Demographics, Tobacco Use, and Tobacco Control Measures of California Cities With Flavored Tobacco Sales Restrictions

In 2020, California passed a flavored tobacco sales restriction (FTSR), but the tobacco companies filed a referendum, and the ban will not be implemented unless approved by voters in November 2022. This study examined the percentage of the California population covered by a city FTSR and identified groups more likely to be covered. Mean demographics as well as tobacco use and control measures were compared for California cities with (n = 93) and without (n = 389) a FTSR, and t tests were used to examine the differences. We calculated adjusted odds ratios using logistic regression models. City FTSR policies covered 20.7% of the California population. Adjusted predictors of having a FTSR included the American Lung Association tobacco control score (odds ratio [OR] = 1.27, 95% confidence interval [CI]: [1.17, 1.38]), voting democratic (OR = 1.06, 95% CI: [1.02, 1.10]). and having a lower adult smoking prevalence (OR = 0.84, 95% CI: [0.72, 0.99]). A state-level policy would cover all populations in California.

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study

BACKGROUND

In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health.

METHODS

Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels.

RESULTS

Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05).

CONCLUSIONS

Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

Does Brand Choice Matter: Associations Between Usual E-Cigarette Brands and E-Cigarette Use Patterns Among U.S. Youth, 2021

BACKGROUND.

To inform youth about e-cigarette use prevention, it is important to understand whether using e-cigarette products from certain brands is associated with youth's differential e-cigarette use patterns and willingness to quit e-cigarettes.

METHODS.

Data for this study come from the 2021 U.S. National Youth Tobacco Survey (NYTS). The sample was current (past-30-day) e-cigarette users (unweighted n = 1,436). We examined the associations between users' usual e-cigarette brands (Puff, Vuse, Smoke, JUUL, and others) and e-cigarette use patterns (use frequency, use with nicotine, use with flavors) and willingness to quit, controlling for covariates.

RESULTS.

In 2021, 25.6%, 9.7%, 8.1%, and 6.5% of users reported Puff, Vuse, Smok, and JUUL as their usual brands, respectively. Having Smok as a usual brand increased the odds of frequent e-cigarette use compared with other brands. Using Puff, Vuse, and Smok increased the odds of using e-cigarettes with nicotine. Using Puff and Smok increased the odds of using e-cigarettes with any flavors and fruit flavors, and using Smok and JUUL increased the odds of using mint flavors. Finally, using Vuse reduced the odds of having a willingness to quit e-cigarettes.

CONCLUSION.

Puff products, which are likely to be used infrequently and with fruit flavors, were the most endorsed usual brand by youth users. Vuse and Smok brand users demonstrated problematic use patterns, including high-frequency use of nicotine and reduced willingness to quit. The high prevalence of using flavors, especially banned flavors (e.g., mint for JUUL products), suggests the need for tightened restrictions on youth's access to flavored e-cigarettes.

Exploring the Influence of E-cigarette Ad Features on Perceived Product Appeal and Use Interest Among Young Adults of Varying Tobacco-Use Behaviors

INTRODUCTION

Exposure to certain features in commercial e-cigarette ads may influence e-cigarette use perceptions. This study explored the reactions toward common features in e-cigarette ads among young adults of various tobacco-use behaviors.

AIMS AND METHODS

We used data from in-depth interviews with U.S. young adults (ages 18-29) who do not use tobacco (n = 26) and who currently smoke cigarettes (n = 26). Participants viewed 30 print e-cigarette ads that included multiple features (eg, fruit flavors, price promotions, smoker-targeted messages) before discussing their perceived influence of memorable ad features. We used reflective thematic analysis to analyze interview data.

RESULTS

Participants from both groups generally noticed fruit and multiple flavors displayed in the ads, which were seen as appealing and were reported to generate product-use interest because of bright colors, sensory appeal, and a variety of flavor options. Participants who smoke perceived price promotions and positive experience testimonials to be appealing, and some reported this generated use interest. Participants from both groups perceived smoker-targeted messages to be unconvincing, and reported this dampened ad and product appeal and use interest. Participants who do not use tobacco perceived nicotine warnings to be unappealing, resulting in reduced perceived appeal of other attractive features (eg, fruit flavors) appearing in the same ads.

CONCLUSIONS

Marketing features appearing in e-cigarette ads may be perceived by young adults of various tobacco-use behaviors in both similar and different ways. Communication and policy strategies that account for these differential perceptions towards various marketing features are needed to reduce the negative impact of e-cigarette marketing.

IMPLICATIONS

This study revealed evidence related to young adults' reactions to and perceived influence of commonly used marketing features (eg, fruit flavors, nicotine warnings, price promotions, smoker-targeted messages) in commercial e-cigarette ads. The results highlight the similar and differential perceived appeal and use interest of e-cigarette products promoted with various marketing features among young adults of different tobacco-use behaviors. The results have implications for informing the design of communication strategies and policies related to e-cigarette marketing aimed at promoting complete product switching among young adults who smoke while simultaneously deterring e-cigarette use interest among those who do not use tobacco.

Associations between e-cigarette marketing exposure and vaping nicotine and cannabis among U.S. adults, 2021

Importance

Vaping has become an increasingly common method for consuming nicotine and cannabis, a trend potentially influenced by e-cigarette marketing. However, little is known about the influence of e-cigarette marketing on cannabis vaping behaviors.

Objective

To examine the associations between e-cigarette marketing exposure and nicotine and cannabis vaping behaviors among adults.

Design Setting and Participants

This cross-sectional study included a U.S. nationally representative sample of adults (≥18 years) from the Wave 6 survey of the Population Assessment of Tobacco and Health (PATH) Study, conducted from March to November 2021.

Exposure

Past 30-day e-cigarette marketing exposure (overall and by ten marketing channels).

Main Outcomes and Measures

Past 30-day vaping behavior (sole- and dual-vaping of nicotine and cannabis) overall and stratified by age.

Results

The study included 30,516 respondents (48.0% male and 63.9% non-Hispanic White). Overall, 52.0% of respondents reported past 30-day e-cigarette marketing exposure, and 89.8%, 5.6%, 3.2%, and 1.4% reported no vaping, sole-nicotine vaping, sole-cannabis vaping, and dual-vaping, respectively. Multinominal logistic regression results show exposure to e-cigarette marketing was associated with increased odds of reporting sole-cannabis vaping versus no vaping (adjusted risk ratio [aRR], 1.31; 95% confidence interval [CI], 1.09-1.57) and dual-vaping versus no vaping (aRR, 1.26; 95% CI, 1.01-1.57). Stratification analysis found these associations among those aged 18-24 and 25-34 years but not older adults (≥35 years). Those exposed to e-cigarette marketing also had increased odds of reporting sole-cannabis vaping versus sole-nicotine vaping (aRR, 1.28; 95% CI, 1.04-1.58). Stratification analysis found this association only among those aged 18-24 years. E-cigarette marketing exposure via several channels (retail stores, billboards, events, newspapers/magazines) was associated with increased odds of reporting sole-cannabis vaping.

