Correlates of current menthol cigarette and flavored other tobacco product use among U.S. young adults

Examining the relationship of flavored tobacco product policy restrictions and flavored tobacco product use, among adolescents and young adults in the U.S

OBJECTIVE

This work examines the relationship between local flavor policy exposure and any tobacco product use and flavored tobacco product use among U.S. youth and young adults, as well as the equity potential of these policies by race/ethnicity.

METHODS

Participants were aged 15-36 (n = 10,893) surveyed from September-December 2019 using national, address- and probability-based sampling. Local flavor policies enacted before survey completion were linked to participant home address. Weighted cross-sectional multivariable logistic regression examined individual coverage by flavor policy vs. no flavor policy, with current any tobacco or flavored tobacco use, controlling for individual and county-level demographics, psychosocial variables, and other tobacco control policies. Interactions between race/ethnicity and any tobacco use and flavored tobacco use were assessed.

RESULTS

Those covered by a flavor policy vs. no policy had lower odds of any tobacco use (aOR = 0.74, 95% CI = 0.55-1.00) and current flavored tobacco use (aOR = 0.67, 95% CI = 0.48-0.93). Compared with Non-Hispanic (NH)-White individuals, NH-Black individuals (aOR = 1.08, CI = 1.04-1.12) had higher odds of any tobacco use, and non-Hispanic Asian individuals had lower odds of any tobacco use (aOR = 0.67, CI = 0.53-0.85). Hispanic individuals exposed to policy had lower odds of flavored tobacco use compared to NH-White peers.

CONCLUSIONS

Exposure to flavor restriction policies is associated with lower odds of any tobacco and flavored use among youth and young adults. Flavor restrictions may be beneficial in reducing tobacco use in youth from diverse racial/ethnic backgrounds. However, passing policies covering NH-Black individuals is needed to mitigate disparities in tobacco use by flavor policy coverage over time.

Addiction potential of combustible menthol cigarette alternatives: a randomised cross-over trial

INTRODUCTION

The Food and Drug Administration (FDA) has issued proposed product standards banning menthol as a characterising flavour in cigarettes and cigars. The public health benefits of these product standards may be attenuated by the role of plausible substitutes in the marketplace. Therefore, the present study examined the addiction potential of plausible combustible menthol alternatives compared with usual brand menthol cigarettes (UBMC).

METHODS

Ninety-eight adult menthol cigarette smokers completed four visits, smoking their UBMC at the first session and three menthol cigarette alternatives in random order at the subsequent visits: (1) a preassembled menthol roll-your-own (mRYO) cigarette using menthol pipe tobacco and mentholated cigarette tube, (2) a menthol filtered little cigar (mFLC) and (3) a non-menthol cigarette (NMC). Measures of smoking topography, exhaled carbon monoxide (CO), craving and withdrawal, subjective effects and behavioural economic demand indices were assessed.

RESULTS

Compared with UBMC, menthol cigarette alternatives resulted in different puffing topography and CO exposure (except mRYO), and lower levels of positive subjective experience and behavioural economic demand indices. Among the alternative products, participants reported the highest level of positive subjective experience and higher demand for mRYO, compared with mFLC and NMC. Similarly, participants were significantly more likely to want to try again, purchase and use the mRYO product regularly compared with mFLC and NMC.

CONCLUSIONS AND RELEVANCE

mRYO cigarettes were the most highly rated cigarette alternative among study products, suggesting their potential appeal as a menthol cigarette substitute and needed inclusion of menthol pipe tobacco and cigarette tubes in FDA's proposed ban.

Expanding local sales restrictions on flavoured tobacco products to include menthol: retail sales changes in two Minnesota cities

BACKGROUND

In 2018, Minneapolis and St. Paul, Minnesota, expanded existing local sales restrictions on flavoured (non-menthol/mint/wintergreen) tobacco products ('flavour policies') to include menthol/mint/wintergreen-flavoured tobacco products ('menthol policies'). All policies included exemptions for certain store types.

METHODS

We obtained weekly retail tobacco product sales for 2015 through 2019 from NielsenIQ for convenience stores and other outlets in the policy jurisdictions and two comparison areas (rest of the state of Minnesota and total USA). We standardised unit sales across product categories and used NielsenIQ-provided descriptors to classify products as menthol (including mint/wintergreen) or flavoured (non-menthol/non-tobacco). Using single group interrupted time series models, we analysed unit sales by product category and by flavour separately for each geography to assess associations between menthol policy implementation and trends in tobacco product unit sales.

RESULTS

Following menthol policy implementation, unit sales of menthol cigarettes and menthol smokeless tobacco decreased in both cities, with smaller decreases in comparison areas. Flavoured cigar sales-which decreased following the flavour policies-further decreased after the menthol policies, while sales of menthol electronic nicotine delivery systems (ENDS) increased in both cities and sales of flavoured ENDS increased in St. Paul.

CONCLUSION

Expanding flavour policies to include menthol/mint/wintergreen was associated with significant decreases in unit sales of most menthol products and in total unit sales by tobacco product category. Increases in menthol and flavoured ENDS sales in these cities may be associated with legal sales by exempted retailers and/or illicit sales by non-compliant retailers, highlighting opportunities for retailer education and enforcement.

Patterns of use, perceptions, and cardiopulmonary health risks of cigar products: a systematic review

OBJECTIVE

A systematic review was conducted to evaluate the use patterns, health perceptions, and cardiopulmonary health effects of cigars.

DATA SOURCES

PubMed and Google Scholar were searched for peer-reviewed articles published between June 2014 and February 2021. Search keywords included cigars, cigarillos, little cigars, and cardiopulmonary health outcomes.

STUDY SELECTION

Of 782 papers identified, we excluded non-English articles, review articles, commentaries, and those without empirical data on cigars. Three coders independently reviewed all articles and compared codes to resolve discrepancies. 93 articles met the inclusion criteria and were included.

DATA SYNTHESIS

Cigars have evolved from premium cigars to encompass little cigars and cigarillos (LCCs). LCCs are available in an array of flavors and at a price advantage, and as a result, are used by different groups compared to premium cigars. LCCs are more frequently used by youth, young adults, and those who identify as Black/African American. LCCs are often used in combination with other tobacco products, alcohol, and cannabis. Despite limited regulation, cigars generate smoke of a similar composition as cigarettes. Among the studies identified, evidence suggests that cigar use is associated with cardiovascular and pulmonary toxicity. Higher all-cause and cancer-related mortalities are associated with cigar use, particularly with more frequent and deeper inhalation, compared to non-tobacco users.

CONCLUSIONS

LCCs are used more frequently by at-risk groups compared to premium cigars. Recent studies evaluating cigar cardiopulmonary health effects are limited but suggest cigars have similar health risks as conferred by cigarette smoking. With the use of LCCs and targeted marketing on the rise among high-risk groups, there is a critical need for continued research in this area.

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use

INTRODUCTION

Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use.

METHODS

This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022.

RESULTS

Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7).

