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Abouk R, De PK, Pesko MF. Estimating the effects of tobacco-21 on youth tobacco use and sales. JOURNAL OF HEALTH ECONOMICS 2024; 94:102860. [PMID: 38341937 DOI: 10.1016/j.jhealeco.2024.102860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/13/2024]
Abstract
We examine the effect of raising the minimum legal sale age of tobacco to 21 (i.e., "T21"). We estimate difference-in-differences models using the Monitoring the Future (MTF) survey data and Nielsen Retail Scanner data from 2012 to 2019. Outcomes include cigarette and e-cigarette use and sales. We find sizable reductions in e-cigarette and cigarette use for 12th graders. T21 also reduced cigarette sales by 12.4 % and e-cigarette sales by 69.3 % in counties with the highest percent quartile of individuals under 21 years of age. In terms of mechanisms, we find that T21 increases ID checking and perceived risks of using both products.
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Affiliation(s)
- Rahi Abouk
- William Paterson University, United States.
| | - Prabal K De
- CUNY City College and The Graduate Center, United States
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Safi AG, Kalaji M, Avery R, Niederdeppe J, Mathios A, Dorf M, Byrne S. Examining Perceptions of Uncertain Language in Potential E-Cigarette Warning Labels: Results from 16 Focus Groups with Adult Tobacco Users and Youth. HEALTH COMMUNICATION 2024; 39:460-481. [PMID: 36717390 PMCID: PMC10387126 DOI: 10.1080/10410236.2023.2170092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
E-cigarette use among youth presents a public health risk. Yet, cigarette smokers who substantially reduce their smoking or switch completely from traditional combustible cigarettes could benefit. As science about e-cigarettes is continually emerging, any potential warnings are likely to contain uncertain language. Hedged verbiage may impact decision making. To assess reactions, we conducted 16 online focus groups; 8 with youth (n = 32, grouped by gender and by vaping experience) and 8 with adult tobacco users (n = 37, grouped by smokers, dual users of e-cigarettes and cigarettes, and former smokers who switched to e-cigarettes). Each focus group viewed and discussed 8 potential warnings messages. We conducted an inductive thematic analysis of the reactions to warning messages that contain uncertain language. Respondents' reactions were often negative, but varied based on specific usages of uncertainty, existing beliefs about uncertainty in law and science, and smoking/vaping use patterns that supported the use of uncertainty related to e-cigarettes. Many youth (and some adults) believed that uncertain language enabled audiences to minimize the likelihood of harm or interpreted it as meaning there are both healthy and unhealthy e-cigarettes. This qualitative study provides evidence that the use of types of uncertain language, the frequency of that use, and/or the selection of particular words in warnings, might not achieve the intended public health aims of increasing understanding of risk, deterring youth uptake, and/or facilitating a substantial switch from cigarettes. The use of certain types of uncertain language appears to have significant potential to bring unintended consequences. Suggestions for research and policy are included.
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Affiliation(s)
- Amelia Greiner Safi
- Department of Public and Ecosystem Health, Cornell University, USA
- Department of Communication, Cornell University, USA
| | - Motasem Kalaji
- Department of Communication Studies, California State University Northridge, USA
| | - Rosemary Avery
- Jeb E. Brooks School of Public Policy, Cornell University, USA
| | - Jeff Niederdeppe
- Department of Communication, Cornell University, USA
- Jeb E. Brooks School of Public Policy, Cornell University, USA
| | - Alan Mathios
- Jeb E. Brooks School of Public Policy, Cornell University, USA
| | | | - Sahara Byrne
- Department of Communication, Cornell University, USA
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Selya A, Shiffman S. Comparative risk perceptions of switching to JUUL vs. continued smoking and subsequent switching away from cigarettes: a longitudinal observational study. BMC Psychol 2023; 11:305. [PMID: 37798775 PMCID: PMC10552465 DOI: 10.1186/s40359-023-01351-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 09/26/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Evidence indicates that electronic nicotine delivery systems (ENDS) pose lower risk than cigarettes; however, many smokers harbor misperceptions that ENDS are equally or more harmful, possibly deterring them from switching. This study examines whether comparative risk perceptions of JUUL vs. smoking are associated with subsequent switching, among smokers who recently purchased JUUL. METHODS N = 16,996 current established smokers who recently purchased a JUUL Starter Kit were followed 6 times over 12 months. Comparative risk perceptions were assessed using both direct and indirect measures (i.e., contrasting JUUL and smoking directly in questions, and deriving from separate absolute scales). Repeated-measures logistic regression examined switching across follow-up (no smoking in past 30 days) as a function of baseline risk perceptions, adjusting for demographics and baseline smoking behavior. RESULTS Perceiving JUUL as less harmful than smoking was associated with higher switching rates, using both direct (e.g., adjusted odds ratio [AOR] = 1.48 for "JUUL much less" vs. "more/much more harmful") and indirect (AOR = 1.07, for each 10-unit increase in fraction; AOR = 1.51 for highest (6-100) vs. lowest (0 to < 1) fraction categories) comparative risk measures (all p < 0.0001). Among the subset smoking 10 + cigarettes per day, associations between risk perceptions and switching were more pronounced (AOR = 2.51 for "JUUL much less" vs. "more/much more harmful"; AOR = 1.81 for 6-100 vs. 0 to < 1 fraction, both p < 0.0001). CONCLUSIONS Smokers who perceive JUUL as less harmful than cigarettes have higher odds of switching. Future research should examine whether messaging which aligns comparative risk perceptions with current evidence can facilitate switching, especially among heavier smokers.
