A digital, coach-assisted intervention to address the psychosocial needs of young adult cancer survivors: Randomized controlled trial protocol and intervention adaptation process

BACKGROUND

Given the increasing number of young adult cancer survivors and the impacts of cancer on various life domains, interventions addressing the psychosocial needs of young adult survivors are crucial. However, such intervention research is limited, and the existing literature has often: 1) overlooked young adult survivors' psychosocial needs; 2) targeted depression, anxiety, or fear of recurrence - rather than positive outcomes like well-being; and 3) failed to consider scalable approaches, like digital health.

METHODS

This paper documents the development and refinement of an 8-week digital, coach-assisted intervention targeting hope among young adult cancer survivors (ages 18-39, within 3 years of treatment completion) and presents the protocol of the 2-arm RCT (comparing intervention vs. attention control). The intervention builds upon a 2017-2018 pilot trial (n = 56); intervention refinements were based on subsequent semi-structured interviews among young adult survivors (n = 23).

RESULTS

The pending trial design involves an increased sample size (n = 150) to increase power and diversified recruitment efforts (i.e., clinic-based, social media, community-based organizations, etc.) to facilitate intervention reach, accessibility, and scalability. The intervention was enhanced by integrating highly relevant theoretical and therapeutic frameworks, specifically the concept of hope and Acceptance and Commitment Therapy, as well as updating intervention delivery technology. Intervention outcomes include feasibility and acceptability at end-of-treatment and preliminary efficacy on hope (primary outcome) and quality of life measures (secondary outcomes) at end-of-treatment and 16-week follow-up.

CONCLUSIONS

This paper may facilitate discussion regarding approaches for addressing the significant psychosocial challenges faced by young adult survivors and catalyze dissemination of trial results.

TRIAL REGISTRATION

NCT05905250.

Changes in online marketing and sales practices among non-medical cannabis retailers in 5 US cities, 2022 to 2023

Objectives

Given the evolving cannabis marketplace (e.g., products, marketing strategies), this study examined online cannabis marketing practices over time.

Methods

In 2022 and 2023, researchers assessed website content (e.g., age verification, sales, delivery, warnings, ad content, promotional strategies) among 175 randomly-selected cannabis retailers' websites across 5 US cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles [LA], California, n=∼35/city). Analyses compared data from 2022 vs. 2023 and considered regulatory factors across cities.

Results

Similar to 2022, in 2023, 76.6 % required age verification for site entry, 85.1 % used social media promotion, and 90.9 % offered online sales (82.4 % of which required age verification and 34.6 % offered delivery). There were significant (p < .05) decreases from 2022 to 2023 in the proportions indicating medical card requirements (27.4 % to 15.4 %), purchase limits (59.4 % to 47.4 %), health warnings (38.9 % to 29.7 %), health benefits (60 % to 47.4 %), and discounts/price promotions (92.6 % to 86.3 %). In 2023, proportions differed across cities in ways reflecting whether state/local law allowed online sales (>90 % in Denver, Las Vegas, LA), allowed discounts/price promotions (100 % in Denver and Las Vegas), or required health warnings (48-60 % in Seattle and LA vs. < 20 % elsewhere). Despite all sites prohibiting youth-oriented content and all but Denver and Las Vegas prohibiting health claims, 30.3 % posted content targeting youth/young adults (LA = 8.1 % to Denver = 74.2 %) and 47.4 % health claims (Seattle = 27.0 % to Denver = 71.0 %).

Conclusions

Online cannabis retail presents risks for access and appeal to minors, emphasizes health benefits, and uses price promotions, regardless of restrictions, indicating need for greater regulatory efforts.

Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults

The marketing of heated tobacco products (HTPs), like IQOS, influences consumers' perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. 'Go smoke-free…') across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.

Impact of exposures to Heated Tobacco Products in the media and through social connections on product perceptions and use

INTRODUCTION

Little is known about media exposures to heated tobacco products (HTPs). In this study, we examined sources of HTP exposure, including from paid and unpaid media and social connections, in relation to HTP use and use intentions.

METHODS

In the fall of 2021, we conducted a cross-sectional survey among adult online panelists (aged 18-45 years) in the US and Israel, oversampling tobacco users. The current study analyzed data from participants who responded to the question about HTP awareness or use (n=2061). Multivariable linear and logistic regression analyses examined the relationship between sources of HTP exposure, HTP use, and use intentions.

RESULTS

Among those aware of HTPs, both Israelis and Americans reported past-month HTP media exposure via advertisements (58.2% vs 48.0%), non-advertisement sources (49.7% vs 30.7%), and social connections (51.5% vs 33.6%), respectively. Factors associated with HTP awareness (n=677/2061; 32.9%) included media use frequency (AOR=1.13; 95% CI: 1.01-1.28) and social connections using HTPs (AOR=2.45; 95% CI: 1.92-3.15). Among those aware of HTPs, past-month HTP exposure via digital media advertisements (AOR=2.06; 95% CI: 1.09-3.91) and non-advertising promotion via radio, podcast, movie, television or theatre (AOR=2.30; 95% CI: 1.19-4.44) and websites (AOR=2.36; 95% CI: 1.32-4.21) were associated with current HTP use. Exposure to digital media advertisements (β=0.35; 95% CI: 0.07-0.62) and non-advertising promotion via social media (β=0.62; 95% CI: 0.34-0.91) were correlated with higher use intentions. Having social connections using HTPs was correlated with higher use (AOR=2.21; 95% CI: 1.19-4.11) and intentions (β=0.66; 95% CI: 0.42-0.91). No significant differences were found across countries.

CONCLUSIONS

Digital media (e.g. online, social media) were particularly salient correlates of HTP intentions and use. Future studies are needed that further examine media exposures to these products, as well as that examine possible regulations to limit HTP promotion via these channels.

Young Adult Cancer Survivors' Perspectives on Cancer's Impact on Different Life Areas Post-Treatment: A Qualitative Study

Purpose: Young adult cancer survivors experience disruptions in various life domains (e.g., relationships, academic/career) during and after treatment. This study examined life disruptions and related supports to update interventions to improve psychological outcomes. Methods: In April-July 2023, young adult survivors (n = 23) were recruited (via clinics, support groups, nonprofit organizations, etc.) to complete semi-structured interviews assessing cancer's impact across life domains, how they coped with related disruptions, and facilitators to improved psychosocial well-being. We used a dual deductive-inductive approach to develop a codebook and then coded transcripts in Dedoose. Results: This sample was on average 33.7 years old (standard deviation [SD] = 4.4), 78.3% female, 73.9% non-Hispanic White, 47.8% married/cohabitating, 2.4 (SD = 1.0) years post-diagnosis, 1.4 years (SD = 0.9) post-treatment, and largely diagnosed with breast cancer (52.1%) or leukemia/lymphoma (34.7%). The most salient themes related to disruptions included mental health, feelings of isolation during survivorship, and disruptions to career and relationships with family or partners. Participants reported challenges navigating these feelings and disruptions, and difficulty understanding and conveying their needs. Many experienced limited support for navigating cancer-related trauma and life disruptions as a survivor. Participants also reported some positive impacts, like reevaluating their values and goals or feeling resilient, and emphasized the need to identify supports, accept that life had changed because of cancer, and have their needs and continued struggles validated by others during survivorship. Conclusions: Young adults experience ongoing disruptions across multiple life domains, underscoring the need for integrated, longer-term psychosocial supports to help them navigate these disruptions and reevaluate their goals.

Racial/ethnic disparities in exposure to e-cigarette advertising among U.S. youth

OBJECTIVES

This study aims to assess exposure to e-cigarette advertising across multiple marketing channels among U.S. youth and to examine whether racial/ethnic disparities exist in exposure to e-cigarette advertisements.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Cross-sectional data were drawn from a longitudinal survey of participants recruited from two nationally representative panels (NORC's AmeriSpeak® and GfK's KnowledgePanel). A total of 2043 youth aged 13-17 completed the initial 2018 survey, and 2013 youth completed the follow-up survey in 2019 (including a replenishment sample of 690 youth). Outcome variables were self-reported e-cigarette advertisement exposure in the past three months through various sources, such as television, point of sale, and online/social media. Generalized estimating equation models were used to estimate the adjusted odds ratios (AOR) of the association between racial/ethnic identity and e-cigarette advertisement exposure.

RESULTS

The prevalence of reported exposure to e-cigarette advertisements through any channel was 79.8% (95% CI: 77.1-82.2) in 2018 and 74.9% (95% CI: 72.5-77.1) in 2019, respectively. Point of sale was the most common source of e-cigarette advertisement exposure in both years. Non-Hispanic Black and non-Hispanic Asian youth were more likely to report exposure to e-cigarette advertisements through television (AOR = 2.07, 95% CI: 1.44-2.99 and AOR = 2.11, 95% CI: 1.17-3.82, respectively) and online/social media (AOR = 1.61; 95% CI: 1.11-2.33 and AOR = 1.99, 95% CI: 1.10-3.59, respectively) channels compared with non-Hispanic White youth.

CONCLUSIONS

A substantial proportion of U.S. youth reported exposure to e-cigarette advertising through a variety of marketing channels. Significant racial/ethnic disparities existed, with non-Hispanic Black and Asian youth reporting more marketing exposure than their non-Hispanic White counterparts.

Two-part models identifying predictors of cigarette, e-cigarette, and cannabis use and change in use over time among young adults in the US

BACKGROUND AND OBJECTIVES

Limited longitudinal research has examined differential interpersonal and intrapersonal correlates of young adult use and use frequency of cigarettes, e-cigarettes, and cannabis. This study aimed to address these limitations.

