.5% of current smokers who were aged <18 years bought cigarettes in the past 30 days. Among them, 83.3% (83.0% of males and 85.2% of females; and 76.5% in MS and 87.6% in HS) had not been refused purchase of cigarettes because they were underage, with 84.1% in urban and 82.9% in rural areas, and 87.3% in central, 83.4% in eastern, and 80.5% in western regions of China. Among current smokers who bought cigarettes in the past 30 days, 77.3% had bought a pack of cigarettes (20 cigarettes) costing >10 RMB and at least 61.4% had more pocket money per week than the cost of a pack of cigarettes. Although 84.2% of current smokers bought cigarettes by the pack, 9.2% of current smokers reported that they bought cigarettes as sticks.

CONCLUSIONS

Although the youth smoking rate dropped down from 2014 to 2019, the proportion of youth smokers that bought cigarettes was still high in China. Due to the high amount of pocket money, the current cigarette price was not an effective price barrier to prevent youth smoking. Selling cigarettes by the stick worsens the situation. Strengthening the enforcement of the 2021 Law on the Protection of Minors, increasing tobacco taxes and prices, and forbidding the selling of cigarette sticks, might assist the progress in youth tobacco control.

Evaluation of Restrictions on Tobacco Sales to Youth Younger Than 21 Years in Cleveland, Ohio, Area

Importance

Tobacco 21 (T21) policies raise the minimum legal age to purchase tobacco from 18 to 21 years to curb youth access to tobacco products. While some studies have found that T21 is associated with reducing prevalence of youth tobacco use, little is known about the impact it may have on youth of different racial and ethnic identities.

Objective

To evaluate the association of T21 policy with the prevalence of high school youth tobacco use across sex, race, and ethnicity.

Design, Setting, and Participants

This survey study used representative survey data collected from the local biennial Youth Risk Behavior Survey from 2013 to 2017 comparing Cleveland, Ohio (which has a T21 policy), to proximal jurisdictions in the first-ring suburbs in Cuyahoga County (which do not have T21 policies). Within-Cleveland demographic information was also collected for 2013 to 2019. Overall high school youth tobacco use rates were compared between Cleveland and the first-ring suburbs and then examined within Cleveland among Hispanic, non-Hispanic Black, and non-Hispanic White high school students. Percentage data were adjusted to more closely align with local population demographics. Data were analyzed from January to June 2022.

Exposures

T21 was implemented in Cleveland in 2016 and not adopted in proximal jurisdictions or at the state and federal level until at least 1 year later.

Main Outcomes and Measures

The main outcomes were prevalence of past 30-day cigarette, cigar product, or e-cigarette use, measured using geographically representative high school youth survey data from 2013 to 2015 (prelegislation) and 2017 to 2019 (postlegislation) and compared using a difference-in-differences analysis.

Results

The unweighted sample included 12 616 high school students (27.0% [95% CI, 26.9%-28.0%] in 10th grade; 50.9% [95% CI, 50.3%-51.6%] females) participating in 1 or more Youth Risk Behavior Surveys from 2013 to 2019, including 7064 students in Cleveland and 5552 students in the first-ring suburbs. Compared with the first-ring suburbs, Cleveland had a greater proportion of younger students (1623 [28.5%] ninth grade students vs 2179 [34.0%] ninth grade students) and Hispanic students (436 students [1.1%] vs 1433 students [12.6%]) and non-Hispanic Black students (2000 students [53.1%] vs 3971 students [75.1%]). Cigars were the most commonly used tobacco product in Cleveland, with use reported by 6201 students (19.8%) in 2013, 5877 students (21.3%) in 2015, and 5784 students (16.8%) in 2019. Compared with the first-ring suburbs, there was a greater decline in prevalence of use of cigars in Cleveland (β = 0.18 [SE, 0.05]; P < .001). The disparity across race, ethnicity, and sex decreased for all current tobacco product use. For example, the maximum difference between demographic subpopulations in current cigarette use was 11.6 (95% CI, 9.5-13.7) percentage points in 2013 between White females (16.1% [95% CI, 11.3%-20.8%]) and Black males (4.5% [95% CI, 3.5%-5.4%]). This maximum difference in current cigarette use decreased significantly to 5.1 (95% CI, 3.5-6.7) percentage points in 2019 between White females (6.9% [95% CI, 3.4%-10.3%]) and Black females (1.8% [95% CI, 0.7%-2.8%]).

Conclusions and Relevance

This survey study found that there was a decline in youth-reported tobacco use across every tobacco product category from 2013 to 2019. This decline changed the trajectory of use among several demographic groups and brought the youth populations with the highest tobacco product use to similar rates of others.

Case for raising the minimum legal age of tobacco sale to 25

Restricting youth access to tobacco is an essential component of a comprehensive tobacco control policy. While there has been a growing movement to raise the minimum legal age (MLA) of purchasing tobacco from 18 to 21, more restrictive measures, such as raising the MLA to 25 (MLA25), have been criticised as being overly restrictive on adult's free choice. We argue that, even within a policy approach that prioritises freedom of choice, there is a strong case for MLA25 in view of neurobiological evidence which shows that, before age 25, people are neurobiologically vulnerable to developing an addiction. We discuss further considerations for an MLA25 policy, in particular its potential impact on the free choice of young adults to start or quit smoking, potential public health impact and potential effectiveness considering that most underage youth source cigarettes from older peers.

Characterizing California licensure status and tobacco user experience with adverse events using Yelp data

•

Yelp is an online business listing platform to rate tobacco/vaping goods retailers.