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Affiliation(s)
- Arielle Selya
- Pinney Associates, Inc, 201 N Craig St., Suite 320, Pittsburgh, PA, 15213, USA.
| | - Saul Shiffman
- Pinney Associates, Inc, 201 N Craig St., Suite 320, Pittsburgh, PA, 15213, USA
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Selya A, Wissmann R, Shiffman S, Chandra S, Sembower M, Joselow J, Kim S. Sales of Electronic Nicotine Delivery Systems (ENDS) and Cigarette Sales in the USA: A Trend Break Analysis. JOURNAL OF CONSUMER POLICY 2023; 46:79-93. [PMID: 36686374 PMCID: PMC9841499 DOI: 10.1007/s10603-022-09533-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 11/30/2022] [Indexed: 06/17/2023]
Abstract
UNLABELLED Electronic nicotine delivery systems (ENDS) are a potentially lower-risk tobacco product which could help smokers switch completely away from cigarettes. However, the lack of strong evidence to date of a measurable, population-level effect on reducing smoking has generated skepticism about ENDS' potential benefits. This study examines whether increased US ENDS sales have been associated with reduced cigarette sales. Retail data on weekly per-capita cigarette and ENDS purchases in the USA during 2014-2019 were obtained from a national sample of brick-and-mortar retail outlets. Trends in cigarette sales were modeled before (2014-2016) ENDS had a substantial market share, and, after adjusting for macroeconomic factors, projected into the post-period (2017-2019). Actual cigarette sales were lower than projected sales (by up to 16% across the post-period), indicating a substantial "cigarette shortfall" in the post-period. To explore whether general (i.e., inclusive of potentially many mechanisms) substitution by ENDS can explain the cigarette shortfall, its association with per-capita ENDS volume sales was examined. Higher ENDS sales were significantly associated with a greater cigarette shortfall: for every additional per-capita ENDS unit, cigarette sales were 1.4 packs-per-capita lower than expected (B = 1.4, p < .0001). Error correction models which account for spurious correlation yielded similar results. These findings support ENDS serving as a substitute for cigarettes (through potentially many mechanisms including cigarette price), causing cigarette consumption to decline. Since ENDS potentially pose lower risk than cigarettes, this general substitution effect suggests that risk-proportionate tobacco regulation could mitigate the tobacco-related health burden. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s10603-022-09533-4.
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Affiliation(s)
- A. Selya
- PinneyAssociates, Inc, Pittsburgh, PA USA
| | | | | | - S. Chandra
- PinneyAssociates, Inc, Pittsburgh, PA USA
| | | | | | - S. Kim
- PinneyAssociates, Inc, Pittsburgh, PA USA
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Rebuli ME, Rose JJ, Noël A, Croft DP, Benowitz NL, Cohen AH, Goniewicz ML, Larsen BT, Leigh N, McGraw MD, Melzer AC, Penn AL, Rahman I, Upson D, Crotty Alexander LE, Ewart G, Jaspers I, Jordt SE, Kligerman S, Loughlin CE, McConnell R, Neptune ER, Nguyen TB, Pinkerton KE, Witek TJ. The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:1-17. [PMID: 36584985 PMCID: PMC9819258 DOI: 10.1513/annalsats.202209-796st] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
E-cigarette or vaping product use-associated lung injury (EVALI) is a severe pulmonary illness associated with the use of e-cigarettes or vaping products that was officially identified and named in 2019. This American Thoracic Society workshop was convened in 2021 to identify and prioritize research and regulatory needs to adequately respond to the EVALI outbreak and to prevent similar instances of disease associated with e-cigarette or vaping product use. An interdisciplinary group of 26 experts in adult and pediatric clinical care, public health, regulatory oversight, and toxicology were convened for the workshop. Four major topics were examined: 1) the public health and regulatory response to EVALI; 2) EVALI clinical care; 3) mechanisms contributing to EVALI; and 4) needed actions to address the health effects of EVALI. Oral presentations and group discussion were the primary modes used to identify top priorities for addressing EVALI. Initiatives including a national EVALI case registry and biorepository, integrated electronic medical record coding system, U.S. Food and Drug Administration regulation and enforcement of nicotine e-cigarette standards, regulatory authority over nontobacco-derived e-cigarettes, training in evaluating exogenous exposures, prospective clinical studies, standardized clinical follow-up assessments, ability to more readily study effects of cannabinoid e-cigarettes, and research to identify biomarkers of exposure and disease were identified as critical needs. These initiatives will require substantial federal investment as well as changes to regulatory policy. Overall, the workshop identified the need to address the root causes of EVALI to prevent future outbreaks. An integrated approach from multiple perspectives is required, including public health; clinical, basic, and translational research; regulators; and users of e-cigarettes. Improving the public health response to reduce the risk of another substantial disease-inducing event depends on coordinated actions to better understand the inhalational toxicity of these products, informing the public of the risks, and developing and enforcing regulatory standards for all e-cigarettes.
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Pesko MF, Cummings KM, Douglas CE, Foulds J, Miller T, Rigotti NA, Warner KE. United States public health officials need to correct e-cigarette health misinformation. Addiction 2022; 118:785-788. [PMID: 36507802 DOI: 10.1111/add.16097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/09/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Michael F Pesko
- Department of Economics, Andrew Young School of Policy Studies, Georgia State University, Atlanta, GA, USA
| | - K Michael Cummings
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Clifford E Douglas
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jonathan Foulds
- Department of Public Health Sciences, Penn State University - College of Medicine, Hershey, PA, USA
| | | | - Nancy A Rigotti
- Department of Medicine, Harvard Medical School, Boston, MA, USA.,Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston, MA, USA
| | - Kenneth E Warner
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
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Avery RJ, Byrne S, Dorf MC, Greiner Safi A, Kalaji M, Mathios AD, Niederdeppe J, Porticella N. Challenges in communicating the benefits of switching from cigarettes to e-cigarettes: Responses from eight adult focus groups with varying smoking experience. Prev Med Rep 2022; 30:102060. [DOI: 10.1016/j.pmedr.2022.102060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/23/2022] Open
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Friedman AS, Pesko MF. Young adult responses to taxes on cigarettes and electronic nicotine delivery systems. Addiction 2022; 117:3121-3128. [PMID: 35852452 PMCID: PMC9796020 DOI: 10.1111/add.16002] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Accepted: 06/27/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Although over half of United States states have passed taxes on electronic nicotine delivery systems (ENDS), recent evidence links ENDS tax rates to increases in smoking, suggesting potentially substantive health costs. Overall health implications will depend on how these taxes affect transitions from experimentation to regular smoking and vaping. Current analyses have not assessed ENDS tax rates' effects in young adulthood (ages 18-25). This study measures the relationship between ENDS and cigarette tax rates and ENDS use and smoking in young adulthood, a key period for initiation of regular tobacco use. DESIGN Observational study of data from the Current Population Survey's 2010-2019 Tobacco Use Supplements. SETTING The United States. PARTICIPANTS/CASES A total of 38 906 18 to 25 year-olds MEASUREMENTS: Multivariable linear regressions estimated two-way fixed effects analyses to assess ENDS and cigarette tax rates' relationships to recent and daily smoking and vaping, adjusting for an array of potential sociodemographic and policy confounders along with state and year fixed effects. FINDINGS A $1 increase in ENDS taxes yielded significant reductions in young adults' daily vaping ( β ̂ = -0.025; 95% CI, -0.037, -0.014) alongside increases in recent smoking ( β ̂ = 0.037; 95% CI, 0.013, 0.061), primarily reflecting greater dual use ( β ̂ =2.078; 95% CI, 0.890, 4.852; P = 0.09). A $1 cigarette tax increase yielded 2.1 and 2.5 percentage point increases in recent and daily vaping, with 95% CIs of (0.004, 0.038) and (0.018, 0.032) respectively. CONCLUSIONS In the United States, higher ENDS tax rates are associated with decreased ENDS use but increased cigarette smoking among 18- to 25-year-olds, with associations reversed for cigarette taxes.
