The great decline in adolescent cigarette smoking since 2000: consequences for drug use among US adolescents

OBJECTIVE

Adolescent cigarette smoking declined steadily and substantially from 2000 to 2018. This paper considers the potential consequences of this 'great decline' for the prevalence of other drug use among adolescents.

METHODS

Data are annual, cross-sectional, nationally representative Monitoring the Future surveys of more than 1.2 million US students in 12th, 10th and 8th grades from 2000 to 2018. Analyses include trends in the past 12 months' non-medical amphetamine, tranquillisers and opioid use overall, among ever and never cigarette smokers, and projected if adolescent cigarette smoking levels had remained at 2000 levels.

RESULTS

Within groups of ever and never cigarette smokers, the prevalence for each of the three substances has either changed little or overall increased in 2018 as compared with 2000. When the two groups were combined into one pool, the overall prevalence for each of the drugs declined by about half. The decline resulted from the growing group of never smokers, whose levels of non-medical drug use over the study period were at least four times lower than the levels of ever smokers.

CONCLUSIONS

The results support the 'gateway' prediction that declines in cigarette smoking among adolescents pull downward their non-medical use of amphetamines, tranquillisers and opioids. Continuing to reduce adolescent smoking through policy and programmatic prevention efforts should have further positive spillover effects on adolescent drug use.

Point-of-sale marketing of little cigars and cigarillos on and near California Tribal lands

INTRODUCTION

American Indians have the highest cigarette smoking prevalence of any racial/ethnic group in the USA. Tobacco marketing at point-of-sale is associated with smoking, possibly due to easy access to cheap tobacco products. The sale of novel tobacco products like little cigars/cigarillos (LCCs) has increased in recent years which may further increase combustible tobacco use among American Indians.

METHODS

Between October 2015 and February 2017, trained community health workers collected LCC product and price information by conducting audits of tobacco retailers on Tribal lands (n=53) and retailers within a 1-mile radius of Tribal lands (n=43) in California. Χ2 analyses were performed to examine associations among the availability and advertising of LCCs, including indoor price promotions and store location.

RESULTS

Overall, 85.4% of stores sold LCCs, 76.0% sold flavoured LCCs and 51.0% sold LCCs for less than $1. Indoor price promotions were displayed at 45 (46.9%) stores. Stores within a 1-mile radius of Tribal lands sold significantly more LCC (p<0.01) and flavoured LCCs (p=0.01) than stores on Tribal lands. Stores within a 1-mile radius of Tribal lands also displayed significantly more LCCs priced at less than $1 (p<0.01) than stores on Tribal lands.

CONCLUSIONS

LCCs are widely available in stores on and near California Tribal lands. Stores located a short distance away from Tribal lands were more likely to sell LCCs, including flavoured versions, more likely to sell LCCs priced below $1, and more likely to advertise little LCC price promotions than stores on Tribal lands. Policy-makers and Tribal leaders should consider regulations that would limit access to LCCs at point of sale to help prevent youth initiation and reduce smoking-related morbidity and mortality among American Indians.

Reactions to electronic nicotine delivery system (ENDS) prevention messages: results from qualitative research used to inform FDA's first youth ENDS prevention campaign

Background

Youth e-cigarette use is a major public health concern. Large-scale tobacco prevention campaigns are a proven strategy to prevent tobacco use. There is a gap in understanding what types of e-cigarette prevention messages might be most effective. This study addresses this gap by reporting youth reactions to health messages aimed at preventing e-cigarette use.

Methods

In 2018, twenty-four focus groups, with 159 teens (12–17) at risk for or experimenting with e-cigarettes were conducted in four cities across the USA. During focus groups, youth responded to creative concepts dealing with (1) the addictive nature of e-cigarettes, (2) the fact that e-cigarettes come in flavours, which may encourage youth initiation, and nicotine which may lead to addiction, or (3) that youth who use e-cigarettes are more likely to use cigarettes. Youth also gave feedback to specific facts about harmful and potentially harmful chemicals in e-cigarettes. Transcripts were analysed using thematic analysis.

Results

Messages focusing on addiction alone did not resonate with participants. While youth found the idea that e-cigarettes may contain nicotine and can be addictive believable, with many describing personal experiences of addiction, they questioned how bad this really was, comparing addiction to e-cigarettes to things like being addicted to food. Participants wanted more information about negative consequences of vaping. Concepts paired with strong health effects messages resonated with participants.

Conclusion

These focus groups clarified which e-cigarette prevention messages might be most persuasive to teens. Youth in this study responded favourably to messages stating specific health consequences of e-cigarette use.

Plain tobacco packaging, increased graphic health warnings and adolescents' perceptions and initiation of smoking: DePICT, a French nationwide study

BACKGROUND

Plain packaging (PP) of tobacco products and increased graphic warnings may contribute to lower attractiveness of smoking, particularly among youths. In France, this policy was introduced on 1 January 2017. We examined changes in smoking-related perceptions and behaviours among a nationwide sample of French adolescents before (2016) and 1 year post (2017) implementation.

METHODS

DePICT is a two-wave cross-sectional national telephone survey of adolescents aged 12-17 years per study wave (2016: n=2046 2017: n=1999). All participants reported smoking-related perceptions, as well as ever and current tobacco use. Smokers were also asked about their perceptions of tobacco brands. Data were weighted to be representative of youths in the French population: adjusted prevalence ratios (PRs, 95% CI) estimating changes between the two study waves were calculated using multivariate log-binomial regression models.

