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The Population Assessment of Tobacco and Health (PATH) Study is a nationally representative study of the US population on tobacco use and its effects on health, with four waves of data collection between 2013 and 2017. Prior work described the methods of the first three waves. In this paper, we describe the methods of Wave 4, during which a replenishment sample was added to the ongoing cohort. We describe the design and estimation methods of the continuing Wave 1 cohort (with four waves of data) and the Wave 4 cohort (the new cohort created at Wave 4). We provide survey quality metrics, including response rates for both cohorts and a panel conditioning analysis, and guidance on understanding the target populations for both cohorts.

Background: The purpose of this study was to examine the association between established cigar use and prevalence and incidence of cardiovascular diseases (CVD; congestive heart failure, stroke, or heart attack/needed bypass surgery) among U.S. adults, 40 years or older. The study also explored if years of use, is associated with CVD prevalence. Methods: Using Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of U.S. adults and youth, pooled prevalence, restricted to adults 40 and older who provided data at every wave (N=10,128 unique respondents and Nobs=46,294;), was estimated to understand the association between established cigar use and self-reported CVD outcomes. Weighted generalized estimating equations were used to examine CVD outcomes among exclusive current/former established cigar smokers (ever cigar smokers who have smoked fairly regularly), exclusive current/former established cigarette smokers (lifetime smokers of 100 or more cigarettes), dual current/former established cigarette and cigar smokers compared to never smokers of cigars or cigarettes, adjusting for covariates. Results: The incidence of CVD among exclusive current/former established cigar smokers over a six-year period was low (overall average rate of 3.0%). The pooled-prevalence of CVD outcome was very similar among exclusive current/former established cigar smokers (10.7%; 95% CI: 7.0-16.1) and exclusive current/former established cigarette smokers (10.7%; 95% CI: 9.4-12.2) and slightly higher among dual users of cigars and cigarettes (14.3%; 95% CI: 11.8-17.1). Compared to never users, exclusive current/former established cigar smokers (OR = 1.67, 95% CI: 1.11-2.51) and exclusive current/former established cigarette smokers (OR = 2.12, 95% CI: 1.45-3.09) were more likely to have any CVD outcome in unadjusted analyses. When adjusted for covariates, only exclusive current/former established cigarette use was associated with CVD outcomes (AOR = 1.63, CI: 1.05-2.53). We did not find a consistent dose response relationship between duration of exclusive current/former established cigar use and CVD prevalence. Conclusions: Understanding how cigar use impacts CVD is important in reducing tobacco-related mortality and morbidity. In this study, exclusive established use of cigars or duration of exclusive cigar use was not associated with CVD prevalence compared to never cigar or cigarette smokers.

ObjectiveTo report on demographic and tobacco use correlates of cessation behaviours across tobacco products (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.DesignData were drawn from the first three waves (2013–2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (ages 12–17) and adults (ages 18+) . Past 30-day (P30D) tobacco users at Wave 1 (W1) or Wave 2 (W2) were included (n=1374 youth; n=14 389 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco use characteristics at baseline, with cessation behaviours at follow-up (discontinuing use, attempting to quit, quitting), over two 1-year periods (W1–W2, W2–Wave 3).ResultsAmong adult users of each type of tobacco product, frequency of use was negatively associated with discontinuing use. Among adult cigarette smokers, non-Hispanic white smokers, those with lower educational attainment and those with lower household income were less likely to discontinue cigarette use; ENDS use was positively associated with making quit attempts but was not associated with cigarette quitting among attempters; smokeless tobacco use was positively associated with quitting among attempters; tobacco dependence was negatively associated with quitting among attempters. Among youth cigarette smokers, tobacco dependence was negatively associated with making quit attempts.DiscussionDemographic correlates of tobacco cessation behaviours underscore tobacco use disparities in the USA. Use of ENDS and use of smokeless tobacco products are positively associated with some adult cigarette cessation behaviours.

ObjectiveTo report on demographic and tobacco product use correlates of tobacco product initiation (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.DesignData were from the first three waves (2013–2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (aged 12–17 years) and adults (aged 18+ years). Never users of at least one type of tobacco product at Wave 1 (W1, 2013/14) or Wave 2 (W2, 2014/15) were included (n=12 987 youth; n=25 116 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco product use characteristics at baseline, and tobacco product initiation at follow-up (ever, past 30 day (P30D), frequent (use on 20 or more of thepast 30 days)) over two 1-year periods (W1–W2 and W2–Wave 3).ResultsYouth aged 15–17 years were more likely than youth aged 12–14 years and adults aged 18–24 years were more likely than older adults to initiate P30D tobacco use across products; non-heterosexuals were more likely than heterosexuals to initiate P30D cigarette and ENDS use. Older adults were more likely than young adults, and males were more likely than females, to be frequent users of ENDS on initiation. Ever use of another tobacco product predicted P30D initiation of each tobacco product.DiscussionOther tobacco product use and age predict P30D tobacco initiation across products whereas associations with other demographic characteristics vary by product. Continued contemporary evaluation of initiation rates within the changing tobacco product marketplace is important.