Conclusions and Relevance

E-cigarette marketing exposure was only associated with sole-cannabis vaping and dual-vaping, not sole-nicotine vaping among U.S. adults. Such associations were mainly driven by young adults aged 18-24 and 25-35 years and were found for multiple marketing channels. Greater restrictions on tobacco marketing may have reduced the influence of e-cigarette marketing on nicotine vaping, while gaps in such marketing restrictions for cannabis may contribute to continued influence of e-cigarette marketing on cannabis vaping.

Noticing people, discounts and non-tobacco flavours in e-cigarette ads may increase e-cigarette product appeal among non-tobacco-using young adults

INTRODUCTION

Young adults new to tobacco (including e-cigarettes) are at an increased risk of e-cigarette use after e-cigarette exposure. This study examined the association between noticing e-cigarette advertising features and perceived product appeal among non-tobacco-using young adults.

METHODS

A sample of non-tobacco-using young adults (ages 18-29 years; n=1993) completed an online survey in 2021. We content analysed visible features from 12 e-cigarette ads that represented commonly used e-cigarette brands. Participants viewed the ads and clicked on the areas of the ads that drew their attention. Participants reported e-cigarette product appeal for each ad, including ad liking, product curiosity and use interest. We used generalised estimating equations to examine within-person associations between noticing specific ad features and reporting each and any type of product appeal, adjusting for noticing other features and participant characteristics.

RESULTS

Noticing people, discounts, non-tobacco (menthol and mint/fruit) flavours, positive experience claims or product images was positively associated with having any e-cigarette product appeal. Noticing discounts or mint/fruit flavours was also positively associated with e-cigarette use interest. In contrast, noticing nicotine warnings or smoking cessation claims was negatively associated with ad liking and product curiosity.

CONCLUSIONS

Attention to several e-cigarette ad features (eg, people, discounts, non-tobacco flavours) was associated with increased e-cigarette product appeal, whereas attention to nicotine warnings and smoking cessation claims was associated with reduced appeal among non-tobacco-using young adults. Restricting appeal-promoting features while strengthening the effects of nicotine warnings and smoker-targeted claims in e-cigarette ads may potentially reduce e-cigarettes' overall appeal among this priority population.

Correlates of Anticipated Responses to Cigar Price Increase Among U.S. Adults Who Smoke Cigars

We examined the prevalence and correlates of anticipated responses to hypothetical cigar price increases. Data are from a 2021 representative sample of U.S. adults who reported past-30-day cigar use (n = 454; mean age = 39.8 years). Weighted multivariable logistic regressions assessed the correlates of behavior change responses. If cigar price increased, 77.2% intend to pay more, 44.7% intend to reduce use, and 39.9%, 37.7%, and 17.1% intend to use other tobacco, cannabis, and cheaper cigars, respectively. Those who smoked cigarillos (vs. other cigars) had higher odds of intending to pay more (adjusted odds ratio [AOR] = 2.73; 95% confidence interval [CI] = [1.41, 5.29]) and use other tobacco (AOR = 2.35; 95%CI = [1.26, 4.36]). Those who smoked within 5 min of waking (vs. >60 min) had higher odds of intending to use cheaper cigars (AOR = 5.19, 95%CI = [1.38, 19.46]). Almost half of U.S. adults who report past-30-day cigar use may reduce cigar smoking in response to price increases, though behavioral response may depend on cigar type smoked and tobacco dependence.

Concern for Police Brutality, Societal Discrimination, and School Shootings and Subsequent Cigarette and Cannabis Use in Los Angeles County Hispanic and Non-Hispanic White Youth: a Longitudinal Study

OBJECTIVE

Examine if concerns for police brutality, societal discrimination, and school shootings relate to subsequent cigarette and cannabis use among Hispanic and non-Hispanic White (NHW) youth. Hispanic youth may be particularly vulnerable to such concern.

METHODS

Data are from the University of Southern California's Happiness and Health Survey, a prospective cohort study, which followed Hispanic (N = 1007) and NHW (N = 251) students from ten inner-city and suburban high schools in Los Angeles County, starting from 2013 until 2019. Participants reported concern, worry, and stress levels regarding police brutality, societal discrimination, and school shootings. Four categories were created to indicate levels of each concern variable over time (consistently low, decreased, increased, and consistently high). Associations with past-30-day cannabis, blunt, THC-oil, and cigarette use in 2019 were assessed. Separate models for each racial/ethnic category were used.

RESULTS

Among Hispanic participants, reporting consistently high concern about police brutality (vs. consistently low concern) was associated with higher odds to subsequently smoke cannabis (aOR = 1.69, 95% CI = 1.18-2.40), smoke blunts (aOR = 1.63, 95% CI = 1.11-2.39), and vape THC-oil (aOR = 1.67, 95% CI = 1.14-2.44). Hispanic participants who reported consistently high concern for societal discrimination also had higher odds (vs. consistently low concern) to subsequently smoke blunts (aOR = 1.54, 95% CI = 1.04-2.29) and vape THC-oil (aOR = 1.65, 95% CI = 1.12-2.43). Among NHW participants, increasing concern over school shootings (vs. consistently low concern) was associated with higher odds to subsequently smoke cannabis (aOR = 2.98, 95% CI = 1.08-7.70).

CONCLUSIONS

Concerns for police brutality, societal discrimination, and school shootings were associated with cannabis use especially among Hispanic participants. Providing Hispanic youth with healthy coping strategies may reduce cannabis use.

Racial/Ethnic Disparities in Vicarious and Direct COVID-19-Related Discrimination and Vigilance

INTRODUCTION

The high visibility of COVID-19-related discrimination underscores the importance of understanding the psychological harms associated with vicariously and directly experiencing such incidents. In this observational study, both vicariously and directly experienced COVID-19-related discrimination and their association with heightened concerns about discrimination and vigilance were examined in U.S. adults who use commercial tobacco.

METHODS

Data were from a nationally representative sample of adults who currently or formerly used commercial tobacco products (N=1,700; mean age=43 years) from an online survey panel administered in January-February 2021 (analyzed in 2021-2022). Participants reported vicariously and directly experienced COVID-19-related discrimination, concern about experiencing such discrimination, and heightened vigilance. Weighted multivariable linear and logistic regression models were used to examine the associations among these variables.

