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Purpose: Research indicates that tobacco marketing contributes to higher pro-tobacco attitudes and behaviors among adolescents, but no studies have been able to assess the impact of real-world tobacco marketing exposures in real-time. The purpose of this study was to examine the magnitude and impact of tobacco marketing exposure on adolescents using ecological momentary assessment (EMA). Our primary hypotheses were that (1) youth would most frequently report tobacco marketing at the retail points-of-sale and (2) greater exposures to tobacco marketing would be associated with more favorable tobacco-related attitudes, use, and expectancies., Methods: Participants were adolescent males from rural and urban Ohio (N = 176, ages 11-16). For ten days, these adolescents were prompted at two-three random times/day to complete a brief smartphone-based survey about their exposures and responses to tobacco-related advertising., Results: Adolescents reported exposures to tobacco marketing an average of 1.9 times over the 10-day EMA period, with over 10% seeing a tobacco advertisement 5 or more times. Reports of marketing exposures occurred most frequently at the point-of-sale; exposures were higher among tobacco users and rural adolescents. Consistent with hypotheses, marketing exposure was related to more positive attitudes to the tobacco advertisements, more tobacco use, and higher expectancies to use in the future., Conclusions: Overall, these findings signal the magnitude of tobacco marketing exposures and their pernicious impact on youth. Findings underscore the importance of federal, state, and local-level tobacco regulatory policies to protect youth from the marketing that puts them at risk for a lifetime of nicotine addiction and tobacco-related diseases., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The tobacco industry spends billions on retail marketing and such marketing is associated with tobacco use. Previous research has not examined actual and potential exposures that adolescents have on a daily basis., Objective: The objective of this study was to determine whether both self-reported and geographically estimated tobacco retailer exposures differ by participant or neighborhood characteristics among urban and rural adolescents., Methods: The data for this study were part of a cohort study of 1220 adolescent males residing in urban and rural (Appalachian) regions in Ohio. The baseline survey asked participants how often they visited stores that typically sell tobacco in the past week (self-reported exposures). The number of tobacco retailers between home and school was determined using ArcGIS software (potential exposures). Adjusted regression models were fit to determine the characteristics that were associated with self-reported or potential exposures to retailers., Results: Adolescents who were non-Hispanic black or other racial/ethnic minority, had used tobacco in the past, and lived in rural areas had higher self-reported exposures. Urban adolescents, non-Hispanic black or other racial/ethnic minority, and those living in neighborhoods with a higher percentage of poverty had more potential exposures to tobacco retailers in their path between home and school., Conclusions: Rural adolescents had more self-reported marketing exposures than urban adolescents. However, urban adolescents had more potential tobacco exposures between home and school. Thus, point of sale marketing limitations might be a more effective policy intervention in rural areas whereas limits on tobacco retailers might be more effective for urban areas.

The recent growth in smokeless tobacco (ST) consumption has raised questions about consumer risk perceptions of ST products, especially in high-risk vulnerable populations. This qualitative study examined risk perceptions of ST among adolescent and adult users and nonusers in Ohio Appalachia. Focus groups and interviews were held with adolescents (n = 53; M age = 17 years) and adults (n = 63; M age = 34 years) from four Ohio Appalachian counties. Participants were asked about their perceptions of ST-related health risks, ST safety, and the relative safety of ST compared with cigarettes. Transcriptions were coded independently by two individuals. Overall, participants were knowledgeable about health problems from ST use (e.g., oral cancers, periodontal disease). Nearly all participants stated that ST use is not safe; however, there was disagreement about its relative safety. Some perceived all tobacco products as equally harmful; others believed that ST is safer than cigarettes for either the user or those around the user. Disagreements about ST relative safety may reflect mixed public health messages concerning the safety of ST. Comprehensive consumer messages about the relative safety of ST compared with cigarettes are needed. Messages should address the effect of ST on the health of the user as well as those exposed to the user.

Objective: As smokeless tobacco (ST) marketing increases and new products emerge on the market, very little is known about consumer perceptions of ST products. To inform development of future ST counter-marketing approaches, this qualitative study examined consumer perceptions of traditional and novel ST products and packaging., Methods: Focus groups and qualitative interviews were held with adolescent (n=23; mean age of 17 years) and adult (n=38; mean age of 29 years) male ST users from rural Ohio counties. Participants were shown a variety of traditional (eg, Copenhagen, Timber Wolf) and novel (eg, Camel Snus, Orbs) ST products and asked about perceptions of these products and their packaging. Transcriptions were coded independently for common themes by two individuals., Findings: Adolescents and adults generally had similar beliefs and reactions about ST products. While participants were familiar with a variety of traditional ST products, Copenhagen was the most frequently used product. Perceptions of quality and price of traditional products were closely tied to product taste and packaging material. Colours, design and size of ST packaging appealed to participants and influenced decisions to purchase. Adults believed novel ST products had a weak taste and were targeted at untraditional ST users. While the vast majority was unfamiliar with dissolvable tobacco, adolescents noted that they would be more convenient to use during school than traditional ST., Conclusions: Packaging has a significant role in shaping perceptions of ST and consumer behaviour. Regulation of product packaging such as shape, size and images should be part of comprehensive tobacco control.

