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Previous research indicates that differences in cigarette smoking exist among those of different race/ethnicity and varying levels of socioeconomic status. However, most research has examined the influence of these factors separately on cigarette smoking despite their observed covariation. To examine the interaction of race/ethnicity and socioeconomic status on adolescent tobacco use and behaviors, this study tests whether or not the social gradient holds for smoking patterns and perceptions of smoking among African American, American Indian/Alaska Native (AIAN), Asian, Hispanic, and White adolescents. Using data from the 2018 National Survey on Drug Use and Health, the sample included African American/Black (Black), American Indian/Alaska Native (AIAN), Asian, Hispanic, and White adolescents (N = 12,474), ages 12–17 years old. Measures included race/ethnicity, annual household income, age, gender, cigarette smoking, perceptions of peer use, parental attitudes, and health risks of smoking; logistic regression analyses were conducted. Findings indicated significant interactions between high income and Black and Hispanic race/ethnicity for having ever smoked a cigarette indicating a difference in comparison to high-income White adolescents (p’s < 0.05). We also found that the interaction between high income and AIAN race/ethnicity for disapproval of peers smoking was significant compared to White adolescents at the same income levels (p < 0.05). No differences were found for smoking health risk perceptions. The relationship between race/ethnicity, income, and smoking may be more complex than previously thought with these results having important preventative implications for identification of adolescents who may be most at risk for tobacco use.

To determine if cigarette smoking, electronic cigarette use, and rate of consumption of these products differed before and after a pandemic lockdown order, two convenience samples of adults in Central California were recruited and surveyed before (March 2020) and after (May 2020) COVID-19 lockdown orders were implemented in California (n = 2571). Multivariable logistic and negative binomial regression models tested the association between adults recruited pre- or post-California lockdown and past month cigarette use, past month electronic cigarette use, past month cigarette consumption, and past month e-cigarette consumption among current users, controlling for demographic differences. Adults pre- and post-lockdown had equal odds of using cigarettes during the past month. Cigarette users who responded post-lockdown had higher cigarette consumption rates compared to cigarette users who responded pre-lockdown (IRR = 1.13, 95% CI = 1.15, 1.23). Adults who responded post-lockdown had lower odds of using electronic cigarettes during the past month compared to participants surveyed before the order (OR = 0.66, 95% CI: 0.55, 0.78). Cigarette users may be using more cigarettes during the state mandated lockdown. Possible causes for this increase in cigarette use may include increased stress, the change in workplace smokefree protections coverage, and increased opportunities for smoking or vaping.

Dual-process theories may be effective at predicting adolescent smoking; however, little is known about the effectiveness of these models across race/ethnicity and gender. Adolescents ( N = 4035) completed biopsychosocial and tobacco-related perception measures in Grade 7 and reported on smoking initiation in Grade 10. Using structural equation modeling and comparing models by gender and race/ethnicity showed differences, where both intentions and willingness predicted smoking initiation for only Black and male adolescents, compared to their Latino and White and female counterparts. Intentions and willingness appear to play a role in whether an adolescent will initiate smoking in the future, but this does not apply universally across gender and race/ethnicity.

Introduction The decline in tobacco smoking among US adolescents has been exceeded by the exponential rise in nicotine vaping with an overall net gain in youth tobacco product use. While cigarette companies are restricted from advertising on television/radio, vaping promotions have been largely unrestricted. This study examined exposure to tobacco product promotions in a US sample of 1003 adolescents and its associations with product use and susceptibility to use. Aims and Methods Adolescents (13–17) were recruited online and anonymously surveyed in 2019 about their ever and current (past 30 days) tobacco smoking (cigarette and cigar) and nicotine vaping behaviors, and among never-users, susceptibility to vaping. Multivariate models tested associations with past-month exposure to tobacco product promotions controlling for demographic features, harm perceptions, and family and peer influences. Results Tobacco product use was 34% ever-use and 20% current-use. Most had seen cigarette (91%) and nicotine vaping (80%) product promotions in the past 30 days. A majority reported exposure at point-of-sale and on major (television and cinema) and social media. In adjusted multivariate models, greater exposure to tobacco product promotions was significantly associated with ever and current smoking and vaping; and among never-users, susceptibility to vaping (all p < .01, effect sizes 1.03–1.05). Family/peer use and attitudes also were significant correlates. Conclusions Tobacco product promotions remain ubiquitous and are significantly associated with adolescents’ tobacco product use and susceptibility to vape. Peers and family are important social influences and may reflect indirect channels of tobacco marketing. Stricter regulatory restrictions on tobacco marketing to young people are warranted. Implications This study adds to mounting evidence showing that tobacco marketing remains pervasive and is associated with tobacco use and susceptibility to use. Most youth report seeing cigarette and nicotine vaping product promotions, with notable differences by channel: traditional media predominate for cigarettes and social media/email for e-cigarettes. Greater exposure to tobacco promotions is significantly associated with ever and current smoking and vaping, and among never-users, susceptibility to vaping. The accumulating findings support stricter regulatory restrictions on marketing of tobacco products in media channels accessed by youth.

