Marketing exposure and smokeless tobacco use initiation among young adults: A longitudinal analysis

Understanding dental practitioners' knowledge and practices of smokeless tobacco: South Texas Oral Health Network study

OBJECTIVE

This study, conducted by the South Texas Oral Health Network, evaluated dental practitioners' knowledge, attitudes, and practice behaviors regarding cultural forms of smokeless tobacco (SLT) use and effects, using the 5As (Ask, Advise, Assess, Assist, and Arrange) framework.

METHODS

Chi-squared tests examined associations between dental practitioners' characteristics, self-confidence, knowledge, attitudes, and practices. The 5As tobacco cessation intervention steps were analyzed using the Wilcoxon rank sum test to measure changes in the frequency of use between successive steps.

RESULTS

The study finds that higher knowledge scores about SLT forms (chewing tobacco, snuff, dip, paan, betel quid, gutka areca nut) were linked to greater adherence to the Assess and Assist of the 5As cessation intervention steps. However, adherence rates to the 5As declined progressively from Ask to Arrange, representing a gap in SLT cessation practice among active dental practitioners. Dental practitioners were found to be more familiar with conventional SLT forms (e.g., snuff) and less with cultural SLT forms (e.g., paan).

CONCLUSION

These findings underscore the need for improved culturally relevant training to enhance practitioner awareness concerning cultural SLT forms and increase progression through the 5As cessation intervention.

PRACTICE IMPLICATIONS

We anticipate that our findings will highlight the critical need for dental practitioners to be aware of diverse cultural forms of SLT and their associated oral and systemic effects to support cessation efforts effectively, primarily due to the growth of culturally diverse communities in the United States and the corresponding rise in the use of previously unrecognized forms of SLT in dental practices. This study is designed to understand the cultural nuances the practitioner needs to develop and communicate the health hazards and importance of cessation of SLT use in the immigrant and refugee populations.

CLINICAL SIGNIFICANCE

This study is significant because it highlights the importance of understanding diverse cultural forms of SLT and cessation practices among dental practitioners. Understanding this will enhance awareness and guide training to improve SLT cessation efforts, improve oral health outcomes, and address disparities in diverse patient populations, particularly amidst increasing immigration trends.

Awareness and use of nicotine pouches in a nationwide sample of adults in Poland

INTRODUCTION

Nicotine pouches are a new type of nicotine-containing product that have been marketed in many countries worldwide, generating growing acceptance among consumers. The aim of this study was to assess factors associated with public awareness and use of nicotine pouches among adults in Poland.

METHODS

A cross-sectional survey was conducted with a nationally representative sample of 1080 adults in Poland (February 2024). Awareness of nicotine pouches, history of use, current (past 30-day) use of nicotine pouches, as well as perception of harm was assessed using a purpose-designed questionnaire.

RESULTS

Awareness of nicotine pouches was reported by 24% of the sample, while 9.2% reported ever having used a nicotine pouch product, and 4.3% using a nicotine pouch in the past 30 days. Among all respondents, 60.7% perceived nicotine pouches as harmful as combustible cigarettes, 28.2% perceived nicotine pouches as less harmful, and 11% as more harmful than combustible cigarettes. In multivariable logistic regression model, women (adjusted odds ratio, AOR=1.40; 95% CI: 1.03-1.91; p<0.05), individuals aged <60 years (p<0.05), current tobacco smokers (AOR=2.59; 95% CI: 1.75-3.82; p<0.001), former tobacco smokers (AOR=1.53; 95% CI: 1.01-2.32; p<0.05) and ever users of e-cigarette or heated tobacco (AOR=2.90; 95% CI: 2.07-4.05; p<0.001) were more likely to declare that had ever heard of nicotine pouches. Moreover, individuals aged <60 years (p<0.05), occupationally active individuals (AOR=1.82; 95% CI: 1.01-3.31; p<0.05), current tobacco smokers (AOR=2.71; 95% CI: 1.48-4.97; p<0.01), and ever users of e-cigarette or heated tobacco (AOR=5.29; 95% CI: 2.96-9.44; p<0.001) were more likely to declare ever use of nicotine pouches.

CONCLUSIONS

This study provides the first national data on public awareness and use (ever and current) of nicotine pouches in Poland. Young adults, current smokers, and ever e-cigarette and heated tobacco users are at higher risk of ever use of nicotine pouches, so policy interventions are needed to protect young people from nicotine pouch marketing and nicotine initiation.