RESULTS

Overall, 69% of individuals reported exposure to vicarious COVID-19-related discrimination, and 22% reported directly experiencing COVID-19-related discrimination. Asian, Hispanic, and Black individuals reported higher levels of concern and vigilance than White individuals (p<0.05). Vicariously and directly experienced COVID-19-related discrimination was independently associated with concern about experiencing COVID-19-related discrimination in the entire sample and within each racial and ethnic group (p<0.05). This concern was associated with increased vigilance (p<0.05) and was stronger in those exposed to vicarious COVID-19-related discrimination than in those who were not (p<0.05).

CONCLUSIONS

COVID-19-related discrimination may undermine the psychological well-being of those who are exposed to it vicariously as well as those who experience it directly and may also make individuals feel vulnerable and unsafe. Interventions to prevent and reduce the impact of COVID-19-related discrimination may have wide-reaching societal benefits.

Exploring Young Adults' Beliefs About Cigar Smoking by Susceptibility: A Belief Elicitation Study

INTRODUCTION

Young adults are at risk for cigar smoking, which is associated with cancers and pulmonary and cardiovascular diseases. Little is known about young adults' beliefs about smoking cigarillos, little filtered cigars, and large cigars, and how these beliefs may vary across cigar types and by cigar susceptibility.

AIMS AND METHODS

The larger study surveyed a U.S. sample of young adults (18-30 years old) who never used tobacco products (n = 948) through Qualtrics online panel services in August 2021-January 2022. We assessed participants' susceptibility to using different cigar types. Participants were randomly assigned to open-ended questions about one of the three cigar types to elicit behavioral, normative, and control beliefs. We conducted thematic analysis to code emergent themes within each belief and examined the frequency of reported themes at the intersection of cigar type and cigar susceptibility.

RESULTS

Cigar susceptible participants reported positive behavioral beliefs (eg, anticipated relaxation, mood regulation, being cool), friends as supportive referents, and easy-to-smoke control beliefs (eg, high accessibility, low cost) more frequently than non-susceptible participants. Varied frequency by cigar type also emerged. For example, cigarillo and little filtered cigar features were mentioned more frequently as easy-to-smoke control beliefs, while low accessibility was reported more frequently as a hard-to-smoke control belief for large cigars.

CONCLUSIONS

Findings identify salient beliefs about cigarillo, little filtered cigar, and large cigar smoking among young adult tobacco never-users. Future research should investigate the potential importance of these beliefs in cigar smoking susceptibility and initiation among young adults, and their potential utility in prevention research.

IMPLICATIONS

This thematic analysis identified salient beliefs about cigarillos, little filtered cigars, and large cigars among a U.S. young adult sample, and differentiated emergent beliefs by cigar susceptibility status and by cigar type. Given the lack of cigar smoking prevention media campaigns, identifying these beliefs is the one of the first steps in developing effective cigar smoking prevention strategies. Future quantitative studies are needed to confirm the relationships between these beliefs and smoking initiation of each cigar type to further inform the types of beliefs to be targeted in strategic communication and help prevent cigar smoking initiation among susceptible young adults.

Race, Concern About COVID-19 Discrimination, and Cigarette Smoking Behavior: Comparison Between US Asian and White Adults Who Use Commercial Tobacco

Anti-Asian discrimination incidents in the USA have resurged during the COVID-19 pandemic. It is unclear how concern about being discriminatorily treated due to the COVID-19 pandemic varies between Asian and Asian American (A&AsA) and White adults. We examined A&AsA vs. White differences in concern about COVID-19 discrimination and associations of this concern with changes in cigarette smoking behaviors before and during the pandemic. Data were from a US representative sample of A&AsA and White adults (≥ 21 years) who currently and formerly used commercial tobacco (n = 1052), collected through an online panel oversampling A&AsA adults in January-February 2021. Participants reported their concern, worry, and stress about COVID-19 discrimination and past-30-day cigarette consumption before and during the pandemic. We examined the association between race and overall concern about COVID-19 discrimination, and this concern's associations with changes in past-30-day cigarette smoking consumption, smoking continuation, and return to smoking using weighted multivariable logistic and linear regression models. Overall concern about COVID-19 discrimination was higher (adjusted mean = 1.7, standard error = 0.16) among A&AsA adults who currently and formerly used commercial tobacco than their White counterparts (adjusted mean = 0.60, standard error = 0.04; p < 0.01). Overall concern about COVID-19 discrimination was associated with increased past-30-day cigarette consumption by 26.5 cigarettes (95% confidence interval [CI] = 1.2-51.9) and 4.4 times (95% CI = 2.3-8.5) greater odds of return to smoking among adults who smoke cigarettes. A&AsA adults who currently and formerly used commercial tobacco disproportionately bore higher concern about COVID-19 discrimination, and in turn could lead to increased smoking behavior and related morbidity and mortality among A&AsA adults.

Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019

INTRODUCTION

Few studies have addressed the use patterns and characteristics of the past 30 days of premium versus non-premium cigar smokers.

AIMS AND METHODS

We pooled 10 years of data from the National Survey on Drug Use and Health (NSDUH; 2010-2019) to evaluate use patterns and demographic and tobacco use characteristics of premium and non-premium cigar smokers ages 12 years and older in the U.S. cigar-type was manually coded as premium or non-premium according to the brand used most often.

RESULTS

Between 2010 and 2019, 4.7% (95% CI = 4.6-4.8) of individuals aged 12 and older currently smoked cigars (past-30-day use). Smoking premium cigars (0.9% [95% CI = 0.8-0.9]) was less prevalent than smoking non-premium cigars (3.0% [95% CI = 2.9-3.1]). Although current non-premium cigar smoking prevalence steadily declined over the years, current premium cigar smoking prevalence remained stable. Premium cigar smokers were more likely to be older (≥25 years), male, non-Hispanic white, heterosexual, college educated, living in a large metro area, and to have income above 200% of the poverty threshold compared to non-premium users (p < .05). Additionally, past-30-day premium cigar smokers were less likely than non-premium users to initiate cigar smoking before the age of 18 years, smoke cigars frequently or daily, smoke cigarettes, or use marijuana (p < .05).

CONCLUSIONS

Overall, premium cigar smoking is less prevalent than non-premium cigar smoking, especially among populations such as youth, racial/ethnic and sexual minorities, and low socioeconomic individuals. Premium cigar smokers tend to smoke infrequently and initiate cigars later in life compared with non-premium smokers. Study results can inform recommendations for regulating premium cigars.