RESULTS

In 2017, as compared with 2016, French adolescents were more likely to report fear of the consequences of smoking (PR=1.06, 95% CI 1.02 to 1.09) and that smoking is dangerous (PR=1.08, 95% CI 1.05 to 1.11). They were also less likely to report that their friends (PR=0.61, 95% CI 0.54 to 0.70) and family (PR=0.51, 95% CI 0.44 to 0.60) accept smoking. Additionally, smoking initiation significantly decreased (PR=0.96, 95% CI 0.93 to 0.98) and a non-statistically significant drop in current tobacco use was observed (PR=0.93, 95% CI 0.78 to 1.11). Smokers' attachment to their tobacco brand also decreased (PR=0.47, 95% CI 0.30 to 0.73).

CONCLUSION

Our findings suggest that PP and increased graphic warnings could contribute to changes in smoking norms and rates among adolescents.

Heated tobacco product use among Korean adolescents

Background

Heated tobacco products (HTPs) may compromise decades-long efforts to marginalise the tobacco industry. Their appeal to adolescents imposes a risk of a new tobacco epidemic. Empirical evidence on the behavioural patterns of HTP use among adolescents is required. We investigated the prevalence of HTP use and the association between use of HTPs and e-cigarettes and attempts to quit smoking cigarettes.

Methods

Nationally representative cross-sectional survey data of South Korean adolescents aged 12–18 years (mean age: 15 years) were used. The survey was conducted 1 year after the introduction of HTPs in Korea. A total of 59 532 adolescents were identified. Descriptive statistics and multiple logistic regression results are presented.

Results

In all, 2.8% of South Korean adolescents were ever HTP users. Among these, 75.5% were current cigarette users, 45.6% were current e-cigarette users and 40.3% were concurrent users of cigarettes and e-cigarettes. Unlike ever use of e-cigarettes, which was associated with a higher likelihood of cigarette quit attempts (adjusted OR (aOR)=1.35, 95% CI: 1.16 to 1.58), no difference in cigarette quit attempts was found for ever use of HTPs (aOR=1.07, 95% CI: 0.91 to 1.26).

Conclusion

Considering the recent introduction of HTPs to the Korean market and less than 1% prevalence of e-cigarette when first introduced, the prevalence of ever HTP use among Korean adolescents is an important concern. The results showing high polytobacco use and the lack of an association between HTP use and cigarette quit attempts call for a ban on HTP advertisements with modified harm claims.

Deaths from smoking and from HIV/AIDS among gay and bisexual men in California, 2005-2050

INTRODUCTION

Deaths from HIV/AIDS have long been of concern to the gay community, but less attention has focused on smoking-attributable deaths despite the relatively high smoking rates among gay and bisexual men. This study compared deaths from HIV/AIDS with smoking-attributable deaths among California gay and bisexual men from 2005 to 2050.

METHODS

Smoking-attributable fractions (SAFs) were estimated using smoking prevalence for gay and bisexual men from the 2011-2014 California Health Interview Surveys and published relative risks of death. Smoking-attributable deaths were calculated by multiplying the SAFs by deaths among gay and bisexual men. Deaths from HIV/AIDS among men who have sex with men was obtained from the California Department of Public Health. Future deaths from smoking and HIV/AIDS were projected using regression equations based on time trends.

RESULTS

From 2005 to 2014, smoking caused over 6800 deaths among gay and bisexual men, while nearly 9500 died from HIV/AIDS. Mortality from both causes has been falling, but deaths from HIV/AIDS have been falling more rapidly. Projections suggest that in the mid-2040s, more gay/bisexual men will die from smoking than from HIV/AIDS.

CONCLUSION

Smoking will surpass HIV/AIDS as a cause of death among gay and bisexual men in California within a few decades. The lesbian, gay, bisexual and transgender (LGBT) community was highly effective in drawing attention and resources to the fight against HIV/AIDS, saving untold lives by hastening effective treatments. Lessons learnt in the fight against AIDS should be used to help fight the tobacco epidemic.

Cigarette smoking quit ratios among adults in the USA with cannabis use and cannabis use disorders, 2002-2016

BACKGROUND

The prevalence of cigarette smoking is nearly three times higher among persons who use cannabis and have cannabis use disorders (CUDs), relative to those who do not. The current study examined cigarette quit ratios from 2002 to 2016 among US adults with and without cannabis use and CUDs.

METHODS

The current study analysed US adults aged 18 years and older from the National Survey on Drug Use and Health, an annual cross-sectional study. Quit ratios (ie, proportion of former smokers among ever-smokers) were calculated annually from 2002 to 2016. Time trends in quit ratios by cannabis use/CUDs were tested using logistic regression.

RESULTS

In 2016, the quit ratios for people with any cannabis use (23%) and CUDs (15%) were less than half the quit ratios of those without cannabis use and CUDs (51% and 48%, respectively). After controlling for demographics and substance use disorders, the quit ratio did not change from 2002 to 2016 among persons with CUD, though it non-linearly increased among persons with cannabis use, without cannabis use and without CUDs. Quit ratios increased more rapidly among those who reported past-month cannabis use compared with those without past-month cannabis use.

CONCLUSIONS

Cigarette smoking quit ratios remain dramatically lower among people who use cannabis and have CUDs and quit ratios did not change significantly from 2002 to 2016 among those with CUDs. Public health and clinical attention are needed to increase quit ratios and reduce harmful cigarette smoking consequences for persons with cannabis use and CUDs.

