Search

Introduction Sociodemographic disparities in tobacco use are prevalent and persistent in the United States. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities. Aims and Methods We used the 2018–2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18–34, 35–54, ≥55 years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income ( Results For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35–54 years (30.7%) and low-income NH White female adults aged 35–54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18–34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use. Conclusions Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups. Implications We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.

Introduction We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke. Aims and Methods We used data from all waves of the International Tobacco Control surveys (2002–2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income. Results The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (β = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups. Conclusions The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC). Implications The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

Background The prevalence of smoking is higher among sexual minority (SM) individuals compared with heterosexuals. The impact of televised anti-tobacco mass media campaigns on smoking outcomes among SMs is not known. Aims We examined whether televised anti-tobacco advertising was differentially associated with current smoking and smoking intensity for SM and heterosexual adults. Method We combined county-level anti-tobacco advertising data (gross rating points) with restricted, geocoded individual-level National Health Interview Survey data on smoking (2013–2015). We estimated associations between advertising and smoking outcomes, including potential effect modification by SM status. Results Greater anti-tobacco advertising exposure was associated with lower smoking prevalence (prevalence ratio [PR] = 0.97; 95% confidence interval [CI] = [0.94, 1.00]). Although the direction of the association differed for heterosexual and SM adults, differences were not statistically significant. No significant associations were observed with regard to smoking intensity. Conclusion Associations between anti-tobacco advertising and smoking were not significantly different for heterosexual and SM adults.

Introduction The cardiovascular health effects of electronic nicotine delivery systems (ENDS) use are not well characterized, making it difficult to assess ENDS as a potential harm reduction tool for adults who use cigarettes. Aims and Methods Using waves 1–5 of the Population Assessment of Tobacco and Health Study (2013–2019), we analyzed the risk of self-reported incident diagnosed myocardial infarction (MI; 280 incident cases) and stroke (186 incident cases) associated with ENDS and/or cigarette use among adults aged 40 + using discrete time survival models. We employed a time-varying exposure lagged by one wave, defined as exclusive or dual established use of ENDS and/or cigarettes every day or some days, and controlled for demographics, clinical factors, and past smoking history. Results The analytic samples (MI = 11 031; stroke = 11 076) were predominantly female and non-Hispanic White with a mean age of 58 years. At baseline, 14.2% of respondents exclusively smoked cigarettes, 0.6% exclusively used ENDS, and 1.0% used both products. Incident MI and stroke were rare during follow-up (< 1% at each wave). Compared to no cigarette or ENDS use, exclusive cigarette use increased the risk of MI (aHR 1.99, 95% CI = 1.40–2.84) and stroke (aHR 2.26, 95% CI = 1.51–3.39), while exclusive ENDS use (MI: aHR 0.61, 95% CI = 0.12–3.04; stroke: aHR 1.74, 95% CI = 0.55–5.49) and dual use (MI: aHR 1.84, 95% CI = 0.64–5.30; stroke: aHR 1.12, 95% CI = 0.33–3.79) were not significantly associated with the risk of either outcome. Conclusions Compared to non-use, exclusive cigarette use was associated with an increased risk of self-reported incident diagnosed cardiovascular disease over a 5-year period, while ENDS use was not associated with a statistically significant increase in the outcomes. Implications Existing literature on the health effects of ENDS use has important limitations, including potential reverse causation and improper control for cigarette smoking. We accounted for these issues by using a prospective design and adjusting for current and former smoking status and cigarette pack-years. In this context, we did not find that ENDS use was associated with a statistically significant increase in self-reported incident diagnosed myocardial infarction or stroke over a 5-year period. While more studies are needed, this analysis provides an important foundation and key methodological considerations for future research on the health effects of ENDS use.

Introduction Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced. Methods We pooled 1999–2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group). Results From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74–0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education. Conclusions The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status. Implications Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.

Purpose To describe patterns of menthol/non-menthol cigarettes with flavored e-cigarettes (tobacco, menthol, sweet/spicy, and other flavorings) use. Design We used cross-sectional data from the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS). Setting United States. Subjects Adults over 18 years old. Sample A nationally representative sample (n = 135 329). Measures We generated a 15-category variable of all combinations of cigarette and e-cigarette flavoring use. Analysis We estimated population prevalence (PP) for the 15-category flavored cigarette and e-cigarette use variable and proportion of flavored cigarette and e-cigarette use among adults who used cigarettes or e-cigarettes (PAU) by age, sex, race/ethnicity, and income. Results Exclusive menthol cigarette use was higher among NH Black (PP = 8.79%, PAU = 68.96%) and low-income (PP = 4.86%, PAU = 29.09%) compared to NH White (PP = 2.63%, PAU = 18.83%) and high-income participants (PP = 1.25%, PAU = 19.02%). Exclusive sweet/spicy e-cigarette use (PP = 1.32%, PAU = 10.22%) and exclusive menthol e-cigarette use (PP = .95%, PAU = 7.40%) was higher in younger (18-34) vs older (35+) adults (PP = .34% and PAU = 2.76%, and PP = .14%, PAU = 1.11%, respectively). Older dual users tended to combine the same flavor in both products (eg, menthol cigarettes + menthol e-cigarettes), while younger adults were more likely to combine menthol and non-menthol cigarettes with sweet/spicy e-cigarettes. Conclusion Findings suggest that a menthol cigarette ban might be most effective in conjunction with sweet/spicy e-cigarette flavor restrictions, given these flavors are attractive for younger adults.