IMPLICATIONS

This study found that between 2010 and 2019, there are meaningful differences in the use patterns and characteristics of past-30-day premium versus non-premium cigar smokers in the United States. Premium cigars comprise a small share of the market compared to other cigar types and are less likely to be used by youth and other tobacco control priority groups (eg, racial/ethnic minorities and individuals with low socioeconomic statuses) that bear a disproportionate burden of risk and harm from using tobacco products. Additionally, most premium cigar users smoke them only occasionally. However, it is important to continue to monitor premium cigar use, as these patterns could shift because of factors like changes in marketing practices, consumer awareness, and product prices. Tobacco policy changes may also alter the patterns and trends of premium cigar use over time. A greater, more comprehensive understanding of premium cigars' physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will together help to inform cigar-related regulations.

Evaluating Correlations Between Premium Cigar Smoking and Mental Health and Substance Use Dependence Conditions Among U.S. Adults, 2010-2019

INTRODUCTION

Improved understanding of health conditions associated with premium cigar smoking can inform efforts to reduce cigar use. This paper extends findings commissioned for the National Academies of Science, Engineering, and Medicine report on premium cigars.

AIMS AND METHODS

We pooled 2010-2019 National Survey on Drug Use and Health data to evaluate cross-sectional associations between premium cigar smoking and mental health and substance use conditions among U.S. adults. A series of logistic regression models adjusted for age, sex, race and ethnicity, cigarette smoking, and alcohol consumption compared odds of each condition associated with past-month premium cigar smoking relative to past-month nonpremium cigar smoking, never tobacco use, and current established cigarette smoking.

RESULTS

Premium cigar smoking was associated with lower adjusted odds of past month serious psychological distress, past year major depressive episode, and cannabis and illicit drug dependence relative to nonpremium cigar and cigarette smoking; however, higher odds of alcohol and cannabis dependence were observed relative to never tobacco use, and lower odds of alcohol dependence were observed relative to current cigarette smoking but not current nonpremium cigar smoking.

CONCLUSIONS

We observed considerable variation in both magnitude and direction of associations between premium cigar smoking and mental health and substance use indicators depending on the condition and reference group to which premium cigar smoking was compared.

IMPLICATIONS

Premium cigar smoking frequently cooccurs with cigarette smoking and alcohol consumption, thus potential health correlates must be considered in appropriate context. We observed considerable variation in direction and magnitude of association depending on the health condition and reference population, as well as potential for reverse causality and residual confounding in this cross-sectional analysis. As the tobacco landscape continues to evolve, rigorous scientific studies that incorporate clear differentiation of cigar type, measures of cumulative use, and temporal data collection are necessary to fully evaluate the health effects of premium cigar smoking and effectively inform Food and Drug Administration regulation.

Effect of a 'tobacco-free nicotine' claim on intentions and perceptions of Puff Bar e-cigarette use among non-tobacco-using young adults

INTRODUCTION

Puff Bar disposable e-cigarettes are now marketed with a 'tobacco-free nicotine' claim. We assessed the effect of this claim on non-tobacco-using young adults' perceptions of and intentions of using Puff Bar.

METHODS

We conducted an online randomised between-subjects experiment among non-tobacco-using young adults (ages 18-29 years; n=1822). Participants viewed depictions of Puff Bar e-cigarettes with the claim that the product contains 'tobacco-free nicotine' (experimental group; n=909) or simply 'nicotine' (control group; n=913). Multivariable regressions were used to assess the associations between experimental conditions and Puff Bar use intentions, harm perceptions, use expectancies and perceived relative use of Puff Bar versus other e-cigarettes, controlling for participant characteristics.

RESULTS

Compared with the control group, the experimental group who saw the 'tobacco-free nicotine' claim reported higher intentions of using Puff Bar (coefficient=0.17, p<0.001). The experimental group had a lower likelihood of perceiving Puff Bar use as 'extremely or very harmful' (OR=0.63, p<0.001) and 'strongly or somewhat' agreeing with the negative expectancy of using Puff Bar (OR=0.67, p<0.001). Additionally, the experimental group reported being 'much more or more likely' to use Puff Bar over other e-cigarettes (OR=1.67, p<0.001).

DISCUSSION

Puff Bar's tobacco-free nicotine claim may increase non-tobacco-using young adults' intentions of using Puff Bar and reduce harm perceptions and negative expectancy towards using Puff Bar. The claim may also prompt the use of Puff Bar over other e-cigarette brands and types. These findings are concerning given the health effects and regulations for tobacco-free nicotine products are not immediately clear.

Financial hardship during the COVID-19 pandemic and increased receipt of commercial tobacco discount coupons among US adults who use commercial tobacco

INTRODUCTION

Many individuals experienced financial hardship during the COVID-19 pandemic; yet commercial tobacco (CT) sales increased in the USA. We examined how experiencing financial hardships relates to increased CT discount coupon reception during the pandemic.

METHODS

A nationally representative sample of 1700 US adults who used CT during the 12 months prior to the survey were surveyed online during January to February 2021. Participants reported if they had received more discount coupons for various CT products during (compared with before) the pandemic. They also reported whether they experienced six different types of financial hardships since the pandemic, and the total number of hardships experienced was counted. Weighted multivariable logistic regressions were used to examine the associations between financial hardships and increased coupon reception, adjusting for demographics and CT product use.

RESULTS

During the first 10-11 months of the pandemic, 21.3% of US adults who used CT during the 12 months prior to the survey reported receiving more CT discount coupons. Experiencing financial hardship during the pandemic was associated with higher odds of receiving more coupons for all types of CT products: every additional count of financial hardship was associated with higher odds of increased reception of discount coupons for all CT products (adjusted odds ratios ranging from 1.13 to 1.23 across products).

CONCLUSIONS

Over one-fifth of US adults who used CT received more discount coupons during the pandemic. Those facing financial hardships had higher discount coupon reception, suggesting potential targeted marketing to financially vulnerable individuals by the tobacco industry.

Awareness and beliefs about FDA e-cigarette regulation in the premarket application review era

INTRODUCTION

In March 2022, FDA granted its first marketing orders for e-cigarettes. Few studies have assessed awareness of FDA e-cigarette regulation and authorization in the era of premarket review. This study describes prevalence of awareness as well as beliefs about regulation among adults who smoke and youth.

METHODS

We conducted a cross-sectional, nationally representative online survey of 866 adults who currently smoke cigarettes and 859 youth (ages 15-20) in June 2022 using Ipsos KnowledgePanel. Population prevalence of regulatory awareness and beliefs are reported. Pearson χ² and multivariable logistic regressions were conducted to assess dependent and independent associations with demographic and tobacco use characteristics.