METHODS

We analyzed five waves of longitudinal data (2018-2020) among 3006 US young adults (Mage = 24.55, 44% male, 32% sexual minority, ~30% racial/ethnic minority). Two-part latent growth models examined likelihood of past-month cigarette, e-cigarette, and cannabis use (binary part) and days used (continuous part) and identified predictors (depressive symptoms, personality traits, adverse childhood experiences [ACEs], parental use) of baseline use and changes over time.

RESULTS

Regarding baseline past-month use (27% cigarettes, 38% e-cigarettes, 39% cannabis), depressive symptoms, ACEs, and parental substance use predicted use outcomes (i.e., likelihood, frequency) for each product; extraversion predicted cigarette and e-cigarette use outcomes; openness predicted e-cigarette and cannabis use outcomes; conscientiousness negatively predicted cigarette and cannabis use outcomes; and agreeableness negatively predicted cannabis use frequency. Regarding longitudinal changes, conscientiousness predicted accelerated increase of cigarette use frequency at later timepoints; depressive symptoms predicted increases in likelihood of e-cigarette use but the association weakened over time; and parental cannabis use predicted decreased cannabis use frequency but the association weakened over time.

DISCUSSION AND CONCLUSIONS

Young adult substance use interventions should target high-risk subgroups and focus on distinct factors impacting use, including chronic, escalating, and decreasing use.

SCIENTIFIC SIGNIFICANCE

This study advances the literature regarding distinct predictors of different substance use outcomes and provides unique data to inform interventions targeting young adult cigarette, e-cigarette, and cannabis use.

Reactions to vaping cessation messaging and strategies among US young adults who use e-cigarettes

INTRODUCTION

Despite high rates of young adult e-cigarette use, research informing cessation interventions for this population, including those unready to quit, is limited.

METHODS

We analyzed 2022 cross-sectional survey data (from a larger longitudinal study) among 172 US young adult, past-month e-cigarette users (mean age=26.95 years; 57.6% female; 73.3% White). We examined: 1) perceived challenges to quitting e-cigarettes; 2) perceived impact of intervention messages targeting motivation and confidence, and their associations with quitting importance and confidence; and 3) poly-use with cigarettes and/or cannabis in relation to poly-product cessation preferences.

RESULTS

In all, 43.6% reported past-year e-cigarette quit attempts, and 55.3% reported quit readiness; 30.2% reported past-month poly-use with cigarettes, and 54.1% with cannabis. Frequently endorsed challenges to quitting/cutting down were related to stress/anxiety (41.9%), delaying cessation attempts (35.5%), and boredom (25.6%). Messages targeting motivation perceived as most impactful (scale: 1 = 'no impact at all' to 7 = 'a lot of impact') were related to saving money (mean score=4.78), improving health (mean score=4.15), and avoiding toxic chemicals (mean score=4.04), messages targeting confidence perceived as most impactful were related to patience (mean score=4.47), staying busy (mean score=4.27), and soliciting support (mean score=3.84). Perceiving greater impact of messages targeting motivation was associated with greater quitting importance (B=1.16; 95% CI: 0.71-1.60, p<0.001). Neither perceived impact of messages targeting motivation nor confidence were related to quitting confidence. E-cigarette-cannabis poly-users preferred to quit cigarettes first, e-cigarette-cigarette users preferred to quit cannabis first, and poly-users of all three products preferred to quit e-cigarettes first, followed by cigarettes, then cannabis.

CONCLUSIONS

E-cigarette cessation interventions must use relevant messages (e.g. target financial and health benefits of quitting) and consider poly-users' preferences for quitting.

Driving Under the Influence of Alcohol, Cannabis, and Delta-8 THC: Perceived Likelihood, Risk Perceptions, and Behaviors

Driving under the influence (DUI) of alcohol or cannabis poses public health risks. Little is known about DUI of Delta-8 THC, a newer cannabis product. Using 2022 survey data among 189 U.S. adults ages 18-25 (58.73% male, 59.26% non-Hispanic White), multivariable logistic regression examined substance-specific (alcohol, cannabis, Delta-8) DUI perceived likelihood and risk in relation to past-year DUI among those with past-year use of each. Overall, 72.49% reported past-year alcohol use, 50.53% cannabis, and 22.46% Delta-8. Among those reporting past-year use of each respective substance, 33.58% reported DUI of alcohol, 32.63% cannabis, and 57.14% Delta-8. On average, participants had the same DUI perceived likelihood ("somewhat unlikely") across substances and perceived alcohol DUI as riskiest. Higher alcohol DUI perceived likelihood and lower perceived risk were associated with alcohol-related DUI. Greater cannabis-related perceived likelihood (but not risk) was associated with cannabis-related DUI. Neither Delta-8 DUI perceived likelihood nor risk were associated with Delta-8 DUI. In sum, perceived DUI likelihood for alcohol, cannabis, or Delta-8 tended to be similar. Among those with past-year use of each, the proportion of DUI was highest for Delta-8. Interventions should target DUI-related perceived likelihood and promote protective behavioral strategies that reduce substance-specific DUI risk.

Patterns of Adverse Childhood Experiences and Problematic Health Outcomes Among US Young Adults: A Latent Class Analysis

INTRODUCTION

Adverse childhood experiences (ACEs) predict problematic health outcomes (eg, substance use, mental health) among young adults; whether specific ACEs are differentially associated with specific substance use and mental health symptoms is understudied.

METHODS

Latent class analysis (LCA) identified classes of ACEs among 2209 US young adults (Mage = 24.69, range: 18-34; 57.4% female; 30.9% sexual minority; 35.8% racial/ethnic minority) in a 2-year study (2018-2020). Multivariable logistic regressions examined ACEs (reported in 2019) in relation to 2020 reports of current (past 30-day) substance use (ie, tobacco use; cannabis use and hazardous use; alcohol use and binge drinking) and mental health (ie, ≥moderate depression and anxiety symptoms), controlling for sociodemographics (ie, age, gender, race, ethnicity, sexual orientation, education).

RESULTS

Overall, 65.4% reported ≥1 ACE (M = 2.09, SD = 2.30); 34.8%, 39.1%, and 71.1% current tobacco, cannabis, and alcohol use; 39.1% and 15.3% hazardous cannabis use and binge drinking; and 24.2% and 34.5% ≥moderate depression and anxiety symptoms, respectively. LCA yielded 4 classes: Low ACEs (referent; 55.6%), Poor family health and divorce (16.3%), Parental abuse (16.0%), and High ACEs (12.1%). High ACEs (vs Low ACEs) was associated with each adverse substance use and mental health outcome except alcohol use. Poor family health and divorce was associated with tobacco use, cannabis use, and both mental health outcomes. Parental abuse was associated with tobacco use, cannabis use, hazardous cannabis use, and both mental health outcomes.

CONCLUSIONS

Health promotion interventions for young adults must assess ACEs, given that certain types of ACEs may be associated with distinct substance use and mental health outcomes.

Trajectories of ENDS and cigarette use among dual users: analysis of waves 1 to 5 of the PATH Study

INTRODUCTION

Concurrent electronic nicotine delivery system (ENDS) and cigarette (dual) use is harmful. Identifying longitudinal trajectories of ENDS and cigarette use among dual users can help to determine the public health impact of ENDS and inform tobacco control policies and interventions.

OBJECTIVES

(1) To identify independent and joint trajectories of ENDS and cigarette use among wave (W) 1 adult dual users across W1 to W5 of the Population Assessment of Tobacco and Health (PATH) Study; and (2) identify W1 predictors of ENDS and cigarette joint trajectory group membership.

METHODS

We used group-based trajectory modelling to estimate independent and joint trajectories of ENDS and cigarette use from wave 1 (W1; 2013-2014) to wave 5 (W5; 2018-2019) among W1 adult established dual users of ENDS and cigarettes (n=545) from the PATH Study. We used multinomial logistic regression to identify W1 predictors of joint trajectories.

RESULTS

Two ENDS (early quitters=66.0%, stable users=34.0%) and three cigarette (stable users=55.2%, gradual quitters=27.3%, early quitters=17.5%) trajectories of W1 were identified. In joint trajectory analysis, 41.6% of participants were early ENDS quitters and stable cigarette users; 14.8% early ENDS quitters and gradual cigarette quitters; 14.6% stable ENDS users and stable cigarette users; 11.2% stable ENDS users and gradual cigarette quitters; 10.3% early ENDS quitters and early cigarette quitters; and 7.4% stable ENDS users and early cigarette quitters. Cigarette and ENDS use frequency, nicotine dependence, cannabis use and other non-combusted tobacco product use predicted trajectory group membership (p values <0.05).

CONCLUSIONS

Most dual users maintained long-term cigarette smoking or dual use, highlighting the need to address cessation of both products. Continued monitoring of trajectories and their predictors is needed, given ongoing changes to the ENDS marketplace.

IQOS and cigarette advertising across regulatory periods and population groups in Israel: a longitudinal analysis

BACKGROUND

Tobacco regulation recently changed in Israel, including a partial advertisement ban. We assessed the impact of regulatory changes on Philip Morris International's (PMI) IQOS and cigarette advertisements.

METHODS

Weekly number of ads and weekly adspend of PMI's IQOS and cigarettes were analysed descriptively and using Quasi-Poisson regressions over time, across regulatory periods and in relation to subpopulations (general public, Arab, Russian and Ultra-Orthodox), from 25 December 2016 to 4 August 2020. Exponentiated coefficients (a value >1 indicates an increase) and 95% CIs are reported.

