Uncontrolled vaping and restraint strategies: A qualitative study

INTRODUCTION

Little is known about uncontrolled vaping, defined as vaping more than the user prefers. We sought to understand e-cigarette users' experiences with uncontrolled vaping and how they restrain their vaping.

METHODS

Participants were 24 US adult e-cigarette users recruited in 2021. We conducted semi-structured qualitative interviews about uncontrolled vaping and restraint strategies and analyzed findings based on behavioral categories described in the Process Model of Self-Control.

RESULTS

While most participants (21 of 24) described experiences of uncontrolled vaping, some expressed ambivalence about how much they vaped. To restrain vaping, willpower was rarely used and was not perceived as effective. Distraction, deployment of attention away from the urge to vape, and reappraisal, thinking differently about vaping such as reminding oneself of health consequences, were common and helped some participants limit use in the moment of wanting to vape. Participants described using both situation selection, choosing to be in situations where e-cigarette use was less possible, and situation modification, modifying their circumstances to restrict opportunities to vape.

DISCUSSION

Uncontrolled vaping is not yet a well-defined concept for many e-cigarette users. E-cigarette users employed proactive situational strategies that required planning ahead to restrain use and found these strategies more effective compared to reactive strategies. Tobacco control programs and interventions should consider leveraging restraint strategies that people who vape are naturally using and perceive to be effective.

Effects of Modified Risk Tobacco Product Claims on Consumer Responses

INTRODUCTION

US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated).

AIMS AND METHODS

Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS.

RESULTS

MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05).

DISCUSSION

MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching).

IMPLICATIONS

We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

The Impact of Menthol Cigarette Bans: A Systematic Review and Meta-Analysis

INTRODUCTION

This review investigates the impacts of banning the sale of menthol cigarettes at stores.

METHODS

A systematic search of studies published in English up to November 2022 was conducted. The following databases were searched: PubMed/Medline, CINAHL, PsycINFO, Web of Science, and Embase, as well as a non-indexed journal. Studies evaluating either the impact of real-world or hypothesized menthol cigarette bans were included. Primary outcomes include tobacco use behaviors. Secondary outcomes include cigarette sales, retailer compliance, and the tobacco industry's response to a menthol ban. Data on tobacco use behavior after a menthol ban were pooled using random-effects models. Two pairs of reviewers independently extracted data and assessed study quality.

RESULTS

Of the 964 articles that were identified during the initial search, 78 were included in the review and 16 were included in the meta-analysis. Cessation rates among menthol cigarette smokers were high after a menthol ban. Pooled results show that 24% (95% confidence interval [95% CI]: 20%, 28%) of menthol cigarette smokers quit smoking after a menthol ban, 50% (95% CI: 31%, 68%) switched to non-menthol cigarettes, 12% (95% CI: 3%, 20%) switched to other flavored tobacco products, and 24% (95% CI: 17%, 31%) continued smoking menthol cigarettes. Hypothesized quitting and switching rates were fairly close to real-world rates. Studies found the tobacco industry attempts to undermine menthol bans. National menthol bans appear more effective than local or state menthol bans.

CONCLUSIONS

Menthol cigarette bans promote smoking cessation suggesting their potential to improve public health.

IMPLICATIONS

Findings from this review suggest that menthol cigarette bans promote smoking cessation among menthol cigarette smokers and have the potential to improve public health.

Spatial Clustering of Tobacco Retailers Near US Public Schools

INTRODUCTION

Previous studies have found that tobacco retailers cluster near schools. However, all retail outlets may be located near each other and near schools due to existing infrastructure and zoning policies. We assessed whether tobacco retailers cluster near schools in the United States more than expected when accounting for existing retail locations.

AIMS AND METHODS

We identified 322 056 probable tobacco retailers, 95 110 public schools, and more than 3.8 million businesses comparable to tobacco retailers in land use and business type. We created 500 simulated tobacco retailer datasets by randomly selecting from the larger list of businesses. For each simulated dataset, we calculated the distance from schools to the nearest tobacco retailer (proximity) and the count of tobacco retailers within 800 m of schools (density). Observed proximity and density values were compared to 95% coverage intervals from the 500 simulations. We stratified analyses by urbanicity, percentage of students in the free and reduced-priced lunch program (FRLP), and percentage of Hispanic/Latino, non-Hispanic Black, and non-Hispanic white students.

RESULTS

Tobacco retailers were closer to schools in rural areas, cities, and towns and more dense around schools in rural areas, cities, and suburbs compared to random locations in potential retail space. Schools with more students receiving FRLP had higher density than expected while schools with fewer students receiving FRLP had lower density than expected. Within rural areas, clustering did not vary across sociodemographic groups. Within non-rural areas, there were inequities in clustering by racial, ethnic, and socioeconomic school composition.

CONCLUSIONS

Tobacco retailers cluster near schools after accounting for existing business patterns. There are inequities in clustering by sociodemographic school composition.

IMPLICATIONS

This study provides compelling evidence that tobacco retailers cluster near US public schools and that there are racial, ethnic, and socioeconomic inequities in clustering, even when accounting for overall retail location patterns. Given that public schools tend to reflect neighborhood demographics, policies to limit tobacco retailers near schools may reduce both school-based and neighborhood-based inequities.

The Use of Social Media to Express and Manage Medical Uncertainty in Dyskeratosis Congenita: Content Analysis

BACKGROUND

Social media has the potential to provide social support for rare disease communities; however, little is known about the use of social media for the expression of medical uncertainty, a common feature of rare diseases.

OBJECTIVE

This study aims to evaluate the expression of medical uncertainty on social media in the context of dyskeratosis congenita, a rare cancer-prone inherited bone marrow failure and telomere biology disorder (TBD).

METHODS

We performed a content analysis of uncertainty-related posts on Facebook and Twitter managed by Team Telomere, a patient advocacy group for this rare disease. We assessed the frequency of uncertainty-related posts, uncertainty sources, issues, and management and associations between uncertainty and social support.

RESULTS

Across all TBD social media platforms, 45.98% (1269/2760) of posts were uncertainty related. Uncertainty-related posts authored by Team Telomere on Twitter focused on scientific (306/434, 70.5%) or personal (230/434, 53%) issues and reflected uncertainty arising from probability, ambiguity, or complexity. Uncertainty-related posts in conversations among patients and caregivers in the Facebook community group focused on scientific (429/511, 84%), personal (157/511, 30.7%), and practical (114/511, 22.3%) issues, many of which were related to prognostic unknowns. Both platforms suggested uncertainty management strategies that focused on information sharing and community building. Posts reflecting response-focused uncertainty management strategies (eg, emotional regulation) were more frequent on Twitter compared with the Facebook community group (χ21=3.9; P=.05), whereas posts reflecting uncertainty-focused management strategies (eg, ordering information) were more frequent in the Facebook community group compared with Twitter (χ21=55.1; P<.001). In the Facebook community group, only 36% (184/511) of members created posts during the study period, and those who created posts did so with a low frequency (median 3, IQR 1-7 posts). Analysis of post creator characteristics suggested that most users of TBD social media are White, female, and parents of patients with dyskeratosis congenita.

CONCLUSIONS

Although uncertainty is a pervasive and multifactorial issue in TBDs, our findings suggest that the discussion of medical uncertainty on TBD social media is largely limited to brief exchanges about scientific, personal, or practical issues rather than ongoing supportive conversation. The nature of uncertainty-related conversations also varied by user group: patients and caregivers used social media primarily to discuss scientific uncertainties (eg, regarding prognosis), form social connections, or exchange advice on accessing and organizing medical care, whereas Team Telomere used social media to express scientific and personal issues of uncertainty and to address the emotional impact of uncertainty. The higher involvement of female parents on TBD social media suggests a potentially greater burden of uncertainty management among mothers compared with other groups. Further research is needed to understand the dynamics of social media engagement to manage medical uncertainty in the TBD community.