RESULTS

Awareness that FDA regulates e-cigarettes was low among adults who smoke (25.4 %) and youth (18.5 %). Awareness that FDA authorizes e-cigarettes was also low among adults who smoke (10.8 %) and youth (12.7 %). Agreement with both positive and negative beliefs regarding FDA e-cigarette regulation was below 50 %. Current e-cigarette use was significantly associated with agreeing that regulation: makes e-cigarettes safer (adult aOR: 2.90, youth aOR: 2.51), helps prevent youth initiation (adult aOR 1.92), takes away freedom to choose to use e-cigarettes (adult aOR: 3.02, youth aOR: 2.58), and limits types of e-cigarettes available (adult aOR: 2.22, youth aOR: 2.49).

DISCUSSION

There is low awareness of FDA e-cigarette regulation and authorization and relatively low agreement with positive beliefs about e-cigarette regulation. Further study is needed to assess how the changing regulatory environment impacts product perceptions, intentions, and behaviors.

Longitudinal associations between receiving E-cigarette price promotions and subsequent E-cigarette use among U.S. Young adult cigarette smokers

INTRODUCTION

E-cigarette price promotions (EPPs; i.e., marketed reductions in cost) may influence young adult cigarette smokers to try, dual use with, or completely transition to e-cigarettes. We assessed whether receiving EPPs was associated with subsequent e-cigarette use among this group.

METHODS

Data were from Waves 4 (2016-2018) and 5 (2018-2019) of the nationally representative Population Assessment of Tobacco and Health (PATH) Study survey. Analysis was restricted to participants who were young adult (18-34 years) established, current cigarette smokers who did not use e-cigarettes at Wave 4 (baseline; n = 2,664; Sample 1), and a subsample of those who tried to quit smoking completely in the past year at Wave 5 (follow-up; n = 948; Sample 2). Multivariable logistic regressions were used to examine associations between receiving EPPs at baseline and past year use of e-cigarettes in general (Sample 1) and to help quit smoking (Sample 2) at follow-up, controlling for covariates.

RESULTS

Overall, 4.1% and 4.9% of Sample 1 and 2 participants received EPPs, respectively; At follow-up, 33.4% of Sample 1 participants used e-cigarettes, and 12.0% of Sample 2 participants used e-cigarettes to quit smoking. Receiving EPPs was associated with subsequent past-year e-cigarette use in general (AOR = 2.07; 95% CI = 1.31 to 3.27), and past-year e-cigarette use to help with quitting smoking (AOR = 3.20; 95% CI = 1.48 to 6.90).

DISCUSSION

EPPs may increase e-cigarette use among established, current smokers and may be used to quit smoking. Research is needed to understand how EPPs may be differentially associated with complete product transition versus dual/poly use among young adult smokers.

Price promotion receipt and use progression of any tobacco, cigarettes, e-cigarettes and cigars among US youth between 2016 and 2018

BACKGROUND

Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression.

METHODS

The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates.

RESULTS

At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation.

DISCUSSION

Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.

Financial challenges and hardship during the COVID-19 pandemic and tobacco expenditure minimizing strategies among U.S. adult commercial tobacco users

INTRODUCTION

Commercial tobacco (CT) users employ tobacco expenditure minimizing strategies (TEMS) to manage their CT expenditures. We examined how financial challenges and hardships during the COVID-19 pandemic relate to increases in TEMS use.

METHODS

Data from a nationally representative sample of 1,700 U.S. adult recent former and current CT users were collected from an online panel during January-February 2021. Participants reported if they had increased use of eight TEMS to save money on CT since the pandemic, and experienced financial challenges (e.g., losing a job) and hardships (e.g., not having enough money to pay for food). The number of financial hardships experienced was counted (range: 0-6). Weighted multivariable logistic regression models were used to examine the associations between financial challenges and hardships and increased TEMS use, adjusting for demographics.

RESULTS

Since the COVID-19 pandemic, three TEMS showed the largest increase in use by U.S. adult current and recent former CT users: cutting back (22.4%), finding less expensive places to purchase (15.6%), and buying by bulk (15.5%). Many financial challenges and hardships were consistently associated with increased uses of TEMS. Furthermore, every additional count of financial hardships was associated with higher odds of increasing use of each TEMS (AORs ranging between 1.12 and 1.23).

CONCLUSIONS

Many CT users increased TEMS use to manage their CT expenditures when facing financial challenges and hardships during the pandemic. This could hinder CT cessation and promote relapse. Prohibiting certain TEMS (e.g., discount coupon and price promotions) may promote CT cessation among this financially vulnerable group.

How the Other Half Sees It: E-cigarette Advertising Exposure and Subsequent E-cigarette Use Among U.S. Young Adult Cigarette Smokers

INTRODUCTION

E-cigarette advertising may benefit young adult cigarette smokers in transitioning to using e-cigarettes. We assessed whether e-cigarette advertising exposure was associated with subsequent e-cigarette use among young adult cigarette smokers.

AIMS AND METHODS

Data were from Waves 4 (2016-2018) and 5 (2018-2019) of the nationally representative Population Assessment of Tobacco and Health (PATH) study adult survey. Respondents were young adult established cigarette smokers at Wave 4 (18-34 years; n = 3391) and a subsample of those who tried to quit smoking cigarettes completely in the past year at Wave 5 (n = 1235). Multivariable logistic regressions were used to examine the associations between e-cigarette advertising exposure (by channel of exposure) and subsequent past-year e-cigarette use in general and e-cigarette use to quit smoking cigarettes, controlling for covariates.

RESULTS

At Wave 5, 43.4% of smokers reported past-year use of e-cigarettes; and 14.8% of smokers who tried to completely quit smoking reported past-year use of e-cigarettes to quit. E-cigarette advertising exposure was associated with subsequent past-year e-cigarette use (adjusted odds ratio [AOR] = 1.53, p < .0001, 95% confidence interval [CI] = 1.27, 1.86) and past-year use to quit smoking cigarettes (AOR = 1.65, p < .01, 95% CI = 1.19, 2.29). Advertising exposure through brick-and-mortar stores or websites/social media was similarly associated with both e-cigarette use behaviors.

DISCUSSION

Exposure to e-cigarette advertising among U.S. young adult established cigarette smokers may be associated with subsequent e-cigarette use and use to quit smoking. More research is needed to understand the features of e-cigarette advertising (eg, discounts, flavors, smoker-targeted claims) that may shape perception and behavior related to e-cigarette use among young adult smokers.

IMPLICATIONS

Little is known about the associations between e-cigarette advertising exposure and e-cigarette use among young adult cigarette smokers who may benefit from switching to e-cigarettes. This study found that e-cigarette advertising exposure was positively associated with (1) subsequent e-cigarette use among U.S. young adult established cigarette smokers and (2) subsequent e-cigarette use to quit smoking cigarettes among those who tried to completely quit in the past year. These observed associations were driven by smokers who did not currently use e-cigarettes at baseline. E-cigarette advertising exposure through brick-and-mortar stores or websites/social media was also positively associated with subsequent e-cigarette use behaviors.