Introduction Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation. Aims and Methods We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies’ potential risk of bias. Results Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies. Conclusions Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point. Implications A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco’s harms and address health inequities.

Introduction A better understanding of how menthol cigarette flavoring and ENDS impact smoking initiation, cessation, and transitions between tobacco products could help elucidate the potential impact of a U.S. menthol ban on combustible tobacco products. Methods A multistate transition model was applied to data on 23,232 adults from Waves 1–4 (2013–2017) of the Population Assessment of Tobacco and Health Study (analysis was conducted in 2020–2021). Transition rates among never, noncurrent, nonmenthol versus menthol cigarette, ENDS, and dual everyday/someday use were estimated, as were transition-specific hazard ratios for age, sex, race/ethnicity, education, and income. Results Non-Hispanic Blacks who smoked menthol discontinued smoking at a much lower rate than those who smoked nonmenthol (hazard ratio=0.43, 95% CI=0.29, 0.64), but there was no statistically significant difference in the discontinuation rates among non-Hispanic Whites (hazard ratio=0.97, 95% CI=0.80, 1.16) or Hispanics (hazard ratio=0.81, 95% CI=0.56, 1.16). Non-Hispanic Whites who smoked menthol were more likely to become dual users than those who smoked nonmenthol (hazard ratio=1.43, 95% CI=1.14, 1.80). Young adults initiated menthol smoking at a higher rate than older adults (age 18–24 years versus ≥55 years: hazard ratio=2.45, 95% CI=1.44, 4.15) but not nonmenthol smoking (hazard ratio=1.02, 95% CI=0.62, 1.69). There were differences by sex in the impact of menthol flavor on smoking initiation and discontinuation but little difference by education or income. Conclusions Sociodemographic differences in product transitions should be accounted for when estimating the potential impact of a menthol ban.

Introduction This study examines whether smoke-free laws are differentially associated with youth smoking outcomes by parental education, race/ethnicity, sex, and college plans in a U.S. sample. Methods This study assessed the relationships between smoke-free laws in workplaces and hospitality venues (restaurants/bars) and past 30-day smoking participation, first cigarette initiation, and daily smoking initiation within a repeated cross-sectional sample of 8th, 10th, and 12th graders from the Monitoring the Future study. Data were collected between 2001 and 2018 and were analyzed in 2020–2021. Grade-stratified Poisson models were used to calculate prevalence ratios and average marginal effects, incorporating interaction terms to examine differential associations across groups. Results Hospitality smoke-free laws were significantly associated with lower probabilities of smoking participation in all grades as well as with first cigarette and daily smoking initiation in 8th and 10th grade. Workplace smoke-free laws were associated with lower probabilities of smoking participation among 10th and 12th graders as well as with first cigarette and daily smoking initiation among 10th graders. Average marginal effects ranged from −0.4 percentage points (hospitality laws and daily smoking initiation in 8th and 10th grades) to −2.2 percentage points (workplace laws and smoking participation in 10th grade). Associations between smoke-free laws and a lower probability of smoking participation were most pronounced among students who definitely planned to attend college. Other instances of effect modification suggested more pronounced associations for students who were female and from high-SES households; however, relationships varied by grade. Conclusions Smoke-free laws were associated with reduced smoking among youth; however, associations varied by grade, sex, parental education, and college plans.