Availability, price and promotions for cigarettes and non-cigarette tobacco products: an observational comparison of US Air Force bases with nearby tobacco retailers, 2016

INTRODUCTION

Active duty military personnel have higher cigarette and smokeless tobacco use rates than civilian populations. Although US Airmen (called Airmen regardless of gender or rank) are required to be tobacco-free during initial training, many resume use once this period ends, perhaps as a result of easy access to cheap tobacco products.

METHODS

Between July and September 2016, we collected tobacco product, price and promotion information by visiting on-base (n=28) and off-base (n=80) tobacco retailers near the eight technical training bases where approximately 99% of Airmen attend training. We conducted mixed linear effects models to examine on-base versus off-base differences.

RESULTS

Cigarette packs were 11%-12% cheaper at on-base retailers compared with off-base retailers. Newport Menthol and Marlboro Red cigarette packs were $0.87 and $0.80 lower on-base (p<0.001) while the cheapest pack available was $0.54 lower on-base (p<0.01). Copenhagen smokeless tobacco was also significantly cheaper on-base (B=-0.65, p<0.01). Interior price promotions were more common on-base.

CONCLUSIONS

Retail stores located on Air Force bases sell cigarettes and smokeless tobacco products at prices well below those in nearby off-base retailers: the vast majority of these retailers feature interior price promotions for these products. Federal policies regulating prices of on-base tobacco sales, if implemented more effectively, have the potential to protect the health of Airmen by helping them remain tobacco-free after technical training.

Cohort effects of tobacco control policy: evidence to support a tobacco-free norm through smoke-free policy

Background

The prevalence of cigarette smoking among South Korean adolescents has decreased markedly over the past decade, which may indicate a norm shift between generations of adolescents. The present study aims to identify the effect of banning smoking in public places and increasing cigarette prices on current adolescent smoking, and to determine whether these policies additionally resulted in cohort effects.

Methods

Repeated cross-sectional survey data, nationally representative of South Korean adolescents, were used. A total of 853 441 adolescents ranging in age from 12 to 18 years (mean age, 15 years) were identified. Models applied were segmented regression model to detect changes in smoking trends and age-period-cohort model to determine the cohort effects on the trends.

Findings

Between 2006 and 2017, smoking decreased from 16% to 9% in boys and from 9% to 3% in girls. After a complete ban on smoking in public places, there were significantly negative trends in the prevalence of smoking for both boys (β=−1.1; 95% CI: −1.9 to −0.2) and girls (β=−0.4; 95% CI: −0.6 to −0.1). Immediate decrease among girls was found after cigarette prices increased (β=−0.8; 95% CI: −1.5 to −0.2). For the cohort effect, the risk of smoking decreased with every consecutive year for boys born after 1998 and girls born after 1997.

Conclusions

Our results indicate the presence of cohort effects in the reduction of adolescent smoking. The cohort effect was induced by smoke-free legislation. Research on cohort effects, and methods to denormalise tobacco, will contribute to preventing adolescents from ever trying a cigarette.

Neighbourhood tobacco supply and individual maternal smoking during pregnancy: a fixed-effects longitudinal analysis using routine data

BACKGROUND

Tobacco policy is increasingly focusing on the 'tobacco endgame' which commits to eradicating tobacco use (prevalence below 5%) within the next two decades. Strategies for achieving the endgame are likely to include addressing the supply of tobacco products, yet current evidence to support this approach is primarily cross-sectional.

METHODS

We use longitudinal smoking information from routine maternity records of all women who gave birth in Scotland between 2000 and 2015. We linked this data to the residential density of retailers selling tobacco products and the neighbourhood prevalence of smoking during pregnancy. In the analysis, individual mothers act as their own controls because we compare changes in their smoking behaviour between pregnancies to changes in exposure to tobacco retailing that arises from residential movement between pregnancies.

RESULTS

Adjusted ORs showed an increased risk of being a smoker associated with increases in exposure to retailer density (OR 1.67, 95% CI 1.27 to 2.20).

CONCLUSIONS

The results provide the strongest evidence to date of an association between the neighbourhood availability of tobacco and smoking, and the first to do so among pregnant women. These findings provide supportive evidence for interventions targeting the supply of tobacco products in achieving the endgame.

Polytobacco use among young adult smokers: prospective association with cigarette consumption

BACKGROUND

The risks of polytobacco use among young adults are unclear because we know relatively little about the consistency of multiproduct patterns over time and how these patterns impact cigarette smoking. The purpose of this study was to examine changes in multiple tobacco product use over time and associations with cigarette smoking quantity.

METHODS

Participants (n=335; 55% male) were 18-24 years old non-daily cigarette smokers living in California. Polytobacco use patterns were assessed quarterly for 2 years.

RESULTS

Transition analyses showed that while the number of products that had been used recently was volatile, the most common pattern was stability between timepoints. A longitudinal negative binomial regression model indicated that those who used more non-cigarette products also reported greater cigarette quantity. The strength of this relationship increased over time.

CONCLUSIONS

Findings suggest that individuals who use more tobacco products are at greater risk for increased cigarette smoking and maintaining a multiple product use pattern.

Cigarette smoking among those with mental disorders in the US population: 2012-2013 update

BACKGROUND

Recent nationally representative estimates from the USA suggest the prevalence of cigarette smoking continues to be much higher among those with mental disorders compared with those without; however, prevalence estimates for current cigarette use by specific diagnoses are outdated.