Background: The cervical cancer burden is high among women living in Appalachia. Cigarette smoking, a cervical cancer risk factor, is also highly prevalent in this population. This project aims to increase smoking cessation among women living in Appalachia by embedding a smoking cessation program within a larger, integrated cervical cancer prevention program. Methods: The broader program, the Take CARE study, is a multi-site research collaborative designed to address three risk factors for cervical cancer incidence and mortality: tobacco use, human papillomavirus (HPV) infection, and cervical cancer screening. Break Free is a primary care clinic-based implementation program that aims to promote smoking cessation among female smokers in Appalachia by standardizing clinical practice protocols. Break Free includes: (1) implementation of a tobacco user identification system in the Electronic Health Record, (2) clinic staff and provider training on the Ask, Advise and Refer (AAR) model, (3) provider implementation of AAR to identify and treat women who want to quit smoking within the next 6 months, (4) facilitated access to cessation phone counseling plus pharmacotherapy, and (5) the bundling of Break Free tobacco cessation with HPV vaccination and cervical cancer screening interventions in an integrated approach to cervical cancer prevention. The study spans 35 Appalachian health clinics across 10 healthcare systems. We aim to enroll 51 adult female smokers per health system (total N = 510). Baseline and follow-up data will be obtained from participant (provider and patient) surveys. The primary outcome is self-reported 12-month point prevalence abstinence among enrolled patients. All randomized patients are asked to complete follow-up surveys, regardless of whether they participated in tobacco treatment. Data analysis of the primary aims will follow intent-to-treat methodology. Secondary outcomes will assess program implementation and cost effectiveness. Discussion: Addressing high tobacco use rates is critical for reducing cervical cancer morbidity and mortality among women living in Appalachia. This study evaluates the implementation and effectiveness of a smoking cessation program in increasing smoking cessation among female smokers. If results demonstrate effectiveness and sustainability, implementation of this program into other health care clinics could reduce both rates of smoking and cervical cancer. Trial registration NCT04340531 (April 9, 2020) [ABSTRACT FROM AUTHOR]

Introduction: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors.Aims and Methods: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3).Results: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance.Conclusions: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance.Implications: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement. [ABSTRACT FROM AUTHOR]

The January 2024 issue of Nicotine & Tobacco Research highlights the use of qualitative research methods in the field of nicotine and tobacco research. Qualitative research involves exploring themes through textual data, often collected through focus group and semi-structured interviews. The six papers in this issue demonstrate how qualitative research can be used to understand new topics, tailor interventions, and evaluate the effectiveness of programs. These methods are valuable for informing the development of interventions, educational programs, and policies related to nicotine and tobacco use. [Extracted from the article]

Objective: In this study, we aimed to examine substance use among college students during the acute period of transition between high school and college. Methods: One week before coming to campus, participants completed an online survey assessing their alcohol, tobacco, and marijuana use. Next, beginning on the first Friday of the semester, they completed a 10-day experience sampling (ES) protocol, receiving one app-based survey each morning assessing recent substance use. Results: Among students who used any tobacco product prior to college, 70% or more reported alcohol use during ES. Among previous marijuana users, 85.7% reported alcohol use during ES. Baseline alcohol and tobacco use were not associated with subsequent marijuana use. Conclusions: Substance use prevention should target the transition to college. [ABSTRACT FROM AUTHOR]

Objectives: In the United States, print advertisements for smokeless tobacco (SLT) feature a large warning covering 20% of the advertisement space, whereas cigarette and e-cigarette advertisements cover approximately 4%. We explored how warning size affects adolescent boys' recollection of the warning, brand-relevant advertisement features, and product risks. Methods: Overall, 1220 adolescent males (ages 11-16) viewed SLT, cigarette, and e-cigarette advertisements and were asked to recall what they remembered most. Coders identified recalls of the warning label, advertisement features, and risks associated with the product in responses. Results: Participants were less likely to recall warnings in the cigarette versus SLT (OR = 0.30, p < .001) and e-cigarette versus SLT (OR = 0.15, p < .001) ads. Separate GEEs revealed that boys who recalled warnings were less likely to mention brand-relevant advertisement features (OR's < 0.32, ps < .001). Logistic regressions revealed that boys who recalled the warnings were more likely to mention risks associated with the products (ORs > 3.50, ps < .001). Conclusions: Adolescent boys are more likely to recall large SLT warnings than small cigarette and e-cigarette warnings. Warning recall is associated with lower likelihood of recalling brand-relevant advertisement features and greater likelihood of mentioning product risks. [ABSTRACT FROM AUTHOR]

