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

Smoking cessation among sexual minority women: Differences in cigarette quit ratios across age, race/ethnicity, and sexual orientation

OBJECTIVE

Sexual minority (SM) women experience tobacco-related disparities and report a higher prevalence of cigarette use, as well as subgroup differences in use, but little is known about their quitting behavior. This study used data from a national sample of United States SM women to examine cigarette quit ratios overall and by age, race/ethnicity, and sexual orientation.

METHODS

Using baseline survey data from the Generations Study (2016-2017, N = 812), we calculated quit ratios among SM women reporting lifetime smoking (100+ cigarettes) who reported currently smoking "not at all" relative to those reporting smoking "every day or some days." Quitting was compared across cohort, race/ethnicity, and sexual orientation, controlling for household income.

RESULTS

SM women reporting lifetime smoking in the older cohort were significantly more likely to report quitting than those in the younger cohort. Bisexual women also reported a greater likelihood of quitting than gay/lesbian women. There was no association between race/ethnicity and the probability of quitting smoking.

CONCLUSIONS

SM women remain a priority for tobacco prevention and cessation efforts. There is evidence that the probability of quitting cigarettes differs across sexual orientation and age cohorts, which has implications for tailoring of interventions and tobacco communications.

Examining Racial/Ethnic Disparities in Tobacco Dependence Treatment Among Medicaid Beneficiaries Using Fifty State Medicaid Claims, 2009-2014

In the USA, low-income racial/ethnic minority groups experience higher smoking rates and greater smoking-related disease burden than their White counterparts. Despite the adverse effects, racial/ethnic minorities are less likely to access tobacco dependence treatment (TDT). Medicaid is one of the largest payers of TDT in the USA and covers predominantly low-income populations. The extent of TDT use among beneficiaries from distinct racial/ethnic groups is unknown. The objective is to estimate racial/ethnic differences in TDT use among Medicaid fee-for-service beneficiaries. Using a retrospective study design and 50 state (including the District of Columbia) Medicaid claims (2009-2014), we employed multivariable logistic regression models and predictive margin methods to estimate TDT use rates among adults (18-64) enrolled (≥ 11 months) in Medicaid fee-for-service programs (January 2009-December 2014) by race/ethnicity. The population included White (n = 6,536,004), Black (n = 3,352,983), Latinx (n = 2,264,647), Asian (n = 451,448), and Native American/Alaskan Native (n = 206,472) beneficiaries. Dichotomous outcomes reflected service use in the past year. Any TDT use was operationalized as any smoking cessation medication fill, any smoking cessation counseling visit, or any smoking cessation outpatient visit. In secondary analyses, we disaggregated TDT use into three separate outcomes. Results suggested that Black (10.6%; 95% CI = 9.9-11.4%), Latinx (9.5%; 95% CI = 8.9-10.2%), Asian (3.7%; 95% CI = 3.4-4.1%), and Native American/Alaskan Native (13.7%; 95% CI = 12.7-14.7%) beneficiaries had lower TDT use rates compared to White beneficiaries (20.6%). Similar racial/ethnic treatment disparities were identified across all outcomes. By identifying significant racial/ethnic disparities in TDT use between 2009 and 2014, this study provides a benchmark against which to measure recent interventions in state Medicaid programs improving equity in smoking cessation interventions.

Public health impact of a US menthol cigarette ban on the non-Hispanic black population: a simulation study

INTRODUCTION

With the US Food and Drug Administration recently proposing to implement a ban on menthol cigarettes, it is critical to estimate the potential public health effects of such a ban. With high rates of menthol cigarette use and important smoking-related health disparity implications, the impact of the ban on the non-Hispanic black (NHB) population merits strong consideration.

METHODS

We apply the previously developed Menthol Smoking and Vaping Model to the NHB population. A status quo scenario is developed using NHB-specific population, smoking and vaping initiation, cessation and death rates. Estimates from a recent expert elicitation on behavioural impacts of a menthol cigarette ban on the NHB population are used to develop a menthol ban scenario implemented in 2021. The public health impacts of the menthol ban are estimated as the difference between smoking and vaping attributable deaths (SVADs) and life years lost (LYLs) in the status quo and the menthol ban scenarios from 2021 to 2060.

RESULTS

Under the menthol ban scenario, overall smoking is projected to decline by 35.7% in 2026 and by 25.3% in 2060 relative to the status quo scenario. With these reductions, SVADs are estimated to fall by about 18.5% and LYLs by 22.1%, translating to 255 895 premature deaths averted, and 4.0 million life years gained over a 40-year period.

CONCLUSIONS

A menthol cigarette ban will substantially reduce the smoking-associated health impact on the NHB population, thereby reducing health disparities.

Neighborhood socioeconomic status and race are associated with incidence disparities in oral cavity cancers

OBJECTIVES

To determine the association between neighborhood socioeconomic status (nSES), race and incidence rate trends of oral cavity cancer (OCC).

MATERIALS AND METHODS

We used data from the SEER (Surveillance, Epidemiology, and End Results) 18 Census Tract-level SES and Rurality Database (2006-2018) database of the National Cancer Institute to create cohorts of OCC patients between 2006 and 2018. Annual incidence rates were calculated and trends in rates were estimated using joinpoints regression.

RESULTS

The incidence of OCC is the highest among low nSES White Americans (2.86 per 100 000 persons) and the lowest among high nSES Black Americans (1.17 per 100 000 persons). Incidence has significantly increased among Asian Americans (annual percent change [APC]: low nSES-2.4, high nSES-2.6) and White Americans (APC: low nSES-1.4, high nSES-1.6). Significant increases in the incidence of oral tongue cancer in these groups primarily drive this increase. Other increases were noted in alveolar ridge cancer among White Americans and hard palate cancer among Asian Americans. OCC incidence decreased significantly in Hispanic Americans of high nSES (APC: -2.5) and Black Americans of low nSES (APC: -2.7). Floor of mouth cancer incidence decreased among most groups.

