Vaping cannabis among adolescents: prevalence and associations with tobacco use from a cross-sectional study in the USA

OBJECTIVE

Previous research suggests that some adolescents are using e-cigarette devices to vaporise ('vaping') cannabis in the form of hash oil, tetrahydrocannabinol (THC) wax or oil, or dried cannabis buds or leaves. However, it is unclear how adolescents who vape cannabis use other tobacco products. This study examined the extent to which adolescents reported ever vaping cannabis and investigated how demographic variables and tobacco behaviours were associated with use.

DESIGN

We used cross-sectional data from adolescents (total response rate 64.5%) who participated in the 2017 North Carolina Youth Tobacco Survey. SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

SETTING

North Carolina, USA.

PARTICIPANTS

Adolescents in high school (n=2835).

PRIMARY OUTCOME AND MEASURE

Adolescents were asked to indicate whether they had ever used an e-cigarette device with marijuana, THC or hash oil, or THC wax.

RESULTS

Approximately 1 in 10 high school students reported ever vaping cannabis in the overall sample (9.6%). In multivariable models, adolescents who reported using cigars (adjusted OR (aOR) 3.76, 95% CI 2.33 to 6.07), waterpipe (aOR 2.32, 95% CI 1.37 to 3.93) or e-cigarettes (aOR 3.18, 95% CI 2.38 to 4.25) in the past 30 days had higher odds of reporting ever vaping cannabis compared with their counterparts. There was no significant association between use of smokeless tobacco (aOR 0.89, 95% CI 0.42 to 1.91) or use of cigarettes (aOR 1.27, 95% CI 0.71 to 2.29) in the past 30 days and odds of reporting ever vaping cannabis.

CONCLUSIONS

These findings provide evidence that large numbers of high school students who use tobacco products have vaped cannabis. As tobacco control policies-such as communication campaigns or smoke-free laws-increasingly focus on e-cigarettes, attention to understanding how adolescents use e-cigarettes to vape substances other than nicotine is essential.

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES

The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign.

METHODS

In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message.

RESULTS

Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source.

CONCLUSIONS

Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.

Trends and Racial Disparities in Mono, Dual, and Poly Use of Tobacco Products Among Youth

Introduction

We examined racial disparities in mono, dual, and poly use of tobacco products including whether racial disparities changed over time.

Methods

We analyzed data on high school students from the North Carolina Youth Tobacco Survey collected in 2011, 2013, and 2015. Dual and poly use included use of two and three or more tobacco products, respectively, in the past month. Multinomial regression models assessed racial differences and changes over time in mono, dual, and poly use. Data include product combinations most commonly used by youth from different racial groups.

Results

In total, 24% (in 2011) and 26% (in 2013 and 2015) of students used tobacco products. No significant changes over time were observed in mono (12%) or dual use (6%). Poly use was 6%, 8%, and 7% in 2011, 2013, and 2015, respectively. Relative to nonuse of tobacco, White students had a higher relative risk than Blacks for mono use. Whites and Hispanics had a higher relative risk than Blacks for dual and poly use. Observed racial differences in tobacco use did not change over time. Types of tobacco products used varied by year and race. In 2015, e-cigarette was the most commonly used product among mono users from all racial groups.

Conclusions

Substantial racial variation persists over time in mono and multiple tobacco product use among North Carolina youth, including racial variation in the types of tobacco products used. Research and policy efforts should examine and eliminate factors that drive multiple tobacco use and racial disparities in use among youth.

Implications

This study reports on racial disparities in mono and multiple tobacco product use among youth. White and Hispanic youth have higher relative risk for dual and poly use of tobacco products than Black youth. In addition, significant racial variation exists in the types of tobacco products used among youth mono, dual, and poly users, with cigarettes, cigars, smokeless tobacco, and e-cigarettes being the most commonly used products. Patterns of multiple tobacco product use vary by race and may warrant tailored prevention efforts. Strengthening tobacco control regulations for other tobacco products than cigarettes is critical to reduce multiple tobacco product use among youth.

The effect of cigarillo packaging elements on young adult perceptions of product flavor, taste, smell, and appeal

Introduction

Product packaging has long been used by the tobacco industry to target consumers and manipulate product perceptions. This study examines the extent to which cigarillo packaging influences perceptions of product flavor, taste, smell, and appeal.