A four-year longitudinal analysis examining the effects of e-cigarette advertisements and disparities among youth with internalizing problems

BACKGROUND

Prior research indicates a direct, short-term effect of e-cigarette advertising on e-cigarette use among youth. This study seeks to investigate the long-term effects of e-cigarette advertisements and disparities in exposure among adolescents with different levels of internalizing problems.

METHODS

Panel data of the Population Assessment of Tobacco and Health (PATH) Study Waves 3-5 (2015-2019) were analyzed. Youth aged 12-17 who were non-e-cigarette users at the time of Wave 3 were included (n = 4,678). A moderated mediation model was employed to examine the mediating role of perceived harm of e-cigarettes and the moderating effect of internalizing problems.

RESULTS

Exposure to e-cigarette advertisements in Wave 3 predicted lower harm perception of e-cigarette in Wave 4 (bp = -0.055, p <.01), leading to more e-cigarette use in Wave 5 (bp = -0.042, p <.001). While e-cigarette advertisements exhibited a lasting indirect effect (bp = 0.002, p <.05), there was no long-term direct effect (bp = 0.017, p >.05) on youth e-cigarette use. Furthermore, a moderating effect of internalizing problems was observed (bp = 0.107, p <.05).

CONCLUSIONS

E-cigarette advertisements can exert a lasting influence indirectly by diminishing harm perception, particularly among those with lower internalizing problems. Adolescents with higher internalizing problems exhibit lower susceptibility to advertisement influence, yet their perceived harm of e-cigarettes is notably lower than their peers with fewer internalizing problems. These disparities underscore the need for tailored prevention strategies: implementing anti-e-cigarette education programs for adolescents with low internalizing problems and providing mental health care for those facing internalizing challenges. Regulatory measures targeting e-cigarette advertising are also crucial.

Tobacco advertising exposure and product use among young adults: An ecological momentary assessment approach

INTRODUCTION

Tobacco-related content is prevalent on social media, yet many methods of measuring exposure are inadequate due to the personalized nature of online marketing. The purpose of this paper is to examine the association between exposure to pro-tobacco messages (both industry-sponsored and user-generated) and the use of tobacco products, as reported via ecological momentary assessment (EMA).

METHODS

Young adults (n = 175) were instructed to record all sightings of marketing (both in-person and online) related to tobacco for 28 days. Tobacco product use and recall of message encounters were assessed daily using app-initiated EMA.

RESULTS

Participants who reported exposure to tobacco messages were significantly more likely to report using tobacco, adjusting for gender, age, race/ethnicity, baseline use of any tobacco product, and having friends who use tobacco and e-cigarettes (p <.001). For each industry-sponsored message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.77 (95 % CI = 1.41, 2.23). For each user-generated message viewed, the odds of using tobacco or e-cigarettes in a given day increased by a factor of 1.52 (95 % CI = 1.27, 1.83).

DISCUSSION

To our knowledge, this is the first study to specifically examine the association between exposure to user-generated messages and daily tobacco use. The findings suggests that there is a unique element to user-generated messages that distinguishes them from both traditional marketing and from simple peer influence.

Variation of Benzo[a]pyrene, NNN, and NNK Levels in 16 Commercial Smokeless Tobacco Products

This study examined the variation of benzo[a]pyrene (B[a]P), N'-nitrosonornicotine (NNN), and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) levels in 16 smokeless tobacco products from several different product subcategories obtained at two different locations and at two different procurement times. B[a]P quantities range from 0.6 to 160 ng/g on a wet-weight basis, whereas NNN and NNK quantities range from 276 to 10473 ng/g and 79 to 28882 ng/g, respectively. The B[a]P, NNN, and NNK quantities vary widely among various smokeless tobacco product categories and among various brands within each product subcategory. Dry snuff products contain the highest B[a]P, NNN, and NNK quantities, whereas loose and portioned snus products contain the lowest B[a]P, NNN, and NNK levels. In general, variation of B[a]P, NNN, and NNK levels across four sets of each product brand purchased six months apart and at two different locations show statistically significant differences (p < 0.05), although with a much narrower product set-to-set variability.

Willingness to Use Commercial Nicotine Gums, Lozenges, and Gummies Among Nontobacco Using Adolescents in Southern California

PURPOSE

New oral nicotine products (ONPs), often advertised as "tobacco-free" (i.e., pouches, gum, lozenges, gummies), come in nontobacco flavors appealing to adolescents. It is unknown how adolescent willingness to use ONPs differs by product type and flavor, and whether sociodemographic disparities exist.