•

CA licensed tobacco/vape stores data was cross-referenced with Yelp listings.

•

We identified Yelp tobacco/vape listings not licensed in California’s database.

•

Identified counterfeit/expired product selling, adverse events, underage selling.

•

Results identify unauthorized tobacco/vape stores and customer safety issues.

Various tobacco vendors, including alternative tobacco product sellers, are listed on the popular crowdsourced business listing platform Yelp. Yelp is used to rate and choose tobacco, electronic nicotine delivery systems (ENDS) goods/services and includes self-reporting of user experiences with shops and products. We cross-referenced California Department of Tax and Fee Administration (CDTFA) licensed tobacco, vape, and head shop retail stores with publicly available Yelp business listings to identify licensed and unlicensed stores in California. We extracted metadata associated with store accounts and analyzed user comments and ratings for discussion of tobacco-related complaints and adverse events. We detected a total of 3,717 shops that were categorized as tobacco/vape/head shops on Yelp and by cross-referencing with CDTFA data, licensed businesses accounted for 49.5% (n = 1,841), licensed individual retailers 31.6% (n = 1,174), and suspected unlicensed storefronts 18.9% (n = 702). Businesses and individuals with a state tobacco retail license received a higher average rating from Yelp users (3.86 out of 5) compared to unlicensed shops (3.57) (p < 0.001). Additionally, 4,682 unique comments about licensed businesses, 1,535 unique comments about individual retailers, and 560 unique comments about unlicensed vendors were reviewed, with themes including discussion about defective and counterfeit products and adverse events including coughing, difficulty breathing and reports of hospitalization detected. In contrast, comments about licensed stores predominantly discussed customer service issues. Close to one-fifth of tobacco, vape and/or head shops reviewed on Yelp were not in CDTFA’s licensure database. Overall self-reported tobacco user experiences appeared to differ in content and severity based on whether an establishment was licensed. These results have the potential to identify unauthorized stores and adverse events associated with their tobacco and vaping products or services.

Local Tobacco 21 Policies are Associated With Lower Odds of Tobacco Use Among Adolescents

INTRODUCTION

Tobacco 21 (T21) policies have shown promise in reducing cigarette use among adolescents. This study examined whether local T21 policies affected adolescent use of a variety of tobacco products and whether results differed by grade level.

METHODS

We used repeated cross-sectional data from eighth, ninth, and eleventh-grade respondents to the 2016 (n = 107 981) and 2019 (n = 102 196) Minnesota Student Surveys. Generalized estimating equations modeled eight adolescent tobacco use outcomes in 2019 (past 30-day use of any tobacco, cigarettes, cigars, e-cigarettes, hookah, chewing tobacco, flavored tobacco, and multiple products) by T21 exposure, defined as respondents' attendance at a school within a jurisdiction with T21 policy implementation between the two surveys. Models controlled for demographic characteristics and product-specific baseline tobacco use at the school level in 2016 and were stratified by grade.

RESULTS

After adjusting for baseline tobacco use and other demographics, T21-exposed eighth and ninth-grade students had significantly lower odds of tobacco use than unexposed peers in five of eight models, i.e. any tobacco (aOR = 0.80, 95% CI: 0.74, 0.87), cigarettes (aOR = 0.81, 95% CI: 0.67, 0.99), e-cigarettes (aOR = 0.78, 95% CI: 0.71, 0.85), flavored tobacco (aOR = 0.79, CI: 0.70, 0.89), and dual/poly tobacco (aOR = 0.77, 95% CI: 0.65, 0.92). T21-exposed eleventh-grade students did not differ significantly in their odds of any tobacco use outcomes relative to their unexposed peers.

CONCLUSIONS

T21 exposure is associated with lower odds of multiple forms of tobacco use, particularly among younger adolescent populations, supporting the implementation of T21 policies to reduce tobacco use in this population.

Classifying the comprehensiveness of flavoured tobacco sales restrictions: development and application of a tool to examine US state and local tobacco policies

OBJECTIVES

Comprehensive tobacco control policies with minimal exemptions can reduce tobacco use and sales. Many states and localities have adopted flavoured tobacco product (FTP) sales restrictions. This study describes the development and application of a schema to characterise the comprehensiveness of these FTP sales restrictions.

DESIGN

We coded state and local FTP sales restrictions enacted June 2007-March 2021 for retailer, tobacco product, and flavour inclusions and exemptions. Guided by FTP literature, legal resources and meetings with FTP policy experts, we developed a six-level classification scheme to characterise coded FTP policies from least to most comprehensive. We present descriptive statistics of FTP policy features and comprehensiveness.

RESULTS

As of 31 March 2021, 7 state-level and 327 local-level FTP sales restrictions were enacted in the USA. Most state-level policies (71.4%) were categorised in the second lowest comprehensiveness category; local policies most commonly fell within the lowest (48.9%) or highest (26.0%) comprehensiveness categories. Across jurisdictions, adult-only retailers were most frequently exempted from the FTP sales restrictions (state: n=1, 14.3%; local: n=184, 56.3%); and most jurisdictions included electronic cigarettes (e-cigarettes) as a banned product (state: n=6, 87.5%; local: n=327, 100%). While just over half of state (n=4, 57.1%) and local (n=169, 51.7%) sales restrictions included menthol e-cigarettes, most excluded menthol cigarettes and/or menthol smokeless tobacco.