RESULTS

The average weekly number of ads and the average weekly adspend of IQOS were higher than cigarettes (42.22 vs 26.76 ads/week and 59 409 vs 45 613 new Israeli shekels/week; p<0.001 for both) during the study period, with exclusive IQOS advertisements during market penetration (December 2016 to May 2017). Variation in both outcomes was observed with regard to regulatory decisions. After the advertisement ban, there was a significant decrease in the weekly number of ads (IQOS: ß=0.04, 95% CI 0.002 to 0.20; cigarettes: ß=0.05, 95% CI 0.01 to 0.15) and weekly adspend (IQOS: ß=0.15, 95% CI 0.07 to 0.29; cigarettes: ß=0.31, 95% CI 0.17 to 0.53) for both products. The Ultra-Orthodox had significantly higher average weekly ads compared with the Arab population (IQOS: 0.67 vs 0.07; cigarettes: 2.74 vs 0.13; p=0.02 for both) but lower adspend.

CONCLUSIONS

IQOS and cigarette advertisements varied over time and appeared to have been impacted by regulatory changes. PMI invested more in IQOS advertisements than in cigarettes, with a partial advertisement ban decreasing both products' advertisements. PMI might be targeting the Ultra-Orthodox Jewish population which has a low smoking rate. Further research and surveillance are needed to better understand targeting strategies in order to inform tobacco control policy.

PMI's IQOS and cigarette ads in Israeli media: a content analysis across regulatory periods and target population subgroups

BACKGROUND

IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes.

METHODS

Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test.

RESULTS

The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging.

CONCLUSIONS

IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.

Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults

BACKGROUND

IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for 'reduced exposure' marketing claims, which has been exploited globally.

METHODS

In November-December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates.

RESULTS

Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message ('IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers') was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers.

CONCLUSIONS

Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.

Disparities in Transitions From E-cigarette Use to Other Tobacco Use Patterns Among Sexual Minority Versus Heterosexual Women and Men in the United States

INTRODUCTION

Despite elevated rates of e-cigarette use among sexual minority versus heterosexual young adults, limited research has examined sexual identity in relation to transitions from e-cigarette use to other tobacco use patterns.

METHODS

We analyzed data from 608 US young adults in a 2-year study (2018-2020) who reported using e-cigarettes in the past 6 months (time period between assessments) but no other tobacco product at baseline (Fall 2018). Multinomial logistic regressions among women and men, separately, examined associations between sexual identity and past 6-month tobacco use in Fall 2020 (nonuse [referent group] vs e-cigarette only, other tobacco product only, e-cigarette and other tobacco product dual use), controlling for age and race/ethnicity.

RESULTS

Among women (n = 340; mean [M]age = 23.42; n = 147 [43.4%] sexual minority; 29.4% racial/ethnic minority), 34.4% reported nonuse at follow-up, 26.8% e-cigarette only, 10.3% other tobacco product only, and 28.5% e-cigarette and other tobacco product dual use. Sexual minority (vs heterosexual) women displayed greater odds of e-cigarette-only use, as well as dual use relative to nonuse at follow-up. Among men (n = 244; Mage = 24.30; n = 51 [20.9%] sexual minority; 36.1% racial/ethnic minority), 25.4% reported no use, 20.9% e-cigarette only, 17.2% other tobacco product only, and 36.5% dual use at follow-up. Sexual minority (vs heterosexual) men displayed lower odds of e-cigarette only, other tobacco product only, and dual use relative to nonuse at follow-up.

CONCLUSIONS

Research is needed to assess and intervene on tobacco/nicotine product perceptions (eg, harm, social acceptability) and reasons for use (eg, mood regulation) associated with high-risk tobacco use patterns and trajectories, particularly among sexual minority young adult women who may have distinct profiles and risks associated with use.

Derived psychoactive cannabis products and 4/20 specials: An assessment of popular brands and retail price discounts in Fort Worth, Texas, 2023

BACKGROUND

Retail sales of derived psychoactive cannabis products (DPCPs) have increased in the U.S. since passing the 2018 Farm Bill and is unregulated in most states. This study investigated the types and commonly sold brands of DPCPs as well as promotional pricing on April 20th, a day associated with cannabis use.

METHODS

On April 19-20, 2023, investigators conducted telephone surveys with 98 retail stores that sold DPCPs in Fort Worth, Texas (where the market was largely unregulated).

RESULTS

Delta-8, Delta-9, and Delta-10 THC products were widely available, with 97%, 72%, and 82% of stores selling each type, respectively. Fifteen additional DPCPs were identified, and selling blends containing multiple types of THC was common. Frequently sold brands included Cake, Medusa/Modus, Torch, Urb, Kik, Tyson, 3Chi, Casper, Hidden Hills, Esco Bars, Happi, Hometown Hero, STNR, Bomb Bars, Baked, Hi On Nature, Looper, and Space God. Overall, 45% reported having 4/20 specials discounting prices on DPCPs, smoking devices/accessories, or everything in the store. Several stores also sponsored 4/20 promotional events including free THC gummies and "live delta demos where people can test cartridges and try smoking flower in the store."

CONCLUSIONS

Findings highlight the growing complexity of the DPCP market, including numerous different intoxicating compounds and blends. Policymakers, researchers, and public health professionals should consider these complexities, as well as the commonly sold brands, when developing strategies to regulate DPCPs and protect consumer safety. Pricing policies may be an especially important form of harm reduction during events associated with heavy cannabis use, including 4/20.

IQOS point-of-sale marketing: a comparison between Arab and Jewish neighborhoods in Israel

Background

Philip Morris International's (PMI) IQOS, with its heatsticks (HEETS), is the heated tobacco product with the largest global market share. IQOS and/or electronic cigarettes use rate is higher among Arabs vs. Jews in Israel. This paper aims to compare IQOS point-of-sale (POS) marketing strategies, and regulatory compliance in Arab vs. Jewish neighborhoods in Israel.

Methods

We integrated data from two separate studies including a cross-sectional survey with IQOS retailers (December 2020-April 2021) and audits of POS that sold IQOS/HEETS (April 2021-July 2021) in 5 large cities in Israel, after marketing restrictions including a POS display ban and plain packaging became effective in Israel (January 2020). The survey included 69 POS (21 Arab, 48 Jewish neighborhoods) and the audits included 129 POS (48 Arab, 81 Jewish neighborhoods). Comparisons of IQOS marketing strategies between POS in Arab and Jewish neighborhoods were conducted using Chi-Square test, Fisher's exact test or Mann-Whitney test, as appropriate. Thematic analysis was used to analyze open-ended questions.

Results

Most marketing strategies, such as promotions to customers, were uniform across POS in Arab and Jewish neighborhoods. The most noteworthy differences were that a higher proportion of retailers from Arab neighborhoods were invited to IQOS parties (47.6% vs. 21.7%, p<0.05) and reported personal communication with a PMI representative (80.0% vs. 51.2%, p<0.05). Additionally, PMI representatives assisted POS in both Arab and Jewish neighborhoods in implementing the display ban by providing free compliant cabinets and product placement instructions, and directly interacted with customers. POS in Arab neighborhoods were more compliant with the display ban (25.5% vs. 8.8%, p<0.05), but less compliant with plain packaging (62.5% vs. 79.3%, p<0.05).

Conclusions

There were not many notable differences in IQOS marketing across POS in Arab vs. Jewish neighborhoods, but PMI utilized marketing elements of cultural significance, especially for POS in Arab neighborhoods, such as more personal communication and invitation to social events. Continuous surveillance of tobacco POS marketing and legislation compliance is needed, with a special focus on demographic/location-based differences.

Nicotine pouch marketing strategies in the USA: an analysis of Zyn, On! and Velo

INTRODUCTION

Nicotine pouches are gaining popularity, yet their marketing is understudied.

METHODS

Using Numerator advertising data from January 2019 to September 2021 regarding three popular brands of nicotine pouch in the USA-Zyn (by Swedish Match, introduced in the USA in July 2016), On! (Altria, August 2016) and Velo (RJ Reynolds, July 2019)-we examined (1) general advertising characteristics (eg, media type, year); (2) ad content (ie, headlines and imagery themes); (3) prominent media channels (ie, specific websites, magazines, etc); and (4) ad expenditures.

RESULTS

There were 286 unique ads (Zyn: 44.4%; On!: 2.8%; Velo: 52.8%), 119 143 occurrences (Zyn: 3.5%; On!: 0.5%; Velo: 96.0%) and $24 774 650 total expenditures (Zyn: 4.7%; On!: 0.6%; Velo: 94.7%). The greatest proportion of ad occurrences and expenditures were accounted for by radio (75.9% and 28.2%, respectively) and television (16.2% and 56.5%), followed by mobile (0.5% and 7.2%) and online display (6.7% and 3.6%). Across ad occurrences and expenditures, prominent headline themes included 'freedom' (26.0% and 17.1%, respectively), 'brand' (9.6% and 18.6%) and 'flavour' (16.4% and 7.6%); images mainly featured the product alone (61.4% and 56.1%), text (16.2% and 24.6%) or men (8.7% and 8.6%); and prominent channel themes were entertainment (34.7% and 37.3%), news/weather (14.3% and 21.7%), business/finance (12.9% and 9.0%) and sports (9.5% and 1.0%). Zyn and On! prioritised online display and print; Velo prioritised radio and television. Zyn's and Velo's headlines focused on 'freedom', with Zyn also emphasising 'brand' and Velo 'innovation'; On!'s headlines emphasised 'flavour'.

CONCLUSIONS

Regulatory efforts must be informed by surveillance of nicotine pouch marketing and impacts on consumer subgroups (eg, young people).

Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial

INTRODUCTION

Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries.

METHODS

We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling.

RESULTS

Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure.

CONCLUSIONS

Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions.

TRIAL REGISTRATION NUMBER

NCT03447912.

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.

