Disparities in retail marketing for menthol cigarettes in the United States, 2015

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019

BACKGROUND

The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC.

METHODS

Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level.

RESULTS

Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors.

CONCLUSIONS

In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity.

IMPLICATIONS

We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

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.

Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999-2018

Introduction

Monitoring menthol cigarette use allows for identification of potential health disparities. We examined sociodemographic and temporal differences in menthol cigarette use among US adults who smoke.

Methods

We analyzed data from the 1999-2018 National Health and Nutrition Examination Survey for adults aged 20 years or older who smoke (N = 11,431) using binary logistic regression.

Results

Among US adults who smoke, 28.8% used menthol cigarettes. After adjusting for age, sex, race and ethnicity, education, income-to-poverty ratio, and health status, the prevalence of menthol use among adults who smoke increased on average by 3.8% (95% CI, 2.7%-4.9%) annually. Non-Hispanic Black adults had the highest average prevalence of menthol cigarette use, 73.0% (95% CI, 70.9%-75.2%), and Mexican American adults had higher average annual increase in menthol cigarette use, 7.1% (95% CI, 4.0%-10.3%). Adults with fair or poor health status had a 4.3% annual increase in menthol cigarette use (95% CI, 2.5%-6.1%). The adjusted prevalence ratios of menthol cigarette use were 1.61 (95% CI, 1.39-1.83) for adults aged 20-29 years compared with those aged 65 years or older, 1.41 (95% CI, 1.32-1.49) for female adults compared with male adults, and 1.17 (95% CI, 1.07-1.27) for high school graduates or higher compared with those with no high school diploma.

Conclusion

Non-Hispanic Black adults who smoke had the highest prevalence of menthol cigarette use among all racial and ethnic groups; the prevalence of menthol cigarette use among adults who smoke increased especially among Mexican American adults, younger adults, and adults who reported fair to poor health status.

Racial and Economic Segregation Over the Life Course and Incident Hypertensive Disorders of Pregnancy Among Black Women in California

Black women in the United States have the highest incidence of hypertensive disorders of pregnancy (HDP) and are disproportionately burdened by its adverse sequalae, compared with women of all racial and ethnic groups. Segregation, a key driver of structural racism for Black families, can provide information critical to understanding these disparities. We examined the association between racial and economic segregation at 2 points and incident HDP using intergenerationally linked birth records of 45,204 Black California-born primiparous mothers (born 1982-1997) and their infants (born 1997-2011), with HDP ascertained from hospital discharge records. Women's early childhood and adulthood neighborhoods were categorized as deprived, mixed, or privileged based on the Index of Concentration at the Extremes (a measure of concentrated racial and economic segregation), yielding 9 life-course trajectories. Women living in deprived neighborhoods at both time points experienced the highest odds of HDP (from mixed effect logistic regression, unadjusted odds ratio = 1.26, 95% confidence interval: 1.13, 1.40) compared with women living in privileged neighborhoods at both time points. All trajectories involving residence in a deprived neighborhood in early childhood or adulthood were associated with increased odds of HDP, whereas mixed-privileged and privileged-mixed trajectories were not. Future studies should assess the causal nature of these associations.

The Association Between the License Fee Increase and the Density of Tobacco Retailers in California-A Segmented Interrupted Time-Series Analysis by Income and Race/Ethnicity

INTRODUCTION

On May 9, 2016, the State of California passed a law to increase the licensing fee for tobacco retailers from a one-time-only fee of $100 to an annual fee of $265, effective on June 9, 2016. This study investigates the association between this fee increase and retailer densities by neighborhood income and race/ethnicity characteristics.

METHODS

We obtained quarterly data on the number of active tobacco retailer licenses from 2011 to 2020 in every zip code in California from the California Department of Tax and Fee Administration. These data were then linked to zip code-level income, race/ethnicity, and population measures. We used a single-group segmented interrupted time-series analysis to assess the association between the increase in licensing fees and retailer densities by neighborhood income and race/ethnicity.

RESULTS

After the implementation of the annual licensing fees, the retailer density decreased both immediately and gradually. Specifically, the retailer density dropped by 0.47 in the first quarter following the intervention. Compared to the pre-intervention time trend, the retailer density decreased quarterly by 0.05. Furthermore, the impacts of increasing licensing fees were more pronounced in low-income and the majority Black zip codes.

CONCLUSIONS

Given that higher smoking prevalence is associated with greater tobacco outlet density, the licensing fee increase could be an effective policy tool to reduce tobacco use among economically disadvantaged and minority Black communities, thereby addressing tobacco-use disparities.

IMPLICATIONS

This study used the single-group segmented interrupted time-series analysis to assess the association between the licensing fee increase and tobacco retailer densities by neighborhood income and race/ethnicity. We found that this licensing fee increase was associated with reduced retailer densities and the total number of active retailers right after the implementation. We further found that the annual licensing fee policy had a continuous effect in reducing tobacco retailer densities in all zip codes. The impacts of increasing licensing fees were more pronounced in low-income and majority of Black zip codes.

Climate change and cancer: the Environmental Justice perspective

Despite advances in cancer control-prevention, screening, diagnosis, treatment, and survivorship-racial disparities in cancer incidence and survival persist and, in some cases, are widening in the United States. Since 2020, there's been growing recognition of the role of structural racism, including structurally racist policies and practices, as the main factor contributing to historical and contemporary disparities. Structurally racist policies and practices have been present since the genesis of the United States and are also at the root of environmental injustices, which result in disproportionately high exposure to environmental hazards among communities targeted for marginalization, increased cancer risk, disruptions in access to care, and worsening health outcomes. In addition to widening cancer disparities, environmental injustices enable the development of polluting infrastructure, which contribute to detrimental health outcomes in the entire population, and to climate change, the most pressing public health challenge of our time. In this commentary, we describe the connections between climate change and cancer through an Environmental Justice perspective (defined as the fair treatment and meaningful involvement of people of all racialized groups, nationalities, or income, in all aspects, including development, implementation, and enforcement, of policies and practices that affect the environment and public health), highlighting how the expertise developed in communities targeted for marginalization is crucial for addressing health disparities, tackling climate change, and advancing cancer control efforts for the entire population.