CONCLUSIONS

Comprehensiveness of FTP sales restrictions in the USA varies widely. Current and future FTP policies would be strengthened by including all flavours and all tobacco products-particularly menthol cigarettes-and by avoiding exemptions for certain retailers, particularly adult-only retailers.

Boosting the Tobacco Control Vaccine: recognizing the role of the retail environment in addressing tobacco use and disparities

Much of the progress in reducing cigarette smoking and tobacco-related morbidity and mortality among youth and adults is attributable to population-level strategies previously described in the context of the Tobacco Control Vaccine. The retail environment is used heavily by the tobacco industry to promote and advertise its products, and variations in exposure to and characteristics of the retail environment exist across demographic groups. It is therefore also an essential environment for further reducing smoking, as well as ameliorating racial, ethnic and socioeconomic tobacco-related disparities. This commentary provides an overview of the importance of incorporating strategies focused on the tobacco retailer environment (availability; pricing and promotion; advertising and display; age of sale; and retail licensure) as part of a comprehensive approach to tobacco prevention and control. To reach tobacco endgame targets, such innovative strategies are a complement to, but not a replacement for, long-standing evidence-based components of the Tobacco Control Vaccine.

Association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. A systematic review and meta-analysis

BACKGROUND

This systematic review described the association between electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS) use among non-smoking children and adolescents aged <20 years with subsequent tobacco use.

METHODS

We searched five electronic databases and the grey literature up to end of September 2020. Prospective longitudinal studies that described the association between ENDS/ENNDS use, and subsequent tobacco use in those aged < 20 years who were non-smokers at baseline were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess risk of bias. Data were extracted by two reviewers and pooled using a random-effects meta-analysis. We generated unadjusted and adjusted risk ratios (ARRs) describing associations between ENDS/ENNDS and tobacco use.

FINDINGS

A total of 36 publications met the eligibility criteria, of which 25 were included in the systematic review (23 in the meta-analysis) after exclusion of overlapping studies. Sixteen studies had high to moderate risk of bias. Ever users of ENDS/ENNDS had over three times the risk of ever cigarette use (ARR 3·01 (95% CI: 2·37, 3·82; p<0·001, I2: 82·3%), and current cigarette use had over two times the risk (ARR 2·56 (95% CI: 1·61, 4·07; p<0·001, I2: 77·3%) at follow up. Among current ENDS/ENNDS users, there was a significant association with ever (ARR 2·63 (95% CI: 1·94, 3·57; p<0·001, I2: 21·2%)), but not current cigarette use (ARR 1·88 (95% CI: 0·34, 10·30; p = 0·47, I2: 0%)) at follow up. For other tobacco use, ARR ranged between 1·55 (95% CI 1·07, 2·23) and 8·32 (95% CI: 1·20, 57·04) for waterpipe and pipes, respectively. Additionally, two studies examined the use of ENNDS (non-nicotine devices) and found a pooled adjusted RR of 2·56 (95% CI: 0·47, 13·94, p = 0.035).

CONCLUSION

There is an urgent need for policies that regulate the availability, accessibility, and marketing of ENDS/ENNDS to children and adolescents. Governments should also consider adopting policies to prevent ENDS/ENNDS uptake and use in children and adolescents, up to and including a ban for this group.

Evaluation of neighborhood deprivation and store characteristics in relation to tobacco retail outlet sales violations

INTRODUCTION

Regulations of the sale of tobacco products to minors have been effective at reducing adolescent tobacco use overall. However, these efforts may not be uniformly enforced in all areas, creating uneven protection against adolescent smoking. Knowledge regarding factors associated with tobacco retail outlet (TRO) violations could help inform better enforcement strategies.

METHODS

In this study, we used Bayesian index regression models to determine if tobacco sales to minors violations across Virginia (2012-2021) were related to store characteristics and neighborhood deprivation and identify geographic areas at significantly elevated risk for violations after adjusting for these factors.

RESULTS

Results show that there were multiple factors associated with a higher likelihood of tobacco sales violations. Store type was an important factor, as grocery stores and pharmacies had significantly lowered likelihood of violations compared with convenience stores. Being located near another TRO was significantly associated with increased risk of sales to a minor. Neighborhood deprivation was also positively associated with TRO sales violations. Further, there were statistically higher likelihood of sales violations occurring in specific areas (e.g., southwest and southeast) of the state that were not explained by neighborhood deprivation and store attributes.

CONCLUSIONS

Together, results highlight the need to better understand where and why TRO sales violations are occurring in order to improve efforts aimed at monitoring and remediating TRO sales violations.

Tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system

INTRODUCTION

An emerging body of research has developed around tobacco retailer density and its contribution to smoking behavior. This cross-sectional study aimed to determine the association between tobacco retailer density and smoking behavior in a rural Australian jurisdiction without a tobacco retailer licensing system in place.

METHODS

A local government database (updated 2018) of listed tobacco retailers (n=93) was accessed and potential unlisted tobacco retailers (n=230) were added using online searches. All retailers (n=323) were visited in 2019 and GPS coordinates of retailers that sold tobacco (n=125) were assigned to suburbs in ArcMap. A community survey conducted in the Local Government Area provided smoking and sociodemographic data amongst adult respondents (n=8981). Associations between tobacco retailer density (calculated as the number of retailers per km² based on respondents’ suburb of residence) and daily, occasional and experimental smoking were assessed using multilevel logistic regression analysis. Separate models with and without covariates were undertaken.