METHODS

We analysed data from the National Epidemiologic Survey on Alcohol and Related Conditions III (2012-2013). We estimated the prevalence of lifetime and past-year smoking, lifetime and past-year daily smoking, and lifetime smoking cessation among ever smokers (ie, the quit ratio) among those with common mood, anxiety and substance use disorders in comparison to those without these disorders.

RESULTS

Across disorders, smoking prevalence was higher and the quit ratio was lower among those with common mental disorders compared with those without, with twofold to sixfold relativedifferences in the odds of the magnitude.

CONCLUSIONS

Despite tobacco control advances since 2000 and resulting declines in smoking prevalence, smoking remains extraordinarily more common among those with mood, anxiety and substance use disorders, with highest rates among those with bipolar and substance use disorders.

JUUL and other stealth vaporisers: hiding the habit from parents and teachers

BACKGROUND

Some consumers wish to use vapour devices discreetly so that family members, teachers and coworkers do not recognise their use of nicotine ortetrahydrocannabinol (THC) laden vapour.

METHODS

Stealthy vapour devices, as well as low-odour and low-vapour e-juices, were identified via a comprehensive online search between March and June 2018.

RESULTS

As evidence of their popularity, a search for 'stealth vaping' on YouTube found 18 200 videos. A variety of cleverly designed vapour devices disguised as USB sticks, pens, remote controls, car fobs, smart phones, sweatshirt drawstrings and even asthma inhalers are on the market. JUUL, which resembles a USB stick, is the archetype of these devices and is especially popular among youth. A search of 'JUUL' on YouTube yielded 148 000 videos with 57 videos having >100 000 views. Searches on 'JUUL at school' (15 500), 'JUUL in class' (6840), 'hiding JUUL in school' (2030) and 'JUUL in school bathroom' (1040) illustrate the product's popularity among students. Some e-juices promote themselves as having low visibility plumes while others profess to be of subtle odour to avoid detection. Numerous techniques have been described to hide the exhaled vapour plume such as by swallowing it or blowing it into one's clothing or into a backpack.

CONCLUSIONS

The vaping industry has demonstrated much ingenuity in devising discreet vaporisers and de-emphasising exhaled vapour plumes and their aroma. The US market for vaping devices with stealthy characteristics is anything but inconspicuous, with JUUL alone accounting for 70.5% of sales (July 2018).

Effectiveness of tobacco cessation pharmacotherapy in the Veterans Health Administration

INTRODUCTION

In 2003, the Veterans Health Administration (VHA) implemented a directive that cessation pharmacotherapy be made available to all who use tobacco and are interested in quitting. Despite the efficacy of cessation pharmacotherapy shown in clinical trials, the generalisability of the results in real-world settings has been challenged. Hence, the specific aim of this study was to determine the effectiveness of cessation pharmacotherapies in the VHA.

METHODS

This retrospective cohort study used VHA's electronic medical record data to compare quit rates among those who use tobacco and who did vs. did not receive any type of cessation pharmacotherapy. Included were 589 862 Veterans identified as current tobacco users during fiscal year 2011 who had not received cessation pharmacotherapy in the prior 12 months. Following a 6-month period to assess treatment, quit rates among those who were treated versus untreated were compared during the 7-18 months (12 months) post-treatment follow-up period. The estimated treatment effect was calculated from a logistic regression model adjusting for inverse probability of treatment weights (IPTWs) and covariates. Marginal probabilities of quitting were also obtained among those treated versus untreated.

RESULTS

Adjusting for IPTWs and covariates, the odds of quitting were 24% higher among those treated versus untreated (OR=1.24, 95% CI 1.23 to 1.25, p<0.001). The marginal probabilities of quitting were 16.7% for the untreated versus 19.8% for the treated based on the weighted model.

CONCLUSION

The increased quit rates among Veterans treated support the effectiveness and continuation of the VHA tobacco cessation pharmacotherapy policy.

Neighbourhood characteristics and health outcomes: evaluating the association between socioeconomic status, tobacco store density and health outcomes in Baltimore City

INTRODUCTION

Several studies suggest that the health of an individual is influenced by the socioeconomic status (SES) of the community in which he or she lives. This analysis seeks to understand the relationship between SES, tobacco store density and health outcomes at the neighbourhood level in a large urban community.

METHODS

Data from the 55 neighbourhoods of Baltimore City were reviewed and parametric tests compared demographics and health outcomes for low-income and high-income neighbourhoods, defined by the 50th percentile in median household income. Summary statistics are expressed as median. Tobacco store density was evaluated as both an outcome and a predictor. Association between tobacco store densities and health outcomes was determined using Moran's I and spatial regression analyses to account for autocorrelation.

RESULTS

Compared with higher-income neighbourhoods, lower-income neighbourhoods had higher tobacco store densities (30.5 vs 16.5 stores per 10 000 persons, P=0.01), lower life expectancy (68.5 vs 74.9 years, P<0.001) and higher age-adjusted mortality (130.8 vs 102.1 deaths per 10 000 persons, P<0.001), even when controlling for other store densities, median household income, race, education status and age of residents.

CONCLUSION

In Baltimore City, median household income is inversely associated with tobacco store density, indicating poorer neighbourhoods in Baltimore City have greater accessibility to tobacco. Additionally, tobacco store density was linked to lower life expectancy, which underscores the necessity for interventions to reduce tobacco store densities.

