Cold Turkey and Hot Vapes? A National Study of Young Adult Cigarette Cessation Strategies

INTRODUCTION

Young adults have high smoking rates and low utilization of evidence-based smoking cessation strategies. We investigated smoking cessation intentions, strategy use, and socioeconomic predictors of strategy use among young adult smokers (age 18-24) and compared patterns with those of older adults (age 25-64).

METHODS

We used a population-based sample from the Population Assessment of Tobacco and Health (PATH) study of young adult (n = 1,881) and older adult (n = 6,366) established smokers of conventional cigarettes at Wave 1 (2013-2014), who were surveyed at Wave 2 (2014-2015). Simple regression analysis compared intentions to quit between age groups. Among Wave 1 smokers who reported a Wave 2 quit attempt (young adults [YA] n = 748; older adults [OA] n = 2,068), bivariate and multinomial logistic regression estimated differences in use of behavioral support, pharmacotherapy, product substitution, and unassisted quit attempts. Interaction terms estimated age-group differences in relationships between predictors and cessation strategy use.

RESULTS

Young adults planned to quit on a longer time frame, expressed lower interest in quitting, and were more confident they would be successful, compared with older adults. Young adults were significantly less likely to use pharmacotherapy (adjusted odds ratio: 0.15; confidence interval: 0.09, 0.24; reference: quitting unassisted). Both groups reported using product substitution (YA: 31.6%; OA: 28.5%), primarily with e-cigarettes, more than any evidence-based cessation strategy. Socioeconomic predictors of cessation strategy use did not differ between age groups.

CONCLUSIONS

More research on why young adult smokers underutilize evidence-based cessation support is needed, as are innovative efforts to increase intentions to quit and utilization of cessation assistance.

IMPLICATIONS

Young adulthood is a key transition time for tobacco use, and early cessation substantially reduces the risk of morbidity and mortality from smoking. In the context of high e-cigarette and polytobacco use, this study finds young adults have significantly less intention to quit than older adults and are less likely to use evidence-based cessation strategies to help quit. Innovative methods are needed to increase young adult intentions to quit and use of evidence-based cessation assistance.

Tobacco Retail Density and Initiation of Alternative Tobacco Product Use Among Teens

PURPOSE

The rise of noncigarette, alternative tobacco product (ATP) use among adolescents may be due in part to an increase in retail availability of ATPs. We examined whether proximity and density of tobacco retailers near students' homes are associated with a higher likelihood of initiating ATP use over time.

METHODS

Using data from 728 adolescents (aged 13-19 years at baseline) residing in 191 different neighborhoods and attending 10 different California high schools, longitudinal multilevel and cross-classified random effect models evaluated individual-level, neighborhood-level, and school-level risk factors for ATP initiation after 1 year. Covariates were obtained from the American Community Survey and the California Department of Education.

RESULTS

The sample was predominantly female (63.5%) and was racially and ethnically diverse. Approximately one third of participants (32.5%) reported ever ATP use at baseline, with 106 (14.5%) initiating ATP use within 1 year. The mean number of tobacco retailers per square mile within a tract was 5.66 (standard deviation = 6.3), and the average distance from each participant's residence to the nearest tobacco retailer was .61 miles (standard deviation = .4). Living in neighborhoods with greater tobacco retailer density at baseline was associated with higher odds of ATP initiation (odds ratio = 1.22, 95% confidence interval = 1.07-2.12), controlling for individual and school factors.

CONCLUSIONS

Tobacco retailers clustered in students' home neighborhood may be an environmental influence on adolescents' ATP use. Policy efforts to reduce adolescent ATP use should aim to reduce the density of tobacco retailers and limit the proximity of tobacco retailers near adolescents' homes and schools.

Join the Commune: A Controlled Study of Social Branding Influencers to Decrease Smoking Among Young Adult Hipsters

PURPOSE

To evaluate the impact of a Social Branding intervention in bars and nightclubs on smoking behavior.

DESIGN

Quasi-experimental controlled study.

SETTING

Bars and nightclubs in San Diego and San Francisco (intervention) and Los Angeles (control).

PARTICIPANTS

"Hipster" young adults (age 18-26) attending bars and nightclubs.

INTERVENTION

Anti-tobacco messages delivered through monthly anti-tobacco music/social events, opinion leaders, original art, direct mail, promotional activities, and online media.

MEASURES

A total of 7240 surveys were collected in 3 cities using randomized time location sampling at baseline (2012-2013) and follow-up (2015-2016); data were analyzed in 2018. The primary outcome was current smoking.

ANALYSIS

Multivariable logistic regression assessed correlates of smoking, adjusting for covariates including electronic cigarette use; differences between cities were evaluated using location-by-time interactions.

RESULTS

Smoking in San Francisco decreased at a significantly faster rate (51.1%-44.1%) than Los Angeles (45.2%-44.5%) (P = .034). Smoking in San Diego (mean: 39.6%) was significantly lower than Los Angeles (44.8%, P < .001) at both time points with no difference in rate of change. Brand recall was not associated with smoking behavior, but recall was associated with anti-tobacco attitudes that were associated with smoking.