CONCLUSION

Despite the overall decreasing incidence of OCC, these trends are inconsistent among all OCC subsites. Differences are seen by race, nSES, and subsite, indicating intersectional barriers that extend beyond nSES and race and ethnicity alone. Further research on risk factors and developing interventions targeting vulnerable groups is needed.

Black Americans' Diminished Return of Educational Attainment on Tobacco Use in Baltimore City

BACKGROUND

Socioeconomic status (SES) indicators such as educational attainment are fundamental factors affecting health. One mechanism through which education affects health is by reducing the likelihood of engaging in high-risk behaviors such as smoking. However, according to the marginalization-related diminished returns (MDRs) theory, the association between education and health may be weaker for marginalized populations such as Black than White, primarily due to racism and discrimination. However, little is known about the racial variations in the differential associations between educational attainment and tobacco use in a local setting.

AIM

This study aimed to investigate the differential association between educational attainment and tobacco use among racial groups in a community sample in Baltimore City.

METHODS

This cross-sectional study used data from a community survey conducted in 2012-2013 in Baltimore City among adults aged 18 years or older. The participants were 3501 adults. Univariate, bivariate, and logistic regression analyses were performed using Stata to investigate the racial difference in the association between education and two outcomes: current smoking status and menthol tobacco product use.

RESULTS

The study found that adults with a graduate degree were less likely to be current smokers (adjusted odds ratio [AOR]: 0.10, 95% confidence interval [CI]: 0.08-0.13) and menthol tobacco users (AOR: 0.10, 95% CI: 0.07-0.14) compared to those with less than high school diploma. The inverse associations between educational attainment and current smoking (AOR: 1.83, 95% CI: 1.05-3.21) and menthol tobacco product use (AOR: 4.73, 95% CI: 2.07-10.80) were weaker for Back individuals than those who were White.

CONCLUSION

Due to MDRs of educational attainment, while highly educated White adults show a low risk of tobacco use, educated Black adults remain at a disproportionately increased risk. The study emphasizes the need for better policies and programs that address minorities' diminished return of education for tobacco use.

Switching away from smoking at 12 months among adult JUUL users varying in recent history of quit attempts made with and without smoking cessation medication

Some smokers switch away from smoking using e-cigarettes, but guidelines recommend trying approved medications first. We analyzed switching in adult smokers using JUUL by their recent history of quit attempts and use of smoking cessation medications. Participants were 8511 adult (21+) established smokers (at baseline), in which 50.3% are daily smokers, in a longitudinal observational study who completed a survey 12 months after first purchasing a JUUL Starter Kit. At baseline, participants reported attempts to quit smoking in the prior year and use of pharmacotherapy (nicotine replacement therapy [NRT] or prescription medication) in their most recent attempt. The outcomes were switching (self-reported no past-30-day smoking) and 50%+ reductions in cigarette consumption. Multivariable analyses were adjusted for baseline covariates. Two thirds of the participants had made a quit attempt in the year before purchasing JUUL. Overall, 59% [58%, 60%] had switched at 12 months. Switching was more likely in those who had used NRT and who attempted quitting without medication versus those who used prescription medications or made no quit attempt. In adjusted multivariable analyses, only making a past-year quit attempt (vs. not) was associated with higher odds of switching (OR = 1.15 [1.04, 1.28]). Over 60% of dual users reduced cigarette consumption by ≥50%. These associations were largely similar in daily smokers. Twelve months after purchasing JUUL, almost all smokers reported either switching or reducing their smoking by 50%+, including those who had recently failed to quit smoking with approved pharmacotherapies. E-cigarettes provide an alternative route to abstinence from smoking for smokers with a history of cessation and cessation treatment failure.

Stagnant daily smoking prevalence between 2008 and 2019 among Black and Hispanic adults with serious psychological distress

BACKGROUND

Racial/ethnic minority status and mental illness independently drive inequity in cigarette smoking and related morbidity. Racial/ethnic minority groups suffer a disproportionate burden of tobacco-related diseases. People with serious mental illness (SMI) smoke at up to 7 times the rate of the general population. There is a need to quantify smoking prevalence and trends among people at the intersection of both groups.

METHODS

This study analyzes 2008-2019 data from the National Survey on Drug Use and Health. Linear time trends of daily smoking prevalence were assessed among people with serious psychological distress (SPD; marker for SMI) and people without SPD reporting White, Black, Hispanic, and Other race/ethnicity using logistic regression, with survey year as the predictor. Models with year-by-smoking status interaction terms and F-tests assessed differential time trends.

RESULTS

The prevalence of daily smoking among people without SPD decreased over time among people reporting White (aOR=0.96, p<0.001), Black (aOR=0.96, p<0.001), Hispanic (aOR=0.95, p<0.001), and Other (aOR=0.97, p=0.002) race/ethnicity. Among people with SPD, the smoking prevalence decreased among people with White race/ethnicity (aOR=0.95, p<0.001), with no significant changes among people of Black, Hispanic, and Other race/ethnicity.

CONCLUSIONS

Smoking among people with SPD who report Black and Hispanic race/ethnicity has not changed significantly in the past 11 years, despite decreasing among non-SPD and White groups. People who are Black/Hispanic and people with SPD struggle to quit smoking, which is amplified intersectionally. Tailored interventions may be a better mechanism to reduce barriers to smoking cessation in this population.

Responses of African American Individuals Who Use Menthol Cigarettes to Potential Flavored Tobacco Bans

INTRODUCTION

The U.S. Food and Drug Administration has proposed new product standards regarding the availability of menthol cigarettes and flavored cigars in the U.S. However, it is unclear whether limiting characterizing flavors in cigarettes and cigars as proposed, or across all tobacco products, produces differential effects on the tobacco use behaviors of African American/Black individuals who use menthol cigarettes. This study assessed whether limiting characterizing flavors in combusted products only or across all tobacco products produces differential impacts on the tobacco use behaviors of African American/Black individuals who use menthol cigarettes.