Methods

A web-based experiment was conducted among young adults. Participants viewed three randomly selected cigarillo packs, varying on pack flavor descriptor, color, type, branding, and warning—totaling 180 pack images. Mixed-effects models were used to estimate the effect of pack elements on product perceptions.

Results

A total of 2,664 current, ever, and never little cigar and cigarillo users participated. Cigarillo packs with a flavor descriptor were perceived as having a more favorable taste (β = 0.21, p < .001) and smell (β = 0.14, p < .001) compared to packs with no flavor descriptor. Compared to packs with no color, pink and purple packs were more likely to be perceived as containing a flavor (β = 0.11, p < .001), and were rated more favorably on taste (β = 0.17, p < .001), smell (β = 0.15, p < .001), and appeal (β = 0.16, p < .001). While warnings on packs decreased favorable perceptions of product taste (pictorial: β = -0.07, p = .03) and smell (text-only: β = -0.08, p = .01; pictorial: β = -0.09, p = .007), warnings did not moderate the effects of flavor descriptor or color.

Conclusions

To our knowledge, this study provides the first quantitative evidence that cigarillo packaging alters consumers’ cognitive responses, and warnings on packs do not suffice to overcome the effects of product packaging. The findings support efforts at federal, state, and local levels to prohibit flavor descriptors and their associated product flavoring in non-cigarette products such as cigarillos, along with new data that supports restrictions on flavor cues and colors.

E-Cigarette Use Among Adolescents Not Susceptible to Using Cigarettes

Introduction

Research suggests that adolescents who use electronic cigarettes (e-cigarettes), including adolescents not susceptible to smoking cigarettes (ie, those who have never smoked cigarettes and are not attitudinally susceptible to using cigarettes), are more likely to initiate using cigarettes or other combustible tobacco products than adolescents who do not use e-cigarettes. In this study, we examined correlates of e-cigarette use and susceptibility among adolescents not susceptible to future cigarette smoking.

Methods

We used data on high school students from the 2015 North Carolina Youth Tobacco Survey (n = 1,627). SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

Results

Increasing perceived harm of e-cigarettes was associated with lower odds of susceptibility to using e-cigarettes (adjusted odds ratio [AOR] = 0.79; 95% confidence interval [CI], 0.65–0.96) and current use of e-cigarettes (AOR = 0.43; 95% CI, 0.25–0.72). Similar patterns were found for perceived harm of secondhand e-cigarette vapor. Exposure to e-cigarette vapor in indoor or outdoor public places was positively associated with susceptibility to using e-cigarettes (AOR = 1.96; 95% CI, 1.33–2.91) and with current e-cigarette use (AOR = 5.69; 95% CI, 2.57–12.61).

Conclusion

To prevent initiation of e-cigarette use, particularly among adolescents not susceptible to smoking cigarettes, educational campaigns could target harm perceptions associated with e-cigarettes. In addition, regulations that limit adolescents’ exposure to e-cigarettes in public places may decrease e-cigarette use by nonsusceptible adolescents.

Effects of Framing Proximal Benefits of Quitting and Motivation to Quit as a Query on Communications About Tobacco Constituents

INTRODUCTION

Little is known on how to communicate messages on tobacco constituents to tobacco users. This study manipulated three elements of a message in the context of a theory-based communication campaign about tobacco constituents: (1) latency of response efficacy (how soon expected health benefits would accrue), (2) self-efficacy (confidence about quitting), and (3) interrogative cue ("Ready to be tobacco-free?").

METHODS

Smokers (N = 1669, 55.4% women) were recruited via an online platform, and were randomized to a 3 (Latency of response efficacy) × 2 (Self-efficacy) × 2 (Interrogative cue) factorial design. The dependent variables were believability, credibility, perceived effectiveness of the communication message, and action expectancies (likelihood of seeking additional information and help with quitting).

RESULTS

Latency of response efficacy influenced believability, perceived effectiveness, credibility, and action expectancies. In each case, scores were higher when specific health benefits were said to accrue within 1 month, as compared to general health benefits occurring in a few hours. The interrogative cue had a marginal positive effect on perceived effectiveness. The self-efficacy manipulation had no reliable effects, and there were no significant interactions among conditions.

CONCLUSIONS

Smokers appear less persuaded by a communication message on constituents where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, smokers appeared to be more persuaded by messages with an interrogative cue. Such findings may help design more effective communication campaigns on tobacco constituents to smokers.