CONCLUSIONS

Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

Impact of a reduced nicotine standard on young adult appeal for menthol and non-menthol cigarettes

INTRODUCTION

The Food and Drug Administration (FDA) announced its intention to reduce the nicotine content in cigarettes as a strategy to promote cessation and reduce smoking-related harm. A low nicotine product standard will apply to all cigarettes on the market, including menthol cigarettes. In December 2021, the FDA approved a modified risk tobacco product application for menthol and non-menthol flavoured very low nicotine cigarettes (VLNC) from the 22nd Century Group. Notably, experimentation with menthol cigarettes is linked to smoking progression, as well as greater nicotine dependence relative to non-menthol cigarette use. If menthol VLNCs are perceived as more appealing than non-menthol VLNCs, this would indicate that some aspect of menthol may maintain smoking even in the absence of nicotine and FDA's regulatory authority to ban or restrict the sale of menthol cigarettes should apply to reduced nicotine content of cigarettes. In April 2022, the FDA announced proposed rulemaking to prohibit menthol cigarettes, however it is unclear if a menthol prohibition would apply to VLNCs.

METHODS AND ANALYSIS

This study will recruit 172 young adult menthol smokers (with a specific subsample of n=40 sexual and gender minority young adults) and measure appeal for smoking experimental menthol and non-menthol VLNCs, and the impact of proposed product standards on tobacco product purchasing behaviour using an Experimental Tobacco Marketplace. Appeal across product standards will be assessed in a controlled laboratory and using ecological momentary assessment.

ETHICS AND DISSEMINATION

The protocol was approved by the University of Oklahoma Health Sciences Center Institutional Review Board (#11865). Findings will examine the effects of a reduced nicotine standard and a menthol ban on young adult smoking and will be disseminated through peer-reviewed journal articles and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04340947.

Flavoring Patterns of Exclusive and Dual-Use of Cigarettes and E-Cigarettes Among US Adults: Results from the TUS-CPS 2018-2019

PURPOSE

To describe patterns of menthol/non-menthol cigarettes with flavored e-cigarettes (tobacco, menthol, sweet/spicy, and other flavorings) use.

DESIGN

We used cross-sectional data from the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS).

SETTING

United States.

SUBJECTS

Adults over 18 years old.

SAMPLE

A nationally representative sample (n = 135 329).

MEASURES

We generated a 15-category variable of all combinations of cigarette and e-cigarette flavoring use.

ANALYSIS

We estimated population prevalence (PP) for the 15-category flavored cigarette and e-cigarette use variable and proportion of flavored cigarette and e-cigarette use among adults who used cigarettes or e-cigarettes (PAU) by age, sex, race/ethnicity, and income.

RESULTS

Exclusive menthol cigarette use was higher among NH Black (PP = 8.79%, PAU = 68.96%) and low-income (PP = 4.86%, PAU = 29.09%) compared to NH White (PP = 2.63%, PAU = 18.83%) and high-income participants (PP = 1.25%, PAU = 19.02%). Exclusive sweet/spicy e-cigarette use (PP = 1.32%, PAU = 10.22%) and exclusive menthol e-cigarette use (PP = .95%, PAU = 7.40%) was higher in younger (18-34) vs older (35+) adults (PP = .34% and PAU = 2.76%, and PP = .14%, PAU = 1.11%, respectively). Older dual users tended to combine the same flavor in both products (eg, menthol cigarettes + menthol e-cigarettes), while younger adults were more likely to combine menthol and non-menthol cigarettes with sweet/spicy e-cigarettes.

CONCLUSION

Findings suggest that a menthol cigarette ban might be most effective in conjunction with sweet/spicy e-cigarette flavor restrictions, given these flavors are attractive for younger adults.

Perceptions of Game cigarillo packaging among young adult tobacco users: The effect of package color and the "natural leaf" descriptor

INTRODUCTION

Tobacco packaging elements have been shown to influence product perceptions and use intentions. Garcia y Vega's Game cigarillos are distinct from other brands in their use of "natural leaf" on packaging. The term "natural" has been linked to misperceptions about lower risk in the context of cigarettes. This study examines the impact of the "natural leaf" descriptor and pack color on young adults' cigarillo perceptions and intentions.

METHODS

In April-June 2020, we conducted an online experiment with 1,063 young adults (ages 18-34) that were past year users of cigars, vaping products, or marijuana. Subjects were randomly assigned to view one of eight images of Game cigarillo packs that varied in color and presence of the "natural leaf" descriptor.

RESULTS

Purple packaging increased perceptions that the product tasted good, smelled nice, was flavored, and that a typical user was young. "Natural leaf" increased beliefs that the product contained high quality tobacco and that a typical user was trendy. When on grey packs, it increased favorable perceptions compared to when on brightly colored packs, including perceptions that the product tasted good, was fresh, that a typical user was trendy, and that the product was flavored.

CONCLUSIONS

This study is the first to present quantitative evidence on the impact of the "natural leaf" descriptor on cigarillo perceptions and intentions, extending work that has been done in the context of cigarettes. Utilizing highly realistic stimuli, findings demonstrate that both the term "natural leaf" and packaging color can increase favorable perceptions of cigarillos.

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study

PURPOSE

Describe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies.

METHODS

Using data on US young adults (ages 18-34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users.

RESULTS

Any flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users.

DISCUSSION

Racial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

Affirming the Abuse Liability and Addiction Potential of Menthol: Differences in Subjective Appeal to Smoking Menthol Versus Non-Menthol Cigarettes Across African American and White Young Adult Smokers

INTRODUCTION

Menthol cigarettes are popular among young adults and are disproportionately used by African American smokers. Menthol's minty and cooling sensations have been hypothesized to enhance the appeal and reinforcement of smoking; however, differences in menthol's subjective appeal across races have been inconsistent. This secondary data analysis examined differences in subjective appeal for smoking menthol versus non-menthol cigarettes between African American and White young adult smokers.

METHODS

Young adults (ages 18-24) recruited from Amazon Mechanical Turk (December 2018-January 2019) completed an online survey of tobacco use behavior. Past year smokers (n = 1726) answered questions about subjective responses to smoking (reward, satisfaction, throat hit, craving reduction, and aversion).

RESULTS

Significantly more African American (73.2%) compared to White (52.4%) smokers preferred menthol cigarettes (p < .001). Menthol smokers reported greater positive and negative subjective responses to smoking than non-menthol smokers. Positive and negative subjective response were both associated with greater smoking intensity and lower cigarette harm perceptions. Interactions of menthol preference and race on indices of subjective appeal also emerged. African American non-menthol smokers reported lower levels of satisfaction, reward, and craving reduction compared to White non-menthol smokers.

CONCLUSIONS

The relationship between menthol preference and subjective response to smoking differs by race. Menthol is rated as more appealing than non-menthol smoking, and appeal indices were linked to smoking intensity and lower harm perceptions, indicating greater abuse liability of menthol cigarettes. Policies that ban menthol cigarettes may have a particularly positive impact on the cigarette smoking of African American young adult smokers.

IMPLICATIONS

The FDA issued an Advanced Notice of Proposed Rule Making to examine the role menthol in tobacco products to inform regulations to restrict or ban flavors. This study showed that menthol smokers reported greater appeal to smoking than non-menthol smokers; and an interaction of race x menthol preference showed African American non-menthol smokers reported the lowest levels of appeal to smoking. Multiple indices of cigarette appeal were positively correlated with smoking intensity and lower cigarette harm perceptions, highlighting the addiction potential of menthol cigarettes. Findings suggest a menthol cigarette ban could help reduce tobacco use among young adults.

Attitudes about and correlates of cannabis legalization policy among U.S. young adults

OBJECTIVE

Cannabis policies are rapidly evolving in the US. This study's purpose was to examine relationships between cannabis harm perceptions, substance use, and demographic characteristics on attitudes toward cannabis policies.

PARTICIPANTS

Participants were 619 undergraduate students in a Mid-Atlantic state where cannabis use was illegal.