RESULTS

Without adjusting for possible confounders, living in suburbs with greater retailer density did not increase the odds of daily smoking (OR=1.01; 95% CI: 0.92–1.12), occasional smoking (OR=1.05; 95% CI: 0.94–1.18), or experimental smoking (OR=0.98; 95% 0.92– 1.05). However, after adjustment, living in suburbs with greater retailer density increased the odds of occasional smoking behavior (AOR=1.37; 95% CI: 1.10–1.71) but not daily or experimental smoking.

CONCLUSIONS

This study found a significant positive association between tobacco retailer density and the likelihood of occasional smoking in a rural Australian jurisdiction without a tobacco retailer licensing system in place. The findings strengthen calls for the introduction of a comprehensive, positive tobacco retailer licensing system to provide a framework for improving compliance with legislation and to reduce the overall availability of tobacco products in the community.

Prevalence of Young Adult Vaping, Substance Vaped, and Purchase Location Across Five Categories of Vaping Devices

INTRODUCTION

The rapidly evolving landscape of vaping devices has complicated analyses of use patterns among youth and young adults. The current study describes the prevalence of use, substances vaped, and purchasing behaviors across five different vaping device categories.

AIMS AND METHODS

Participants (n = 2505; mean age = 19.2, SD = 0.46) from a cohort in the Los Angeles area completed web-based surveys from June 2018 to October 2019. For each of four device type categories depicted via digital images (any pod-style vape, cigalike, box-mod, vape pen) and for JUUL specifically, participants reported ever and past 30-day use, substance vaped (mostly nicotine, nicotine and tetrahydrocannabinol [THC], mostly THC, neither), ownership of device (yes/no), where they obtained that device (eg, purchased themselves, from a friend), and if purchased, purchase location (eg, vape shop, online).

RESULTS

Overall, 44.9% reported ever use, and 26.2% reported past 30-day use of at least one of the devices. The prevalence of past 30-day use was highest for pod-style vapes (any pod = 17.0%; JUUL = 15.1%). Among respondents who reported ever owning any device (n = 643 [25.7%]), 59.9% reported purchasing the device themselves, despite not being of legal purchasing age (15.4% of total sample); across all device types, products were most often purchased in vape shops or online.

CONCLUSIONS

Across all devices, the prevalence of self-purchase of vaping devices among underage young adults in the Los Angeles area was high, and most were purchased from a vape shop or online. Tobacco control policies to prevent underage purchase of tobacco products-particularly among never smokers-are needed.

IMPLICATIONS

A high proportion of underage young adults reported owning their own vaping device and having purchased it themselves from a vape shop or online. Stronger tobacco control policies and better enforcement efforts are needed to successfully prevent underage purchase of tobacco products.

Adolescent Susceptibility to E-Cigarettes: An Update From the 2018 National Youth Tobacco Survey

PURPOSE

Examine correlates of e-cigarette susceptibility among adolescents.

DESIGN

Secondary data analyses using the 2018 National Youth Tobacco Survey, excluding participants under 12 and over 17.

SETTING

United States middle and high schools.

SUBJECTS

Never e-cigarette users (n = 12,439) ages 12-17.

MEASURES

Relationships between e-cigarette susceptibility and age, sex, race/ethnicity, ever tobacco use, perceived ease of purchasing tobacco products, perceived harm, relative addictiveness, household use of e-cigarettes/tobacco were examined.

ANALYSIS

Odds of susceptibility were modeled with weighted multivariable logistic regressions.

RESULTS

Thirty-five percent (unweighted n = 4,436) of adolescents were susceptible to e-cigarettes. Adolescents who were female (aOR = 1.2), Hispanic (aOR = 1.3), perceived e-cigarettes as anything less than "a lot of harm" (aOR = 2.2-4.9) and "easy" to purchase (aOR = 1.4), had ever used combustible tobacco (aOR = 2.9), or reported household use of e-cigarettes (aOR = 1.5) were susceptible. Non-Hispanic black respondents (vs. non-Hispanic white; aOR = 0.72) had significantly lower odds of susceptibility to e-cigarettes.

CONCLUSION

In the 2018 NYTS adolescent sample, perceptions of harm and ease of tobacco product purchase appear to be significantly related to higher odds of e-cigarette susceptibility, in addition to other demographic factors. Longitudinal data, particularly cohort data following adolescents from susceptible to actual or no use, are needed to assess predictors of e-cigarette use initiation.

Tobacco 21 Policies in the U.S.: The Importance of Local Control With Federal Policy

INTRODUCTION

In December 2019, the U.S. raised the minimum legal sales age of tobacco to 21 years, a law commonly known as Tobacco 21. This study examines local Tobacco 21 policies for the inclusion of model policy components: comprehensive tobacco definition, age verification and tobacco access, enforcement measures, tobacco retail license, and violation penalties.

METHODS

A document analysis of Tobacco 21 local policies passed in the U.S. before July 1, 2019 (N=477) was conducted in May 2020 using a Tobacco 21 policy assessment tool. Policies were coded by 2 independent coders for the inclusion of components.

RESULTS

Many localities included model component: comprehensive tobacco definition (65%), appearance age (70.9%), local tobacco retail license (72%), a graduated monetary penalty structure (93%), and tobacco retail license suspensions or revocations (74%) for repeated violations. However, only 17.4% of policies included an appearance age in compliance with federal law (30 years). Furthermore, few policies included enforcement components, such as a mandatory number of inspections (5.9%) or compliance checks (6.7%) per year, or a minimum age for the underage purchasers used during compliance checks (8.4%).

