Differential use of other tobacco products among current and former cigarette smokers by income level

Cross-sectional survey on cigarette smoking in Chinese high-income areas

OBJECTIVE

To evaluate smoking status and its influencing factors in high-income areas of China.

DESIGN

Cross-sectional.

SETTING

High-income areas in China.

PARTICIPANTS

4064 persons aged 15 years or older from the survey results in Global Adult Tobacco Survey-China 2018.

METHODS

Gross national income data were used to determine China's high-income economic regions, and the results of the survey in Global Adult Tobacco Survey-China 2018 were used for statistical analysis.

RESULTS

A total of 4064 people were included in our study, including 881 current smokers, 2884 who had never smoked and 299 who had quit smoking. Using the standardised rate method, the standardised smoking rates in high-income and non-high-income areas in China were calculated to be 23.56% and 27.77%, respectively. Men, high school education or below, knowledge of e-cigarette information, permission to smoke at home and people with poor smoking health literacy are the main influencing factors of smokers in high-income areas of China.

CONCLUSION

The smoking rate of people in China's high-income areas is lower than the overall smoking rate in China, and we should increase the public awareness that smoking is harmful to health, encourage the prohibition of smoking at home, increase investment in higher education and improve residents' smoking health literacy level. The purpose of this study was to encourage reduction in the rate of smoking and better control the prevalence of smoking.

Tobacco Use Prevalence and Transitions From 2013 to 2018 Among Adults With a History of Cardiovascular Disease

Background Although tobacco product use and transitions have been characterized in the general population, few studies have focused on individuals with established cardiovascular disease (CVD) in a population-based sample. Methods and Results We examined tobacco use prevalence and longitudinal patterns of tobacco product transitions in adults (≥18 years) of the nationally representative PATH (Population Assessment of Tobacco and Health) study, from 2013 to 2014 (Wave 1) through 2016 to 2018 (Wave 4). Prevalent CVD was classified through self-report of having had a heart attack, heart failure, stroke, or other heart condition. Factors associated with tobacco product use and transitions were investigated using survey logistic regression. We examined 2615 participants with self-reported CVD at Wave 1. Overall, 28.9% reported current tobacco use, equating to ≈6.2 million adults in the United States with prevalent CVD and current tobacco use. Among adults with CVD who are current tobacco users, the most commonly used product was cigarettes (82.8%), followed by any type of cigar (23.7%), and e-cigarette use (23.3%). E-cigarette use without concurrent cigarette use among participants with prevalent CVD was uncommon (1.1%). Factors associated with tobacco use were younger age, male sex, had lower education level, and lack of knowledge about the association between smoking and CVD. Men with prevalent CVD were less likely to use e-cigarettes compared with women (odds ratio [OR], 0.7; 95% CI, 0.5-0.9). Among cigarette users with CVD, transition rates between Waves 1 and 4 demonstrated <5% decrease in cigarette, with a 0.5% increase in e-cigarette use. Only ≈10% were in formal tobacco cessation programs. Conclusions Despite known harmful cardiovascular effects, over one fourth of adults with prevalent CVD use tobacco products and few quit smoking over the 4 waves of the PATH data set.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Managers' Practices of Tobacco and Marijuana Smoking Policies in Hispanic-Occupied Multiunit Housing

Purpose: This study assessed the knowledge, attitudes, and practices of managers of Hispanic-occupied multiunit housing (MUH) related to the prevalence and prevention of secondhand smoke (SHS), thirdhand tobacco smoke, and secondhand marijuana smoke (SHMS). Methods: A narrative analysis was conducted of 20 interviews with live-in apartment managers. Their opinions on policies and an educational fotonovela were also gathered. Results: The properties were located in 10 cities within the Los Angeles County, representing a wide array of local policies and practices. Only two managers were correctly informed of the existing MUH smoking policies in their cities. Participants reported ambiguity in city laws and company rules regarding smoking. Managers do not distinguish between smoking recreational marijuana and medicinal marijuana. Several respondents believed the landlords have more power to create rules. Most favored a total ban on smoking of all substances on the premises. Conclusions: Most managers report low agency in being able to pass no-smoking rules. Participants support smoking policies that include all smokable products. Managers would like new government policies, manager trainings, tenant education, and ways to enforce rules to protect apartment tenants from SHS and SHMS. Educational interventions should coincide with the timing of key manager/tenant activities. Results can be used in policy development and educational interventions.