Concussion-Related Decision-Making by Certified Athletic Trainers: Implications for Concussion Prevention and Care

Concussions are a common sport-related injury that require appropriate initial care. Athletic trainers, often a primary source of healthcare for student-athletes, are key individuals involved in initial concussion diagnostic and management decisions. Challenges exist within the athletic environment that may hinder the consistency, efficacy, and/or effectiveness of concussion-related decision-making by athletic trainers, thereby impacting secondary concussion prevention and patient health. The purpose of this study was to identify factors that impact the intentions of athletic trainers to make appropriate concussion-related decisions under various circumstances. Overall, 1029 participants completed a survey examining educational precursors (quantity and quality of healthcare communication educational focus), demographic precursors (age, gender, educational degree, and employment setting), theory-based mediators (attitudes, perceived norms, and personal agency), and external mediators (knowledge, salience, and communication/collaboration practices) on appropriate concussion-related decision-making intentions. Data were analyzed using a two-step structural equation modeling approach. Quality of healthcare communication educational focus indirectly impacted appropriate concussion-related decision-making intentions via perceived behavioral control and communication/collaboration practices. Additionally, several factors impacted intentions to make appropriate concussion-related decisions directly including employment setting, self-efficacy, and general attitudes towards decision-making and concussions. Concussion prevention is aided by the initial and appropriate action taken by a healthcare professional to reduce immediate consequences; however, this action may be influenced by stakeholder relationships. These influential factors of decision-making may place athletes at further injury risk and negatively impact overall athlete health. As such, a sound theoretical framework incorporating the complexity of factors that may influence decision-making is needed.

Terms tobacco users employ to describe e-cigarette aerosol

BACKGROUND

The scientific term for the substance people inhale and exhale from a vaping device is 'aerosol', but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols.

METHODS

Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what 'people inhale and exhale when they vape', using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term 'aerosol' or 'vapor' (eg, 'E-cigarette aerosol/vapor contains nicotine, which can lead to seizures').

RESULTS

In open-ended responses, tobacco users most commonly provided the terms 'vapor' (31%) and 'smoke' (23%) but rarely 'aerosol' (<1%). In closed-ended responses, the most commonly endorsed terms were again 'vapor' (57%) and 'smoke' (22%) but again infrequently 'aerosol' (2%). In closed-ended responses, use of the term 'vapor' was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p<0.05). In the experiment, warnings using the terms 'aerosol' and 'vapor' were equally effective (all p>0.05).

CONCLUSIONS

The public rarely uses the term 'aerosol' to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms 'aerosol' and the more popular 'vapor' to better inform vaping risk communication.

Online Purchase Attempts of Flavored E-Cigarettes to Minors in California Before and After Senate Bill 793

This survey study assesses whether the online purchase attempt completion rate of e-cigarettes changed after passage of California Senate Bill 793.

The special sauce of the Cancer Prevention and Control Research Network: 20 years of lessons learned in developing the evidence base, building community capacity, and translating research into practice

PURPOSE

The Cancer Prevention and Control Research Network (CPCRN) is a national network focused on accelerating the translation of cancer prevention and control research evidence into practice through collaborative, multicenter projects in partnership with diverse communities. From 2003 to 2022, the CPCRN included 613 members.

METHODS

We: (1) characterize the extent and nature of collaborations through a bibliometric analysis of 20 years of Network publications; and (2) describe key features and functions of the CPCRN as related to organizational structure, productivity, impact, and focus on health equity, partnership development, and capacity building through analysis of 22 in-depth interviews and review of Network documentation.

RESULTS

Searching Scopus for multicenter publications among the CPCRN members from their time of Network engagement yielded 1,074 collaborative publications involving two or more members. Both the overall number and content breadth of multicenter publications increased over time as the Network matured. Since 2004, members submitted 123 multicenter grant applications, of which 72 were funded (59%), totaling more than $77 million secured. Thematic analysis of interviews revealed that the CPCRN's success-in terms of publication and grant productivity, as well as the breadth and depth of partnerships, subject matter expertise, and content area foci-is attributable to: (1) its people-the inclusion of members representing diverse content-area interests, multidisciplinary perspectives, and geographic contexts; (2) dedicated centralized structures and processes to enable and evaluate collaboration; and (3) focused attention to strategically adapting to change.

CONCLUSION

CPCRN's history highlights organizational, strategic, and practical lessons learned over two decades to optimize Network collaboration for enhanced collective impact in cancer prevention and control. These insights may be useful to others seeking to leverage collaborative networks to address public health problems.

Changes in retail tobacco product sales and market share among retail payroll establishments in the U.S. Economic Census between 1997 and 2017

The tobacco industry spends the vast majority of their marketing and promotional budget at retail outlets. However, few studies have used publicly available data to examine trends in the number and types of retail establishments where tobacco products are sold. Using the U.S. Economic Census for 1997, 2002, 2007, 2012 and 2017 (the latest year), we examined the number, type, and sales of payroll establishments selling tobacco products. Nine store types accounted for 94% - 99% of tobacco product sales between 1997 and 2017. Gas/convenience stores had the greatest market share (33% - 49% of tobacco sales). The number of warehouse clubs selling tobacco quadrupled; however, market share only increased from 9.6% to 10.3%. Supermarkets experienced the largest decrease in percent of stores selling tobacco. Pharmacy tobacco sales increased in 2012 then decreased in 2017; per store sales volume more than doubled between 1997 and 2012. Online shopping accounted for less than 1% of the market share between 1997 and 2012, but rose to 6.3% in 2017. Between 1997 and 2017, consumers shifted where they purchased tobacco products. Declining tobacco sales in supermarkets is a promising trend for consumers seeking healthy food without exposure to tobacco product marketing; however, the consistently large number of tobacco retailers, and thus widespread tobacco availability, is concerning. Consumer tobacco purchase changes over time support the case for point-of-sale policies that affect different retail types, including pharmacy bans, to reduce tobacco retailer density. Additionally, the rapid shift to online tobacco purchasing in 2017 identifies a new target for enhanced regulation and enforcement.

Tobacco company agreements with tobacco retailers for price discounts and prime placement of products and advertising: a scoping review

OBJECTIVE

The objectives of this scoping review are to examine existing research on the often-secretive contracts between tobacco manufacturers and retailers, to identify contract requirements and incentives, and to assess the impact of contracts on the sales and marketing of tobacco products in the retail setting.

DATA SOURCES

The systematic search was conducted in PubMed/MEDLINE, Web of Science, Scopus, ProQuest Political Science Database, Business Source Premier, ProQuest Agricultural & Environmental Science Collection, and Global Health through December 2020.

STUDY SELECTION

We included studies that collected and analysed empirical data related to tobacco contracts, tobacco manufacturers, and tobacco retailers. Two reviewers independently screened all 2786 studies, excluding 2694 titles and abstracts and 65 full texts resulting in 27 (0.97%) included studies.

DATA EXTRACTION

Study characteristics, contract prevalence, contract requirements and incentives, and the influence of contracts on the retail environment were extracted from each study.

DATA SYNTHESIS

We created an evidence table and conducted a narrative review of included studies.

CONCLUSIONS

Contracts are prevalent around the world and handsomely incentivise tobacco retailers in exchange for substantial manufacturer control of tobacco product availability, placement, pricing and promotion in the retail setting. Contracts allow tobacco companies to promote their products and undermine tobacco control efforts in the retail setting through discounted prices, promotions and highly visible placement of marketing materials and products. Policy recommendations include banning tobacco manufacturer contracts and retailer incentives along with more transparent reporting of contract incentives given to retailers.

Do Vaping Prevention Messages Impact Adolescents and Young Adults? A Meta-Analysis of Experimental Studies

Vaping prevention messages are widely used to communicate the health harms and addiction risks of vaping and discourage vaping among adolescents and young adults. We conducted a meta-analysis of experimental studies to examine the effects of these messages and to understand their theoretical mechanisms. Systematic, comprehensive searches generated 4,451 references, among which 12 studies (cumulative N = 6,622) met inclusion criteria for the meta-analysis. Across these studies, a total of 35 different vaping-related outcomes were measured, and 14 outcomes assessed in two or more independent samples were meta-analyzed. Results showed that compared to control, exposure to vaping prevention messages led to higher vaping risk perceptions, including harm perceptions (d = 0.30, p < .001), perceived likelihood of harm (d = 0.23, p < .001), perceived relative harm (d = 0.14, p = .036), addiction perceptions (d = 0.39, p < .001), perceived likelihood of addiction (d = 0.22, p < .001), and perceived relative addiction (d = 0.33, p = .015). Also, compared to control, exposure to vaping prevention messages led to more vaping knowledge (d = 0.37, p < .001), lower intentions to vape (d = -0.09, p = .022), and higher perceived message effectiveness (message perceptions; d = 0.57, p < .001; effects perceptions; d = 0.55, p < .001). Findings suggest vaping prevention messages have an impact, yet may operate through different theoretical mechanisms than cigarette pack warnings.