E-cigarette Marketing Expenditures in the United States From 2016 to 2021: Targeted Media Outlets Geared Toward People Who Are at Increased Risk for Tobacco Use

INTRODUCTION

E-cigarette advertising exposure is linked to e-cigarette initiation and use. Thus, monitoring trends in e-cigarette advertising practices is important to understand e-cigarette use patterns observed over recent years.

AIMS AND METHODS

E-cigarette advertising expenditures (January 2016-July 2021; Numerator Ad Intel) for 154 U.S. market areas were harmonized with U.S. Census sociodemographic data through Nielsen zip code designations by market area. Descriptive statistics and multivariable linear regressions were used to examine trends in e-cigarette advertising expenditures across media outlets and associations between sociodemographic characteristics and e-cigarette advertising over time.

RESULTS

E-cigarette advertising expenditures peaked in 2018/2019, followed by a sharp decline in 2020. Expenditures were concentrated primarily on print (58.9%), TV (20.6%), and radio (14.4%). Major print outlets were Sports Illustrated, Rolling Stone, and Star magazines. Top TV channels were AMC, Investigation Discovery, and TBS. TV advertisements were purchased commonly during popular movies and TV series (eg King of Queens, Everybody Loves Raymond, The Walking Dead). Higher expenditures were associated with U.S. market areas that had (1) a larger percentage of non-rural zip codes (radio), (2) smaller male populations (radio), and (3) larger White or Caucasian, Black or African American, American Indian or Alaska Native, Asian, and Other or Multiracial populations (radio, print, online display, and online video).

CONCLUSIONS

E-cigarette companies advertised in print magazines geared toward males and youth and young adults, radio commercials focused in urban areas with smaller male populations, and nationwide TV commercials. Declines in e-cigarette advertising expenditures in 2020 demonstrate the potential impact that federal policies may have on protecting populations who are at higher risk for tobacco use from predatory advertising practices.

IMPLICATIONS

E-cigarette advertising exposure is associated with the initiation and use of e-cigarettes. This study shows how e-cigarette marketing expenditures in the United States may have targeted specific consumers (eg youth and young adults) between 2016 and 2021. The precipitous drop in advertising expenditures across all outlets during early 2020 corresponds with the implementation of the Tobacco 21 federal policy, the federal enforcement policy to remove most unauthorized flavored e-cigarette cartridges from the U.S. market, preparations for FDA's premarket review of e-cigarette products, and the decision by several TV broadcast companies to stop showing e-cigarette ads. The potential impact of federal policies may have far-reaching implications for protecting populations who are at high risk for tobacco use and its health consequences.

Nicotine Pouch: Awareness, Beliefs, Use, and Susceptibility among Current Tobacco Users in the United States, 2021

Little is known about awareness, beliefs, and use of nicotine pouches (NPs). Data from 1583 U.S. adult (age ≥ 21 years) current tobacco users were collected in 2021. Respondents self-reported NP awareness, beliefs, use, and susceptibility as well as current tobacco product use and socio-demographics. We used weighted logistic and multinomial regression models to explore the associations between these variables. Overall, 46.6% of U.S. adult current tobacco users were aware of, 16.4% had ever used, and 3.0% currently used NPs. Younger individuals (vs. 61+ years) were more likely to have ever heard of NPs, while Black individuals (vs. White) were less likely to have ever heard of NPs. Individuals younger than 45 years (vs. 61+ years) and those using smokeless tobacco products (vs. non-users) were more likely to have ever used NPs. Additionally, younger than 45 years (vs. 61+ years) and current use of certain tobacco products (e.g., smokeless) were associated with current NP use. Holding favorable beliefs about NPs was associated with susceptibility to and more advanced NP use statuses (p < 0.05). Continuous surveillance of NP use and beliefs is important.

Heated Tobacco Products: Awareness, Beliefs, Use and Susceptibility among US Adult Current Tobacco Users, 2021

Limited data exist on the awareness, beliefs, and use of heated tobacco products (HTPs). Data from 1583 U.S. adult (age ≥ 21 years) current tobacco users were collected in 2021. Participants self-reported HTP awareness, beliefs, use, and susceptibility, as well as current tobacco product use and sociodemographics. We used weighted logistic and multinomial regression models to explore their associations. Overall, 23.6% were aware of, 8.9% had ever used, and 3.0% currently used HTPs. Younger individuals (vs. 61+ years), those with annual income $50,000+ (vs. <$50,000), and those currently using electronic vaping products (vs. non-users) were more likely to be aware of, to have ever used, and to currently be using HTPs (p < 0.05). Black individuals (vs. White) were more likely to report ever and current HTP use (p < 0.05). Current cigarette smoking was not associated with HTP awareness and use (p > 0.05). Holding favorable HTP beliefs was associated with susceptibility to and more advanced HTP use statuses (p < 0.05). Sociodemographics associated with HTP use may reflect HTP marketing strategies. The lack of association with cigarette smoking suggests HTPs may be unlikely cigarette substitutes. Addressing favorable HTP-related beliefs may prevent dual use.

The Landscape of Cigar Marketing in Print Magazines from 2018-2021: Content, Expenditures, Volume, Placement and Reach

Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018-2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences (i.e., appearances in magazines), translating to $46,504,578 in expenditures. All ads featured the word "enjoy/enjoyment" and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA's efforts to reduce health disparities through regulations and public education.

Correlates of behavior change intents in response to a hypothetical flavored cigar sales restriction among U.S. adult flavored cigar smokers

Flavored cigar sales restrictions (FCSRs) may reduce cigar smoking and protect public health. This study examined the correlates of behavior change intents in response to a hypothetical FCSR. Data were from a nationally representative sample of adult flavored cigar smokers (ages ≥21; n = 343) collected through an online survey in 2021. Respondents selected their behavior change intents in response to a hypothetical FCSR, including (1) quitting cigars altogether; (2) smoking plain or non-flavored cigars; (3) smoking other flavored tobacco products; (4) smoking cannabis; and (5) other options. Weighted logistic regressions were used to examine the associations of socio-demographic backgrounds, tobacco use history, and tobacco dependence with behavioral change intents. In response to an FCSR, 15.1% of respondents would quit smoking cigars altogether, 41.6% would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, and 29.2% would substitute flavored cigars with cannabis. Large cigar smokers and blunt smokers were less likely to quit cigars altogether than non-smokers of those products; females and racial/ethnic minorities were more likely to substitute flavored cigars with other flavored tobacco and cannabis products, respectively, than males and non-Hispanic White respondents. Results suggest that FCSRs may reduce cigar smoking among a portion of U.S. flavored cigar smokers while leaving more continuing to smoke plain cigars or transitioning to use other flavored tobacco products or cannabis. Implementing FCSRs should be accompanied by comprehensive flavored tobacco sales restrictions, cessation programs, and educational messages aimed at reducing the use of cigars and other substances.