Use of other combustible tobacco products among priority populations of smokers: Implications for U.S. tobacco regulatory policy

Certain sub-populations (e.g., those living in poverty, racial/ethnic minorities, sexual minorities, and people with mental health conditions) experience profound tobacco-related health disparities. Ongoing surveillance of use of various combustible tobacco products by priority populations of cigarette smokers is needed, particularly in the changing U.S. tobacco regulatory landscape. In 2018 the FDA announced their consideration of a tobacco product standard that would limit the level of nicotine in combustible cigarettes, and such regulations should consider potential effects on tobacco-related disparities. If certain subgroups of cigarette smokers are also using other combustible products, they may be particularly likely to continue dual use or switch to exclusive use of those products if a nicotine reduction standard only applies to cigarettes. Accordingly, this study provided recent U.S. nationally representative data on use of other combustible tobacco products among current cigarette smokers by sociodemographic characteristics. Data were drawn from current cigarette smokers (n = 2559) in 2016 and 2017 U.S. nationally representative surveys. Associations between sociodemographic variables (poverty status, education, race/ethnicity, sexual orientation, and mental health status) with use of little cigars and cigarillos (LCCs), traditional cigars, and hookah were examined. Among current cigarette smokers, those living in poverty, racial/ethnic minorities, and those with mental health conditions were particularly likely to use LCCs. Racial/ethnic minority smokers were more likely to smoke traditional cigars. Non-heterosexual smokers, Hispanic smokers, and smokers with mental health conditions were particularly likely to use hookah. These findings have important implications for tobacco regulatory policy and other efforts to combat tobacco-related disparities.

US Adult Cigar Smoking Patterns, Purchasing Behaviors, and Reasons for Use According to Cigar Type: Findings From the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014

Introduction

The US cigar market is diverse, yet until recently most research studies and tobacco surveillance systems have not reported behavioral and related outcomes by cigar type.

Methods

The 2013-2014 Population Assessment of Tobacco and Health Study collected data separately for filtered cigars (FCs), cigarillos, and traditional cigars, which were further distinguished as premium or nonpremium. Descriptive statistics for adult established current smokers of each cigar type and cigarettes were calculated for demographic characteristics, tobacco use patterns, purchasing behaviors and reasons for use. Adjusted prevalence ratios (APRs) using a marginal predictions approach with logistic regression assessed correlates of dual cigar and cigarette smoking.

Results

Age, sex, race/ethnicity, education level, and poverty status of smokers varied according to cigar type. Daily cigar smoking prevalence and number of cigars smoked per day were higher for FCs (37.3%; median: 1.6 cigars/day, respectively), than all other cigar types (6.7%-25.3%, all p < .01; 0.1-0.4 cigars/day, all p < .01, respectively); daily smoking and cigars per day were similar for nonpremium cigars and cigarillos (p = .11; p = .33, respectively). Cigarette smoking was twice as common among smokers of nonpremium cigars, cigarillos, and FCs (58.0%-66.0%) than among premium cigars (29.9%). Among current cigar smokers, FC smokers (APR = 1.23, 95% confidence interval [CI] = 1.09-1.39), other tobacco product users (APR = 1.27, 95% CI = 1.15-1.41), and those with a GED/high school diploma or less (APR = 1.20, 95% CI = 1.09-1.33) were more likely to also smoke cigarettes.

Conclusion

User characteristics, cigar smoking patterns, and dual smoking with cigarettes varied by cigar type highlighting the importance of adequately describing the cigar type studied and, where appropriate, differentiating results by cigar type.

Implications

Despite the diversity of the cigar market place, historically many research studies and tobacco surveillance systems have treated cigars as a single product type. This study describes similarities and differences in the user characteristics, tobacco use patterns, and purchasing behaviors of premium, nonpremium, cigarillo, and filtered cigar smokers. To enhance tobacco regulatory science, sufficient descriptions of the cigar type(s) studied and, where appropriate, differentiation of the particular cigar type(s) studied should be undertaken to improve the interpretation of study findings, understanding of cigar use patterns and related behaviors and future approaches to reducing cigar-attributable morbidity and mortality.

The social patterning of electronic nicotine delivery system use among US adults

There is little research examining the social patterning of electronic nicotine delivery system (ENDS) use. This study investigated the association between socioeconomic status (SES) (education, income, and employment status) and current and former ENDS use. Data were collected from 2561 participants from the American Heart Association Tobacco Regulatory and Addiction Center (A-TRAC) online survey. Participants were 18-64 years old and reported demographic, SES, and ENDS use. Poisson regression was used to estimate prevalence ratios (PR 95% confidence interval-CI) of participants' current and former (vs. never) ENDS use. Models were adjusted for age, sex, sexual orientation, race/ethnicity, marital status, and reasons for ENDS use. In the unadjusted analysis, ENDS use was primarily patterned by education and employment status. College educated persons (vs. those with less than a high school diploma) had a 37% greater prevalence of current ENDS use (PR 1.37, 95% CI 1.20-1.55), and a 16% greater prevalence of former ENDS use (PR 1.16, 95% CI 1.06-1.28) in the fully-adjusted model. Persons with household incomes above $90 K (vs. less than $20,000) had a greater prevalence of current (PR 1.30, 95% CI 1.19-1.41) and former (PR 1.17, 95% CI 1.05-1.30) ENDS use. Those who were employed (vs. not employed) had a 13% greater prevalence of current ENDS use (PR 1.13, 95% CI 1.07-1.19) after full adjustment. Higher SES (vs. lower SES) persons were more likely to use ENDS.