Tax incidence for menthol cigarettes by race: Evidence from Nielsen Homescan data

We use Nielsen Homescan data to examine whether the incidence of cigarette taxes on menthol products varies with race. We find that taxes are shifted at significantly lower rates to Black smokers of menthol cigarettes than any other smokers. One possible explanation is that the industry targets price promotions to Black menthol smokers because they tend to be more responsive to cigarette prices relative to other smokers. We find evidence that Black smokers receive significantly more price discounts for menthol products than white menthol smokers. Our findings indicate that increasing cigarette taxes would effectively reduce menthol smoking among Black Americans because tax pass-through rate for Black menthol smokers is still substantially above zero.

Impact of Canada's menthol cigarette ban on quitting among menthol smokers: pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the USA

INTRODUCTION

Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA.

METHODS

Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health.

RESULTS

After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans).

CONCLUSIONS

This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

Does removing menthol cigarettes in convenience stores reduce susceptibility to cigarette smoking? An experimental investigation in young people

BACKGROUND

Evidence for the effectiveness of menthol cigarette bans comes mostly from studies of adults that smoke. This experiment evaluated whether the absence of menthol products from a convenience store influenced young people's susceptibility to cigarette smoking after they shopped in the store.

METHODS

This experiment took place in the RAND StoreLab (RSL), a life-sized research convenience store. A three-group, between-subjects design was used. Study conditions differed in the mix of flavored tobacco products the RSL displayed: 1) All tobacco-, sweet-, and menthol-flavors displayed; 2) only tobacco- and menthol-flavors displayed; and 3) only tobacco-flavors displayed. Participants were randomly assigned to shop in the RSL under one of these conditions and after shopping, completed measures of their susceptibility to cigarette smoking, one measure for menthol cigarettes and one for unflavored cigarettes (scores on each susceptibility measure was dichotomized: 0 = not susceptible; 1 = susceptible).

RESULTS

Multivariable logistic regression assessed the main effects of condition on susceptibility to smoking menthol and unflavored cigarettes. There was no condition effect on susceptibility to smoking unflavored cigarettes. However, removing menthol-flavored products significantly increased participants' susceptibility to smoking menthol cigarettes compared to when all flavored products were available (OR = 3.66, 95% CI [1.33, 10.03]). This significant effect was only found among young people with some pre-existing risk of cigarette smoking (OR = 5.92, 95% CI [1.81, 19.39]).

CONCLUSION

Results suggest the need to consider that menthol bans could unintentionally increase the appeal of menthol cigarettes among youth already at risk of smoking.

Evaluation of a Statewide Flavored Tobacco Restriction on Use, Access, and Cessation Among Black and White Tobacco Users in Massachusetts

PURPOSE

To evaluate the impact of a statewide flavored tobacco restriction among Massachusetts residents who use menthol or flavored tobacco and to assess differences in impact between Black and White users, as the tobacco industry has targeted menthol to Black users.

DESIGN

An online survey was distributed through a panel provider and household mailings.

SETTING

Eleven Massachusetts communities with higher-than-state-average Black, Indigenous or People of Color populations.

SUBJECTS

Black (n = 63) and White (n = 231) non-Hispanic residents who used menthol or other flavored tobacco products in the past year.

MEASURES

Impact of the law on use, access, and quitting behaviors.

ANALYSIS

Outcomes were assessed between Blacks and Whites using Pearson chi-square tests.

RESULTS

Over half (53% of White, 57% of Black) of respondents believed the law made it more difficult to access menthol products; two-thirds (67% of White,64% of Black) accessed menthol products in another state. Black users were significantly more likely to report purchasing menthol products off the street (P ≤ .05). One-third (28% of White, 32% of Black) believed the law made it easier to quit, and one-third (27% of White, 34% of Black) completely quit in the past year.

CONCLUSIONS

Flavored tobacco restrictions may positively and equitably impact cessation. Cross-border access and off-the-street purchasing suggest the need for greater cessation support and underscore the importance of a national policy.

Follow the money: a closer look at US tobacco industry marketing expenditures

INTRODUCTION

While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

METHODS

We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

RESULTS

US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

CONCLUSIONS

Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

A Longitudinal Study of Perceptions of the Massachusetts Menthol Ban and Its Impact on Smoking Behaviors among Marginalized Individuals

Menthol cigarettes have had a profound adverse effect on public health. On 1 June 2020, Massachusetts became the first state to ban the sale of menthol cigarettes. We explored how perceptions of the ban and smoking behaviors changed over time among a group of 27 individuals who smoked menthol cigarettes at our safety-net hospital. In a convergent mixed methods study, we administered questionnaires and interviews simultaneously at two timepoints: 1 month pre-ban and 6 months post-ban. Pre-ban, we assessed perceptions of the ban and anticipated smoking behaviors after the ban. Post-ban, we assessed participants' actual smoking behaviors and elicited suggestions to avoid unintended consequences that might undermine intended policy effects. Several respondents perceived the Massachusetts ban as positive because it could promote smoking cessation, prevent youth initiation, and mitigate unfair targeting of socioeconomically disadvantaged populations. Others perceived the ban as an overreach of government policy, financially motivated, and unfairly targeting the Black community. Many continued to smoke menthol cigarettes obtained outside Massachusetts. Individuals suggested promoting tobacco treatment for people affected by the ban and a national ban to circumvent out-of-state purchasing of menthol cigarettes. Our findings suggest that in order to be most effective, healthcare systems must promote tobacco treatment and ensure that treatment is accessible to all individuals affected by the ban.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

OBJECTIVES

Develop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.