METHODS

In 2016, participants completed a cross-sectional survey. Multinomial logistic regressions tested associations between attitudes toward cannabis policies (recreational cannabis use, use in private, or public) while controlling for harm perceptions, substance use, and demographics.

RESULTS

The majority (64%) of participants supported recreational cannabis legalization, while 78% supported private and 29% supported public use. Perceiving cannabis as less harmful and current cannabis use were positively associated with supporting all three cannabis policies.

CONCLUSIONS

Results highlight diversity of young adults' opinions regarding specific cannabis policies and underscore relationships between cannabis use behaviors, harm perceptions, and support for legalization that may inform policy making and prevention efforts.

Cigarette Brand Use and Sexual Orientation: Intersections With Gender and Race or Ethnicity

Introduction

Lesbian, gay, and bisexual (LGB) populations have higher cigarette smoking rates than heterosexual populations. The tobacco industry has leveraged LGB, gender, and racial or ethnic identities to establish cigarette brand preference. We examined cigarette brand use among smokers by sexual orientation and the implications of gender and race or ethnicity for brand use.

Methods

We used the National Survey on Drug Use and Health (NSDUH; 2015–2017) to conduct weighted bivariate analyses in 2019–2020 of the prevalence of 5 commonly used cigarette brands among adult smokers (N = 24,310) by sexual orientation. We conducted weighted regressions to test relationships between sexual orientation and brand use and interactions between sexual orientation, gender (defined in NSDUH as male or female), and race or ethnicity.

Results

LGB smokers were more likely to use Camel (lesbian/gay, OR = 1.7 [95% CI, 1.2–2.3], bisexual, OR = 1.8 [95% CI, 1.5–2.2]) and American Spirit cigarettes (lesbian/gay, OR = 2.8 [95% CI, 1.9–4.1], bisexual, OR = 3.2 [95% CI, 2.5–4.1]) than heterosexual smokers. Lesbian/gay smokers had higher odds of Marlboro cigarette use (OR = 1.2; 95% CI, 1.0–1.4) than heterosexual smokers. Bisexual smokers were more likely to smoke Newport cigarettes (OR = 1.7; 95% CI, 1.4–2.1) than heterosexual smokers. Interactions between LGB and female identities (vs gay or bisexual male) were positively associated with Camel, Marlboro, and Newport use. The interaction between lesbian/gay and Hispanic/Latino ethnicity (vs lesbian/gay White) was also positively associated with Newport use.

Conclusion

LGB smokers may be more likely to smoke some commonly used cigarette brands than heterosexual smokers, and gender and race or ethnicity may have implications for brand preference. Future research could examine specific contributors to brand use among LGB smokers (eg, tobacco marketing).

Menthol Smoking and Nicotine Dependence among Black/African American Women Smokers Living in Low-Resource, Rural Communities

Black/African American women from low-resource, rural communities bear a disproportionate burden of tobacco-related morbidity and mortality. This study examined associations between menthol smoking and socioeconomic deprivation with nicotine dependence and quitting behaviors among Black/African American women cigarette and/or little cigar/cigarillo smokers, aged 18–50 living in low-resource, rural communities. Baseline survey data from a randomized controlled behavioral/intervention trial (#NCT03476837) were analyzed (n = 146). Outcomes included time to first tobacco product (cigarette/little cigar/cigarillo) use within 5 min of waking, Fagerstrom Test for Nicotine Dependence (FTND) score, and ever attempting to quit cigarettes. Socioeconomic deprivation measures included education, income, and receiving supplemental nutritional assistance (SNAP) program benefits. In adjusted regression analyses, menthol smoking was associated with both greater FTND scores and time to first tobacco product use within 5 min of waking, but not ever attempting to quit cigarettes. Regardless of menthol status, only 25.0% of smokers reported that they would quit smoking if menthol cigarettes were banned. The proportion of smokers who smoked their first tobacco product within 5 min of waking increased slightly with greater socioeconomic deprivation. Additional research and targeted efforts are needed to reduce nicotine dependence among Black/African American women smokers living in rural, low-resource communities where access to cessation services is limited.

Fresher with flavour: young women smokers' constructions and experiences of menthol capsule cigarettes and regular cigarettes

Background

Flavour capsule cigarettes are one of the fastest growing segments of the tobacco market, and there is evidence that Australian young people are increasingly using menthol flavoured capsule cigarettes. This qualitative research examines how young women construct and experience menthol flavour capsule cigarettes as part of their smoking practices, and explores the perceived differences between menthol capsule cigarettes and regular cigarettes. Semi-structured face-to-face in-depth interviews were conducted with 41 Australian young women smokers, using a constructivist grounded theory approach.

Results

Findings reveal that the perceived fresh and improved taste of menthol and the ability to customise the smoking process positively contributed to young women’s experiences of smoking menthol capsule cigarettes. In particular, menthol capsule flavour cigarettes were constructed by the young women as “fresh”, “light” and “minty”, and “popping” the menthol capsule allowed the young women to personalise their smoking experience.

Conclusion

These results indicate that specific public health campaigns and legislation should be developed to counter the powerfully alluring effects and the innovative appeal of menthol capsule cigarettes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01297-2.

Defeating JUUL's Effort to Rewrite San Francisco's E-Cigarette Regulations

In 2019, San Francisco, California, prohibited the sale of electronic cigarettes lacking US Food and Drug Administration authorization. JUUL then promoted a ballot initiative (Proposition C) to replace San Francisco's e-cigarette legislation with legislation JUUL wrote that required future legislation to be approved by the voters. JUUL promoted Proposition C as a way to reduce youth e-cigarette use while allowing adult choice.Health groups argued that JUUL's measure could nullify San Francisco's prohibition on selling flavored tobacco products. Health groups benefitted from having an established campaign network that recently defended the flavor ban. They successfully framed Proposition C as a tobacco industry ploy to undo San Francisco's e-cigarette regulations, particularly the prohibition on selling flavored tobacco products. JUUL ended its campaign on September 30, 2019, and the measure failed on election day, with 82% voting against it.Lessons learned from the campaign include the importance of framing an industry initiative as a threat to local public health lawmaking and the potential for the e-cigarette issue to attract parents as new leaders and engage a powerful constituency to support tobacco control measures.

Cross-Sectional Associations of Multiple Tobacco Product Use with Depressive and Anxiety Symptoms among Young Adult E-Cigarette Users

BACKGROUND

Tobacco users with mental health conditions are a vulnerable population in tobacco research, yet few studies have evaluated the association of depressive and anxiety symptoms with multiple tobacco product (MTP) use among young adult electronic cigarette (ENDS) users.

METHODS

Cross-sectional survey data on U.S. young adult past 30-day ENDS users (N = 2348) were collected via Amazon MTurk from May-July 2019. Binary logistic regressions evaluated the association of tobacco use pattern (exclusive ENDS use, ENDS + one other tobacco product [OTP; dual use], ENDS + two or more OTPs [poly-use]) with depressive (PHQ-9) and anxiety (GAD-7) symptoms. Among MTP users (n = 1736), we evaluated the association of ENDS use relative to OTP use and same-day MTP use with depressive and anxiety symptoms.