Optimising messages and images for e-cigarette warnings

BACKGROUND

The US Food and Drug Administration (FDA) requires electronic cigarettes (e-cigarettes) to have a single addiction warning, but many other health harms are associated with vaping and warnings grow stale over time. We aimed to develop new warning messages and images to discourage e-cigarette use.

METHODS

Participants were 1629 US adults who vaped or smoked. We randomised each participant to evaluate 7 of 28 messages on newly developed warning themes (metals exposure, DNA mutation, cardiovascular problems, chemical exposure, lung damage, impaired immunity, addiction), and the current FDA-required warning (total of 8 messages). Then, participants evaluated images of hazards (eg, metal), internal harms (eg, organ damage) or people experiencing harms.

RESULTS

Regarding intended effects, new warning themes all discouraged vaping more than the current FDA-required warning (all p<0.001), led to greater negative affect (all p<0.001) and led to more anticipated social interactions (all p<0.001). The most discouraging warnings were about toxic metals exposure. Regarding unintended effects, the new themes led to more stigma against people who vape (6 of 7 themes, p<0.001) and led to a greater likelihood of thinking vaping is more harmful than smoking (all 7 themes, p<0.001), although unintended effects were smaller than intended effects. Images of harms (internal or people experiencing) discouraged vaping more than images of hazards (all p<0.001).

DISCUSSION

Vaping warning policies should communicate a broader range of hazards and harms, beyond addiction, to potentially increase awareness of health harms. Images of internal harm or people experiencing harms may be particularly effective at discouraging vaping.

Can Extant Vaping Prevention Message Experiments Tell Us Something About What Works? A Response to O'Keefe

In his commentary, O'Keefe raises some interesting questions about the meaning of effect sizes in meta-analyses of experiments, focusing on our recent meta-analysis on vaping prevention messages. In this commentary, we respond to O'Keefe's comments and make several points. First, it is not uncommon to include experiments with different control conditions in a meta-analysis. Second, the set of studies in our meta-analysis were relatively homogenous, all being experiments testing messages to discourage vaping among adolescents and young adults. Third, the control conditions in each of the studies in the meta-analysis were appropriate for each given study, and our results show homogenous effects on most outcomes. Fourth, our meta-analysis finds meaningful effects that are timely and will be useful to researchers and practitioners alike. As this literature continues to grow, so too will knowledge about the effects of vaping prevention messages and moderators of those effects.

Realizing the Tobacco Endgame: Understanding and mobilizing public support for banning combustible cigarette sales in the United States

BACKGROUND

There is little research on public support for banning the sale and purchase of combustible cigarettes even though a ban is an essential step towards achieving the endgame for tobacco products.

PURPOSE

We report the first studies designed to (a) examine predictors of support for a ban (Study 1), and (b) test interventions to increase such support (Studies 2-4).

METHODS

In Study 1, current, former, and never smokers (N = 479) were randomized to conditions measuring their willingness to ban the sale of cigarettes vs. an unspecified product. Smokers were randomized to a persuasive communication in Study 2 and a paradoxical thinking intervention in Study 3 (Ns = 300 and 302, respectively). In Study 4 (N = 336), we randomized smokers to self-persuasion and issue-framing interventions.

RESULTS

Whereas nonsmokers were willing to ban the sale of both cigarettes and equivalent products, current and former smokers exempted cigarettes from a ban. Reactance to prohibition and perceived effectiveness predicted willingness to ban cigarette sales in all three smoking status groups (Study 1). Neither persuasive communication nor paradoxical thinking increased support for banning cigarette sales in Studies 2-3. However, self-persuasion and framing the ban as "protecting Americans from avoidable harm" both led to increased support for banning cigarette sales (Study 4).

CONCLUSIONS

Reactance and doubt about the effectiveness of banning the sale of cigarettes are key barriers to supporting a ban. Self-persuasion and issue framing may be effective means of mobilizing policy support among smokers. The present research offers new insights relevant to promoting the "Tobacco Endgame" and helps specify directions for future research on public support for health policies.

Recommendations to advance equity in tobacco control

Reducing racial and socioeconomic inequities in smoking has been declared a priority for tobacco control in the USA for several decades. Yet despite the rhetoric, these inequities persist and some have actually worsened over time. Although tobacco companies have targeted racially and ethnically diverse and lower-income tobacco users, which substantially contributes to these disparities, less attention has been given to the role of individuals and organisations within the tobacco control movement who have allowed progress in eliminating disparities to stagnate. We examine the failure of tobacco control professionals to ensure the widespread adoption of equity-focused tobacco control strategies. Review of major US tobacco control reports found that the focus on equity often stops after describing inequities in tobacco use. We suggest ways to advance equity in tobacco control in the USA. These recommendations fall across five categories: surveillance, interventions, funding, accountability and addressing root causes. Policy interventions that will have a pro-equity impact on smoking and related disease should be prioritised. Funding should be designated to tobacco control activities focused on eliminating racial and socioeconomic inequities in smoking, and tobacco control programmes should be held accountable for meeting equity-related goals.

Associations of tobacco retailer density and proximity with adult tobacco use behaviours and health outcomes: a meta-analysis

OBJECTIVE

We sought to conduct a systematic review and meta-analysis of evidence to inform policies that reduce density and proximity of tobacco retailers.

DATA SOURCES

Ten databases were searched on 16 October 2020: MEDLINE via PubMed, PsycINFO, Global Health, LILACS, Embase, ABI/Inform, CINAHL, Business Source Complete, Web of Science and Scopus, plus grey literature searches using Google and the RAND Publication Database.

STUDY SELECTION

Included studies used inferential statistics about adult participants to examine associations between tobacco retailer density/proximity and tobacco use behaviours and health outcomes. Of 7373 studies reviewed by independent coders, 37 (0.5%) met inclusion criteria.

DATA EXTRACTION

Effect sizes were converted to a relative risk reduction (RRR) metric, indicating the presumed reduction in tobacco use outcomes based on reducing tobacco retailer density and decreasing proximity.

DATA SYNTHESIS

We conducted a random effects meta-analysis and examined heterogeneity across 27 studies through subgroup analyses and meta-regression. Tobacco retailer density (RRR=2.55, 95% CI 1.91 to 3.19, k=155) and proximity (RRR=2.38, 95% CI 1.39 to 3.37, k=100) were associated with tobacco use behaviours. Pooled results including both density and proximity found an estimated 2.48% reduction in risk of tobacco use from reductions in tobacco retailer density and proximity (RRR=2.48, 95% CI 1.95 to 3.02, k=255). Results for health outcomes came from just two studies and were not significant. Considerable heterogeneity existed.

CONCLUSIONS

Across studies, lower levels of tobacco retailer density and decreased proximity are associated with lower tobacco use. Reducing tobacco supply by limiting retailer density and proximity may lead to reductions in tobacco use. Policy evaluations are needed.

A Review of Web-Based Tobacco Control Media Archives for Researchers and Practitioners

Web-based resources for tobacco use prevention and control provide valuable tools for cancer education. This study sought to (a) identify existing websites that archive prevention and cessation media content and (b) characterize the content and features of those websites. We used a comprehensive search strategy to identify web-based resources. Websites were included if (1) the content was focused on tobacco; (2) a primary purpose of the website was to house a national or international historical archive of anti- or pro-tobacco media or communication content; and (3) the website was designed for researchers or practitioners. Of the 55 websites initially identified, N = 9 met criteria. All websites contained anti-tobacco media content (100%), although 56% also contained pro-tobacco content. Most websites focused on multiple tobacco products (89%), while 11% focused solely on cigarettes. The most common media content in the archives were print ads (67%), warning labels (56%), and video ads (33%). Most archives contained a search function or content filters (67%). While most websites provided free media content with no restrictions (78%), 22% contained paid or restricted content. Other website material included research reports (89%), newsfeeds (89%), fact sheets (67%), advocacy information (56%), and tools for practitioners (44%). This study provides a systematic summary of web-based tobacco prevention and control resources that archive communication and media content. The identified websites can assist researchers and practitioners in their tobacco control efforts, although additional archives focused specifically on vaping media and communication content are needed as the vaping epidemic among youth continues to intensify.