METHODS

We developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.

RESULTS

The CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.

CONCLUSIONS

The CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Recent, national trends in US adolescent use of menthol and non-menthol cigarettes

OBJECTIVE

In light of the current U.S. Food and Drug Administration (FDA) proposal to ban menthol cigarettes, this study updates trends in menthol cigarette use among adolescents age 13-18 years up to the year 2020. The study considers a potential role for the ban to reduce black/non-black disparities in menthol cigarette use, as well as a counterargument that a ban is not necessary because menthol use is already diminishing.

METHODS

Data are from annual, cross-sectional, nationally representative Monitoring the Future (MTF) surveys of 85 547 8th, 10th and 12th grade students surveyed between 2012 and 2020. Analyses include trends in past 30-day menthol and non-menthol cigarette smoking among the total adolescent population, as well as stratified by race/ethnicity.

RESULTS

Declines in adolescent menthol and non-menthol cigarette smoking continued through 2020 so that in 2018-2020 past 30-day prevalence for each was less than 1% for non-Hispanic black adolescents and less than 2.2% for non-black adolescents. For non-Hispanic black adolescents no smoking declines in mentholated or non-mentholated cigarette use from 2015-2017 to 2018-2020 were statistically significant, in part because prevalence levels approached a floor effect and had little room to fall further. Menthol levels were lower for non-Hispanic black versus all other adolescents in all study years.

CONCLUSIONS

Continuing declines in adolescent menthol prevalence indicate that both menthol prevalence and also black/non-black disparities in its use are steadily decreasing. However, these decreases in adolescence will take decades to reach later ages through generational replacement. Efforts to accelerate menthol decreases will require new initiatives to increase cessation among adult menthol users.

Trends in Education-Related Smoking Disparities Among U.S. Black or African American and White Adults: Intersections of Race, Sex, and Region

INTRODUCTION

Despite its overall decline in the United States, trends in cigarette smoking could vary by intersection with demographic characteristics. We explored trends in education-related disparities in current smoking among U.S. adults by race (Black or African American and White), sex, and U.S. census region.

AIMS AND METHODS

Data were from U.S. civilian non-institutionalized adults (aged ≥18 years) who self-identified as Black or African American and White and participated in the 1995-2019 Tobacco Use Supplement to the Current Population Survey. We estimated average annual percent changes in current cigarette smoking by the intersections of race, sex, census region, and educational attainment. We calculated educated-related prevalence differences in current cigarette smoking by subtracting the prevalence of bachelor's degrees from that of

RESULTS

Education-related disparities in current cigarette smoking increased over time, especially among Black or African American male (PD1995-1996 = 22.8%; PD2018-2019 = 27.2%) and female adults (PD1995-1996 = 12.1%; PD2018-2019 = 16.5%). By region, Black or African American male adults in the Midwest showed the largest increase in education-related current cigarette smoking disparities, followed by Black or African American male and female adults in the South, and White male and female adults in the Midwest. These findings were because of small to no declines in the prevalence of current cigarette smoking among those with

CONCLUSION AND RELEVANCE

The gap in the prevalence of current cigarette smoking by education widened over time, especially among Black or African American adults in certain regions.

IMPLICATIONS

Despite the decline in the prevalence of current cigarette smoking in the U.S. population overall, such public health gain may not benefit all individuals equally. Using the data from a U.S. representative serial cross-sectional survey study during 1995-2019, we found that disparities in current cigarette smoking prevalence between those with Collapse

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MESH Headings

• Adult
• Female
• Humans
• Male
• Black or African American
• Cigarette Smoking/epidemiology
• Cross-Sectional Studies
• Educational Status
• Prevalence
• Surveys and Questionnaires
• United States/epidemiology
• White
• Health Status Disparities

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Grants

• FDA HHS
• NIMHD NIH HHS
• National Institute on Minority Health and Health Disparities
• U.S. Food and Drug Administration

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Affiliation(s)

Kelvin Choi Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Jamal T Jones Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Andrea L Ruybal Office of Science, Center for Tobacco Products, U.S. Food and Drug Administration, Beltsville, Maryland, USA
Timothy S McNeel Information Management Services, Inc., Calverton, Maryland, USA
Danielle A Duarte Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA
Monica Webb Hooper Office of the Director, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA

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Heated Tobacco Products: Awareness, Beliefs, Use and Susceptibility among US Adult Current Tobacco Users, 2021

Limited data exist on the awareness, beliefs, and use of heated tobacco products (HTPs). Data from 1583 U.S. adult (age ≥ 21 years) current tobacco users were collected in 2021. Participants self-reported HTP awareness, beliefs, use, and susceptibility, as well as current tobacco product use and sociodemographics. We used weighted logistic and multinomial regression models to explore their associations. Overall, 23.6% were aware of, 8.9% had ever used, and 3.0% currently used HTPs. Younger individuals (vs. 61+ years), those with annual income $50,000+ (vs. <$50,000), and those currently using electronic vaping products (vs. non-users) were more likely to be aware of, to have ever used, and to currently be using HTPs (p < 0.05). Black individuals (vs. White) were more likely to report ever and current HTP use (p < 0.05). Current cigarette smoking was not associated with HTP awareness and use (p > 0.05). Holding favorable HTP beliefs was associated with susceptibility to and more advanced HTP use statuses (p < 0.05). Sociodemographics associated with HTP use may reflect HTP marketing strategies. The lack of association with cigarette smoking suggests HTPs may be unlikely cigarette substitutes. Addressing favorable HTP-related beliefs may prevent dual use.

Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers

To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.

Neighborhood distribution of availability of newer tobacco products: A US four-site study, 2021

Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.

Ethnicity and the mechanisms of point-of-sale e-cigarette marketing's influence on behavior: A longitudinal study

Objective: To test the mechanisms by which exposure to point-of-sale (POS) e-cigarette marketing mediate the relationship between an ethnic minority group highly vulnerable for tobacco product use, namely Native Hawaiian/Other Pacific Islander (NHPI), and increased future e-cigarette use through explicit (positive outcome expectancies) and implicit (spontaneous positive reactions) pathways. Method: Four waves of data were collected in 6-month intervals from 2,327 multiethnic young adults (Mage = 21.2, SD = 2.2; 54% women) enrolled across two 4-year and four 2-year colleges belonging to a University system in Hawaii. POS e-cigarette marketing exposure was assessed with an objective measure involving store visit patterns and store audits, as well as a measure of self-reported exposure. Spontaneous reactions were assessed with an implicit measure, namely Affect Misattribution Procedure (AMP). Path analyses were used to test the hypotheses. Results: In a model employing the objective measure of POS exposure, a statistically significant pathway was found from NHPI ethnicity to increased current e-cigarette use at Wave 4 mediated through increased POS exposure at Wave 2, and increased affect regulation expectancies at Wave 3. Similar indirect effects on prospective e-cigarette use were found for Asian ethnicity. The dual process model of the effects of POS exposure on e-cigarette use was not fully supported, although the implicit measure was found to independently predict e-cigarette use. Conclusions: Differential exposure to POS marketing may explain some of the ethnic disparities in tobacco product use behavior such as e-cigarette use. POS marketing may affect e-cigarette use behavior mainly through the explicit pathway, notably affect regulation expectancies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A content analysis of website marketing for cooling flavored e-liquids in a sample of brick-and-mortar vape shops in the Greater Los Angeles area

INTRODUCTION

Menthol is a characterizing flavor in combustible cigarettes and electronic nicotine delivery systems (ENDS). E-liquids are recognized as an important reason for ENDS use. Yet, compared to menthol cigarettes, menthol flavored e-liquids and other cooling flavors, including mint and 'ice' for ENDS, are an understudied area of investigation. The present study examined cooling flavored e-liquid website marketing among brick-and-mortar vape shops in Greater Los Angeles Area.

METHODS

A total of 104 brick-and-mortar vape shops were identified, and 38 had active websites. Over a 30-day period (28 September - 28 October 2020), we collected marketing for all flavored refillable e-liquids (photos/images) from each website. Data were collected for 1330 products. Only refillable e-liquid bottles were selected for this study, excluding prefilled pod vapes and disposable vapes. Each e-liquid per website was coded (e.g. menthol or not) and grouped into categories (e.g. type of menthol). The three flavor descriptor categories that the e-liquids were grouped into were menthol, mint, or ice. An 'other' category was also created for identified e-liquids with flavor descriptors that did not mention menthol, mint, or ice.

RESULTS

A total of 1330 e-liquid flavors were identified from 38 active websites. Among them, 219 were coded as menthol/mint/ice flavor e-liquids. Frequencies included ice/iced/icy (n=123; 56%), menthol (n=32; 15%), mint (n=23; 11%), and other (n=41; 19%). Of the 123 ice-flavor e-liquids, 70.3% (n=83) were in combination with fruit (e.g. 'Apple Ice', 'Grape Iced', 'Icy Mango'). Of the 32 menthol-flavored e-liquids, 63.3% (n=19) were in combination with fruit (e.g. 'Dragon Fruit Menthol', 'Blue Raspberry Menthol', 'Fresh Peach Menthol'). Flavors in the other category were ice-related flavor descriptors (e.g. 'Arctic Air', 'Brain Freeze', 'Frozen Hulk Tears').

CONCLUSIONS

Brick-and-mortar vape shops in the Greater Los Angeles Area market a variety of cooling flavor e-liquids on their websites. Such marketing focused largely on ice fruit flavor combinations. Future research is needed to understand how exposure to and appeal of cooling flavored e-liquid marketing differs among diverse consumer groups, including adult menthol cigarette smokers and non-smoking youth.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Cancer statistics for African American/Black People 2022

African American/Black individuals have a disproportionate cancer burden, including the highest mortality and the lowest survival of any racial/ethnic group for most cancers. Every 3 years, the American Cancer Society estimates the number of new cancer cases and deaths for Black people in the United States and compiles the most recent data on cancer incidence (herein through 2018), mortality (through 2019), survival, screening, and risk factors using population-based data from the National Cancer Institute and the Centers for Disease Control and Prevention. In 2022, there will be approximately 224,080 new cancer cases and 73,680 cancer deaths among Black people in the United States. During the most recent 5-year period, Black men had a 6% higher incidence rate but 19% higher mortality than White men overall, including an approximately 2-fold higher risk of death from myeloma, stomach cancer, and prostate cancer. The overall cancer mortality disparity is narrowing between Black and White men because of a steeper drop in Black men for lung and prostate cancers. However, the decline in prostate cancer mortality in Black men slowed from 5% annually during 2010 through 2014 to 1.3% during 2015 through 2019, likely reflecting the 5% annual increase in advanced-stage diagnoses since 2012. Black women have an 8% lower incidence rate than White women but a 12% higher mortality; further, mortality rates are 2-fold higher for endometrial cancer and 41% higher for breast cancer despite similar or lower incidence rates. The wide breast cancer disparity reflects both later stage diagnosis (57% localized stage vs 67% in White women) and lower 5-year survival overall (82% vs 92%, respectively) and for every stage of disease (eg, 20% vs 30%, respectively, for distant stage). Breast cancer surpassed lung cancer as the leading cause of cancer death among Black women in 2019. Targeted interventions are needed to reduce stark cancer inequalities in the Black community.