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Affiliation(s)
| | - Michael F. Pesko
- Georgia State UniversityAtlantaGAUSA,Institute of Labor EconomicsBonnGermany
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Tattan-Birch H, Brown J, Jackson SE. 'Give 'em the vape, sell 'em the pods': razor-and-blades methods of pod e-cigarette pricing. Tob Control 2022; 31:773-774. [PMID: 33766938 PMCID: PMC9606490 DOI: 10.1136/tobaccocontrol-2020-056354] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Harry Tattan-Birch
- Behavioural Science and Health, University College London, London, London, UK
| | - Jamie Brown
- Behavioural Science and Health, University College London, London, London, UK
| | - Sarah E Jackson
- Behavioural Science and Health, University College London, London, London, UK
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Katchmar A, Shafer P, Siegel M. Analysis of state portrayals of the risks of e-cigarette use and the cause of the EVALI outbreak. Harm Reduct J 2022; 19:112. [PMID: 36199112 PMCID: PMC9535934 DOI: 10.1186/s12954-022-00694-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION In August 2019, an outbreak of "e-cigarette or vaping product use-associated lung injury" (EVALI) prompted many states and health organizations to warn against the use of electronic cigarettes, or e-cigarettes, due to the presumed link between e-cigarette use and the illness. However, it was later shown that vitamin E acetate, a component of some illicit vaporizable THC products, was the causative agent in this outbreak. METHODS We conducted a series of cross-sectional surveys of the websites of all state departments of health to determine how they communicated the risk of e-cigarette use during and after the EVALI outbreak. We then paired this analysis with data from the 2016 through 2020 Behavioral Risk Factor Surveillance System to measure changes in cigarette and e-cigarette use. RESULTS Website data from 24 states was available for analysis at all three time points of interest, and BRFSS data was only available for 8 of these states. We found that by January 2020, a majority of the states surveyed did not list vaporizable THC use as a cause of EVALI; however, differences in state messaging did not appear to be associated with changes in e-cigarette and cigarette use. CONCLUSIONS Given the number of states that did not appear to update their messaging regarding the cause of EVALI, we believe that states should re-evaluate this messaging to accurately communicate the risks of e-cigarette use.
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Affiliation(s)
- Amanda Katchmar
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA.
| | - Paul Shafer
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany St, Boston, MA, 02118, USA
| | - Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
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Noar SM, Gottfredson NC, Kieu T, Rohde JA, Hall MG, Ma H, Fendinger NJ, Brewer NT. Impact of Vaping Prevention Advertisements on US Adolescents: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2236370. [PMID: 36227597 PMCID: PMC9561946 DOI: 10.1001/jamanetworkopen.2022.36370] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 08/26/2022] [Indexed: 11/22/2022] Open
Abstract
Importance Understanding whether prevention advertisements reduce susceptibility to vaping is important owing to concerning levels of adolescent vaping. Objective To examine whether vaping prevention advertisements from the US Food and Drug Administration (FDA) national Real Cost campaign lead to lower susceptibility to vaping among adolescents. Design, Setting, and Participants For this 3-group randomized clinical trial with parallel assignment, participants were US adolescents aged 13 to 17 years who were susceptible to vaping or current e-cigarette users, recruited from online panels. Adolescents were randomized to 1 of 2 Real Cost vaping prevention trial groups (health harms- or addiction-themed advertisements) or to a control group (investigator-created neutral videos about vaping). Adolescents completed 4 weekly online surveys at visits 1 to 4 over a 3-week period. Data were analyzed from December 1, 2021, to August 25, 2022. Interventions Adolescents saw 3 randomly ordered 30-second video advertisements online at each of 3 weekly study visits (visits 1, 2, and 3). Main Outcomes and Measures The primary trial outcome was susceptibility to vaping. Surveys also assessed susceptibility to smoking cigarettes to examine any spillover effects of vaping prevention advertisements on smoking outcomes. Both susceptibility measures had 3 items and ranged from 1 (indicating not susceptible) to 4 (indicating highly susceptible). The primary analyses compared Real Cost groups (combined) with the control group, while exploratory analyses compared the Real Cost groups with each other. Results Participants were 1514 adolescents (1140 [75.3%] boys; mean [SD] age, 15.22 [1.18] years), including 504 randomized to the Real Cost health harms group, 506 randomized to the Real Cost addiction group, and 504 randomized to the control group. Adolescents in the Real Cost groups (combined) had lower susceptibility to vaping at visit 4 than those in the control group (b = -0.21; 95% CI, -0.32 to -0.10). The Real Cost groups did not differ from one another on susceptibility to vaping (visit 4: b = -0.05; 95% CI, -0.17 to 0.07). Adolescents in the Real Cost groups (combined) also had lower susceptibility to smoking cigarettes than those in the control group (b = -0.21; 95% CI, -0.32 to -0.10). For both vaping and smoking, Real Cost groups had less positive attitudes (vaping: b = -0.27; 95% CI, -0.40 to -0.14; smoking: b = -0.23; 95% CI, -0.39 to -0.08) compared with the control group. Conclusions and Relevance These findings suggest that vaping prevention advertisements from the FDA Real Cost campaign led to lower adolescent susceptibility to vaping and had beneficial spillover effects on cigarette smoking outcomes. Tobacco prevention campaigns can help reduce youth tobacco use. Trial Registration ClinicalTrials.gov Identifier: NCT04836455.