RESULTS

The sample included 26% exclusive ENDS, 27% dual, and 47% poly-users. We observed a gradient-relationship for depressive and anxiety symptoms: poly-users had greater odds of depressive and anxiety symptoms compared to dual users (aOR = 1.86 [95%CI:1.50-2.30] and aOR = 1.61 [95%CI:1.30-2.01], respectively), and dual users had greater odds of depressive and anxiety symptoms compared to exclusive ENDS users (aOR = 1.42 [95%CI:1.11-1.81] and aOR = 1.56 [95%CI:1.20-2.02], respectively). MTP users who used ENDS more often than OTPs (vs. less often than OTPs) had greater odds of depressive (aOR = 1.38 [95%CI:1.06-1.80]) and anxiety (aOR = 1.37 [95%CI:1.04-1.79]) symptoms.

CONCLUSIONS

The majority of young adult past 30-day ENDS users in this sample reported OTP use. Future research on MTP use should distinguish between dual and poly-use. Tobacco prevention efforts for young adults with mental health symptoms are needed.

Cigarette and cigar sales in Hawaii before and after implementation of a Tobacco 21 Law

INTRODUCTION

On 1 January 2016, Hawaii raised the minimum legal age for tobacco access from 18 to 21 years ('Tobacco 21 (T21)') statewide, with no special population exemptions. We assessed the impact of Hawaii's T21 policy on sales of cigarettes and large cigars/cigarillos in civilian food stores, including menthol/flavoured product sales share.

METHODS

Cigarette and large cigar/cigarillo sales and menthol/flavoured sales share were assessed in Hawaii, California (implemented T21 in June 2016 with a military exemption), and the US mainland using the only Nielsen data consistently available for each geographical area. Approximate monthly sales data from large-scale food stores with sales greater than US$2 million/year covered June 2012 to February 2017. Segmented regression analyses estimated changes in sales from prepolicy to postpolicy implementation periods.

RESULTS

Following T21 in Hawaii, average monthly cigarette unit sales dropped significantly (-4.4%, p<0.01) coupled with a significant decrease in menthol market share (-0.8, p<0.01). This combination of effects was not observed in comparison areas. Unit sales of large cigars/cigarillos decreased significantly in each region following T21 implementation. T21 policies in Hawaii and California showed no association with flavoured/menthol cigar sales share, but there was a significant increase in flavoured/menthol cigar sales share in the USA (7.1%, p<0.01) relative to Hawaii's implementation date, suggesting T21 may have attenuated an otherwise upward trend.

CONCLUSIONS

As part of a comprehensive approach to prevent or delay tobacco use initiation, T21 laws may help to reduce sales of cigarette and large cigar products most preferred by US youth and young adults.

Modulation of "Protective" Nicotine Perception and Use Profile by Flavorants: Preliminary Findings in E-cigarettes

INTRODUCTION

Characterizing flavors are widely available in e-cigarettes and motivate initiation and continued use. Flavors may enhance appeal and facilitate development of addiction to tobacco products through modulation of tobacco products' reinforcing or aversive actions. Palatable flavors (eg, fruit) may increase appeal through primary reinforcing properties. Menthol's cooling and anesthetic effects may increase appeal by counteracting nicotine's aversive effects. Genetics provide a method for modeling individual differences in sensitivity to nicotine's effects. A common polymorphism, rs16969968, encoded in the α5 nicotinic acetylcholine receptor subunit gene (CHRNA5), is a well-recognized marker for smoking risk and reduces sensitivity to nicotine aversiveness.

METHODS

This pilot study tested how flavors impacted e-cigarette appeal and self-administration. In a single testing day, cigarette smokers (N = 32; 94% menthol-smokers) self-administered e-cigarettes containing e-liquids differing in nicotine level (0 mg/mL, 24 mg/mL) and flavor (unflavored, menthol, fruit-flavored) within directed and ad libitum e-cigarette paradigms. Subjective drug effects, number of puffs, rs16969968 genotype, plasma nicotine, and menthol glucuronide levels were collected.

RESULTS

Menthol partially ameliorated nicotine aversiveness; fruit did not. In nicotine's absence, fruit flavor increased self-reported preference and ad libitum use relative to menthol-containing or unflavored e-liquids. Individuals with high-smoking-risk rs16969968 genotype (N = 7) reported greater craving alleviation following directed administration of nicotine-containing e-liquids, showed a trend rating nicotine-containing e-liquids as less harsh, and self-administered more nicotine during ad libitum compared to individuals with low-smoking-risk genotype (N = 23).

CONCLUSIONS

While menthol countered aversiveness of nicotine-containing e-liquids, fruit flavor increased appeal of nicotine-free e-liquids. These preliminary findings suggest menthol and fruit flavor increase e-cigarettes' appeal through distinct mechanisms.

IMPLICATIONS

This study provides a detailed characterization of the effects of flavors (unflavored, menthol, fruit), nicotine (0 mg/mL, 24 mg/mL) and their interactions on the subjective drug effects and ad libitum self-administration of e-cigarettes. Genetics were used to assess these effects in higher-smoking-risk (diminished sensitivity to nicotine aversiveness) and lower-risk groups. Findings could inform impact of regulation of flavors or nicotine in e-cigarettes, and their impacts on vulnerable sub-populations.

National Support for a Menthol Cigarette Sales Ban

OBJECTIVES

The US Food and Drug Administration (FDA) and local jurisdictions have different authorities to regulate menthol cigarettes, and a growing number of localities and the FDA are considering these policy options. The objective of this study was to update previous research on public support for a menthol ban, including examining differences in support by demographic factors, geographic region, and smoking status.

METHODS

We assessed policy support among a cross-sectional sample of 2871 adults aged 18-64 from a nationally representative online panel. We calculated weighted estimates of support by demographic factors, political ideology, region (Northeast, Midwest, South, West), and smoking status (never, former, current nonmenthol, current menthol). We used weighted adjusted logistic regression analysis to examine correlates of support for a menthol ban.

RESULTS

Overall, 56.4% (95% CI, 54.4%-58.3%) of participants supported a government policy to ban menthol cigarette sales. Support was significantly higher among women than among men (62.5% vs 50.1%; P < .001); among Hispanic/Latino (69.3%), non-Hispanic African American (60.5%), and non-Hispanic other (65.8%) people than among non-Hispanic White people (50.4%; P < .001); and among never (64.8%) and former (47.0%) smokers than among current nonmenthol cigarette smokers (30.1%; P < .001). A significant proportion (28.5%; P < .001) of current menthol cigarette smokers supported a ban. After controlling for other factors, geographic region was not significantly associated with support for a ban.

CONCLUSIONS

Efforts are needed to further increase support for a ban among current menthol cigarette smokers. These findings can be used to assist policy makers and communities in efforts to ban menthol cigarettes in their jurisdictions.

Young adult e-cigarette use: A latent class analysis of device and flavor use, 2018-2019

OBJECTIVE

The myriad of e-cigarette devices and flavors used by young adults (YAs) complicates identification of the particular e-cigarette products that are associated with more frequent tobacco use and merit consideration for regulation. The current study used latent class analysis to identify distinct patterns of e-cigarette device and flavor use and evaluate their association with vaping and smoking frequency.

METHODS

Cross-sectional survey data (2018-2019) from a Southern California cohort were analyzed. YAs reporting past 30-day nicotine vaping (N = 550; M age = 19.2 years) self-reported e-cigarette device type/brand and flavor. Six device (e-cig/vape pen, mech mod, box mod, JUUL, non-JUUL pod, disposable) and three flavor (tobacco, mint/menthol, sweet/fruit) indicators were included in a latent class analysis. Past 30-day nicotine vaping and cigarette smoking frequency were assessed as correlates of device and flavor class membership.