Tobacco industry misappropriation of American Indian culture and traditional tobacco

Objective

Describe the extent to which tobacco industry marketing tactics incorporated American Indian culture and traditional tobacco.

Methods

A keyword search of industry documents was conducted using document archives from the Truth Tobacco Documents Library. Tobacco industry documents (n=76) were analysed for themes.

Results

Tobacco industry marketing tactics have incorporated American Indian culture and traditional tobacco since at least the 1930s, with these tactics prominently highlighted during the 1990s with Natural American Spirit cigarettes. Documents revealed the use of American Indian imagery such as traditional headdresses and other cultural symbols in product branding and the portrayal of harmful stereotypes of Native people in advertising. The historical and cultural significance of traditional tobacco was used to validate commercially available tobacco.

Conclusions

The tobacco industry has misappropriated culture and traditional tobacco by misrepresenting American Indian traditions, values and beliefs to market and sell their products for profit. Findings underscore the need for ongoing monitoring of tobacco industry marketing tactics directed at exploiting Native culture and counter-marketing tactics that raise awareness about the distinction between commercial and traditional tobacco use. Such efforts should be embedded within a culturally sensitive framework to reduce the burden of commercial tobacco use.

UK news media representations of smoking, smoking policies and tobacco bans in prisons

BACKGROUND

Prisoner smoking rates remain high, resulting in secondhand smoke exposures for prison staff and non-smoker prisoners. Several jurisdictions have introduced prison smoking bans with little evidence of resulting disorder. Successful implementation of such bans requires staff support. As news media representations of health and other issues shape public views and as prison smoking bans are being introduced in the UK, we conducted content analysis of UK news media to explore representations of smoking in prisons and smoke-free prisons.

METHODS

We searched 64 national and local newspapers and 5 broadcast media published over 17 months during 2015-2016, and conducted thematic analysis of relevant coverage in 106 articles/broadcasts.

RESULTS

Coverage was relatively infrequent and lacked in-depth engagement with the issues. It tended to reinforce a negative view of prisoners, avoid explicit concern for prisoner or prison staff health and largely ignore the health gains of smoke-free policies. Most coverage failed to discuss appropriate responses or support for cessation in the prison context, or factors associated with high prisoner smoking rates. Half the articles/broadcasts included coverage suggesting smoke-free prisons might lead to unrest or instability.

CONCLUSIONS

Negative news media representations of prisoners and prison smoking bans may impact key stakeholders' views (eg, prison staff, policy-makers) on the introduction of smoke-free prison policies. Policy-makers' communications when engaging in discussion around smoke-free prison policies should draw on the generally smooth transitions to smoke-free prisons to date, and on evidence on health benefits of smoke-free environments and smoking cessation.

Population exposure to smoking and tobacco branding in the UK reality show 'Love Island'

BACKGROUND

Reality television shows are popular with children and young adults; inclusion of tobacco imagery in these programmes is likely to cause smoking in these groups. Series 3 of the UK reality show Love Island, broadcast in 2017, attracted widespread media criticism for high levels of smoking depicted. We have quantified this tobacco content and estimated the UK population exposure to generic and branded tobacco imagery generated by the show.

METHODS

We used 1-min interval coding to quantify actual or implied tobacco use, tobacco paraphernalia or branding, in alternate episodes of series 3 of Love Island, and Census data and viewing figures from Kantar Media to estimate gross and per capita tobacco impressions.

RESULTS

We coded 21 episodes comprising 1001 min of content. Tobacco imagery occurred in 204 (20%) intervals; the frequency of appearances fell significantly after media criticism. An identifiable cigarette brand, Lucky Strike Double Click, appeared in 16 intervals. The 21 episodes delivered an estimated 559 million gross tobacco impressions to the UK population, predominantly to women, including 47 million to children aged <16 and 44 million gross impressions of Lucky Strike branding, including 4 million to children <16.

CONCLUSION

Despite advertising legislation and broadcasting regulations intended to protect children from smoking imagery in UK television, series 3 of Love Island delivered millions of general and branded tobacco impressions both to children and adults in the UK. More stringent controls on tobacco content in television programmes are urgently needed.

Impacts of Canada's minimum age for tobacco sales (MATS) laws on youth smoking behaviour, 2000-2014

BACKGROUND

Recently, the US Institute of Medicine has proposed that raising the minimum age for tobacco purchasing/sales to 21 years would likely lead to reductions in smoking behavior among young people. Surprisingly few studies, however, have assessed the potential impacts of minimum-age tobacco restrictions on youth smoking.

OBJECTIVE

To estimate the impacts of Canadian minimum age for tobacco sales (MATS) laws on youth smoking behaviour.

DESIGN

A regression-discontinuity design, using seven merged cycles of the Canadian Community Health Survey, 2000-2014.

PARTICIPANTS

Survey respondents aged 14-22 years (n=98 320).

EXPOSURE

Current Canadian MATS laws are 18 years in Alberta, Saskatchewan, Manitoba, Quebec, the Yukon and Northwest Territories, and 19 years of age in the rest of the country.

MAIN OUTCOMES

Current, occasional and daily smoking status; smoking frequency and intensity; and average monthly cigarette consumption.

RESULTS

In comparison to age groups slightly younger than the MATS, those just older had significant and abrupt increases immediately after the MATS in the prevalence of current smokers (absolute increase: 2.71%; 95% CI 0.70% to 4.80%; P=0.009) and daily smokers (absolute increase: 2.43%; 95% CI 0.74% to 4.12%; P=0.005). Average past-month cigarette consumption within age groups increased immediately following the MATS by 18% (95% CI 3% to 39%; P=0.02). There was no evidence of significant increases in smoking intensity for daily or occasional smokers after release from MATS restrictions.