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Affiliation(s)
- Seth M. Noar
- Hussman School of Journalism and Media, University of North Carolina, Chapel Hill
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Nisha C. Gottfredson
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Talia Kieu
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
| | - Jacob A. Rohde
- Hussman School of Journalism and Media, University of North Carolina, Chapel Hill
| | - Marissa G. Hall
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
- Carolina Population Center, University of North Carolina, Chapel Hill
| | - Haijing Ma
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | | | - Noel T. Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill
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Kim S, Shiffman S, Sembower MA. US adult smokers' perceived relative risk on ENDS and its effects on their transitions between cigarettes and ENDS. BMC Public Health 2022; 22:1771. [PMID: 36123722 PMCID: PMC9484256 DOI: 10.1186/s12889-022-14168-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
Background Perceived risk reduction motivates smokers to switch to electronic nicotine delivery systems (ENDS). This research examines US smokers’ relative risk perceptions and their prospective association with various behavioral stages of switching to ENDS. Methods Data from the nationally representative, longitudinal Population Assessment of Tobacco and Health (PATH) Adult survey, Waves 1 (2014) through 5 (2019), were analyzed. We assessed the association between the perceived risk of ENDS relative to cigarettes (“less harmful” vs. “equally harmful” or “more harmful”) and 1) adoption of ENDS (among never-ENDS-using smokers), 2) complete switching to ENDS (i.e., stopping smoking, among ever-ENDS-using smokers), and 3) avoiding reversion to smoking (among smokers who had switched to ENDS), at the next wave. Results The proportion of US smokers perceiving ENDS as less harmful than cigarettes continually decreased, reaching 17.4% in Wave 5 (2019). Current smokers with such belief were more likely to adopt ENDS (aOR 1.31; 95% CI 1.15–1.50) and switch completely to ENDS (aOR 2.24; 95% CI 1.89–2.65) in the subsequent wave. Among smokers who had switched within the past year, such beliefs predicted avoidance of resumption of smoking in the next wave (aOR 0.55; 95% CI 0.33–0.93). Conclusions Smokers’ beliefs about the relative risk of ENDS compared to cigarettes had a strong and consistent association with transitions between smoking and ENDS use. Addressing the growing misperception about ENDS has the potential to contribute to public health by encouraging smokers’ switching to ENDS. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-14168-8.
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Affiliation(s)
- Sooyong Kim
- PinneyAssociates Inc, 201 N. Craig St, Ste 320, Pittsburgh, PA, 15213, USA.
| | - Saul Shiffman
- PinneyAssociates Inc, 201 N. Craig St, Ste 320, Pittsburgh, PA, 15213, USA
| | - Mark A Sembower
- PinneyAssociates Inc, 201 N. Craig St, Ste 320, Pittsburgh, PA, 15213, USA
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Bandi P, Asare S, Majmundar A, Nargis N, Jemal A, Fedewa SA. Relative Harm Perceptions of E-Cigarettes Versus Cigarettes, U.S. Adults, 2018-2020. Am J Prev Med 2022; 63:186-194. [PMID: 35868816 DOI: 10.1016/j.amepre.2022.03.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION It is unknown how U.S. adults' relative harm perceptions of E-cigarettes versus cigarettes and associated behaviors changed during the E-cigarette or vaping product use‒associated lung injury epidemic (late 2019) and COVID-19 pandemic (since early 2020). METHODS Data from cross-sectional nationally representative Health Information National Trends Survey collected in 2018 (n=3,360), 2019 (n=3,217), and 2020 (n=3,677) (analyzed in 2021) were used to estimate changes in relative harm perceptions of E-cigarettes versus cigarettes (less harmful, as harmful, more harmful, don't know as a measure of uncertainty). In addition, changes in exclusive cigarette smoking, exclusive E-cigarette use, and dual use were estimated for each relative harm perception level. RESULTS Perceptions of E-cigarettes as more harmful than cigarettes doubled year on year, increasing most between 2019 and 2020 (2018: 6.8%, 2019: 12.8%, 2020: 28.3%), whereas uncertainty in relative harm declined (2018: 38.2%, 2019: 34.2%, 2020: 24.7%). Less harmful relative perceptions declined (2018:17.6%, 2019:15.3%, 2020:11.4%), whereas as harmful perceptions remained steady (2018: 37.4%, 2019: 37.7%, 2020: 35.6%). Exclusive cigarette smoking increased between 2019 and 2020 among those who perceived E-cigarettes as relatively more harmful (2018: 18.5%; 2019: 8.4%; 2020: 16.3%), exclusive E-cigarette use increased linearly among those who perceived them as relatively less harmful (7.9%, 15.3%, 26.7%), and dual use increased linearly in those who perceived them relatively as harmful (0.1%, 1.4%, 2.9%). CONCLUSIONS Perceptions of E-cigarettes as more harmful than cigarettes increased sharply between 2019 and 2020. Increases in tobacco product use were potentially guided by product-specific relative harm perceptions because changes occurred primarily in individuals who perceived their preferred product as relatively less harmful, suggesting the need for accurate messaging of relative and absolute product risks.
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Affiliation(s)
- Priti Bandi
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia.
| | - Samuel Asare
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Anuja Majmundar
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Nigar Nargis
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Ahmedin Jemal
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia
| | - Stacey A Fedewa
- Department of Surveillance & Health Equity Science, American Cancer Society, Atlanta, Georgia
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Xu Y, Jiang L, Prakash S, Chen T. The Impact of Banning Electronic Nicotine Delivery Systems on Combustible Cigarette Sales: Evidence From US State-Level Policies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:1352-1359. [PMID: 35260317 DOI: 10.1016/j.jval.2021.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 12/16/2021] [Accepted: 12/27/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES In the fall of 2019, several states in the United States passed emergency bans on the sale of electronic nicotine delivery systems (ENDS), in response to an outbreak of illnesses strongly linked to tetrahydrocannabinol vaping products that received national news coverage. Given that ENDS are potential alternative nicotine products for adult smokers, banning ENDS may have unintended consequences. This study provides evidence of an association between state-level ENDS bans and cigarette sales. METHODS We used difference-in-differences and generalized synthetic control methods to estimate the impacts of the emergency ENDS bans on cigarette sales by comparing treatment states that passed ENDS bans in fall 2019 (Massachusetts, Washington, and Rhode Island), halted states that revoked the announced ENDS bans, and control states. RESULTS Our results show that cigarette sales in ban states were higher than would have been observed otherwise in the post-ban period. A full ban on ENDS was associated with increased cigarette sales of 7.5% in Massachusetts (P < .01); banning non-tobacco flavored ENDS was associated with 4.6% (P < .1) higher-than-expected cigarette sales. We did not detect statistically significant impacts in halted states, and placebo tests, which randomly assigned control states as treatments, showed no difference in observed cigarette sales in the same period. CONCLUSIONS This study provides evidence that banning ENDS is associated with increased cigarette sales. Future research is needed to determine the long-term impact of these policies.