Longitudinal Associations Between Changes in Cigarette Smoking and Alcohol Use, Eating Behavior, Perceived Stress, and Self-Rated Health in a Cohort of Low-Income Black Adults

BACKGROUND

Black adults in the U.S. experience significant health disparities related to tobacco use and obesity. Conducting observational studies of the associations between smoking and other health behaviors and indicators among Black adults may contribute to the development of tailored interventions.

PURPOSE

We examined associations between change in cigarette smoking and alcohol use, body mass index, eating behavior, perceived stress, and self-rated health in a cohort of Black adults who resided in low-income urban neighborhoods and participated in an ongoing longitudinal study.

METHODS

Interviews were conducted in 2011, 2014, and 2018; participants (N = 904) provided at least two waves of data. We fit linear and logistic mixed-effects models to evaluate how changes in smoking status from the previous wave to the subsequent wave were related to each outcome at that subsequent wave.

RESULTS

Compared to repeated smoking (smoking at previous and subsequent wave), repeated nonsmoking (nonsmoking at previous and subsequent wave) was associated with greater likelihood of recent dieting (OR = 1.59, 95% CI [1.13, 2.23], p = .007) and future intention (OR = 2.19, 95% CI [1.61, 2.98], p < .001) and self-efficacy (OR = 1.64, 95% CI [1.21, 2.23], p = .002) to eat low calorie foods, and greater odds of excellent or very good self-rated health (OR = 2.47, 95% CI [1.53, 3.99], p < .001). Transitioning from smoking to nonsmoking was associated with greater self-efficacy to eat low calorie foods (OR = 1.89, 95% CI [1.1, 3.26], p = .021), and lower perceived stress (β = -0.69, 95% CI [-1.34, -0.05], p = .036).

CONCLUSIONS

We found significant longitudinal associations between smoking behavior and eating behavior, perceived stress, and self-rated health. These findings have implications for the development of multiple behavior change programs and community-level interventions and policies.

A commentary on adolescent electronic cigarette use and nicotine addiction

Adolescent electronic cigarette (e-cigarette) use has continued due to the ongoing struggle with nicotine addiction affecting teenagers. By briefly discussing the timeline of the emergence of e-cigarettes and nicotine addiction in adolescents, this author hopes to shed some light on mitigation strategies to curtail this ongoing epidemic of youth e-cigarette use and nicotine addiction through public health education and advocacy.

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).

Inequitable distribution of FTP marketing by neighborhood characteristics: further evidence for targeted marketing

Introduction

Flavored tobacco products (FTPs) are disproportionately used among young people and racial/ethnic minority populations. However, few studies have examined the retail distribution of such product marketing beyond menthol cigarettes. This study created geographic-based predictions about marketing of FTPs (overall, cigarettes, cigars, e-cigarettes, and smokeless) in stores across Washington, DC neighborhoods. We examined neighborhood-level demographic correlates of the amount of FTP and non-FTP marketing.

Methods

We conducted photographic audits of interior and exterior tobacco marketing in 96 Washington, DC tobacco retailers visited by 149 young adult respondents between 2018–2019. We created a geographic predictive surface of overall and product-specific tobacco marketing and then estimated the average predicted amount of marketing at the census-tract level using zonal statistics. Using linear regression, we examined neighborhood demographic correlates (race/ethnicity, family poverty, and youth population under 18) of FTP and non-FTP marketing.

Results

The predicted amount of non-FTP ads/displays were evenly distributed with no neighborhood variability (Range 8.46–8.46). FTP marketing overall was geographically concentrated with greater range across neighborhoods (Range 6.27–16.77). Greater FTP marketing overall and flavored cigar marketing was available in neighborhoods with higher percentages of Black residents. Flavored cigar marketing was less available in neighborhoods with more Hispanic residents, but there was greater flavored smokeless tobacco marketing. Nonflavored marketing overall and by product did not vary across neighborhoods.

Conclusions

This study provides evidence of disproportionate distribution of FTP marketing in Black neighborhoods, especially for flavored cigars, at the point-of-sale. Policies that restrict the sale of FTPs may enhance health equity.

Implications

Tobacco marketing has frequently been shown to be more prevalent in neighborhoods with lower household income and more Black residents. Using geographic-based predictions, we find that greater flavored tobacco marketing in these neighborhoods, not decreased marketing for nonflavored tobacco, is driving this disparity. Targeting Black neighborhoods with increased marketing of flavored tobacco products, which has been found to be more appealing, easier to use, and harder to quit is a social justice issue.