CONCLUSION

This is the first controlled study of Social Branding interventions. Intervention implementation was accompanied by decreases in smoking (San Francisco) and sustained lower smoking (San Diego) among young adult bar patrons over 3 years.

Financial Conflicts of Interest and Stance on Tobacco Harm Reduction: A Systematic Review

Background. Tobacco companies have actively promoted the substitution of cigarettes with purportedly safer tobacco products (e.g., smokeless tobacco, e-cigarettes) as tobacco harm reduction (THR). Given the tobacco, e-cigarette, and pharmaceutical industries' substantial financial interests, we quantified industry influence on support for THR. Objectives. To analyze a comprehensive set of articles published in peer-reviewed journals assessing funding sources and support for or opposition to substitution of tobacco or nicotine products as harm reduction. Search Methods. We searched PubMed, Embase, Web of Science, and PsycINFO with a comprehensive search string including all articles, comments, and editorials published between January 1, 1992, and July 26, 2016. Selection Criteria. We included English-language publications published in peer-reviewed journals addressing THR in humans and excluded studies on modified cigarettes, on South Asian smokeless tobacco variants, on pregnant women, on animals, not mentioning a tobacco or nicotine product, on US Food and Drug Administration-approved nicotine replacement therapies, and on nicotine vaccines. Data Collection and Analysis. We double-coded all articles for article type; primary product type (e.g., snus, e-cigarettes); themes for and against THR; stance on THR; THR concepts; funding or affiliation with tobacco, e-cigarette, pharmaceutical industry, or multiple industries; and each author's country. We fit exact logistic regression models with stance on THR as the outcome (pro- vs anti-THR) and source of funding or industry affiliation as the predictor taking into account sparse data. Additional models included article type as the outcome (nonempirical or empirical) and industry funding or affiliation as predictor, and stratified analyses for empirical and nonempirical studies with stance on THR as outcome and funding source as predictor. Main Results. Searches retrieved 826 articles, including nonempirical articles (21%), letters or commentaries (34%), editorials (5%), cross-sectional studies (15%), systematic reviews and meta-analyses (3%), and randomized controlled trials (2%). Overall, 23.9% disclosed support by industry; 49% of articles endorsed THR, 42% opposed it, and 9% took neutral or mixed positions. Support from the e-cigarette industry (odds ratio [OR] = 20.9; 95% confidence interval [CI] = 5.3, 180.7), tobacco industry (OR = 59.4; 95% CI = 10.1, +infinity), or pharmaceutical industry (OR = 2.18; 95% CI = 1.3, 3.7) was significantly associated with supportive stance on THR in analyses accounting for sparse data. Authors' Conclusions. Non-industry-funded articles were evenly divided in stance, while industry-funded articles favored THR. Because of their quantity, letters and comments may influence perceptions of THR when empirical studies lack consensus. Public Health Implications. Public health practitioners and researchers need to account for industry funding when interpreting the evidence in THR debates.

Tobacco use in the sexual borderlands: The smoking contexts and practices of bisexual young adults

Little is known about why bisexual people use tobacco at higher rates than any other sexual identity group. Non-binary sexualities, such as bisexuality, exist within the socially constructed borderland between homosexuality and heterosexuality. Exploration of the everyday smoking contexts and practices of bisexual individuals may reveal unique mechanisms driving tobacco use. We employed a novel mixed method, integrating real-time, smartphone-administered surveys of (non)smoking situations, location tracking, spatial visualization of participant data, and subsequent map-led interviews. Participants (n = 17; ages 18-26, California) identified as bisexual, pansexual, and/or queer. Most were cisgender women. Survey smoking patterns and situational predictors were similar to other young adults'. However, interviews revealed unique roles of tobacco use in participants' navigation of differently sexualized spaces in everyday life: 1) stepping away from uncomfortable situations related to bisexual identity; 2) facilitating belonging to LGBTQ+ community; and 3) recovering from bisexual identity perception management. Similar studies can examine the place-embedded practices and spatio-temporal patterns of other substance use and other stigmatized identity experiences.

Young adults report increased pleasure from using e-cigarettes and smoking tobacco cigarettes when drinking alcohol

BACKGROUND

Cigarettes share a high rate of co-use with alcohol, particularly among young adults. Studies have demonstrated greater perceived pleasure from smoking cigarettes when drinking alcohol. However, little is known about co-use of electronic cigarettes (e-cigs) and alcohol. The current study sought to compare extent of use and perceived pleasure from cigarettes and e-cigs when drinking alcohol.

METHODS

Young adult bar patrons in California cities (San Diego, Los Angeles, and San Francisco) were recruited in 2015-16 using randomized time-location sampling. Participants completed cross-sectional surveys in bars, reporting the percent of cigarette smoking/e-cig use that occurred under the influence of alcohol, and reported if pleasure from smoking cigarettes/using e-cigs changed when drinking alcohol. Analyses are limited to participants reporting current (past 30-day) use of cigarettes, e-cigs, and alcohol (N = 269; M age = 24.1; 40.1% female, 36.1% Non-Hispanic White).