CONCLUSION

The study provides relevant evidence supporting the effectiveness of Canadian MATS laws for limiting smoking among tobacco-restricted youth.

The Convention on the Rights of Persons with Disabilities as a tobacco control tool in the mental health setting

BACKGROUND

Smoking rates remain high among people with mental health conditions, even though smoking contributes to negative mental health outcomes and is a leading cause of mortality. Many mental health facilities are not covered by smoke-free laws or do not encourage smoking cessation, and people with mental health conditions are often targeted in tobacco industry promotions.

OBJECTIVE

To analyse how the Convention on the Rights of Persons with Disabilities (CRPD), to which most countries are a Party, obliges State Parties to review policies and practices for tobacco control in the mental health setting.

METHOD

Analysis of CRPD Articles relevant to smoking and mental health.

RESULTS

The CRPD contains several provisions that oblige State Parties to address the issue of smoking and mental health, particularly in relation to quit services, smoke-free policies in mental health facilities, health education focused on correcting misperceptions about smoking and mental health, and protecting people with mental health conditions from tobacco industry targeting.

CONCLUSIONS

The CRPD is a potentially powerful tool to promote tobacco control in the mental health context.

The impact of flavour, device type and warning messages on youth preferences for electronic nicotine delivery systems: evidence from an online discrete choice experiment

OBJECTIVE

To examine the impact of flavour, device type and health warning messages on youth preference for electronic nicotine delivery systems (ENDS), and to provide evidence and data to inform the Food and Drug Administration's potential regulatory actions on ENDS.

DESIGN

An online discrete choice experiment was conducted in September 2015. Each participant was given nine choice sets and asked to choose one out of two alternative ENDS products, with varying characteristics in three attributes (flavour, device type and warning message). The impact of the attributes on the probability of choosing ENDS was analysed using conditional and nested logit regressions, controlling for individual sociodemographic characteristics and current smoking status.

SETTING AND PARTICIPANTS

A general population sample of 515 participants (50 ever-users and 465 never-users of ENDS) aged 14-17 years were recruited to complete the experiment using an online panel.

RESULTS

Fruit/sweets/beverage flavours significantly increase the probability of choosing ENDS among youth (p<0.01 for never-users and <0.1 for ever-users) and flavour has the most pronounced impact among three attributes. Among never-users, menthol flavour also increases (p<0.05) the probability of choosing ENDS compared with tobacco flavour. Vaping devices that are modifiable, compared with cigarette-like e-cigarettes, increase (p<0.05) the probability of choosing ENDS among adolescent never-users. Warning messages reduce (p<0.01) the probability of choosing ENDS among never-users.

CONCLUSIONS AND RELEVANCE

Restricting fruit/sweets/beverage flavours in ENDS, regulating modifiable vaping devices and adopting strong health warning messages may reduce the uptake of ENDS among youth.

Patterns of youth tobacco and polytobacco usage: The shift to alternative tobacco products

BACKGROUND

Despite significant declines in youth cigarette smoking, overall tobacco usage remains over 20% as non-cigarette tobacco product usage is increasingly common and polytobacco use (using 1+ tobacco product) remains steady.

OBJECTIVES

The present study was designed to identify patterns of youth tobacco use and examine associations with sociodemographic characteristics and tobacco dependence.

METHODS

The current analysis uses Latent Class Analysis (LCA) to examine the 6,958 tobacco users (n = 2,738 female) in the National Youth Tobacco Survey (2012 and 2013). We used as indicators past month use of tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookah, snus, pipes, bidis, and kreteks) and regressed resulting classes on sociodemographic characteristics and tobacco dependence.

RESULTS

Nine classes emerged: cigarette smokers (33.4% of sample, also included small probabilities for use of cigars and e-cigarettes), cigar smokers (16.8%, nearly exclusive), smokeless tobacco users (12.3%, also included small probabilities for cigarettes, cigars, snus), hookah smokers (11.8%), tobacco smokers/chewers (10.7%, variety of primarily traditional tobacco products), tobacco/hookah smokers (7.2%), tobacco/snus/e-cig users (3.3%), e-cigarette users (2.9%,), and polytobacco users (1.7%, high probabilities for all products). Compared to cigarette smokers, tobacco/hookah smokers and hookah smokers were more likely to report Hispanic ethnicity. Polytobacco users were more likely to report dependence (AOR:2.77, 95% CI:[1.49-5.18]), whereas e-cigarette users were less likely (AOR:0.49, 95% CI:[0.24-0.97]).

CONCLUSION

Findings are consistent with other research demonstrating shifts in adolescent tobacco product usage towards non-cigarette tobacco products. Continuous monitoring of these patterns is needed to help predict if this shift will ultimately result in improved public health.

Tobacco policy reform and population-wide antismoking activities in Australia: the impact on smoking during pregnancy

Introduction

This study examined the impact of antismoking activities targeting the general population and an advertising campaign targeting smoking during pregnancy on the prevalence of smoking during pregnancy in New South Wales (NSW), Australia.