The impact of menthol cigarette use on quit attempts and abstinence among smokers with opioid use disorder

An exceedingly high proportion of persons with opioid use disorder (OUD) smoke cigarettes. Smokers with OUD face multiple barriers to smoking cessation. While menthol cigarette use has been associated with low cessation rates, research has not explored the impact of menthol cigarette use on tobacco use outcomes among smokers with OUD. Participants were current smokers, in methadone treatment for OUD, participating in randomized controlled trials of smoking cessation therapies. We examined the use of menthol cigarettes, and the association between menthol cigarette use and achieving 24-hour quit attempts and seven-day point prevalence abstinence. Of 268 participants, 237 (88.4%) reported menthol use. A similar proportion of menthol and non-menthol smokers achieved a 24-hour quit attempt (83.1% vs. 83.8%, p = 0.92). Though fewer menthol smokers (vs. non-menthol smokers) achieved abstinence (12.7% vs. 22.6%), this did not reach statistical significance (p = 0.14). In this sample of smokers with OUD, menthol smoking was nearly ubiquitous. Menthol smoking was not associated with differences in quit attempts, but was associated with differences in cessation that were not statistically significant. Menthol smoking may contribute to the challenges in achieving abstinence among smokers with OUD.

Reducing Health Disparities in Radiology Through Social Determinants of Health: Lessons From the COVID-19 Pandemic

During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect the critical role of social determinants of health, which are manifestations of entrenched structural inequities. In radiology, social determinants of health lead to disparate use of imaging services through multiple intersecting contributors, on both the provider and patient side, affecting diagnosis and treatment. Disparities on the provider side include ordering of initial or follow-up imaging studies and providing standard-of-care interventional procedures, while patient factors include differences in awareness of screening exams and confidence in the healthcare system. Disparate utilization of mammography and lung cancer screening lead to delayed diagnosis, while differential provision of minimally invasive interventional procedures contributes to differential outcomes related to treatment. Interventions designed to mitigate social determinants of health could help to equalize the healthcare system. Here we review disparities in access and health outcomes in radiology. We investigate underlying contributing factors in order to identify potential policy changes that could promote more equitable health in radiology.

The Relationship Between Menthol Cigarette Use, Smoking Cessation, and Relapse: Findings From Waves 1 to 4 of the Population Assessment of Tobacco and Health Study

INTRODUCTION

Some, but not all, studies suggest that menthol cigarette smokers have more difficulty quitting than non-menthol cigarette smokers. Inconsistent findings may be a result of differences in smoker characteristics (eg, daily vs. non-daily smokers) across studies. This study examines the relationship between menthol cigarette use, cessation, and relapse in a longitudinal, nationally representative study of tobacco use in the United States.

AIMS AND METHODS

Data come from four waves of the Population Assessment of Tobacco and Health Study. Waves 1-4 were conducted approximately annually from September 2013 to January 2018. Generalized estimating equation models were used to prospectively examine the relationship between menthol cigarette use, cessation, and relapse in non-daily and daily adult (18+) smokers. Cessation was defined as smokers who had not used cigarettes within the past 30 days at their subsequent assessment. Relapse was defined as cessation followed by past 30-day smoking in the next assessment.

RESULTS

Among daily smokers (n = 13 710), 4.0% and 5.3% of menthol and non-menthol smokers quit after 1 year, respectively. In an adjusted model, menthol smokers were less likely to quit compared with non-menthol smokers (odds ratio [OR] = 0.76 [0.63, 0.91]). When the sample was stratified by race/ethnicity, African American (OR = 0.47 [0.24, 0.91]) and White (OR = 0.78 [0.63, 0.97]) daily menthol users were less likely to have quit. Among non-daily smokers (n = 3608), there were no significant differences in quit rates. Among daily and non-daily former smokers, there were also no differences in relapse rates between menthol and non-menthol smokers.

CONCLUSIONS

Menthol cigarette use is associated with lower odds of cessation.

IMPLICATIONS

Findings from this study suggest that menthol cigarette use is associated with lower odds of cessation, but not relapse. Removing menthol cigarettes from the market may improve cessation rates.

One health disparities and COVID-19

 

The global impact of the COVID-19 pandemic has disproportionately affected some communities and populations more than others. We propose that an interdisciplinary framework of 'One Health Disparities' advances understanding of the social and systemic issues that drive COVID-19 in vulnerable populations. One Health Disparities integrates the social environment with One Health perspectives on the interconnectedness of human, animal, and environmental health. To apply this framework, we consider One Health Disparities that emerge in three key components of disease transmission: exposure, susceptibility, and disease expression. Exposure disparities arise through variation in contact with COVID-19's causative agent, SARS-CoV-2. Disparities in susceptibility and disease expression also exist; these are driven by biological and social factors, such as diabetes and obesity, and through variation in access to healthcare. We close by considering how One Health Disparities informs understanding of spillback into new animal reservoirs, and what this might mean for further human health disparities.

Lay summary

One Health focuses on interconnections between human, animal, and environmental health. We propose that social environments are also important to One Health and help illuminate disparities in the coronavirus pandemic, including its origins, transmission and susceptibility among humans, and spillback to other species. We call this framework One Health Disparities.

Retail Marketing of Menthol Cigarettes in Los Angeles, California: a Challenge to Health Equity

INTRODUCTION

Sales of menthol cigarettes continue to increase, accounting for a third of the US cigarette market. Retail marketing of menthol cigarettes is a contributing factor to tobacco-related health disparities. To inform regulation to address associated disparities, we examined retail marketing strategies for menthol cigarettes and their features and characteristics in relation to neighborhood racial/ethnic composition.

METHODS

We used multilevel regression models to examine associations of neighborhood racial/ethnic composition and store type with menthol cigarette sales outcomes, including availability, exterior advertising, price promotions, and price in a sample of tobacco retailers (N = 673) in Los Angeles County neighborhoods with a median or below-median household income. We also recorded the prices of Newport cigarettes (the highest selling menthol cigarette brand in the United States) and blu disposable menthol e-cigarettes.