METHODS

Adult African American/Black individuals who use menthol cigarettes in the U.S. were recruited through Qualtrics (n=373) and in Richmond, VA (n=206) for an online experiment from September 2021 to August 2022. Participants reported how their tobacco use behaviors would change under 3 scenarios: maintenance of the status quo, limited flavor ban (ban characterizing flavors in cigarettes and cigars), and comprehensive flavor ban (ban characterizing flavors in all tobacco products). Seemingly unrelated regressions compared differences in expected responses to policy scenarios (p<0.05).

RESULTS

Both flavor ban scenarios resulted in higher quitting intentions for cigarettes and all tobacco products than the status quo (p<0.05). The comprehensive ban resulted in greater intentions to quit all tobacco products and lower intentions to switch to certain alternative products (e.g., E-cigarettes, smokeless tobacco, heated tobacco products) than the limited ban (p<0.05).

CONCLUSIONS

African American/Black individuals who use menthol cigarettes appear more likely to quit smoking if characterizing flavors in combusted products (e.g., menthol cigarettes) are banned, regardless of if characterizing flavors are available in noncombusted alternative tobacco products.

Racial/ethnic differences in the association between menthol cigarette use and mental illness among adults who smoke in the United States

Data from the National Survey on Drug Use and Health (2012-2018) were used to characterize the association between menthol cigarette use and indicators of Any (AMI) and Serious (SMI) Mental Illness among adults who smoke in the United States. In general, people who smoke menthol cigarettes were more likely to have AMI (aOR = 1.123 [1.063-1.194]) than people who smoke non-menthol cigarettes, but not SMI (aOR = 1.065 [0.966-1.175]). However, among non-Hispanic African American/Black people who smoke, those that used menthol cigarettes had lower adjusted odds of both AMI (aOR = 0.740 [0.572-0.958]) and SMI (aOR = 0.592 [0.390-0.899]) than their counterparts who used non-menthol cigarettes. Results suggest there may be race/ethnicity-specific drivers of the association between menthol cigarette use and mental illness.

Addicted to green: priming effect of menthol cigarette packaging on brain response to smoking cues

INTRODUCTION

Mentholated tobacco cigarettes are believed to be more addictive than non-menthol ones. Packaging of most menthol cigarette brands includes distinctive green hues, which may act as conditioned stimuli (ie, cues) and promote menthol smoking. To examine the cue properties of menthol cigarette packaging, we used a priming paradigm to assess the effect of packaging on the neural substrates of smoking cue reactivity. We hypothesised that menthol packaging will exert a specific priming effect potentiating smoking cue reactivity in menthol compared with non-menthol smokers.

METHODS

Forty-two menthol and 33 non-menthol smokers underwent functional MRI while viewing smoking and neutral cues. The cues were preceded (ie, primed) by briefly presented images of menthol or non-menthol cigarette packages. Participants reported craving for cigarettes in response to each cue.

RESULTS

Menthol packaging induced greater frontostriatal and occipital smoking cue reactivity in menthol smokers than in non-menthol smokers. Menthol packaging also enhanced the mediation by neural activity of the relationship between cue exposure and cigarette craving in menthol but not non-menthol smokers. Dynamic causal modelling showed stronger frontostriatal-occipital connectivity in response to menthol packaging in menthol compared with non-menthol smokers. The effects of non-menthol packaging did not differ between categories of smokers.

CONCLUSIONS

Our findings demonstrate heightened motivational and perceptual salience of the green-hued menthol cigarette packaging that may exacerbate menthol smokers' susceptibility to smoking cues. These effects could contribute to the greater addiction severity among menthol smokers and could be considered in the development of science-based regulation and legal review of tobacco product marketing practices.

Testing the Outcomes of a Smoking Cessation Smartphone App for Nondaily Smokers: Protocol for a Proof-of-concept Randomized Controlled Trial

BACKGROUND

Nondaily smoking is a widespread, increasingly prevalent pattern of smoking, particularly in ethnic minority and vulnerable populations. To date, no effective treatment approach for this type of smokers has been identified.

OBJECTIVE

This study aims to use a randomized controlled trial to evaluate proof-of-concept markers of the Smiling instead of Smoking (SiS) app, a smoking cessation smartphone app designed specifically for nondaily smokers. This app was developed iteratively and is now in its third version. Previous studies have demonstrated acceptability and feasibility when participants were onboarded in person (study 1) and remotely (study 2) and showed within-person changes in line with hypothesized mechanisms of change. This is the first randomized test of this app.

METHODS

In total, 225 adult nondaily smokers will be asked to undertake a quit attempt while using smoking cessation support materials for a period of 7 weeks. Participants will be randomized to use the SiS smartphone app, the National Cancer Institute smartphone app QuitGuide, or the National Cancer Institute smoking cessation brochure "Clearing the Air." Participants will take part in a 15-minute scripted onboarding phone call during which study staff will introduce participants to their support materials. Survey links will be sent 2, 6, 12, and 24 weeks after the participants' initially chosen quit date. The primary outcome is self-efficacy to remain abstinent from smoking at treatment end, measured using the Smoking Self-Efficacy Questionnaire. Secondary outcomes cover several domains relevant to treatment development and implementation: treatment acceptability (eg, satisfaction with smoking cessation support, measured using the Client Satisfaction Questionnaire, and app usability, measured using the System Usability Scale); treatment feasibility (eg, measured using the number of days participants used the SiS or QuitGuide app during the prescribed treatment period); and, in an exploratory way, treatment efficacy assessed using self-reported 30-day point prevalence abstinence.

RESULTS

Recruitment began in January 2021 and ended June 2022. The final 24-week follow-up was completed in January 2023. This trial is funded by the American Cancer Society.