METHODS

Adolescent never tobacco product users (n = 1, 289) in ninth or 10th grade from 11 high schools in Southern California were surveyed in fall 2021 about ever and past 6-month use of ONPs and sociodemographic characteristics. Adolescents were randomized to view five different ONPs in either fruit or mint flavor, and asked to rate their willingness to use each product. Multivariable logistic random effect-repeated measures regression examined associations of product type, flavor, and sociodemographic characteristics with any willingness to use ONPs.

RESULTS

Compared to traditional smokeless tobacco (willingness = 17.8%), adolescents reported greater willingness to use ONPs (gum, 28.2%; pouches, 21.1%; lozenge, 22.4%; gummies, 24.1%); adjusted odd ratios [aORs] 1.25-1.84; p-values<.001). Mint flavor (23.3%) compared to fruit flavor (21.4%), significantly increased odds of willingness to use across all ONPs (aOR [95%CI] = 1.15 [1.05, 1.26], p = .004). Younger adolescents (ninth, 24.2% vs. 10th grade, 21.4%) and LGBTQ+ (34.2%) versus heterosexual (19.7%) and cisgender (18.8%) adolescents were more willing to use these products.

DISCUSSION

Adolescents reported greater willingness to use new ONPs compared to traditional smokeless tobacco. Adolescents who were younger (vs. older adolescents) or identified as LGBTQ+ (vs. heterosexual and cisgender) were more willing to use new ONPs. Efforts to monitor adolescents' willingness to use and actual use of these products are warranted.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.

Exploring factors associated with smokeless tobacco use among young people: A systematic scoping review

PURPOSE

While smoking is declining among young people, smokeless tobacco use is increasing. Identifying who is using smokeless tobacco and why is essential in preventing smokeless tobacco use. This study aimed to comprehensively explore the factors of young people's use of smokeless tobacco in western countries and identify research gaps.

METHODS

We conducted a systematic scoping review of studies that examined factors associated with smokeless tobacco use among young people (ages 13-29) from western countries published between January 2011 and September 2021. Searches were conducted in CINAHL, Medline, and Scopus. Studies on adults, total tobacco use (i.e., did not differentiate between tobacco product types), dual and multiple uses of tobacco, and studies on smokeless tobacco cessation programs were excluded.

RESULTS

A total of 160 studies were included in this scoping review. The studies were primarily undertaken in the US and the Scandinavian countries, and the majority explored smokeless tobacco use without distinguishing between the specific types. Smokeless tobacco users were more likely to be male, non-Hispanic white, engaging in physical activity, and using other substances, including cigarettes and alcohol. The role of friends and family were identified as critical factors that were related to the use of smokeless tobacco.

CONCLUSIONS

This scoping review suggests that preventative measures against smokeless tobacco use should focus on peer and family members' roles and that these measures may benefit from targeting males. Additional research, including systematic reviews on this area to validate the identified associated factors, would improve the understanding of smokeless tobacco use.

Testing if attitudes mediate the association between advertising exposure and adolescent tobacco use

INTRODUCTION

A growing body of evidence indicates that exposure to tobacco advertising among adolescents increases the likelihood of subsequent tobacco use. It is important to understand the process by which this occurs, in order to appropriately target factors for intervention. The objective of this study was to test whether attitudes towards tobacco advertising mediates the impact of advertising exposure on tobacco use.

METHODS

From an ongoing prospective cohort study of male adolescents (aged 11-16 at baseline), we recruited a subset of tobacco users and non-users to participate in an additional ecological momentary assessment (EMA) project (N = 164). Adolescents completed smartphone-based surveys 2-3 times/day over a 10-day period with items assessing their exposures and attitudes towards tobacco-related advertising. If participants reported exposure to tobacco advertising, they were asked about their attitudes toward it (how much they enjoyed it, liked it, and found it appealing).

RESULTS

Adolescents who reported a greater amount of advertising exposure during the EMA period were more likely to report past-30-day tobacco use at their next cohort follow-up (6-12 months later). Moreover, the impact of advertising exposure on subsequent use was mediated by attitudes toward the tobacco advertisements, as reported during the EMA. This effect remained after controlling for baseline tobacco use.

CONCLUSIONS

By pairing EMA with long-term follow-up, we identified attitudes as a mediator between adolescent advertising exposure and subsequent tobacco use. Interventions to lessen adolescents' positive attitudes toward tobacco advertisements may help disrupt this impact.

Association between smokeless tobacco use and cigarette smoking amount by age

BACKGROUND

The use of smokeless tobacco has increased worldwide among young people. This study aimed to investigate the association between smokeless tobacco use and cigarette smoking amount in adult smoker groups stratified by age.