RESULTS

Overall, 94.5% of retailers sold menthol cigarettes, 31.2% displayed menthol cigarette price promotions, and 30.2% displayed at least one menthol cigarette advertisement on their exterior. Adjusting for racial/ethnic zip code cluster and store type, stores located in predominantly African American neighborhoods showed significantly higher odds in the availability of Newport cigarettes than stores in Hispanic neighborhoods (OR = 0.21; 95% CI, 0.09-0.53; P = .001) or non-Hispanic White (OR = 0.12; 95% CI, 0.05-0.31; P < .001) neighborhoods. Stores located in predominantly African American neighborhoods displayed significantly higher odds of having price promotions for menthol cigarettes and storefront advertisements than those in Hispanic neighborhoods (OR = 0.51; 95% CI, 0.30-0.88; P = .02 and OR = 0.25; 95% CI, 0.13-0.48; P < .001, respectively).

CONCLUSION

In 2016 and 2017, menthol cigarettes were widely available in Los Angeles County across racial/ethnic neighborhoods. We found a disproportionate number of storefront advertisements and price promotions for menthol cigarettes in stores located in predominantly African American neighborhoods along with the lowest advertised pack price. This evidence supports tobacco control policies that restrict menthol cigarette sales in the retail environment.

Differences in Smoking Topography and Subjective Responses to Smoking Among African American and White Menthol and Non-Menthol Smokers

INTRODUCTION

It has been suggested that menthol increases exposure to harmful elements of smoking and makes smoking more rewarding, easier to initiate, and harder to quit. Isolating the direct effects of menthol is challenging as African American (AA) race and menthol preference are highly overlapping. This study evaluated smoking behavior and subjective responses among a balanced sample of AA and white menthol and non-menthol smokers. In addition, smoking topography (ST) was compared to naturalistic smoking (NS) and interactions with menthol and race were explored.

AIMS AND METHODS

Smokers (N = 100) smoked and rated their preferred brand of cigarettes via ST or NS during two laboratory visits (counterbalanced).

RESULTS

Controlling for baseline differences among the groups (eg, nicotine dependence), menthol smokers took shorter and smaller puffs and AA smokers took longer puffs, but there were no differences in total puff volume, carbon monoxide, or other ST parameters. Menthol smokers reported greater urge reduction and lower sensory stimulation. The smoking method (ST vs. NS) had no effects on smoking behavior or exposure. Cigarettes smoked via ST were rated stronger. Differences in satisfaction based on the smoking method interacted with race and menthol status. Ratings of aversion differed by race and menthol status.

CONCLUSIONS

Menthol was not associated with increased smoke exposure or reward (except for urge reduction). ST caused minimal experimental reactivity relative to NS. Additional research that isolates the effects of menthol and examines potential interactive effects with race and other variables is needed to better understand its role in smoking-related health disparities.

IMPLICATIONS

Menthol and non-menthol smokers differed on some demographic variables and menthol preference was associated with greater nicotine dependence and greater urge reduction after smoking. Menthol was not associated with greater smoke exposure. Future research that investigates the unique risks associated with menthol and examines potential interactive effects with race and other related variables is warranted to better understand the role of menthol in smoking-related health disparities.

High Rates of Menthol Cigarette Use Among Pregnant Smokers: Preliminary Findings and Call for Future Research

INTRODUCTION

Smoking during pregnancy remains widespread and is causally associated with infant morbidity and mortality. Despite links between menthol cigarette use and decreased smoking cessation, little is known regarding rates or characteristics of pregnant menthol cigarette smokers.

METHODS

Participants were drawn from two low-income, racially/ethnically diverse cohorts of pregnant smokers recruited from 2006 to 2015 (N = 166, Mage = 25 ± 5). Demographics, menthol cigarette use, daily cigarette use, quit status, and consecutive weeks quit were assessed by prospective interviews. Nicotine dependence was assessed using the Fagerström Test of Nicotine Dependence. Nicotine levels were assessed via saliva cotinine.

RESULTS

High rates of menthol use were found in both cohorts (85% and 87%). Across both cohorts, menthol smokers were more likely to identify as racial/ethnic minorities, were less educated, and reported lower income than non-menthol smokers (ps < .03). Menthol smokers also reported fewer continuous weeks quit (8.4 vs. 14.5 weeks quit; p < .03) and a tendency toward decreased likelihood of quitting smoking over pregnancy (29% vs. 48%; p < .08) in unadjusted but not in covariate-adjusted analyses. No differences emerged in cigarettes per day, nicotine dependence or nicotine exposure.

CONCLUSIONS

We found very high rates of menthol cigarette use in pregnant smokers-particularly among racial/ethnic minority and low socioeconomic status smokers-and some evidence for associations with reduced smoking cessation in pregnancy. Consideration of pregnant smokers as a uniquely vulnerable population is warranted in evaluating regulation of menthol in cigarettes. Further research is needed regarding the impact of menthol on smoking persistence in pregnancy and on maternal and infant health outcomes.

IMPLICATIONS

This study highlights high rates of menthol cigarette use in pregnant women in the Northeast, United States, with evidence for higher rates of menthol use among racial/ethnic minority, less educated and low-income pregnant smokers, and preliminary evidence for associations between menthol cigarette use and reduced smoking cessation. Consideration of the effects of menthol on smoking persistence in pregnant women and on the health of their offspring is warranted in the development of regulations regarding menthol in cigarettes.

Inequities in tobacco advertising exposure among young adult sexual, racial and ethnic minorities: examining intersectionality of sexual orientation with race and ethnicity

OBJECTIVE

This study examined sexual orientation differences in encoded exposure to tobacco product ads and intersections with race and ethnicity.