CONCLUSIONS

Local policies can play an important role in tobacco control by providing an added layer to ensure adequate enforcement of age-restriction policies and allow an avenue to introduce strict measures that may diffuse into higher branches of government for policy adoption. Although many local Tobacco 21 policies fill regulatory gaps within the state and federal laws, often there is a lack of model components to ensure that policies are implemented as intended.

Convenience Store Access and E-cigarette Advertising Exposure Is Associated With Future E-cigarette Initiation Among Tobacco-Naïve Youth in the PATH Study (2013-2016)

PURPOSE

The association between e-cigarette marketing exposure and youth e-cigarette initiation is not well understood. This study examines whether convenience store access, exposure to retail e-cigarette marketing, and having a favorite e-cigarette ad before e-cigarette use is associated with susceptibility to use and future e-cigarette initiation in a national longitudinal study of youth.

METHODS

A nationally representative longitudinal cohort of youth in the Population Assessment of Tobacco and Health study (12-17 years) was followed up over three waves of annual data collection (2013-2016). Tobacco-naïve (wave 1) and e-cigarette-naïve (wave 2) youth (n = 6,470) were included. Marketing exposure at wave 2 was examined in association with e-cigarette susceptibility (wave 2) and e-cigarette initiation (wave 3) using adjusted logistic regression models. Analysis occurred in 2019.

RESULTS

Youth visiting convenience stores at least weekly (vs. never) had 1.51 times the odds of e-cigarette susceptibility (95% confidence interval [CI]: 1.25, 1.81) and 1.79 times the odds of e-cigarette initiation (95% CI: 1.29, 2.48). Noticing a retail e-cigarette ad (vs. not noticing) was associated with e-cigarette susceptibility (adjusted odds ratio [AOR] 1.36, 95% CI: 1.18, 1.57), but not initiation. Youth reporting a favorite branded e-cigarette ad had greater odds of both susceptibility (AOR 1.31, 95% CI, 1.10, 1.56) and e-cigarette initiation (AOR 1.60, 95% CI: 1.18, 2.17) compared to youth without a favorite ad.

CONCLUSIONS

Tobacco-naïve youth with frequent convenience store access and exposure to e-cigarette marketing were at greater risk of e-cigarette susceptibility and progression to e-cigarette initiation over a 2-year period. Policies to restrict retailer locations and e-cigarette marketing could enhance youth e-cigarette use prevention efforts.

E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy

BACKGROUND

Tobacco 21 (T21) laws, which raise the minimum legal age of sale of tobacco products to 21, have been proposed and implemented in states and cities across the USA. However, limited data are available on the effect of T21 laws on youth tobacco purchasing behaviours and access to tobacco products.

METHODS

Participants in a population-based prospective cohort in southern California completed questionnaires before (n=1609, age=18-19 y) and after (n=1502, age=19-20 y) T21 was implemented in California (June 2016). We examined the prevalence of past 30-day cigarette and e-cigarette use, and among past 30-day users, purchase location of tobacco products before (pre-) versus after (post-) T21. We also examined whether, post-T21, participants were refused purchase of tobacco products due to their age, and the perceived relative ease of purchasing cigarettes and e-cigarettes (vs pre-T21).

RESULTS

Negligible changes in cigarette and e-cigarette use were observed pre-T21 versus post-T21. At both time points, the majority of past 30-day users purchased cigarettes from gas stations and e-cigarettes from vape shops. Post-T21, the proportion of participants who reported purchasing cigarettes at gas stations decreased. Post-T21, most past 30-day cigarette or e-cigarette users were not refused purchase of cigarettes (65.4%) or e-cigarettes (82.0%) in the past 30 days, despite being under 21; half of the participants felt it was harder to purchase cigarettes (54.3%) and e-cigarettes (43.6%) post-T21.

CONCLUSION

Post-T21, few participants were refused purchase of any tobacco product, despite the illegality of such sales. Better enforcement of T21 is needed to improve the efficacy of T21 legislation.

E-Cigarette-Only and Dual Use among Adolescents in Ireland: Emerging Behaviours with Different Risk Profiles

E-cigarette-only use and dual-use are emerging behaviours among adolescent nicotine product users which have not yet been sufficiently explored. This study examines the prevalence of, and the factors associated with, nicotine product use in adolescence. The study is a cross-sectional analysis of the 2018 Planet Youth survey completed by 15–16 year olds in the West of Ireland in 2018. The outcome of interest was current nicotine product use, defined as use at least once in the past 30 days. A main effects multinomial logistic regression model was used to examine the association between potential risk and protective factors and nicotine product use. Among 4422 adolescents 22.1% were current nicotine product users, consisting of 5.1% e-cigarette only users, 7.7% conventional cigarette only users, and 9.3% dual-users. For risk factors, the odds of association were weaker for e-cigarette only use compared to conventional cigarette and dual use. Participating in team sport four times/week or more significantly reduced the odds of conventional cigarette and dual use but had no association with e-cigarette only use (Cig: adjusted odds ratio (AOR) 0.63, 95% confidence interval (CI) 0.44–0.90; Dual-use: AOR 0.63, 95% CI 0.43–0.93). Similarly, having higher value for conventional social norms reduced the odds of conventional cigarette and dual use but not e-cigarette only use. This is the first study to show, among a generalisable sample, that dual-use is the most prevalent behaviour among adolescent nicotine product users in Ireland. Risk factor profiles differ across categories of use and prevention initiatives must be cognisant of this.

