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ObjectiveIn April 2018, JUUL Labs announced a $30 million investment in efforts to combat underage use of its products through ‘independent research, youth and parent education and community engagement’. Prior evidence demonstrates that tobacco industry-funded prevention programmes are ineffective and may work against tobacco control efforts; they do not discourage novices and youth from tobacco use but often improve the tobacco industry’s public image. We describe the nature, timing of and expenditures related to the JUUL underage use prevention advertisements across media channels.MethodsExpenditures for newspaper, magazine, television, and radio marketing and promotional efforts were collected through Kantar Media’s ‘Stradegy’ dashboard, an online platform which provides counts of advertisement occurrences and expenditures on various media channels. JUUL public relations and corporate social responsibility ads were identified in the Kantar Database. All ad expenditures were extracted and aggregated by date. Analysis of the expenditure data was triangulated with newspaper and industry advertisement archives.ResultsAdvertisements aired nationally and in over half of all US-designated market areas (n=130) across media platforms including newspapers, magazines, radio, and online in mobile web and internet displays. In 2018, JUUL Labs spent $30 million, predominantly for print advertising. The ‘What Parents Need to Know about JUUL’ ads primarily advertised JUUL’s smoking reduction ‘mission’ and promoted the product. By 2019, advertising increased to $36.2 million. JUUL’s message strategy transitioned to ‘Cracking Down on Underage Sales in Retail Stores’ and featured adult smoker testimonies, linking JUUL to smoking cessation.DiscussionMarketing expenditures promoting JUUL’s corporate social responsibility mission exceeded their $30 million investment in the underage use prevention efforts. The expenditures were focused on the media market areas where health organisation and legislative officials were launching investigations into JUUL social media and other promotional strategies.

Bidi Stick is a single use electronic cigarette (e-cigarette) launched in 2020 by Bidi Vapor.1 Distributed and sold online and in retail stores in the USA,2 the brand’s popularity is growing, with Bidi Stick sales comprising 28% of the disposable e-cigarette market in the fourth quarter of 2020.1 3 In their recent campaign ‘Bidi Cares,’ Bidi Vapor presents their company as the industry leader in environmental consciousness, protection, and care. Central to their marketing is greenwashing , a technique in which products or brands are portrayed as eco-friendly or natural.4–6 Cigarette7–10 and e-cigarette advertising11–14 have both leveraged greenwashing tactics, including cigarette advertisements (predominantly Natural American Spirit) describing their products as ‘natural,’ ‘additive-free,’ ‘organic;’15 16 using nature-related imagery;7–9 17 and highlighting pro-environment corporate social responsibility activities (eg, anti-litter campaigns)7–10 and e-cigarette advertisements touting their products as better for the environment than cigarettes14 and organic or natural.13 Although greenwashing tactics do not make explicit claims about a product’s health benefits or risk profile, they have nonetheless been linked to reduced harm perceptions18–26 and youth appeal.27 28 While analysing media surveillance for an …

ObjectiveThe Framework Convention on Tobacco Control recommends health warning labels (HWLs) include an attribution source. Little is known regarding the perceived credibility and effectiveness of different message sources. This study examined perceptions of four HWL attribution sources among adults in China – the world’s largest consumer of cigarettes.DesignCross-sectional experimental survey design.ParticipantsData were collected in 2017 from a convenience sample of 1999 adults across four cities in China; 80% of the sample were current smokers.Main outcome measuresParticipants viewed four versions of the same HWL, each with a different attribution source: the China Center for Disease Control (ref. group); the regulatory arm of China’s domestic tobacco company (STMA); Liyuan Peng, China’s first lady; and the WHO. Respondents indicated which HWL was the most: (1) credible, (2) effective at making people quit and (3) effective at preventing youth initiation.ResultsMultinomial logistic regression models estimated adjusted relative risk ratios (aRRRs) of the three outcomes. Controlling for demographics and smoking status, HWLs attributed to STMA and Liyuan Peng, respectively, were perceived as significantly less credible (aRRR=0.81, pConclusionResults suggest the unique role of health organisations in conveying smoking-related messages that appear credible and effective at motivating others to quit smoking or never start smoking in China. Findings can inform global recommendations regarding HWL attribution sources.

BackgroundChina is the country with the highest burden of tobacco-caused disease. We characterised the extent to which cigarette pack marketing features (eg, imagery, text, pack color) could potentially mislead consumers by suggesting products are healthy.MethodsWe used two methods: group concept mapping and content analysis. First, we used a group concept mapping approach to generate and sort Chinese consumer responses to an open-ended prompt asking what marketing features suggest a product is ‘healthy’ or ‘good for you’. Second, based on the concept mapping results, we developed a codebook of health-related features on cigarette packs that were relevant to the unique cultural context of product marketing in China. Two trained coders who were native Chinese speakers double-coded a sample of 1023 cigarette packs purchased in 2013 (wave 1) and 2017 (wave 2). We examined differences in the presence of features overall and over time.ResultsOverall, 83.5% (n=854) of Chinese cigarette packs in our sample contained at least one ‘healthy’ or ‘good for you’ feature, and the presence of health-related features on packs remained constant between wave 1 (83.5%, n=354) and wave 2 (83.5%, n=500; p=1.00). Across both waves, the most common categories of culturally specific health features present related to recycling symbols, rare animal imagery, bright colours (eg, bright yellow) and botanical imagery (eg, bamboo, mint).ConclusionHealth-related features on cigarette packs sold in China are common. Enhanced policies to address tobacco packaging, labelling and branding could support and facilitate a reduction in the high tobacco burden in China.