RESULTS

Participants reported a greater percentage of cigarette smoking compared to e-cig use under the influence of alcohol (cigarettes M = 63.6%; e-cigs M = 46.7%; p < .001). Participants also reported increased pleasure both from smoking cigarettes (M = 3.9; [compared to midpoint of scale 3 - "no change"] p < .001) and using e-cigs (M = 3.3; p < .001) when drinking alcohol. The increase in pleasure was more pronounced for cigarettes compared to e-cigs (p < .001).

CONCLUSIONS

Drinking alcohol is associated with increases in perceived rewarding effects of both cigarettes and e-cigs and thus may increase their abuse liability. This effect may be stronger for cigarettes, which could be an important barrier to switching completely from smoking cigarettes to using e-cigs, or quitting both entirely.

Association of Alternative Tobacco Product Initiation With Ownership of Tobacco Promotional Materials Among Adolescents and Young Adults

IMPORTANCE

Use of alternative tobacco products (ATPs) such as electronic cigarettes, chewing tobacco, pipes, cigars, cigarillos, little cigars, and hookah is rapidly increasing. Although marketing restrictions exist for cigarettes, marketing of ATPs is not yet fully regulated, and studies have not assessed the association between ownership of ATP promotional materials and subsequent ATP or cigarette initiation among adolescents and young adults.

OBJECTIVE

To estimate the association between marketing receptivity measured at baseline and ATP and any tobacco initiation 1 year later, including cigarettes, among adolescents and young adults.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal cohort study of adolescents and young adults aged 13 to 19 years recruited at high schools in California from July 2014 to October 2015, with follow-up 1 year later. Data were analyzed from January to March 2018.

EXPOSURES

Ownership of ATP-specific promotional material and ownership of any tobacco promotional materials (eg, samples, coupons, branded caps, t-shirts, or posters) assessed in wave 1.

MAIN OUTCOMES AND MEASURES

Outcomes were (1) ATP initiation and (2) either ATP or cigarette initiation in wave 2.

RESULTS

Of 757 participants (mean [SD] age at wave 1, 16.1 [1.1] years; 481 [63.5%] female; 166 [21.9%] Asian or Pacific Islander, 202 [26.7%] white, and 276 [36.4%] Latino), 129 (17.0%) initiated ATP use and 141 (18.6%) initiated ATP or cigarette use 1 year later. In unadjusted models, wave 2 ATP initiation was found to be significantly associated with wave 1 ownership of ATP promotional materials (odds ratio, 2.23; 95% CI, 1.26-3.97). After adjustment for wave 1 demographic covariates, the association between ownership of ATP promotional material and ATP initiation 1 year later yielded similar results (odds ratio, 2.13; 95% CI, 1.16-3.91). Results of models assessing a combined outcome variable of either ATP or cigarette ever use were not statistically significant.

CONCLUSIONS AND RELEVANCE

Ownership of ATP promotional materials was associated with subsequent initiation of ATPs. The results of this study are consistent with the suggestion that current marketing restrictions for cigarettes, including restrictions of the distribution of samples, coupons, and other promotional material, should extend to ATPs.

Young adult perceptions of JUUL and other pod electronic cigarette devices in California: a qualitative study

OBJECTIVE

Electronic cigarettes (e-cigarettes) which utilise prefilled 'pods' (pod devices) entered the US market in 2015. One brand, JUUL, captured more than half the e-cigarette market in early 2018, and the US Food and Drug Administration recently warned its manufacturer about adolescent uptake. This is the first qualitative study to describe distinct features of pod devices that appear to contribute to their popularity among young people.

DESIGN

Qualitative interview study of young adults who had used pod devices. Participants were recruited from Facebook, other social media, street recruitment and via snowball sampling.

SETTING

Participants were from California, with most from the San Francisco Bay Area.

PARTICIPANTS

Young adults (aged 18-29 years) using multiple tobacco products (cigarettes, e-cigarettes and/or smokeless tobacco) were recruited. Of the sample of 60 participants, 24 were included in this analysis: 10 who reported experience with pod devices and 14 who used other non-pod e-cigarette devices.

RESULTS

Ten participants had used a pod device in the past year. Of the pod device users, seven still used a pod device at the time of the interview and five did so daily. Nearly all (n=9) pod device users smoked cigarettes in the past month; none were daily smokers. The 14 participants who used non-pod devices provided a point of comparison. Participants highlighted some distinct aspects of pod devices that facilitated use, including their aesthetic similarity to personal electronics, high levels of nicotine delivery with distinct psychoactive effects, more discreet and shorter duration use sessions, and greater social acceptability than more ostentatious non-pod e-cigarettes.

CONCLUSIONS

Pod devices' unique characteristics likely encourage pod device uptake among young people. Limitations on advertising in youth channels, flavours and distribution, and education about nicotine addiction may decrease initiation among young people and non-smokers.