METHOD

2013-2015 National Health Interview Survey was used. A total of 19,635 subjects were included in our analysis. Propensity score matching was used to adjust for selection and any other bias. Generalized estimating equation was used to analyze the association between smokeless tobacco use and cigarette smoking amount by age.

RESULTS

All 580 smokeless tobacco users were matched to 2,900 non-smokeless tobacco users. Among those who were aged under 30, smokeless tobacco use was positively associated with the number of cigarettes used per day. Smokeless tobacco users who were aged under 30 and tried quitting smoking used more cigarettes than those who did non-smokeless tobacco users.

CONCLUSIONS

The present study revealed that among those who were aged under 30, smokeless tobacco use was positively associated with the number of cigarettes used per day. This study could contribute to understand the behaviors and tendencies of smoking in young adulthood and to establish effective smoking cessation methods for their age.

Age of Onset of Susceptibility to Different Tobacco Products Among Non-Susceptible US Young Adults: Findings from the Population Assessment of Tobacco and Health Study Waves 2-4 (2014-2017)

INTRODUCTION

Initiation of tobacco products is increasing in young adulthood. This study prospectively estimated the age of onset of susceptibility to cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos among young adults, which is a cognitive precursor to initiation.

METHODS

Secondary data analyses of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative longitudinal cohort study of US adults. Young adults (18-24 years) who were non-susceptible to each tobacco product (cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos) at waves 2 or 3 were followed-up into waves 3-4 to prospectively estimate the age of onset of susceptibility to each tobacco product. Weighted interval-censored survival methods and interval-censored Cox regression models were implemented to estimate the age of onset of susceptibility, and to estimate differences in the hazard function by sex and by race/ethnicity, while controlling for the total number of other tobacco products ever used at their first wave of participation in PATH.

RESULTS

By age 21, 16.5%, 16.0%, 12.6%, 12.4%, and 5.9% of young adults reported onset of susceptibility to hookah, e-cigarettes, cigarillos, cigarettes, and smokeless tobacco, respectively. Among young adults who were non-susceptible to each tobacco product at waves 2 or 3, the highest increase in onset of susceptibility occurred between ages 18 and 19 for cigarettes, e-cigarettes, and hookah, while the highest increase in onset of susceptibility occurs between ages 22 and 23 for cigarillos. Young adult males had increased risk of onset of susceptibility to cigarillos and smokeless tobacco at earlier ages than young adult females. Differences in onset of susceptibility to each tobacco product were also observed by race/ethnicity among young adults.

CONCLUSIONS

With the changing landscape of tobacco products, monitoring the age of onset of susceptibility of tobacco product use among non-susceptible young adults longitudinally is critical to prevent initiation. Communication and education campaigns tailored to address differences in susceptibility among young adults by tobacco product and sociodemographic factors will be useful.

Associations between Cognitive and Affective Responses to Tobacco Advertisements and Tobacco Use Incidence: A Four-Year Prospective Study among Adolescent Boys

Exposure to tobacco advertisements is associated with initiation of tobacco use among youth. The mechanisms underlying this association are less clear. We estimated longitudinal associations between youths' cognitive and affective responses to advertisements for cigarettes, e-cigarettes, and smokeless tobacco (SLT) and initiation of these products. N = 1220 Ohio-residing boys of ages 11-16 were recruited into a cohort in 2015 and 2016. Participants completed surveys every six months for four years. Surveys assessed cognitive and affective responses to tobacco advertisements (which included health warnings) and tobacco use after an advertisement viewing activity. We used mixed-effects Poisson regression models with robust standard errors to estimate risk of initiating use of each tobacco product according to participants' cognitive (i.e., memorability of health risks) and affective (i.e., likability of advertisement) responses to advertisements for that product. No associations between affective responses to advertisements and tobacco use outcomes were detected in adjusted models. However, finding health risks memorable was associated with reduced risk of ever smoking initiation (aRR = 0.57; 95% CI: 0.34, 0.95) and a reduced risk of ever SLT initiation that approached statistical significance (aRR = 0.61; 95% CI: 0.36, 1.05). Measures to increase saliency of health risks on cigarette and SLT advertisements might reduce use among youth.

Digital marketing of smokeless tobacco: A longitudinal analysis of exposure and initiation among young adults

OBJECTIVES

This study examines the relationships between recall of exposure to digital marketing of smokeless tobacco, via the internet and social media, and subsequent initiation of smokeless tobacco use at one-year follow-up, among young adult never users of smokeless tobacco in Texas.

