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ObjectiveTo investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000-2019 decline in cigarette smoking among US 18-24 year-olds.MethodsSmoking behaviour was assessed in the 24 most populous US states using the 1992-2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011.ResultsBetween 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018-2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean.ConclusionNational programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

ObjectiveTo compare trends in cigarette smoking and nicotine vaping among US population aged 17-18 years and 18-24 years.MethodsRegression analyses identified trends in ever and current use of cigarettes and e-cigarettes, using three US representative surveys from 1992 to 2022.ResultsFrom 1997 to 2020, cigarette smoking prevalence among those aged 18-24 years decreased from 29.1% (95% CI 27.4% to 30.7%) to 5.4% (95% CI 3.9% to 6.9%). The decline was highly correlated with a decline in past 30-day smoking among those aged 17-18 years (1997: 36.8% (95% CI 35.6% to 37.9%; 2022: 3.0% (95% CI 1.8% to 4.1%). From 2017 to 2019, both ever-vaping and past 30-day nicotine vaping (11.0% to 25.5%) surged among those 17-18 years, however there was no increase among those aged 18-24 years. Regression models demonstrated that the surge in vaping was independent of the decline in cigarette smoking. In the 24 most populous US states, exclusive vaping did increase among those aged 18-24 years, from 1.7% to 4.0% to equivalent to 40% of the decline in cigarette smoking between 2014-15 and 2018-19. Across these US states, the correlation between the changes in vaping and smoking prevalence was low (r=0.11). In the two US states with >US$1/fluid mL tax on e-cigarettes in 2017, cigarette smoking declined faster than the US average.ConclusionsSince 1997, a large decline in cigarette smoking occurred in the US population under age 24 years, that was independent of the 2017-19 adolescent surge in past 30-day e-cigarette vaping. Further research is needed to assess whether the 2014-15 to 2018-19 increase in exclusive vaping in those aged 18-24 years is a cohort effect from earlier dependence on e-cigarette vaping as adolescents.

ObjectiveTo assess the effectiveness of e-cigarettes in smoking cessation in the USA from 2017 to 2019, given the 2017 increase in high nicotine e-cigarette sales.MethodsIn 2017, the PATH Cohort Study included data on 3578 previous year smokers with a recent quit attempt and 1323 recent former smokers. Respondents reported e-cigarettes or other products used to quit cigarettes and many covariates associated with e-cigarette use. Study outcomes were 12+ months of cigarette abstinence and tobacco abstinence in 2019. We report weighted unadjusted estimates and use propensity score matched analyses with 1500 bootstrap samples to estimate adjusted risk differences (aRD).ResultsIn 2017, 12.6% (95% CI 11.3% to 13.9%) of recent quit attempters used e-cigarettes to help with their quit attempt, a decline from previous years. Cigarette abstinence for e-cigarette users (9.9%, 95% CI 6.6% to 13.2%) was lower than for no product use (18.6%, 95% CI 16.0% to 21.2%), and the aRD for e-cigarettes versus pharmaceutical aids was -7.3% (95% CI -14.4 to -0.4) and for e-cigarettes versus any other method was -7.7% (95% CI -12.2 to -3.2). Only 2.2% (95% CI 0.0% to 4.4%) of recent former smokers switched to a high nicotine e-cigarette. Subjects who switched to e-cigarettes appeared to have a higher relapse rate than those who did not switch to e-cigarettes or other tobacco, although the difference was not statistically significant.ConclusionsSales increases in high nicotine e-cigarettes in 2017 did not translate to more smokers using these e-cigarettes to quit smoking. On average, using e-cigarettes for cessation in 2017 did not improve successful quitting or prevent relapse.

ObjectivesTo make projections of cigarette consumption that incorporate state-specific trends in smoking behaviors, assess the potential for states to reach an ideal target, and identify State-specific targets for cigarette consumption.MethodsWe used 70 years (1950-2020) of annual state-specific estimates of per capita cigarette consumption (expressed as packs per capita or "ppc") from the Tax Burden on Tobacco reports (N = 3550). We summarized trends within each state by linear regression models and the variation in rates across states by the Gini coefficient. Autoregressive Integrated Moving Average (ARIMA) models were used to make state-specific forecasts of ppc from 2021 through 2035.ResultsSince 1980, the average rate of decline in US per capita cigarette consumption was 3.3% per year, but rates of decline varied considerably across US states (SD = 1.1% per year). The Gini coefficient showed growing inequity in cigarette consumption across US states. After reaching its lowest level in 1984 (Gini = 0.09), the Gini coefficient began increasing by 2.8% (95% CI: 2.5%, 3.1%) per year from 1985 to 2020 and is projected to continue to increase by 48.1% (95% PI = 35.3%, 64.2%) from 2020 to 2035 (Gini = 0.35; 95% PI: 0.32, 0.39). Forecasts from ARIMA models suggested that only 12 states have a realistic chance (≥50%) of reaching very low levels of per capita cigarette consumption (≤13 ppc) by 2035, but that all US states have opportunity to make some progress.ConclusionWhile ideal targets may be out of reach for most US states within the next decade, every US state has the potential to lower its per capita cigarette consumption, and our identification of more realistic targets may provide a helpful incentive.