Area-Level Predictors of Tobacco 21 Coverage in the U.S. Before the National Law: Exploring Potential Disparities

INTRODUCTION

The goal of the paper is to characterize the geographic and sociodemographic patterns of policies prohibiting tobacco sales to people aged <21 years (i.e., Tobacco 21) at the local, county, and state levels in the U.S. before the national law.

METHODS

This study assessed area-level markers for region, race/ethnicity, education, poverty status, and smoke-free law coverage as predictors of Tobacco 21 passage as of December 20, 2019, using modified Poisson and negative binomial regression models with robust SEs. Data were analyzed in 2020.

RESULTS

Before the passage of the national policy, 191 million people were covered by Tobacco 21 laws. Counties with higher percentages of non-Hispanic Blacks and individuals living below the poverty line had a lower probability of coverage, whereas counties with higher percentages of Hispanics/Latinxs and individuals with a college degree had a higher probability of coverage. Tobacco 21 coverage also varied by region, with far greater coverage in the Northeast than in the Midwest and South.

CONCLUSIONS

The national Tobacco 21 law may address disparities in coverage by SES, race/ethnicity, and region that could have lasting implications with regard to health equity.

Health Disparities in Tobacco Use and Exposure: A Structural Competency Approach

Fourteen percent of US adults use tobacco products. Because many of those who use tobacco are parents and/or caregivers, children are disproportionately exposed to tobacco smoke. People who use tobacco products often become addicted to nicotine, resulting in tobacco dependence, a chronic, relapsing disease. Tobacco use and exposure are more likely to occur in vulnerable and marginalized groups, including those living in poverty. Although some view tobacco use as a personal choice, evidence suggests that structural forces play an important role in tobacco uptake, subsequent nicotine addiction, and perpetuation of use. Viewing tobacco use and tobacco dependence through a structural competency lens promotes recognition of the larger systemic forces perpetuating tobacco use, including deliberate targeting of groups by the tobacco industry, lack of enforcement of age-for-sale laws, inferior access to health insurance and health care, poor access to cessation resources, and economic stress. Each of these forces perpetuates tobacco initiation and use; in turn, tobacco use perpetuates the user's adverse health and economic conditions. Pediatricians are urged to view family tobacco use as a social determinant of health. In addition to screening adolescents for tobacco use and providing resources and treatment of tobacco dependence, pediatricians are encouraged to systematically screen children for secondhand smoke exposure and support family members who smoke with tobacco cessation. Additionally, pediatricians can address the structural issues perpetuating tobacco use by becoming involved in policy and advocacy initiatives.

Local and State Policy Action Taken in the United States to Address the Emergence of E-Cigarettes and Vaping: A Scoping Review of Literature

INTRODUCTION

In response to rising rates of youth vaping and e-cigarette use, states and localities in the United States have adopted various tobacco control policies and have extended their utility to these emerging products. However, the extent to which these policies have been evaluated for their impact on youth use is unknown.

METHOD

Two databases (PubMed, Google Scholar) were searched for English language peer-reviewed articles pertaining to electronic cigarette policy evaluation between 2009 and 2020. Primary articles of interest were journal articles that evaluated an e-cigarette policy. Secondary articles of interest were journal articles that identified any e-cigarette policy action without a formal evaluation component, those that evaluated tobacco policy, or those that described e-cigarette behaviors and trends. Tertiary articles included gray literature that provided context for e-cigarette trends and additional policy identification.

RESULTS

The final sample consisted of 12 relevant articles with an e-cigarette policy evaluation component and 62 relevant articles without such component, and 19 gray literature sources. Findings were synthesized based on policy type: product classification, age restrictions, smoke-free policies, flavor bans, sales restrictions, taxation, packaging, and advertising.

CONCLUSION

Policies that address access and use of e-cigarettes are common on the federal, state, and local level, are mostly reactionary, and mimic tobacco control efforts. Few policies have been formally evaluated for their effectiveness in reducing or preventing youth vaping. Strengthening the evidence base should be a priority for researchers going forward, given the potential of these policies to intervene on social and environmental conditions that affect youth initiation and uptake.

Tobacco use and other aspects related to smoking among school-going adolescents aged 13-15 years in Malaysia: Analysis of three cross-sectional nationally representative surveys in 2003, 2009 and 2016

INTRODUCTION

Periodic surveys on tobacco use patterns and other aspects of tobacco use among school-going adolescents in Malaysia provide information on the effectiveness of anti-smoking measures implemented. However, such information is limited in Malaysia. We investigated the prevalence of smoking and other related aspects among middle-secondary school students in Malaysia from the years 2003-2016 to fill this gap.

METHODS

We analyzed data from the Global Youth Tobacco Survey (GYTS) 2003, GYTS 2009, and the Tobacco and Electronic Cigarette Survey among Malaysia Adolescents (TECMA) 2016. The surveys employed multistage sampling to select representative samples of adolescents attending secondary school in Malaysia. Data were collected using a pre-validated self-administered anonymous questionnaire adopted from the GYTS.

RESULTS

Between 2003 and 2016, major changes occurred in which there were reductions in the prevalence of ever smoking, current smoking, and susceptibility to smoking. Reductions were also observed in exposure to SHS in public places and in the home. The proportion of school-going adolescents who support a ban on smoking in public places increased between 2013 to 2016, and there was a significant reduction in the proportion of respondents that were offered 'free' cigarettes by tobacco company representatives. However, there was no difference in the proportion of adolescents who initiated smoking before the age of 10 years and current smokers seeking advice to quit smoking across the time period.

