The menthol marketing mix: targeted promotions for focus communities in the United States

E-Cigarette Brand Use by Race/Ethnicity in a US Sample of Adolescent and Young Adult E-Cigarette Users, 2022-2023

INTRODUCTION

To determine whether e-cigarette brand use varies according to race/ethnicity among adolescent and young adult e-cigarette users.

AIMS AND METHODS

Data are from a cross-sectional online survey of respondents aged 15-24 years (January 2022-June 2023; 300 unique respondents/week). The analytic sample was restricted to current e-cigarette users (n = 6387). Respondents selected their usual brand and reported frequency of past 30-day e-cigarette use (in days). ANOVAs measured differences in frequency of use by usual brand, stratified by race/ethnicity. Linear regression identified changes in usual brand over time by race/ethnicity, controlling for age and use of other tobacco/nicotine products.

RESULTS

One-quarter (25.6%) of Black and 22.2% of Hispanic e-cigarette users reported JUUL as their usual brand, compared to those who are White (15.7%) or another race (16.5%). Puff Bar was the second-most reported brand among Black (15.1%) or Hispanic (16.6%) e-cigarette users, to a greater extent than White (7.8%) e-cigarette users. Frequency of use varied significantly according to respondents' usual brand when stratified by race/ethnicity (p < .001).

CONCLUSIONS

Across all racial and ethnic categories, frequency of use was greater for brands marketed with more flavor options and containing nicotine (EB Design, SMOK, Hyde, and Vuse). Despite declines in popularity, Black or Hispanic respondents report using JUUL and Puff Bar to a greater extent than other respondents, and vape less frequently than White non-Hispanic respondents regardless of brand. As e-cigarette brands continue to proliferate, monitoring e-cigarette brand selection by race/ethnicity can inform studies of nicotine exposure, polyuse, and health disparities.

IMPLICATIONS

Our study demonstrates the importance of research methods to detect rapidly changing patterns of e-cigarette use by race/ethnicity and age. The inclusion of measures capturing brand use can detect evidence of product features and targeted marketing that may have consequences for patterns of tobacco use and nicotine exposure among these groups.

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.

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.

'No-Barriers' tobacco product? Selling smokeless tobacco to women, people of colour and the LGBTQ+ community in the USA

BACKGROUND

In both Sweden and the USA, smokeless tobacco (ST) is legal and used predominantly by men. Starting in the 1970s, US tobacco companies attempted to expand the ST market to women, African Americans, Hispanic Americans and lesbian, gay, bisexual, transgender, queer and other sexual orientation (LGBTQ+) people.

DESIGN

We analysed industry documents from the Truth Tobacco Industry Documents Library triangulating findings with recent ST advertising and publicly available literature.

FINDINGS

We found tobacco companies used design innovations such as pouched moist snuff, snus and dissolvable products to expand the market. In addition, diverse advertising campaigns targeted women, people of colour (Hispanic, African American) and LGBTQ+ communities with identity-targeted messages emphasising novelty, convenience, cleanliness and use in smoke-free environments. However, stereotypes of ST users as rural white males endured, perpetuated by continued marketing aimed at this customer base, which created cognitive dissonance and stymied marketer's hopes that pouch products would 'democratize' ST.

CONCLUSION

These failed campaigns suggest novel products such as nicotine pouch products may provide a 'clean slate' to similarly target women and other low-ST-using groups. Based on this history, the risk of new tobacco and nicotine products to increase health disparities should be closely monitored.

E-cigarette Flavors, Sensory Perception, and Evoked Responses

The chemosensory experiences evoked by flavors encompass a number of unique sensations that include olfactory stimuli (smell), gustatory stimuli (taste, i.e., salty, sweet, sour, bitter, and umami (also known as "savoriness")), and chemesthesis (touch). As such, the responses evoked by flavors are complex and, as briefly stated above, involve multiple perceptive mechanisms. The practice of adding flavorings to tobacco products dates back to the 17th century but is likely much older. More recently, the electronic cigarette or "e-cigarette" and its accompanying flavored e-liquids emerged on to the global market. These new products contain no combustible tobacco but often contain large concentrations (reported from 0 to more than 50 mg/mL) of nicotine as well as numerous flavorings and/or flavor chemicals. At present, there are more than 400 e-cigarette brands available along with potentially >15,000 different/unique flavored products. However, surprisingly little is known about the flavors/flavor chemicals added to these products, which can account for >1% by weight of some e-liquids, and their resultant chemosensory experiences, and the US FDA has done relatively little, until recently, to regulate these products. This article will discuss e-cigarette flavors and flavor chemicals, their elicited responses, and their sensory effects in some detail.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation

INTRODUCTION

Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation.