ObjectiveThis study examines sociodemographic and tobacco use correlates of reuptake and relapse to tobacco use across a variety of tobacco products (cigarettes, electronic nicotine delivery systems, cigars, hookah and smokeless tobacco) among the US population.DesignData were drawn from the first three waves (2013–2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (ages 12–17) and adults (ages 18+). Reuptake (past 30-day use among previous tobacco users) and relapse (current use among former established users; adults only) were examined among previous users of at least one type of tobacco product at Wave 1 (W1) or Wave 2 (W2) (n=19 120 adults, n=3039 youth). Generalised estimating equations were used to evaluate the association between demographic and tobacco use characteristics at baseline, with reuptake/relapse at follow-up, over two 1-year periods (W1–W2 and W2–Wave 3).ResultsAny tobacco product reuptake occurred in 7.8% of adult previous users and 30.3% of youth previous users. Correlates of any tobacco reuptake included being male, non-Hispanic black and bisexual in adults, but race and sexual orientation were not consistent findings in youth. Among recent former users, relapse rates were greater (32.9%). Shorter time since last use and greater levels of tobacco dependence showed the strongest association with any tobacco relapse.DiscussionContinued clinical and public health efforts to provide adults with tools to cope with tobacco dependence symptoms, especially within the first year or two after quitting, could help prevent relapse.

Potential mechanisms by which e-cigarette use may relate to combustible cigarette smoking cessation are not well-understood. We used U.S. nationally representative data to prospectively evaluate the relationship between e-cigarette flavor use and frequency of e-cigarette use among adult cigarette/e-cigarette dual users who attempted to quit smoking cigarettes. Analyses used Population Assessment of Tobacco and Health (PATH) Study data from adult dual users (2015/16) who attempted to quit smoking between 2015/16 and 2016/17 (Wave 3-Wave 4, n = 685, including those who did/did not quit by 2016/17). E-cigarette flavor use (usual/last flavor, past 30-day flavor; assessed in 2015/16) was categorized into Only tobacco; Only menthol/mint; Only non-tobacco, non-menthol/mint; and Any combination of tobacco, menthol/mint, other flavor(s). The key outcome, evaluated at follow-up in 2016/17, was frequent e-cigarette use, which was defined as use on 20+ of past 30 days. Logistic regression was used to evaluate associations between e-cigarette flavor use in 2015/16 and frequent e-cigarette use at follow-up in 2016/17. Dual users who attempted to quit smoking had greater odds of frequent e-cigarette use at follow-up when they used only non-tobacco, non-menthol/mint flavor than when they used only tobacco flavor as their regular/last e-cigarette flavor (OR = 1.9, 95% CI: 1.1–3.4); findings were no longer significant when adjusted for factors including e-cigarette device type (AOR = 1.4, 95% CI: 0.7–2.8). Past 30-day e-cigarette flavor use results were generally similar, although frequent e-cigarette use at follow-up was highest among those who used any combination of tobacco, menthol/mint, or other flavors. Findings indicate that e-cigarette flavor use among dual users who attempt to quit smoking may be related to e-cigarette use frequency overall, which may indicate a mechanism underlying findings for e-cigarette use and smoking cessation. Further longitudinal research may help to disentangle how e-cigarette characteristics uniquely impact e-cigarette use frequency and smoking cessation/sustained use.

Highlights • A variety of approaches were used to describe quantity across device types. • The most common approach was number of times/puffs per day, but specificity varied. • Some described quantity in device-specific terms (cartridge/pod, device, e-liquid). • Tank users varied in how they described quantity of e-liquid used., The purpose of this qualitative study was to gain a deeper understanding of how adult e-cigarette users describe quantity of e-cigarettes used. Data for this analysis came from a qualitative study of U.S. adult dual e-cigarette and cigarette users and former cigarette smokers aged 18 years and older. Eligible respondents from Wave 4 (2016–2017) of the Population Assessment of Tobacco and Health (PATH) Study responded to a brief web questionnaire and participated in an in-depth telephone interview (n = 112) between March and August 2018. Using the respondent’s native terminology for their e-cigarette device, interviewers asked respondents to describe in their own words the quantity of e-cigarettes used. Using NVivo software, interview transcripts were coded and analyzed to identify themes and patterns. Respondents described quantity used in three different ways: number of times and/or puffs; device-specific terms (i.e., replacement of disposable devices, cartridges/pods; use of e-liquid); and perceived equivalence to a quantity of traditional cigarettes. The most commonly reported approach across all device types and levels of device proficiency, although with varying ease and specificity, was the number of times and/or puffs taken in a day. Several respondents used multiple approaches to describe quantity. E-cigarette users use a variety of approaches to describe quantity of e-cigarette used, contributing to challenges developing standardized survey measures. The variety of approaches should be taken into consideration along with device type and other contextual factors such as device proficiency when developing survey questions.