CONCLUSIONS

This study is designed to test whether the prescribed use of the SiS app results in greater self-efficacy to abstain from smoking in nondaily smokers than commonly recommended alternative treatments and whether the SiS app treatment is acceptable and feasible. Positive results will mean that the SiS app warrants testing in a large-scale randomized controlled trial to test its effectiveness in supporting smoking cessation in nondaily smokers. The design of this study also provides insights into issues pertinent to smoking cessation smartphone app treatment development and implementation by measuring, in a randomized design, markers of treatment satisfaction, engagement with the technology and content of the treatment, and adherence to the treatment plan.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04672239; https://clinicaltrials.gov/ct2/show/NCT04672239.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40867.

Trends in cigarette smoking prevalence and status among U.S. adults with disabilities, 2015-2019

INTRODUCTION

The prevalence of current cigarette smoking is higher in people with disabilities compared to those without. However, little is known about smoking status and trends in smoking by disability functioning domain.

METHODS

Data from the 2015-2019 National Surveys on Drug Use and Health were used to estimate the prevalence of past-month and daily cigarette smoking, former smoking, and nicotine dependence for people with any disability and six disability functioning domains. Logistic regression models estimated the odds of each outcome by disability domain compared to no disability, adjusting for sociodemographic factors.

RESULTS

From 2015-2019, the overall prevalence of current cigarette smoking (23.3% vs. 16.7%) and the proportion of those with nicotine dependence (14.6% vs 8.0%) was higher in people with any disability compared to those without (ps < 0.001). The prevalence of current cigarette smoking decreased while the prevalence of former cigarette smoking increased from 2015 to 2019 (ps < 0.05). People with any disability had higher odds of current smoking (AOR=1.20; 95% CI 1.16, 1.25) and similar odds of former smoking (AOR=1.00; 95% CI 0.95, 1.06) compared to people without disabilities. Odds of current and former smoking varied by domain.

CONCLUSION

The prevalence of cigarette smoking among people with any disability decreased over time but remained higher than those without. People with any disability had similar odds of former smoking, though differences existed by disability domain. Future research should explore additional smoking and quit behaviors by disability functioning domain.

Association Between Smoking, Smoking Cessation, and Mortality by Race, Ethnicity, and Sex Among US Adults

Importance

Patterns of cigarette smoking and smoking cessation vary considerably across demographic groups in the US, but there is limited evidence on whether the hazards of smoking and benefits of quitting vary across these groups. Population-specific evidence on the benefits of quitting smoking may motivate cessation among groups historically underrepresented in medical research.

Objective

To quantify the association between smoking, smoking cessation, and mortality by race, ethnicity, and sex.

Design, Setting, and Participants

This nationally representative, prospective cohort study used data from the US National Health Interview Survey collected via questionnaire between January 1997 and December 2018 among adults aged 25 to 84 years at recruitment. Participants were followed up for cause-specific mortality through December 31, 2019.

Exposures

Self-reported smoking status at recruitment, age at quitting smoking, and years since quitting smoking.

Main Outcomes and Measures

The main outcomes were all-cause mortality and mortality from cancer, cardiovascular disease, and lower respiratory disease. Adjusted mortality rate ratios comparing never, former, and current smokers were calculated using Cox proportional hazards regression. Weighted analyses were conducted by race, ethnicity, and sex as reported by participants.

Results

Among the 551 388 participants in the main analyses, the mean (SD) age at recruitment was 48.9 (15.3) years; 307 601 (55.8%) were women, 87 207 (15.8%) were Hispanic, 75 545 (13.7%) were non-Hispanic Black, 355 782 (64.5%) were non-Hispanic White, and 32 854 (6.0%) identified as other non-Hispanic race and ethnicity. There were 74 870 deaths among participants aged 25 to 89 years during follow-up (36 792 [49.1%] among men; 38 078 [50.9%] among women). The all-cause mortality rate ratio (RR) for current vs never smoking was 2.80 (95% CI, 2.73-2.88) overall. The RRs were similar by sex but varied by race and ethnicity: Hispanic, 2.01 (95% CI, 1.84-2.18); non-Hispanic Black, 2.19 (95% CI, 2.06-2.33); non-Hispanic White, 3.00 (95% CI, 2.91-3.10); and other non-Hispanic race and ethnicity, 2.16 (95% CI, 1.88-2.47). When comparing those who quit smoking before age 45 years with never smokers, all-cause mortality RRs were 1.15 (95% CI, 1.03-1.28) among Hispanic individuals, 1.16 (95% CI, 1.07-1.25) among non-Hispanic Black individuals, 1.11 (95% CI, 1.08-1.15) among non-Hispanic White individuals, and 1.17 (95% CI, 0.99-1.39) among other non-Hispanic individuals.

Conclusions and Relevance

In this prospective cohort study, among men and women from diverse racial and ethnic groups, current smoking was associated with at least twice the all-cause mortality rate of never smoking. Quitting smoking, particularly at younger ages, was associated with substantial reductions in the relative excess mortality associated with continued smoking.

Web-delivered Acceptance and Commitment Therapy (ACT) for smoking cessation: Is it engaging and efficacious for US Hispanic/Latinx adult smokers?