IMPLICATIONS

This paper describes, for the first time, how components of tobacco constituent messages are perceived. We now know that smokers appear to be less persuaded by communication messages where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, including an interrogative cue ("Ready to be tobacco free?") may make messages more effective, whereas the self-efficacy manipulation designed to increase confidence about quitting had no effect. While messages were universally impactful across smoker subpopulations, everyday smokers and smokers with less trust in the government may be less receptive to communication campaigns.

Consumers' Preferences for Electronic Nicotine Delivery System Product Features: A Structured Content Analysis

To inform potential governmental regulations, we aimed to develop a list of electronic nicotine delivery system (ENDS) product features important to U.S. consumers by age and gender. We employed qualitative data methods. Participants were eligible if they had used an ENDS at least once. Groups were selected by age and gender (young adult group aged 18-25, n = 11; middle-age group aged 26-64, n = 9; and women's group aged 26-64, n = 9). We conducted five individual older adult interviews (aged 68-80). Participants discussed important ENDS features. We conducted a structured content analysis of the group and interview responses. Of 34 participants, 68% were white and 56% were female. Participants mentioned 12 important ENDS features, including: (1) user experience; (2) social acceptability; (3) cost; (4) health risks/benefits; (5) ease of use; (6) flavors; (7) smoking cessation aid; (8) nicotine content; (9) modifiability; (10) ENDS regulation; (11) bridge between tobacco cigarettes; (12) collectability. The most frequently mentioned ENDS feature was modifiability for young adults, user experience for middle-age and older adults, and flavor for the women's group. This study identified multiple features important to ENDS consumers. Groups differed in how they viewed various features by age and gender. These results can inform ongoing regulatory efforts.

Public attitudes toward larger cigarette pack warnings: Results from a nationally representative U.S. sample

A large body of evidence supports the effectiveness of larger health warnings on cigarette packages. However, there is limited research examining attitudes toward such warning labels, which has potential implications for implementation of larger warning labels. The purpose of the current study was to examine attitudes toward larger warning sizes on cigarette packages and examine variables associated with more favorable attitudes. In a nationally representative survey of U.S. adults (N = 5,014), participants were randomized to different warning size conditions, assessing attitude toward "a health warning that covered (25, 50, 75) % of a cigarette pack." SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights. Across experimental groups, nearly three-quarters (72%) of adults had attitudes supportive of larger warning labels on cigarette packs. Among the full sample and smokers only (N = 1,511), most adults had favorable attitudes toward labels that covered 25% (78.2% and 75.2%, respectively), 50% (70% and 58.4%, respectively), and 75% (67.9% and 61%, respectively) of a cigarette pack. Young adults, females, racial/ethnic minorities, and non-smokers were more likely to have favorable attitudes toward larger warning sizes. Among smokers only, females and those with higher quit intentions held more favorable attitudes toward larger warning sizes. Widespread support exists for larger warning labels on cigarette packages among U.S. adults, including among smokers. Our findings support the implementation of larger health warnings on cigarette packs in the U.S. as required by the 2009 Tobacco Control Act.

Believability of Cigar Warning Labels Among Adolescents

PURPOSE

Despite high rates of cigar use among youth, little information exists about how cigar warnings are received by youth. We examined believability of different cigar warning messages with different sources among adolescents in a national phone survey.

METHODS

Adolescents (aged 13-17 years) in the US (N = 1,125; total response rate, 66%) were randomized to receive one of three health messages ("cigar smoking can cause cancers of the mouth and throat, even if you do not inhale," "cigar smoking can cause lung cancer and heart disease," and "cigars are not a safe alternative to cigarettes") and one of four warning sources (Food and Drug Administration, Surgeon General, Centers for Disease Control and Prevention, and no source). Believability was assessed with "how believable is this warning," and responses were dichotomized for "not at all or somewhat" versus "very."

RESULTS

Weighted logistic regression results indicated that most youth found the cigar warnings very believable (60.5%). Messages about mouth and throat cancer (regardless of inhalation) and the safety of cigars in comparison to cigarettes were rated as significantly less believable than messages about lung cancer and heart disease related to cigars. There were no significant differences by source or other demographics. However, youth susceptible to using cigarettes were less likely to report the cigar warnings to be very believable.

CONCLUSIONS

The messages of cigar warning labels are not viewed as equally believable among adolescents. Future studies should examine how youth process messages about health effects of cigars and the impact of different cigar warnings on youth experimentation with and use of cigars.