Effects of e-Cigarette Advertisements on Adolescents' Perceptions of Cigarettes

This study examined the effect of exposure to "cigalike" (products resembling cigarettes) e-cigarette advertisements on adolescents' perceptions of cigarettes. A nationally representative sample of 802 adolescents (13-17 years old) was randomly assigned to watch three e-cigarette or three control advertisements. Never-smokers who saw the e-cigarette advertisements (n = 352) reported significantly lower perceived risks of smoking than those in the control condition (n = 320). Ever-smokers (n = 130) did not show significant differences across the conditions. In subgroup analyses, current smokers (reported smoking in the past 30 days, n = 31) in the e-cigarette condition reported significantly lower perceived benefits of smoking than those in the control condition. E-cigarette advertisements can affect adolescents' perceptions of cigarettes. Many advertisements, especially the ones promoting "cigalikes," depict e-cigarettes as being similar to cigarettes (e.g., look, flavor) but also as a solution for cigarettes' shortcomings (e.g., bad smell). While the advertisements include messages about problems posed by cigarettes, proposing e-cigarettes as a solution may decrease the perceived risks of smoking among never-smokers. It may also not be clear to adolescents whether advertisements are for cigarettes or e-cigarettes. Regulating e-cigarette advertisements to minimize adolescents' exposure may prevent potential harmful effects on never-smokers' perception of smoking.

Differential Associations Between Anti-Tobacco Industry Attitudes and Intention to Quit Smoking Across Young Adult Peer Crowds

PURPOSE

To compare the relationship between anti-tobacco industry attitudes and intention and attempts to quit smoking across 6 young adult peer crowds.

DESIGN

A cross-sectional bar survey in 2015.

SETTING

Seven US cities (Albuquerque, Los Angeles, Nashville, Oklahoma City, San Diego, San Francisco, and Tucson).

PARTICIPANTS

Two thousand eight hundred seventeen young adult bar patrons who were currently smoking.

MEASURES

Intention to quit in the next 6 months and having made a quit attempt in the last 12 months were binary outcomes. Anti-industry attitudes were measured by 3 items indicating support for action against the tobacco industry. Peer crowd affiliation was measured using the I-Base Survey.

ANALYSIS

Adjusted multivariable logistic regression models examined the association between anti-industry attitudes and the outcomes for the total sample and for each peer crowd.

RESULTS

Overall, anti-industry attitudes were positively associated with both intention to quit (odds ratio [OR] = 1.37, 95% confidence interval [CI] = 1.24-1.52) and attempt to quit (OR = 1.14, 95% CI = 1.03-1.27). Intriguingly, the relationship between anti-industry attitudes and intention to quit differed by peer crowd affiliation, with significant associations for Homebody, Partier, Hipster, and Hip Hop, but not for Young Professional and Country.

CONCLUSIONS

Developing health communication messages that resonate with unique peer crowd values can enhance the relevance of public health campaigns. Tobacco control practitioners should tailor anti-industry messages to promote intention to quit smoking among the highest risk young adults.

Does Experienced Discrimination Explain Patterns of Menthol Use Among Young Adults? Evidence from the 2014 San Francisco Bay Area Young Adult Health Survey

BACKGROUND

Young adults are at high risk for using flavored tobacco, including menthol and underrepresented populations, such as Latino and African American young adults, are at particular risk.

OBJECTIVES

The purpose of this study is to identify sociodemographic correlates of menthol use among young adult smokers and examine the potential role of experienced discrimination in explaining any associations.

METHODS

We conducted a probabilistic multimode household survey of young adults (aged 18-26) residing in Alameda and San Francisco Counties in California in 2014 (n = 1,350). We used logistic regression to evaluate associations between menthol cigarette use and experienced discrimination among young adult smokers as well as with respect to sociodemographic, attitudinal, and behavioral predictors. Interactions between experienced discrimination and race/ethnicity, sex and LGB identity were also modeled.

RESULTS

Latino and non-Hispanic Black young adult smokers were more likely to report current menthol use than non-Hispanic Whites, while those with college education were less likely to do so. Experienced discrimination mediated the relationship between race and menthol use for Asian/Pacific Islander and Multiracial young adult smokers with odds of use increasing by 32 and 42% respectively for each additional unit on the experienced discrimination scale. Conclusions/Importance: Latino and African American young adult smokers have disproportionately high menthol use rates; however, discrimination only predicted higher use for Asian/Pacific Islander and Multiracial young adult smokers. Limits on the sale of menthol cigarettes may benefit all nonwhite race/ethnic groups as well as those with less education.

Latent Class Analysis to Examine Patterns of Smoking and Other Tobacco Products in Young Adult Bar Patrons

PURPOSE

Use of multiple tobacco products is increasing, particularly among young adults. Latent class analysis of substance-use patterns provides a framework for understanding the heterogeneity of use. We sought to identify different patterns of cigarette, e-cigarette, hookah, cigarillo, and smokeless tobacco use among young adult bar patrons.

METHODS

We conducted repeated cross-sectional surveys of randomized time location samples of young adult California bar patrons in 2013 and 2014. Latent class analysis was used to examine patterns of use among current (past 30-day) tobacco users. Classes were compared on demographic characteristics and tobacco use correlates.