RESULTS

Three classes were identified: Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (prevalance:47%); Non-JUUL-Sweet/Fruit Flavor Users (28%); and Poly-Device-Poly-Flavor Users (25%). Greater frequency of vaping and smoking were associated with higher odds of belonging to the Poly-Device-Poly-Flavor Users class vs. the Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.36[1.16, 1.59], p < .001; smoking: aOR[95%CI] = 1.25[1.02, 1.54], p = .03) and Non-JUUL-Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.30[1.10, 1.53], p < .01; smoking: aOR[95%CI] = 1.42[1.07, 1.88], p = .02) classes.

CONCLUSIONS

Although YAs that predominately used pod devices alongside non-tobacco flavors were most common, YAs characterized by a proclivity toward using many different devices and flavors were appreciably prevalent and smoked and vaped more frequently. Regulations targeting a wide spectrum of vaping products may be optimal in protecting YA health.

Trends and Associations of Menthol Cigarette Smoking Among US Middle and High School Students-National Youth Tobacco Survey, 2011-2018

INTRODUCTION

Youth cigarette smoking decreased significantly over the last two decades in the United States. This study provides estimates and trends from 2011 to 2018 and factors associated with youth menthol and non-menthol smoking from 2016 to 2018.

METHODS

Using data from the 2011-2018 National Youth Tobacco Surveys, past 30-day (current) menthol and non-menthol cigarette smoking were estimated for all youth (prevalence) and youth smokers (proportions). Trends were examined using Joinpoint regression, calculating the annual percent change (APC). Multivariate logistic regression analyses identified factors associated with menthol smoking.

RESULTS

From 2011 to 2018, menthol cigarette smoking among current youth cigarette smokers significantly decreased from 57.3% to 45.7% (APC: -3.0%), while non-menthol (38.2% to 47.3% [APC: 2.9%]) and unknown menthol status (not sure\missing) (4.5% to 7.0% [APC: 7.1%]) significantly increased. Menthol cigarette smoking among high school, male, female, and non-Hispanic white current cigarette smokers decreased, but remained unchanged among middle school, non-Hispanic black, and Hispanic smokers. Significantly higher proportions of menthol cigarette smokers smoked on ≥20 days, ≥2 cigarettes per day, and ≥100 cigarettes in their lifetime compared to non-menthol smokers. Among current cigarette smokers, non-Hispanic blacks, Hispanics, flavored non-cigarette tobacco users, frequent smokers (≥20 days), those smoking 2-5 cigarettes per day, and those living with someone who uses tobacco had higher odds of menthol cigarette smoking.

CONCLUSIONS

In 2018, nearly half of current youth cigarette smokers smoked menthol cigarettes. While menthol cigarette smoking declined from 2011 to 2018 among all youth and among youth smokers, there was no change in menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school cigarette smokers.

IMPLICATIONS

This study finds that overall cigarette and menthol cigarette smoking declined in youth from 2011 to 2018. However, menthol cigarette smoking among non-Hispanic black, Hispanic, and middle school youth cigarette smokers did not change. Information from this study can help inform efforts to reduce menthol cigarette smoking among US youth, particularly racial/ethnic minority populations.

Menthol Cigarettes, Tobacco Dependence, and Smoking Persistence: The Need to Examine Enhanced Cognitive Functioning as a Neuropsychological Mechanism

INTRODUCTION

Despite the overall decline in the prevalence of cigarette use in the United States, menthol cigarette use among smokers is rising, and evidence shows that it may lead to more detrimental effects on public health than regular cigarette use. One of the mechanisms by which nicotine sustains tobacco use and dependence is due to its cognitive enhancing properties, and basic science literature suggests that menthol may also enhance nicotine's acute effect on cognition.

AIMS AND METHODS

The purpose of this review is to suggest that the cognitive enhancing effects of menthol may be a potentially important neuropsychological mechanism that has yet to be examined. In this narrative review, we provide an overview of basic science studies examining neurobiological and cognitive effects of menthol and menthol cigarette smoking. We also review studies examining menthol essential oils among humans that indicate menthol alone has acute cognitive enhancing properties. Finally, we present factors influencing the rising prevalence of menthol cigarette use among smokers and the importance of this gap in the literature to improve public health and smoking cessation treatment.

CONCLUSIONS

Despite the compelling evidence for menthol's acute cognitive enhancing and reinforcing effects, this mechanism for sustaining tobacco dependence and cigarette use has yet to be examined and validated among humans. On the basis of the basic science evidence for menthol's neurobiological effects on nicotinic receptors and neurotransmitters, perhaps clarifying menthol's effect on cognitive performance can help to elucidate the complicated literature examining menthol and tobacco dependence.

IMPLICATIONS

Menthol cigarette use has continued to be a topic of debate among researchers and policy makers, because of its implications for understanding menthol's contribution to nicotine dependence and smoking persistence, as well as its continued use as a prevalent flavoring in tobacco and nicotine products in the United States and internationally. As international tobacco regulation policies have begun to target menthol cigarettes, research studies need to examine how flavoring additives, specifically menthol, may acutely influence neurobiological and cognitive functioning as a potential mechanism of sustained smoking behavior to develop more effective treatments.

The impact of a comprehensive tobacco product flavor ban in San Francisco among young adults

OBJECTIVE

Flavors play an important role in the initiation and use of tobacco products. The FDA, states, and cities have been implementing or considering banning flavored e-cigarettes or any flavored tobacco products. This study empirically assessed the impact of one of the first comprehensive bans of all flavored tobacco products other than tobacco-flavored e-cigarettes among young adults in San Francisco, California.

METHODS

Using Amazon Mechanical Turk, a sample of San Francisco residents aged 18-34 who previously used tobacco products (N = 247) were surveyed about their tobacco use both before and after the ban. Descriptive statistics and regression models were applied.

RESULTS

The prevalence of overall flavored tobacco use decreased from 81% and 85% to 69% and 76% for 18-24 years and 25-34 years old, respectively. The prevalence of flavored e-cigarettes decreased from 57% and 56% to 45% and 48% for 18-24 years and 25-34 years old, respectively. The prevalence of cigars uses reduced as well. However, cigarette smoking increased, although not statistically significant among 25-34 years old. 66% of participants did not support the ban and 65% believed the ban had not been enforced completely. Most users reported being able to obtain flavored tobacco products in multiple ways despite the ban.

CONCLUSIONS

These findings suggest that comprehensive local flavor bans, by themselves, cannot sharply reduce the availability or use of flavored tobacco products among residents. Nevertheless, local bans can still significantly reduce overall e-cigarette use and cigar smoking but may increase cigarette smoking.

Trends in Sales of Flavored and Menthol Tobacco Products in the United States During 2011-2015

Introduction

Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels.

Methods

Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change.

Results

Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland).

Conclusions

Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption.

Implications

Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

Longitudinal Response to Restrictions on Menthol Cigarettes Among Young Adult US Menthol Smokers, 2011-2016

Objectives. To examine responses to hypothetical restrictions on menthol cigarettes among young adult menthol smokers in the United States.Methods. We surveyed Truth Initiative Young Adult Cohort respondents 18 to 34 years of age every 6 months from December 2011 through October 2016. Menthol cigarette smokers (n = 806, n = 1963 observations) indicated their response if menthol cigarettes were unavailable. Weighted analyses accounting for repeated measures were used to estimate the prevalence and correlates of responses and trends over time.Results. Overall, 23.5% of young adult menthol smokers said they would quit if menthol cigarettes were unavailable, with this response largely unchanged between 2011 and 2016. There was a significant increase in the switch to another tobacco product response (from 7.4% to 13.2%; P = .01) associated with current noncigarette use. In adjusted analyses, African Americans, women, those with less than a high school education, and those with any quit intention were more likely to say they would quit smoking.Conclusions. Increased intentions to switch products suggest the acceptability and availability of alternatives to menthol cigarette smokers. Menthol cigarette restrictions benefit vulnerable groups and those interested in quitting, but the availability of menthol in noncigarette products could limit benefits.