Impact of The Real Cost Campaign on Adolescents' Recall, Attitudes, and Risk Perceptions about Tobacco Use: A National Study

The Food and Drug Administration’s (FDA) The Real Cost campaign advertisements (ads) have targeted U.S. youth with messages designed to prevent and reduce tobacco use. This study examined exposure to The Real Cost campaign, including ad and slogan recall, and associations with attitudes and risk perceptions among U.S. adolescents. We analyzed data from a nationally representative sample of adolescents aged 13 to 17 years (n = 1125) surveyed by phone from October 2014 to June 2015. We assessed aided recall of and attitudes toward four campaign ads and the one slogan. Logistic regression models assessed whether aided recall of The Real Cost ads or slogan was associated with perceived likelihood of serious health consequences of cigarette smoking. Most (88%) adolescents reported seeing or hearing at least one of four ads for The Real Cost, and 54% recalled The Real Cost slogan. The majority of adolescents reported more negative attitudes toward tobacco products after seeing or hearing the ads. Recall of any The Real Cost ad was significantly associated with greater perceptions of serious health consequences of cigarette smoking (Adjusted Odd Ratios (AOR) = 5.58, 95% Confidence Interval (CI) = 1.20–25.90). The FDA’s The Real Cost campaign has achieved very high reach and is associated with more negative attitudes toward tobacco products and greater risk perceptions of cigarette smoking among U.S. adolescents.

Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review

Objective

This systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults.

Data sources

English-language peer-reviewed publications indexed in 4 databases were searched through April 2016.

Study selection

A search strategy was developed related to tobacco products and flavours. Of 1688 articles identified, we excluded articles that were not English-language, were not peer-reviewed, were qualitative, assessed menthol-flavoured tobacco products only and did not contain original data on outcomes that assessed the impact of flavours in tobacco products on perceptions and use behaviour.

Data extraction

Outcome measures were identified and tabulated. 2 researchers extracted the data independently and used a validated quality assessment tool to assess study quality.

Data synthesis

40 studies met the inclusion criteria. Data showed that tobacco product packaging with flavour descriptors tended to be rated as more appealing and as less harmful by tobacco users and non-users. Many tobacco product users, especially adolescents, reported experimenting, initiating and continuing to use flavoured products because of the taste and variety of the flavours. Users of many flavoured tobacco products also showed decreased likelihood of intentions to quit compared with non-flavoured tobacco product users.

Conclusions

Flavours in most tobacco products appear to play a key role in how users and non-users, especially youth, perceive, initiate, progress and continue using tobacco products. Banning non-menthol flavours from tobacco products may ultimately protect public health by reducing tobacco use, particularly among youth.

"The Job Has Become Advocating for the Job": Threats to Funding Dramatically Influence Program Outcomes

As public health funding is increasingly threatened, a better understanding is needed about how periods of funding uncertainty impact program staff, activities, and outcomes. In North Carolina, 2 years of uncertainty and threats of funding cuts for a statewide youth tobacco prevention initiative contributed to reduced grantee morale and confidence about achieving program goals, displaced focus from core program activities, and caused premature loss of personnel, resulting in substantially reduced program activities and outcomes. The range of negative impacts of funding uncertainty and threats highlights the need for programs to create an infrastructure to support ongoing sustainability planning and activities.

Electronic Cigarette Use Among High School Students and Its Association With Cigarette Use And Smoking Cessation, North Carolina Youth Tobacco Surveys, 2011 and 2013

Introduction

Although adolescent cigarette use continues to decline in the United States, electronic cigarette (e‑cigarette) use among adolescents has escalated rapidly. This study assessed trends and patterns of e‑cigarette use and concurrent cigarette smoking and the relationships between e-cigarette use and smoking cessation intentions and behaviors among high school students in North Carolina.

Methods

Data came from high school students who completed the school-based, cross-sectional North Carolina Youth Tobacco Survey in 2011 (n = 4,791) and 2013 (n = 4,092). This study assessed changes in prevalence of e-cigarette and cigarette use from 2011 through 2013, and cessation-related factors associated with those students’ current and past use of e‑cigarettes in 2013.