Author(s): Epperson, Anna E; Crouch, Maria; Skan, Jordan; Benowitz, Neal L; Schnellbaecher, Matthew; Prochaska, Judith J | Abstract: IntroductionApproximately 9 million American adults use two or more tobacco products regularly, referred to as dual or poly tobacco users. In Alaska, where tobacco is not native, approximately 20% of the population smokes cigarettes, and among smokers, 10% use two or more tobacco products. Previous research suggests that dual tobacco product use may be especially high among Alaska Native people. The current study examined cultural and demographic characteristics associated with dual tobacco use.MethodsAlaska Native adults reporting daily smoking and identified with high blood pressure or cholesterol were recruited in the Norton Sound region of Alaska between 2015-2019 as part of a treatment trial targeting cardiovascular disease risk factors. Participants reported their tribal group, level of identification with their Alaska Native heritage, speaking of their tribal language, basic demographic characteristics, and past 30-day use of tobacco products in addition to smoking cigarettes.ResultsParticipants (n=299) were 48.5% female and identified as Yup'ik (31.1%), Inupiat (60.5%), and other or multiple tribal group(s) (8.4%). Most participants (85.3%) strongly identified with their Alaska Native heritage. Past 30-day dual tobacco use was reported by 10.0%, specifically 9.0% chew/snuff, 1.3% e-cigarettes, and 0.7% Iq'mik. Multivariate regression models indicated that dual tobacco use was more likely among men (OR=3.35; 95% CI: 1.30-8.64), younger participants (OR range: 10.97-12.35; 95% CI: 2.33-57.86), those identifying as Yup'ik (OR=2.86; 95% CI: 1.13-7.19), and those who identified very little or not at all with their Alaska Native heritage (OR=2.98; 95% CI: 1.14-7.77).ConclusionsYoung men identifying as Yup'ik were more likely to use dual forms of tobacco. Stronger identification with one's Alaska Native heritage was associated with lower risk of dual tobacco use. The findings highlight cultural and demographic factors for further consideration and attention in tobacco cessation treatment interventions.

PurposeExamine adolescents' and young adults' (AYAs) knowledge and perceptions about the composition and environmental harms of cigarette filters and determine how perceptions are associated with support for policy interventions.MethodsCross-sectional, convenience sample from 10 California schools. AYAs (N= 429; 70% < 21years) were surveyed about tobacco use, perceptions of cigarette filters, their impact on the environment, and cigarette sales bans.ResultsMost agreed that filters are harmful to the environment and not biodegradable (89%, n= 383 respectively); fewer knew filters are made of plastic (43%, n= 185). AYAs who agreed that filters are harmful to the environment were more supportive of cigarette sales bans (OR= 2.78 [95% CI: 1.18, 6.58]).ConclusionsKnowledge of the environmental harms of cigarettes among AYAs may strengthen support for tobacco control. More research is needed to further understand the knowledge and attitudes about the environmental impact of tobacco and to clarify how this might add support for tobacco-related policies.

BACKGROUND:Research suggests that an immigrant paradox exists where those who were not born in the United States (1st generation) have significantly better health than those who were born in the U.S. (2nd generation or more). The aim of the current study was to examine the immigrant paradox with respect to tobacco-related perceptions and parenting influences in smoking initiation among Latinx adolescents. METHODS:Data came from the 7th and 10th grade Healthy Passages™ assessments of Latinx participants in three U.S. urban areas (N = 1536) who were first (18%25), second (60%25), and third (22%25) generation. In addition to demographics, measures included perceived cigarette availability and peer smoking, intentions and willingness to smoke, and general monitoring by parents. Parents reported on generational status and their own tobacco use. The primary outcome was participant's reported use of cigarettes. RESULTS:By 10th grade, 31%25 of Latinx youth had tried a cigarette, compared to 8%25 in 7th grade. After controlling for age, gender, and socioeconomic status, regression analyses indicated that there were no significant differences related to generational status in cigarette smoking initiation in either 7th or 10th grade. Youth tobacco-related perceptions, general parental monitoring, and parental tobacco use predicted Latinx adolescent cigarette use initiation by 10th grade. CONCLUSIONS:Latinx adolescents might not have deferential smoking rates based on generation status, suggesting that the immigrant paradox concept may not hold for smoking initiation among Latinx adolescents. Rather, factors influencing cigarette initiation generally in adolescents as a group appear to apply to Latinxs as well.