Income disparities in smoking cessation and the diffusion of smoke-free homes among U.S. smokers: Results from two longitudinal surveys

Background

Lower rates of successful quitting among low-income populations in the United States may be from slower dissemination of smoke-free homes, a predictor of cessation.

Objectives

To explore the role of smoke-free homes in cessation behavior across income levels.

Participants

Current smokers who were ≥18 years and who participated in the longitudinal 2002–2003 (n = 2801) or 2010–2011 (n = 2723) Tobacco Use Supplements to the Current Population Survey.

Measurements

We categorized income as multiples of the federal poverty level (FPL) (<300% FPL versus ≥300% FPL). We examined the association of smoke-free homes with 1+day quit attempts and 30+days abstinence at 1-year follow-up. We then conducted a mediation analysis to examine the extent that smoke-free homes contributed to income disparities in 30+days abstinence.

Results

Between the two surveys, heavy smoking (≥ 1 pack/day) declined by 17%, and smoking prevalence declined by 15% among those with higher-incomes (>300%FPL). Although similar in 2002, the prevalence of smoke-free homes was 33% lower among individuals living <300% FPL than those living ≥300% FPL. Although the quit attempt rate was similar, the 30+days abstinence rate was higher in the 2010–11 cohort than in 2002–3 cohort (20.6% versus 15.5%, p<0.008). Whereas smoking ≥ 1 pack/ day was associated with lower odds of 30+days abstinence (Adjusted odds ratio [AOR] 0.7; 95% CI 0.5–0.9), having a higher income (AOR 1.9, 95% CI 1.4–2.6) and a smoke-free home (AOR 1.6, 95% CI 1.2–2.1) were associated with greater odds of 30+day abstinence. Differential changes in smoke-free homes across income groups between the two surveys contributed to 36% (95% CI 35.7–36.3) of the observed income disparity in 30+days abstinence.

Conclusions

Increasing the diffusion of smoke-free homes among low-income populations may attenuate at least a third of the income disparities in smoking cessation, highlighting the need for interventions to increase adoption of smoke-free homes among low-income households.

Comparative risk assessment and cessation information seeking among smokeless tobacco users

INTRODUCTION

This research examined (1) smokeless tobacco users' comparative optimism in assessing the health and addiction risks of their own product in comparison with cigarettes, and (2) the effects of comparative optimism on cessation information-seeking.

METHODS

A nationally-representative sample from the 2015 Health Information National Trends Survey (HINTS)-FDA was employed.

RESULTS

The analyses revealed the presence of comparative optimism in assessing both health and addiction risks among smokeless tobacco users. Comparative optimism was negatively correlated with most cessation information-seeking variables. Health bias (the health risk rating gap between the subject's own tobacco product and cigarettes) was associated with decreased intent to use cessation support. However, the health bias and addiction bias (the addiction risk rating gap between the subject's own tobacco product and cigarettes) were not consistent predictors of all cessation information-seeking variables, when covariates of socio-demographics and tobacco use status were included. In addition, positive correlations between health bias and past/recent cessation-information searches were observed.

CONCLUSIONS

Optimisic biases may negatively influence cessation behaviors not only directly but also indirectly by influencing an important moderator, cessation information-seeking. Future interventions should prioritize dispelling the comparative optimism in perceiving risks of smokeless tobacco use, as well as provide more reliable cessation information specific to smokeless tobacco users.

Hazards of cigarettes, smokeless tobacco and waterpipe in a Middle Eastern Population: a Cohort Study of 50 000 individuals from Iran

BACKGROUND

There is limited information about the hazards of cigarettes, smokeless tobacco and waterpipe in the Middle East. The aim of this study was to determine the association between different types of tobacco use and earlier death in the Golestan Cohort Study.

METHODS

The Study includes 50 045 adults (aged 40-75 years) from north eastern Iran. The baseline questionnaire (2004-2008) assessed information about use of cigarettes, chewing tobacco (nass) and waterpipe. To assess the use of each type of tobacco compared with never tobacco users, we used Cox regression models adjusted for age, socioeconomic status, area of residence, education and other tobacco used, and stratified by sex, ethnicity and opium use.