Patterns of Tobacco and Cannabis Use Among Sexual Minority Females and Males From PATH Wave 5: The Role of Sociodemographic and Psychosocial Correlates

INTRODUCTION

Although sexual minority (SM; vs heterosexual) individuals display higher rates of tobacco and cannabis use, limited research has examined sociodemographic and psychosocial correlates of single and co-use among this population.

METHODS

Participants were SM-identifying female (N = 2419; Mage = 27.80; 50.0% racial/ethnic minority) and male (N = 1142; Mage = 30.34; 46.1% racial/ethnic minority) adults from Wave 5 of the Population Assessment of Tobacco and Health study. Multinomial logistic regressions examined sociodemographic (ie, sexual identity, age, race/ethnicity, education, income) and psychosocial (ie, alcohol use, mental health, substance use) correlates of single and co-use (ie, no use [referent], tobacco-only, cannabis-only, co-use), controlling for state cannabis legalization, among SM females and males, separately.

RESULTS

The proportions of SM females reporting no use, tobacco-only, cannabis-only, and co-use were 37.9%, 24.0%, 10.5%, and 27.6%, respectively. Among males, 40.6%, 27.8%, 10.1%, and 21.5% reported no use, tobacco-only, cannabis-only, and co-use, respectively. Among females and males, substance use problems were associated with all 3 use groups (vs no use); past-month alcohol use was associated with cannabis-only and co-use; and mental health symptoms were associated with co-use (and cannabis-only in males). Sociodemographic correlates among females were: tobacco-only-identifying as bisexual (vs lesbian), White (vs Black), older, lower education, and lower income; cannabis-only-bisexual, other race (vs White); and co-use-White (vs Hispanic), lower education, and lower income. Among males, sociodemographic correlates were: tobacco-only-older, lower education, and lower income; cannabis-only-Black (vs White) and higher income.

CONCLUSIONS

Public health efforts to reduce tobacco and cannabis use among SM adults should target single versus co-use patterns and their corresponding sociodemographic, mental health, and substance use profiles.

Exposure to E-Cigarette Advertisements or Reviews and E-Cigarette Use Progression: A Longitudinal Examination of Short-Term and Long-Term Associations among US Young Adults

Limited research has investigated the impact of e-cigarette advertising and reviews on the progression of e-cigarette use among young adults in the US. This study utilized five-wave longitudinal data (2018-2020) with 3006 young adults aged 18-34, reporting exposure to e-cigarette advertisements or reviews at Wave 1 (W1) and W3. Generalized estimating equations (GEE) were used to examine the prospective associations between frequent exposure to e-cigarette advertisements or reviews and e-cigarette use progression in four groups: never users (n = 1271 at W1), former users (previously used but quit ≥ 6 months ago, n = 422 at W1), recent former users (used in the past 6 months but not in the past month, n = 186 at W1), and current users (used in the past month, n = 1127 at W1). Among baseline former users, frequent exposure to e-cigarette reviews was associated with current use at 6-month follow-up (aOR = 4.40, 95%CI = 1.46-13.29). Among baseline current users, frequent exposure to e-cigarette reviews was associated with increased days of use at 6-month follow-up (IRR = 1.20, 95%CI = 1.07-1.34) and 12-month follow-up (IRR = 1.18, 95%CI = 1.03-1.35). E-cigarette reviews may contribute to relapse among recent former users and increased usage frequency among current users, highlighting the need for enhanced e-cigarette promotional activity regulation.

Driving under the influence of cannabis versus alcohol: A mixed-methods study examining perceptions and related risk behaviors among US and Israeli adults

BACKGROUND

Despite the dangers of driving under the influence (DUI), little is known about DUI substance-specific risk perceptions or risk factors for riding with drunk/drugged drivers (RDD).

METHODS

In this sequential exploratory mixed-methods study, we conducted: 1) multivariable analyses of cross-sectional survey data from 2222 US and Israeli adults to identify correlates of perceived cannabis- vs. alcohol-related DUI risks (linear regression) and past-month RDD involving alcohol-only, cannabis-only, or both (alcohol-cannabis) (multinomial logistic regression); and 2) deductive-inductive thematic analyses of qualitative interview data from 84 participants to identify themes elaborating on survey findings regarding DUI-related risk perceptions.

RESULTS

54.0 % reported past-month alcohol use, 16.7 % cannabis use, 4.2 % alcohol-only RDD, 5.5 % cannabis-only RDD, and 7.9 % alcohol-cannabis RDD. Being from the US, not having children at home, and cannabis non-use correlated with lower perceived cannabis vs. alcohol DUI risk. Lower perceived cannabis vs. alcohol DUI risk correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. cannabis-only) RDD. Alcohol use correlated with alcohol-only (vs. no) RDD and alcohol-cannabis (vs. cannabis-only) RDD. Cannabis use correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. alcohol-only) RDD. Being from the US correlated with alcohol-only (vs. alcohol-cannabis and none) RDD and cannabis-only (vs. alcohol-cannabis) RDD; being from Israel correlated with alcohol-cannabis (vs. no) RDD. Qualitative data indicated most participants perceived greater risk of DUI of alcohol vs. cannabis and desired more effective DUI-related prevention and regulatory efforts.

CONCLUSIONS

Prevention interventions targeting DUI- and RDD-related risk perceptions are needed, particularly for high-risk populations.

Parental openness and communication regarding cannabis and alcohol use with their children

BACKGROUND AND OBJECTIVES

Given increases in youth cannabis and alcohol use and changes in the cannabis market, we examined parental openness and communication about cannabis and alcohol.

METHODS

Among 197 participants who had children ≤18 years old and lived in six US metropolitan areas (Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, Seattle), we examined sociodemographic and use correlates of parental openness (i.e., acceptability of child use, rules regarding use in the home or around children, communication) about cannabis and alcohol, as well as being more open about cannabis versus alcohol.

RESULTS

In this sample (Mage  = 32.30, 70.1% female, 30.5% sexual minority, 33.0% racial/ethnic minority, 41.6% in recreational cannabis state), 33.5% reported past-month cannabis use, and 59.9% alcohol (22.8% used both, 29.4% used neither). Multivariable regression indicated that cannabis users (vs. nonusers) and sexual minority (vs. heterosexual) individuals were more open about cannabis use; alcohol users (vs. nonusers) were more open about alcohol use. Additionally, older parental and child age correlated with greater cannabis- and alcohol-related communication, and females (vs. males) reported greater cannabis-related communication. Those married/cohabitating and reporting past-month alcohol use were less likely to allow cannabis versus alcohol in the home or near children. Parents in legalized recreational (vs. nonlegalized) states, females, and heterosexual individuals reported greater cannabis- versus alcohol-related communication.

DISCUSSION AND CONCLUSIONS

Interventions are needed to support parental communication regarding substance use, particularly cannabis.

SCIENTIFIC SIGNIFICANCE

This study addressed parenting and youth substance use during evolving cannabis legislation and can inform youth substance use prevention interventions targeting parent-child communication.

Cannabis Retailer Communication About Cannabis Products, Health Benefits, and Risks: A Mystery Shopper Study of Licensed Retailers in Five U.S. Cities

OBJECTIVE

As the U.S. cannabis market expands, surveillance of retailer practices, especially product health claims and risks, is crucial to protect consumers. In this study, mystery shoppers (i.e., staff not explicitly identified as researchers) examined retail personnel communication regarding product recommendations, health benefits, safety, and/or risks among U.S. cannabis retailers.

METHOD

In Summer 2022, mystery shoppers audited 140 licensed cannabis retailers in 5 cities in states with established nonmedical (i.e., recreational) cannabis sales and diverse regulations (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive and bivariate analyses characterized retail personnel communication overall and across cities.

RESULTS

Common product recommendations for new users included edibles, pre-rolled joints, and bud/flower, and 8.6% offered free/inexpensive ways to sample products. Although Colorado, Washington, and Oregon explicitly prohibited health claims in advertising or labels, more than 90% of retailers there endorsed use for anxiety, insomnia, and/or pain. Whereas 54.3% endorsed use for pregnancy-related nausea (least common in Denver, 23.3%; most common in Seattle, 76.7%), 26.4% warned against use during pregnancy (most frequently in Denver, 46.7%; least frequently in Seattle and Portland, 13.3%). Overall, 52.1% warned against driving after use (most frequently in Denver, 80.0%; least frequently in Las Vegas, 20.0%). Almost all (≥90%) sold cannabidiol (CBD) products and endorsed their health benefits and safety, but few (<10%) sold or endorsed delta-8 tetrahydrocannabinol (THC), etc. (all of which were in Los Angeles).

CONCLUSIONS

Ongoing cannabis retail surveillance, particularly using protocols assessing factors outside those visibly observable, is needed to inform regulatory and enforcement efforts, especially related to health claims.

Cumulative Exposure to E-Cigarette Coupons and Changes in E-Cigarette Use Among U.S. Adults

INTRODUCTION

Coupons are an effective, frequently used tobacco marketing strategy. This study examined prospective associations between cumulative exposure to e-cigarette coupons and changes in e-cigarette use among U.S. adults.

METHODS

Data were from a representative U.S. adult cohort (n=19,824) in the Population Assessment of Tobacco and Health Study (waves [W] 2, 3, 4, and 5), collected from October 2014 to November 2019. Analysis was conducted in 2022. Four logistic regression models examined associations of a number of waves for which participants received e-cigarette coupons during W2-W4 with changes in e-cigarette use: W2 never use to W5 current use (initiation); W2 current nondaily use to W5 daily use (progression); W2 current use to W5 former use (cessation), and W2 former use to W5 current use (return-to-use).