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15
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Streck JM, Regan S, Neil J, Kalkhoran S, Gupta PS, Bearnot B, Coker FK, Kalagher KM, Park ER, Wakeman S, Rigotti NA. Interest in Electronic Cigarettes for Smoking Cessation Among Adults With Opioid Use Disorder in Buprenorphine Treatment: A Mixed-Methods Investigation. Nicotine Tob Res 2022; 24:1134-1138. [PMID: 34915581 PMCID: PMC9199932 DOI: 10.1093/ntr/ntab259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/13/2021] [Accepted: 12/14/2021] [Indexed: 11/14/2022]
Abstract
INTRODUCTION Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known. METHODS A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use. RESULTS One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes. CONCLUSIONS E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach. IMPLICATIONS Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation.
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Affiliation(s)
- Joanna M Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Jordan Neil
- Department of Family and Preventive Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Health Promotion Research Center, Stephenson Cancer Center, Oklahoma City, OK, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Priya S Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Faith K Coker
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Kelly M Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Elyse R Park
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston MA, USA
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16
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East K, Reid JL, Burkhalter R, Wackowski OA, Thrasher JF, Tattan-Birch H, Boudreau C, Bansal-Travers M, Liber AC, McNeill A, Hammond D. Exposure to negative news stories about vaping, and harm perceptions of vaping, among youth in England, Canada, and the US before and after the outbreak of E-cigarette or Vaping-Associated Lung Injury (EVALI). Nicotine Tob Res 2022; 24:1386-1395. [PMID: 35368062 PMCID: PMC9356695 DOI: 10.1093/ntr/ntac088] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 03/21/2022] [Accepted: 03/30/2022] [Indexed: 02/02/2023]
Abstract
Introduction Little is known about the international impact of E-cigarette or Vaping-Associated Lung Injury (‘EVALI’) on youth perceptions of vaping harms. Methods Repeat cross-sectional online surveys of youth aged 16–19 years in England, Canada, and the United States before (2017, 2018), during (2019 August/September), and after (2020 February/March, 2020 August) the ‘EVALI’ outbreak (N = 63380). Logistic regressions assessed trends, country differences, and associations between exposure to negative news stories about vaping and vaping harm perceptions. Results Exposure to negative news stories increased between 2017 and February–March 2020 in England (12.6% to 34.2%), Canada (16.7% to 56.9%), and the United States (18.0% to 64.6%), accelerating during (2019) and immediately after (February–March 2020) the outbreak (p < .001) before returning to 2019 levels by August 2020. Similarly, the accurate perception that vaping is less harmful than smoking declined between 2017 and February–March 2020 in England (77.3% to 62.2%), Canada (66.3% to 43.3%), and the United States (61.3% to 34.0%), again accelerating during and immediately after the outbreak (p < .001). The perception that vaping takes less than a year to harm users’ health and worry that vaping will damage health also doubled over this period (p ≤ .001). Time trends were most pronounced in the United States. Exposure to negative news stories predicted the perception that vaping takes less than a year to harm health (Adjusted Odds Ratio = 1.55, 1.48-1.61) and worry that vaping will damage health (Adjusted Odds Ratio = 1.32, 1.18-1.48). Conclusions Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. Effects were seen in all countries but were most pronounced in the United States. Implications This is the first study examining changes in exposure to news stories about vaping, and perceptions of vaping harms, among youth in England, Canada, and the United States before, during, and after ‘EVALI’. Between 2017 and February–March 2020, youth exposure to negative news stories, and perceptions of vaping harms, increased, and increases were exacerbated during and immediately after ‘EVALI’. By August 2020, exposure to negative news stories returned to 2019 levels, while perceptions of harm were sustained. Exposure to negative news stories also predicted two of the three harm perception measures. Overall, findings suggest that ‘EVALI’ may have exacerbated youth’s perceptions of vaping harms internationally.
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Affiliation(s)
- Katherine East
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Ontario, Canada.,National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jessica L Reid
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Ontario, Canada
| | - Robin Burkhalter
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Ontario, Canada
| | - Olivia A Wackowski
- School of Public Health, Rutgers, The State University of New Jersey, NJ, USA
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Harry Tattan-Birch
- Department of Behavioural Science and Health, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Christian Boudreau
- Department of Statistics and Actuarial Science, University of Waterloo, Ontario, Canada
| | - Maansi Bansal-Travers
- Department of Health Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Alex C Liber
- Cancer Prevention and Control, Lombardi Comprehensive Cancer Center, Georgetown University, Washington, DC, USA
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Hammond
- School of Public Health Sciences, Faculty of Health, University of Waterloo, Ontario, Canada
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17
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Janmohamed K, Nakamura-Sakai S, Soale AN, Forastiere L, Altice FL, Kumar N. News events and their relationship with US vape sales: an interrupted time series analysis. BMC Public Health 2022; 22:479. [PMID: 35272644 PMCID: PMC8915465 DOI: 10.1186/s12889-022-12858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 02/24/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE News coverage around vaping-related events may have furthered misconceptions regarding the relative harms of vapes. Such information may influence the decisions of individuals who smoke, around switching to vaping, potentially affecting the overall tobacco mortality burden. Thus, it is prudent to study how news events (e.g., 2019 vaping illness epidemic) are associated with vape sales in the United States, to possibly reduce the tobacco mortality burden. METHODS We used weekly retail sales data for e-cigarettes (30 December 2018 - 28 December 2019) from the US retail scanner data compiled by the Nielsen Company. We used an interrupted time series design with segmented regression analysis to determine immediate and longer-term impacts of individual news events (e.g. Trump administration's planned ban on some flavored vaping products) on vape sales, controlling for pre-existing trends. RESULTS Unexpectedly, we noted a statistically significant positive relationship between vape sales and the CDC announcing an investigation into vaping-related illnesses (Change: 6.59%, Estimate: 0.066; 95% CI: 0.036, 0.092; P < 0.001). We also observed a similar positive association between vape sales and the CDC's announcement on the link between Vitamin E acetate and EVALI (Change: 2.93%, Estimate: 0.029; 95% CI: 0.003, 0.055; P < 0.05). There was a steep decline in sales after these events. CONCLUSIONS News events may be associated with US vape sales. Findings have implications for the management of risk perceptions around vaping to improve health outcomes of tobacco users. Information-based policy instruments can be applied to balance the effects of news events that may influence vape sales.