ObjectivesTo identify how the 2017 rapid surge in sales of JUUL e-cigarettes affected usage among US youth and young adults.MethodsAnnual surveys in the Population Assessment of Tobacco and Health Study assess tobacco use by product and brand among the US population. We identified 2 cohorts aged 14 to 34 years, 1 with baseline survey in 2014 before the rapid surge of JUUL and the other in 2017 as the surge in JUUL sales was occurring. For 5 age groups, we compared 2-year incidence of first tobacco use and of new-onset daily tobacco use by product, and report levels of dependence.ResultsSociodemographic variables and rates of experimentation with any tobacco product were similar between cohorts. Among baseline nondaily tobacco users, only those aged 14 to 17 years had an increase in the 2-year incidence of new daily tobacco use (2014 cohort = 4.8%, 95% confidence interval 4.3, 5.5 vs 2017 cohort = 6.3%, 95% confidence interval 5.8-7.0) to rates approaching those in the 1990s. In 2019, three-quarters of new daily tobacco users aged 14 to 17 vaped daily and had e-cigarette dependence scores similar to daily cigarette smokers and older adult e-cigarette vapers. We estimate that about 600 000 Americans aged

BackgroundIn 2016, the California Department of Healthcare Services (DHCS) released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage among Medicaid beneficiaries. However, implementation remains poor. We apply the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify barriers and facilitators to fidelity to APL 16-014 across California Medicaid MCPs.MethodsWe assessed fidelity through semi-structured interviews with MCP health educators (N = 24). Interviews were recorded, transcribed, and reviewed to develop initial themes regarding barriers and facilitators to implementation. Initial thematic summaries were discussed and mapped onto EPIS constructs.ResultsThe APL (Innovation) was described as lacking clarity and specificity in its guidelines, hindering implementation. Related to the Inner Context, MCPs described the APL as beyond the scope of their resources, pointing to their own lack of educational materials, human resources, and poor technological infrastructure as implementation barriers. In the Outer Context, MCPs identified a lack of incentives for providers and beneficiaries to offer and participate in tobacco-cessation programs, respectively. A lack of communication, educational materials, and training resources between the state and MCPs (missing Bridging Factors) were barriers to preventing MCPs from identifying smoking rates or gauging success of tobacco-cessation efforts. Facilitators included several MCPs collaborating with each other and using external resources to promote tobacco cessation. Additionally, a few MCPs used fidelity monitoring staff as Bridging Factors to facilitate provider training, track providers' identification of smokers, and follow-up with beneficiaries participating in tobacco-cessation programs.ConclusionsThe release of the evidence-based APL 16-014 by California's DHCS was an important step forward in promoting tobacco-cessation services for Medicaid MCP beneficiaries. Improved communication on implementation in different environments and improved Bridging Factors such as incentives for providers and patients are needed to fully realize policy goals.Plan language summaryIn 2016, the California Department of Healthcare Services (DHCS) in California released an "All Plan Letter" (APL 16-014) to its Medicaid managed care plans (MCPs) providing guidance on implementing tobacco-cessation coverage to address tobacco use among Medicaid beneficiaries. We conducted semi-structured interviews with health educators in California Medicaid MCPs to explore the barriers and facilitators to implementing the APL using the Exploration, Preparation, Implementation, Sustainment framework. According to MCPs, barriers included a lack of clarity in the APL guidelines; a lack of resources, including educational materials, infrastructure to identify smokers, and human resources; and a lack of incentives or penalties for providers to provide tobacco-cessation materials to beneficiaries. Facilitators included collaboration between MCPs and state and/or national public health programs. Overall, our findings can provide avenues for improving the implementation of tobacco-cessation services within Medicaid MCPs.