Hispanic/Latinx adult smokers in the United States (US) face barriers to receiving and utilizing evidenced-based cessation treatments compared with other racial/ethnic groups. The lack of efficacious and accessible smoking cessation treatments for this population further contributes to such smoking disparities. In a secondary analysis, we explored the efficacy of an Acceptance and Commitment Therapy (ACT)-based website (WebQuit.org) versus a US Clinical Practice Guidelines (USCPG)-based website (Smokefree.gov) for smoking cessation in a subset of Hispanic/Latinx adult participants enrolled in the WebQuit trial. Of the 2,637 participants who were randomized in the parent trial, 222 were Hispanic/Latinx (n = 101 in WebQuit, n = 121 in Smokefree). Smoking cessation outcomes were measured at 3, 6, and 12-months. The primary outcome was self-reported complete-case 30-day point prevalence abstinence (PPA) at 12-months. Treatment engagement and satisfaction, change in acceptance of urges to smoke, and commitment to quitting smoking were compared across conditions. Retention rate was 88% at 12-months. WebQuit participants had higher odds of smoking cessation compared to Smokefree participants at 12-months (40% vs. 25%; OR = 1.93 95% CI: 1.04, 3.59). Findings were similar using multiple imputation. WebQuit participants engaged more with the website than Smokefree participants through multiple indicators of engagement, including spending more time using the website (IRR = 2.32; 95% CI: 1.68, 3.20). Although WebQuit participants engaged more with the website than Smokefree participants, there was no evidence that differences in quit rates were mediated by engagement level. This study provides initial empirical evidence that digital interventions may be efficacious for helping Hispanic/Latinx adults quit smoking.

Trends in smoking prevalence in urban and rural China, 2007 to 2018: Findings from 5 consecutive nationally representative cross-sectional surveys

BACKGROUND

Tobacco smoking is a leading cause of premature death in China, especially among adult men. Since the implementation of the Framework Convention on Tobacco Control in 2005, nationwide tobacco control has been strengthened, but its long-term impact on smoking prevalence is unclear.

METHODS AND FINDINGS

Five nationally representative surveys of the China Chronic Disease and Risk Factor Surveillance (CCDRFS) were conducted in 2007, 2010, 2013, 2015, and 2018. A total of 624,568 adults (278,605 men and 345,963 women) aged 18 to 69 years were randomly selected from 31 provinces (or equivalent) in China. Temporal changes in smoking prevalence and patterns (e.g., percentages of those smoking manufactured cigarettes, amount smoked, and age at smoking initiation) were analyzed, overall and by sex, urban or rural residence, year of birth, education and occupation, using linear regression methods. Among men, the standardized prevalence of current smoking decreased from 58.4% (95% confidence interval [CI]: 56.1 to 60.7) to 50.8% (95% CI: 49.1 to 52.5, p < 0.001) between 2007 and 2018, with annual decrease more pronounced in urban (55.7% [95% CI: 51.2 to 60.3] to 46.3% [95% CI: 43.7 to 49.0], p < 0.001) than rural men (59.9% [95% CI: 57.5 to 62.4] to 54.6% [95% CI: 52.6 to 56.6], p = 0.05) and in those born before than after 1980. Among rural men born after 1990, however, the prevalence increased from 40.2% [95% CI: 34.0 to 46.4] to 52.1% ([95% CI: 45.7 to 58.5], p = 0.007), with the increase taking place mainly before 2015. Among women, smoking prevalence remained extremely low at around 2% during 2007 to 2018. No significant changes of current smoking prevalence (53.9% to 50.8%, p = 0.22) were observed in male patients with at least 1 of major chronic diseases (e.g., hypertension, diabetes, myocardial infarction, stroke, chronic obstructive pulmonary disease (COPD)). In 2018, 25.6% of adults aged ≥18 years smoked, translating into an estimated 282 million smokers (271 million men and 11 million women) in China. Across 31 provinces, smoking prevalence varied greatly. The 3 provinces (Yunnan, Guizhou, and Hunan) with highest per capita tobacco production had highest smoking prevalence in men (68.0%, 63.4%, and 61.5%, respectively), while lowest prevalence was observed in Shanghai (34.8%). Since the children and teenage groups were not included in the surveys, we could not assess the smoking trends among youths. Furthermore, since the smoking behavior was self-reported, the smoking prevalence could be underestimated due to reporting bias.

CONCLUSIONS

In this study, we observed that the smoking prevalence has decreased steadily in recent decades in China, but there were diverging trends between urban and rural areas, especially among men born after 1980. Future tobacco control strategies should target rural young men, regions with high tobacco production, and patients suffering from chronic diseases.

Differences between adult sexual minority females and heterosexual females on menthol smoking and other smoking behaviors: Findings from Wave 4 (2016-2018) of the population assessment of tobacco and health study

BACKGROUND

Sexual minority females have higher rates of cigarette smoking than heterosexual females. Additionally, menthol cigarette use disproportionately impacts minority smokers, including sexual minority individuals. This study examined differences between sexual minority and heterosexual females on several smoking variables, including initiation with a menthol cigarette, and past 30-day cigarette and menthol cigarette use.

METHODS

Participants were female ever smokers (N = 11,576; n = 1,474, 12.7% sexual minority) who completed Wave 4 of the Population Assessment of Tobacco and Health Survey. Participants reported on the age they began smoking regularly (≤18 years old, 18-24, >25), whether they initiated with a menthol cigarette, past 30-day cigarette smoking and menthol cigarette use, cigarettes smoked per day (≤10, 11-20, >20), cigarette dependence (smoke ≤ 5 min of waking or > 5 min of waking), and whether they were a current (someday/every day) or former (no past year/current use) established smoker (≥100 lifetime cigarettes), or an experimental smoker (<100 lifetime cigarettes). Chi-square and multivariable logistic regression analyses examined differences between sexual minority females and heterosexual females on smoking variables.

RESULTS

Sexual minority female smokers began smoking regularly at an earlier age and smoked fewer cigarettes per day than heterosexual females. Sexual minority females were more likely to initiate smoking with a menthol cigarette (aOR = 1.27), report past 30-day smoking (aOR = 1.36) and menthol cigarette use (aOR = 1.24) compared to heterosexual females. There were no differences on cigarette dependence.

CONCLUSIONS

Given the high rates of initiation and current menthol smoking, policies to regulate menthol may decrease smoking disparities for sexual minority females.