PurposeNatural American Spirit (NAS) cigarettes, which have recently grown in popularity, are marketed as eco-friendly and natural. The present study examined whether NAS's on-the-pack messaging influences adolescents' health perceptions of the brand.MethodsIn a mixed-factor design, adolescent participants (N= 1,003, ages 13-17, 75% female) were randomized to one of the six exposure conditions. All viewed images of an NAS and a Pall Mall (comparison brand) cigarette pack, but differed in pack color (blue, green, or gold/orange) and brand viewed first. Perceptions of pack logos, addictiveness, harms to the smoker, others, and the environment were assessed directly after viewing pack images for each brand.ResultsAdolescents who perceived NAS as more pro-environment tended to perceive NAS cigarettes to be less addictive, r=-.19, p < .01. NAS cigarettes also were perceived as less addictive and better for the environment than Pall Mall. Most (90%) participants provided nature-friendly words (e.g., environment, recycle) when asked to describe logos on the NAS packs. In adjusted models, relative to Pall Mall, NAS was perceived as healthier for smokers, healthier for smokers' family and friends, and safer for the environment. Findings did not differ by pack color and ever tobacco use.ConclusionsAdolescents perceived a health advantage for NAS cigarettes with its on-the-pack, eco-friendly and pro-health marketing. The findings are consistent with prior research with adults. Given the accumulating evidence of consumer misperceptions, eco-friendly messaging on cigarettes is a public health concern that warrants further consideration for regulatory intervention.

Many college campuses now prohibit tobacco use. At a private U.S. university, the current study assessed cigarette and e-cigarette use and characterized the climate for adopting a comprehensive tobacco-free policy. Data were gathered January–August 2018 via an: environmental scan; cigarette-urn audit; and representative surveys with campus community members. Despite low prevalence of tobacco (0.5%–8%) and e-cigarette use (0.9%–6%) among all groups, campus cigarette clean-up costs exceeded $114,000 for an estimated >1 million butts left on campus annually. A majority of respondents (63% of N = 2218) favored a campus-wide tobacco-free policy, 16% opposed, and 21% abstained. Most respondents endorsed benefits of supporting health (93%), ensuring tobacco-free air to breathe (92%), reducing litter (88%), preventing tobacco use (84%) and fires (83%), and helping tobacco users quit (65%). Identified challenges included policy enforcement (69%) and stigmatization of smoking (57%); 30% viewed a policy as compromising personal freedoms. In a model explaining 35% of variance in policy support, those more likely to favor comprehensive tobacco-free campus policy were Asian respondents; diagnosed with asthma; exposed to secondhand smoke on campus; who viewed campus cigarette butt litter as problematic; and identified health, prevention, and cessation benefits of a tobacco-free campus. Those less likely in favor were students, those who smoke, and those perceiving impingement upon personal freedoms, stigmatization, and broader (slippery slope) implications. Findings indicate low tobacco use prevalence among the campus community, yet a large volume of butt litter and high tobacco clean-up costs. Predictors of policy support can inform campus outreach efforts.

Author(s): Epperson, Anna E; Depaoli, Sarah; Song, Anna V; Wallander, Jan L; Elliott, Marc N; Cuccaro, Paula; Tortolero Emery, Susan; Schuster, Mark | Abstract: ObjectiveThis aim of this study was to examine whether the construct of physical appearance perception differed among the three largest racial/ethnic groups in the United States using an adolescent sample.MethodsBlack (46%), Latino (31%), and White (23%) adolescents in Grade 10 from the Healthy Passages study ( N = 4,005) completed the Harter's Self-Perception Profile for Adolescents-Physical Appearance Scale (SPPA-PA) as a measure of physical appearance perception.ResultsOverall, Black adolescents had a more positive self-perception of their physical appearance than Latino and White adolescents. However, further analysis using measurement invariance testing revealed that the construct of physical appearance perception, as measured by SPPA-PA, was not comparable across the three racial/ethnic groups in both males and females.ConclusionsThese results suggest that observed differences may not reflect true differences in perceptions of physical appearance. Measures that are equivalent across racial/ethnic groups should be developed to ensure more precise measurement and understanding.