Introduction Although cigarette use in the United States has declined over time, smokeless tobacco (SLT) use has remained steady. Direct-mail advertising and coupon redemption have been linked to increased tobacco use, and efforts to promote SLT through direct-mail advertising may contribute to sustained SLT use. We examined reach of SLT direct-mail advertisements by recipient demographics and promotional features, including coupons. Methods Direct-mail data (n = 418) were acquired from Comperemedia (Mintel) and coded for product type (traditional [eg, chewing tobacco], pouched [eg, moist snuff, snus], or both [traditional SLT and any pouched SLT products]); promotions (eg, coupons); flavors; and themes (eg, masculinity). Using Mintel’s volume estimates for number of pieces sent, we calculated the proportion of mail volume sent by recipient demographics (age, income, region) and advertising features across product type. Results Between July 2017 and August 2018, tobacco companies sent an estimated 249 million pieces of SLT direct-mail to US households; approximately half (49.6%) featured pouched SLT products. Across product types, over 75% of mail volume was sent to 31- to 60-year-old adults and 30–40% was sent to low-income households. The majority (>70%) of pouched SLT product mail contained coupons and flavor promotions. Outdoor and blue-collar-lifestyle themes were prominent in advertisements for all product types, along with less common adventure- and fun-related appeals. Conclusions Coupons, flavors, and a combination of blue-collar and fun/adventure message themes were used to promote traditional and pouched SLT products through direct-mail, particularly to low-income households. Results support limits on direct-mail coupon distribution and continued surveillance of marketing appeals. Implications There is a long history of research into tobacco advertising practices, largely focusing on cigarettes. This study highlights specific direct-mail marketing tactics used by the tobacco industry, including coupons to promote SLT products across the United States. Given the limited success in reducing SLT use and the association between direct-mail promotions and tobacco use, these study results provide support for policies to restrict use of coupons in direct-to-consumer tobacco marketing and indicate the need for continued surveillance of direct-mail advertisements as the SLT market continues to evolve.

Youth and young adults are the largest consumers of social media content. Individuals with large followers are paid to share social media content using specific products for compensation. This type of activity is considered commercial sponsorship and requires a disclosure in order to comply with Federal Trade Commission regulations. Between July and August 2019, youth and young adult (ages 16-24; n = 200) participants were recruited into an eye-tracking laboratory to view their native Instagram feed on a mobile device where a set of posts from e-cigarette influencers were inserted with one of the two potential labeling strategies: #ad and #sponsored. Participants spent an average of 6.6 seconds viewing e-cigarette influencer posts. Youth and young adults spent 3.1 seconds on the area labeled #ad, compared to 2.2 seconds on the area of interest labeled #sponsored (

Introduction Receptivity to tobacco advertising is an important component in the progression from exposure to advertising to use behavior, yet little is known about current tobacco advertising tactics that increase receptivity. This study tests the effect of three advertising features identified in earlier work as potentially appealing to adolescents and young adults: flora imagery, eco-friendly language, and sweepstakes. Aims and Methods We conducted an online survey in which 1,000 US adolescents (age 15–17) and 1,000 US young adults (age 18–24), equally stratified by smoking status, were exposed to three experimental modules manipulating presence/absence of each feature of interest on cigarette ads. After viewing each ad, participants reported their receptivity to the advertisement. Bivariable analysis and multivariable logistic regression analyses were used to assess the effect of each appeal’s presence on receptivity. Results Adolescents (aOR = 1.55, 95%CI: 1.12–2.14) and young adults (aOR = 1.43, 95%CI: 1.06–1.93) were more likely to be receptive to ads with flora imagery. The effect of sweepstakes on receptivity was modified by the specific ad for young adults. Ecofriendly language did not significantly impact receptivity among either group. Exploratory subgroup analysis found a significant ad by sweepstakes interaction among young adult noncurrent smokers. Conclusion These findings provide evidence that use of flora imagery increases cigarette advertising receptivity among adolescents and young adults, while the effect of sweepstakes on young adults might additionally depend on the ad shown. Restrictions on youth appealing advertising tactics, such as those identified in this study, as well as broader content-neutral advertising restriction policies, should be considered. Implications This study provides evidence for the appeal of flora imagery in cigarette advertising for both adolescents and young adults, as well as the complexity of how use of sweepstakes interacts with branding in specific ads to predict receptivity among young adults. Because receptivity to cigarette advertising is a documented step in the pathway between advertising exposure and product use, restrictions on use of these tactics should be implemented, and broader content-neutral advertising restriction policies should be considered.

Introduction Effective in August 10, 2018, FDA requires advertisements for electronic nicotine delivery systems (ENDS) that meet the definition of a “covered tobacco product” to feature a standard nicotine warning statement. To date, limited data exist on the presence of warning statements in ENDS advertising. Methods We acquired ENDS ads (n = 459) that first ran six months before (February 10, 2018–August 9, 2018) and after (August 10, 2018–February 9, 2019) the effective date. The sample included online, print, and outdoor static ads (ie, without video or animated graphics) (n = 166 before, n = 198 after), online and television video ads (n = 16 before, n = 49 after), and radio ads (n = 9 before, n = 21 after). We coded ads for the presence of the verbatim FDA warning. Ads with verbatim warnings were coded for required formatting and additional features. Results Overall, 28% of static (n = 46/166), 62% of video (n = 10/16), and 67% of radio (n = 6/9) ads that ran before the effective date contained the verbatim warning versus 84% (n = 167/198, p < .001), 96% (n = 47/49, p = .002), and 86% (n = 18/21, p =.329) of ads that ran after, respectively. Following the effective date, nearly all static ads placed the warning as required at the top of the ad (76% [n = 35/46] before, 97% [n = 162/167] after, p < .001), and many video ads featured the warning statement for the entire ad duration (0% [n = 0/10] before, 60% [n = 28/47] after, p < .001). Half (n = 9/18) of radio warnings running after the effective date were read faster than the other promotional content. Conclusions The presence of the nicotine warning statement on paid promotional static, video, and radio ENDS ads in this sample increased after August 10, 2018, but a notable number still lacked the warning. Implications Results from this study provide initial insights into the extent to which required nicotine warning statements appear in ENDS ads in the study sample across traditional (eg, magazines, television, radio) and digital (eg, online/mobile ads) advertising mediums. Following the August 10, 2018, effective date, we observed a substantial increase in the presence of the required FDA warning statement on the ENDS ads in this sample. However, a notable number of ads in the study lacked the required warning and warnings did not always include the required formatting displays.