Background There is a dearth of research on within-person relationships between tobacco price and cigarette smoking initiation and progression in young adulthood. This project examines the within-person association between cigarette pack price and smoking initiation and progression between age 18 and 21/22, focusing on differences across subgroups. Methods Data came from the longitudinal Monitoring the Future (MTF) project. MTF examines drug use behaviors with nationally representative samples of 12th graders annually. Subsamples of 12th graders are annually selected and followed longitudinally. Among 12th graders from baseline years 2000–2014, we examined past 30-day cigarette smoking initiation among baseline never smokers (N = 15 280) and progression to daily smoking among youth who were not daily smokers at baseline (N = 26 998). We used hierarchical logistic regression and interaction terms to assess differences across sex, race/ethnicity, and parental education. Results The within-person relationship between pack price and smoking indicated that a one-dollar increase in pack price corresponded with a 72% decrease in the odds of initiation (AOR = 0.28, 95% CI = 0.18, 0.44) and 70% decrease in the odds of progression to daily smoking (AOR = 0.30, 95% CI = 0.21, 0.44). There was a linear age trend for both smoking initiation and progression. There were no statistically significant interactions between price and demographics, making it difficult to disentangle differences across subgroups. Conclusions Exposure to increased cigarette prices during young adulthood was associated with lower odds of cigarette smoking initiation and progression. Additional policies and programs beyond cigarettes prices could help reduce tobacco-related disparities in smoking initiation and progression among young adults. Implications There is a strong, within-person relationship between cigarette prices and smoking initiation and progression during the transition to young adulthood: higher prices are associated with decreased odds of both initiation and progression. Cigarette taxation can help to prevent smoking initiation and progression among youth, but it is less clear how taxes are associated with disparities in smoking experienced by certain subgroups. We could not draw definitive conclusions about the impact of cigarette prices on tobacco-related disparities. Tobacco taxes should be increased on a regular basis to ensure young adults experience within-person increases in prices, and complementary programs geared toward reducing tobacco-related disparities among young adults should be promoted.

Background With the increasing changes in tobacco use patterns, “current use” definition and the survey used may have important implications for monitoring population use trends. Methods Using three US surveys (2014/15 TUS-CPS, NHIS and PATH), we compared the adult (age 18+) prevalence of four product groups (cigarettes, other combustibles, smokeless tobacco, and e-cigarettes) based on three past 30-day frequency of use thresholds: 1+, 10+, and 25+ days. We also examined mutually exclusive single, dual, and polytobacco users as a percentage of total users for each product group. Results Regardless of threshold or product, the prevalence was higher in PATH followed by NHIS and TUS-CPS, in some cases by large percentages. The differences in cigarette and smokeless tobacco use prevalence in going from the 1+ to 10+ days and to the 25+ days threshold were minimal. Applying different frequency thresholds had the largest impact on other combustibles prevalence, with a 60% reduction with the 10+ days threshold and a 80% reduction with the 25+ days threshold, compared to the 1+ days threshold, followed by e-cigarettes with 40 and 60% reductions, respectively. The proportion of dual and polytobacco users decreased considerably when using the 10+ vs. the 1+ days threshold and polytobacco use was almost non-existent with the 25+ days threshold. Conclusion The estimated prevalence of each tobacco product use depends largely on the survey and frequency of use threshold adopted. The choice of survey and frequency threshold merits serious consideration when monitoring patterns of tobacco use.

Fragmented industry and occupation surveillance data throughout the COVID-19 pandemic has left public health practitioners and organizations with an insufficient understanding of high-risk worker groups and the role of work in SARS-CoV-2 transmission.We drew sequential probability samples of noninstitutionalized adults (18+) in the Michigan Disease Surveillance System with COVID-19 onset before November 16, 2020 (N = 237,468). Among the 6000 selected, 1839 completed a survey between June 23, 2020, and April 23, 2021. We compared in-person work status, source of self-reported SARS-CoV-2 exposure, and availability of adequate personal protective equipment (PPE) by industry and occupation using weighted descriptive statistics and Rao-Scott χEmployed respondents (n = 1244) were predominantly female (53.1%), aged 44 and under (54.4%), and non-Hispanic White (64.0%). 30.4% of all employed respondents reported work as the source of their SARS-CoV-2 exposure and 78.8% were in-person workers. Work-related exposure was prevalent in Nursing and Residential Care Facilities (65.2%); Justice, Public Order, and Safety Activities (63.3%); and Food Manufacturing (57.5%). By occupation, work-related exposure was highest among Protective Services (57.9%), Healthcare Support (56.5%), and Healthcare Practitioners (51.9%). Food Manufacturing; Nursing and Residential Care; and Justice, Public Order, and Safety Activities were most likely to report having adequate PPE "never" or "rarely" (36.4%, 27.9%, and 26.7%, respectively).Workplaces were a key source of self-reported SARS-CoV-2 exposure among employed Michigan residents during the first year of the pandemic. To prevent transmission, there is an urgent need in public health surveillance for the collection of industry and occupation data of people infected with COVID-19, as well as for future airborne infectious diseases for which we have little understanding of risk factors.