The article discusses how the Santa Fe Natural Tobacco Co. uses health-oriented marketing terms on the packaging of the firm's Natural American Spirit tobacco products, and it mentions tobacco products-related advertising. According to the article, the Santa Fe Natural Tobacco Co. is owned by Reynolds American Inc. which is the second largest tobacco company in the U.S. Risk perceptions are examined, along with a smoking-related health halo involving organic labeling.

Background/Aims. The aim of this investigation was to identify which design elements on Natural American Spirit packs are salient to (i.e., noticed by) U.S. adult smokers and what meanings smokers derive from these elements. Method. We conducted a secondary analysis of qualitative data from a study of cigarette packaging design. U.S. adult smokers ( n = 33) from all nine census regions participated in six telephone-based focus groups in March 2017. We used constant comparison analysis to identify key themes. Results. Four themes were identified, two focused on salient design elements and two focused on design element meanings. The themes of “bright and flashy color” and “the American Indian logo” were identified as key design elements, while the themes of “healthy and safer” and “targeting at-risk smokers” were identified as meanings smokers derived from design elements. Conclusions. Pack design elements influence smokers’ perceptions about reduced health risk of Natural American Spirit cigarettes and may be especially dangerous to vulnerable populations, including young adults and American Indians. Findings from this study suggest that the banning of text descriptors may not be enough to address misconceptions about “healthier” cigarettes.

Introduction Little is known about how incentives may encourage low income smokers to call for quitline services. This study evaluates the impact of outreach through health channels on California Medicaid (Medi-Cal) quitline caller characteristics, trends, and reach. Study design Longitudinal study. Setting/participants Medi-Cal quitline callers. Intervention Statewide outreach was conducted with health providers, Medi-Cal plans (all-household mailings with tracking codes), and public health organizations (March 2012–July 2015). For incentives, Medi-Cal callers could ask for a $20 gift card; in September 2013, callers were offered free nicotine patches. Main outcome measures Caller characteristics were compared with chi-square analyses, joinpoint analysis of call trends was performed accounting for Medi-Cal population growth, referral source among Medi-Cal and non–Medi-Cal callers was documented, and the annual percentage of the population reached who called the Helpline was calculated. Analyses were conducted 2016–2018. Results Total Medi-Cal callers were 92,900, a 70% increase from prior annual averages: 12.4% asked for the financial incentive, 17.3% reported the mailing code, and 73.3% received nicotine patches while offered. Among the two thirds of callers who completed counseling, 15.5% asked for the financial incentive, and 13.6% reported the mailing code. A joinpoint analysis showed call trends increased 23% above expected for the Medi-Cal population growth after mailings to providers and members began, and decreased after outreach ended. Annual reach increased from 2.3% (95% CI=2.1, 2.6) in 2011 to peak at 4.5% (95% CI=3.6, 5.3) in 2014. Among subgroups with higher reach rates, some also had higher rates of asking for the financial incentive (African Americans, American Indian), reporting the tracking code (whites), or both (aged 45–64 years). Medi-Cal callers were more likely than non–Medi-Cal callers to report providers (32.3% vs 23.8%) and plans (19.7% vs 1.4%) as their referral source, and less likely to cite media (20.2% vs 44.4%, p Conclusions Statewide outreach through health channels incentivizing Medi-Cal members increased the utilization and reach of quitline services. Supplement information This article is part of a supplement entitled Advancing Smoking Cessation in California's Medicaid Population, which is sponsored by the California Department of Public Health.