AIMS AND METHODS

We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias.

RESULTS

Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies.

CONCLUSIONS

Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point.

IMPLICATIONS

A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

Global market trends of flavor capsule cigarettes and menthol (non-capsule) cigarettes: An ecological analysis using commercial data across 78 countries, 2010–2020

INTRODUCTION

This study describes market trends of flavor capsule cigarettes (FCCs) and menthol (non-capsule) cigarettes (MNCCs) across 78 countries from 2010 to 2020 and examines country-level factors associated with market shares of these products.

METHODS

Market share and retail volume data came from the Euromonitor Passport database and country-level data came from the World Health Organization (WHO), World Bank, and International Monetary Fund. Multivariable linear fixed effects panel regression analyses were conducted to evaluate the relationship between predictor variables and the market shares of menthol (non-capsule) cigarettes and flavor capsule cigarettes.

RESULTS

The overall market share (i.e. the percentage retail volume out of total retail volume of all cigarette types) increased from 0.23% in 2010 to 4.5% in 2020 for FCCs and decreased from 5.0% to 3.8% for MNCCs. Market shares of FCCs grew most rapidly in the Americas region and among upper middle-income countries. Market shares of MNCCs remained stable across most regions and were highest in the Western Pacific and Africa regions. The overall market share of FCCs was positively associated with the unemployment rate (β=0.28; 95% CI: 0.12–0.44, p=0.001), and inversely associated with the percent of the population aged 15–29 years (β= -0.57, 95% CI: -0.98 – -0.15, p=0.008), percent of urban population (β= -0.88; 95% CI: -1.28 – -0.48, p<0.001), GDP PPP per capita (β= -0.13; 95% CI: -0.24 – -0.03, p=0.015), and age-standardized prevalence of cigarette smoking (β= -0.93; 95% CI: -1.38 – -0.49, p<0.001). In contrast, the overall market share of MNCCs was positively associated with urbanicity (β=0.24; 95% CI: 0.08–0.40, p=0.003), and negatively associated with the unemployment rate (β= -0.09; 95% CI: -0.17 – -0.02, p=0.014).

CONCLUSIONS

Global sales of flavor capsule cigarettes grew substantially in the last decade, surpassing menthol (non-capsule) cigarettes, which also continued to be high in many regions. There is a need for increased efforts to address flavors and novel tobacco products, features that are known to appeal to 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.

Impact of Local Flavored Tobacco Sales Restrictions on Policy-Related Attitudes and Tobacco Product Access

BACKGROUND

As of September 2020, more than 300 state and local jurisdictions restrict the sales of flavored tobacco, with some including menthol.

AIMS

To evaluate the impact of local ordinances restricting the sale of flavored tobacco, we surveyed Californians regarding policy support and perceived access to flavored tobacco.

METHODS

In 2019, we conducted an online survey of 3,075 California youth and young adults recruited via social media, about half of whom lived in a policy jurisdiction. Logistic regressions assessed differences on propensity score-weighted outcomes, policy support, and perceived access.

RESULTS

Most respondents indicated agreement with almost all policy support statements. Although policy respondents were less likely than rest-of-California respondents to report perceived difficulty in buying flavored cigars, flavored vape users in policy jurisdictions were more likely than those in the rest of California to report perceived difficulty in buying flavored e-liquid. Regardless of jurisdiction, certain priority subgroups were significantly more likely to report perceived difficulty in accessing flavored cigars, flavored vaping products, flavored e-liquid, and menthol cigarettes.

DISCUSSION

With some exceptions, these findings demonstrate that among vape users in policy jurisdictions and priority subgroups, there is a higher likelihood of reporting perceived difficulty to access flavored tobacco products.

CONCLUSIONS

Findings might be an early indication of shifts in social norms about flavored tobacco products in California, which could gain traction as local sales restriction ordinances proliferate throughout the state and a statewide flavored-tobacco sales restriction goes into effect.

Racial/ethnic group comparisons of quit ratios and prevalences of cessation-related factors among adults who smoke with a quit attempt

BACKGROUND

Smoking-related disparities exist among racial/ethnic minoritized groups.

OBJECTIVE

We compared quit ratios and smoking cessation-related protective and risk factors by race/ethnicity to inform approaches to reduce disparities.