BackgroundE-cigarette promotion on social media coincided with the rapid growth of e-cigarette use among American youth, particularly with the increased JUUL pod vaporiser use. We examined commercial JUUL-related messages on Instagram to identify marketing appeals used to target users along the continuum of e-cigarette use; we mapped the appeals to existing theoretical marketing frameworks to better understand industry strategies.MethodsHashtag-based keyword rules were used to collect JUUL-related posts from the Instagram application programming interface, 1 March–13 November 2018. Posts were classified as commercial or non-commercial. A combination of machine learning methods, keyword algorithms and human coding were used to characterise message themes in commercial posts.ResultsKeyword filters captured 50 817 relevant posts and 41% were commercial. Among commercial posts, 91% contained recruitment/trial-based appeals (eg, combustible tobacco cessation; product sampling; giveaways) and 71% featured reinforcement/addiction-related appeals (eg, loyalty programmes). None of the commercial messages contained e-cigarette cessation-related appeals and less than 25% mentioned quitting combustible tobacco as a recruitment appeal.ConclusionsInstagram posts featuring e-cigarette related marketing can increase exposure to persuasive messages encouraging e-cigarette trial and use particularly among susceptible youth. Stronger regulations are needed to prevent exposure to social media marketing among young social media users.

This study used semantic network analysis to investigate the themes of JUUL electronic cigarette-related messages on Instagram posted by three account types (commercial, vape community, and organic users) and explore the function of hashtags in the JUUL-related discourse across these groups. Posts were collected from 1 March 2018 to 15 May 2018. We conducted network analyses for each user group, with separate analyses to examine texts with and without inclusion of hashtags. Network statistics determined which words occurred most frequently, which words co-occurred or clustered together, and what communication function hashtags perform. Analyses of message content with hashtags included revealed that the largest cluster of terms by account type was brand promotion (commercial), brand engagement (community), and youth social use of JUUL and other substances, such as marijuana (organic users). On removal of hashtags, the largest cluster for each group was online and offline retailer promotion (commercial), JUUL promotion or shares of existing promotional content (community), and youth social use (organic users). Commercial accounts used hashtags to increase brand visibility and engage with vape communities present on Instagram. Community accounts served as discursive intermediaries between commercial accounts and organic users, fostering organic user engagement with brands. Social media serve as an extension of real-life peer groups among youth and young adults. Community accounts, which likely have greater credibility among users compared to commercial accounts, may help enhance the effects of targeted promotion and normalize vaping comprehensive regulation of commercial digital tobacco marketing is necessary to reduce the amount of commercial content youth and other consumers are exposed to through overt commercial and influential community accounts.

BackgroundIn Bangladesh, smokeless tobacco (SLT) is available in a variety of pack shapes and sizes. Lack of standard packaging could limit compliance with pictorial health warning label (HWL) requirements. We explored Bangladeshi SLT users’ and non-users’ perceptions of a proposed standard pack shape forgul(tobacco powder) andzordha(chewing tobacco), including the role that HWL placement plays on harm perceptions.MethodsWe conducted 28 focus groups across three regions of Bangladesh: Dhaka, Sylhet and Khulna. Groups were stratified equally by urban/rural residence, gender and SLT use. Trained facilitators used a standardised guide to discuss perceived attractiveness, noticeability of HWLs and perceived harm of current versus standard packs.ResultsMost groups found bright colours, ‘brand owner’ portrait imagery, and strong, sturdy pack material of current packs attractive. Many of the same features increased perceived attractiveness of the standard packs. Pictorial HWLs on the standard packs appeared larger and increased the visibility and noticeability of HWLs compared with current packs. Lack of HWLs or limited visibility of HWL due to discolouration contributed to lower levels of perceived harm of the current packs. In contrast, HWL prominence and placement on both sides of the standard pack increased perceived harm of standard packs.ConclusionThe findings suggest a standard shape and size for SLT sold in Bangladesh, coupled with proper implementation of HWLs per the law, could improve HWL noticeability and increase harm perceptions. Additional plain packaging policies that also standardise pack colour may be required to reduce attractive colours and branding.

Background: Declines in smoking prevalence among low-income adults lag behind national samples. Understanding the influence of social context factors such as gender, and normative influence on smoking attitudes and behaviors, can inform smoking cessation interventions. Objective: This study explored how gender, smoking dependence, and cessation norms influenced the likelihood of current quit attempts among urban-dwelling, predominately African American adults. Methods: Participants answered questions about their current quit attempts, smoking dependence (heaviness of smoking index [HSI]), and cessation norms (descriptive: having friends who quit smoking; injunctive: friends disapproving of smoking) as a part of a parent study exploring social and environmental factors in tobacco use. Logistic regression stratifying by gender and adjusting for demographics examined main and interaction effects of norms and HSI on odds of having a current quit attempt. Results: Among men, having a higher smoking dependence was associated with a reduced likelihood of trying to quit (AOR = 0.30 [0.15-0.59]), but this effect was moderated by having friends who had quit smoking (AOR = 2.40 [1.20-4.78]). When accounting for the effect of friends quitting smoking, men were not influenced by friends disapproving of smoking. Among women, currently attempting to quit was predicted by neither smoking dependence nor norms. Conclusions/Importance: Cessation norms and smoking dependence influenced the likelihood of quit attempts for men, but not women, in this study. This highlights the importance of conducting gender stratification in smoking cessation research so as to better understand how social and environmental factors differently impact cessation outcomes for men and women.

Objective: Proposed regulation may establish nicotine standards in cigarettes to sub-addictive levels. In this study, we explore the association between nicotine perceptions and responses to a reduced nicotine policy scenario among current smokers. Methods: Data from a nationally representative sample of 18-54-year-old current tobacco users were collected in March-April 2018 (N = 1746). Current smokers (N = 854) were asked about nicotine-related health beliefs and nicotine addiction. Time to first cigarette (TTFC) was used to examine nicotine dependence. Adjusted and weighted logistic regression models examined these nicotine-related factors in association to support for a proposed government policy and related behavioral intentions. Results: Although 63% of survey participants accurately identified nicotine alone as the addiction cause, 49% incorrectly indicated that cancer and 56% indicated that increased health risk caused by cigarette smoking comes from nicotine. Smokers showed high support (72%) for a proposed low-nicotine policy. Greater misperception about nicotine harm was associated with greater odds (aOR = 1.66, p < .05) of policy support. Shorter TTFC was associated with greater intent to smoke low-nicotine cigarettes but was not associated with policy support. Conclusion: Evidence could inform health message development to address knowledge and misperceptions around nicotine when garnering public support for a low-nicotine policy.