Evidence-Based Point-of-Sale Policies to Reduce Youth Tobacco Use in North Carolina

Many states and localities in the United States are implementing evidence-based tobacco control policies at the retail level, including Tobacco 21 laws, tobacco retailer licensing, restrictions on point-of-sale promotions, and bans on flavored tobacco products. With the passage of new point-of-sale tobacco control policies, North Carolina could reduce youth tobacco use rates.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Neighborhood Inequities in Tobacco Retailer Density and the Presence of Tobacco-Selling Pharmacies and Tobacco Shops

Studies document inequitable tobacco retailer density by neighborhood sociodemographics, but these findings may not be robust to different density measures. Policies to reduce density may be less equitable depending on how the presence of store types differs by neighborhood characteristics. We built a 2018 list of probable tobacco retailers in the United States and calculated four measures of density for all census tracts (N = 71,495), including total count, and number of retailers per 1,000 people, square mile, and kilometers of roadway. We fit multivariable regression models testing associations between each density measure and tract-level sociodemographics. We fit logistic regression models testing associations between sociodemographics and the presence of a tobacco-selling pharmacy or tobacco shop. Across all measures, tracts with a greater percentage of residents living below 150% of the federal poverty level (FPL) had higher density. A higher percentage of Black residents, Hispanic or Latino residents, and vacant housing was inconsistently associated with density across measures. Neighborhoods with a greater percentage of Black residents had a lower odds of having a pharmacy (adjusted odds ratio [aOR] = 0.96, 95% confidence interval [CI; 0.95, 0.97]) and tobacco shop (aOR = 0.87, CI [0.86, 0.89]), while those with a greater percentage of residents living below 150% FPL had greater odds of having a tobacco shop (aOR = 1.18, CI [1.16, 1.20]). Researchers and policymakers should consider how various measures of retailer density may capture different aspects of the environment. Furthermore, there may be an inequitable impact of retailer-specific policies on tobacco availability.

Trends in Cigarette Marketing Expenditures, 1975-2019: An Analysis of Federal Trade Commission Cigarette Reports

INTRODUCTION

With tightened regulations on cigarette marketing and decreased smoking, the major tobacco companies quickly shifted their marketing expenditures in recent decades to maintain profits. We investigated cigarette marketing expenditures in the United States from 1975 through 2019 to examine the trends in cigarette marketing expenditures over the past 45 years.

AIMS AND METHODS

Cigarette marketing expenditure data were obtained from the Federal Trade Commission (FTC) cigarette reports, 1975-2019. Based on individual expenditure categories included in the FTC reports, we created seven aggregate categories for marketing expenditures: Retail; Print; Out of home; Free tobacco products and gifts; Sports, public entertainment, and sponsorships; Telephone and digital; and Other. Dollar amounts and percentages by category were examined to assess trends in marketing expenditures.

RESULTS

Cigarette marketing expenditures increased since 1975 and peaked in 2003 at $21.1 billion (adjusted dollars); afterward, they declined dramatically until 2010 and remained stable at around $9 billion through 2019. While all other expenditures decreased, retail expenditures increased, comprising more than 50% of expenditures in 1988 and reaching about 98% in 2019. In the retail category, tobacco companies spent the most on promotional allowances, coupons, and retail-value-added bonuses between 1988 and 2003, after which price discounts dominated retail spending.

CONCLUSIONS

Overall, cigarette marketing expenditures peaked in 2003 and retail first became the leading category in 1988. Tobacco companies adapted their marketing strategies in retail and allocated most of their retail spending on price discounts since 2003 to lower cigarette prices.

IMPLICATIONS

The major US tobacco companies directed the bulk of their vast spending on the retail environment since 1988. Moreover, they have dramatically shifted their marketing strategies within the retail category from cigarette advertising before 2003 to customer-directed price discounts since then. This shift may imply a change in focus from recruiting new smokers to retaining current smokers, in response to tax increases and government regulations. Accordingly, restrictions on price-related promotions in retail and nontax strategies should be implemented to counter tobacco companies' marketing efforts in retail.

The impact of cigarette pack anti-littering messages

OBJECTIVE

Tobacco butts are the most littered item worldwide and pose a critical environmental and public health hazard. Given the positive impact of required graphic warnings on smoking, we sought to assess the impact of a policy requiring cigarette pack anti-littering messages on smokers' littering intentions.

METHODS

We randomly assigned US adult smokers (n = 719) to receive labels on the side of their cigarette packs for three weeks: anti-littering messages or messages about chemicals in cigarette smoke.

RESULTS

Anti-littering messages elicited higher intentions to refrain from littering in the next month compared to chemical messages (p < .05). Anti-littering messages also led to increased knowledge about cigarette butts being the most common form of litter, the number of conversations about littering, and thinking about the proper disposal of cigarettes (all p < .05). Finally, smoking from packs labeled with anti-littering messages led to fewer weeks littering from car windows compared to packs labeled with chemical messages (p < .05), but did not affect completely refraining from littering cigarette butts. Mediators of the messages' impact on littering intentions were thinking about proper cigarette butt disposal and perceived message effectiveness (both p < .05).

CONCLUSIONS

Policies requiring anti-littering messages on cigarette packs would raise awareness about the problem of cigarette butt litter and bolster intentions to not litter.

Addressing lower-priced cigarette products through three-pronged comprehensive regulation on excise taxes, minimum price policies and restrictions on price promotions

The prices that smokers pay out-of-pocket for their tobacco products ultimately influence their smoking behaviour. Although cigarette excise taxes are arguably the best and most used policy to increase cigarette prices, taxes are only one component of retail cigarette prices. The persistence of lower-priced products, disproportionately purchased by lower-income smokers, in jurisdictions with high excise taxes is an Achilles heel for tobacco tax policy. When governments raise excise taxes, the tobacco industry responds. The industry reduces tax pass-through to minimise the price increases for lower-priced brands and offers price discounts to retailers and coupons to consumers. In addition, smokers who do not quit after tax increases may downshift brands, purchase in bulk or substitute lower-priced tobacco product types. This may be particularly true for price-sensitive smokers, including those with lower incomes. We propose that raising excise taxes will be more effective in reducing the persistence of lower-priced products and income-based smoking disparities when taxes are designed to raise prices frequently and substantially for all products and are combined with (a) minimum price laws and (b) bans on coupons, discounts and other promotions. In combination, these three complementary policies restrict the tobacco industry's ability to undermine the impact of higher excise taxes upon consumer prices. Very few jurisdictions have implemented comprehensive three-pronged tobacco price regulation, but doing so would likely address many of the limitations that come with a sole focus on raising excise taxes.

Barriers to and Facilitators of COVID-19 Prevention Behaviors Among North Carolina Residents

COVID-19 was the third leading cause of death in the United States in 2020. Prior to the wide dissemination of SARS-CoV-2 vaccines, individual prevention behaviors, such as wearing face masks, have been the primary non-pharmaceutical interventions to reduce infections. We surveyed 404 North Carolina residents recruited through Amazon MTurk in July 2020 to assess adherence to key prevention behaviors (6-foot distancing, mask wearing, and gathering limits) and barriers to and facilitators of adherence. Participants reported past 7-day prevention behaviors and behavioral barriers and facilitators informed by the Integrated Behavior Model and the Health Belief Model (perceived risk, perceived severity, behavioral attitudes, injunctive and descriptive norms, and personal agency). Reported adherence to each behavior in the past 7 days was generally high, with lower adherence to 6-foot distancing and mask wearing in the work context. The most commonly endorsed barriers to 6-foot distancing included physical impediments, forgetting, and unfavorable descriptive norms. For mask wearing, ability to keep a distance, discomfort/inconvenience, and forgetting were most commonly endorsed. In logistic regression models, injunctive social norms followed by perceived personal agency were the strongest independent correlates of 6-foot distancing. Behavioral attitudes and injunctive social norms were independently associated with mask wearing. For gathering size limit adherence, perceived personal agency was the strongest independent predictor followed by perceived severity of COVID-19. Messaging campaigns targeting these barriers and facilitators should be tested. Interventions improving the convenience and salience of physical distancing and mask wearing in high-density public places and places of work may also promote prevention behaviors.