Racial/ethnic differences in daily, nondaily, and menthol cigarette use and smoking quit ratios in the United States: 2002 to 2016

In the United States (US), racial/ethnic groups differ in cigarette smoking behaviors. We examined changes in cigarette prevalence and quit ratios over 15 years by racial/ethnic group (Non-Hispanic (NH) White, NH Black, Hispanic, NH Other). Data were drawn from the 2002-2016 National Survey on Drug Use and Health (NSDUH) public use data files and analyzed in 2018. Linear time trends of the prevalence of daily, nondaily, and menthol cigarette use and quit ratios (i.e., proportion of former smokers among lifetime smokers) were assessed using logistic regression models. 19.35% of NH White persons were daily smokers in 2016; this prevalence was significantly higher than all other groups (NH Black 10.99%, Hispanic 6.81%, NH Other 9.10%). Menthol use was significantly more common among NH Black individuals than all other groups in every year from 2002 to 2016 (2016: NH Black 23.38%, NH White 14.52%, Hispanic 10.49%, NH Other 8.97%). From 2002 to 2016, daily and nondaily smoking decreased significantly among all groups. The rate of decline of nondaily smoking was more rapid among Hispanic than NH White individuals while the rate of menthol smoking decline was more rapid among NH White than among Hispanic individuals. The quit ratio did not change significantly from 2002 to 2016 among NH Black individuals (31% to 35%) in contrast to a significant increase among NH White (2002, 45%; 2016, 50%) and Hispanic (2002, 33%; 2016, 41%) individuals. Further progress in tobacco control for vulnerable groups may need to include innovative strategies to address these concerning trends.

Widespread use of flavored e-cigarettes and hookah tobacco in the United States

In 2009, the U.S. Food and Drug Administration banned the sale of flavored cigarettes (excluding menthol) in the U.S. However, the sale of flavored e-cigarettes (FE) and flavored hookah tobacco (FHT) is still legal. In this study (conducted in the US in the period from October 2018 to February 2019), we estimated the prevalence of use of FE and FHT across users' sociodemographic characteristics (e.g., age, sex, race/ethnicity) and identified the key characteristics of tobacco users associated with use of FE and FHT. We analyzed the 2014–2015 Tobacco Use Supplement to the Current Population Survey data for current e-cigarette (n = 3691) and hookah tobacco (n = 658) users. Among e-cigarette users, 65.5% used FE; and among hookah tobacco users, 87.3% used FHT. Among e-cigarette users, the prevalence of use of FE was significantly higher for 18–24 year-old than 45+ year-old adults; women than men; Southern than Northeastern residents; and never smokers of regular cigarettes than current smokers of regular cigarettes (all adjusted p's < 0.05). Among hookah tobacco users, the rates of FHT use were significantly higher for women than men, and never smokers of regular cigarettes than current smokers (all adjusted p's < 0.05). Because availability and accessibility of flavored tobacco products may promote tobacco use, revising regulatory guidelines concerning manufacturing and distribution of FE and FHT may help reduce the popularity of emerging tobacco products.

Implications

Among users of emerging tobacco products such as e-cigarettes and hookah tobacco, use of flavored products is very common. Among e-cigarette users, 66% consumed flavored e-cigarettes; and among users of hookah tobacco, 87% consumed flavored hookah tobacco. Use of flavored products was especially common among users who were young adults, women, or never and former smokers of regular cigarettes. Availability of emerging tobacco products in many different flavors could be a reason for tobacco use initiation and continued use of tobacco after cessation of regular-cigarette smoking.

Cigarette Use Among Individuals with Alcohol Use Disorders in the United States, 2002 to 2016: Trends Overall and by Race/Ethnicity

BACKGROUND

Individuals with alcohol use disorders (AUDs) who smoke cigarettes experience greater health risks than those using either substance alone. Further, disparities exist in AUDs and smoking by race/ethnicity. Although smoking has declined in the general population, it is not known whether the smoking prevalence has changed over time for individuals with AUDs. The current study used representative U.S. data to estimate the prevalence of current cigarette use from 2002 to 2016 by AUD status and severity overall and by race/ethnicity.

METHODS

Data were drawn from the National Survey on Drug Use and Health, an annual cross-sectional study of U.S. individuals, from 2002 to 2016 (total analytic sample n = 837,326). Cigarette smoking prevalence was calculated annually among those with and without past-year AUD and by AUD severity level (mild, moderate, severe AUD). Time trends in smoking prevalence by AUD status and severity were tested using logistic regression for the overall sample and significant interactions were subsequently stratified by race/ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, NH Other).

RESULTS

Cigarette use was persistently over twice as common among those with AUDs compared to without AUDs (2016: 37.84% vs. 16.29%). Cigarette use was also more common among those at each level of AUD severity criteria (2016: mild AUD 34.59%; moderate AUD 35.35%; severe AUD 52.23%). Approximately half of NH Black respondents with AUDs, and three-quarters of NH Black respondents with severe AUDs, reported smoking in 2016. The prevalence of smoking decreased significantly over time among respondents with and without AUDs; however, there were differences by race. There was no decline in smoking prevalence among NH Black respondents with AUDs over time in contrast to a significant decrease for every other racial/ethnic group with and without AUDs.

CONCLUSIONS

Individuals with AUDs may need additional resources and interventions to quit smoking, especially NH Black individuals.

Co-occurring vulnerabilities and menthol use in U.S. young adult cigarette smokers: Findings from Wave 1 of the PATH Study, 2013-2014

This study incorporates intersectionality theory to address potential effects of age on other documented risk factors for current smoking and menthol cigarette use in young adults aged 18-34 using Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014). We explored known correlates of current cigarette and menthol cigarette smoking and interaction analyses by age group (18-24 vs. 25-34), accounting for survey weighting. Use of non-cigarette tobacco products and e-cigarettes was characterized among current cigarette smokers. Young adults experience multiple vulnerabilities to smoking beyond age and some of these known risk factors for smoking place those aged 18-24 at different risk of cigarette smoking compared to their 25-34 year old counterparts. These include lower odds of cigarette smoking by age for sex (female; AOR = 0.62 in those aged 18-24 vs. 0.72 in those aged 25-34) and Hispanic ethnicity (vs. White; AOR = 0.77 vs. 0.45), and higher odds of smoking among past 30-day alcohol users aged 18-24 vs. 25-34 (AOR = 1.62 vs. 1.32). Correlations between lower education and smoking were nearly two-fold higher in 25-34 than 18-24 year olds. Having any medical comorbidity had opposite effects on current smoking by age (18-24 positive correlation, AOR = 1.17; 25-34 negative correlation, AOR = 0.84). Lower education was correlated with menthol cigarette use among young adult smokers. This study suggests that higher smoking prevalence among young adults is associated with the intersection of multiple vulnerabilities to smoking.

Flavored E-cigarette Use and Cigarette Smoking Reduction and Cessation-A Large National Study among Young Adult Smokers

BACKGROUND

E-cigarette use prevalence has increased drastically among young adult cigarette smokers in recent years.