ImportanceAlthough e-cigarettes are not approved as a cessation device, many who smoke believe that e-cigarettes will help them quit cigarette smoking successfully.ObjectiveTo assess whether people who recently quit smoking and who had switched to e-cigarettes or another tobacco product were less likely to relapse to cigarette smoking compared with those who remained tobacco free.Design, setting, and participantsThis cohort study analyzed a nationally representative sample of US households that participated in 4 waves of the Population Assessment of Tobacco and Health Study (conducted 2013 through 2017), combining 2 independent cohorts each with 3 annual surveys. Eligible participants were individuals who smoked at baseline, had recently quit at the first follow-up, and completed the second follow-up survey.ExposuresUse of e-cigarettes or alternate tobacco products at follow-up 1 after recently quitting smoking.Main outcomes and measuresWeighted percentage of participants with over 12 months abstinence by follow-up 2.ResultsOf a total of 13 604 participants who smoked cigarettes at baseline, 9.4% (95% CI, 8.7%-10.0%) recently had quit smoking (mean age, 41.9; 95% CI, 39.7-46.6 years; 641 [43.2%] women) Of these, 22.8% (95% CI, 19.7%-26.0%) had switched to e-cigarettes, with 17.6% (95% CI, 14.8%-20.5%) using them daily. A total of 37.1% (95% CI, 33.7%-40.4%) used a noncigarette tobacco product and 62.9% (95% CI, 59.6%-66.3%) were tobacco free. Rates of switching to e-cigarettes were highest for those who were in the top tertile of tobacco dependence (31.3%; 95% CI, 25.0%-37.7%), were non-Hispanic White (26.4%; 95% CI, 22.3%-30.4%), and had higher incomes (annual income ≥$35 000, 27.5%; 95% CI, 22.5%-32.4% vs

Vaping products containing cannabidiol (CBD), a cannabis-derived compound used in wellness products and available in all 50 US states, were recently implicated in outbreaks of poisonings. Little is known about the commercial availability of CBD products in vape shops (i.e., stores that sell e-cigarettes). To document the availability and marketing of CBD products in online vape shops, in June 2020, we used the Google Chrome browser without cached data to collect the first two pages of search results generated by five Google queries (n = 100 search results) indicative of shopping for vaping products (e.g., "order vapes"). We then determined whether and what type of CBD products could be mail-ordered from the returned websites, and whether any explicit health claims were made about CBD. Over a third of the search results (n = 37; 37.0%) directed to vape shops that allowed visitors to also mail-order CBD. These shops sold 12 distinct categories of CBD products-some with direct analogs of tobacco or cannabis products including CBD cigarettes, edibles, flowers, pre-rolled joints, and vapes. Two vape shops made explicit health claims of the therapeutic benefits of CBD use, including in the treatment of anxiety, inflammation, pain, and stress. The abundance and placement of CBD in online vape shops suggests a growing demand and appeal for CBD products among e-cigarette users. Additional surveillance on the epidemiology of CBD use and its co-use with tobacco is warranted.

BackgroundCalifornia Proposition 56 increased cigarette excise tax by $2 per pack with equivalent increases on non-cigarette tobacco products. We estimated the changes in cigarette price, cigarette use, and non-cigarette use following the implementation of Proposition 56 in California in 2017.MethodsSeven waves of Tobacco Use Supplements to the Current Population Survey (TUS-CPS) 2011-2019 data were used to obtain state-level aggregate self-reported outcomes, including cigarette price per pack, current and daily cigarette use, cigarette consumption per day, and current and daily use of non-cigarette tobacco products (hookah, pipe, cigar, and smokeless tobacco). A modified version of a synthetic control method was used to create a "synthetic" California that best resembled pre-policy sociodemographic characteristics and outcome trends in California while correcting time-invariant pre-policy differences. Various sensitivity analyses were also conducted.ResultsThe implementation of Proposition 56 was associated with an increase in self-reported cigarette price per pack in California ($1.844, 95%CI: $0.153, $3.534; p = 0.032). No evidence suggested that Proposition 56 was associated with the changes in the prevalence of current or daily cigarette use, cigarette consumption per day, or the prevalence of current or daily use of non-cigarette tobacco products.ConclusionMost of the cigarette tax increase following Proposition 56 in California was passed on to consumers. There is a lack of evidence that the implementation of Proposition 56 was associated with the changes in the use of cigarettes and other tobacco products such as hookah, pipe, cigar, and smokeless tobacco.