METHODS

Among adults who smoke with a quit attempt from Wave 4 (2016-2017) Population Assessment of Tobacco Use and Health Study, the following factors were examined by racial/ethnic group (American Indians/Alaska Native [AI/AN;n = 165], Black/African American [AA;n = 526], Asian [n = 38], Hispanic/Latino/Latina/Spanish [n = 475], or White [n = 1,960]), wherein each were nearly gender-balanced: cessation medications, counseling/self-help materials, home smoking ban, social support, e-cigarette use, sleep, and mental health.

RESULTS

Quit ratio was lower for AI/AN (adjusted odds ratio[aOR]:0.61) and Black/AA (aOR:0.49) and higher for Asian (aOR:1.90) and Hispanic/Latino/Latina/Spanish (aOR:1.30) than White adults. Medication use was low among all and lower among Black/AA (aOR:0.70) and Hispanic/Latino/Latina/Spanish (aOR:0.56) than White adults. Use of counseling/self-help materials were low among all and higher in AI/AN (aOR:1.85), Black/AA (aOR:1.87), and Hispanic/Latino/Latina/Spanish (aOR:1.49) than White adults. Presence of a smoking ban was lower among Black/AA (aOR:0.40) and higher in Hispanic/Latino/Latina/Spanish (aOR:1.59) than White adults. E-cigarette use was lower in Black/AA (aOR:0.53) and Hispanic/Latino/Latina/Spanish (aOR:0.43) than White adults. Sadness, anxiety, and sleep difficulties were higher in AI/AN (aORs:1.57, 1.50, 1.64) than White adults.

CONCLUSIONS

All racial/ethnic groups would benefit from policies and programs that increase cessation medications and counseling. Quit ratios were particularly low among Black/AA and AI/AN adults. Black/AA adults may benefit from efforts to increase smoking bans, while AI/AN adults may benefit from cessation approaches that simultaneously target sleep and mental health.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Piloting a spatial mixed method for understanding neighborhood tobacco use disparities

The tobacco retail environment is where most advertising dollars are spent. However, most research on the retail environment has not methodologically situated tobacco retailers as part of a larger community, and few studies have incorporated community member perspectives of their own tobacco use in relation to their local environments. The purpose of this study is to describe and evaluate a multilevel, multimodal, mixed methods approach for understanding tobacco use in context. We combine quantitative data collected from tobacco retailer audits and geographically-explicit interviews with neighborhood residents to tell a more complete story of tobacco use behavior among adults in San Francisco's Marina district, and the Oakland Coliseum neighborhood in Alameda County, California. We find that while area-level and retail data provide a broad snapshot of two distinct communities with respect to sociodemographic characteristics and tobacco availability, interviews with community residents who use tobacco add important perspectives regarding how tobacco retailers are viewed and how residents interact with their neighborhood landscapes on a daily basis. The method we describe and critique has the potential to be scaled to incorporate a broader set of geographies, or tailored to address a multitude of health-related questions. Our approach further demonstrates the utility of including geolocated participant narratives as a means of understanding where researcher interpretations of urban environments diverge from those of community residents.

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 last line of marketing': Covert tobacco marketing tactics as revealed by former tobacco industry employees

In countries with bans on tobacco advertising and promotion, tobacco companies have focused their promotional expenditure on business-to-business relationship marketing activities aimed at retailers. However, evidence of such activities has been obtained through secondary sources only, including surveys and interviews with tobacco retailers and analyses of tobacco industry documents. To understand the breadth of promotional strategies employed in the retail sector to enhance tobacco sales, 10 semi-structured interviews were conducted with a sample of key informants who formerly worked for tobacco companies operating in Australia. A qualitative iterative approach was used to develop a thematic analysis of tobacco brand promotion and retailer marketing. Participants described tobacco retail marketing and promotion strategies that were categorised into three primary themes: (1) the provision of financial incentives, such as price promotions, cash payments and rebates; (2) the provision of experiential incentives, such as all-expenses paid vacations, exclusive parties and events, and (3) targeted marketing and education, which enabled retailers to market to consumers on behalf of tobacco companies. Such strategies had the ultimate objective of increasing market share and driving sales. For countries to comprehensively restrict all tobacco marketing, legislation must be introduced to outlaw these activities in tobacco advertising and promotion legislation.