RESULTS

17% of participants reported a history of cigarette smoking, 7.5% chewing tobacco (nass) and 1.1% smoking waterpipe, and these figures declined in the later birth cohorts. During a median follow-up of 8 years, 4524 deaths occurred (mean age 64.8+9.9 years). Current (HR=1.44; 95% CI 1.28 to 1.61) and former (HR=1.35; 95% CI 1.16 to 1.56) cigarette smokers had higher overall mortality relative to never tobacco users. The highest cigarette-associated risk was for cancer death among current heavy smokers (HR=2.32; 95% CI 1.66 to 3.24). Current nass chewing was associated with overall mortality (HR=1.16; 95% CI 1.01 to 1.34), and there was a 61% higher risk of cancer death in people chewing nass more than five times a day. We observed an association between the cumulative lifetime waterpipe use (waterpipe-years≥28) and both overall (HR=1.66; 95% CI 1.11 to 2.47), and cancer mortality (HR=2.82; 95% CI 1.30 to 6.11).

CONCLUSIONS

Regular use of cigarettes, smokeless tobacco and waterpipe were associated with the risk of earlier death (particularly from cancer) in our cohort.

The Relationship between Neighborhood Disorder, Social Networks, and Indoor Cigarette Smoking among Impoverished Inner-City Residents

Impoverished urban neighborhoods tend to have higher rates of smoking and higher rates of exposure to secondhand smoke as compared to more affluent neighborhoods. Contextual factors of neighborhood disorder and social network and household composition may have an impact on indoor smoking behaviors. The TIDE study examined psychosocial factors associated with smoking behaviors among impoverished inner-city smokers in Baltimore, Maryland. Among a community-recruited sample of 413 smokers who lived with others, most (73%) reported that they or others smoked in their residence. Cohabitation with children, elderly, and those with asthma and other respiratory condition was not associated with indoor smoking. Neighborhood disorder, the proportion of social network members who smoked with the study participant, and the proportion of household members who smoked were all independently associated with smoking indoors. The study findings suggest the importance of addressing neighborhood and social network factors when developing programs for promoting indoor smoking bans as well as cessation and prevention programs.

Other tobacco product and electronic cigarette use among homeless cigarette smokers

OBJECTIVE

We determined the prevalence and correlates of other tobacco product and electronic cigarette (e-cigarette) use in a clinic-based sample of homeless cigarette smokers.

METHODS

In April-July 2014, we used time-location sampling to conduct a cross-sectional, in-person survey of 306 currently homeless adult cigarette smokers recruited from 5 clinical sites at Boston Health Care for the Homeless Program. We assessed past-month use of large cigars, little cigars, smokeless tobacco, and e-cigarettes. Among those who had used e-cigarettes, we assessed the reasons for doing so. We used logistic regression analysis to identify the participant characteristics associated with the use of each product.

RESULTS

Eighty-six percent of eligible individuals participated in the survey. In the past month, 37% of respondents used large cigars, 44% used little cigars, 8% used smokeless tobacco, 24% used an e-cigarette, and 68% used any of these products. Reasons for e-cigarette use included curiosity (85%) and to help quit conventional cigarettes (69%). In multivariable regression analyses, homeless smokers with greater subsistence difficulties were more likely to use little cigars (p=0.01) and less likely to use e-cigarettes (p=0.001). Non-Hispanic black (p=0.01), Hispanic (p<0.001), and rough-sleeping (p=0.04) participants were more likely to use large cigars. Readiness to quit was not associated with other tobacco product use but was significantly associated with e-cigarette use to help quit smoking (p=0.02).

CONCLUSIONS

Health care providers who serve homeless people should consider routine screening for the use of other tobacco products and e-cigarettes to help guide smoking cessation discussions and tobacco treatment planning.

Do Socioeconomic Risk Factors for Cigarette Smoking Extend to Smokeless Tobacco Use?

INTRODUCTION

Individuals with lower socioeconomic status (SES) are at increased risk for cigarette smoking. Less research has been conducted characterizing the relationship between SES and risk of using of other tobacco products. The present study examined SES as a risk factor for smokeless tobacco (ST) use in a US nationally representative sample, utilizing data from the 2012 National Survey on Drug Use and Health.

METHODS

Odds were generated for current cigarette smoking and ST use among adults (≥18 years) based on SES markers (educational attainment, income, blue-collar employment, and unemployment) after controlling for the influence of demographics and other substance dependence.

RESULTS

Odds of current cigarette smoking increased as a graded, inverse function of educational attainment as well as lower income and being unemployed. Odds of current ST use also increased as a function of lower educational attainment, although not in the linear manner seen with cigarette smoking. Odds of ST use but not cigarette smoking also increased with blue-collar employment. In contrast to patterns seen with cigarette smoking, ST use did not change in relation to income or unemployment.

CONCLUSIONS

Markers of SES are significantly associated with odds of cigarette smoking and ST use, but which indicators are predictive and the shape of their relationship to use differs across the two tobacco products.