Examining Tobacco Treatment Perceptions and Barriers among Black versus Non-Black Adults Attending Lung Cancer Screening

The US Preventive Services Task Force recommends annual lung cancer screening for patients at high risk based on age and smoking history. Understanding the characteristics of patients attending lung cancer screening, including potential barriers to quitting smoking, may inform ways to engage these high-risk patients in tobacco treatment and address health disparities. Patients attending lung cancer screening who currently smoke cigarettes completed a survey at Smilow Cancer Hospital at Yale-New Haven (N = 74) and the Medical University of South Carolina (N = 73) at the time of their appointment. The survey assessed demographics, smoking history, and perceptions and concerns about quitting smoking.

Patients were 55 to 76 years old (mean = 63.3, SD = 5.3), N = 64 (43.5%) female, and N = 31 (21.1%) non-Hispanic Black. Patients smoked 16.3 cigarettes per day on average (SD = 9.2) and rated interest in quitting smoking in the next month as moderate (mean = 5.6, SD = 3.1, measured from 0 = "very definitely no" to 10 = "very definitely yes"). The most frequently endorsed concerns about quitting smoking were missing smoking (70.7%), worry about having strong urges to smoke (63.9%), and concerns about withdrawal symptoms (59.9%). In comparison with other races/ethnicities, Black patients were less likely to report concerns about withdrawal symptoms and more likely to report smoking less now and perceiving no need to quit. Findings identified specific barriers for tobacco treatment and differences by race/ethnicity among patients attending lung cancer screening, including concerns about withdrawal symptoms and perceived need to quit. Identifying ways to promote tobacco treatment is important for reducing morbidity and mortality among this high-risk population.

PREVENTION RELEVANCE

The current study examines patient characteristics and tobacco treatment perceptions and barriers among patients attending lung cancer screening who continue to smoke cigarettes that may help inform ways to increase treatment engagement and address tobacco-related health disparities to reduce morbidity and mortality from smoking.

Differences in switching away from cigarettes and JUUL use characteristics among adult menthol and nonmenthol smokers who purchased the JUUL System

OBJECTIVES

Studies have assessed switching away from cigarettes among adult smokers who use electronic nicotine delivery systems (ENDS), but there is little data assessing differences in likelihood of switching or ENDS use characteristics by menthol smoking.

METHODS

Adult (age ≥ 21) established smokers who purchased a JUUL Starter Kit (N = 15,036) completed baseline and 1-, 2-, 3-, 6-, 9- and 12-month assessments. Switching (no past-30-day cigarette smoking) and flavor use were assessed at each follow-up. Repeated-measure logistic regression models evaluated association of menthol smoking and switching across 1 year.

RESULTS

Across the 6 follow-ups, more menthol smokers primarily used Menthol/Mint-flavored JUULpods (53.8%) than nonmenthol smokers (22.9%). Only 6.4% of menthol smokers primarily used Tobacco flavors (vs. 25.9% of nonmenthol smokers). Across all follow-ups menthol smokers (41.2% of sample) were more likely to switch than nonmenthol smokers (42.6% vs. 38.8%: OR [95% CI] = 1.17 [1.11, 1.23]); this association remained significant after adjustment for sociodemographic, smoking and JUUL use covariates (aOR [95% CI] = 1.13 [1.05, 1.21]). Nonmenthol smokers, but not menthol smokers, were significantly more likely to switch when primarily using Menthol/Mint-flavored (vs. Tobacco-flavored) JUULpods (aOR [95% CI] = 1.14 [1.04, 1.25]). Differences in baseline smoking characteristics between menthol and nonmenthol smokers were small in magnitude.

CONCLUSIONS

Adult menthol (vs. nonmenthol) smokers using JUUL were more likely to switch. More than twice as many menthol (vs. nonmenthol) smokers primarily used Menthol/Mint-flavor JUULpods; few menthol smokers used tobacco flavors. Given these pronounced differences in flavor preferences, availability of ENDS in menthol flavors may be particularly important for menthol smokers, but may also benefit some nonmenthol smokers.

The Impact of Menthol Cigarette Flavor in the U.S.: Cigarette and ENDS Transitions by Sociodemographic Group

INTRODUCTION

A better understanding of how menthol cigarette flavoring and ENDS impact smoking initiation, cessation, and transitions between tobacco products could help elucidate the potential impact of a U.S. menthol ban on combustible tobacco products.

METHODS

A multistate transition model was applied to data on 23,232 adults from Waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health Study (analysis was conducted in 2020-2021). Transition rates among never, noncurrent, nonmenthol versus menthol cigarette, ENDS, and dual everyday/someday use were estimated, as were transition-specific hazard ratios for age, sex, race/ethnicity, education, and income.

RESULTS

Non-Hispanic Blacks who smoked menthol discontinued smoking at a much lower rate than those who smoked nonmenthol (hazard ratio=0.43, 95% CI=0.29, 0.64), but there was no statistically significant difference in the discontinuation rates among non-Hispanic Whites (hazard ratio=0.97, 95% CI=0.80, 1.16) or Hispanics (hazard ratio=0.81, 95% CI=0.56, 1.16). Non-Hispanic Whites who smoked menthol were more likely to become dual users than those who smoked nonmenthol (hazard ratio=1.43, 95% CI=1.14, 1.80). Young adults initiated menthol smoking at a higher rate than older adults (age 18-24 years versus ≥55 years: hazard ratio=2.45, 95% CI=1.44, 4.15) but not nonmenthol smoking (hazard ratio=1.02, 95% CI=0.62, 1.69). There were differences by sex in the impact of menthol flavor on smoking initiation and discontinuation but little difference by education or income.

CONCLUSIONS

Sociodemographic differences in product transitions should be accounted for when estimating the potential impact of a menthol ban.