RESULTS

Overall 84.4% of the current tobacco users were cigarette smokers, 38.7% used electronic cigarettes, 35.9% used hookah, 30.1% smoked cigars/cigarillos, and 15.4% used smokeless tobacco in the past 30 days. We extracted six latent classes: "Cigarette only" (n = 1690), "Hookah mostly" (n = 479), "High overall use" (n = 528), "Smokeless mostly" (n = 95), "E-cigarette mostly" (n = 439), "Cigars mostly" (n = 435). These classes differed in their risk profiles on both current use compared to no use, and number of days they used each tobacco product. Differences between classes emerged on demographics (age, sex, race/ethnicity) and tobacco correlates including perceived peer smoking, antitobacco industry attitudes, prioritizing social activities, and advertising receptivity.

CONCLUSIONS

Understanding different patterns of multiple tobacco product use may inform both prevention and cessation programming for young adults. It may be efficient to tailor messages to different latent classes and address the distinct demographic and attitudinal profiles of groups of multiple tobacco product users.

Real-time predictors of smoking among sexual minority and heterosexual young adults: An ecological momentary assessment study

BACKGROUND

Sexual minority young adults have higher smoking rates than the general young adult population, but reasons for this disparity are poorly understood. The current study aimed to: 1) identify real-time predictors of smoking among sexual minority and heterosexual smokers and 2) examine between-group differences in these predictors.

METHODS

We conducted an ecological momentary assessment (EMA) study in the San Francisco Bay Area, California in 2016-2017. Data from 84 young adult smokers (44% identified as sexual minority, including 29 bisexual and 8 gay/lesbian) with 6498 EMA assessments were analyzed. Both internal and external predictors and interaction terms between each predictor and sexual group were examined using generalized estimating equation models.

RESULTS

Common correlates of smoking were found for both groups (e.g., craving, absence of smoking bans, presence of other smokers, outside location, and seeing triggers). Unique factors for sexual minority smokers were being at a bar (aOR = 1.75, 95% CI = 1.06-2.90) and the number of other smokers present (aOR = 1.12, 95%CI = 1.04-1.20), while the presence of a smoking family member reduced the odds of smoking in this group (aOR = 0.13, 95%CI = 0.02-0.85). In interaction models, the number of other smokers exerted a greater influence on sexual minority participants compared to their heterosexual counterparts (aOR = 1.10, 95%CI = 1.01-1.20), while craving (aOR = 0.84, 95%CI = 0.75-0.93) and presence of a smoking family member (aOR = 0.11, 95%CI = 0.01-0.82) had weaker influences.

CONCLUSIONS

Our study highlights unique situational factors associated with smoking among sexual minority young adults and differences in these factors by sexual identity. Future interventions targeting sexual minorities should address bar attendance and specific triggers.

Revolution or redux? Assessing IQOS through a precursor product

Background

Philip Morris International (PMI) currently claims that its heated tobacco product, IQOS, reduces health risk by reducing users’ exposure to harmful and potentially harmful constituents present in tobacco smoke. Given the tobacco industry’s long history of misrepresenting and obfuscating research, independent assessment of PMI’s claims is important. Analysis of Accord, a failed but strikingly similar precursor to IQOS, may help contextualise PMI’s claims in its Modified Risk Tobacco Product (MRTP) application.

Methods

We analysed previously secret internal Philip Morris (PM) and PMI documents, public communications and MRTP application.

Results

PM marketed Accord as a ‘cleaner’ tobacco product in an attempt to address smokers’ growing health concerns without making explicit health claims. While PM communications asserted that Accord reduced users’ exposure to harmful constituents, company scientists and executives consistently stressed to both regulators and the public that such reductions did not render Accord safer. IQOS’s design and marketing are similar to Accord’s. On the basis of aerosol chemistry data, IQOS reduces user exposure to some compounds compared with Accord but raises them for others.

Discussion

IQOS appears to be a variant of Accord without consistent improvements in exposure to aerosol toxic compounds. In contrast to PM’s past claims for Accord, PMI now claims in its MRTP application that IQOS reduces health risk. This shift in stance is likely not the result of any toxicological difference between Accord and IQOS, but rather a change in the social and regulatory landscape permitting these claims.

Tobacco company strategies to identify and promote the benefits of nicotine

BACKGROUND

In response to a changing regulatory and consumer landscape, tobacco companies developed new strategies to promote cigarettes and smoking. We examined one of these strategies: to fund and conduct scientific research related to potential benefits of nicotine, and to use their findings to promote nicotine.

METHODS

Qualitative analysis of previously secret tobacco industry documents from the Truth (formerly Legacy) Tobacco Documents Library (industrydocuments.library.ucsf.edu/tobacco), triangulated with data from other sources, including the online search engine Google, from the 1970s to December 2017.