Methods

Monthly prevalence of smoking during pregnancy was calculated using linked health records for all pregnancies resulting in a birth (800 619) in NSW from 2003 to 2011. Segmented regression of interrupted time series data assessed the effects of the extension of the ban on smoking in enclosed public places to include licensed premises (evaluated in combination with the mandating of graphic warnings on cigarette packs), television advertisements targeting smoking in the general population, print and online magazine advertisements targeting smoking during pregnancy and increased tobacco tax. Analyses were conducted for all pregnancies, and for the population stratified by maternal age, parity and socioeconomic status. Further analyses adjusted for the effect of the Baby Bonus maternity payment.

Results

Prevalence of smoking during pregnancy decreased from 2003 to 2011 overall (0.39% per month), and for all strata examined. For pregnancies overall, none of the evaluated initiatives was associated with a change in the trend of smoking during pregnancy. Significant changes associated with increased tobacco tax and the extension of the smoking ban (in combination with graphic warnings) were found in some strata.

Conclusions

The declining prevalence of smoking during pregnancy between 2003 and 2011, while encouraging, does not appear to be directly related to general population antismoking activities or a pregnancy-specific campaign undertaken in this period.

An international systematic review of smoking prevalence in addiction treatment

AIMS

Smoking prevalence is higher among people enrolled in addiction treatment compared with the general population, and very high rates of smoking are associated with opiate drug use and receipt of opiate replacement therapy (ORT). We assessed whether these findings are observed internationally.

METHODS

PubMed, PsycINFO and the Alcohol and Alcohol Problems Science Database were searched for papers reporting smoking prevalence among addiction treatment samples, published in English, from 1987 to 2013. Search terms included tobacco use, cessation and substance use disorders using and/or Boolean connectors. For 4549 papers identified, abstracts were reviewed by multiple raters; 239 abstracts met inclusion criteria and these full papers were reviewed for exclusion. Fifty-four studies, collectively comprising 37,364 participants, were included. For each paper we extracted country, author, year, sample size and gender, treatment modality, primary drug treated and smoking prevalence.

RESULTS

The random-effect pooled estimate of smoking across people in addiction treatment was 84% [confidence interval (CI) = 79, 88%], while the pooled estimate of smoking prevalence across matched population samples was 31% (CI = 29, 33%). The difference in the pooled estimates was 52% (CI = 48%, 57%, P < .0001). Smoking rates were higher in programs treating opiate use compared with alcohol use [odds ratio (OR) = 2.52, CI = 2.00, 3.17], and higher in ORT compared to out-patient programs (OR = 1.42, CI = 1.19, 1.68).

CONCLUSIONS

Smoking rates among people in addiction treatment are more than double those of people with similar demographic characteristics. Smoking rates are also higher in people being treated for opiate dependence compared with people being treated for alcohol use disorder.

'The times are changing': New Zealand smokers' perceptions of the tobacco endgame

BACKGROUND

The New Zealand government's goal of achieving a smoke-free society by 2025 reflects growing interest in 'endgame' solutions to tobacco smoking. However, tobacco companies have framed 'endgame' strategies as contrary to individual freedoms and 'choice'; these claims heighten politicians' sensitivity to 'nanny state' allegations and may undermine tobacco control policies. Public support for stronger policies could strengthen political will; however, little is known about how smokers perceive endgame scenarios or the factors underlying their support or opposition to these.

METHODS

The authors conducted 47 in-depth interviews with four priority groups: Māori, Pacific, young adults and pregnant women; all were smokers or very recent quitters. The authors used thematic analysis to interpret the transcripts.

RESULTS

Most participants strongly supported the 2025 smoke-free goal, recognised the broader social good that would result and accepted the personal inconvenience of quitting. Yet they wanted to retain control over when and how they would quit and asserted their 'freedom' to smoke. Participants identified interventions that would extend current policy and maintain the autonomy they valued; the authors classified these into four themes: restricting supply, diminishing visibility, decreasing availability and affordability, and increasing quit support.

CONCLUSIONS

Politicians may have a stronger mandate to implement endgame policies than they appreciate. Participants' use of industry arguments when asserting their freedom to 'choose' to smoke and quit suggests a need for denormalisation strategies that challenge industry propaganda, demonstrate how endgame measures would empower smokers and re-iterate the community benefits a smoke-free society will deliver.

Evaluating the effectiveness of the US Navy and Marine Corps Tobacco Policy: an assessment of secondhand smoke exposure in US Navy submariners

OBJECTIVE

To evaluate the effectiveness of the US Navy and Marine Corps tobacco policy in protecting submariners from secondhand smoke (SHS) by determining if non-tobacco users experienced a significant increase in urinary cotinine levels at sea when compared with in port levels.

METHODS

From February to August 2009, 634 volunteers recruited from nine US Navy submarines completed a survey to collect demographic data, information on tobacco use and pre-deployment exposure to SHS. Non-tobacco users (n=239) were requested to provide two urine samples (pre-deployment and while at sea) to quantify exposure to SHS using urinary cotinine as a biomarker. Matched samples were analysed using liquid chromatography-tandem mass spectrometry.

RESULTS

Overall, deployed cotinine levels were 2.1 times the in port levels in non-tobacco using submariners (95% CI 1.8 to 2.4, p<0.001, n=197). A significant increase in deployed urinary cotinine levels was found aboard six of nine submarines (p<0.05). A subgroup of submariners (n=91) who reported no SHS exposure within 10 days prior to in port cotinine sampling had deployed cotinine levels 2.7 times the in port levels (95% CI 2.2 to 3.3, p<0.001). Applying a 4.5:1 urine cotinine to serum cotinine correction factor, submariners' deployed geometric means are similar to recent US male population values at the 75th percentile.