E-cigarettes are often marketed as a safer alternative to combustible cigarettes. However, their health effects, especially those associated with long-term use, remain largely uncertain. We conducted an umbrella review of the cardiopulmonary and carcinogenic risks of e-cigarette use, distinguishing between short-term and long-term health effects. The search for systematic reviews was conducted across four electronic databases through 25 January 2022. Methodological quality was assessed using the AMSTAR-2 quality appraisal tool. Seventeen systematic reviews, including five meta-analyses, were included in our umbrella review. There was a clear underreporting of e-cigarette devices and e-liquid types, e-cigarette and cigarette exposure, and the health and smoking status of study participants. Overall, the findings suggest that short-term use of e-cigarettes may be associated with acute cardiopulmonary risks, although to a lesser extent than cigarette use. Long-term e-cigarette use may have pulmonary/respiratory benefits in those who switch from chronic cigarette smoking, particularly in individuals with asthma and chronic obstructive pulmonary disease (COPD). Evidence on intermediate and long-term carcinogenic effects is lacking. This umbrella review underscores the urgent need for systematic reviews with better adherence to established reporting guidelines, consistent definitions of duration of e-cigarette use, a focus on newer devices, and accounting for the impacts of former or current smoking.

Introduction Little is known about the relationship between smoke-free laws and persistent disparities in secondhand smoke (SHS) exposure among nonsmoking adults in the United States. Aims and Methods We constructed time-varying smoke-free law measures representing whether or not at least 50% of each US county’s population was covered by smoke-free laws in workplaces and hospitality venues (restaurants/bars). We merged these data with restricted data on cotinine-derived SHS exposure among nonsmokers from the National Health and Nutrition Examination Survey, 1999–2014 (N = 25 444). Using logistic regression, we estimated associations between smoke-free law coverage and SHS exposure among all nonsmokers, and within age strata (25–39, 40–59, 60+). We explored differential associations by gender, race/ethnicity, education, and poverty–income ratio (PIR) by testing the significance of interactions terms for the full sample and within age strata. Results In adjusted models, hospitality coverage was associated with lower odds of SHS exposure in the full sample (odds ratio [OR] = 0.62; 95% confidence interval [CI] = 0.51–0.76), and within each age group, with ORs ranging from 0.58 (ages 25–39) to 0.67 (ages 60+). Workplace coverage was associated with lower SHS exposure only among younger adults (OR = 0.81; 95% CI = 0.65–0.99). Within the full sample and among adults ages 40–59, hospitality laws were associated with narrowing SHS exposure differentials between males and females. Among adults ages 40–59, workplace laws were associated with narrowing exposure differentials between males and females, but worsening exposure disparities by PIR. Conclusions Smoke-free laws may reduce SHS exposure among adult nonsmokers, but may be insufficient to improve disparities in SHS exposure. Implications In a repeated cross-sectional sample of adult nonsmokers, smoke-free laws in hospitality venues were consistently associated with lower odds of SHS exposure and appeared to narrow exposure differentials between males and females. Associations between workplace smoke-free laws and SHS exposure were variable by age. Among adults ages 40–59, workplace laws were associated with narrowing exposure differentials between males and females while exacerbating exposure differentials by PIR. Differential patterns of association highlight the need to examine the impacts of tobacco control policies on downstream health equity.

BackgroundA better understanding of sociodemographic transition patterns between single, dual and poly tobacco product use may help improve tobacco control policy interventions.MethodsHRs of transition between never, non-current (no past 30-day use), cigarette, e-cigarette, other combustible, smokeless tobacco (SLT), dual and poly tobacco use states in adults were estimated for age, sex, race/ethnicity, education and income using a multistate model for waves 1–4 of the Population Assessment of Tobacco and Health study (2013–2017), a US-based cohort study, accounting for complex survey design.ResultsSole cigarette and SLT use were persistent, with 77% and 78% of adults continuing use after one wave. Other use states were more transient, with 29%–48% of adults reporting the same pattern after one wave. If single-product users transitioned, it was most likely to non-current use while dual or poly cigarette users were most likely to transition to exclusive cigarette use. Males were more likely than females to initiate combustible product use after a history of no use, and after a period of tobacco use cessation. Hispanic and non-Hispanic black participants initiated cigarette use at higher rates than non-Hispanic white participants, and had higher rates of experimentation with tobacco products between study waves. Lower socioeconomic status was associated with higher rates of transition into combustible tobacco use.ConclusionsDual and poly tobacco use is largely transient, while single-use patterns are more stable over time. Transitions differ by age, sex, race/ethnicity, education and income, which may influence the impact of current and future tobacco control efforts.