Introduction The purpose of this study is to examine awareness, attitudes, and related knowledge of e-cigarettes, and JUUL specifically, among parents of middle and high school students. Methods Data were collected in October–November 2018 from a nationally representative sample of U.S. parents of middle and high school students aged 11–18 years (n=2,885) to examine e-cigarette and JUUL awareness, concern about e-cigarette use, and school communication regarding e-cigarettes. Weighted frequencies and percentages are reported; Rao–Scott chi-square tests examined differences by school level. Data were analyzed in 2019. Results Although most parents (96.2%) had seen or heard of e-cigarettes, only 55.9% had seen or heard of JUUL, and only 44.2% accurately identified an image of JUUL as a vaping device. Many parents reported concern about adolescent e-cigarette use (60.6%), but fewer reported concern about their own child's use (32.9%). Most parents (73.5%) reported receiving no communication from their child's school about e-cigarettes or JUUL. Conclusions There are notable gaps in parents’ awareness of JUUL. School-to-parent communication efforts are necessary to build parents’ knowledge of e-cigarettes like JUUL to prevent the growing youth uptake of these novel and addictive products.

Objective: Limited research has examined feminine marketing appeals on cigarette packs in low-and middle-income countries (LMICs). We reviewed a systematically collected sample of cigarette packs sold across 14 LMICs in 2013 (Wave 1) and 2015–2017 (Wave 2).Methods: Packs in Wave 1 (n = 3,240) and Wave 2 (n = 2,336) were coded for feminine imagery and descriptors (flowers, fashion, women/girls, color “pink”). We examined trends in feminine appeals over time, including co-occurrence with other pack features (slim or lipstick shape, flavor, reduced harm, and reduced odor claims).Results: The proportion of unique feminine cigarette packs significantly decreased from 8.6% (n = 278) in Wave 1 to 5.9% (n = 137) in Wave 2 (p < 0.001). Among all feminine packs, flower-and fashion-related features were most common; a substantial proportion also used flavor and reduced odor appeals.Conclusion: While there was a notable presence of feminine packs, the decline observed may reflect global trends toward marketing gender-neutral cigarettes to women and a general contempt for using traditional femininity to market products directly to women. Plain packaging standards may reduce the influence of branding on smoking among women.

International audience; The rivers of Appalachia (United States) are among the most biologically diverse freshwater ecosystems in the temperate zone and are home to numerous endemic aquatic organisms. Throughout the Central Appalachian ecoregion, extensive surface coal mines generate alkaline mine drainage that raises the pH, salinity, and trace element concentrations in downstream waters. Previous regional assessments have found significant declines in stream macroinvertebrate and fish communities after draining these mined areas. Here, we expand these assessments with a more comprehensive evaluation across a broad range of organisms (bacteria, algae, macroinvertebrates, all eukaryotes, and fish) using high-throughput amplicon sequencing of environmental DNA (eDNA). We collected water samples from 93 streams in Central Appalachia (West Virginia, United States) spanning a gradient of mountaintop coal mining intensity and legacy to assess how this land use alters downstream water chemistry and affects aquatic biodiversity. For each group of organisms, we identified the sensitive and tolerant taxa along the gradient and calculated stream specific conductivity thresholds in which large synchronous declines in diversity were observed. Streams below mining operations had steep declines in diversity (-18 to -41%) and substantial shifts in community composition that were consistent across multiple taxonomic groups. Overall, large synchronous declines in bacterial, algal, and macroinvertebrate communities occurred even at low levels of mining impact at stream specific conductivity thresholds of 150-200 mu S/cm that are substantially below the current U.S. Environmental Protection Agency aquatic life benchmark of 300 mu S/cm for Central Appalachian streams. We show that extensive coal surface mining activities led to the extirpation of 40% of biodiversity from impacted rivers throughout the region and that current water quality criteria are likely not protective for many groups of aquatic organisms.

BackgroundLittle is known regarding how oral nicotine products (eg, nicotine pouches, lozenges) are marketed to consumers, including whether potential implicit reduced harm claims are used. In the current study, we explored the marketing claims present in a sample of direct-mail oral nicotine advertisements sent to US consumers (March 2018–August 2020).MethodsDirect-mail ads (n=50) were acquired from Mintel and dual-coded for the following claims: alternative to other tobacco products, ability to use anywhere, spit-free, smoke-free and product does not contain tobacco leaf. We merged the coded data with Mintel’s volume estimate (number of mail pieces sent to consumers) and calculated the proportion of oral nicotine advertisements containing claims by category.ResultsOf the 38 million pieces of oral nicotine direct-mail sent to US consumers, most featured claims that the product could be used anywhere (84%, 31.8 million pieces); was an alternative to other tobacco products (69%, 26.1 million pieces); and did not contain tobacco leaf (eg, ‘tobacco leaf-free’, ‘simple’ approach of extracting nicotine from tobacco; 55%, 20.7 million pieces). A slightly smaller proportion contained claims that oral nicotine was ‘spit-free’ (52%, 19.8 million pieces) or ‘smoke-free’ (31%, 11.7 million pieces).ConclusionOur results provide an early indication of marketing claims used to promote oral nicotine. The strategies documented, particularly the use of language to highlight oral nicotine is tobacco-free, may covey these products as lower-risk to consumers despite the lack of evidence or proper federal authorisation that oral nicotine products are a modified-risk tobacco product. Future research is needed to examine consumer perceptions of such claims.