CONCLUSIONS

Our study indicates that the smoking policies and measures have been effective in reducing smoking prevalence, secondhand smoke exposure, and access to cigarettes, among school-going adolescents in Malaysia. However, measures to reduce smoking initiation and increase smoking cessation need to be strengthened to reduce the burden of smoking-related diseases in Malaysia in the long-term.

Development of a tobacco 21 policy assessment tool and state-level analysis in the USA, 2015-2019

OBJECTIVE

Policies raising the minimum legal sales age (MLSA) of tobacco products to 21 are commonly referred to as tobacco 21. This study sought to identify components of tobacco 21 policies and develop an instrument to examine policy language within 16 state laws adopted by July 2019.

METHODS

The multistage tool development process began with a review of established literature and existing tobacco 21 policies. In a series of meetings, tobacco control experts identified key policy components used to develop an initial tool. After testing and revisions, the instrument was used to code the existing tobacco 21 state-level policies. Inter-rater reliability (κ=0.70) was measured and discrepancies were discussed until consensus was met. Policy component frequencies were reported by state.

RESULTS

While all 16 states raised the MLSA to 21, the laws varied widely. Two laws omitted purchaser identification requirements. Fifteen laws mentioned enforcement would include inspections, but only three provided justification for conducting inspections. All 16 states provided a penalty structure for retailer/clerk violations, but penalties ranged considerably. Fourteen states required a tobacco retail licence, nine renewed annually. Six laws contained a military exemption, five were phased-in and 10 contained purchase, use or possession laws, which penalised youth. Four states introduced or expanded pre-emption of local tobacco control.

CONCLUSIONS

The instrument developed is the first to examine policy components within state-level tobacco 21 laws. Policies that include negative components or omit positive components may not effectively prevent retailers from selling to youth, which could result in less effective laws.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

World vaping update

PURPOSE OF REVIEW

Although death and injury related to e-cigarette use and vaping products has decreased since the peak in 2019, concern over the popularity of electronic nicotine delivery systems (ENDS - a term which includes vape pens, electronic or e-cigarettes, and products that produce vapor for inhaling rather than combusting to produce smoke) continues. ENDS are used as an aid to quit smoking and for harm reduction.

RECENT FINDINGS

This review covers peer-reviewed literature from January 2019 through February 2020 on vaping (the process of using ENDS). Prevalence, risk factors for use, and health risks and benefits from use predominated. Policy articles, commentaries and editorials were excluded from review. E-cigarette or vaping product use-associated lung injury (EVALI)-related injury and death were in the news and literature this year. Because most EVALI-related injury and death occurred among young people who had vaped tetrahydrocannabinol (THC), data from the Healthy Minds (United States) study are reviewed to consider variation in risk factors for vaping THC compared with nicotine.

SUMMARY

Findings provide up-to-date information on vaping as a way to consume a drug, whether THC or nicotine. Harm reduction benefits were shown in a year-long follow-up of smoking cessation; harms continue to accumulate, including from passive consumption.

Cigarette and E-Cigarette Retail Marketing on and Near California Tribal Lands

Introduction. Retail settings are major channels for the tobacco industry to market commercial tobacco products. However, few studies have examined marketing strategies on Tribal lands. The resulting evidence is important, especially given that American Indian/Alaska Native (AI/AN) youth and adults have the highest smoking prevalence of any racial/ethnic group in the United States. In this study, we examined cigarette, e-cigarette, and vape/vaporizer availability, advertising, and price-reducing promotions in retail settings on and within a 1-mile radius of Tribal lands in California. Method. Trained AI/AN community health representatives (n = 8) conducted store observations (n = 96) using a checklist adapted from the Standardized Tobacco Assessment for Retail Settings observation tool. Chi-square analyses were performed to look for potential differences in availability, exterior advertising, and price promotions for cigarettes, e-cigarettes, and vapes between stores. Results. All stores sold cigarettes and over 95% sold menthol cigarettes. Nearly 25% of stores on Tribal lands were located inside a casino, and 40.4% of stores on Tribal lands offered a Tribal member discount. Stores within a 1-mile radius of Tribal lands sold significantly (p < .01) more e-cigarettes (69.8%), including flavored e-cigarettes (53.4%), compared to stores on Tribal lands (37.7% and 28.3%, respectively). Price promotions for cigarettes were significantly (p < .01) more common in stores located within a 1-mile radius of Tribal lands (46.5%) than stores on Tribal lands (22.6%). Discussion. To our knowledge, this study is the first to use store observations to examine cigarette and e-cigarette availability, advertising, and price promotions in retail settings on and near California Tribal lands. We recommend future studies build on our initial efforts to take an AI/AN Tribal community-engaged approach in assessing and documenting tobacco marketing practices on and near Tribal lands. Tribal governments can consider tobacco policies to help reduce smoking disparities and advance health equity for their communities.

Association of Electronic Cigarette Regulations With Electronic Cigarette Use Among Adults in the United States

IMPORTANCE

Millions of Americans use electronic cigarettes (e-cigarettes). A growing number of state and local governments have started to draft and implement laws regarding the sale, marketing, and use of e-cigarettes. The association of US state regulations regarding e-cigarettes with e-cigarette use remains unknown.

OBJECTIVE

To examine the association of US state regulations regarding e-cigarettes with current e-cigarette use among adults in the United States.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included adults aged 18 years or older from the 2016 and 2017 Behavioral Risk Factor Surveillance System, which is a nationwide, telephone-administered survey that collects state-representative data on health-related risk behaviors, chronic health conditions, and use of preventive services. Data analysis was performed from February 1, 2019, to April 31, 2019.