ImportanceThe prevalence of electronic nicotine delivery systems (ENDS) use has increased, leading to a concern about their respiratory health outcomes. It is unclear whether ENDS use increases the risk of wheezing, a common symptom of respiratory conditions.ObjectiveTo provide an analysis of the longitudinal association between ENDS and cigarette use and self-reported wheezing among US adults.Design, Setting, and ParticipantsThe US nationally representative Population Assessment of Tobacco and Health (PATH) Study was used. Longitudinal data for adults 18 years or older from wave 1 (2013-2014) to wave 5 (2018-2019) were analyzed. Data were analyzed from August 2021 to January 2023.Main Outcomes and MeasuresThe prevalence of self-reported wheezing (waves 2-5) was estimated for 6 strata of tobacco product use (never cigarette and noncurrent ENDS use, never cigarette and current ENDS use, current cigarette and noncurrent ENDS use, current cigarette and current ENDS use, former cigarette and noncurrent ENDS use, and former cigarette and current ENDS use). A generalized estimating equations framework evaluated the association between cigarette and ENDS use and self-reported wheezing at the subsequent wave. An interaction term between cigarette and ENDS use was added to estimate the association between joint cigarette and ENDS use categories and the association of ENDS within strata of cigarette use.ResultsThe analytical sample consisted of 17 075 US adults with a mean (SD) age of 45.4 (17) years, of whom 8922 (51%) were female and 10 242 (66%) were Non-Hispanic White. When compared with never cigarette and noncurrent ENDS use, the greatest association in reporting wheezing was for current cigarette and current ENDS use (adjusted odds ratio [AOR], 3.26; 95% CI, 2.82-3.77), which was similar to current cigarette and noncurrent ENDS use (AOR, 3.20; 95% CI, 2.91-3.51) and substantially greater than former cigarette and current ENDS use (AOR, 1.94; 95% CI, 1.57-2.41). Associations were small and not statistically significant for the odds of self-reported wheezing among never cigarette and current ENDS use when compared with never cigarette and noncurrent ENDS use (AOR, 1.20; 95% CI, 0.83-1.72), and for odds of wheezing and current cigarette and current ENDS use when compared with current cigarette and noncurrent ENDS use (AOR, 1.02; 95% CI, 0.91-1.15).Conclusions and RelevanceIn this cohort study, exclusive ENDS use was not associated with an increase in the risk of self-reported wheezing. However, a small increase in risk between ENDS use and wheezing was reported by individuals who use cigarettes. This study adds to the literature about the potential health effects associated with ENDS use.

ObjectiveElectronic nicotine delivery systems (ENDS) products have emerged as the most popular alternative to combustible cigarettes. However, ENDS products contain potentially dangerous toxicants and chemical compounds, and little is known about their health effects. The aim of the present study was to examine the prospective association between cigarette and ENDS use on self-reported incident hypertension.DesignLongitudinal cohort study.SettingNationally representative sample of the civilian, non-institutionalised population in the USA.Participants17 539 adults aged 18 or older who participated at follow-up and had no self-reported heart condition or previous diagnosis of hypertension or high cholesterol at baseline.MeasuresWe constructed a time-varying tobacco exposure, lagged by one wave, defined as no use, exclusive established use (every day or some days) of ENDS or cigarettes, and dual use. We controlled for demographics (age, sex, race/ethnicity and household income), clinical risk factors (family history of heart attack, obesity, diabetes and binge drinking) and smoking history (cigarette pack-years).OutcomesSelf-reported incident hypertension diagnosis.ResultsThe self-reported incidence of hypertension was 3.7% between wave 2 and wave 5. At baseline, 18.0% (n=5570) of respondents exclusively smoked cigarettes; 1.1% (n=336) exclusively used ENDS; and 1.7% (n=570) were dual users. In adjusted models, exclusive cigarette use was associated with an increased risk of self-reported incident hypertension compared with non-use (adjusted HR (aHR) 1.21, 95% CI 1.06 to 1.38), while exclusive ENDS use (aHR 1.00, 95% CI 0.68 to 1.47) and dual use (aHR 1.15, 95% CI 0.87 to 1.52) were not.ConclusionsWe found that smoking increased the risk of self-reported hypertension, but ENDS use did not. These results highlight the importance of using prospective longitudinal data to examine the health effects of ENDS use.

Purpose: To evaluate sociodemographic differences in the relationship between state and national anti-smoking media campaigns and cessation behaviors among adult smokers in the U.S. Design: Repeated cross-sectional analysis. Setting: U.S. nationally representative survey of adults ages 18 and older, 2001-2015. Subjects: 76,278 year-ago smokers from the 2001-2015 Tobacco Use Supplement to the Current Population Survey. Measures: Area-level exposure to State-sponsored and “Tips from former smokers” anti-tobacco media campaigns was the primary predictor of this study. Outcome variables included: quit attempt in the past 12 months, past 30-day smoking cessation, and past 90-day smoking cessation among year-ago smokers. Analysis: We conducted modified Poisson regression models to examine the association between media campaign exposure and cessation behaviors. We also examined effect modification on the additive scale by sex, race/ethnicity, income, and education using average marginal effects. Results: Year-ago smokers with greater exposure to media campaigns were more likely to report 30-day (Prevalence Ratio [PR]: 1.18, CI: 1.03, 1.36) and 90-day cessation (PR: 1.18, CI: 1.00, 1.41) compared to respondents with less campaign exposure. We found no evidence of effect modification by sociodemographic variables. Conclusion: Exposure to anti-smoking media campaigns were associated with year-ago smokers’ cessation behaviors. However, there were no differences in the association by sex, race/ethnicity, income, or education, indicating that broadly focused media campaigns may be insufficient to reduce smoking cessation among priority populations, and thus health disparities generally.