RESULTS

After publication of the 1988 Surgeon General's report on nicotine addiction, tobacco companies (particularly RJ Reynolds) intensified efforts to promote the benefits of nicotine while downplaying its addictiveness and health risks. Activities included building relationships with academic institutions and funding scientific studies of the benefits of nicotine on cognition and other performance areas through intramural and extramural programmes. Companies then promoted their research findings through public relations campaigns, often minimising nicotine's health risks by comparing it to caffeine or coffee. These comparisons appeared in highly publicised scientific meetings and interviews with the press. Nicotine-positive messages reappeared in the popular press and on some company websites in the 2010s.

CONCLUSIONS

Tobacco companies implemented strategies to promote benefits of nicotine to scientific and general audiences while minimising its health risks. These strategies reappeared at the time novel tobacco products like electronic cigarettes were introduced. A greater awareness of the source of claims related to purported benefits of nicotine could inform discussions about emerging tobacco products.

Origins of tobacco harm reduction in the UK: the 'Product Modification Programme' (1972-1991)

OBJECTIVE

To better understand the current embrace of long-term nicotine maintenance by British governmental agencies and tobacco harm reduction by several leading British public health organisations, describe the context and deliberations of the UK's first formal tobacco risk reduction programme: 'Product Modification'.

METHODS

Analysis of previously secret tobacco industry documents, news archives and Parliamentary debate records.

RESULTS

From 1972 to 1991, the British government sought to investigate safer smoking through the 'product modification programme'. The Independent Scientific Committee on Smoking and Health (ISCSH) advised the British government on these efforts and collaborated with the tobacco industry, with which government then negotiated to determine policy. The ISCSH operated from four industry-backed premises, which contributed to the ISCSH's support of safer smoking: (1) reduced toxicity indicates reduced risk; (2) collaboration with the tobacco industry will not undermine tobacco control; (3) nicotine addiction is unavoidable; (4) to curtail cigarette use, solutions must be consumer-approved (ie, profitable). These premises often undermined tobacco control efforts and placed the ISCSH at odds with broader currents in public health. The product modification programme was abandoned in 1991 as the European Community began requiring members to adopt upper tar limits, rendering the ISCSH redundant.

POLICY IMPLICATIONS

Endorsements of reduced harm tobacco products share the same four premises that supported the product modification programme. Current tobacco harm reduction premises and policies supported by the British government and leading British public health organisations may reflect the historical influence of the tobacco industry.

Invisible smoke: third-party endorsement and the resurrection of heat-not-burn tobacco products

Background

Tobacco companies are introducing new ‘heat-not-burn’ cigarettes in dozens of countries. Historically, these products failed commercially, and independent researchers contested their health claims. The most prominent early heat-not-burn cigarette was RJ Reynolds’s (RJR’s) Premier, introduced in the USA in 1988. Curiously, The Lancet endorsed Premier as a ‘near-perfect low tar cigarette’ in a 1991 editorial, 2 years after Premier had been removed from the market. We examined the context of this endorsement.

Methods

To ascertain what RJR knew about this endorsement, we systematically searched and analysed previously secret RJR documents in public archives and triangulated the industry document data with other published work.

Results

RJR had a long-standing interest in collaborating with outside scientists to endorse potentially reduced harm cigarettes. The author of The Lancet editorial had previously corresponded with RJR regarding Premier’s health effects and market potential. Internally, RJR regarded The Lancet’s editorial, its stance on novel tobacco products, and its endorsement of Premier as major successes. While the editorial came too late to save Premier, RJR saw future business opportunities for novel products if endorsed by health authorities.

Conclusions

Endorsement by high-impact medical journals and health authorities may be critical in helping heat-not-burn’ products succeed where previous attempts have failed. Conflicts of interest influenced these endorsements in the past. Health leaders and academic journals should consider both conflicts of interest and the ethics of endorsing tobacco product substitution, as tobacco companies simultaneously work to promote cigarette smoking and undermine tobacco control globally.

A randomized controlled evaluation of the tobacco status project, a Facebook intervention for young adults

AIMS

To test the efficacy of the Tobacco Status Project (TSP) Facebook smoking cessation intervention for young adults relative to referral to an on-line program on biochemically verified 7-day abstinence from smoking.

DESIGN

Two-group parallel randomized controlled trial, comparing TSP (n = 251) to on-line control (n = 249) with follow-up to 12 months.

SETTING

On-line, throughout the United States.

PARTICIPANTS

Young adult cigarette smokers (mean age 21 years; 73% white, 55% female, 87% daily smokers).

INTERVENTIONS AND COMPARATOR

TSP provided private Facebook groups tailored to stage of change to quit smoking, daily contacts, weekly live counseling sessions, and for those ready to quit, six cognitive behavioral therapy counseling sessions. Some TSP groups were assigned randomly to receive a monetary incentive for engagement. Control provided referral to the National Cancer Institute Smokefree.gov website.

MEASUREMENTS

PRIMARY OUTCOME: Biochemically verified 7-day abstinence over 12 months.

SECONDARY OUTCOMES

Post-treatment (3-month) abstinence; reported abstinence, quit attempt, reduction in smoking, readiness to quit smoking over 12 months.