RESULTS

Overall, 66.1% of U.S. adults never used e-cigarettes, 10.6% currently used e-cigarettes, and 23.4% formerly used e-cigarettes at W2. The average number of waves for which participants received e-cigarette coupons during W2-W4 was 0.13: 0.10 among W2 individuals who never used e-cigarettes, 0.30 among individuals who currently used e-cigarettes on a nondaily basis, 0.50 among individuals who currently used e-cigarettes, and 0.17 among individuals who formerly used e-cigarettes. Receiving coupons at increased waves was associated with (1) greater odds of initiation (AOR=1.58, 95% CI=1.26-1.97); (2) lower odds of cessation (AOR=0.78, 95% CI=0.67-0.91); and (3) increased odds of return-to-use (AOR=1.39, 95% CI=1.14-1.69). Findings did not differ by W2 cigarette smoking status.

CONCLUSIONS

E-cigarette coupons may encourage and sustain e-cigarette use. Policies restricting e-cigarette coupons may curb e-cigarette use.

U.S. Vietnamese parents' trusted sources of information and preferences for intervention messaging about HPV vaccination: A mixed methods study

Objective

Assess trusted sources of information, perceived message effectiveness, and preferred dissemination strategies regarding adolescent HPV vaccination among U.S. Vietnamese parents.

Methods

Data came from an observational, explanatory sequential mixed-methods study with U.S. Vietnamese parents of adolescents (408 survey participants; 32 interview participants). Surveys and interviews were conducted in both Vietnamese and English. Mixed-methods data were integrated and analyzed for confirmation, expansion, or discordance.

Results

Both quantitative and qualitative findings confirm high trust in HPV vaccination information from providers, government agencies, and cancer organizations. Messages perceived as effective emphasize vaccine safety, experts' endorsement, importance of vaccination prior to HPV exposure, and preventable cancers. Qualitative findings expanded quantitative results, demonstrating a desire for evidence-based information in the Vietnamese language and addressing cultural concerns (e.g., effectiveness or potential side effects specific to Vietnamese adolescents, whether parents should delay HPV vaccination for Vietnamese adolescents). Quantitative and qualitative findings were incongruent about whether parents would trust information about HPV vaccination that is disseminated via social media.

Conclusion

We identified credible messengers, feasible strategies, and elements of impactful messages for interventions to increase adolescent HPV vaccination for U.S. Vietnamese.

Innovation

We focus on a high-risk, underserved population and integrate mixed-methods design and analysis.

Disparities in cannabis use outcomes, perceived risks and social norms across sexual orientation groups of US young adult women and men

Little research has examined mechanisms driving cannabis use disparities among sexual minority (SM; versus heterosexual) young adults (YAs). Participants were US YA women (N = 1345; 24.8% bisexual, 6.1% lesbian) and men (N = 998: 8.9% bisexual, 13.8% gay). Bivariate analyses examined associations between sexual orientation (heterosexual, gay/lesbian, bisexual) and cannabis use outcomes (past 30-day [current] use, use frequency, cannabis-tobacco dual use, use intentions), perceived risks (harm, addictiveness) and social norms (social acceptability, peer use). Regressions examined sexual orientation, perceived risks and social norms as correlates of cannabis outcomes. Bisexual and lesbian (versus heterosexual) women reported lower cannabis-related perceived risks, greater social norms and higher odds of current use. Bisexual (versus heterosexual) women reported more days of use, higher odds of cannabis-tobacco dual use and greater use intentions. Gay (versus heterosexual) men reported lower perceived addictiveness, greater social norms and higher odds of current use. Lower perceived risks and greater social norms predicted greater use outcomes for women and men. Bisexual women displayed higher odds of several cannabis use outcomes, whereas lesbian women and gay men displayed higher odds of current cannabis use only. Cannabis-related perceptions and social norms may be important targets for public health messaging for SMYAs.

Development of a cervical cancer prevention text-messaging program for women living with HIV

Cervical cancer screening and human papillomavirus (HPV) vaccination are critical for those immunocompromised due to human immunodeficiency virus (HIV). Health education programs, including text messaging, can effectively improve knowledge of cervical cancer and recommended screening. This paper describes the data-driven development of a 4-week text-messaging intervention to improve HPV and cervical cancer knowledge among women living with HIV (WLH). This study reports data from surveys (n = 81; January 2020 to September 2021) and focus group discussions (FGDs, n = 39; April-June 2020) conducted among WLH in the DC area. While most WLH revealed that their usual sources of health information were through in-person group sessions, they pointed out that these were impractical options due to the coronavirus 2019 pandemic. They noted that a text-messaging intervention was feasible and acceptable. FGD participants' responses structured around the Protection Motivation Theory constructs informed the text-messaging library, covering topics such as (I) understanding of cervical cancer and HPV, (II) cervical cancer prevention and (III) HPV self-sampling. The utilization of low-cost and easily accessible health education interventions, such as mobile-based text messaging, can effectively increase knowledge and awareness of cervical cancer in populations that have been historically difficult to access and during times when health services are disrupted such as during a global pandemic or public health emergency.

Cannabidiol Knowledge, Perceptions, and Use Among Young Adults in 6 U.S. Metropolitan Areas

Background: Cannabidiol (CBD) has gained popularity in the United States, particularly among certain populations, including young adults. Thus, we examined (1) CBD product knowledge, perceptions, use, and use intentions among young adults and (2) correlates of use and use intentions. Methods: We analyzed data from a Fall 2020 survey regarding tobacco and other substance use among 2464 young adults in 6 U.S. cities (Mage=24.67; 57.4% female; 28.7% racial/ethnic minority). We used multinomial regression to identify correlates of use status (i.e., former [ever but no past 6 months] use vs. current [past 6 months] and never use, respectively), and linear regression to examine use intentions among never users. Results: Around 51.4% reported ever use, and 32.0% reported current use. On average, participants perceived CBD as safe and effective for addressing pain, anxiety, and sleep (also prominent use motives: ∼40% to 60%, respectively). Use intentions were relatively high, particularly for edibles and topicals (also the most common use modes). Roughly one-fourth mistakenly believed that CBD products were required to be approved by U.S. Food and Drug Administration (24.9%), tested/proven safe (28.8%), and proven effective to be marketed for pain, anxiety, sleep, and so on. (27.2%). Compared to former users, never users perceived greater CBD-related risk (p<0.001), less social acceptability (p<0.001), and greater difficulty accessing CBD (p=0.004); current users perceived more health benefits (p<0.001). Among never users, greater use intentions were associated with greater perceived social acceptability (p<0.001), health benefits (p<0.001), and difficulty accessing CBD (p=0.005). Conclusions: Given misperceptions about CBD, surveillance of young adults' knowledge, perceptions, and use of CBD is critical as its market expands.

Cannabidiol Marketing Strategies in the United States: An Analysis of Three Prominent Companies

Introduction: The popularity and market for cannabidiol (CBD) products have expanded. Materials and Methods: Using Numerator advertising data from 2017 to 2021 regarding three popular CBD companies in the United States (Charlotte's Web, Green Roads, Medterra), we examined (1) general advertising characteristics (e.g., media channel, year); (2) ad content (i.e., themes of headlines and imagery); (3) themes of prominent sources (i.e., specific websites, magazines, etc.); and (4) ad expenditures. Results: Across companies during the study timeframe, there were 475 unique ads (i.e., unique content), 4767 ad occurrences, and $1,471,944 total expenditures. Charlotte's Web accounted for the greatest proportion of unique ads, ad occurrences, and expenditures (53.3%, 62.8%, and 70.3%, respectively), followed by Medterra (40.4%, 33.9%, and 28.5%) and Green Roads (6.3%, 3.3%, and 1.2%). The largest proportion of occurrences and expenditures were via online display (83.5%, 54.8%), followed by mobile (15.9%, 24.8%) and print (0.4%, 20.1%). Per ad occurrences and expenditures, ads prominently featured headline themes focused on brand/trust/quality (27.5%, 18.3%, respectively), wellness (17.5%, 17.7%), pain/sport (9.9%, 20.0%), and promotions (13.2%, 11.6%), in addition to visual themes of the product itself (74.3%, 78.5%) or with women (5.3%, 10.0%). The most prominent source themes were focused on health/wellness (21.0% of ad occurrences, 18.1% of expenditures), followed by other websites and search engines (18.3%, 11.2%), news/weather (12.9%, 21.3%), and entertainment/lifestyle/culture (12.6%, 28.0%). Despite some distinctions between companies, ad and source themes were similar. Conclusions: Regulatory efforts must be informed by ongoing surveillance of CBD marketing and how specific consumer subgroups are impacted by marketing exposure.

Gaps in Adhering to Pap Testing Recommendations and Related Barriers in a Sample of Young Adults in the US

Given ongoing gaps in adherence to Pap testing recommendations, this study examined: 1) adherence to Pap test screening recommendations; and 2) barriers to Pap test screening among those who were nonadherent, using constructs from the Andersen model. We analyzed Spring 2022 survey data among 541 US young adults who reported having a cervix (n = 541; mean age = 27.73, 42.1% heterosexual, 57.9% sexual minority, 86.0% woman, 3.7% transgender man, 68.2% White, 31.8% racial/ethnic minority). Multivariable logistic regression examined sociodemographic correlates of nonadherence to Pap testing recommendations (i.e., no Pap testing in the past 3 years). Among those who were nonadherent, barriers to Pap testing were assessed. 68.6% (n = 371) were defined as adherent and 31.4% (n = 170) nonadherent. Multivariable regression findings indicated significant differences by race/ethnicity such that Asians (vs. Whites) were more likely to be nonadherent (OR = 2.41, CI = 1.11, 3.70, p = .021); no other differences in relation to race/ethnicity or sexual/gender identity were found. The most commonly reported barriers were: "I have not gotten around to it" (42.9%), "getting a Pap test is just not a priority for me" (30.6%), "fear/worry" (28.2%), "dislike/don't like having procedures done" (27.1%), "my healthcare provider has never mentioned it" (21.2%), "haven't had sex so I don't consider myself at high risk" (20.6%), and "COVID-19 pandemic prevented me" (15.3%). Pap testing is underutilized among young adults in the US, particularly Asians. Multilevel interventions must address barriers within the healthcare system (e.g., provider recommendation), external environment (e.g., societal factors), and individual realm (e.g., perceptions).