Building on nascent literature examining the health-related effects of vicarious structural racism, we examined indirect exposure to the Flint Water Crisis (FWC) as a predictor of birth outcomes in Michigan communities outside of Flint, where residents were not directly exposed to lead-contaminated water. Using linear regression models, we analyzed records for all singleton live births in Michigan from 2013 to 2016, excluding Flint, to determine whether birth weight (BW), gestational age (GA), and size-for-gestational-age (SzGA) decreased among babies born to Black people, but not among babies born to White people, following the highly publicized January 2016 emergency declaration in Flint. In adjusted regression models, BW and SzGA were lower for babies born to both Black and White people in the 37 weeks following the emergency declaration compared to the same 37-week periods in the previous 3 years. There were no racial differences in the association of exposure to the emergency declaration with BW or SzGA. Among infants born to Black people, GA was 0.05 weeks lower in the 37-week period following the emergency declaration versus the same 37-week periods in the previous 3 years (95% CI: −0.09, −0.01; p = 0.0177), while there was no change in GA for infants born to White people following the emergency declaration (95% CI: −0.01, 0.03; p = 0.6962). The FWC, which was widely attributed to structural racism, appears to have had a greater impact, overall, on outcomes for babies born to Black people. However, given the frequency of highly publicized examples of anti-Black racism over the study period, it is difficult to disentangle the effects of the FWC from the effects of other racialized stressors.

Introduction To help offset the increased price of cigarettes and promote brand loyalty, tobacco companies distribute coupons, particularly to price-sensitive consumers. Few studies, however, have examined the longitudinal association between coupon receipt and smoking cessation. Aims and Methods Using adult data from waves 1–5 (2013–2019) of the Population Assessment of Tobacco and Health Study, we examined the longitudinal association between coupon receipt and short-term smoking cessation. Multivariable discrete-time survival models were fit to an unbalanced person-period dataset for adult respondents (≥18 years) with current established smoking status at baseline (person n = 9472, risk period n = 29 784). Short-term smoking cessation was measured as discontinued cigarette use (no past 30-day cigarette use at follow-up) and self-reported complete quitting. Coupon receipt was measured as a time-varying exposure, measured in the wave preceding the outcome. Tobacco dependence and time-varying cigarette use intensity were controlled as potential confounders. Effect modification by age, sex, race-ethnicity, and education was assessed by examining interaction terms. Results We found that adults who received a coupon were 19% less likely to quit smoking compared to adults who did not receive a coupon, adjusting for covariates (adjusted hazard rate [aHR]: 0.81, 95% CI: 0.74–0.89). None of the interaction terms were statistically significant, suggesting that the association between coupon receipt and short-term smoking cessation may not differ across the sociodemographic groups that we examined. Conclusions Taken together, our results reveal that coupon receipt reduces the likelihood of short-term smoking cessation, and that this association does not differ by age, sex, race-ethnicity, or education. Implications (97/100) Tobacco companies distribute coupons for tobacco products to price-sensitive customers in the United States, and these coupons can be particularly effective in partly offsetting the impact of a tax increases and promoting brand loyalty. This study provides longitudinal evidence that coupon receipt is associated with a decrease in short-term smoking cessation among US adults who smoke cigarettes after adjusting for covariates and tobacco-related confounders. The findings from this study suggest that coupons are an effective tool for tobacco companies to prevent adults who smoke from quitting, and a national ban on coupons may help to facilitate smoking cessation.

Sociodemographic disparities in tobacco use are prevalent and persistent in the US. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities.We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, 55+ years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income ($50,000, $50,000-$99,999, ≥$100,000). Estimates accounted for the complex survey design.For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use.Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups.We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.

We examined associations between smoke-free laws and smoking outcomes in a nationally representative sample of US adults, including exploring whether these associations differed for heterosexual and sexual minority (SM) adults.We constructed county-level variables representing the percent of the population covered by state-, county-, or city-level smoke-free laws in workplaces and hospitality venues. We combined this information with restricted individual-level adult data with masked county identifiers from the National Health Interview Survey (NHIS), 2013-2018. We used modified Poisson regression to explore associations between each type of smoke-free law and the prevalence ratio (PR) of current smoking, and we used linear regression to explore associations with smoking intensity (mean cigarettes per day). We assessed interactions between smoke-free laws and SM status on the additive scale to determine whether associations were different for SM and heterosexual adults.In adjusted models without interaction terms, smoke-free laws in hospitality venues were associated with lower prevalence of current smoking (PR = 0.93, 95% confidence interval (CI) = 0.89, 0.98). Both types of smoke-free laws were associated with lower mean cigarettes per day (workplace law change in mean = - 0.50, 95% CI = - 0.89, - 0.12; hospitality law change in mean = - 0.72, 95% CI = - 1.14,-0.30). We did not observe any statistically significant interactions by SM status, though statistical power was limited.We did not find evidence that smoke-free laws were differentially associated with smoking outcomes for heterosexual and SM adults. Additional studies are needed to further explore the potential for tobacco control policies to address the elevated risk of smoking in SM communities.

Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Introduction Anti-tobacco media campaigns can prevent youth smoking, but there is little research on how adult-targeted campaigns affect youth. We investigated the association between the Tips From Former Smokers (Tips) campaign and youth smoking behaviors and anti-tobacco attitudes, and variation by sex, race and/or ethnicity, or socioeconomic status. Aims and Methods We used data from the monitoring of the future study, a nationally representative survey on 8th, 10th, and 12th graders, from 2013–2015. Quartiles of Tips gross rating points (GRPs) were used to estimate exposure. Youth smoking behavior outcomes included smoking prevalence, initiation, and susceptibility. The anti-tobacco attitude outcomes included the extent that anti-tobacco ads made participants (1) less favorable towards smoking or (2) less likely to smoke cigarettes. Modified Poisson regression models estimated average marginal effects; separate additive interactions between Tips GRP exposure and sex, race and/or ethnicity, parents’ highest education, and college plans (12th graders only) were used to test for effect modification. Results Tips GRPs were not associated with smoking behaviors within any grade. However, 12th graders in the highest quartile of Tips had a 7.0 percentage point higher probability (95% CI = 0.023–0.116) of responding that anti-tobacco ads made them less likely to smoke. Tips GRPs were associated with a lower probability of past 30-day smoking prevalence among 10th grade females, but not males (joint P-value = .002). No additional statistically significant interactions were found for any other outcomes for any grade. Conclusions This study revealed the potential for adult-targeted campaigns to increase youth’s anti-smoking attitudes, but campaign exposure was not associated with smoking behaviors. Implications Few studies have examined the potential for anti-smoking media campaigns to influence audiences outside their targeted audience. In this study, we show the potential for adult-targeted campaigns to impact youth and suggest that Tips exposure may promote anti-smoking attitudes among youth.

BackgroundUnderstanding the relationship between electronic nicotine delivery systems (ENDS) use and chronic obstructive pulmonary disease (COPD) and other respiratory conditions is critical. However, previous studies have not adequately controlled for history of cigarette smoking.Research QuestionTo examine the prospective association between ENDS use and self-reported incident COPD after adjusting for cigarette smoking history.Study Design and MethodsUsing waves 1-5 of the US Population Assessment of Tobacco and Health (PATH) study, we examined the association between ENDS use and self-reported incident COPD among adults aged 40+ using discrete time survival models. Current ENDS use was measured as a time-varying covariate, lagged by one wave, defined as established daily or some days use. We controlled for baseline demographics (age, sex, race/ethnicity, education), health characteristics (asthma, obesity, exposure to second-hand smoke), and smoking history (smoking status and cigarette pack-years).ResultsIncident COPD was self-reported by 925 respondents during the five-year follow-up period. Prior to adjusting for other covariates, time-varying ENDS use appeared to nearly double the risk of incident COPD (HR 1.98, 95% CI 1.44-2.74). However, ENDS use was no longer significantly associated with COPD (aHR 1.10, 95% CI 0.78-1.57) after adjusting for current cigarette smoking and cigarette pack-years. The risk of self-reported incident COPD increased with cigarette pack-years and was higher for respondents who were older, female, less educated, and had baseline asthma or obesity.InterpretationENDS use did not significantly increase the risk of self-reported incident COPD over a five-year period once current smoking status and cigarette pack-years were taken into account. Cigarette pack-years, on the other hand, remained associated with a net increase in the risk of self-reported incident COPD. These findings highlight the importance of using prospective longitudinal data and properly controlling for cigarette smoking history to assess the independent health effects of ENDS.

This study examined the relationship between perceived racial discrimination (PRD) and patterns of substance use. Data come from the 2001-2003 National Survey of American Life (N=3,589). PRD was derived from the Major Experiences of Discrimination Scale. Multinomial logistic regression estimated the relationship between PRD and patterns of substance use (i.e., never, single-substance, dual-substance, and polysubstance (3+ substances)) based on six substances; effect modification by ethnicity and sex was assessed by stratification. Study findings indicate that PRD was associated with greater odds of lifetime and current polysubstance use. Results from the effect modification analyses suggested differential associations by ethnicity and sex.