OBJECTIVES

This study seeks to understand which e-cigarette flavors-sweet and fruity or tobacco and menthol/mint-are more likely to be associated with smoking reduction and cessation among young adults.

METHODS

Longitudinal data (waves 1 and 2) of the Population Assessment of Tobacco and Health (PATH) Study from young adult (aged 18-34) cigarette smokers (n = 4,645) at wave 1 and current e-cigarette users (n = 844) at wave 2 were used. Univariate and multivariate regressions were conducted to examine the associations between past-year smoking reduction and cessation and current e-cigarette flavor use at wave 2.

RESULTS

At wave 2, 25.9% of respondents either reduced or quit smoking, and 6.7%, 5.2%, and 6.3% of them reported currently using e-cigarettes with tobacco/menthol (TM) flavors, one non-tobacco/non-menthol (NTM) flavor, and multiple NTM flavors, respectively. E-cigarette users with one (AOR = 2.5, p < 0.001) and multiple NTM flavors (AOR = 3.0, p < 0.001) were more likely to have reduced or quit smoking over the past year compared to non-e-cigarette users. NTM flavor use was positively associated with e-cigarette use of a higher frequency and larger amount.

CONCLUSIONS

The positive association between past-year smoking reduction and cessation and current NTM flavored e-cigarette use may be explained by young adults' escalated e-cigarette use with NTM flavors. Public health professionals should prevent and reduce multiple tobacco use through enhanced education about the harm of vaping NTM flavors and by advising young adult smokers to quit tobacco altogether using evidence-based methods.

Young adult susceptible non-smokers’ and smokers’ responses to capsule cigarettes

Background

Flavour capsule cigarette variants (FCVs), which allow users to customise their smoking experience and reduce the harshness of smoking, have captured an increasing share of many markets. We examined tobacco companies’ argument that such product innovations aim simply to shift market share, by estimating smokers’ and susceptible non-smokers’ responses to FCVs.

Methods

We conducted an online survey of 425 smokers (daily and non-daily), susceptible non-smokers (n=224) and former smokers (n=166) aged between 18 and 25. Restrpondents completed a choice experiment, a behavioural probability measure and a perception task. We analysed the choice data using a conditional logistic regression and a rank-ordered logistic regression, and the probability and perception data using t-tests and descriptive statistics.

Results

Non-smokers preferred an FCV relative to an unflavoured cigarette, whereas the opposite was the case for smokers. Susceptible non-smokers and former smokers were more likely to try a fruit flavoured FCV than an unflavoured stick, while daily smokers were more likely than non-daily smokers to do the same. Susceptible non-smokers, former smokers and non-daily smokers also had more positive perceptions of FCVs relative to unflavoured sticks than did daily smokers.

Conclusions

FCVs appeal more to non-smokers than to smokers, and more to non-daily smokers than to daily smokers. They thus appear likely to recruit non-smokers and potentially increase overall smoking prevalence. Policy responses include ensuring standardised packaging legislation disallows FCVs by specifically regulating the appearance and design of tobacco products, or introducing bespoke regulation that addresses the threat posed by FCVs.

Prospective predictors of flavored e-cigarette use: A one-year longitudinal study of young adults in the U.S

INTRODUCTION

E-cigarettes with fruit and candy flavors are appealing among young adults. This study examined the prospective predictors of young adults' flavored e-cigarette use to inform regulation and prevention efforts.

METHODS

We used the wave 1 (2013-2014) and wave 2 (2014-2015) data of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study of U.S. youth and adults. We analyzed a sample of young adults aged 18-34 (n = 12,383) to identify wave 1 prospective predictors (i.e., socio-demographic characteristics, mental health symptoms, marijuana use, tobacco use, and e-cigarette harm perceptions) of wave 2 flavored e-cigarette use.

RESULTS

At wave 2, 8.0% of young adults used e-cigarettes, and 2.5% and 5.5% used tobacco and menthol (TM) and non-tobacco and non-menthol flavors (NTM) flavors, respectively. In the multivariable model, significant prospective predictors (wave 1) of NTM flavored e-cigarette use compared to TM flavored e-cigarette use (wave 2) were younger age (18-24 years) (AOR = 1.82, p < 0.001), female gender (AOR=1.81, p < 0.001), education attainment of high school graduate and higher (AOR=1.60, p = 0.024), marijuana use (AOR=1.96, p < 0.001), ever but non-past-month cigarette smoking (AOR=2.75, p < 0.001), never cigarette smoking (AOR=5.08, p = 0.016), and lower harm perception of e-cigarettes (AOR=1.59, p = 0.005).

CONCLUSION

This study highlights high rates of NTM flavor use and specific predictors of NTM flavored e-cigarettes use among young adults in the U.S. Regulation and prevention efforts for curbing flavored e-cigarette use among young adults should focus on these risk factors and high-risk groups (e.g., 18-24 years, female, and never cigarette smokers).

Differences in Subjective Experiences to First Use of Menthol and Nonmenthol Cigarettes in a National Sample of Young Adult Cigarette Smokers

Purpose

Menthol has been hypothesized to ease the harshness of cigarette smoke. Thus, sensory experiences at first cigarette use may be one mechanism by which menthol facilitates progression to regular smoking. This study examined differences in subjective experiences to the first use of a menthol versus nonmenthol cigarette among new young adult smokers.

Methods

Data were drawn from waves 5-8 of the Truth Initiative Young Adult Cohort Study, a national sample of 18-34 year olds assessed every 6 months. Analyses included a subset of young adult current smokers (n = 251) who initiated smoking in the past 6 months. Subjective responses to first cigarette use were assessed across menthol and nonmenthol initiators in bivariate analyses and adjusted models controlling for smoking correlates.

Results

Fifty-two percent of new young adult smokers used a menthol cigarette at first use. First use of a menthol cigarette was higher in those aged 18-24 (vs. 25-34). Most black smokers (93.1%) were menthol initiators compared to 43.9% of white smokers. More than half of menthol and nonmenthol initiates felt relaxed or calm, dizzy, lightheaded, liking the taste and a rush or buzz at first use. Menthol initiators were less likely in bivariate and multivariable analyses to experience feeling nauseated at first use (adjusted odds ratio = 0.45; p = .020) compared to nonmenthol initiators.

Conclusions

While few differences were found between menthol and nonmenthol initiators in their subjective experiences, fewer menthol initiates felt nauseated at first cigarette use. Future research needs to identify additional mechanisms linking menthol initiation to smoking progression.

Implications

Menthol initiators were more likely to be younger (18-24 vs. 25-34), and black (vs. white) compared to nonmenthol initiators. Our finding that menthol initiators were less likely to feel nauseated at first cigarette use compared to nonmenthol initiators suggests that menthol may reduce aversion to early cigarette use among young smokers and thus has the potential to facilitate continued experimentation. Interventions and policy approaches to reduce tobacco use initiation and progression are urgently needed in young people.

A fMRI study on the impact of advertising for flavored e-cigarettes on susceptible young adults

BACKGROUND

E-cigarettes are sold in flavors such as "skittles," "strawberrylicious," and "juicy fruit," and no restrictions are in place on marketing e-cigarettes to youth. Sweets/fruits depicted in e-cigarette advertisements may increase their appeal to youth and interfere with health warnings. This study tested a brain biomarker of product preference for sweet/fruit versus tobacco flavor e-cigarettes, and whether advertising for flavors interfered with warning labels.