Objectives The US Food and Drug Administration (FDA) and local jurisdictions have different authorities to regulate menthol cigarettes, and a growing number of localities and the FDA are considering these policy options. The objective of this study was to update previous research on public support for a menthol ban, including examining differences in support by demographic factors, geographic region, and smoking status. Methods We assessed policy support among a cross-sectional sample of 2871 adults aged 18-64 from a nationally representative online panel. We calculated weighted estimates of support by demographic factors, political ideology, region (Northeast, Midwest, South, West), and smoking status (never, former, current nonmenthol, current menthol). We used weighted adjusted logistic regression analysis to examine correlates of support for a menthol ban. Results Overall, 56.4% (95% CI, 54.4%-58.3%) of participants supported a government policy to ban menthol cigarette sales. Support was significantly higher among women than among men (62.5% vs 50.1%; P < .001); among Hispanic/Latino (69.3%), non-Hispanic African American (60.5%), and non-Hispanic other (65.8%) people than among non-Hispanic White people (50.4%; P < .001); and among never (64.8%) and former (47.0%) smokers than among current nonmenthol cigarette smokers (30.1%; P < .001). A significant proportion (28.5%; P < .001) of current menthol cigarette smokers supported a ban. After controlling for other factors, geographic region was not significantly associated with support for a ban. Conclusions Efforts are needed to further increase support for a ban among current menthol cigarette smokers. These findings can be used to assist policy makers and communities in efforts to ban menthol cigarettes in their jurisdictions.

ObjectivesMore than 250 US localities restrict sales of flavoured tobacco products (FTPs), but comprehensiveness varies, and many include retailer-based exemptions. The purpose of this study is to examine resulting changes in the US retail environment for FTPs if there was a hypothetical national tobacco control policy that would prohibit FTP sales in all retailers except (1) tobacco specialty stores or (2) tobacco specialty stores and alcohol outlets.Design and settingA cross-sectional analysis of the FTP retail environment in every US Census tract (n=74 133). FTP retailers (n=3 10 090) were enumerated using nine unique codes from a national business directory (n=296 716) and a national vape shop directory (n=13 374).Outcome measuresWe assessed FTP availability using static-bandwidth and adaptive-bandwidth kernel density estimation. We then calculated the proportion of FTP stores remaining and the mean density of FTP retailers under each policy scenario for the overall population, as well as across populations vulnerable to FTP use.ResultsExempting tobacco specialty stores alone would leave 25 276 (8.2%) FTP retailers nationwide, while exempting both tobacco specialty stores and alcohol outlets would leave 54 091 (17.4%) retailers. On average, the per cent remaining FTP availability per 100 000 total population was 7.1% for a tobacco specialty store exemption and 18.1% for a tobacco specialty store and alcohol outlet exemption. Overall, density estimate trends for remaining FTP availability among racial/ethnic populations averaged across Census tracts mirrored total population density. However, estimates varied when stratified by metropolitan status. Compared with the national average, FTP availability would remain 47%–49% higher for all racial/ethnic groups in large metropolitan areas.ConclusionsRetailer-based exemptions allow greater FTP availability compared with comprehensive policies which would reduce FTP availability to zero. Strong public policies have the greatest potential impact on reducing FTP availability, particularly among urban, and racial/ethnic minority populations.

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette–specific tobacco retail licensing (TRL) laws. Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either “core” (e.g., presence of license terms, fees, and penalties) or “descriptive” (e.g., license fee amount and term length). Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5–$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws. Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Introduction Cigarette advertising is a causal agent of smoking uptake among young people. Although prior research links ad receptivity to tobacco product interest and use, little is known regarding the specific advertising tactics associated with increased product appeal among young people. Methods A national sample of 13–20 year-olds (N = 3688, youth) and 21–24 year-olds (N = 1556, young adults) in the US participated in an online survey in 2017 (mean age 18.1 years). The majority (72.0%) of youth and nearly half (44.8%) of young adults were never smokers. Participants were shown a cigarette ad, randomly assigned from a pool of 50 advertisements, and reported how much they liked the ad, and were curious about and interested in using the advertised product. All 50 advertisements were content analyzed for a variety of features. Data from the survey and content analysis were merged and mixed effects analyses used to identify the features associated with increased liking, curiosity, and interest in using, referred to collectively as product appeal. Results Presence of a sweepstakes offer was associated with increased liking, curiosity and interest among youth and curiosity and interest among young adults. Outdoors settings, flora imagery, natural descriptors, and environmental themes were associated with increased appeal. Price reductions (eg, coupons) were associated with decreased appeal among youth. Conclusions This study identified several advertising tactics associated with increased appeal among youth and young adults. If additional research confirms these findings, the U.S. Food and Drug Association should consider restricting use of these tactics in tobacco advertising. Implications This study's findings provide insight into features of cigarette ads that appeal to youth and young adults. Overall, the presence of sweepstakes appealed to youth and young adults and outdoors and environmental themes were particularly appealing to young adults. Such tactics could serve to further brand engagement, improve brand image and lead to initiation or escalation of use. If confirmatory studies further demonstrate the effects of the tactics identified in this study on youth product appeal, U.S. Food and Drug Administration should consider using its authority to restrict the use of youth-appealing tactics.

Introduction Digital e-cigarette marketing is largely unregulated and remains easily accessible to young people. The growing public concern around youth JUUL use and its viral presence on social media led the company to engage in several voluntary actions to remove and reduce JUUL-related content on Instagram in May 2018. The current study examined how JUUL-related Instagram content changed in the US following JUUL Labs' wave of voluntary actions in May 2018. Methods In 2019, we collected a total of 50,817 JUUL-relevant posts by 16,323 unique users on Instagram from March 1-May 15, 2018 (Phase 1) and May 16-November 11, 2018 (Phase II) using the application programming interface. We conducted a semantic network analysis to identify major topic clusters over time. Results Approximately 14,838 JUUL-related posts were made by 5,201 accounts in Phase I and 35,979 posts were made by 11,122 accounts in Phase II. Major content clusters remained unchanged over time-key topics were JUUL-related product characteristics and JUUL-communities; the general vape community; and cannabis-related behavior. Of note, cannabis-related content grew in Phase II, particularly use of the term CBD. Conclusions Our results reflect the limits of voluntary industry actions to reduce or change vaping-related content on social media. Rather, strong federal restriction on commercial tobacco marketing is the optimal pathway to reduce initial product marketing exposure among youth. These limits would make the emergence and viral contagion of brand-related social media content less likely and reduce its influence on youth behavior.