espanolObjetivo. Calcular la prevalencia de consumo de cigarros con capsula de sabor, la proporcion de uso entre los usuarios de tabaco en la poblacion mexicana de 10 anos o mas, y los factores asociados a su consumo. Material y metodos. Se utilizo la Encuesta Nacional de Salud y Nutricion 2018-19. Se utilizo un modelo Poisson para obtener la razon de prevalen-cias del uso de cigarros con capsulas de sabor ajustando por sexo, edad, educacion e indice de bienestar. Resultados. El 6.6% de los mexicanos fuma cigarros con capsulas de sabor, lo que corresponde a 43% del total de usuarios de tabaco. Las mujeres, adolescentes y adultos jovenes son los grupos con la mayor proporcion de consumo. Conclusiones. Mexico tiene una alta prevalencia de consumo de cigarros con capsula de sabor. Para reducirla, se deben implementar politicas para prohibir la venta de cigarros con saborizantes y eliminar los disenos atractivos en las cajetillas de los cigarros. EnglishObjective. To estimate the prevalence of flavor capsule cigarette, use among Mexicans who are 10 years and older, to determine the proportion of smokers who use flavor capsules, and to characterize the sociodemographic correlates of flavor capsule cigarette use. Materials and methods. Data came from the National Health and Nutrition Survey 2018-19. The prevalence and proportion of flavor capsule cigarette use were estimated by sex, age, education, and wealth. Poisson models were used to evaluate sociodemographic factors as-sociated with flavor capsule cigarette use. Results. Among Mexicans,the prevalence of flavor capsule cigarettes use was 6.6%, which is 43% of all smokers. Women, adolescents, and young adults were more likely than other groups to use flavor capsule cigarettes. Conclusions. Mexicans report a high prevalence of flavor capsule cigarette use. Banning cigarettes with flavors may reduce the appeal of smoking, particularly for youth and women.

ObjectiveThis study examines the extent to which cigarette taxes affect smoking behaviour and disparities in smoking among adolescents by gender, socioeconomic status (SES) and race/ethnicity.MethodsWe used US nationally representative, repeated cross-sectional data from the 2005 to 2016 Monitoring the Future study to evaluate the relationship between state cigarette taxes and past 30-day current smoking, smoking intensity, and first cigarette and daily smoking initiation using modified Poisson and linear regression models, stratified by grade. We tested for interactions between tax and gender, SES and race/ethnicity on the additive scale using average marginal effects.ResultsWe found that higher taxes were associated with lower smoking outcomes, with variation by grade. Across nearly all of our specifications, there were no statistically significant interactions between tax and gender, SES or race/ethnicity for any grades/outcomes. One exception is that among 12th graders, there was a statistically significant interaction between tax and college plans, with taxes being associated with a lower probability of 30-day smoking among students who definitely planned to attend college compared with those who did not.ConclusionWe conclude that higher taxes were associated with reduced smoking among adolescents, with little difference by gender, SES and racial/ethnicity groups. While effective at reducing adolescent smoking, taxes appear unlikely to reduce smoking disparities among youth.

Rationale & Objective Previous studies of inflammation and anemia management in hemodialysis (HD) patients may be biased due to patient differences. We used a self-matched longitudinal design to test whether new inflammation, defined as an acute increase in C-reactive protein (CRP) level, reduces hemoglobin response to erythropoiesis-stimulating agent (ESA) treatment. Study Design Self-matched longitudinal design. Setting & Participants 3,568 new inflammation events, defined as CRP level > 10 mg/L following a 3-month period with CRP level ≤ 5 mg/L, were identified from 12,389 HD patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 4 to 6 (2009-2018) in 10 countries in which CRP is routinely measured. Predictor “After” (vs “before”) observing a high CRP level. Outcomes Within-patient changes in hemoglobin level, ESA dose, and ESA hyporesponsiveness (hemoglobin 6,000 [Japan] or >8,000 [Europe] U/wk). Analytical Approach Linear mixed models and modified Poisson regression. Results Comparing before with after periods, mean hemoglobin level decreased from 11.2 to 10.9 g/dL (adjusted mean change, −0.26 g/dL), while mean ESA dose increased from 6,320 to 6,960 U/wk (adjusted relative change, 8.4%). The prevalence of ESA hyporesponsiveness increased from 7.6% to 12.3%. Both the unadjusted and adjusted prevalence ratios of ESA hyporesponsiveness were 1.68 (95% CI, 1.48-1.91). These associations were consistent in sensitivity analyses varying CRP thresholds and were stronger when the CRP level increase was sustained over the 3-month after period. Limitations Residual confounding by unmeasured time-varying risk factors for ESA hyporesponsiveness. Conclusions In the 3 months after HD patients experienced an increase in CRP levels, hemoglobin levels declined quickly, ESA doses increased, and the prevalence of ESA hyporesponsiveness increased appreciably. Routine CRP measurement could identify inflammation as a cause of worsened anemia. In turn, these findings speak to a potentially important role for anemia therapies that are less susceptible to the effects of inflammation., Graphical Abstract