Results

The prevalence of current e-cigarette use (use in the past 30 days) significantly increased from 1.7% (95% CI, 1.3%–2.2%) in 2011 to 7.7% (95% CI, 5.9%–10.0%) in 2013. Among dual users, current e-cigarette use was negatively associated with intention to quit cigarette smoking for good (relative risk ratio [RRR] = 0.51; 95% CI, 0.29–0.87) and with attempts to quit cigarette smoking in the past 12 months (RRR = 0.69; 95% CI, 0.49–0.97). Current e-cigarette smokers were less likely than those who only smoked cigarettes to have ever abstained from cigarette smoking for 6 months (RRR = 0.42; 95% CI, 0.21–0.82) or 1 year (RRR = 0.21; 95% CI, 0.09–0.51) and to have used any kind of aids for smoking cessation (RRR = 0.46; 95% CI, 0.29–0.74).

Conclusion

Public health practitioners and cessation clinic service providers should educate adolescents about the risks of using any nicotine-containing products, including e-cigarettes, and provide adequate tobacco cessation resources and counseling to adolescent tobacco users.

Pilot Implementation of a Wellness and Tobacco Cessation Curriculum in North Carolina Group Homes

Despite a steady decline in smoking rates in recent decades, individuals with mental illness continue to smoke at disproportionately higher rates than the general population. Adults with mental illness are motivated to quit and quit with rates similar to the general population when evidence-based cessation interventions are used. To build an evidence base for a wellness and cessation curriculum aimed at individuals with mental illness, the Breathe Easy Live Well (BELW) program was pilot tested in two group homes in North Carolina in the spring of 2014. Evaluators conducted pre- and post-implementation site visits and interviews with program instructors to assess outcomes as well as barriers and facilitators to implementation. Qualitative analysis of the data indicated that implementation was successful in both group homes, and the following themes emerged: (1) Training and technical assistance provided throughout implementation was sufficient; (2) Instructors used prior professional experiences and goal setting to facilitate program success and participant engagement; (3) Fostering positive coping strategies contributed to reports of reduced smoking; (4) Curriculum length may be a barrier to recruitment. Additional results included an increased interest among group home residents in more diligently managing mental illness symptoms and one group home moving the designated smoking area out of the direct path of the entrance/exit. Results of this pilot project suggest that BELW could be a potentially useful tool for group home staff to address health and wellness along with smoking cessation among individuals with mental illness.

"May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections

Most smokers become addicted to tobacco products before they are legally able to purchase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We conducted a narrative review and examined implications of two types of legal authority for protocols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present themselves naturally and attempt to match the community's demographic makeup.

Neighborhood Inequalities in Retailers' Compliance With the Family Smoking Prevention and Tobacco Control Act of 2009, January 2014-July 2014

Introduction

Retailer noncompliance with limited US tobacco regulations on advertising and labeling was historically patterned by neighborhood in ways that promote health disparities. In 2010, the US Food and Drug Administration (FDA) began enforcing stronger tobacco retailer regulations under the Family Smoking Prevention and Tobacco Control Act of 2009. However, recent research has found no differences in compliance by neighborhood characteristics for FDA advertising and labeling inspections. We sought to investigate the neighborhood characteristics associated with retailer noncompliance with specific FDA advertising and labeling inspections (ie, violations of bans on self-service displays, selling single cigarettes, false or mislabeled products, vending machines, flavored cigarettes, and free samples).

Methods

We coded FDA advertising and labeling warning letters (n = 718) for type of violations and geocoded advertising and labeling inspections from January 1 through July 31, 2014 (N = 33,543). Using multilevel models, we examined cross-sectional associations between types of violations and neighborhood characteristics previously associated with disparities (ie, percentage black, Latino, under the poverty line, and younger than 18 years).

Results

Retailer advertising and labeling violations are patterned by who lives in the neighborhood; regulated tobacco products are more likely to be stored behind the counter as the percentage of black or Latino residents increases, and single cigarettes are more often available for purchase in neighborhoods as the percentage of black, poor, or young residents increases.

Conclusion

Contrary to previous null findings, noncompliance with FDA advertising and labeling regulations is patterned by neighborhood characteristics, sometimes in opposite directions. Given the low likelihood of self-service violations in the same neighborhoods that have high likelihood of single cigarette sales, we suggest targeted approaches to FDA retailer inspections and education campaigns.

Single Cigarette Sales: State Differences in FDA Advertising and Labeling Violations, 2014, United States

IMPORTANCE

Single cigarettes, which are sold without warning labels and often evade taxes, can serve as a gateway for youth smoking. The Family Smoking Prevention and Tobacco Control Act of 2009 gives the US Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products, including prohibiting the sale of single cigarettes. To enforce these regulations, the FDA conducted over 335,661 inspections between 2010 and September 30, 2014, and allocated over $115 million toward state inspections contracts.