Development and validation of the trust in my doctor, trust in doctors in general, and trust in the health care team scales

RATIONALE

Historic and present-day racism and inequity in the United States (U.S.) have resulted in diminished trust in health care among many populations. A key barrier to improving trust in health care is a dearth of well-validated measures appropriate for diverse populations. Indeed, systematic reviews indicate a need to develop and test updated trust measures that are multidimensional and inclusive of relevant domains (e.g., fairness).

OBJECTIVE

We developed three trust measures: the Trust in My Doctor (T-MD), Trust in Doctors in General (T-DiG), and Trust in the Health Care Team (T-HCT) scales.

METHODS

After developing an initial item pool, expert reviewers (n = 6) provided feedback on the face validity of each scale. We conducted cognitive interviews (n = 21) with a convenience sample of adults to ensure items were interpreted as intended. In 2020, we administered an online survey to a convenience sample of U.S. adults recruited through the Qualtrics Panel (n = 801) to assess scale reliability and validity.

RESULTS

Exploratory and confirmatory factor analyses indicated acceptable model fit for second order latent factor models for each scale (root mean square error of approximation: <0.07, comparative fit index: ≥0.98, and standardized root mean square residual: ≤0.03). The T-MD contained 25 items and six subscales: communication competency, fidelity, systems trust, confidentiality, fairness, and global trust. The T-DiG and T-HCT each contained 29 items and seven subscales (the same subscales in the T-MD plus an additional subscale related to stigma-based discrimination). Each scale was strongly correlated with existing trust measures and perceived racism in health care and was significantly associated with delayed health care seeking and receipt of a routine health exam.

CONCLUSIONS

The multidimensional T-MD, T-DiG, and T-HCT scales have sound psychometric properties and may be useful for researchers evaluating trust-related interventions or conducting studies where trust is an important construct or main outcome.

Cheaper tobacco product prices at US Air Force Bases compared with surrounding community areas, 2019

INTRODUCTION

In March 2017, the US Department of Defense (DoD) implemented a policy requiring all military stores to set tobacco prices equal to 'prevailing prices' in the 'local community' adjusted for state and local taxes. We compared tobacco product prices in a sample of retailers located on five Air Force Bases (AFBs) in Texas and Mississippi with those sold in nearby off-base stores.

METHODS

We constructed a list of on-base and off-base tobacco retailers. Off-base retailers included stores that were located within a 1.5-mile road network service area from main AFB gates. Between July and September 2019, a trained auditor visited 23 on-base and 50 off-base retailers to confirm tobacco product sales, and documented the price of cigarettes and Copenhagen smokeless tobacco. For each area, the median price for each product, as well as the difference in median prices by on-base versus off-base status, was calculated.

RESULTS

The median price of cigarettes and smokeless products was cheaper at on-base retailers. All products were cheaper at on-base stores in Fort Sam Houston and Lackland AFB. Similarly, all products were cheaper in on-base stores at Keesler AFB, with the exception of Marlboro Red packs ($0.22 more), and at Sheppard AFB with the exception of cheapest cigarette cartons ($6.26 more).

CONCLUSION

Despite the implementation of the new DoD policy, tobacco products are cheaper in on-base retailers compared with off-base retailers. Refining of the definitions used and improved compliance with the new DoD policy are needed.

Cigarette Promotions in U.S. Pharmacies

BACKGROUND

The sale of tobacco products within American pharmacies has generated controversy for several decades, leading two US states and 45 municipalities to adopt tobacco-free pharmacy policies. While previous research has reported cheaper cigarette prices in pharmacies, compared to other retailers, little is known about cigarette promotions in pharmacies, which are associated with increased youth smoking and unplanned cigarette purchases among adults.

METHODS

Between May and August 2015, trained data collectors conducted store audits at 2128 tobacco retailers located within 97 US counties in 40 states. Observations were made for three types of cigarette promotions: special price (e.g., $0.30 off/pack), multi-pack promotions (e.g., buy one pack, get one free), and cross-product promotions (e.g., buy a pack of cigarettes and a get free can of snus). We calculated weighted estimates of the proportion of pharmacies and other retailer types with cigarette promotions and used weighted multivariable logistic regression to compare cigarette promotions by tobacco retailer type, accounting for clustering at the county level and controlling for county-level demographic characteristics.

RESULTS

Cigarette promotions were observed in 94.0% of pharmacies, more than any other retailer type (e.g., convenience stores: 82.0%, tobacco stores: 77.0%). All retailer types had lower odds of promotions for Marlboro, Newport, Camel, menthol, or any interior cigarette promotion, compared to pharmacies.

CONCLUSIONS

Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. Whether voluntarily or legislatively, tobacco-free pharmacies would eliminate a prevalent retail source of cigarette promotions.

IMPLICATIONS

This is the first known national study to examine prevalence of cigarette promotions in US pharmacies compared to other retailer types. Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. These findings underscore the inherent contradiction of pharmacies serving both as an important component of the healthcare system, but also as purveyors and promotors of addictive and lethal tobacco products. Whether voluntarily or legislatively, tobacco-free pharmacy policies would eliminate a prevalent retail source of cigarette promotions.

Identifying neural signatures of tobacco retail outlet exposure: Preliminary validation of a "community neuroscience" paradigm

An extensive epidemiological literature indicates that increased exposure to tobacco retail outlets (TROs) places never smokers at greater risk for smoking uptake and current smokers at greater risk for increased consumption and smoking relapse. Yet research into the mechanisms underlying this effect has been limited. This preliminary study represents the first effort to examine the neurobiological consequences of exposure to personally relevant TROs among both smokers (n = 17) and nonsmokers (n = 17). Individuals carried a global positioning system (GPS) tracker for 2 weeks. Traces were used to identify TROs and control outlets that fell inside and outside their ideographically defined activity space. Participants underwent functional MRI (fMRI) scanning during which they were presented with images of these storefronts, along with similar store images from a different county and rated their familiarity with these stores. The main effect of activity space was additive with a Smoking status × Store type interaction, resulting in smokers exhibiting greater neural activation to TROs falling inside activity space within the parahippocampus, precuneus, medial prefrontal cortex, and dorsal anterior insula. A similar pattern was observed for familiarity ratings. Together, these preliminary findings suggest that the otherwise distinct neural systems involved in self-orientation/self-relevance and smoking motivation may act in concert and underlie TRO influence on smoking behavior. This study also offers a novel methodological framework for evaluating the influence of community features on neural activity that can be readily adapted to study other health behaviors.

Associations of County Tobacco Retailer Availability With U.S. Adult Smoking Behaviors, 2014-2015

INTRODUCTION

Greater availability of tobacco product retailers in an area may be associated with smoking behaviors, and the majority of people who smoke purchase their cigarettes at gas stations and convenience stores. This cross-sectional study investigates the associations of overall tobacco retailer density and gas/convenience density with adult smoking behaviors.

METHODS

This study built a list of tobacco retailers in 2014 and calculated the county-level number of retailers per 1,000 people. Individual-level smoking behavior data were drawn from the 2014-2015 Tobacco Use Supplement for a sample of adults (n=88,850) residing in metropolitan counties across the U.S. General estimating equation models were fit to investigate the associations between retailer density and cigarette smoking behaviors (smoking status, quit attempt, quit length). Analyses were conducted in 2020.

RESULTS

A greater number of tobacco retailers (AOR=1.63, 95% CI=1.35, 1.96) and gas stations and convenience stores (AOR=3.29, 95% CI=2.39, 4.52) per 1,000 people were each associated with a higher odds of a respondent smoking every day than the odds of a respondent not smoking. In addition, both measures were associated with a higher odds of a respondent being an every-day than being a some-day smoker. Associations for gas/convenience density were similar in models that additionally controlled for other tobacco retailers (excluding gas/convenience). Study results did not support associations between retailer density and cessation.

CONCLUSIONS

Tobacco retailer density, especially gas/convenience density, is correlated with daily smoking, the most harmful tobacco use behavior. Calculating tobacco retailer density using gas/convenience stores may be a feasible proxy for overall tobacco retailer density.

Sociodemographic inequities in tobacco retailer density: Do neighboring places matter?