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Affiliation(s)
| | | | - Abdul-Nasah Soale
- Department of Statistical Science, Fox School of Business, Temple University, Philadelphia, PA, USA
| | - Laura Forastiere
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, 135 College Street, Suite 323, New Haven, 06510, CT, USA
| | - Navin Kumar
- Yale School of Medicine, Section of Infectious Diseases, 135 College Street, Suite 323, New Haven, 06510, CT, USA.
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18
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Streck JM, Regan S, Kalkhoran S, Kalagher KM, Bearnot B, Gupta PS, Wakeman S, Rigotti NA. Perceptions of E-cigarettes among adults in treatment for opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100023. [PMID: 36845890 PMCID: PMC9949332 DOI: 10.1016/j.dadr.2022.100023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
Background Individuals with opioid use disorder (OUD) have a high prevalence of smoking and limited success quitting smoking with existing tools. There is ongoing debate about whether electronic cigarettes (e-cigarettes) may be a viable harm reduction strategy. We sought to determine the potential acceptability of e-cigarettes for cigarette harm reduction among individuals receiving medication treatment for opioid use disorder (MOUD) with buprenorphine. Among individuals receiving MOUD we investigated health harm perceptions of cigarettes, nicotine e-cigarettes, and nicotine replacement therapy (NRT), and perceptions of the helpfulness of e-cigarettes and NRT for quitting cigarettes. Methods Cross-sectional telephone survey conducted among adults in buprenorphine treatment at five community health centers in the Boston, MA metropolitan area from February to July 2020. Results 93% and 63% of participants rated cigarettes and e-cigarettes, respectively, as very or extremely harmful to health, and 62% rated NRT as not to slightly harmful to health. Over half (58%) rated cigarettes as more harmful than e-cigarettes; 65% and 83% perceived e-cigarettes and NRT, respectively, to be helpful for reducing/quitting cigarette use. In bivariate analyses, nicotine e-cigarette users, compared to nonusers, perceived e-cigarettes to be less harmful to health and more often rated e-cigarettes as helpful for reducing/quitting cigarette use (both p<0.05). Conclusions This study suggests that Massachusetts patients receiving MOUD with buprenorphine have concerns about the health harms of e-cigarettes yet rate them as helpful tools for reducing or quitting cigarette smoking. Future research is needed to test the efficacy of e-cigarettes for cigarette harm reduction.
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Affiliation(s)
- Joanna M. Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Kelly M. Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Priya S. Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy A. Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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19
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Wackowski OA, Gratale SK, Jeong M, Delnevo CD, Steinberg MB, O'Connor RJ. Over 1 year later: smokers' EVALI awareness, knowledge and perceived impact on e-cigarette interest. Tob Control 2022:tobaccocontrol-2021-057190. [PMID: 35228318 DOI: 10.1136/tobaccocontrol-2021-057190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 02/14/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The e-cigarette or vaping product use-associated lung injury (EVALI) outbreak caused serious lung injuries in over 2800 people in the USA in 2019. By February 2020, most cases were determined as linked with vaping tetrahydrocannabinol (THC), including black market products using vitamin E acetate. This study examined smokers' EVALI awareness, knowledge and perceived impact on their e-cigarette interest approximately 16 months after its peak. DESIGN Between January and February 2021, we surveyed 1018 adult current smokers from a nationally representative US research panel. Participants were asked if they had heard about EVALI prior to COVID-19, knew its main cause, and if EVALI had impacted their interest in future e-cigarette use. RESULTS Approximately 54% of smokers had heard of EVALI. Among those who had heard of EVALI (n=542), 37.3% believed its main cause was e-cigarettes used to vape nicotine, like JUUL. Fewer (16.6%) thought the main cause was products for vaping marijuana/THC, and 20.2% did not know. About 29% had heard vitamin E acetate was associated with EVALI, and 50.9% indicated EVALI made them less interested in using e-cigarettes in the future. EVALI awareness was significantly associated with e-cigarette risk perceptions (ie, that e-cigarettes are as harmful as smoking). CONCLUSIONS Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.
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Affiliation(s)
- Olivia A Wackowski
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA .,Deptartment of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | | | - Michelle Jeong
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA.,Deptartment of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Cristine D Delnevo
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA.,Deptartment of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, New Jersey, USA
| | - Michael B Steinberg
- Center for Tobacco Studies, Rutgers University, New Brunswick, New Jersey, USA.,Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey, USA
| | - Richard J O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
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20
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Streck JM, Regan S, Bearnot B, Gupta PS, Kalkhoran S, Kalagher KM, Wakeman S, Rigotti NA. Prevalence of Cannabis Use and Cannabis Route of Administration among Massachusetts Adults in Buprenorphine Treatment for Opioid Use Disorder. Subst Use Misuse 2022; 57:1104-1110. [PMID: 35410577 PMCID: PMC10091221 DOI: 10.1080/10826084.2022.2063899] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis' effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing. METHODS The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use. RESULTS Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression. CONCLUSIONS Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts' adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.
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Affiliation(s)
- Joanna M Streck
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Regan
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Bearnot
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Priya S Gupta
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Sara Kalkhoran
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Kelly M Kalagher
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Wakeman
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Nancy A Rigotti
- Tobacco Research and Treatment Center, Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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21
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Liber AC, Cahn Z, Diaz MC, Donovan E, Vallone D, Schillo B. The EVALI outbreak and tobacco sales in the USA, 2014-2020. Tob Control 2021:tobaccocontrol-2021-056807. [PMID: 34911815 DOI: 10.1136/tobaccocontrol-2021-056807] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 11/26/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The E-cigarette, or Vaping Product-Use Associated Lung Injury (EVALI) Outbreak of 2019 hospitalised thousands and killed dozens of people in the USA and raised perceptions of the dangers posed to health by electronic cigarettes (e-cigarettes). These illnesses along with continued increases in youth vaping rates lead to the passage of many state and federal laws intended to curtail the sale of flavoured e-cigarettes. Little is known about the impact of these events on US e-cigarette and cigarette retail sales. METHODS Using Nielsen Scantrack sales data from January 2014 to January 2020 for 23 US states, we evaluate the effect of the EVALI outbreak. First-differenced state-panel regressions tracking unit sales of total-level and category-level e-cigarettes and cigarette sales controlling for price, Tobacco 21 policy coverage, product distribution, seasonality, EVALI-attributable deaths, and state-level e-cigarette policies affecting the availability of e-cigarettes (non-tobacco flavoured and total) were employed. RESULTS Dollar sales of e-cigarettes declined 29% from their pre-EVALI peak by January 2020. Total sales of e-cigarettes declined in response to EVALI deaths and the total e-cigarette sales ban put in place in Massachusetts adopted in its wake. Cigarette sales were largely unchanged by either the direct or indirect policy effects of the EVALI outbreak, except for in Massachusetts, where cigarette sales-particularly those smoked by young people-rose temporarily after a total ban on e-cigarette sales. CONCLUSION Sales of e-cigarettes declined in response to the EVALI outbreak and from the most restrictive regulatory policies that were adopted in response, while sales of cigarettes were affected less.