METHODS

We analysed data from young adults (18-24) from the US Population Assessment of Tobacco and Health Study in 2013 and 2014 (N=9110). First, we compared encoded exposure to cigarette, electronic cigarette (e-cigarette), cigar and smokeless tobacco ads between sexual minorities (lesbian/gay, bisexual and something else) versus heterosexual young adults. We then analysed encoded ad exposure across sexual orientation, racial and ethnic subgroups. Analyses controlled for demographic and tobacco use variables.

RESULTS

Bisexual women had significantly higher prevalence of encoded exposure to cigarette and cigar ads compared with heterosexual women, and significantly higher prevalence of encoded e-cigarette ad exposure compared with both heterosexual and lesbian/gay women. There were no significant differences in encoded ad exposure between lesbian versus heterosexual women and between gay or bisexual men versus heterosexual men. Compared with heterosexual white counterparts, increased encoded ad exposures were reported by heterosexual black women (cigarette and cigar ads), black heterosexual men (cigar ads) and bisexual black women (cigarette and cigar ads). Compared with heterosexual non- Hispanic counterparts, increased encoded ad exposures were reported by bisexual Hispanic women (cigarette, e-cigarette and cigar ads) and heterosexual Hispanic men (cigarettes and cigar ads).

CONCLUSION

Sexual minority women of colour and black heterosexual women and men have increased encoded exposure to certain forms of tobacco ads. Further research is needed to address the impact of tobacco ads among multiple minority individuals based on sex, sexual orientation, race and ethnicity.

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.

Perceptions of Use Patterns and Health Consequences Associated With Mentholated Cigarettes Among U.S. Adults

Despite declines in overall cigarette smoking in the United States, menthol cigarette smoking prevalence has increased among young adults (18-25 years) and remains constant among older adults (26 years and older). Disparities in menthol cigarette use exist, with higher prevalence among younger adult smokers and among racial/ethnic minority populations. Menthol in cigarettes has been shown to play a role in increasing smoking initiation and making it more difficult to quit smoking. Little research focuses on perceptions of the addictive potential and health consequences of menthol cigarette use. This analysis uses data from a national panel of U.S. adults (n = 1,303) surveyed in 2016. Participants were asked to what extent they agreed with various statements regarding menthol use among demographic and tobacco use subgroups. These data reveal disparities in perceptions of the impact of menthol use, with Black, non-Hispanic, and Hispanic adults and adults with lower income and less education misperceiving the health effects and addiction potential of menthol in cigarettes. Determining how and to what extent population subgroups understand the effect of menthol cigarette use can inform public education strategies and, in turn, policy efforts to ban or restrict menthol cigarette availability.

Mind the Gap: Changes in Cigarette Prices After California's Tax Increase

Objective

To investigate whether California's 2017 cigarette tax increase was passed onto smokers equally.

Methods

Auditors recorded 4 cigarette prices in the same random sample of licensed tobacco retailers (N = 1049) before the tax increase (January-March 2017) and after (April-September 2018): Natural American Spirit (ultra-premium), Newport menthol (premium), and Pall Mall (value) all from the same manufacturer, and Marlboro (premium). Ordinary least squares regressions examined how the gap in prices (increase greater or less than $2.00 tax) varied by market segment and neighborhood demographics, controlling for store type and months since implementation. Paired t-tests assessed whether industry/retail revenue (price in excess of state and federal excise taxes) increased.

Results

Over-shifting (increase greater than tax) was evident for all 4 brands and was significantly greater for ultra-premium (Mean = $0.40, SD = 0.75) than premium (Mean = $0.25, SD = 0.78) and greater for premium than value brand (Mean = $0.16, SD = 0.67). However, under-shifting (increase less than tax) was evident for Newport in African-American neighborhoods and Pall Mall in Hispanic neighborhoods. After the tax increase, prices were significantly more likely to be discounted and significantly more stores advertised a discount on cigarettes.

Conclusion

California's tax increase was not passed onto consumers equally. Non-tax mechanisms to increase price could support intended effects of tobacco taxes.

Flavour types used by youth and adult tobacco users in wave 2 of the Population Assessment of Tobacco and Health (PATH) Study 2014-2015

BACKGROUND

Most youth and young adult (YA) tobacco users use flavoured products; however, little is known about specific flavours used.

METHODS

We report flavour types among US tobacco users from the Population Assessment of Tobacco and Health Study, wave 2, 2014-2015. At wave 2, we examined (1) flavour use and type at past 30-day use; (2) new flavoured tobacco product use and type; (3) product-specific flavour patterns across youth (ages 12-17) (n=920), YA (18-24) (n=3726) and adult (25+) (n=10 346) past 30-day and new tobacco users and (4) concordance between self-coded and expert-coded brand flavour type among all adults (18+).

RESULTS

Prevalence of flavoured tobacco product use was highest among youth, followed by YA and adult 25+ any tobacco users. Within each age group, flavoured use was greatest among hookah, e-cigarette and snus users. Overall, menthol/mint, fruit and candy/sweet were the most prevalent flavour types at first and past 30-day use across age groups. For past 30-day use, all flavour types except menthol/mint exhibited an inverse age gradient, with more prevalent use among youth and YAs, followed by adults 25+. Prevalence of menthol/mint use was high (over 50% youth, YAs; 76% adults 25+) and exhibited a positive age gradient overall, though the reverse for cigarettes. Brand-categorised and self-reported flavour use measures among adults 18+ were moderately to substantially concordant across most products.

CONCLUSIONS

Common flavours like menthol/mint, fruit and candy/sweet enhance appeal to young tobacco users. Information on flavour types used by product and age can inform tobacco flavour regulations to addess flavour appeal especially among youth.