OBJECTIVE

To examine differences in single cigarette violations across states and determine if likely correlates of single cigarette sales predict single cigarette violations at the state level.

DESIGN

Cross-sectional study of publicly available FDA warning letters from January 1 to July 31, 2014.

SETTING

All 50 states and the District of Columbia.

PARTICIPANTS

Tobacco retailer inspections conducted by FDA (n = 33 543).

EXPOSURES FOR OBSERVATIONAL STUDIES

State cigarette tax, youth smoking prevalence, poverty, and tobacco production.

MAIN OUTCOMES AND MEASURES

State proportion of FDA warning letters issued for single cigarette violations.

RESULTS

There are striking differences in the number of single cigarette violations found by state, with 38 states producing no warning letters for selling single cigarettes even as state policymakers developed legislation to address retailer sales of single cigarettes. The state proportion of warning letters issued for single cigarettes is not predicted by state cigarette tax, youth smoking, poverty, or tobacco production, P = .12.

CONCLUSIONS AND RELEVANCE

Substantial, unexplained variation exists in violations of single cigarette sales among states. These data suggest the possibility of differences in implementation of FDA inspections and the need for stronger quality monitoring processes across states implementing FDA inspections.

Impact of the adoption of tobacco-free campus policies on student enrollment at colleges and universities, North Carolina, 2001-2010

OBJECTIVE

College and university administrators have expressed concern that adoption of tobacco-free policies may reduce applications and enrollment. This study examines adoption and implementation of 100% tobacco-free campus policies by institutions of higher education on applications and enrollment.

PARTICIPANTS

North Carolina private colleges and universities and public community colleges. Analysis was conducted in 2011.

METHODS

Student enrollment and application data were analyzed by campus type to determine (a) if there was a difference in student applications and enrollment before and after policy implementation, and (b) if there was a difference in student applications and enrollment for campuses with versus without a policy.

RESULTS

No significant differences were found in student enrollment or applications when comparing years prior to and following policy implementation or when comparing with institutions without 100% tobacco-free campus policies.

CONCLUSIONS

The authors found no evidence that 100% tobacco-free policy adoption had an impact on student enrollment or applications.

Valuation of tobacco control policies by the public in North Carolina: comparing perceived benefit with projected cost of implementation

BACKGROUND

After 40 years of continuous decline, smoking rates in the United States have stabilized signaling a challenge for tobacco control. Renewed decline may be guided by public opinion where support for tobacco control is strong. This study sought the public's preferences about tobacco control strategies.

METHODS

This contingent valuation study investigated whether the public's valuations of 2 tobacco control policies outweighed their implementation costs. In a hypothetical referendum, a representative sample of North Carolinians aged 45-64 years (n = 644) was asked to indicate whether they would prefer a policy that would halve the youth smoking rate or one that would reduce smoking-related deaths by 10%, and to indicate how much additional tax they would be willing to pay to implement their preferred policy. This willingness-to-pay value formed the perceived "benefit" component in a cost-benefit analysis. Costs to halve youth smoking were calculated from evidence about the resources required to increase the state tobacco excise tax. Costs to reduce tobacco-related deaths were based on evidence about the resources required for a counseling quitline offering free nicotine replacement therapy.

RESULTS

The majority (85%) of respondents voted to halve the youth smoking rate. The mean maximum amount per person that voters were willing to pay in 1 year to do that was $14.90 (95% CI, $10.10-$19.60), and the maximum amount per person they were willing to pay in 1 year to reduce smoking-related deaths was $13.70 (95% CI, $2.10-$25.40). When aggregated to the North Carolina population aged 45-64 years (N = 2,400,144), the perceived benefit of halving youth smoking was $35.8 million. Implementation of a program to achieve this outcome would cost $109.8 million. Aggregating to the same population, the perceived benefit of a 10% reduction in tobacco-related deaths was $32.9 million, an amount that exceeds the $12.8 million estimated cost of achieving the outcome.

CONCLUSION

A counseling quitline with free nicotine replacement therapy would achieve a positive net benefit.