Exposure to e-cigarette advertisements and non-advertising content in relation to use behaviors and perceptions among US and Israeli adults

INTRODUCTION

As e-cigarette marketing strategies diversify, it is important to examine exposure to and impact of e-cigarette advertisements and non-advertising content (e.g. on social media) via multiple media channels among adults in different regulatory contexts.

METHODS

Using 2021 cross-sectional data among 2222 adults in the US (n=1128) and Israel (n=1094), multivariable regression examined past-month e-cigarette advertisement and non-advertising content exposure in relation to past-month e-cigarette use (logistic regression), as well as use intentions and risk perceptions (linear regressions), controlling for sociodemographics and tobacco use.

RESULTS

Overall, 20.3% reported past-month e-cigarette use (15.5% US, 25.2% Israel), 46.1% any advertisement exposure (28.7% digital media, 25.2% traditional media, 16.8% retail settings), and 34.1% any non-advertising exposure (19.4% social media, 13.6% websites, 12.3% movie/television/theater, 5.8% radio/podcasts). Exposure to digital media advertisements (AOR=1.95; 95% CI: 1.42-2.66), traditional media advertisements (AOR=2.00; 95% CI=1.49-2.68), and social media non-advertising (AOR=1.72; 95% CI: 1.25-2.36) correlated with e-cigarette use. Exposure to traditional media advertisements (β=0.23; 95% CI: 0.08-0.38) and social media non-advertising (β=0.26; 95% CI: 0.09-0.43) correlated with use intentions. Exposure to digital media advertisements (β= -0.32; 95% CI: -0.57 - -0.08), retail setting advertisements (β= -0.30; 95% CI: -0.58 - -0.03), and radio/podcast non-advertising (β= -0.44; 95% CI: -0.84 - -0.03) correlated with lower perceived addictiveness. Radio/podcast non-advertising exposure (β= -0.50; 95% CI: -0.84 - -0.16) correlated with lower perceived harm. However, retail setting advertisement exposure was associated with e-cigarette non-use (AOR=0.61; 95% CI: 0.42-0.87), and traditional media advertisement (β=0.38; 95% CI: 0.15-0.61) and social media non-advertising exposure (β=0.40; 95% CI: 0.14-0.66) correlated with greater perceived addictiveness.

CONCLUSIONS

E-cigarette-related promotional content exposure across media platforms impacts perceptions and use, thus warranting regulation.

Differences by Emotion Regulation in the Association Between Discrimination and Tobacco Use Among Sexual Minority Young Adults

Little research has examined factors, such as emotion regulation strategies, that amplify or mitigate associations between discrimination and tobacco use among sexual minority young adults (SMYAs). SM-identifying YA (ages 18-34) women (N = 450; Mage = 24.11; 31.1% racial or ethnic minority) and men (N = 254; Mage = 24.68; 28.0% racial or ethnic minority) residing in 6 US metropolitan areas were surveyed. Bivariate analyses examined associations of sociodemographics (i.e. age, race, ethnicity, education), discrimination, and emotion regulation strategies (i.e. cognitive reappraisal, expressive suppression) with tobacco use outcomes (i.e. past 30-day cigarette, e-cigarette, other tobacco [aggregated across cigars, hookah] use). Multivariable logistic regressions were built for each tobacco use outcome and included sociodemographic covariates, discrimination and emotion regulation strategies, and interactions between discrimination and emotion regulation strategies. Among SMYA women, a significant interaction of discrimination and cognitive reappraisal indicated that discrimination was associated with greater odds of past 30-day e-cigarette use only among women with lower levels of cognitive reappraisal. Discrimination and emotion regulation were not significantly associated with tobacco use among men. SMYA women with lesser use of cognitive reappraisal may be at heightened risk for e-cigarette use if they experience discrimination. Tobacco cessation programs for SM women should incorporate emotion regulation skills.

E-cigarette cessation interest and quit attempts among young adults reporting exclusive e-cigarette use or dual use with other tobacco products: How can we reach them?

INTRODUCTION

There is limited evidence to inform e-cigarette quitting interventions. This mixed-methods study examined: 1) e-cigarette and other tobacco product perceptions and cessation-related factors; and 2) potential behavioral intervention strategies among young adults reporting exclusive e-cigarette use or dual use with other tobacco products.

METHODS

We analyzed Fall 2020 survey data from 726 participants reporting past 6-month e-cigarette use (mean age=24.15 years, 51.1% female, 38.5% racial/ethnic minority) from 6 US metropolitan areas and Spring 2021 qualitative interview data from a subset (n=40), comparing tobacco-related perceptions and cessation-related factors among those reporting exclusive use versus dual use.

RESULTS

Among survey participants (35.5% exclusive e-cigarette use, 64.5% dual use), those reporting dual use indicated greater importance of quitting all tobacco or nicotine products (mean=5.28, SD=3.44 vs mean=4.65, SD=3.75, p=0.033), whereas those reporting exclusive use expressed greater confidence in quitting e-cigarettes (mean=7.59, SD=3.06 vs mean=7.08, SD=3.01, p=0.029) and all tobacco and nicotine products (mean=7.00, SD=3.16 vs mean=6.31, SD=3.13, p=0.008), as well as less favorable perceptions (i.e. more harmful to health and addictive, less socially acceptable) of cigarettes, cigars, and smokeless tobacco (p<0.05). Interview participants (50.0% exclusive e-cigarette use; 50.0% dual use) attributed previous failed e-cigarette quit attempts to their inability to cope with social influences, stress, and withdrawal symptoms. Although most expressed disinterest in quitting due to belief of eventually outgrowing e-cigarettes (among those reporting exclusive use) or unreadiness to abstain from nicotine (among those reporting dual use), many acknowledged the need for quitting interventions.

CONCLUSIONS

Young adult e-cigarette cessation interventions should target risk perceptions, cessation barriers, and social influences/support.

Health warning labels on heated tobacco products and their impact on use intentions and risk perceptions: a cross-sectional study of adult tobacco users in the US and Israel

BACKGROUND

Health warning labels (HWLs) represent an evidence-based tobacco control strategy; however, their application to heated tobacco products (HTPs) and related impacts are understudied. This study examined the impact of HTP HWLs on HTP use intentions and risk perceptions among current tobacco users.

METHODS

We analyzed cross-sectional survey data from adults in the US and Israel reporting past-month tobacco use and awareness of HTPs (N = 424). Multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of HTP HWLs (i.e., more concerned about HTP use, reassured, no effect [referent]) among those who noticed HTP HWLs (multinomial regressions); and (2) HWL impacts in relation to HTP use intentions and perceived addictiveness and harm (linear regressions).

RESULTS

Among participants who noticed HTP HWLs (n = 372, 87.7%), 27.7% reported HWLs increased their concerns about HTP use, 22.6% were reassured about use, and 49.7% reported no effect. Factors associated with increased concern (vs. no effect) included other tobacco product use (aOR = 2.10, 95% CI 1.21-3.64) and being female (aOR = 1.77, 95% CI 1.03-3.05). Factors associated with being reassured about HTPs use (vs. no effect) included current HTP use (aOR = 2.11, 95% CI 1.11-4.00) and being from Israel (vs. US: aOR = 3.85, 95% CI 1.85-7.69), female (aOR = 1.91, 95% CI 1.07-3.42), and less educated (< college education: aOR = 2.57, 95% CI 1.42-4.63). Reporting that HWLs on HTPs increased concern (β = 0.46, 95% CI 0.03-0.89) and reassured of use (β = 0.94, 95% CI 0.47-1.41) were positively associated with HTP use intentions; no associations with risk perceptions were found.

CONCLUSIONS

Findings indicate that most tobacco users noticed HWLs on HTPs, but the majority reported no effect or being reassured of using HTPs, effects that were magnified for specific subgroups. Both increased concern and reassurance correlated with greater use intentions. Additional research should evaluate HTP HWL impacts and ensure effectiveness in communicating risks and discouraging use.

Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors

BACKGROUND

Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months.

METHODS

Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home.

RESULTS

In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers.

CONCLUSIONS

SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.

Disparities in trajectories of cigarette and E-cigarette use across sexual orientation groups of young adult men and women in the US

INTRODUCTION

Limited research has examined differences in cigarette/e-cigarette use trajectories among specific subgroups of sexual minority (SM) young adult (SMYA) men and women.

METHODS

Repeated measures latent profile analyses (RMLPAs) examined past 6-month cigarette and e-cigarette use trajectories across 5 waves of data (2018-2020) among men (n = 1235; Mage = 25.56, SD = 4.85; 8.0% bisexual, 12.7% gay; 36.4% racial/ethnic minority) and women (n = 1574; Mage = 24.64, SD = 4.72; 23.8% bisexual, 5.9% lesbian; 35.3% racial/ethnic minority) residing in 6 US metropolitan statistical areas. Multinomial logistic regressions examined associations among sexual orientation (bisexual, gay/lesbian, heterosexual) and tobacco use trajectories among men and women, separately.