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Affiliation(s)
- Alex C Liber
- Lombardi Cancer Center, Georgetown University, Washington, DC, USA
| | | | - Megan C Diaz
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | - Emily Donovan
- Schroeder Institute, Truth Initiative, Washington, DC, USA
| | - Donna Vallone
- Schroeder Institute, Truth Initiative, Washington, DC, USA
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22
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Jeong M, Singh B, Wackowski OA, Mukherjee R, Steinberg MB, Delnevo CD. Content Analysis of E-cigarette News Articles Amidst the 2019 Vaping-Associated Lung Injury (EVALI) Outbreak in the U.S. Nicotine Tob Res 2021; 24:799-803. [PMID: 34624099 PMCID: PMC8962717 DOI: 10.1093/ntr/ntab203] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/06/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION News media can shape public perceptions about e-cigarettes, particularly in the context of ongoing uncertainty from the recent outbreak of e-cigarette or vaping product use-associated lung injury (EVALI). This study aimed to characterize news articles published about e-cigarettes in 2019, including before and during the EVALI outbreak. METHODS Using 24 e-cigarette-related search terms, we gathered all articles published in leading print and online U.S. news sources in 2019 from databases (i.e., Factiva, Access World News) and archival websites (i.e., www.newspapers.com). We conducted a content analysis of e-cigarette themes and statements, identifying differences in themes between articles that did and did not mention EVALI. RESULTS Of the 1,643 e-cigarette news articles published in 2019, 62% mentioned EVALI. Frequency of e-cigarette articles peaked in September (n=532) at the height of the EVALI outbreak. Among all articles discussing e-cigarettes, the most prevalent main topics were policy/regulation (45%) and health effects (35%). Articles that mentioned EVALI frequently discussed youth e-cigarette use (40%) and JUUL (33%). Compared to non-EVALI articles, EVALI articles were more likely to discuss health effects (p<.001) but less likely to discuss policies/regulations, except for flavor bans (47% of EVALI articles vs. 39% of non-EVALI articles, p=.002). EVALI articles were also less likely to discuss e-cigarettes being less risky than cigarettes (p=.005). CONCLUSIONS E-cigarette news coverage was prevalent in 2019, and patterns in frequency and content reflected major events (i.e., EVALI). In turn, news media can shape public perceptions, and even policy, about e-cigarettes and must continue to be monitored. IMPLICATIONS E-cigarette news coverage in 2019 was high, driven in large part by news coverage of the EVALI outbreak. Indeed, the peak in e-cigarette news articles in September directly coincided with the peak in EVALI cases in the U.S. Of note, articles that mentioned EVALI frequently discussed youth e-cigarette use, JUUL, and flavor bans, which may have triggered national and state-level policy responses, and likely influenced public perceptions (including misperceptions) regarding the harms of e-cigarettes.
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Affiliation(s)
- Michelle Jeong
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ
| | - Binu Singh
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ
| | - Olivia A Wackowski
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ
| | - Rohit Mukherjee
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ
| | - Michael B Steinberg
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ.,Department of Medicine, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ
| | - Cristine D Delnevo
- Rutgers Center for Tobacco Studies, Rutgers University, New Brunswick, NJ.,Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Piscataway, NJ
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Chaffee BW, Cheng J, Couch ET, Hoeft KS, Halpern-Felsher B. Adolescents' Substance Use and Physical Activity Before and During the COVID-19 Pandemic. JAMA Pediatr 2021; 175:715-722. [PMID: 33938922 PMCID: PMC8094031 DOI: 10.1001/jamapediatrics.2021.0541] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/03/2021] [Indexed: 11/14/2022]
Abstract
Importance Stay-at-home policies related to the COVID-19 pandemic could disrupt adolescents' substance use and physical activity. Objective To compare adolescents' substance use and physical activity behaviors before and after stay-at-home restrictions. Design, Setting, and Participants Ongoing prospective cohort study of tobacco use behaviors among ninth- and tenth-grade students enrolled at 8 public high schools in Northern California from March 2019 to February 2020 and followed up from September 2019 to September 2020. Race/ethnicity was self-classified from investigator-provided categories and collected owing to racial/ethnic differences in tobacco and substance use. Exposures In California, a COVID-19 statewide stay-at-home order was imposed March 19, 2020. In this study, 521 six-month follow-up responses were completed before the order and 485 were completed after the order. Main Outcomes and Measures The prevalence of substance use (ie, past 30-day use of e-cigarettes, other tobacco, cannabis, and alcohol) and physical activity (active ≥5 days/week) was compared at baseline and follow-up. A difference-in-difference approach was used to assess whether changes from baseline to 6-month follow-up varied if follow-up occurred after the stay-at-home order, adjusting for baseline behaviors and characteristics. All models were weighted for losses to follow-up using the inverse probability method. Weights were derived from a logistic regression model for having a follow-up response (dependent variable), as predicted by baseline characteristics and behaviors. Results Of 1423 adolescents enrolled at baseline, 1006 completed 6-month follow-up (623 [62%] were female, and 492 [49%] were non-Hispanic White). e-Cigarette use declined from baseline to 6-month follow-up completed before the stay-at-home order (17.3% [89 of 515] to 11.3% [58 of 515]; McNemar χ2 = 13.54; exact P < .001) and 6-month follow-up completed after the stay-at-home order (19.9% [96 of 482] to 10.8% [52 of 482]; McNemar χ2 = 26.16; exact P < .001), but the extent of decline did not differ statistically between groups responding before vs after the stay-at-home order (difference-in-difference adjusted odds ratio, 0.84; 95% CI, 0.47-1.52; P = .58). In contrast, being physically active was unchanged from baseline if follow-up was before the order (53.7% [279 of 520] to 52.9% [275 of 520]; McNemar χ2 = 0.09; exact P = .82) but declined sharply from baseline if follow-up was after the order (54.0% [261 of 483] to 38.1% [184 of 483]; McNemar χ2 = 30.72; exact P < .001), indicating a pronounced difference in change from baseline after the stay-at-home order (difference-in-difference adjusted odds ratio, 0.49; 95% CI, 0.35-0.69; P < .001). Overall in the cohort, reported use of other tobacco, cannabis, and alcohol did not differ meaningfully before and after the order. Conclusions and Relevance In this cohort, a reduction in e-cigarette use occurred independently of COVID-19 stay-at-home restrictions, but persistent cannabis and alcohol use suggest continued need for youth substance use prevention and cessation support. Declining physical activity during the pandemic is a health concern.