Reducing tobacco use is an important public health objective. It is the largest preventable cause of death and disease, yet inequalities remain. This study examines combined educational and racial/ethnic disparities in the United States related to cigarette smoking for the three largest racial/ethnic groups (African Americans, Hispanics/Latinos, and non-Hispanic Whites). Data included nine Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) conducted in the United States from 1992/1993-2018 for four smoking metrics: ever smoking rates, current smoking rates, consumption (cigarettes per day), and quit ratios. Across all TUS-CPS samples, there were 9.5% African Americans, 8.8% Hispanics/Latinos, and 81.8% non-Hispanic Whites who completed surveys. Findings revealed that lower educational attainment was associated with increased ever and current smoking prevalence over time across all racial/ethnic groups, and education-level disparities within each race/ethnicity widened over time. Disparities in ever and current smoking rates between the lowest and highest categories of educational attainment (less than a high school education vs. completion of college) were larger for African Americans and non-Hispanic Whites than Hispanics/Latinos. Non-Hispanic Whites had the highest cigarette consumption across all education levels over time. College graduates had the highest quit ratios for all racial/ethnic groups from 1992- 2018, with quit ratios significantly increasing for Hispanics/Latinos and non-Hispanic Whites, but not African Americans. In conclusion, educational disparities in smoking have worsened over time, especially among African Americans and Hispanics/Latinos. Targeted tobacco control efforts could help reduce these disparities to meet public health objectives, although racial/ethnic disparities may persist regardless of educational attainment.

IntroductionIn 2016, the California Department of Health Care Services issued All Plan Letter 16-014 to the Medi-Cal Managed Care plans to provide information on requirements for comprehensive tobacco-cessation services. Researchers at the University of California, San Diego set out to (1) examine Medi-Cal's Managed Care plans' progress in implementing each section of All Plan Letter 16-014, (2) understand various factors related to implementation of the All Plan Letter, and (3) make recommendations to improve implementation.MethodsResearchers surveyed health educators within California's 25 Medi-Cal Managed Care plans to document each one's smoking-cessation services and policies in 2018. Data were collected for 24 of the 25 Medi-Cal Managed Care plans (96%) through 3 methods, including: (1) a web-based survey, (2) an in-depth phone interview, and (3) collection of smoking cessation-relevant documents.ResultsManaged Care plans demonstrate low levels of full implementation, with only 1 fully implementing all 20 provisions of the All Plan Letter. On average, Managed Care plans implemented 13 of the 20 provisions. Managed Care plans had the highest implementation rates for provisions related to requirements for coverage of the 7 U.S. Food and Drug Administration-approved medications for tobacco cessation, in which 12 (55%) fully implemented all related required provisions. Managed Care plans had lowest implementation rates for provisions related to data collection, with only 4 (18%) fully implementing all 3 requirements.ConclusionsAlthough All Plan Letter 16-014 was successful in creating more comprehensive and consistent benefits across Managed Care plans, 95% of Managed Care plans have not fully implemented it. Further guidance from the Department of Health Care Services and integration with the California Smokers' Helpline may be needed to achieve full implementation.

Purpose: Previous research has shown that Asian Americans are less likely to receive recommended clinical preventive services especially for cancer compared with non-Hispanic whites. Health insurance expansion has been recommended as a way to increase use of these preventive services. This study examines the extent to which utilization of preventive services by Asians overall and by ethnicity compared with non-Hispanic whites is moderated by health insurance. Methods: Data from the California Health Interview Survey (CHIS) was used to examine preventive service utilization among non-Hispanic whites, Asians, and Asian subgroups 50-64 years of age by insurance status. Six waves of CHIS data from 2001 to 2011 were combined to allow analysis of Asian subgroups. Logistic regression models were run to predict the effect of insurance on receipt of mammography, colorectal cancer (CRC) screening, and flu shots among Asians overall and by ethnicity compared with whites. Results: Privately insured Asians reported significantly lower adjusted rates of mammography (83.1% vs. 87.6%) and CRC screening (54.7% vs. 59.4%), and higher rates of influenza vaccination (48.7% vs. 38.5%) than privately insured non-Hispanic whites. Adjusted rates of cancer screening were lower among Koreans and Chinese for mammography, and lower among Filipinos for CRC screening. Conclusion: This study highlights the limitations of providing insurance coverage as a strategy to eliminate disparities for cancer screening among Asians without addressing cultural factors.