We apply a spatial perspective to measure the extent to which the 2018 U.S. racial, ethnic, and socioeconomic composition of census tracts were each associated with tobacco retailer density within a tract and in its neighboring tracts (n = 71,409). A 10-percentage point increase in the Black population was associated with 0.07 (p < 0.05) more retailers per square mile within a focal tract and 0.35 (p < 0.001) more retailers per square mile in its neighbors on average. A greater percent of Hispanic/Latino residents was associated with more retailers per square mile, both within a focal tract (b = 0.95, p < 0.001) and in its neighbors 0.39 (p < 0.001). Inverse associations were observed for percent white. We also observed inequities by socioeconomic status. The overall magnitude of inequities may be underestimated if the spatial dependence between focal tracts and their neighbors are not taken into consideration. Policymakers should prioritize interconnected geographic areas experiencing high racialized and socioeconomic segregation when designing and implementing policies to reduce retail tobacco product availability.

Trends in the Number and Type of Tobacco Product Retailers, United States, 2000-2017

INTRODUCTION

Tobacco product retailers provide access to tobacco products and exposure to tobacco marketing. Without a national tobacco retailer licensing system in the United States (U.S.), there are no estimates of national trends in tobacco retailer numbers and store type over time.

METHODS

We developed a protocol to identify likely tobacco retailers across the U.S. between 2000-2017 using industry codes and retailer names in the annual National Establishment Time Series (NETS) database. We calculated annual counts of tobacco retailers in seven store type categories, and annual numbers of tobacco retailers that opened and closed.

RESULTS

We estimate that there were 317,492 tobacco product retailers in 2000; the number grew to 412,536 in 2009 before falling to 356,074 in 2017, for a net 12% increase overall. Gas/convenience stores and grocery stores accounted for more than two thirds of all retailers. On average, new openings accounted for 8.0% of the total retailers, while 7.3% of retailers closed or stopped selling tobacco each year, with stronger market volatility following the Great Recession. Since 2011, there was a disproportionate reduction in tobacco-selling pharmacies, and an increase in both tobacco-specialty shops and tobacco-selling discount stores.

CONCLUSIONS

During two decades when smoking declined, tobacco retailer availability increased in the U.S. The economic climate, corporate and public policies, and new tobacco products may all contribute to trends in tobacco retailer availability. State and local jurisdictions considering tobacco retailer policies may find retailer trend information useful for forecasting or evaluating potential policy impacts.

IMPLICATIONS

This study provides historic data tracking tobacco retailers in the U.S. between 2000-2017, documenting trends that unfolded as the general economic market contracted and grew, with greater regulation of the tobacco retailer environment. These data provide a context for better understanding future changes in the tobacco retailer market. In addition, the protocol established in this study could be applied in any U.S.-based location without tobacco retailer licensing to allow identification of stores and tracking of trends.

Development and Application of an Interdisciplinary Rapid Message Testing Model for COVID-19 in North Carolina

INTRODUCTION

From the onset of the COVID-19 pandemic, public health officials have sought to develop evidence-based messages to reduce COVID-19 transmission by communicating key information to media outlets and the public. We describe the development of an interdisciplinary rapid message testing model to quickly create, test, and share messages with public health officials for use in health campaigns and policy briefings.

METHODS

An interdisciplinary research team from the University of North Carolina at Chapel Hill assembled in March 2020 to assist the state health department in developing evidence-based messages to influence social distancing behaviors in the state. We developed and iteratively executed a rapid message testing model; the components of the 4-step model were message creation, survey development, survey administration, and analysis and presentation to health department officials. The model was executed 4 times, each during a 7-day period in April and May, and each subsequent survey included new phrasing and/or messaging informed by the previous week's survey. A total of 917 adults from North Carolina participated in the 4 surveys.

RESULTS

Survey participants rated messages focused on protecting oneself and others higher than messages focused on norms and fear-based approaches. Pairing behaviors with motivations increased participants' desire to social distance across all themes and subgroups. For example, adding "Protect your grandmother, your neighbor with cancer, and your best friend with asthma," to messaging received a 0.9-point higher score than the base message, "Stay 6 feet apart from others when out in public."

PRACTICE IMPLICATIONS

Our model to promote social distancing in North Carolina during the COVID-19 pandemic can be used for rapid, iterative message testing during public health emergencies.

The Relationship Between Menthol Cigarette Use, Smoking Cessation, and Relapse: Findings From Waves 1 to 4 of the Population Assessment of Tobacco and Health Study

INTRODUCTION

Some, but not all, studies suggest that menthol cigarette smokers have more difficulty quitting than non-menthol cigarette smokers. Inconsistent findings may be a result of differences in smoker characteristics (eg, daily vs. non-daily smokers) across studies. This study examines the relationship between menthol cigarette use, cessation, and relapse in a longitudinal, nationally representative study of tobacco use in the United States.

AIMS AND METHODS

Data come from four waves of the Population Assessment of Tobacco and Health Study. Waves 1-4 were conducted approximately annually from September 2013 to January 2018. Generalized estimating equation models were used to prospectively examine the relationship between menthol cigarette use, cessation, and relapse in non-daily and daily adult (18+) smokers. Cessation was defined as smokers who had not used cigarettes within the past 30 days at their subsequent assessment. Relapse was defined as cessation followed by past 30-day smoking in the next assessment.

RESULTS

Among daily smokers (n = 13 710), 4.0% and 5.3% of menthol and non-menthol smokers quit after 1 year, respectively. In an adjusted model, menthol smokers were less likely to quit compared with non-menthol smokers (odds ratio [OR] = 0.76 [0.63, 0.91]). When the sample was stratified by race/ethnicity, African American (OR = 0.47 [0.24, 0.91]) and White (OR = 0.78 [0.63, 0.97]) daily menthol users were less likely to have quit. Among non-daily smokers (n = 3608), there were no significant differences in quit rates. Among daily and non-daily former smokers, there were also no differences in relapse rates between menthol and non-menthol smokers.

CONCLUSIONS

Menthol cigarette use is associated with lower odds of cessation.

IMPLICATIONS

Findings from this study suggest that menthol cigarette use is associated with lower odds of cessation, but not relapse. Removing menthol cigarettes from the market may improve cessation rates.

Motivations, barriers, and communication recommendations for promoting face coverings during the COVID-19 pandemic: Survey findings from a diverse sample

State and local health departments have been tasked with promoting the use of face coverings to decrease the spread of COVID-19 in their respective communities. However, little is known about motivations and barriers to wearing face coverings in the context of COVID-19 prevention, particularly among communities of color who are at an increased risk of serious illness from the disease. The purpose of this study was to identify common motivations and barriers to face covering use, as well as explore perceptions of messages encouraging the use of face coverings among a racially and ethnically diverse sample. A survey was distributed electronically to North Carolina (NC) residents through NC Department of Health and Human Services listservs in July 2020. Participants self-categorized as Latino/a (33.5%), Black (39.1%), or white or another race (27.5%). The most commonly endorsed motivations for wearing face coverings were to avoid spreading COVID-19 (77%), as well as to protect people who are vulnerable (76%) and one's community (72%). Being uncomfortable (40%) was the most commonly endorsed barrier. Messages that included a clear request (ex. please wear a face covering) and a direct benefit (ex. keep community safe) were more commonly endorsed than those that did not. Commonly endorsed motivations, behaviors, and messages differed by race and ethnicity. Increased attention to message content, message structure, and access to information and resources may aid local officials in increasing consistent use of face coverings.

Associations of tobacco retailer availability with chronic obstructive pulmonary disease related hospital outcomes, United States, 2014

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12-1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21-1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs.

Motivations and Barriers for the Use of Face Coverings during the COVID-19 Pandemic: Messaging Insights from Focus Groups

Widespread use of face coverings is a key public health strategy to prevent the spread of COVID-19. However, few studies have examined why Americans use or do not use face coverings, and little is known about the most effective messaging strategies. This study explored perceptions of face coverings, including motivations and barriers for use, and examined reactions to messaging promoting the use of face coverings. Six virtual focus groups were conducted with 34 North Carolina residents in July 2020. Participants reported high compliance with face covering recommendations but often did not wear them around family, friends, and colleagues. The most prevalent motivation for the use of face coverings was to protect or respect other people, including high-risk populations and individuals. Other motivators were self-protection, responsibility, desire for control, requirements, and expert advice. Barriers included physical and social discomfort, confusion or misinformation, low perceived susceptibility to COVID-19, and perceptions of identity and autonomy. Even among individuals who frequently wear face coverings, there are opportunities to improve compliance. Messaging should highlight how face coverings protect the wearer and others around them, normalize the use of face coverings in social settings, and emphasize requirements. Positive messages that focus on unity, personal experiences and the rationale for face coverings are recommended.