CONCLUSIONS

This study provides evidence that non-tobacco using submariners were exposed to SHS. Exposure was seen in all submarine classes and was not limited to personnel working in proximity to the smoking area. The existing policy was inadequate to protect non-smokers from exposure to SHS and required revision. As a result of a policy review, informed by this study, smoking below decks was banned aboard all US Navy submarines effective 31 December 2010.

Menthol use among smokers with psychological distress: findings from the 2008 and 2009 National Survey on Drug Use and Health

OBJECTIVE

The Food and Drug Administration is considering regulation of menthol cigarettes. While persons with mental distress are known to smoke cigarettes at high rates, little is known about their use of menthol. The authors examined the association of psychological distress and menthol use in a national sample of adult smokers.

METHODS

Data were from the 2008 and 2009 National Survey on Drug Use and Health. Past month smokers (N=24,157) were categorised for menthol or non-menthol use. Psychological distress was categorised as none/mild, moderate or severe on the Kessler six-item scale.

RESULTS

The prevalence of menthol use was higher among individuals with severe psychological distress, women, young adults, African-Americans, Native Hawaiians/Pacific Islanders, persons with fewer years of education and lower income, and the unmarried and uninsured. In a multivariate model controlling for socio-demographic factors, smoking intensity and time to first cigarette, smokers with severe (adjusted OR (AOR) 1.23, 95% CI 1.04 to 1.46, p=0.02) but not moderate (AOR 1.03, 95% CI 0.92 to 1.15, p=0.58) psychological distress were significantly more likely to smoke menthols compared with smokers with none/mild distress.

CONCLUSION

An elevated prevalence of menthol use was found among persons with severe psychological distress, suggesting another group that could potentially benefit from the regulation of menthol cigarettes.

The effect of tobacco control policies on smoking prevalence and smoking-attributable deaths in Ireland using the IrelandSS simulation model

OBJECTIVES

This study estimates the relative contribution of policies implemented between 1998 and 2010 to reductions in smoking prevalence by 2010. It then models the impact of implementing stronger policies, relative to a scenario of inaction, on smoking prevalence and smoking-attributable mortality in Ireland.

METHODS

IrelandSS is an adapted version of SimSmoke, a dynamic simulation model used to examine the effect of tobacco control policies on smoking prevalence, through initiation and cessation, and associated future premature mortality.

RESULTS

Model predictions for smoking prevalence are reasonably close to those from surveys. As a result of tobacco control policies implemented between 1998 and 2010, there was a 22% relative reduction in smoking prevalence and 1716 fewer smoking-attributable deaths (SADs) by 2010 increasing to a 29% relative reduction in prevalence and 50 215 fewer SADs by 2040. With the introduction of stricter FCTC-compliant policies in 2011, the smoking prevalence can be decreased by as much as 13% initially, increasing to 28% by 30 years. With these stronger policies, a total of 24 768 SADs will be averted by 2040.

CONCLUSIONS

Predictions from the IrelandSS model suggest that policies implemented between 1998 and 2010 have had considerable effect; however, appreciable reductions in smoking prevalence and SADs can still be achieved through increasing taxes, maintaining a high-intensity tobacco control media campaign, introducing graphic health warnings and improving smoking cessation services.

Using findings from a public opinion poll to build political support for tobacco control policy in Kenya

OBJECTIVE

To assess the level of public support for tobacco control policies and to discuss how these findings could be used to influence the legislative process in the passing of tobacco control law in the country.

METHODS

A cross-sectional study conducted in Kenya between March and May 2007 on a random sample of 2021 (991 men and 1030 women) respondents aged 18 years and above. Interviews were done using a structured questionnaire by a research consultancy firm with long-standing experience in public polling.

RESULTS

The majority of respondents supported tobacco control policies as proposed by WHO Framework Convention on Tobacco Control. For example, 95% of the respondents supported smoking restrictions in all enclosed public places and workplaces, 94% supported visible health warnings on tobacco product packages, 83% supported a ban on advertisements of cigarettes and tobacco products and 69% supported a ban on sponsorship of events by tobacco companies. However, 60% perceived that there was very little commitment by legislators to tobacco control.

CONCLUSIONS

There was overwhelming public support for tobacco control policies and a general view that government was not doing enough in implementing policies to protect the public from tobacco harm. This public opinion poll was used as an advocacy tool to generate support among legislators for national tobacco control law.

Second-hand smoke exposure and mitigation strategies among home visitation workers

OBJECTIVES

Protection of workers from second-hand smoke (SHS) in occupational settings is an important policy priority, yet little attention has been given to SHS protection for home visitation health workers, who number almost 2 million in the USA. Self-reported SHS exposure, SHS mitigation strategies and suggestions for further SHS exposure reduction approaches were obtained from home visitation health workers in Massachusetts.

METHODS

A cross-sectional survey was conducted among Massachusetts Early Intervention workers (N=316) at their state-wide conference in April 2010.

RESULTS

Eighty-three per cent of respondents reported at least 1 hour per month of SHS exposure, and 16% reported at least 11 hours per month. Nevertheless, only 22% of workers counselled clients on maintaining a smoke-free home. Fewer than 30% of workers had ever voiced concerns to their employing agency, and just 12% had raised their concerns directly with clients. Only 14% stated that their agency had rules designed to protect workers from SHS.

CONCLUSIONS

SHS exposure occurs frequently among home visitation health workers. The data point to a substantial population who are not protected from SHS exposure by formal policies.