National Support for a Menthol Cigarette Sales Ban

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using Peer Crowd Affiliation to Address Dual Use of Cigarettes and E-Cigarettes among San Francisco Bay Area Young Adults: A Cross Sectional Study

Given the emerging tobacco landscape, dual use of cigarettes and e-cigarettes has increased among young adults, but little is known about its associated factors. Peer crowds, defined as macro-level connections between individuals with similar core values (e.g., "Hip Hop" describing a group that prefers hip hop music and values strength, honor, and respect), are a promising way to understand tobacco use patterns. We examined associations between peer crowds and tobacco use patterns by using data from a cross sectional survey of 1340 young adults in the San Francisco Bay Area in 2014. Outcomes were the past 30-day use of: neither cigarettes nor e-cigarettes; cigarettes but not e-cigarettes; e-cigarettes but not cigarettes; and both cigarettes and e-cigarettes. Peer crowds included Hipster, Hip Hop, Country, Partier, Homebody, and Young Professional. Multinomial regression analysis indicated that peer crowds were significantly associated with different tobacco use patterns. Compared to Young Professionals, Hip Hop and Hipster crowds were more likely to dual use; Hipsters were more likely to use e-cigarettes only, and Country participants were more likely to smoke cigarettes only. These findings suggest that tobacco control campaigns and cessation interventions should be tailored to different young adult peer crowds and address poly-tobacco use.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers

INTRODUCTION

This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts.

METHODS

We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices.

RESULTS

There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans.

CONCLUSIONS

Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed.

IMPLICATIONS

The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

“Because There’s Just Something About That Menthol”: Exploring African American Smokers’ Perspectives on Menthol Smoking and Local Menthol Sales Restrictions

Introduction

Local governments are pursuing policies to limit the availability of menthol cigarettes at the point-of-sale. Although African Americans are disproportionately impacted by menthol cigarettes, little is known about African American smokers’ perspectives on emerging menthol policy. The purpose of this study was to fill a gap in the literature by exploring African American adult (25+) smoker perspectives on menthol and a local menthol sales restriction.

Methods

In-depth semi-structured interviews were conducted with African American smokers (n = 27) in the Minneapolis–St. Paul area June–September 2017. Interviews explored smoking behaviors, harm perceptions, perspectives of menthol in the community and reactions to local menthol sales restrictions. The framework method guided identification of key themes and synthesis of findings.

Results

Almost all (96%) participants smoked Newport cigarettes. The majority of participants indicated that menthol cigarettes were more harmful than non-menthol cigarettes, citing strength and additives and because they were targeted to African Americans. Some participants were receptive to policy change while others viewed the policy as inconvenient and unfair. Overall, there was a lack of understanding of the policy’s intended public health impact. Some participants indicated that the policy would have no impact on their purchasing or smoking behaviors while others who were contemplating quitting noted that a menthol restriction was encouragement to prompt a quit attempt.

Conclusions

Sales restrictions can provide a unique opportunity to persuade menthol smokers to quit. Efforts are needed to increase awareness and support of these policies as well as to support African American menthol smokers achieve cessation.

Implications

There is growing momentum to restrict local menthol tobacco sales; however, little is known about perceptions among populations most impacted. In Minneapolis–St. Paul, where menthol restrictions were passed in 2017, African American smokers expressed limited awareness and uneven policy support. While some participants were unconvinced the restriction would impact smoking, others indicated it would encourage decreased consumption and prompt quit attempts. There is a need for public education to increase awareness of menthol’s harms, to help menthol smokers quit, and to increase support for menthol policies.

Similarities Between Alcohol and Tobacco Advertising Exposure and Adolescent Use of Each of These Substances

OBJECTIVE

Underage alcohol use is a major public health problem and substantial corporate money supports alcohol advertising across multiple venues. A diverse research literature demonstrates that adolescent exposure to such advertising is associated with drinking attitudes and behavior, but no scientific body has determined these associations to be causal. The objective of this study was to assess the association between alcohol advertising and teen drinking in the context of the "Analogy" criterion of the Bradford Hill criteria and consider a determination that the association between exposure to alcohol advertising and alcohol use is causal.

METHOD

This study was a narrative review on the association between adolescent exposure to alcohol advertising and subsequent alcohol use in the context of domains utilized in the Surgeon General's 2012 Report, Preventing Tobacco Use Among Youth and Young Adults, which concluded, "Advertising and promotional activities by tobacco companies have been shown to cause the onset and continuation of smoking among adolescents and young adults."

RESULTS

In every aspect compared (i.e., adolescent knowledge; attitudes toward; initiation of use; continuation of use; mediums of advertisement; the use of mascots, celebrities, and themes; and frequency and density of advertisements and retailers), the findings for both tobacco and alcohol and their association with exposure to advertising are analogous.