FINDINGS

Verified 7-day abstinence was not significantly different for intervention compared with control over 1 year: month 3 (8.3 versus 3.2%), 6 (6.2 versus 6.0%), and 12 (5.9 versus 10.0%); odds ratio (OR) = 1.07; 95% confidence interval (CI) = 0.23, 4.97; retention = 71%. There was an effect at 3 months (OR = 2.52; CI = 1.56, 4.04; P < 0.0001). There were no 12-month treatment effects for reported abstinence (P = 0.746), reduction in smoking by 50% or more (P = 0.533), likelihood of having made a quit attempt (P = 0.387) or stage of change over time (0.968). Participants in TSP engaged more and rated the intervention more favorably than those in the control condition.

CONCLUSIONS

Compared with referral to a smoking cessation website, a novel USA-focused Facebook smoking cessation intervention did not improve abstinence from smoking over 1 year, but increased abstinence at the end of treatment and was engaging to participants.

Voluntary Smoke-Free Measures Among Oklahoma Nightlife Owners: Barriers and Facilitators

Smoke-free policies prevent exposure to secondhand smoke and encourage tobacco cessation. Local smoke-free policies that are more comprehensive than statewide policies are not allowed in states with preemption, including Oklahoma, which has the sixth highest smoking prevalence in the United States. In states with preemption, voluntary smoke-free measures are encouraged, but little research exists on venue owners' and managers' views of such measures, particularly in nightlife businesses such as bars and nightclubs. This article draws from semistructured interviews with 23 Oklahoma bar owners and managers, examining perceived risks and benefits of adopting voluntary smoke-free measures in their venues. No respondents expressed awareness of preemption. Many reported that smoke-free bars and nightclubs were an inevitable societal trend, particularly as younger customers increasingly expected smoke-free venues. Business benefits such as decreased operating and cleaning costs, improved atmosphere, and employee efficiency were more convincing than improved employee health. Concerns that voluntary measures created an uneven playing field among venues competing for customers formed a substantial barrier to voluntary measures. Other barriers included concerns about lost revenue and fear of disloyalty to customers, particularly older smokers. Addressing business benefits and a level playing field may increase support for voluntary smoke-free nightlife measures.

Soda intake and tobacco use among young adult bar patrons: A cross-sectional study in seven cities

Young adults are among the greatest consumers of sugar sweetened beverages, and they also have high smoking rates. However, few studies address the relationship between these risk behaviors; this study examined the relationship between soda consumption and smoking among young adult bar patrons, a high-risk understudied population. A cross-sectional survey of young adult bar patrons (between January 2014 and October 2015) was conducted using randomized time location sampling (N = 8712) in Albuquerque, NM, Los Angeles, CA Nashville, TN, Oklahoma City, OK, San Diego, CA, San Francisco, CA, and Tucson, AZ. The survey found the prevalences of daily regular soda intake ranged from 32% in San Diego to 51% in Oklahoma City and current smoking ranged from 36% in Los Angeles, CA to 49% in Albuquerque, NM. In multinomial multivariate models with no soda consumption as the reference group and controlling for demographics and location, non-daily (OR = 1.24, 95% CI = 1.05, 1.47) and daily smokers (OR = 1.34, 95% CI = 1.08, 1.66) were both more likely to drink regular soda compared to not drinking any soda. No effects were found for diet soda consumption. These linked risks suggest that comprehensive health promotion efforts to decrease sugar sweetened beverage consumption and tobacco use, among other risky behaviors, may be effective in this population.

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Young adult (YA) bar patrons who smoke consume more regular soda than nonsmokers.

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Being a non-daily or a daily-smoker increased odds of drinking regular soda.

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Prevalence of smoking among YA bar patrons who were regular soda drinkers varied by region.

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YA bar patrons attending or graduated from college were less likely to drink soda.

Peer crowd affiliation as a segmentation tool for young adult tobacco use

BACKGROUND

In California, young adult tobacco prevention is of prime importance; 63% of smokers start by the age of 18 years, and 97% start by the age of 26 years. We examined social affiliation with 'peer crowd' (eg, Hipsters) as an innovative way to identify high-risk tobacco users.

METHODS

Cross-sectional surveys were conducted in 2014 (N=3368) among young adult bar patrons in 3 California cities. We examined use rates of five products (cigarettes, e-cigarettes, hookah, cigars and smokeless tobacco) by five race/ethnicity categories. Peer crowd affiliation was scored based on respondents' selecting pictures of young adults representing those most and least likely to be in their friend group. Respondents were classified into categories based on the highest score; the peer crowd score was also examined as a continuous predictor. Logistic regression models with each tobacco product as the outcome tested the unique contribution of peer crowd affiliation, controlling for race/ethnicity, age, sex, sexual orientation and city.

RESULTS

Respondents affiliating with Hip Hop and Hipster peer crowds reported significantly higher rates of tobacco use. As a categorical predictor, peer crowd was related to tobacco use, independent of associations with race/ethnicity. As a continuous predictor, Hip Hop peer crowd affiliation was also associated with tobacco use, and Young Professional affiliation was negatively associated, independent of demographic factors.