In 2009, flavored cigarettes (except menthol) were banned in the United States, but other flavored tobacco products (FTPs) were allowed. Women, populations of color, youth, sexual minority, and low–socioeconomic status populations disproportionately use FTPs. Localities have passed sales restrictions on FTPs that may reduce disparities if vulnerable populations are reached. This study assessed the extent to which FTP restrictions reached these subgroups (“reach equity”). We identified 189 U.S. jurisdictions with FTP policies as of December 31, 2018. We linked jurisdictions with demographics of race/ethnicity, gender, age, partnered same-sex households and household poverty, and stratified by policy strength. We calculated Reach Ratios (ReRas) to assess reach equity among subgroups covered by FTP policies relative to their U.S. population representation. Flavor policies covered 6.3% of the U.S. population (20 million individuals) across seven states; 0.9% were covered by strong policies (12.7% of policies). ReRas indicated favorable reach equity to young adults, women, Hispanics, African Americans, Asians, partnered same-sex households, and those living below poverty. Youth, American Indians/Alaska Natives (AIAN) and Native Hawaiians/Pacific Islanders (NHPI) were underrepresented. Strong policies had favorable reach equity to young adults, those living below poverty, Asians, NHPIs, individuals of 2+ races, and partnered same-sex households, but unfavorable reach equity to women, youth, Hispanic, AIAN, and African American populations. U.S. flavor policies have greater reach to many, but not all, subgroups at risk of FTP use. Increased enactment of strong policies to populations not covered by flavor policies is warranted to ensure at-risk subgroups sufficiently benefit.

Objectives Few e-cigarette social media posts are authentic posts to friends; most come from commercially sponsored influencers. Potential disclosure strategies need to be tested to confirm whether users recognize such posts as commercially sponsored. Methods Between July – August 2019, young adult (ages 16–24; n = 200) participants were recruited to view their native Instagram feed on a laboratory mobile device. Posts from e-cigarette influencers were manipulated to add either #ad or #sponsored while eye tracking software measured visual attention. Participants self-reported their interpretation of the hashtags in open-ended responses. Logistic regression analyses compared recognition of commercial content by condition, and qualitative content analyses summarized the key themes related to the hashtags. Results The #ad condition had nearly twice the odds of commercial recognition compared to #sponsored (OR = 1.98, CI: 1.14–3.38). Every second of attention paid to the hashtag significantly increased the odds of commercial recognition by 22% (OR: 1.22, CI: 1.00–1.33). Conclusion The #ad disclosure attracted visual attention and significantly increased recognition of commercial sponsorship from young social media users. Labeling commercially sponsored content on social media is a promising strategy to better inform users about paid social media influence.

Introduction Parents are essential stakeholders for policy implementation. However, data on parents’ support for e-cigarette- and tobacco-related policies is limited. This study examines parents’ support for five e-cigarette- and tobacco-related policies targeted to prevent youth initiation and exposure to industry marketing practices. Methods Data were from a 2018 nationally representative sample of US parents of 11- to 18-year-old middle and high school students. Weighted adjusted logistic regression models examined correlates of support for policy outcomes, controlling for demographics. Analyses were performed among the full sample (n = 2743) and among current tobacco users (n = 355). Results The majority of parents, including current tobacco users, supported tobacco control efforts to protect adolescents. More than 90% of all parents supported restrictions on e-cigarette marketing to youth and 75% supported a ban on flavored e-cigarette sales. Additionally, more than 80% of all parents supported increasing the age of tobacco product sale to 21, limiting tobacco retailer density near schools, and keeping tobacco products out of view where youth shop. Presence of strict home tobacco rules or reporting a high priority to prevent child’s e-cigarette use were significantly associated with higher odds of policy support. Results were similar among current tobacco users. Conclusions Parents are an important group of tobacco control stakeholders and should be utilized to garner support for tobacco control policies in the context of the recent growth in youth tobacco and e-cigarette use. Parents’ public support for tobacco control policies, particularly regulations on e-cigarette sales and marketing, can motivate advocates and policymakers to advance tobacco control policy agendas. Implications Youth tobacco and e-cigarette use in the United States has increased in recent years. Parents are important stakeholders to inform policy agendas and advance efforts to restrict youth access and exposure to tobacco products. This study provides evidence that parents of adolescents are highly supportive of youth-centered tobacco control policies, particularly those that restrict access to youth-targeted e-cigarette marketing and the sale of youth-appealing flavored e-cigarettes. Utilizing policy support to mobilize parents may be an important advocacy strategy to advance tobacco control policy agendas and curb rising rates of youth e-cigarette and tobacco use.

BackgroundThe electronic nicotine delivery system (ENDS) JUUL has quickly captured the ENDS market, representing 74.6% of the total dollar share for this category as of November 2018. Although JUUL is marketed as an alternative to cigarettes intended for current adult smokers, evidence suggests that a majority of ENDS users are concurrently current cigarette smokers. Little is known about the dual use of JUUL and cigarettes, as well as the reasons for trying JUUL among adult tobacco users.MethodsA survey fielded via web and phone of 1332 current cigarette, cigar, little cigar or cigarillo (CLCC), and ENDS users aged 18–54 years was conducted from March to May 2018. Weighted descriptive and bivariate analyses examined JUUL use and reasons for trying JUUL by demographics, combustible tobacco use, ENDS use and intention to quit.ResultsApproximately 81% of our sample reported current use of two or more tobacco products, including cigarettes, CLCCs or ENDS. Among current tobacco users, 15% ever used JUUL and 12% used JUUL in the past 30 days. Most individuals (74%) reporting ever JUUL use indicated using it for 5 days or fewer in the past 30 days. The most common reason for trying JUUL was trying to quit smoking cigarettes (37%), followed by family, friends or colleagues using the product (32%).ConclusionAlthough some tobacco users may be initiating JUUL to decrease combustible use, most were using the product infrequently and concurrently with other products. Findings have significant implications for cessation intervention efforts and policy development to help smokers quit.