Smoking Cessation in Stroke Survivors in the United States: A Nationwide Analysis

BACKGROUND AND PURPOSE

Continued smoking after stroke is associated with a high risk of stroke recurrence and other cardiovascular disease. We sought to comprehensively understand the epidemiology of smoking cessation in stroke survivors in the United States. Furthermore, we compared smoking cessation in stroke and cancer survivors because cancer is another smoking-related condition in which smoking cessation is prioritized.

METHODS

We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Using pooled data from 2013 to 2019, we identified stroke and cancer survivors with a history of smoking. We used survey procedures to estimate frequencies and summarize quit ratios with attention to demographic and geographic (state-wise and rural-urban) factors for stroke survivors. The quit ratio is conventionally defined as the proportion of ever smokers who have quit. Then, we used multivariable logistic regression to compare quit ratios in stroke and cancer survivors while adjusting for demographics and smoking-related comorbidities.

RESULTS

Among 4 434 604 Americans with a history of stroke and smoking, the median age was 68 years (interquartile range, 59-76), and 45.4% were women. The overall quit ratio was 60.8% (95% CI, 60.1%-61.6%). Quit ratios varied by age group, sex, race and ethnicity, and several geographic factors. There was marked geographic variation in quit ratios, ranging from 48.3% in Kentucky to 71.5% in California. Furthermore, compared with cancer survivors, stroke survivors were less likely to have quit smoking (odds ratio, 0.72 [95% CI, 0.67-0.79]) after accounting for differences in demographics and smoking-related comorbidities.

CONCLUSIONS

There were considerable demographic and geographic disparities in smoking quit ratios in stroke survivors, who were less likely to have quit smoking than cancer survivors. A targeted initiative is needed to improve smoking cessation for stroke survivors.

Depression symptom profiles and long-term response to cognitive behavioral therapy plus contingency management for smoking cessation

BACKGROUND

Depression is heterogeneous in nature and using diagnostic categories limits insight into understanding psychopathology and its impact on treatment efficacy. This secondary analysis sought to: 1) identify distinct subpopulations of cigarette users with depression, and 2) examine their response to cognitive-behavioral treatment (CBT) + contingency management (CM) for smoking cessation at one year.

METHOD

The sample comprised 238 (74 % females) adults who smoke receiving CBT only or CBT + CM. A latent class analysis was conducted on baseline depressive symptoms measured using the Beck Depression Inventory-II. Generalized estimating equations assessed the main and interactive effects of class, time, treatment, and sex on smoking abstinence.

RESULTS

Three distinct classes were identified: C1 (n= 76/238), characterized by mild depression, loss of energy, pessimism, and criticism, C2 (n= 100/238) presenting moderate severity and decreased appetite, and C3 (n= 62/238) showing severe depression, increased appetite, and feelings of punishment. There was a significant cluster × treatment interaction, which indicated additive effects of CM over CBT alone for Class 1 and 2. Persons in Class 1 and 2 were 3.60 [95 % CI: 1.62, 7.97] and 2.65 [95 % CI: 1.19, 5.91] times more likely to be abstinent if CBT + CM was delivered rather than CBT only. No differential sex effects were observed on treatment response according to cluster.

CONCLUSIONS

Profiling depression symptom subtypes of cigarette users may be more informative to improve CM treatment response than merely focusing on total scores.

Basaloid squamous cell carcinoma of the hypopharynx: an analysis of 213 cases

PURPOSE

Basaloid squamous cell carcinoma (BSCC) is a rare aggressive variant of squamous cell carcinoma (SCC) with a poor prognosis. No large series of exclusively hypopharyngeal BSCC patients have been previously reported. Therefore, this retrospective population-based study aims to explain the patient demographics, clinicopathologic characteristics, incidence, and survival outcomes of hypopharyngeal BSCC and how it relates to conventional-type SCC.

METHODS

The National Cancer Institute's Surveillance, Epidemiology, and End Results database registry was queried for patients diagnosed with hypopharyngeal BSCC and conventional-type SCC between 2001 and 2016.

RESULTS

The incidence of hypopharyngeal BSCC from 2001 to 2016 was 0.0161 per 100,000 individuals. The BSCC group comprised 213 patients, and the SCC group 7958 patients. The majority of BSCCs were considered high grade (Grade III/IV, 89.58%). Most BSCC patients were diagnosed at an advanced stage (American Joint Committee on Cancer [AJCC] stage IV, 65.38%). The 1-, 5-, and 10-year disease-specific survival (DSS) rates for hypopharyngeal BSCC were 84.10%, 57.40%, and 46.20%, respectively. Multivariate analysis, after adjustment for sex, age, race, tumor location, grade, and AJCC stage, showed that patients with BSCC had significantly better DSS than those with conventional-type SCC. Surgery with radiation contributed to a favorable DSS for BSCC patients in comparison with other treatments.

CONCLUSION

This analysis of the largest hypopharyngeal BSCC series indicates a better prognosis for this pathologic type compared with conventional-type hypopharyngeal SCC. Multimodality treatment with surgery and radiation may result in a favorable prognosis for hypopharyngeal BSCC patients.

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 in prevalence and sociodemographic and geographic patterns of current menthol cigarette use among U.S. adults, 2005-2015

Despite overall reductions in U.S. smoking prevalence, prior evidence suggests similar reductions may not have occurred for menthol cigarette users. This study examines nationally representative current menthol and non-menthol cigarette use prevalence and trends for adults (18+) overall and by sociodemographic and geographic characteristics using the 2005 (n = 31,132), 2010 (n = 26,967), and 2015 (n = 33,541) National Health Interview Survey. Between 2005 and 2015, non-menthol cigarette use decreased overall (14.7% to 9.6%, p < 0.001) and within all sociodemographic and geographic subgroups analyzed (i.e., by sex, age, race/ethnicity, sexual orientation, education, family income, and geographic region), except non-Hispanic American Indians/Alaskan Natives (NH AI/AN) and non-Hispanic Others. Menthol cigarette use significantly decreased overall (5.3% to 4.4%, p < 0.001), and among females (5.6% to 4.6%); participants aged 18-24 (7.1% to 4.3%) and 35-54 (6.2% to 4.9%); non-Hispanic Whites (4.1% to 3.6%) and non-Hispanic Blacks (14.8% to 11.9%); participants with high school degrees/GEDs (7.0% to 5.9%); participants with a family income of $75,000 or higher (3.4% to 2.3%); and participants residing in the Northeast (6.0% to 4.3%). Menthol cigarette use remained stable or did not significantly decrease among males; adults aged 25-34 and 55 years and older; NH AI/ANs, NH Others, and Hispanics; participants with less than high school education, some college, or a college degree; participants with a family income below $75,000; and participants residing in the North Central/Midwest, South, and West. Given that menthol cigarette use did not significantly change or decrease for multiple subgroups, further restriction on menthol manufacturing may help reduce tobacco use disparities.