Introduction: Smokers are using electronic cigarettes, also known as e-cigarettes, as a cessation aid, despite uncertainty about their efficacy. This report describes the association between use of e-cigarettes before and after cessation treatment and tobacco abstinence at 12 months. It also presents characteristics of e-cigarette users and reasons for use.Methods: A longitudinal observational secondary analysis of self-reported e-cigarette use was conducted among adult Appalachian smokers enrolled in a community-based tobacco dependence treatment trial (n = 217). Data were collected at baseline, 3, 6, and 12 months following treatment. The primary outcome measure was biochemically-confirmed 7-day point prevalence tobacco abstinence at 12 months post-treatment.Results: One in five participants reported using e-cigarettes post-treatment. Baseline sociodemographic and tobacco-related characteristics did not differ by e-cigarette use. Primary reasons for e-cigarette use included help in quitting, help in cutting down on cigarettes, and not as bad for health. At the 12 month follow-up, tobacco abstinence was significantly lower among post-treatment e-cigarette users (4.7%) than nonusers (19.0%); (OR = 0.21 95% CI: 0.05-0.91, p = .021). Baseline use was not associated with 12-month abstinence.Conclusions: Among adult Appalachian smokers enrolled in community-based tobacco cessation treatment, use of e-cigarettes post-treatment was associated with lower abstinence rates at 12 months.Implications: This descriptive report of electronic cigarette use after participation in a community-based group randomized tobacco dependence treatment trial adds to the body of science examining e-cigarette use and cessation. Post-treatment e-cigarette use was associated with less success in achieving abstinence at 12 months, as compared to nonuse. At 3 months post-treatment, the majority of those who reported use of e-cigarettes did so to assist with cessation. [ABSTRACT FROM AUTHOR]

Introduction: While it is clear that tobacco use has been increasing in developing countries, it is unclear whether smokers in these countries utilize cessation assistance to quit. We examined the extent to which smokers in developing countries use assistance when making a cessation attempt.Methods: Data from the Global Adult Tobacco Survey of 16 low and middle income countries were analyzed. This nationally representative household survey collected data on assistance that smokers used to quit, such as provider advice, pharmacotherapy, and quit lines between 2008 and 2012.Results: Use of any of the recommended assistance in the past 12 months varied greatly in lower middle income countries (4% to 27%), and to a lesser extent in upper middle income countries (5% to 18%). Counseling and pharmacotherapy were more commonly used than other types of assistance, though the prevalence was low across countries (counseling: 1% to 15%; pharmacotherapy: 1% to 27%). Quit lines were rarely used (0.1% to 1.5%). The average age of assistance users and nonusers was both around 40. In general, past users of cessation assistance tended to have higher education levels than nonusers.Conclusions: Cessation assistance is underused in these low and middle income countries. Tobacco control advocates in these countries should work on ways to promote use of cessation assistance to enhance quit rates. [ABSTRACT FROM AUTHOR]

Introduction: Compared to the majority of non-Hispanic white ("white") cigarette smokers, many African American smokers demonstrate a later age of initiation. The goal of the present study was to examine African American late-onset smoking (ie, regular smoking beginning at age 18 or later) and determine whether late-onset (vs. early-onset) smoking is protective in terms of quit rates and health outcomes.Methods: We used data from the National Survey of Midlife Development in the United States (MIDUS) because the wide age range of participants (20-75 at baseline) allowed the examination of smoking cessation and mortality incidence across the lifespan.Results: Consistent with previous research, results indicated a later average age of smoking onset among African Americans, compared to whites. Disentangling effects of race from age-of-onset, we found that the cessation rate among late-onset African American smokers was 33%, whereas rates for early-onset African American smokers and early- and late-onset white smokers ranged from 52% to 57%. Finally, results showed that among white, low-socioeconomic status (SES) smokers, the hazard rate for mortality was greater among early- versus late-onset smokers; in contrast, among African American smokers (both low- and high-SES) hazard rates for mortality did not significantly differ among early- versus late-onset smokers.Conclusions: Although late (vs. early) smoking onset may be protective for whites, the present results suggest that late-onset may not be similarly protective for African Americans. Tobacco programs and regulatory policies focused on prevention should expand their perspective to include later ages of initiation, in order to avoid widening tobacco-related health disparities.Implications: This study indicates that late-onset smoking is not only the norm among African American adult smokers, but that late- versus early-onset smoking (ie, delaying onset) does not appear to afford any benefits for African Americans in terms of cessation or mortality. These results suggest that prevention and intervention efforts need to consider individual groups (not just overall averages) and that tobacco control efforts need to be targeted beyond the teenage years. Tobacco programs and regulatory policies focused on prevention should expand their perspective to include later ages of initiation, to avoid widening tobacco-related health disparities. [ABSTRACT FROM AUTHOR]