Neighborhood Disparities in the Availability, Advertising, Promotion, and Youth Appeal of Little Cigars and Cigarillos, United States, 2015

INTRODUCTION

Between 2012 and 2016, sales of cigars increased by 29% in the United States. In small local studies, greater little cigar and cigarillo (LCC) availability and marketing has been documented in neighborhoods with a greater proportion of Hispanic or Latino and black residents, and near schools. This national study of cigarette retailers assesses whether LCC availability and marketing at the point of sale is associated with neighborhood racial, ethnic, income, and percent youth demographics.

METHODS

In 2015, we collected LCC availability and marketing data through retailer audits of a nationally representative sample of 2128 cigarette retailers. Using 2011-2015 American Community Survey census tract estimates, we modeled associations of neighborhood demographics (in quartiles) with availability of LCC-flavored products, and presence of exterior advertisements, youth marketing, and promotions.

RESULTS

Nearly 90% of retailers sold LCCs, 83.0% sold flavored LCCs, and 30.9% had youth marketing. Controlling for retailer type and other neighborhood characteristics, neighborhoods with the highest proportion of black residents had significantly higher odds of flavored LCC availability (adjusted odds ratio [AOR] = 2.24, 95% confidence interval [CI] = 1.52, 3.30); exterior advertisements (AOR = 2.84, 95% CI = 1.94, 4.16); price promotions (AOR = 1.62; 95% CI = 1.07-2.45), and youth appeal (AOR = 1.49, 95% CI 1.08-2.08) compared to the lowest. Disparities in flavored LCC availability, exterior advertising, and youth appeal were also present for lower income neighborhoods.

CONCLUSION

Neighborhoods with a greater proportion of black or lower income residents have greater flavored LCCs availability and LCC marketing. Without stronger LCC regulation, residents of these neighborhoods may be at a greater risk of LCC use.

IMPLICATIONS

LCCs are harmful combustible tobacco products that are less regulated than cigarettes (eg, lower taxation, cheaper outlay due to small package sizes, availability of flavors), which makes them an affordable and appealing product to youth. This study documents greater availability, advertising, and marketing of LCCs in neighborhoods with a higher proportion of black or lower-income residents, potentially putting these populations at a greater risk of using or switching to these products in the face of increasing cigarette regulations. These findings underscore the need for local, state, and federal LCC regulatory action.

Reactions to messages about smoking, vaping and COVID-19: two national experiments

Introduction

The pace and scale of the COVID-19 pandemic, coupled with ongoing efforts by health agencies to communicate harms, have created a pressing need for data to inform messaging about smoking, vaping, and COVID-19. We examined reactions to COVID-19 and traditional health harms messages discouraging smoking and vaping.

Methods

Participants were a national convenience sample of 810 US adults recruited online in May 2020. All participated in a smoking message experiment and a vaping message experiment, presented in a random order. In each experiment, participants viewed one message formatted as a Twitter post. The experiments adopted a 3 (traditional health harms of smoking or vaping: three harms, one harm, absent) × 2 (COVID-19 harms: one harm, absent) between-subjects design. Outcomes included perceived message effectiveness (primary) and constructs from the Tobacco Warnings Model (secondary: attention, negative affect, cognitive elaboration, social interactions).

Results

Smoking messages with traditional or COVID-19 harms elicited higher perceived effectiveness for discouraging smoking than control messages without these harms (all p <0.001). However, including both traditional and COVID-19 harms in smoking messages had no benefit beyond including either alone. Smoking messages affected Tobacco Warnings Model constructs and did not elicit more reactance than control messages. Smoking messages also elicited higher perceived effectiveness for discouraging vaping. Including traditional harms in messages about vaping elicited higher perceived effectiveness for discouraging vaping (p <0.05), but including COVID-19 harms did not.

Conclusions

Messages linking smoking with COVID-19 may hold promise for discouraging smoking and may have the added benefit of also discouraging vaping.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents

INTRODUCTION

The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts.

METHODS

Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints.

RESULTS

The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers.

CONCLUSION

Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking.

IMPLICATIONS

Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

Communicating Evidence about the Causes of Obesity and Support for Obesity Policies: Two Population-Based Survey Experiments

Public support for numerous obesity policies is low, which is one barrier to their implementation. One reason for this low support is the tendency to ascribe obesity to failings of willpower as opposed to the environment. Correlational evidence supports this position. However, the experimental evidence is mixed. In two experimental studies, participants were randomised to receive no message, messages about the environment's influence on obesity (Study 1 & 2), or messages about the environment's influence on human behaviour (Study 1). We investigated whether communicating these messages changed support for obesity policies and beliefs about the causes of obesity. Participants were recruited from nationally representative samples in Great Britain (Study 1 & 2) and the USA (Study 2) (total n = 4391). Study 2 was designed to replicate existing research. Neither study found evidence that communicating the messages increased support for obesity policies or strengthened beliefs about the environment's role in obesity. Study 2, therefore, did not replicate two earlier experimental studies. Instead, the studies reported here suggest that people's beliefs about the causes of obesity are resistant to change in response to evidence and are, therefore, not a promising avenue to increase support for obesity policies.

E-cigarette availability, price promotions and marketing at the point-of sale in the contiguous United States (2014-2015): National estimates and multilevel correlates

Electronic cigarette (e-cigarette) sales and use have increased rapidly, yet point-of-sale e-cigarette availability and marketing is understudied. We estimated changes in e-cigarette availability and marketing among tobacco retailers in the U.S., and associations with neighborhood characteristics. A national sample of tobacco retailers in the Contiguous U.S. was audited in 2014 and 2015 (n = 1,905 and n = 2,126, respectively) to observe e-cigarette availability and marketing (signs, ads, displays and promotions) and generate national prevalence estimates. Store, neighborhood and state level correlates of 2015 e-cigarette availability, price promotions and exterior advertising were analyzed using multilevel mixed-effects generalized linear models. E-cigarettes were sold at 72.0% of retailers in 2014 and at 79.2% in 2015. Price promotions increased from 11.9% to 20.2% of retailers. Among retailers that did not previously sell e-cigarettes in 2012, availability in 2015 was greater for retailers in neighborhoods with the highest proportion of Black residents (vs. lowest). E-cigarette price promotions were more prevalent in neighborhoods with more Hispanic residents, while exterior e-cigarette marketing was more prevalent in neighborhoods with more Black residents. State smoking prevalence was positively associated with e-cigarette availability, promotions and advertising. E-cigarette point-of-sale availability and marketing increased between 2014 and 2015 and expanded to neighborhoods with a higher proportion of Black residents between 2012 and 2015. Retailers located within states with high smoking prevalence appear to be targeted by e-cigarette marketing. As e-cigarettes become the target of more regulations, understanding changes in the e-cigarette retail environment is critical to inform potential policies regulating their sale and marketing.

E-Cigarette Health Harm Awareness and Discouragement: Implications for Health Communication

INTRODUCTION

Evidence for the health harms of e-cigarettes is growing, yet little is known about which harms may be most impactful in health messaging. Our study sought to identify which harms tobacco product users were aware of and which most discouraged them from wanting to vape.

METHODS

Participants were a convenience sample of 1,872 U.S. adult e-cigarette-only users, cigarette-only smokers, and dual users recruited in August 2018. In an online survey, participants evaluated 40 e-cigarette harms from seven categories: chemical exposures, device explosions, addiction, cardiovascular harm, respiratory harm, e-liquid toxicity, and other harms. Outcomes were awareness of the harms ("check all that apply") and the extent to which the harms discouraged vaping (5-point scale; (1) "not at all" to (5) "very much").

RESULTS

Awareness of most e-cigarette harms was modest, being highest for harms in the device explosions category of harms (44%) and lowest for the e-liquid toxicity category (16%). The harms with the highest mean discouragement from wanting to vape were the respiratory harm (M = 3.82) and exposure to chemicals (M = 3.68) categories. Harms in the addiction category were the least discouraging (M = 2.83) compared with other harms (all p < .001). Findings were similar for e-cigarette-only users, cigarette-only smokers, and dual users.

CONCLUSIONS

Addiction was the least motivating e-cigarette harm, a notable finding given that the current FDA e-cigarette health warning communicates only about nicotine addiction. The next generation of e-cigarette health warnings and communication campaigns should highlight other harms, especially respiratory harms and the chemical exposures that may lead to health consequences.