Author(s): Epperson, Anna E; Anzai, Nicole E; Prochaska, Judith J | Abstract: IntroductionDespite steady declines in the US smoking prevalence over the past 50 years, Natural American Spirit cigarettes (NAS), marketed as natural and organic, have seen a 400% rise in sales. In a sample of smokers with mental illness, based on previous research, we hypothesized that preference for NAS would be associated with younger age, higher education, and a stronger health-orientation.MethodsAdult smokers were interviewed during acute psychiatric hospitalization in California between 2009-2013, reporting their preferred top 3 brands of cigarettes, smoking behaviors, self-rated health, and dietary and physical activity behaviors. The sample (N=956; M age=38.7, SD=13.5; 48.7% women) identified as 14.5% Hispanic ethnicity and 49.6% White, 23.7% African American, and 23.8% other race.ResultsNAS was identified as a top preferred brand by 15.2% of participants and was the fourth most popular brand for the sample overall. In a multivariate logistic regression, preference for NAS was significantly greater among participants who were younger (OR=0.97), had some college education or more (OR=2.64 to 4.31), ate a low-fat diet (OR=1.56) and reported better overall health (OR=1.26), p'sl.05. Identifying as Hispanic ethnicity (OR=1.80) and White race (OR=3.00) also predicted NAS preference, p'sl.05. NAS preference did not differ by gender or psychiatric diagnosis.ConclusionsStudy findings indicate greater NAS brand appeal among smokers living with mental illness who are younger, more highly educated, and have a stronger orientation to health, perhaps because they perceive NAS to be a healthier cigarette to smoke. Marketing language that obscures the harms of smoking ought to be prohibited.

Author(s): Prochaska, Judith J; Epperson, Anna; Skan, Jordan; Oppezzo, Marily; Barnett, Paul; Delucchi, Kevin; Schnellbaecher, Matthew; Benowitz, Neal L | Abstract: BackgroundTobacco use and tobacco-related diseases disproportionately affect Alaska Native (AN) people. Using telemedicine, this study aims to identify culturally-tailored, theoretically-driven, efficacious interventions for tobacco use and other cardiovascular disease (CVD) risk behaviors among AN people in remote areas.DesignRandomized clinical trial with two intervention arms: 1) tobacco and physical activity; 2) medication adherence and a heart-healthy AN diet.ParticipantsParticipants are N = 300 AN men and women current smokers with high blood pressure or high cholesterol.InterventionsAll participants receive motivational, stage-tailored, telemedicine-delivered counseling sessions at baseline and 3, 6, and 12 months follow-up; an individualized behavior change plan that is updated at each contact; and a behavior change manual. In Group 1, the focus is on tobacco and physical activity; a pedometer is provided and nicotine replacement therapy is offered. In Group 2, the focus is on medication adherence for treating hypertension and/or hypercholesterolemia; a medication bag and traditional food guide are provided.MeasurementsWith assessments at baseline, 3, 6, 12, and 18 months, the primary outcome is smoking status, assessed as 7-day point prevalence abstinence, biochemically verified with urine anabasine. Secondary outcomes include physical activity, blood pressure and cholesterol, medication compliance, diet, multiple risk behavior change indices, and cost-effectiveness.CommentsThe current study has the potential to identify novel, feasible, acceptable, and efficacious interventions for treating the co-occurrence of CVD risk factors in AN people. Findings may inform personalized treatment and the development of effective and cost-effective intervention strategies for use in remote indigenous communities more broadly. Clinical Trial Registration # NCT02137902.

The flip side of Natural American Spirit cigarette packs now align the brand with ‘Respect for the Earth’, a corporate social responsibility (CSR) campaign. It champions a ‘100% zero-waste-to-landfill’ manufacturing facility, ‘earth-friendly tobacco’, easier pack recycling, and ‘U.S.-grown tobacco’ (figure 1). Such marketing appeals to biospheric values, with emphasis on the intrinsic value of the ecosystem, implying a moral imperative to act pro-environmentally.1–3 Biospheric values inspire consumers to pay a premium for products perceived as eco-friendly, such as energy-efficient appliances and organic foods.3 Notably, the market share for premium-priced Natural American Spirit increased by more than 400% since 2002,4 even as the number of cigarette smokers in the USA declined to a record low.5 Figure 1 Front and back of four types of Natural American Spirit cigarette packs with ‘Respect for the Earth’ campaign. In reality, biospheric values are entirely incompatible with smoking cigarettes of …

Natural American Spirit (NAS) cigarettes feature a pro-environment marketing campaign on the packs. The NAS “Respect for the Earth” campaign is the first example of on-the-pack corporate social responsibility advertising. In a randomized survey design, we tested perceptions of NAS relative to other cigarette brands on harms to self, others, and the environment. Never (n = 421), former (n = 135), and current (n = 358) US adult smokers were recruited for an online survey from January through March 2018. All participants viewed packs of both NAS and Pall Mall. Participants were randomized to view NAS vs. Pall Mall and to pack color (blue, green, or yellow/orange), which was matched between brands. Survey items assessed perceptions of health risk of the cigarette brand to self, others, and the environment and corporate perceptions. Consistently on all measures, NAS cigarettes were rated as less harmful for oneself, others, and the environment relative to Pall Mall (p's