Associations between living in localities with e-cigarette sales restrictions and e-cigarette use change among young adults in Los Angeles County

INTRODUCTION

Local e-cigarette sales restrictions (ESRs) may impact e-cigarette use. This study examined the associations between living in localities with various ESR policies and changes in e-cigarette use among young adults in Los Angeles (LA) County, California, USA.

METHODS

Data were from a cohort of LA County young adults (18-21 years; n=2100) who completed two waves of surveys (Fall 2018-Summer 2019 and Summer-Fall 2020). Local flavoured (n=9) and comprehensive (n=2) ESRs in LA County implemented between June 2019 and May 2020 were identified, coded and merged with the baseline data. Multivariable logistic regressions were used to examine the associations between living in ESR localities and e-cigarette use at follow-up, controlling for covariates and stratified by cigarette smoking at baseline.

RESULTS

Overall, 20.9% and 14.3% of participants lived in localities with flavoured and comprehensive ESRs, respectively. Participants who were non-Hispanic, had higher socioeconomic statuses and were currently using e-cigarettes were generally more likely to live in ESR localities than their counterparts. The associations between living in ESR localities and e-cigarette use at follow-up were not found among baseline non-e-cigarette users regardless of their cigarette smoking status; a positive relationship was found among baseline e-cigarette users who also smoked cigarettes but not among non-smokers.

DISCUSSION

Participants who lived in localities with various ESR policies were different in their baseline e-cigarette use and socioeconomic backgrounds. Future research examining the potential impact of ESRs on e-cigarette use change should consider the localities' overall sociodemographic and tobacco-using characteristics and individuals' cigarette smoking histories.

Longitudinal associations between U.S. youth exposure to E-cigarette marketing and E-cigarette use harm perception and behavior change

E-cigarette marketing tactics to reach and appeal to youth are rapidly changing. This study examined to what extent youth e-cigarette marketing exposure was associated with e-cigarette use behavior change one year later, during a time when youth e-cigarette use was starting to surge in the U.S. Using nationally representative longitudinal public-use data from the Population Assessment of Tobacco and Health (PATH) Study, we examined associations between recalled e-cigarette marketing exposure (2016-2018) at Wave (W) 4 and e-cigarette use harm perception and behavior change (ever, current, and regular use) one year later (W4.5; 2017-2018) among W4 never tobacco users (n = 9405). Recall of exposure to e-cigarette marketing through different channels was also examined in multivariable models controlling for socio-demographic factors and established e-cigarette use risk factors. Results show that the most frequently recalled channels of e-cigarette marketing exposure were retail stores (50.3%), television (22.2%), and websites/social media (20.2%). Over one year, 21.2%, 7.8%, 3.4%, and 1.2% of respondents reported reduced harm perceptions, and ever, current, and regular use of e-cigarettes, respectively, at follow-up. Recalled exposure to e-cigarette marketing was associated with reduced e-cigarette harm perception (AOR = 1.20; 95% CI = 1.05-1.37) and ever (AOR = 1.26; 95% CI = 1.01-1.56) and current use (AOR = 1.40; 95% CI = 1.02-1.92) at follow-up. E-cigarette marketing exposure through websites/social media was associated with reduced harm perceptions and all stages of e-cigarette use change, including regular use. Identifying marketing techniques and channels that change youth e-cigarette harm perceptions and influence e-cigarette use progression is essential to inform e-cigarette regulatory policies and prevention campaigns.

Examining Visual Attention to Tobacco Marketing Materials among Young Adult Smokers: A Protocol for a Remote Webcam-based Eye-Tracking Experiment (Preprint)

BACKGROUND

Eye tracking provides an objective way to measure attention, which can advance researchers' and policy makers' understanding of tobacco marketing influences. The development of remote webcam-based eye-tracking technology, integrated with web-based crowdsourcing studies, may be a cost-effective and time-efficient alternative to laboratory-based eye-tracking methods. However, research is needed to evaluate the utility of remote eye-tracking methods.

OBJECTIVE

This study aimed to detail the process of designing a remote webcam-based eye-tracking experiment and provide data on associations between participant characteristics and the outcomes of experiment completion.

METHODS

A total of 2023 young adult (aged 18-34 years) cigarette smokers in the United States were recruited to complete a web-based survey that included a 90-second remote eye-tracking experiment that examined attention to e-cigarette marketing materials. Primary outcome measures assessed the completion of the remote eye-tracking experiment-specifically, experiment initiated versus not initiated, experiment completed versus not completed, and usable versus nonusable eye-tracking data generated. Multivariable logistic regressions examined the associations between outcome measures and participants' sociodemographic backgrounds, tobacco use history, and electronic devices (mobile vs desktop) used during the experiment.

RESULTS

Study recruitment began on April 14, 2022, and ended on May 3, 2022. Of the 2023 survey participants, 1887 (93.28%) initiated the experiment, and 777 (38.41%) completed the experiment. Of the 777 participants who completed the experiment, 381 (49%) generated usable data. Results from the full regression models show that non-Hispanic Black participants (adjusted odds ratio [AOR] 0.64, 95% CI 0.45-0.91) were less likely to complete the eye-tracking experiment than non-Hispanic White participants. In addition, female (vs male) participants (AOR 1.46, 95% CI 1.01-2.11), those currently using (vs not using) e-cigarettes (AOR 2.08, 95% CI 1.13-3.82), and those who used mobile (vs desktop) devices (AOR 5.10, 95% CI 3.05-8.52) were more likely to generate usable eye-tracking data.

CONCLUSIONS

Young adult participants were willing to try remote eye-tracking technology, and nearly half of those who completed the experiment generated usable eye-tracking data (381/777, 49%). Thus, we believe that the use of remote eye-tracking tools, integrated with crowdsourcing recruitment, can be a useful approach for the tobacco regulatory science research community to collect high-quality, large-scale eye-tracking data in a timely fashion and thereby address research questions related to the ever-evolving tobacco marketing landscape. It would be useful to investigate techniques to enhance completion rates and data usability.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/43512.

U.S. Trends in Age of Cigar Smoking Initiation by Race/Ethnicity and Education

INTRODUCTION

Younger age of initiating cigar smoking is associated with greater nicotine dependence and current use. Age of initiating cigarette smoking has increased over time, whereas trends in age of initiating cigar smoking remain understudied. These trends were examined by race/ethnicity, by education, and at their intersection.