METHODS

Data were from waves 6 (Spring 2017) and 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Study (Project M-PACT); a longitudinal study of two- and four-year Texas college students. Participants were 2731 young adult never smokeless tobacco users (ages 20-32) with complete data at both assessment periods. A multi-level, multiple logistic regression model was applied, accounting for school clustering, to examine the relationship between recall of exposure to digital marketing of smokeless tobacco at baseline (wave 6) and smokeless tobacco use initiation at one-year follow-up (wave 7). Analyses controlled for important baseline covariates (socio-demographic factors, other marketing exposure, other tobacco product use).

RESULTS

Overall, 14.6% of never smokeless tobacco users reported exposure to smokeless tobacco marketing via digital media. Exposure to digital marketing of smokeless tobacco at baseline was associated with greater odds of smokeless tobacco use initiation among young adult never users (AOR: 2.14; 95%CI: 1.12 - 4.06) at one-year follow-up.

CONCLUSIONS

Findings reveal exposure to smokeless tobacco marketing via digital media was common. Further, there appears to be a strong relationship between this exposure and subsequent smokeless tobacco use among young adult never smokeless tobacco users.

The Reasons for Using Smokeless Tobacco: A Review

Background:

Smokeless tobacco use is a public health problem in some parts of the world. The major objective of this study was to investigate the reasons and factors of consumption.

Methods:

A content analysis was conducted on articles for the past thirty years (1989–2019). We reviewed and selected 400 abstracts of original articles from PubMed databases by the search strategy, and reviewed one by one. Among these, 45 abstracts were selected, in which the patterns of use, the reasons for using, and the determinants and predictors were described. Eleven papers were selected based on the results and related to the research objectives. The results of these articles were evaluated precisely word by word and phrase by phrase with content analysis method and inductive approach.

Results:

The reasons for the use of smokeless tobacco fell in two main themes: socio-cultural structure; and, beliefs, each contained Sub-themes such as “culture and living conditions”, “laws”, “family and peer relationships”, “beliefs related to psychological” and “beliefs related to physical influences”, “beliefs”, “The role of harm perceptions “.

Conclusion:

There was a difference between beliefs, cultures and social conditions among the people about using of smokeless tobacco and the association of these factors is investigated in future studies. We also suggest for the prevention and control of smokeless tobacco use, cultural norms and beliefs will need to address adequately.

Going Smokeless: Promotional Features and Reach of US Smokeless Tobacco Direct-Mail Advertising (July 2017–August 2018)

Introduction

Although cigarette use in the United States has declined over time, smokeless tobacco (SLT) use has remained steady. Direct-mail advertising and coupon redemption have been linked to increased tobacco use, and efforts to promote SLT through direct-mail advertising may contribute to sustained SLT use. We examined reach of SLT direct-mail advertisements by recipient demographics and promotional features, including coupons.

Methods

Direct-mail data (n = 418) were acquired from Comperemedia (Mintel) and coded for product type (traditional [eg, chewing tobacco], pouched [eg, moist snuff, snus], or both [traditional SLT and any pouched SLT products]); promotions (eg, coupons); flavors; and themes (eg, masculinity). Using Mintel’s volume estimates for number of pieces sent, we calculated the proportion of mail volume sent by recipient demographics (age, income, region) and advertising features across product type.

Results

Between July 2017 and August 2018, tobacco companies sent an estimated 249 million pieces of SLT direct-mail to US households; approximately half (49.6%) featured pouched SLT products. Across product types, over 75% of mail volume was sent to 31- to 60-year-old adults and 30–40% was sent to low-income households. The majority (&gt;70%) of pouched SLT product mail contained coupons and flavor promotions. Outdoor and blue-collar-lifestyle themes were prominent in advertisements for all product types, along with less common adventure- and fun-related appeals.

Conclusions

Coupons, flavors, and a combination of blue-collar and fun/adventure message themes were used to promote traditional and pouched SLT products through direct-mail, particularly to low-income households. Results support limits on direct-mail coupon distribution and continued surveillance of marketing appeals.

Implications

There is a long history of research into tobacco advertising practices, largely focusing on cigarettes. This study highlights specific direct-mail marketing tactics used by the tobacco industry, including coupons to promote SLT products across the United States. Given the limited success in reducing SLT use and the association between direct-mail promotions and tobacco use, these study results provide support for policies to restrict use of coupons in direct-to-consumer tobacco marketing and indicate the need for continued surveillance of direct-mail advertisements as the SLT market continues to evolve.