RESULTS

RMLPAs yielded a 6-profile solution: stable low-level cigarette and e-cigarette use (66.6%), stable low-level cigarette and high-level e-cigarette use (12.2%), stable low-level cigarette and decreasing e-cigarette use (6.2%), stable mid-level cigarette and low-level e-cigarette use (6.2%), stable high-level cigarette and low-level e-cigarette use (4.5%), and stable high-level cigarette and e-cigarette use (4.2%). Gay (vs. heterosexual) men were less likely to display stable low-level cigarette and stable high-level e-cigarette use. Bisexual (vs. heterosexual) women were more likely to display stable low-level cigarette and stable high-level e-cigarette use, stable low-level cigarette and decreasing high-level e-cigarette use, and stable high-level cigarette and stable low-level e-cigarette use.

CONCLUSIONS

Bisexual women were at greatest risk for displaying several problematic cigarette and e-cigarette use trajectories, whereas few differences emerged for men. Tailored interventions and campaigns are needed to curtail ongoing tobacco use disparities among SMYA men and women, particularly bisexual women.

The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco

Background

Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied.

Design and Methods

Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions).

Results

Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (β = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (β = -0.61, 95% CI:-1.05, -0.18), and harm (β = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (β = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk.

Conclusion

Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia

CONTEXT

Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018).

OBJECTIVE

We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings.

DESIGN

We analyzed 2022 survey data.

SETTING

Data were from 28 communities in Armenia and Georgia.

PARTICIPANTS

The sample comprised 1468 adults (31.6% past-month smokers).

METHODS

We conducted multivariable regressions, controlling for country and sociodemographics.

RESULTS

Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs.

CONCLUSIONS

Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

Assessment of Online Marketing and Sales Practices Among Recreational Cannabis Retailers in Five U.S. Cities

Background: With more states legalizing recreational cannabis, examining cannabis retail and marketing is crucial, as it may influence consumers' perceptions and behaviors. Particularly understudied is online cannabis retail. Methods: In Spring 2022, coders collected and analyzed data regarding retailer characteristics, age verification, and marketing strategies (e.g., product availability, health-related content, promotions, website imagery) among 195 cannabis retail websites in five U.S. cities (Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California). Descriptive analyses characterized the websites overall and across cities. Results: Overall, 80.5% verified age for website entry, and 92.8% offered online purchases (92.3% of retailers in Seattle, where prohibited). Of these, 82.9% required age verification for purchases, and 30.9% offered delivery. Almost all (>92%) offered flower/bud, concentrates, edibles, vaping devices, topicals, and tinctures. Health warnings were displayed on 38.3% of websites. Although all five states required health warnings regarding use during pregnancy, only 10.3% had these warnings. In addition, 59.0% posted some unsubstantiated health claims, most often indicating physical and mental health benefits (44.6%). Although Colorado, Washington, and Oregon prohibit health claims, 51.2-53.8% of these retailers posted them. Discounts, samples, or promotions were present on 90.8% of websites; 63.6% had subscription/membership programs. Subpopulations represented in website content included the following: 27.2% teens/young adults, 26.2% veterans, 7.2% sexual/gender minorities, and 5.6% racial/ethnic minorities. Imagery also targeted young people (e.g., 29.7% party/cool/popularity, 18.5% celebrity/influencer endorsement). Conclusions: Regulatory efforts are needed to better monitor promotional strategies and regulatory compliance (e.g., health claims, youth-oriented content, underage access) among online cannabis retailers.

Theory-based correlates of cannabis use and intentions among US and Israeli adults: a mixed methods study

BACKGROUND

In the US and Israel, non-medical ('recreational') cannabis use is illegal at the national level; however, use rates are high and decriminalization and legalization is spreading. Thus, theory-based intervention efforts, especially for youth prevention, are crucial.

METHODS

This mixed-methods study of adults in the US (n = 1,128) and Israel (n = 1,094) analyzed: 1) cross-sectional survey data (Fall 2021) to identify theory-based correlates (risk perceptions, social norms) of past-month cannabis use, next-year use intentions, and intentions to use in the home or among children if non-medical cannabis was legal, using multivariable regression; and 2) qualitative interviews regarding perceptions of cannabis policies and use (US n = 40, Israel n = 44).

RESULTS

16.7% reported past-month use; 70.5%, 56.3%, and 82.6% indicated "not at all likely" regarding next-year use and use in the home and among children if legal. Lower perceived risk and greater social norms were associated with past-month use, greater use intentions, and greater intentions to use in the home or among children. Past-month use was more prevalent among US (vs. Israeli) participants (22.0% vs. 11.2%); however, in multivariable regression controlling for past-month use, being from Israel was associated with greater use intentions (next-year; in the home/among children). Qualitative themes indicated: concerns about use (e.g., increasing use, health risks, driving-related risks) and legalization (e.g., impact on society/economy, marketing), and perceived benefits of use (e.g., medical) and legalization (e.g., access/safety, economic, individual rights).

CONCLUSIONS

Despite differences in cannabis perceptions and use across countries, perceived risk and social norms are relevant intervention targets regardless of sociopolitical context.

IQOS Marketing Strategies and Expenditures in the United States From Market Entrance in 2019 to Withdrawal in 2021

INTRODUCTION

IQOS entered the U.S. market in October 2019, then received the Food and Drug Administration (FDA)'s modified risk tobacco product authorization (MRTPA) allowing use of "reduced exposure" claims in marketing in July 2020. A May 2021 court decision regarding patent infringement required IQOS' removal from the U.S. market in November 2021.

AIMS AND METHODS

Using 2019-2021 Numerator marketing data, this study characterized ad occurrences and expenditures-including allocation per ad content (headline theme, imagery) and media type and channel-pre- and post-MRTPA; exploratory analyses characterized the post-court to withdrawal period separately.

RESULTS

The study period entailed 685 occurrences and $15 451 870 in expenditures. The proportions of occurrences across the three periods (pre-MRTPA, post-MRTPA, and post-court) were 39.3%, 48.8%, and 12.0%, respectively (p < .001); the proportions of expenditures were 8.6%, 30.0%, and 61.5%. Overall, 73.1% of ad occurrences were via online display; 99.6% of expenditures occurred in print. Per occurrences, prominent pre-MRTPA headline themes included "future" (40.2%), "real tobacco" (38.7%), "get IQOS" (35.3%), and "innovation or technology" (20.1%); post-MRTPA, prominent themes included "not burned or heat control" (32.7%), "reduced exposure" (26.4%), and "distinct from e-cigarettes" (20.7%). Visuals mainly depicted the product alone (pre-MRTPA: 86.6%; post-MRTPA: 76.1%), but increasingly featured women (pre-MRTPA: 8.6%; post-MRTPA: 21.5%). The most prominent media channel theme pre-MRTPA was "technology" (19.7%), but post-MRTPA included "women's fashion" (20.4%) and "entertainment or pop culture/gaming" (19.0%).

CONCLUSIONS

IQOS leveraged MRTPA in ads, continued marketing post-court decision, and targeted key consumer groups (ie, women). Marketing surveillance of products granted MRTPA is needed, domestically and in other countries, to assess its use and impact.

IMPLICATIONS

Philip Morris (PM) leveraged IQOS' MRTPA from the U.S. FDA, and continued marketing IQOS after its withdrawal from the U.S. market due to a patent-infringement-related court decision. Notably, IQOS marketing increasingly targeted key consumer groups (eg, women). Given IQOS' potential return to the United States, PM's use of FDA's MRTPA to promote IQOS as a risk reduction product in other countries, and FDA's MRTPA for other products, it is crucial to monitor products receiving MRTPA, their marketing, and their population impact, domestically and in other countries.

Parental influences on tobacco use and likelihood of future use among sexual minority young adult men and women in the United States

BACKGROUND AND OBJECTIVES

Limited research has examined mechanisms, including parenting behaviors, contributing to tobacco use disparities among sexual minority young adults (SMYAs).

METHODS

Participants were 644 young adult (ages 18-29; 36.5% racial/ethnic minority) women (N = 416; 44.7% bisexual, 7.2% lesbian, 48.1% heterosexual) and men (N = 288; 11.0% bisexual, 13.2% gay, 75.9% heterosexual). Bivariate analyses examined differences among sex-by-sexual identity subgroups in perceived parenting (psychological control, behavioral control, knowledge, autonomy support, warmth, communication), past 30-day cigarette, e-cigarette, and cigar use, and likelihood of future use. Multivariable regression examined associations of sexual identity subgroup and parenting behaviors to tobacco use outcomes among women and men.

RESULTS

Bisexual (vs. heterosexual) women reported greater parental psychological control and less autonomy support, warmth, and communication. Bisexual (vs. heterosexual) women had greater odds of past 30-day cigarette and cigar use and greater likelihood of future cigarette and e-cigarette use, and parenting behaviors were associated with past 30-day cigarette (knowledge, warmth), e-cigarette (psychological control, autonomy support, warmth), and cigar use (behavioral control, warmth) and likelihood of future cigarette (psychological control, warmth) and e-cigarette use (autonomy support, communication). Gay (vs. heterosexual) men reported greater parental behavioral control, less knowledge, autonomy support, warmth, and communication. Sexual identity and parenting behaviors were largely not associated with tobacco use among men.

DISCUSSION AND CONCLUSIONS

Findings highlight the role of parenting behaviors as potential mechanisms contributing to tobacco use disparities among SMYA women.

SCIENTIFIC SIGNIFICANCE

Tobacco prevention/cessation programs should be tailored toward specific SMYA subgroups, combinations of parenting behaviors, and patterns of tobacco use.