CONCLUSIONS

Tobacco product use is not the same across racial/ethnic groups or peer crowds, and peer crowd predicts tobacco use independent of race/ethnicity. Antitobacco interventions targeting peer crowds may be an effective way to reach young adult tobacco users.

TRIAL REGISTRATION NUMBER

NCT01686178, Pre-results.

Beyond the brotherhood: Skoal Bandits' role in the evolution of marketing moist smokeless tobacco pouches

Background

Since 2006, "snus" smokeless tobacco has been sold in the U.S.. However, U.S. Smokeless Tobacco (USST) and Swedish Match developed and marketed pouched moist snuff tobacco (MST) since 1973.

Methods

Analysis of previously secret tobacco documents, advertisements and trade press.

Results

USST partnered with Swedish Match, forming United Scandia International to develop pouch products as part of the "Lotus Project." Pouched MST was not commonly used, either in Sweden or the U.S. prior to the Lotus Project's innovation in 1973. The project aimed to transform smokeless tobacco from being perceived as an "unsightly habit of old men" into a relevant, socially acceptable urban activity, targeting 15-35 year-old men. While USST's initial pouched product "Good Luck," never gained mainstream traction, Skoal Bandits captured significant market share after its 1983 introduction. Internal market research found that smokers generally used Skoal Bandits in smokefree environments, yet continued to smoke cigarettes in other contexts. Over time, pouch products increasingly featured increased flavor, size, nicotine strength and user imagery variation.

Conclusions

Marlboro and Camel Snus advertising mirrors historical advertising for Skoal Bandits, designed to recruit new users and smokers subjected to smokefree places. Despite serious efforts, pouched MST marketing has been unable to dispel its association with traditional smokeless tobacco stereotypes as macho and rural. Public education efforts to discourage new users and dual use of MST and cigarettes should emphasize that "new" pouch products are simply repackaging "old" smokeless tobacco.

Perceived harms and benefits of tobacco, marijuana, and electronic vaporizers among young adults in Colorado: implications for health education and research

AIMS

To evaluate how young adults perceive and compare harms and benefits of marijuana and tobacco products in the context of a legal marijuana market in Colorado.

DESIGN

Semi-structured qualitative interviews.

SETTING

Denver, CO, USA.

PARTICIPANTS

Thirty-two young adults (aged 18-26 years) who used tobacco/marijuana/vaporizers.

MEASUREMENTS

Semi-structured interviews addressed perceived harms and benefits of various tobacco and marijuana products and personal experiences with these products.

FINDINGS

Young adults evaluated harms and benefits using five dimensions: (1) combustion-smoking was considered more harmful than non-combustible products (e.g. e-cigarettes, vaporizers and edibles); (2) potency-edibles and marijuana concentrates were perceived as more harmful than smoking marijuana flower because of potential to receive too large a dose of tetrahydrocannabinol (THC); (3) chemicals-products containing chemical additives were seen as more harmful than 'pure' or 'natural' plant products; (4) addiction-participants recognized physiological addiction to nicotine, but talked primarily about psychological or life-style dependence on marijuana; and (5) source of knowledge-personal experiences, warning labels, campaigns, the media and opinions of product retailers and medical practitioners affected perceptions of harms and benefits.

CONCLUSIONS

Among young adults in Colorado, USA, perceived harms and benefits of tobacco and marijuana include multiple dimensions. Health educational campaigns could benefit from addressing these dimensions, such as the potency of nicotine and cannabis concentrates and harmful chemicals present in the organic material of tobacco and marijuana. Descriptors such as 'natural' and 'pure' in the promotion or packaging of tobacco and marijuana products might be misleading.

Reducing Cancer and Cancer Disparities: Lessons From a Youth-Generated Diabetes Prevention Campaign

Adolescence and young adulthood, a period essential for determining exposures over the life-course, is an ideal time to intervene to lower cancer risk. This demographic group can be viewed as both the target audience and generator of messages for cancer prevention, such as skin cancer, obesity-, tobacco-, and human papillomavirus-related cancers. The purpose of this paper is to encourage innovative health communications that target youth; youth behavior; and the structural, environmental, and social determinants of youth behavior as critical areas of focus for cancer prevention and disparities reduction. The authors describe the rationale, processes, products, and early impacts of an award-winning youth diabetes prevention communication campaign model (The Bigger Picture) that harnesses spoken-word messages in school-based and social media presentations. The campaign supports minority adolescent and young adult artists to create content that aligns with values held closely by youth-values likely to resonate and affect change, such as defiance against authority, inclusion, and social justice. This campaign can be leveraged to prevent obesity, which is a cancer risk factor. Then, the authors propose concrete ways that The Bigger Picture's pedagogical model could be adapted for broader cancer prevention messaging for youth of color and youth stakeholders regarding tobacco-related cancers, skin cancers, and human papillomavirus-related cancers. The goal is to demonstrate how a youth-generated and youth-targeted prevention campaign can: (1) reframe conversations about cancer prevention, (2) increase awareness that cancer prevention is about social justice and health equity, and (3) catalyze action to change social norms and confront the social and environmental drivers of cancer disparities.