EXPOSURES

United States state laws regulating e-cigarette use, including prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; requiring retailers to purchase a license to sell e-cigarettes; prohibiting self-service displays of e-cigarettes; prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and e-cigarette taxes.

MAIN OUTCOMES AND MEASURES

Current use of e-cigarettes.

RESULTS

Among 894 997 participants aged 18 years or older (503 688 women [51.3%], 679 443 non-Hispanic white [62.6%], 71 730 non-Hispanic black [16.3%], 69 823 Hispanic [11.4%], and 74 001 non-Hispanic other races [9.8%]), 28 907 (weighted prevalence, 4.4%) were currently using e-cigarettes. The age-standardized weighted prevalence of current e-cigarette use varied across US states and territories, from 1.0% in Puerto Rico to 6.2% in Guam. After adjustment for demographic, socioeconomic, and lifestyle factors, including conventional cigarette use, the odds ratios of current e-cigarette use were 0.90 (95% CI, 0.83-0.98) for state laws prohibiting e-cigarette use in indoor areas of private workplaces, restaurants, and bars; 0.90 (95% CI, 0.85-0.95) for state laws requiring retailers to purchase a license to sell e-cigarettes; 1.04 (95% CI, 0.99-1.09) for state laws prohibiting self-service displays of e-cigarettes; 0.86 (95% CI, 0.74-0.99) for state laws prohibiting sales of tobacco products, including e-cigarettes, to persons younger than 21 years; and 0.89 (95% CI, 0.83-0.96) for state laws applying taxes to e-cigarettes.

CONCLUSIONS AND RELEVANCE

These findings suggest that several state regulations regarding e-cigarettes may be associated with reduced e-cigarette use among US adults.

E-cigarette Retail Licensing Policy and E-cigarette Use Among Adolescents

PURPOSE

The present study evaluated whether Pennsylvania's 2016 law requiring a retail license for the sale of e-cigarettes was associated with adolescent e-cigarette use.

METHODS

Data were drawn from the 2015-2017 Youth Risk Behavior Surveillance System. We examined the prepolicy and postpolicy change in e-cigarette use for the state with the retail licensing requirement (Pennsylvania) compared with control states (New York and Virginia).

RESULTS

Results showed that e-cigarette licensing policy was significantly associated with e-cigarette use. E-cigarette use among Pennsylvania adolescents reduced by 5.2 percentage points in 2017 when compared with New York adolescents, and a corresponding 21.6% decrease from its baseline prevalence level in 2015. Similarly, there was a 7.4 percentage point decrease in e-cigarette use in Pennsylvania when compared with Virginia (30.7% relative decrease from the baseline prevalence).

CONCLUSIONS

An e-cigarette retail licensing requirement may be a useful policy tool in reducing e-cigarette use among adolescents.

Protecting Youth From the Risks of Electronic Cigarettes

The rapid increase in e-cigarette use among adolescents and young adults has led to drastic changes in patterns of nicotine consumption worldwide. The use of e-cigarettes, many of which contain high levels of nicotine, is especially harmful in this age group and is associated with increased use of cigarettes and other substances among youth. While the risks of short- and long-term e-cigarette use and secondhand aerosol exposure remain only partially understood, e-cigarettes should not be recommended for smoking cessation for youth in any circumstances given the lack of evidence for effectiveness and potential harmful physical and mental health effects. The perceptions of low e-cigarette risk of adolescents and young adults combined with few market regulations and the appeal of youth-friendly flavors, have created ideal conditions for the e-cigarette industry to thrive and place millions of youth at risk of developing an addiction to nicotine. Policies and regulations aiming to prevent youth-directed marketing and sales of e-cigarette and all nicotine delivery products are needed to protect young people. Public health-led education campaigns and educational curricula are also needed to help inform youth and families about the risks of e-cigarette use. While more research is required to determine the best ways to help youth quit e-cigarette use, adolescent health providers can play a key role in screening and counseling youth about e-cigarette use and should be adequately trained and supported to care for youth with e-cigarette addiction.

Assurances of Voluntary Compliance: A Regulatory Mechanism to Reduce Youth Access to E-Cigarettes and Limit Retail Tobacco Marketing

Objectives. To evaluate assurances of voluntary compliance (AVCs) between state attorneys general and retail chains by assessing e-cigarette sales to underage decoys and tobacco marketing violations in corporate-owned stores (that sign AVCs) and franchise stores (that do not sign AVCs).Methods. Decoys 18 to 19 years of age attempted to purchase e-cigarettes without presenting ID in California convenience stores (n = 540). Auditors characterized the presence and content of age-of-sale signage and advertising for tobacco products. Data were collected and analyzed in 2018.Results. Corporate-owned stores were less likely than were franchise stores to violate ID requests (adjusted odds ratio [AOR] = 0.29; 95% confidence interval [CI] = 0.12, 0.71) and to sell e-cigarettes illegally (AOR = 0.37; 95% CI = 0.15, 0.88). Regardless of AVC category, advertising violations were common in stores (vaping products, 26.3%; other tobacco products, 74.3%).Conclusions. The differences in violation rates found in corporate and franchise stores imply that AVCs could reduce youth access to e-cigarettes. However, merchant education and routine enforcement are needed to better leverage restrictions on retail tobacco marketing in AVCs.Public Health Implications. Strengthening compliance with existing AVCs and establishing new agreements with retailers shown to be in violation through federal or state inspections could reduce youth access to e-cigarettes and exposure to tobacco marketing.