BackgroundJUUL, a high-tech, popular vaping device, was the first major electronic cigarette (e-cigarette) brand to incorporate social media into its marketing strategy. There is growing concern around the increasing use of JUUL and other electronic nicotine delivery devices among youth, and their potential to addict a new generation to nicotine. The current study analysed the amount and characteristics of JUUL-related posts on Instagram, a social media platform used frequently among youth and young adults.MethodsHashtag-based keyword queries (n=50) were used to collect JUUL-related posts from the Instagram application programming interface, March 2018–May 2018. Using a combination of machine learning methods, keyword algorithms and human coding, posts were characterised as featuring content related to product promotion, nicotine and addiction, youth culture and lifestyle.ResultsKeyword queries captured 14 838 JUUL-relevant posts by 5201 unique users. Over one-third of posts were promotional (eg, linked to commercial website) and 11% contained nicotine and addiction-related information. Approximately half of posts featured content related to youth (55%) or lifestyle (57%). Youth-related content or lifestyle appeals were also notably present within promotional posts and nicotine and addiction-related posts, respectively. Nicotine and addiction-related posts featured memes, hashtags (eg, #nichead, #juulbuzz) and tag lines (eg, ‘more flavor, more buzz’).ConclusionsFindings reveal a proliferation of JUUL-related content on Instagram, which focused on product promotion and nicotine and addiction that included youth culture and lifestyle appeals. Regulatory actions should focus on restricting promotional efforts for e-cigarette products, particularly on social media platforms where young people are a primary audience.

IntroductionIn the USA, menthol cigarettes are associated with smoking initiation and decreased likelihood of cessation, particularly for low-income and non-White populations. Local ordinances to restrict menthol cigarette sales are an emergent policy option. In July 2016, Chicago, Illinois became the first major US city to ban menthol cigarette sales within 500 feet of schools. This study assessed ban compliance in June 2017.MethodsWe randomly selected 100 of 154 stores within 500 feet of a high school. Ninety stores were included in the analysis, excluding permanently closed stores or stores that did not sell tobacco prior to the ban. Compliance was determined by whether a menthol cigarette pack was purchased. We also assessed presence of menthol cigarette replacement packs. Multivariable logistic regression modelled compliance by store type, school (distance to high school, school type) and neighbourhood-level factors (poverty level, proportion of non-White residents).ResultsCompliance rate was 57% (weighted, n=53) and no replacement packs were observed. Non-compliant stores were more likely to advertise menthol cigarettes, but ads were present in eight compliant stores. Gas stations had 81% lower odds (OR=0.19, 95% CI 0.06 to 0.58) of complying with the menthol cigarette ban compared with larger/chain stores. School-level and neighbourhood factors were not associated with compliance.DiscussionThe poor compliance observed with Chicago’s partial menthol cigarette ban highlights the need for comprehensive efforts. Optimising local resources to target enforcement efforts in gas stations could improve compliance. Ordinances that also restrict advertising could potentially enhance ban impact by reducing exposure to product and promotions.

Impoverished urban neighborhoods tend to have higher rates of smoking and higher rates of exposure to secondhand smoke as compared to more affluent neighborhoods. Contextual factors of neighborhood disorder and social network and household composition may have an impact on indoor smoking behaviors. The TIDE study examined psychosocial factors associated with smoking behaviors among impoverished inner-city smokers in Baltimore, Maryland. Among a community-recruited sample of 413 smokers who lived with others, most (73%) reported that they or others smoked in their residence. Cohabitation with children, elderly, and those with asthma and other respiratory condition was not associated with indoor smoking. Neighborhood disorder, the proportion of social network members who smoked with the study participant, and the proportion of household members who smoked were all independently associated with smoking indoors. The study findings suggest the importance of addressing neighborhood and social network factors when developing programs for promoting indoor smoking bans as well as cessation and prevention programs.

Objective There is emerging evidence that e-cigarettes are being used by some to mitigate weight gain after quitting smoking, and being used to help control weight. This study sought to identify and describe patents related to innovations for e-cigarette devices associated and weight loss. Methods Relevant patents were identified using Google Patents with the core search terms: "electronic cigarette" OR "e-cigarette" OR "vaporizer" OR "vapourizer" AND "nicotine" AND "weight loss" OR "weight control" OR "obesity" OR "hunger". Patents were reviewed to identify and classify the innovation related to weight loss or weight control. Results Our search identified 23 unique patents that were filed between 2004 and 2015. Patent applications were sponsored by individual inventors (n = 7), tobacco companies (n = 5), e-cigarette companies (n = 8), pharmaceutical companies (n = 2) and a cannabis company (n = 1). More than half the patents (n = 12) were filed in the United States; other countries included China, Germany, South Korea, and South Africa. Strategies included using e-cigarette devices to deliver constituents to users that support weight loss through altered metabolism, reduced nutrient absorption, suppressed appetite, or supported healthy behavior change. In most cases (n = 18), the innovations detailed in the patents were intended to be used with an e-cigarette device that delivered nicotine to the user. Conclusions Companies from around the world, and from a range of industries are developing and patenting technologies related to e-cigarettes and weight loss. E-cigarettes may be presented to cigarette users as a possible solution to support smoking cessation and address the fear of weight gain. Implications This article presents evidence that a range of industries are innovating to design e-cigarettes or constituents to be used with e-cigarettes to deliver a variety of drugs beyond nicotine including weight loss drugs, laxatives, and nutritional supplements. This study may inform surveillance studies to systematically include weight loss as a possible motivation to use e-cigarettes. Further, market surveillance of e-cigarette products needs to monitor ingredients in e-liquids including constituents that have been historically used for weight loss or weight control. Regulations around e-cigarette marketing, promotion, product design including e-liquid constituents need to consider weight loss claims.