METHODS

The analytic sample included U.S. Hispanic, Black, and White cigar-ever-smokers aged 24‒25 years (n=29,715) from the 2002‒2019 National Survey on Drug Use and Health. Participants reported their age, race/ethnicity, sex, education (≤high school; some college; ≥bachelor's degree), age of initiating cannabis use, and cigar smoking. Weighted multivariable linear regressions adjusted for sex and age of cannabis use initiation were used to examine trends in age of initiating cigar smoking by race/ethnicity, education, and education Χ year interactions within racial/ethnic groups. Age of initiating cigar smoking comparisons across race/ethnicity and education were examined using the most recent 2019 data.

RESULTS

During 2002‒2019, across education, White cigar-ever-smokers started smoking cigars at an older age, whereas it remained unchanged among Hispanic cigar-ever-smokers. Among Black cigar-ever-smokers, age of initiating cigar smoking did not change among those with ≤high school and some college, and was older among those with ≥bachelor's degree. In 2019, age of initiating cigar smoking did not vary by educational level among Hispanic and White cigar-ever-smokers. Black cigar-ever-smokers with ≥bachelor's degree initiated cigar smoking at older ages than their White counterparts.

CONCLUSIONS

Black individuals experienced widening education-related disparities, and Hispanic individuals had no progress in delaying age of initiating cigar smoking. Regulatory action banning cigar flavors may impact these trends.

Exploring the hypothetical impact of flavored cigar sales restrictions among black young adult cigar smokers: a semi-structured in-depth interview investigation

This study assessed the hypothetical impact of flavored cigar sales restrictions on cigar smoking among Black young adult cigar smokers (ages 21-29). Forty in-depth interviews were conducted in 2020. Interviews were independently coded and analyzed using thematic analysis. When asked how they would smoke cigars given a flavor sales restriction, half of participants reported they would smoke in the same way, a third would stop or reduce smoking, and a few were unsure of what they would do. Cigar smoking outcome expectancies, preference for flavors, and perceived addictiveness of cigar products may predict cigar smoking change given flavor sales restrictions.

Exploring the Experiences and Perceptions of Cigar Craving and Addiction among Young Adult Black Cigar Smokers

Black young adults have the highest prevalence of cigar smoking in the U.S. Little is known about how this population perceives addiction to cigar smoking, which may influence long-term smoking and cessation outcomes. This study used semi-structured in-depth interviews to understand cravings, triggers, and perceived addiction from cigar smoking among a purposive sample of Black young adult cigar smokers (N = 40; 21-29 years). An iterative process was used to develop the codebook, and thematic analysis was used to capture findings based on the products predominantly used: cigarillos, large cigars, or blunts. Results suggest that while participants may share similar types of cravings and triggers (e.g., stress) across the use of these products, predominant blunt smokers reported more unique triggers related to relieving physical discomforts. While most participants reported cigars could be addictive to people in general, only a few perceived that they themselves were addicted. Participants who predominantly smoked cigarillos reported high perceived addiction to cigars, while those who predominantly smoked blunts reported low addiction. Education messages are needed to inform young Black adult cigar smokers about the risks and health symptoms of cigar addiction. These efforts may help increase cigar cessation seeking and reduce cigar addiction-related health consequences and disparities among Black populations.

Examining the Survey Setting Effect on Current E-Cigarette Use Estimates among High School Students in the 2021 National Youth Tobacco Survey

The 2021 National Youth Tobacco Survey (NYTS) was completed by youth online during class time, either in school or at home due to the COVID-19 pandemic. Given the role of NYTS data in tobacco regulatory science, it is vital to understand the effect of survey settings (home, school) on tobacco-use estimates. We used a series of multivariable logistic regressions to examine whether survey settings (home vs. school) predicted current e-cigarette use among high school students, controlling for other known predictors of e-cigarette use as well as the pandemic learning model that was dominant in students' counties (e.g., nearly all at-home, majority in school). We observed a significant survey setting effect. Those who completed the survey in school had higher odds of current e-cigarette use than those who completed the same survey at home (AOR = 1.74); this effect was attenuated when we controlled for the pandemic learning model (AOR = 1.38). Moreover, e-cigarette use was independently associated with students' learning model; students whose schools were nearly entirely in-person had the highest odds of e-cigarette use compared to students whose learning model was nearly all at-home (AOR = 1.65). Survey setting is a methodological artifact in the 2021 NYTS. Perceived privacy and peer effects can potentially explain this artifact.

Physical and Sociocultural Community-Level Influences on Cigar Smoking among Black Young Adults: An In-Depth Interview Investigation

Black young adults experience disparately high rates of cigar use and its health consequences. Little research has explored community-level influences on cigar smoking in this population, especially concerning product-specific influences and cigar smokers' perceptions. We conducted in-depth interviews with 40 Black young adult (ages 21-29) cigar smokers in the Washington, D.C. area and analyzed themes regarding physical and sociocultural community-level factors perceived to influence cigar use. Themes were further analyzed based on participants' predominant cigar products (cigarillos, large cigars, blunts). Participants reported easy access to affordable cigarillos, widespread cigarillo sales and targeted marketing, norms of cigar and blunt smoking for stress relief, socialization, and cultural participation, and ubiquitous cigar and blunt smoking cues, all of which promoted cigar use in their communities. Future research should further explore how community-level influences contribute to disproportionate cigar use among Black young adults. Our findings suggest that programs and policies addressing physical and sociocultural community-level pro-smoking influences may help mitigate cigar smoking disparities.

Cigar Warning Noticing and Demographic and Usage Correlates: Analysis from the United States Population Assessment of Tobacco and Health Study, Wave 5

Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.

Cigar-Smoking-Cessation Interest and Experience among Black Young Adults: A Semi-Structured In-Depth Interview Investigation

Although Black/African American populations have high cigar-smoking prevalence, little is known about cigar-smoking cessation among this group. This study explored the perceptions and experiences of cigar-smoking cessation and assistance received from healthcare providers among forty Black young-adult cigar smokers (ages 21-29). Semi-structured in-depth phone interviews were transcribed and coded. Qualitative data were analyzed by using thematic analysis. Participants mostly smoked cigarillos, large cigars, and blunts. Overall, many regular cigarillo smokers reported interest in quitting eventually, while large-cigar and blunt smokers shared less interest in quitting because they perceived low harm from smoking these products. The reasons for cigar-smoking cessation were health concerns and financial constraints. Most of the participants who attempted to quit cigars did not use any cessation aids. The reasons for relapse included nicotine withdrawal, stress, and easy access. Additionally, most participants reported their healthcare providers did not ask whether they smoked cigars, and even when they knew, little assistance for cigar-smoking cessation was provided. Informing Black cigar smokers of the harm of cigar smoking and encouraging healthcare providers to screen for and assist with cigar-smoking cessation may alleviate the health burden of cigar smoking in this population.