Introduction:: Widespread tobacco use and high interest in quitting make prisons an ideal environment for smoking cessation interventions; however, little has been done to assist prisoners in their efforts to quit. Valid measurement of tobacco use is a prerequisite to evaluation of cessation programs, yet there has been only one published examination of tobacco use measures among prisoners. [ABSTRACT FROM PUBLISHER]

Abstract: Lung cancer is the leading cause of cancer death for both men and women in the United States. Patient quality of life (QOL) prior to cancer treatment is known to be a strong predictor of survival and toleration of treatment toxicities. A lung cancer patient''s self-assessment of QOL is highly valued among clinicians as it guides treatment-related decisions and impacts clinical outcomes. Smokers are known to report a lower QOL. Limited research has been conducted on QOL outcomes in lung cancer patients who continue to smoke. To assess QOL, a reliable and valid QOL measure specific to lung cancer is required. The functional assessment of cancer therapy-lung cancer (FACT-L) and lung cancer symptom scale (LCSS) are instruments that specifically examine QOL among lung cancer patients. The LCSS is a focused QOL instrument that includes physical and functional domains of QOL and disease symptomatology. The FACT-L is a broader QOL instrument that includes physical, functional, social and emotional domains and disease symptomatology. Both are psychometrically valid and are widely used in the literature, but have not been exclusively evaluated in smokers. Furthermore, there is no ‘gold standard’ instrument since there has never been a correlation study to compare estimates of reliability and validity between these instruments. The purpose of this study is to report the internal consistency and convergence validity of the FACT-L and the LCSS among newly diagnosed lung cancer patients who smoke. This data were collected and analyzed from a larger study examining smoking behavior among newly diagnosed lung cancer patients (n =51). Descriptive statistics were calculated on the FACT-L and LCSS scores, internal consistency was assessed by estimating Cronbach''s alpha coefficients, and Pearson correlation coefficients were estimated between the two scales. Internal consistency coefficients demonstrated good reliability for both scales, and the two instruments demonstrated a strong correlation, suggesting good convergence validity. Either of these instruments are appropriate measures for QOL in lung cancer patients who smoke. Given the conceptual difference between the two instruments, it is important to carefully consider the research aims when selecting the appropriate QOL measurement instrument. [Copyright &y& Elsevier]

Introduction:: This study sought to determine the relationship between acculturation and misclassification of tobacco use among Hispanic Americans. [ABSTRACT FROM PUBLISHER]

The purpose of this study was to extend research regarding the perceptions smokers have of the advantages and disadvantages of using potential reduced exposure products (PREPs). Five focus groups with female current smokers were conducted in the Appalachian region of Ohio. The semistructured discussion guide was developed to capture information on reasons why women smoke, why and how they quit smoking, and reasons why women would switch to PREPs. The results suggest that these smokers did not express enthusiasm for using PREPs as an aid to smoking cessation or as a harm reduction product. In general, the concept of harm reduction in the sense of reducing disease risks did not engage the participants. Early in the discussion the women had identified some problems caused by their smoking and later PREPs were viewed as reducing these. The results suggest that PREPs may be attractive to some smokers because they offer benefits that other products lack. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to estimate tobacco use prevalence among the Amish in Holmes County, Ohio, using both self-report and a biochemical marker of nicotine exposure. Methods: Amish adults (n = 134) were interviewed as part of a lifestyle study. Self-reported tobacco use was measured using standardized questions, and cotinine was measured from a saliva sample. The prevalence of smoking, total tobacco use, and misclassification were estimated separately by gender, and then compared to 2 non-Amish groups. One group was selected from 2 counties contained within the Holmes County Amish settlement (n = 154) and the other was representative of non-Hispanic whites in the United States (n = 4,099). Findings: No Amish women reported current tobacco use and only 2 reported former use. This was significantly different ( P < .0001) from the patterns observed among non-Amish in the settlement counties (15.7%) and US white (23.3%) women. The prevalence of tobacco use among Amish men was 17.6% and this was significantly lower than estimates from non-Amish in the settlement counties (38.8%, P= .04) and US white (32.2%, P= .005) men. No Amish women and only 2 Amish men underreported tobacco use and misclassification was similar in the comparison groups. Conclusions: Tobacco use is significantly lower among adults in the largest Amish settlement in the world compared to their non-Amish neighbors in Appalachia Ohio and US whites. A strength of this study is that self report was verified with a marker of nicotine, a critical measure to include in any study conducted in a group that stigmatizes tobacco use. [ABSTRACT FROM AUTHOR]