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Affiliation(s)
- Benjamin W. Chaffee
- Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, San Francisco
| | - Jing Cheng
- Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, San Francisco
| | - Elizabeth T. Couch
- Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, San Francisco
| | - Kristin S. Hoeft
- Division of Oral Epidemiology and Dental Public Health, University of California, San Francisco, San Francisco
| | - Bonnie Halpern-Felsher
- Division of Adolescent Medicine, Department of Pediatrics, Stanford University, Stanford, California
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24
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Selya AS. Reducing the smoking-related health burden in the USA through diversion to electronic cigarettes: a system dynamics simulation study. Harm Reduct J 2021; 18:36. [PMID: 33743722 PMCID: PMC7981929 DOI: 10.1186/s12954-021-00484-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 03/11/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Electronic cigarettes ("e-cigarettes") have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA. METHODS A system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included. RESULTS The base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time "shock" introduced by policy changes. CONCLUSIONS The simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.
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Affiliation(s)
- Arielle S Selya
- Behavioral Sciences Group, Sanford Research, 2301 East 60th Street North, Sioux Falls, SD, 57104, USA.
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, 1400 West 22nd St, Sioux Falls, SD, 57105, USA.
- System Dynamics Group, Department of Geography, University of Bergen, Postboks 7802, 5020, Bergen, Norway.
- Pinney Associates, Inc, 201 North Craig St. Suite 320, Pittsburgh, PA, 15213, USA.
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25
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Kenkel D, Mathios A. Analysis Points to Important Research Gaps About the Impact of E-cigarettes. Nicotine Tob Res 2021; 23:770-771. [PMID: 33029640 DOI: 10.1093/ntr/ntaa206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/01/2020] [Indexed: 11/12/2022]
Affiliation(s)
- Don Kenkel
- Department of Policy Analysis and Management, Cornell University, Ithaca, NY
| | - Alan Mathios
- Department of Policy Analysis and Management, Cornell University, Ithaca, NY
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26
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Algiers O, Wang Y, Laestadius L. Content Analysis of U.S. Newspaper Coverage of Causes and Solutions to Vaping-Associated Lung Injury. Subst Use Misuse 2021; 56:522-528. [PMID: 33627031 DOI: 10.1080/10826084.2021.1883663] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
In 2019, an outbreak of vaping-associated lung injury (also known as "EVALI") spread throughout the U.S., linked to use of illicit THC cartridges. This paper examines U.S. newspaper coverage on the causes and solutions to EVALI. Methods: A content analysis of 417 articles from April to December 2019 from two national newspapers, one regional newspaper, and the Associated Press was conducted. Articles were coded for information about EVALI causes, mentions of the brand Dank Vapes, calls for individuals take a specific action to prevent harm, and mentions of policy actions to address vaping. Mentions of increasing youth vaping and JUUL were also coded. Results: Most articles (77%) provided an update on the number of EVALI cases and/or deaths. Fewer described EVALI symptoms (20%) or mentioned vaping cessation resources available to the public (2%). Almost half of articles also mentioned youth vaping as a concern (49%). Dank Vapes was mentioned rarely (4%) compared to JUUL (39%). After CDC recommendations changed to no longer recommend avoiding all vaping products, news articles became significantly less likely to mention nicotine products as a cause of EVALI or suggest that individuals cease all vaping. While policy was generally not articulated as a solution to EVALI, banning or limiting flavored nicotine vaping products were the most common policy actions mentioned. Conclusions/Importance: The discussions of causes of and solutions to EVALI were often intertwined with coverage of youth vaping, potentially failing to convey a clear sense of how the public should respond to the EVALI outbreak.
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Affiliation(s)
- Olivia Algiers
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Yang Wang
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Linnea Laestadius
- Joseph J. Zilber School of Public Health, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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27
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Pesko MF, Courtemanche CJ, Catherine Maclean J. The effects of traditional cigarette and e-cigarette tax rates on adult tobacco product use. JOURNAL OF RISK AND UNCERTAINTY 2020; 60:229-258. [PMID: 33584006 PMCID: PMC7880200 DOI: 10.1007/s11166-020-09330-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
We study the effects of traditional cigarette and e-cigarette taxes on use of these products among adults in the United States. Data are drawn from the Behavioral Risk Factor Surveillance System and National Health Interview Survey over the period 2011 to 2018. Using two-way fixed effects models, we find evidence that higher traditional cigarette tax rates reduce adult traditional cigarette use and increase adult e-cigarette use. Similarly, we find that higher e-cigarette tax rates increase traditional cigarette use and reduce e-cigarette use. Cross-tax effects imply that the products are economic substitutes. Our results suggest that a proposed national e-cigarette tax of $1.65 per milliliter of vaping liquid would raise the proportion of adults who smoke cigarettes daily by approximately one percentage point, translating to 2.5 million extra adult daily smokers compared to the counterfactual of not having the tax.
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Affiliation(s)
- Michael F Pesko
- Department of Economics, Andrew Young School of Policy Studies, Georgia State University, Atlanta
| | - Charles J Courtemanche
- Gatton College of Business and Economics, University of Kentucky; Research Associate, National Bureau of Economic Research; Research Affiliate, Institute of Labor Economics (IZA)
| | - Johanna Catherine Maclean
- Department of Economics, Temple University; Research Associate, National Bureau of Economic Research; Research Affiliate, Institute for the Study of Labor, Philadelphia
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