IMPLICATIONS

E-cigarette health harms related to respiratory effects, chemical exposures, and other health areas most discouraged vaping among tobacco users. In contrast, health harms about addiction least discouraged use. Several countries have begun implementing e-cigarette health warnings, including the United States, and many others are considering adopting similar policies. To increase impact, future warnings and other health communication efforts should communicate about health harms beyond addiction, such as the effects of e-cigarette use on respiratory health. Such efforts should communicate that e-cigarette use is risky and may pose less overall risk to human health than smoking, according to current evidence.

One-item susceptibility measure predicts waterpipe and little cigar/cigarillo uptake in a national sample of adolescents and young adults in the United States

INTRODUCTION

Adolescents and young adults in the United States (US) are increasingly using non-cigarette tobacco products such as waterpipe (WP) and little cigars/cigarillos (LCC). One way to predict which non-user adolescents and young adults are most likely to use these products is through measuring their susceptibility or openness to using the products.

METHODS

We conducted a national phone survey (baseline) and an internet survey (follow-up) of adolescents and young adults (ages 13–25 years), who, at baseline, had never used WP (N=1002) or LCC (N=990). At baseline, we measured susceptibility using a single item, asking participants whether they would try WP or LCC if their best friend offered it to them, and subsequently measured uptake at follow-up. We conducted multivariate regression analyses to determine whether product-specific susceptibility was a significant predictor of uptake at follow-up.

RESULTS

Participants who were susceptible and participants who had ever used another tobacco product had higher odds of using WP (AOR=3.5, AOR=4.2) and LCC (AOR=3.2, AOR=5.3) at follow-up than those who were not susceptible to those products, and had not ever used tobacco products respectively, controlling for sociodemographic factors. The one-item measure had adequate sensitivity (WP=51.4%, LCC=40.2%) and specificity (WP=84.9%, LCC=87.9%).

CONCLUSIONS

Our national study of US adolescents and young adults shows that a one-item susceptibility measure at baseline was a significant predictor of WP and LCC uptake at follow-up, even after controlling for other predictors. Future research should assess the predictive validity of the one-item compared to the multi-item scale.

Understanding Why Pictorial Cigarette Pack Warnings Increase Quit Attempts

BACKGROUND

Our randomized trial found that pictorial cigarette pack warnings elicited more quit attempts than text-only warnings.

PURPOSE

In the current study, we sought to identify psychological mechanisms that explain why pictorial cigarette pack warnings change behavior.

METHODS

In 2014 and 2015, we recruited 2,149 adult smokers in NC and CA, USA. We randomly assigned smokers to receive on their cigarette packs for 4 weeks either a text-only warning (one of the USA's current warnings on the side of cigarette packs) or a pictorial warning (one of the USA's proposed text warnings with pictures on the top half of the front and back of cigarette packs).

RESULTS

Pictorial warnings increased attention to, reactions to, and social interactions about cigarette pack warnings (all p < .05). However, pictorial warnings changed almost no belief or attitude measures. Mediators of the impact of pictorial warnings included increased attention, negative affect, social interactions, thinking about the warning and harms of smoking, and intentions to quit (all p < .05). Analyses also found that pictorial warnings led to greater avoidance of the warnings, which was associated with more quit attempts (p < .05).

CONCLUSIONS

Pictorial warnings increased quit attempts by eliciting aversive reactions and by keeping the message vividly in smokers' minds. Contrary to predictions from several theories of health behavior, the warnings exerted little of their influence through changes in beliefs and attitudes and none of their influence through changes in risk perception. We propose the Tobacco Warnings Model based on these findings.

CLINICAL TRIAL INFORMATION

ClinicalTrials.gov identifier: NCT02247908; https://clinicaltrials.gov/ct2/show/NCT02247908.

Interest in Illicit Purchase of Cigarettes Under a Very Low Nicotine Content Product Standard

Significance

The US Food and Drug Administration (FDA) is considering a very low nicotine content (VLNC) product standard to substantially reduce nicotine in cigarettes. We examined whether learning about a potential VLNC standard increased smokers’ interest in illicit purchases of cigarettes with regular nicotine content if such a standard were adopted.

Methods

Participants were a national convenience sample of 1712 US adult smokers. In an online experiment, we randomly assigned smokers to view information about a new VLNC standard (experimental condition) or no information (control condition). The experimental condition explained that a VLNC standard would remove 95% of the nicotine in cigarettes and would require stores to only sell VLNC cigarettes. Then, the survey assessed smokers’ interest in purchasing regular cigarettes from three illicit sources.

Results

Smokers who learned about the VLNC standard were more likely to be very or extremely interested in purchasing regular cigarettes illicitly from a Web site compared to smokers in the control group (24% vs. 16%, p < .001). They were also more interested in illicitly buying cigarettes from a street vendor (19% vs. 13%, p < .001) and a store on an Indian reservation (28% vs. 22%, p < .05), compared to the control. The impact of learning about the VLNC standard on interest in illicit purchases did not differ by smoking frequency or current e-cigarette use.

Conclusions

A VLNC standard could increase smokers’ interest in illicit purchases of regular nicotine cigarettes. To prevent VLNC-induced illicit trade from undermining public health, FDA should consider proven measures such as track and trace for these products.

Implications

Little is known about how a VLNC cigarette standard would affect consumer interest in regular content cigarettes purchased from illicit sources (eg, the Internet). We found that smokers informed about a potential VLNC product standard had greater interest in illicit cigarette purchases, compared to controls. This suggests the importance of proactive measures accompanying a VLNC standard, such as track-and-trace cigarette packaging regulations and communication campaigns, in order to maximize the standard’s public health impact.

Neighborhood racial, ethnic, and income disparities in accessibility to multiple tobacco retailers: Mecklenburg County, North Carolina, 2015

•Existing studies assess an individual's proximity to a single tobacco retailer.•Measuring proximity to more than one retailer may better capture accessibility.•Disparities in multi-retailer proximity exist by neighborhood race and income.•Policies to address disparities in tobacco retailer exposure are needed.

Are state-level income-based disparities in adult smoking declining?

The United States (US) has identified income-based disparities in smoking as a critical public health issue, but the extent to which these disparities are changing over time within states is not well documented. This study examined recent trends in current cigarette smoking in each state and the District of Columbia by self-reported annual household income. Data came from the Behavioral Risk Factor Surveillance System, a state-representative survey of US adults. Sample sizes for each state and year ranged from 2914 to 36,955 participants. We fit logistic regression models to examine linear time trends in cigarette smoking status in each state between 2011 and 2017. In every state, the odds of smoking were 1.4 to 3.0 times greater in the lower-income group as compared to the higher-income group in 2017. Among 47 states, linear time trends in smoking did not significantly differ by income group, suggesting no change in income-based disparities. In three states (Florida, Maine, West Virginia) disparities widened, primarily because smoking prevalence only dropped among higher-income groups. Disparities declined in only one state. In New York, smoking prevalence declined more for lower-income groups compared to higher-income groups. Findings from this study suggest that little progress has been made toward reducing income-based differences in smoking and additional policy and tobacco control efforts may be required to meet national disparity reduction goals.

Strategies to Reduce Illicit Trade of Regular Nicotine Tobacco Products After Introduction of a Low-Nicotine Tobacco Product Standard

The US Food and Drug Administration is considering mandating a substantial reduction in the nicotine level of cigarettes and possibly other combusted tobacco products to render them minimially addictive. This would likely result in several public health benefits, including increased cessation, decreased progression to dependence, and reduced consumption of combusted tobacco products. However, findings from clinical trials of reduced-nicotine cigarettes suggest that many smokers consuming low nicotine-content cigarettes sought out regular nicotine-content cigarettes, even when they were asked to only smoke free low-nicotine cigarettes. If this policy were implemented without ensuring that cessation treatments and appealing alternative products (e.g., e-cigarettes) were readily available, some consumers would be likely to seek banned regular nicotine-content combusted tobacco products from illicit sources: retail, online, and individuals. Left unchecked, this illicit market could undermine the public health benefits of the policy. We describe supply and demand factors in an illicit market. Informed by the literature on controlling Internet tobacco sales and reducing illicit trade in low-cost cigarettes when there are price differentials, we recommend tracking and tracing products and greater surveillance and enforcement efforts to minimize illicit trade in normal nicotine products under a low-nicotine tobacco product standard.