The Primary Care Capacity Project (PCCP) of the Gulf Region Health Outreach Program aims to expand access to integrated high quality, sustainable, community-based primary care with linkages to specialty mental and behavioral health, and environmental and occupational health services in four Gulf States following the Deepwater Horizon Oil Spill. This paper presents findings from community and clinic assessments in Gulf Coast counties and parishes impacted by the oil spill and how these findings informed technical assistance and funding to Federally Qualified Health Centers (FQHCs) and the communities they serve. This process included community and clinic assessments. The community health assessments included existing and data and data from community stakeholders on demographics, health determinants, and health status. Existing data were gathered from sources including the U.S. 2010 Census, Vital Statistics, and the Center for Disease Control and Prevention's Behavioral Risk Factor Surveillance System and Gulf State Population Survey. State, county, and sub-county level data were gathered for 17 Gulf coast counties. These data were summarized and analyzed to create community profiles for each of the counties to characterize their demographic profile, health status, healthcare access, social environment, and oil spill impact. These profiles were then used to facilitate a community prioritization process with county stakeholders. Stakeholders representing multiple sectors of the community participated in focus groups and a group consensus building activity to determine the health priorities for their counties. Concurrent to the community assessment, clinic assessments were conducted with FQHCs identified through the Health Resources and Services Administration Data Warehouse in 16 of the 17 counties. The clinic assessment was conducted with FQHC administrative staff and clinic staff to measure clinic capacity and needs.Data gathered from the community and clinic assessments suggest that mental health and chronic illness, such as diabetes, hypertension, and heart disease are health priorities in the Gulf Region. Primary care and mental health care provider shortages were “access to care” priorities as evidenced by both the community and clinic assessments. Also, transportation and proximity to primary care facilities were access to care priorities. These findings helped to inform funding and technical assistance to the FQHCs located in Gulf Coast counties. The assessment processes and how the data and information gathered through them can translate to preparedness, response, and recovery action planning and decision making following oil spills or other natural or man-made disasters.

Introduction Evidence suggests that reducing the nicotine concentration in cigarettes to sub-addictive levels would reduce use. Until a low-nicotine cigarette policy is enacted, population-level effects are unknown. This study examines the behavioral intentions of current U.S. cigarette smokers if a low-nicotine policy were implemented. Methods Data were drawn from a nationally representative probability-based panel and opt-in panel. Weighted logistic regressions examined likelihood to (1) smoke lower nicotine cigarettes, (2) quit using tobacco, (3) use e-cigarettes, (4) illegally buy high-nicotine cigarettes, and (5) smoke cigars, cigarillos, or little cigars (CLCCs) among smokers, controlling for demographics, tobacco products used, dependence, and intentions to quit cigarettes. Latent class analyses (LCA) characterized patterns of behavioral intentions. Results If a low-nicotine policy were implemented, most participants indicated a likelihood to smoke low-nicotine cigarettes (78.4%) or quit tobacco (61.9%), followed by use e-cigarettes (46.5%). Individuals with greater dependence had greater odds of intending to smoke low-nicotine cigarettes, use e-cigarettes, and illegally buy high-nicotine cigarettes. Current e-cigarette or CLCCs users had higher odds of intending to use these products. LCA revealed that individuals would 1) use low-nicotine cigarettes with low intentions to use other tobacco products or 2) use multiple tobacco products, including low-nicotine cigarettes. Conclusions A reduced nicotine standard for all combustible tobacco products is needed given that many tobacco users would likely intend to continue to use tobacco products. Differences in intentions by tobacco use and demographic characteristics indicate a need for additional cessation support and education around the harms of continued use of combustible tobacco.

Progesterone receptors (PRs) are critical regulators of mammary gland development and contributors to breast cancer progression. Posttranslational modifications of PR have been shown to alter hormone responsiveness. Site-directed mutagenesis demonstrated that upon hormone binding, PR is acetylated at the consensus sequence, KXKK (amino acids 638-641), located within the hinge region. We created an acetylation-deficient (K-A) mutant as well as acetylation mimics (K-Q or K-T). Interestingly, similar to K-A PR, PR acetylation mimics (K-Q or K-T) displayed delayed phosphorylation and nuclear entry relative to wild-type (wt) PR-B, indicative of disruption of PR nuclear-cytoplasmic shuttling. Wt PR-B, but not K-mutant PRs, induced c-myc at 1 h of progestin treatment. However, at 6 h of treatment, c-myc induction was comparable with levels induced by wt PR-B, suggesting that the precise timing of PR phosphorylation and nuclear retention are critical for cells to rapidly initiate robust transcriptional programs. In contrast to c-myc, progestin-induced serum- and glucocorticoid-regulated kinase (SGK) expression displayed sensitivity to PR acetylation but not nuclear entry. Namely, in the presence of progestin, acetylation-deficient (K-A) mutant PR-B up-regulated SGK mRNA relative to wt PR; progesterone response element-luciferase assays confirmed this result. However, K-Q and K-T acetylation mimics only weakly induced SGK expression independently of nuclear retention. These data reveal the ability of PR acetylation to alter the magnitude of transcriptional response at selected (slow response) promoters (SGK), whereas the hinge region dictates the kinetics of the transcriptional response to hormone at other (rapid response) promoters (c-myc). In sum, the PR hinge region is multifunctional. Understanding the ability of this region to couple acetylation, phosphorylation, and nuclear entry may provide clues to mechanisms of altered hormone responsiveness.

Young women with HIV and histories of physical and/or sexual abuse in childhood may be vulnerable to difficulties with disclosure to sexual partners. Abuse in childhood is highly prevalent in HIV-positive women, and has been associated with poorer communication, low assertiveness, low self worth, and increased risk for sexual and other risk behaviors that increase the risk of secondary transmission of HIV. HIV disclosure may be an important link between abuse and sexual risk behaviors. Qualitative interviews with 40 HIV-positive young women with childhood physical and/or sexual abuse were conducted; some women had also experienced adult victimization. Results suggest that HIV-positive women with abuse histories use a host of strategies to deal with disclosure of HIV status, including delaying disclosure, assessing hypothetical responses of partners, and determining appropriate stages in a relationship to disclose. Stigma was an important theme related to disclosure. We discuss how these disclosure processes impact sexual behavior and relationships and discuss intervention opportunities based on our findings.