Addiction beliefs about tobacco use are associated with intentions to use and use of tobacco products. Exposure to information about tobacco products in media sources may affect addiction beliefs.To examine the relationship between media exposure and tobacco product addiction beliefs.A nationally representative sample of US adults (n=3738) from the 2015 National Cancer Institute's Health Information National Trends Survey was used to examine addiction beliefs about cigarettes, cigars, smokeless tobacco, electronic cigarettes, hookah/waterpipe tobacco, and roll-your-own cigarettes. We used logistic regression to examine the relationship between media exposure and addiction beliefs. We defined media exposure by hours exposed, as well as exposure to tobacco use health effects information through media sources including social media. We categorized media sources by whether respondents actively or passively engaged with the source.A majority (60.6% to 87.3%) of respondents believed that cigarettes, cigars, roll-your-own cigarettes and smokeless tobacco are addictive. Less than half of respondents believed that electronic cigarettes or hookah/waterpipes are addictive (45.2% and 49.8%, respectively). Respondents exposed to messages about tobacco use health effects on active media channels (e.g., social media) had greater odds of believing that smokeless tobacco (adjusted odds ratio [AOR]=1.48), hookah/waterpipe (AOR=1.69), and roll-your-own cigarettes (AOR=1.61) are addictive. Respondents exposed to tobacco use health effects messages on passive media channels (e.g., television), had greater odds of believing that cigarettes (AOR=2.76) and electronic cigarettes (AOR=2.12) are addictive.US adult exposure to information about the health effects of tobacco use was associated with addiction beliefs about tobacco products.

Objective To examine whether mental health problems predict incident use of 12 different tobacco products in a nationally representative sample of youth and young adults. Method This study analyzed Wave (W) 1 and W2 data from 10,533 12- to 24-year-old W1 never tobacco users in the Population Assessment of Tobacco and Health (PATH) Study. Self-reported lifetime internalizing and externalizing symptoms were assessed at W1. Past 12-month use of cigarettes, electronic nicotine delivery systems (ENDS), traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, other smokeless tobacco, bidis and kreteks (youth only), and dissolvable tobacco was assessed at W2. Results In multivariable regression analyses, high-severity W1 internalizing (adjusted odds ratio [AOR] = 1.5, 95% CI = 1.3−1.8) and externalizing (AOR = 1.3, 95% CI = 1.1−1.5) problems predicted W2 onset of any tobacco use compared to no/low/moderate severity. High-severity W1 internalizing problems predicted W2 use onset across most tobacco products. High-severity W1 externalizing problems predicted onset of any tobacco (AOR = 1.6, 95% CI = 1.3−1.8), cigarettes (AOR = 1.4, 95% CI = 1.0−2.0), ENDS (AOR = 1.8, 95% CI = 1.5−2.1), and cigarillos (AOR = 1.5, 95% CI = 1.0−2.1) among youth only. Conclusion Internalizing and externalizing problems predicted onset of any tobacco use. However, findings differed for internalizing and externalizing problems across tobacco products, and by age, gender, and race/ethnicity. In addition to screening for tobacco product use, health care providers should screen for a range of mental health problems as a predictor of tobacco use. Interventions addressing mental health problems may prevent youth from initiating tobacco use.

Background While evidence suggests bidirectional associations between cigarette use and substance (alcohol or drug) use, how these associations are reflected across the range of currently available tobacco products is unknown. This study examined whether ever tobacco use predicted subsequent substance use, and ever substance use predicted subsequent tobacco use among 11,996 U.S. youth (12–17 years) from Waves 1 (2013–2014) and 2 (2014–2015) of the Population Assessment of Tobacco and Health (PATH) Study. Methods Ever use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, smokeless tobacco excluding snus pouches, dissolvable tobacco, bidis, kreteks, alcohol, marijuana, prescription drugs, and other drugs (cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens) was assessed at Wave 1 followed by past 12-month use assessments at Wave 2. The analyses included covariates (demographics, mental health, sensation seeking, prior use) to mitigate confounding. Results Ever tobacco use predicted subsequent substance use. The magnitude of the associations was lowest for alcohol, higher for marijuana, and highest for other drugs. Ever substance use also predicted subsequent tobacco use. Specifically, ever alcohol, marijuana, and non-prescribed Ritalin/Adderall use predicted tobacco-product use. Ever e-cigarette and cigarette use exclusively and concurrently predicted subsequent any drug (including and excluding alcohol) use. E-cigarette and cigarette use associations in the opposite direction were also significant; the strongest associations were observed for exclusive cigarette use. Conclusion Tobacco and substance use prevention efforts may benefit from comprehensive screening and interventions across tobacco products, alcohol, and drugs, and targeting risk factors shared across substances.