Introduction: A growing body of evidence indicates that exposure to tobacco advertising among adolescents increases the likelihood of subsequent tobacco use. It is important to understand the process by which this occurs, in order to appropriately target factors for intervention. The objective of this study was to test whether attitudes towards tobacco advertising mediates the impact of advertising exposure on tobacco use.Methods: From an ongoing prospective cohort study of male adolescents (aged 11-16 at baseline), we recruited a subset of tobacco users and non-users to participate in an additional ecological momentary assessment (EMA) project (N = 164). Adolescents completed smartphone-based surveys 2-3 times/day over a 10-day period with items assessing their exposures and attitudes towards tobacco-related advertising. If participants reported exposure to tobacco advertising, they were asked about their attitudes toward it (how much they enjoyed it, liked it, and found it appealing).Results: Adolescents who reported a greater amount of advertising exposure during the EMA period were more likely to report past-30-day tobacco use at their next cohort follow-up (6-12 months later). Moreover, the impact of advertising exposure on subsequent use was mediated by attitudes toward the tobacco advertisements, as reported during the EMA. This effect remained after controlling for baseline tobacco use.Conclusions: By pairing EMA with long-term follow-up, we identified attitudes as a mediator between adolescent advertising exposure and subsequent tobacco use. Interventions to lessen adolescents' positive attitudes toward tobacco advertisements may help disrupt this impact. [ABSTRACT FROM AUTHOR]

Background: Married couples often share similar health-related characteristics and behaviors, including cigarette smoking status. Despite their rising popularity in the U.S., little research has examined the patterns of spousal concordance (SC) for alternative tobacco products (ATPs), such as e-cigarettes, cigars, and hookah.Methods: The purpose of this project was to examine the roles of age, gender, and culture in the strength of SC for these ATPs. Analyses focused on a diverse community sample of married individuals in Ohio, U.S. (N=278), but also examined patterns in Austria, Greece, Israel, the Netherlands, and Slovakia. All participants completed a survey in which they indicated both their own, and their spouse's ever-use of various tobacco products.Results: For the U.S. sample, SC was highest for e-cigarettes, flavored e-cigarettes, flavored cigarettes, and hookah (ϕs=0.48- 0.61); SC appeared to be stronger among younger couples, and when there was only a small female vs. male differences in use. Similar patterns were found in the other countries, with a few key exceptions. In particular, there was low SC for e-cigarettes and flavored e-cigarettes in the other countries, where e-cigarettes had been federally regulated by the time of data collection.Conclusion: Overall, these findings have implications for the continued spreading popularity of these tobacco use behaviors. [ABSTRACT FROM AUTHOR]

Researchers have proposed numerous factors that may contribute to rural adolescents' heightened risk for tobacco use. Some of these include well-known risk factors for tobacco use, whereas others concern factors unique to rural populations, reflecting norms and values ("rural culture") that accept and encourage tobacco use. This study aimed to test a broad range of tobacco-use risk factors to determine which were a) universal risk factors for both urban and rural adolescents vs. b) unique risk factors for rural adolescents. Data came from a prospective cohort study of 1220 adolescent males in Ohio who were aged 11-16 (average = 14 years) when surveyed at baseline (2015-2016). Follow-up surveys occurred every 6 months. The present study examined tobacco-use outcomes-prevalent use and incident use-by the two-year follow-up (2017-2018). Findings indicated a higher prevalence of ever-use of cigarette and smokeless tobacco among rural, vs. urban, adolescents at baseline. By the two-year follow-up, the urban/rural difference was attenuated but remained. Stratified multivariable logistic regression indicated that some baseline risk factors were associated with subsequent tobacco use for both rural and urban adolescents. Having an adult tobacco user in the home (for prevalent use) and susceptibility to a male family member offer of tobacco products (for both prevalent and incident use) were associated with tobacco use only for rural adolescents. These findings align with qualitative work demonstrating that masculinity and an intergenerational tobacco culture are important to male adolescents. This unique rural profile should be considered when developing prevention efforts. [ABSTRACT FROM AUTHOR]