Heterogeneity in past-year smoking, current tobacco use, and smoking cessation behaviors among light and/or non-daily smokers

INTRODUCTION

Prevalence of light daily smoking, <10 cigarettes per day (CPD), and non-daily smoking has increased in the US population. This analysis examined the heterogeneity in past-year smoking behavior, current tobacco use behaviors, and smoking cessation behaviors among light and/or non-daily smokers.

METHODS

Current adult (≥18 years old) smokers (N=26196) participated in the 2010–2011 US Current Population Survey – Tobacco Use Supplement, which reported current (T1) and past 12-month (T0) smoking behaviors. Responses were categorized by intensity (light ≤10 CPD vs heavy >10 CPD) and frequency (non-daily vs daily). Combinations of T0 and T1 smoking behaviors resulted in 15 smoking trajectories ending in light/non-daily smoking and a 16th category of heavy daily smokers at T1. Differences in demographics, tobacco use, and smoking cessation behaviors were assessed by using weighted multivariable regression models.

RESULTS

Overall, 46.1% of US smokers were heavy smokers, 24.6% remained light daily smokers and 12.5% remained light non-daily smokers between T0 and T1. Current cigar, smokeless tobacco, and pipe use differed by smoking trajectories (p<0.05). All light and/or non-daily smokers were more likely than heavy daily smokers to have made a quit attempt (p<0.05) but use of cessation treatments varied. Smokers in many light and/or non-daily smoking trajectories were less likely than heavy daily smokers to be aided by healthcare providers for smoking cessation (p<0.05).

CONCLUSIONS

Among heavy daily smokers who became light non-daily smokers, the mismatch between intent to quit (80.9%) and receiving advice to set a quit date (33.7%) is one example of a potential opportunity for a clinical intervention.

Medical Vulnerability of Young Adults to Severe COVID-19 Illness-Data From the National Health Interview Survey

PURPOSE

COVID-19 morbidity and mortality reports in the U.S. have not included findings specific to young adults. The Centers for Disease Control and Prevention provides a list of conditions and associated behaviors, including smoking, conferring vulnerability to severe COVID-19 illness regardless of age. This study examines young adults' medical vulnerability to severe COVID-19 illness, focusing on smoking-related behavior.

METHODS

A young adult subsample (aged 18-25 years) was developed from the National Health Interview Survey, a nationally representative data set, pooling years 2016-2018. The medical vulnerability measure (yes vs. no) was developed, guided by the Centers for Disease Control and Prevention medical indicators. The estimates of medical vulnerability were developed for the full sample, the nonsmoking sample, and the individual risk indicators. Logistic regressions were conducted to examine differences by sex, race/ethnicity, income, and insurance.

RESULTS

Medical vulnerability was 32% for the full sample and half that (16%) for the nonsmoking sample. Patterns and significance of some subgroup differences differed between the full and the nonsmoking sample. Male vulnerability was (33%) higher than female (30%; 95% CI: .7-.9) in the full sample, but lower in nonsmokers: male (14%) versus female (19%; 95% CI: 1.2-1.7). The white subgroup had higher vulnerability than Hispanic and Asian subgroups in both samples-full sample: white (31%) versus Hispanic (24%; 95% CI: .6-.9) and Asian (18%; 95% CI: .4-.5); nonsmokers: white (17%) versus Hispanic (13%; 95% CI: .06-.9) and Asian (10%; 95% CI: .3-.8).

CONCLUSIONS

Notably, lower young adult medical vulnerability within nonsmokers versus the full sample underscores the importance of smoking prevention and mitigation.

Truck Drivers' Cigarette Smoking and Preferred Smoking Cessation Methods

Introduction:

Some studies show that truck drivers use tobacco and other stimulants to stay awake as they drive. Despite their increased risks for many of tobacco-related health disparities, there is limited engagement of truck drivers in smoking cessation programs. The objective of this study was to describe smoking characteristics and identify their preferred smoking cessation methods among truck drivers.

Methods:

This was a cross-sectional mixed methods study. Participants were truck drivers recruited at trucking companies in Utah in 2019. Participants were either individually interviewed (n = 4), or filled out a survey (n = 33). We conducted qualitative data analysis of the interviews followed by descriptive statistics of smoking and cessation characteristics from the survey.

Results:

Reasons for smoking included, staying awake, stress reduction, or something to do while driving. Of the drivers surveyed, 68.8% were daily smokers while 97% had smoked at least 100 cigarettes in their life time. The mean number of cigarettes per day (cpd) was 15.7, and 25 among those who had 10 or more cpd. Sixty-one percent had made at least a quit attempt. In addition to counseling or brief advice, 68% reported interest in using Nicotine Replacement Therapy (NRT) either as gum or patch to help them quit. 21% reported interest in telephone text messaging to engage them in treatment.

Conclusion:

Cigarette smoking is a public health problem among truck drivers. Our findings suggest that truck drivers are interested in quitting smoking. Evidence based interventions tailored to this population are needed to help them quit and reduce their smoking-related morbidity.