Three cigarette smoking behaviors influence lung cancer rates: how many people start, the amount they smoke, and the age they quit. California has reduced smoking faster than the rest of the United States and trends in these three smoking behaviors should inform lung cancer trends. We examined trends in smoking behavior (initiation, intensity, and quitting) in California and the rest of United States by regression models using the 1974-2014 National Health Interview Surveys (n = 962,174). Lung cancer mortality data for 1970-2013 was obtained from the National Surveillance, Epidemiology, and End Results (SEER) Program. Among those aged 18 to 35 years, California had much larger declines than the rest of the United States in smoking initiation and intensity, and increased quitting. In 2012-2014, among this age group, only 18.6% [95% confidence interval (CI), 16.8%-20.3%] had ever smoked; smokers consumed only 6.3 cigarettes/day (95% CI, 5.6-7.0); and 45.7% (95% CI, 41.1%-50.4%) of ever-smokers had quit by age 35. Each of these metrics was at least 24% better than in the rest of the United States. There was no marked California effect on quitting or intensity among seniors. From 1986 to 2013, annual lung cancer mortality decreased more rapidly in California and by 2013 was 28% lower (62.6 vs. 87.5/100,000) than in the rest of the United States. California's tobacco control efforts were associated with a major reduction in cigarette smoking among those under age 35 years. These changes will further widen the lung cancer gap that already exists between California and the rest of the United States.

OBJECTIVE:Cigarette smoking and smoking-related diseases disproportionately affect low-income populations. Health insurance coverage of smoking cessation treatments is increasingly used to encourage quitting. We assess the relationship between state Medicaid coverage of smoking cessation treatments and past-year quitting in adult Medicaid beneficiaries. DATA SOURCES:2009-2014 National Health Interview Survey (NHIS); 2008-2013 indicators of state Medicaid coverage of smoking cessation treatments. STUDY DESIGN:A triple-differencing specification based on differences in Medicaid cessation coverage policies across states as well as within-state differences between Medicaid beneficiaries and a counterfactual group of low-income adults not covered by Medicaid. DATA COLLECTION/EXTRACTION METHODS:Individual-level NHIS data with restricted geographical identifiers were merged with state-year Medicaid coverage indicators. PRINCIPAL FINDINGS:Combined coverage of both cessation counseling and medications in state Medicaid programs was associated with increased quitting, with an estimated mean increase in past-year quitting of 3.0 percentage points in covered Medicaid beneficiaries relative to persons without coverage. CONCLUSIONS:Combined coverage of both smoking cessation counseling and medication by state Medicaid programs could help reduce cigarette smoking among Medicaid beneficiaries.

OBJECTIVES:To estimate potential impacts of California Assembly Bill (AB) 1316: a requirement for universal screening and insurance coverage for child blood lead testing. METHODS:In April 2017 the California Health Benefits Review Program (Oakland, CA) analyzed AB 1316 for the California legislature, including a systematic review of lead screening effectiveness, commercial insurer surveys regarding screening coverage, and actuarial utilization and cost implication assessments. RESULTS:Universal screening requirements would increase child lead testing by 273%, raise affected populations' premiums by 0.0043%, and detect an additional 4777 exposed children 1 year after implementation. CONCLUSIONS:The evidence for a net societal benefit of universal screening approach is limited and is not supported by prominent medical professional groups. Public Health Implications. California expanded targeted screening to identify additional children at higher risk for lead poisoning on the basis of California-specific risk factors, while mitigating the potential harms of universal screening such as an increase in false positive tests and health care costs.

Background and aimsThe California Tobacco-Use Prevention Education (TUPE) program promotes the use of evidence-based tobacco-specific prevention and cessation programs for adolescents within the school setting. Through a competitive grant process, schools are funded to provide programs for grades 6-12. This research evaluates the association between TUPE funding and tobacco prevention activities and tobacco use prevalence.MethodsThis study utilized two data sources: (1) 2016 California Educator Tobacco Survey (CETS), and (2) 2015-2016 California Student Tobacco Survey (CSTS). The CETS collected data from educators about school prevention efforts, priority of tobacco prevention, and confidence in addressing tobacco issues with students. A total of 3,564 educators from 590 schools participated in CETS. The CSTS collected data from 8th, 10th, and 12th graders in California on their exposure to, attitudes about, and utilization of tobacco products. A total of 47,981 students from 117 schools participated in CSTS.ResultsThis study found that TUPE-funded schools were more likely to provide tobacco-specific health education programs, to place a priority on tobacco-prevention efforts, and to prepare educators to address tobacco use than non-TUPE schools. Educators at both types of schools felt better prepared to talk with students about traditional tobacco products than about emerging products such as e-cigarettes. Overall, students at TUPE-funded schools were more likely to report receiving anti-tobacco messages from school-based programs than those at non-TUPE schools. The former were also less likely to use tobacco products, even when the analysis controlled for demographics and school-level characteristics (OR = 0.82 [95% CI = 0.70-0.96]).ConclusionsTUPE funding was associated with an increase in schools' tobacco-specific prevention activities and these enhanced activities were associated with lower tobacco use among students. This study also found that education and prevention efforts regarding emerging tobacco products need to be strengthened across all schools.

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