Community coalitions for smoke-free environments in Armenia and Georgia: A mixed methods analysis of coalition formation, implementation and perceived effectiveness

Effective models for aligning public health and civil society at the local level have the potential to impact various global health issues, including tobacco. Georgia and Armenia Teams for Healthy Environments and Research (GATHER) is a collaboration between Armenia, Georgia and U.S. researchers involving a community randomized trial testing the impact of community coalitions to promote smoke-free policy adoption and compliance in various settings. Community Coalition Action Theory (CCAT) was used to guide and describe coalition formation, implementation and effectiveness. Mixed methods were used to evaluate 14 municipality-based coalitions in Georgia and Armenia, including semi-structured interviews (n = 42) with coalition leaders and active members, coalition member surveys at two timepoints (n = 85 and n = 83), and review of action plans and progress reports. Results indicated successful creation of 14 multi-sectoral coalitions, most commonly representing education, public health, health care, and municipal administration. Half of the coalitions created at least one smoke-free policy in specific settings (e.g., factories, parks), and all 14 promoted compliance with existing policies through no-smoking signage and stickers. The majority also conducted awareness events in school, health care, and community settings, in addition to educating the public about COVID and the dangers of tobacco use. Consistent with CCAT, coalition processes (e.g., communication) were associated with member engagement and collaborative synergy which, in turn, correlated with perceived community impact, skills gained by coalition members, and interest in sustainability. Findings suggest that community coalitions can be formed in varied sociopolitical contexts and facilitate locally-driven, multi-sectoral collaborations to promote health. Despite major contextual challenges (e.g., national legislation, global pandemic, war), coalitions were resilient, nimble and remained active. Additionally, CCAT propositions appear to be generalizable, suggesting that coalition-building guidance may be relevant for local public health in at least some global contexts.

Experiences of Microaggressions, Attributions, and Impact Among US Young Adults: An Intersectional Perspective Regarding Sexual/Gender and Racial/Ethnic Minorities

BACKGROUND

Understanding discrimination (e.g., microaggressions) toward sexual/gender minorities (SGM) and racial/ethnic minorities (REM) from an intersectional perspective is critical in informing interventions to reduce such experiences and their impacts.

PURPOSE

This study examined US young adults identifying as SGM, REM, both, or neither in relation to microaggression experiences, and these factors in relation to mental health.

METHODS

Using 2022 data from 932 US adults (Mage = 27.61) in an online survey study, we compared subgroups (SGM-only, REM-only, both, neither) in relation to microaggression experiences and mental health symptoms, stratified by sex (male, female). Multivariable linear regression examined: 1) sex and intersectional subgroup in relation to number of microaggressions experienced; and 2) sex, subgroup, and number of microaggression experiences in relation to mental health symptoms.

RESULTS

Among females (n = 612), 42.0% were SGM-only, 17.3% REM-only, 15.2% both, and 25.5% neither. Among males (n = 320), 25.0% were SGM-only, 25.0% REM-only, 8.4% both, and 41.6% neither. Females (vs. males) reported more microaggressions (M = 5.67, SD = 3.00 vs. M = 3.95, SD = 3.46, p < .001). Those with intersecting minority identities experienced the most microagressions (females: M = 6.98, SD = 2.64; males: M = 6.44, SD = 2.95, respectively). In multivariable analyses, females and those in any of the 3 minority-identifying subgroups experienced more microaggressions; those with intersecting minority identities experienced more microaggressions than SGM-only and REM-only. Identifying as SGM-only or both SGM and REM, as well as experiencing more microaggressions, was associated with greater mental health symptoms.

CONCLUSIONS

Intersecting minority identities increase risk for microaggressions and mental health consequences. Multilevel interventions must reduce minority subgroups' experiences of microaggressions and their impacts.

Cannabis retailer marketing strategies and regulatory compliance: A surveillance study of retailers in 5 US cities

As cannabis retail expands in the US, its surveillance is crucial to inform regulations and protect consumers. This study addresses this need by conducting point-of-sale audits examining regulatory compliance (e.g., age verification, signage), advertising/promotional strategies, products, and pricing among 150 randomly-selected cannabis retailers in 5 US cities (30/city: Denver, Colorado; Seattle, Washington; Portland, Oregon; Las Vegas, Nevada; Los Angeles, California) in Summer 2022. Descriptive and bivariate analyses characterized the retailers overall and across cities. Age verification rates were high (>90%). The majority of retailers had signage indicating restricted access (e.g., no minors; 87.3%), onsite consumption (73.3%), and distribution to minors (53.3%). Retailers were likely to post warnings regarding use during pregnancy/breastfeeding (72.0%), followed by health risks (38.0%), impacts on children/youth (18.7%), and DUI (14.0%). Overall, 28.7% posted health claims, 20.7% posted youth-oriented signage, and 18.0% had youth-oriented packaging. Price promotions were prevalent, particularly price specials (75.3%), daily/weekly/monthly specials (66.7%), and membership programs (39.3%). One-fourth had signs/promotions indicating curbside delivery/pick-up (28.0%) and/or online ordering (25.3%); 64.7% promoted their website or social media page. The most potent cannabis products were most often e-liquids (38.0%) or oils (24.7%); the least potent were often edibles (53.0%). The most expensive product was often bud/flower (58.0%); the least was joints (54.0%). The vast majority (≥81%) sold vaporizers, wrapping papers, and hookah/waterpipes/bongs, and 22.6% sold CBD products. Marketing strategies differed across cities, reflecting differences in state-specific regulations and/or gaps in compliance/enforcement. Findings underscore the need for ongoing cannabis retail surveillance to inform future regulatory and enforcement efforts.

Listening for rain: Principal component analysis and linear discriminant analysis for broadband acoustic rainfall detection

Rain falling on the ocean creates acoustic signals. Ma and Nystuen [(2005). J. Atmos. Oceanic Technol. 22, 1225-1248] described an algorithm that compares three narrowband "discriminant" frequencies to detect rain. In 2022, Trucco, Bozzano, Fava, Pensieri, Verri, and Barla [(2022). IEEE J. Oceanic Eng. 47(1), 213-225] investigated rain detection algorithms that use broadband spectral data averaged over 1 h. This paper implements a rainfall detector that uses broadband acoustic data at 3-min time resolution. Principal Component Analysis (PCA) reduces the dimensionality of the broadband data. Rainfall is then detected via a Linear Discriminant Analysis (LDA) on the data's principal component projections. This PCA/LDA algorithm was trained and tested on 5 months of data recorded by hydrophones in a shallow noisy cove, where it was not feasible to average spectral data over 1 h. The PCA/LDA algorithm successfully detected 78 ± 5% of all rain events over 1 mm/h, and 73 ± 5% of all rain events over 0.1 mm/h, for a false alarm rate of ≈ 1% in both cases. By contrast, the Ma and Nystuen algorithm detected 32 ± 5% of the rain events over 1.0 mm/h when run on the same data, for a comparable false alarm rate.

Substance Use and Depression Impede ART Adherence Among Female Sex Workers Living with HIV in the Dominican Republic

Female sex workers (FSW) have worse HIV outcomes in part due to lower anti-retroviral therapy (ART) adherence. Substance use and depression are important barriers to ART adherence, yet few studies have assessed these relationships among FSW in longitudinal studies. Cross-Lagged Panel Models and autoregressive mediation analyses assessed substance use (illicit drug use and alcohol use disorders) in relation to ART non-adherence and the mediation role of depressive symptoms among 240 FSW living with HIV in the Dominican Republic. In annual visits (T1, T2, T3), the majority (70%, 66%, and 53%) reported at-risk drinking and 15%, 13% and 9% used illicit drug during the past 6 months. Most FSW (70%, 62% and 46%) had mild-to-severe depression. Illicit drug use predicted later ART non-adherence. This relationship was not mediated via depressive symptoms. Integrated substance use and HIV care interventions are needed to promote ART adherence and viral suppression among FSW.

IQOS marketing strategies in the USA before and after US FDA modified risk tobacco product authorisation

INTRODUCTION

Given that the US Food and Drug Administration (FDA) authorised reduced exposure messaging to be used in IQOS marketing, we examined: (1) IQOS ad content; (2) advertising media channels and (3) changes in advertising efforts over time.

METHODS

We conducted a mixed-methods study regarding IQOS ad content (headlines, themes, images), ad occurrence characteristics (including content, media channels and adspend) in the USA from August 2019 to April 2021 using Numerator advertising/marketing data.

RESULTS

Across 24 unique ads and 591 occurrences (84.6% online, 8.0% print, 7.4% mobile), there was $4 902 110 total adspend (98.9% allocated to print). Across unique ads, occurrences and adspend, prominent themes included 'real tobacco' (45.8%, 47.4%, 30.1%, respectively), less odour/ash (29.2%, 21.0%, 29.9%) and switching from cigarettes (25.0%, 19.5%, 69.4%), and images mainly featured the product alone (58.2%, 61.4%, 99.5%) or with women (25.0%, 19.1%, 0.3%). Per occurrences and adspend, the most prominent media channel themes (eg, magazine/website topics) were technology (19.3%, 10.6%), women's fashion (18.1%, 26.2%), weather/news (9.0%, 15.3%) and entertainment/pop culture/gaming (8.5%, 23.1%). Ad themes appearing only post-FDA authorisation included switching from traditional cigarettes, same-day/home-delivery, convenience (eg, use indoors), reduced exposure to some dangerous substances, science/research and distinction from e-cigarettes. Overall adspend per occurrence increased postauthorisation (p=0.016); the highest adspend per unique ad (69.3% of total) focused on ads featuring reduced exposure.

CONCLUSIONS

Regulatory efforts must be informed by ongoing surveillance of IQOS marketing efforts and its impacts, particularly how specific consumer subgroups (eg, tobacco non-users, women, young people) are impacted by marketing exposure.