Environmental tobacco smoke and periodontitis in U.S. non-smokers

PURPOSE

The association of second hand smoke or environmental tobacco smoke (ETS) and periodontitis in non-smokers has not been confirmed using a biomarker of ETS exposure. To estimate periodontitis prevalence in non-smokers with detectable serum cotinine, and to investigate racial/ethnic and socioeconomic variation in ETS exposure in a representative sample of the U. S. adult population. Determining periodontitis risk indicators occurring with ETS appears to be a salient purpose as this study is the first of its kind to provide a link (a salivary biomarker) between second hand smoke and risk for periodontitis.

METHODS

Data were collected from the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES). Subjects were 3,137 adults who had smoked fewer than 100 cigarettes and had not used other forms of tobacco. ETS exposure was classified as negligible (cotinine concentrations below sex and race/ethnicity cut-points for smokers), moderate (cotinine 0.5-<1.5 μg/mL) or high (cotinine ≥ 1.5 ng/mL). Periodontitis was classified according to the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP) case definition for moderate-severe disease. Survey estimation procedures were used to estimate prevalence and odds ratios (OR) were from multivariable logistic regression models.

RESULTS

ETS exposure was observed in 40.5% of subjects and 2.6% had periodontitis. ETS exposure was inversely associated with educational attainment and family income and was higher in non-Hispanic blacks than whites. After adjusting for age, sex and year of survey, adults with high ETS exposure (cotinine ≥ 1.5 ng/mL) had more than twice the odds of periodontitis as people with negligible exposure (OR=2.3, 95% confidence interval=1.3, 4.1).

CONCLUSION

High ETS exposure was a risk indicator for periodontitis in lifetime non-smokers.

Assessment of college and university campus tobacco-free policies in North Carolina

OBJECTIVE

To develop a reliable and efficient method for assessing prevalence and strength of college/university tobacco-related policies.

PARTICIPANTS

North Carolina (NC) public universities, community colleges, and private colleges/universities (N = 110).

METHODS

A census of policies using campus handbooks and Web sites was conducted in March 2011.

RESULTS

The rating tool is reliable and valid. Ninety-nine percent of NC college/university campuses are smoke-free in all indoor areas. The majority (94/110 [85%]) of colleges and universities regulate smoking and/or tobacco in some or all outdoor areas. Less than 20% of campuses had restrictions for industry marketing, promotion, and sales.

CONCLUSIONS

Clean indoor air policies are present at all but 1 NC college/university campus, and a growing number have enacted broad outdoor limits to protect students, faculty, and staff from secondhand smoke. Policy census approaches across all other states would quantify the national tobacco-free college campus policy environment and facilitate adoption of tobacco-free campus policies.

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses

BACKGROUND

Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.

METHODS

We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse members (n = 271) in nine clubhouses.

RESULTS

Fifty-eight percent of clubhouse participants completed surveys. Results showed tobacco users open to tobacco-free policies (62%) and perceiving more discussions about quitting tobacco with healthcare providers (69%). Analyses of staff interviews and member surveys revealed four key themes: (1) the curriculum was successfully implemented and appreciated; (2) technical assistance kept implementation on track; (3) adding wellness content and interactive components should enhance the curriculum; and, (4) the curriculum advanced other healthful policies and practices.

CONCLUSIONS

Mental health settings are important locations for implementing programs to address tobacco use. In this real-world implementation of a model curriculum in psychosocial rehabilitation clubhouses, the curriculum tested well, was feasible and well-received, and suggests potential impact on tobacco use outcomes. Revision, dissemination, and a randomized controlled trial evaluation of the model curriculum should now occur.

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses

Background

Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.

Methods

We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse members (n = 271) in nine clubhouses.

Results

Fifty-eight percent of clubhouse participants completed surveys. Results showed tobacco users open to tobacco-free policies (62%) and perceiving more discussions about quitting tobacco with healthcare providers (69%). Analyses of staff interviews and member surveys revealed four key themes: (1) the curriculum was successfully implemented and appreciated; (2) technical assistance kept implementation on track; (3) adding wellness content and interactive components should enhance the curriculum; and, (4) the curriculum advanced other healthful policies and practices.

Conclusions

Mental health settings are important locations for implementing programs to address tobacco use. In this real-world implementation of a model curriculum in psychosocial rehabilitation clubhouses, the curriculum tested well, was feasible and well-received, and suggests potential impact on tobacco use outcomes. Revision, dissemination, and a randomized controlled trial evaluation of the model curriculum should now occur.