METHODS

Participants (N = 26) were college-age young adults who had tried an e-cigarette and were susceptible to future e-cigarette use. They viewed advertisements in fMRI for sweet/fruit and tobacco flavor e-cigarettes, menthol and regular cigarettes, and control images of sweets/fruits/mints with no tobacco product. Cue-reactivity was measured in the nucleus accumbens, a brain biomarker of product preference. Advertisements randomly contained warning labels, and recognition of health warnings was tested post-scan. Visual attention was measured using eye-tracking.

RESULTS

There was a significant effect of e-cigarette condition (sweet/tobacco/control) on nucleus accumbens activity, that was not found for cigarette condition (menthol/regular/control). Nucleus accumbens activity was greater for sweet/fruit versus tobacco flavor e-cigarette advertisements and did not differ compared with control images of sweets and fruits. Greater nucleus accumbens activity was correlated with poorer memory for health warnings.

CONCLUSIONS

These and exploratory eye-tracking findings suggest that advertising for sweet/fruit flavors may increase positive associations with e-cigarettes and/or override negative associations with tobacco, and interfere with health warnings, suggesting that one way to reduce the appeal of e-cigarettes to youth and educate youth about e-cigarette health risks is to regulate advertising for flavors.

An American Thoracic Society/National Heart, Lung, and Blood Institute Workshop Report: Addressing Respiratory Health Equality in the United States

Health disparities related to race, ethnicity, and socioeconomic status persist and are commonly encountered by practitioners of pediatric and adult pulmonary, critical care, and sleep medicine in the United States. To address such disparities and thus progress toward equality in respiratory health, the American Thoracic Society and the National Heart, Lung, and Blood Institute convened a workshop in May of 2015. The workshop participants addressed health disparities by focusing on six topics, each of which concluded with a panel discussion that proposed recommendations for research on racial, ethnic, and socioeconomic disparities in pulmonary, critical care, and sleep medicine. Such recommendations address best practices to advance research on respiratory health disparities (e.g., characterize broad ethnic groups into subgroups known to differ with regard to a disease of interest), risk factors for respiratory health disparities (e.g., study the impact of new tobacco or nicotine products on respiratory diseases in minority populations), addressing equity in access to healthcare and quality of care (e.g., conduct longitudinal studies of the impact of the Affordable Care Act on respiratory and sleep disorders), the impact of personalized medicine on disparities research (e.g., implement large studies of pharmacogenetics in minority populations), improving design and methodology for research studies in respiratory health disparities (e.g., use study designs that reduce participants' burden and foster trust by engaging participants as decision-makers), and achieving equity in the pulmonary, critical care, and sleep medicine workforce (e.g., develop and maintain robust mentoring programs for junior faculty, including local and external mentors). Addressing these research needs should advance efforts to reduce, and potentially eliminate, respiratory, sleep, and critical care disparities in the United States.

Regulating Cannabis Manufacturing: Applying Public Health Best Practices from Tobacco Control

State legalization and regulation of cannabis, despite continued federal illegality, is a massive shift in regulatory approach. Manufactured cannabis, including concentrates, extracts, edibles, tinctures, topicals and other products, has received less attention than more commonly used dried flower, but represents emerging regulatory challenges due to additives, potency, consumption methods, and abuse and misuse potential. In November 2017, the California Department of Public Health (CDPH) released initial cannabis manufacturing regulations as part of a new state regulatory structure. As the largest U.S. medical cannabis market (and largest legal adult use market in the world beginning in 2018), California's regulatory approach will potentially influence national and global policy. Comparing CDPH's initial regulations to tobacco control best practices reveals that, while the regulations recognize the need to protect public health, prioritizing public health over business interests requires stronger approaches to labeling, packaging, and product formulations. Based on tobacco best practices, we recommend that cannabis regulations incorporate large and proportionately sized informational labels, a prominent universal cannabis symbol, rotating and pictorial health warnings, mandatory plain packaging, a comprehensive ban on characterizing flavors and addictive additives, and strict limits on the potency of inhalable products and those easily confused with non-cannabis products.

Menthol cigarettes and the public health standard: a systematic review

Background

Although menthol was not banned under the Tobacco Control Act, the law made it clear that this did not prevent the Food and Drug Administration from issuing a product standard to ban menthol to protect public health. The purpose of this review was to update the evidence synthesis regarding the role of menthol in initiation, dependence and cessation.

Methods

A systematic review of the peer-reviewed literature on menthol cigarettes via a PubMed search through May 9, 2017. The National Cancer Institute’s Bibliography of Literature on Menthol and Tobacco and the FDA’s 2011 report and 2013 addendum were reviewed for additional publications. Included articles addressing initiation, dependence, and cessation were synthesized based on study design and quality, consistency of evidence across populations and over time, coherence of findings across studies, and plausibility of the findings.

Results

Eighty-two studies on menthol cigarette initiation (n = 46), dependence (n = 14), and cessation (n = 34) were included. Large, representative studies show an association between menthol and youth smoking that is consistent in magnitude and direction. One longitudinal and eight cross-sectional studies demonstrate that menthol smokers report increased nicotine dependence compared to non-menthol smokers. Ten studies support the temporal relationship between menthol and reduced smoking cessation, as they measure cessation success at follow-up.

Conclusions

The strength and consistency of the associations in these studies support that the removal of menthol from cigarettes is likely to reduce youth smoking initiation, improve smoking cessation outcomes in adult smokers, and in turn, benefit public health.

Electronic supplementary material

The online version of this article (10.1186/s12889-017-4987-z) contains supplementary material, which is available to authorized users.

Prevalence and characteristics of flavoured tobacco use among students in grades 10 through 12: a national cross-sectional study in Canada, 2012-2013

BACKGROUND

Tobacco use is the leading cause of preventable death in Canada and the world. Despite documented decreases in the prevalence of smoking in Canada, increases in flavoured tobacco use by its youth poses a serious public health concern. This study examined the prevalence and characteristics of flavoured tobacco use among a national sample of Canadian students in grades 10 through 12.

METHODS

This study used a cross-sectional design on a nationally generalizable, school-based, Youth Smoking Survey (YSS), 2012-2013. It incorporated data from a representative sample of 19,979 students in grades 10-12 from across Canada. Univariate and multivariate logistic regression models were used to examine differences in flavoured tobacco use (menthol cigarettes, flavoured little cigar or cigarillo, flavoured cigar, flavoured tobacco in water pipe [hookah]) by demographic (sex, grade and ethnicity) and social characteristics (friends, siblings, parents/guardians who are smokers and weekly personal spending money).

RESULTS

This study found that 14.8% of the participating students used flavoured tobacco in the past 30-days. Results of the logistic regression analysis show that flavoured tobacco use was significantly higher among male students [(OR = 1.63; 95% CI = 1.36-1.95)], who had at least one friend or sibling who smoke [(OR = 2.20; CI = 1.62 to 2.99) and (OR = 1.51; CI = 1.22 to 1.88), respectively] and who received greater than $20/week in personal spending money [(OR = 1.76; CI = 1.26 to 2.45)].

CONCLUSIONS

The results of our study indicate that flavoured tobacco use is a growing public health concern and has a strong appeal among youth in Canada. This is a particularly troubling finding, especially in light of the fact that there is a national ban on certain flavoured tobacco products. To be effective, strategies specifically tailored for youth using flavoured tobacco would require appropriate educational/prevention initiatives, more comprehensive legislation and better regulatory mechanisms.