CONCLUSIONS

Application of the Analogy criterion of the Bradford Hill criteria comparing alcohol and tobacco supports a judgment that the association between exposure to alcohol advertising and increased adolescent knowledge, attitudes toward, initiation, and continuation of alcohol use are causal in nature.

Transferring Racial/Ethnic Marketing Strategies From Tobacco to Food Corporations: Philip Morris and Kraft General Foods

Objectives. To investigate the transfer of marketing knowledge and infrastructure for targeting racial/ethnic minorities from the tobacco to the food and beverage industry in the United States.Methods. We analyzed internal industry documents between April 2018 and April 2019 from the University of California San Francisco Truth Tobacco Industry Documents Library, triangulated with other sources.Results. In the 1980s, Philip Morris Companies purchased General Foods and Kraft Foods and created Kraft General Foods. Through centralized marketing initiatives, Philip Morris Companies directly transferred expertise, personnel, and resources from its tobacco to its food subsidiaries, creating a racial/ethnic minority-targeted food and beverage marketing program modeled on its successful cigarette program. When Philip Morris Companies sold Kraft General Foods in 2007, Kraft General Foods had a "fully integrated" minority marketing program that combined target marketing with racial/ethnic events promotion, racial/ethnic media outreach, and corporate donations to racial/ethnic leadership groups, making it a food industry leader.Conclusions. The tobacco industry directly transferred racial/ethnic minority marketing knowledge and infrastructure to food and beverage companies. Given the substantial growth of food and beverage corporations, their targeting of vulnerable populations, and obesity-related disparities, public policy and community action is needed to address corporate target marketing.

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.

Prevalence, Use Behaviors, and Preferences among Users of Heated Tobacco Products: Findings from the 2018 ITC Japan Survey

Heated tobacco products (HTPs), such as IQOS, glo, and Ploom TECH, with a variety of flavored tobacco-containing inserts, have reportedly achieved a significant market share in Japan. We analyzed data from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted in February to March 2018 among 4684 adult participants to estimate the prevalence of HTP use, describe characteristics of HTP users, and explore user preferences for HTP device and flavor. The overall prevalence of monthly HTP use was 2.7% (1.7% daily use). Virtually all HTP users were current cigarette smokers (67.8%) or former smokers (25.0%); only 1.0% of HTP users were never smokers. Among HTP users, IQOS was the most frequently reported brand used (64.5%), and menthol was the most common flavor reported (41.5%). IQOS was used more by younger respondents and those who reported daily use, while Ploom TECH was more popular among older respondents and non-daily HTP users. This is one of the first non-industry funded studies to explore the use of HTPs in Japan.

Sales Trends in Price-Discounted Cigarettes, Large Cigars, Little Cigars, and Cigarillos-United States, 2011-2016

Introduction

Tobacco manufacturers continue to implement a range of pricing strategies to increase the affordability and consumption of tobacco products. To demonstrate the extent of retail- and brand-level price discounts at the point of sale, this study assessed national sales trends in price-discounted cigarettes, large cigars, little cigars, and cigarillos.

Methods

Retail scanner data for tobacco product sales were obtained for convenience stores (C-store) and all-other-outlets-combined (AOC) from September 25, 2011, to January 9, 2016. The proportion of price-discounted sales, average nondiscounted unit price, and average discounted unit price were examined by product category and brand. JoinPoint regression was used to assess average monthly percentage change.

Results

Overall, price-discounted sales accounted for 11.3% of cigarette, 3.4% of large cigar, 4.1% of little cigar, and 3.9% of cigarillo sales. The average difference between nondiscounted and discounted prices was 25.5% (C-store) and 36.7% (AOC) for cigarettes; 11.0% (C-store) and 11.2% (AOC) for large cigars; 19.2% (C-store) and 9.6% (AOC) for little cigars; and 5.3% (C-store) and 14.7% (AOC) for cigarillos. Furthermore, price-discounted sales of top-selling tobacco brands comprised up to 36% of cigarette, 7.4% of large cigar, 7.7% of little cigar, and 4.2% of cigarillo unit sales.

Conclusions

These findings highlight the use of price discounts by tobacco manufacturers to reduce the cost of cigarettes, large cigars, little cigars, and cigarillos to consumers. These sales patterns underscore the importance of sustained efforts to implement evidence-based strategies to increase prices and reduce availability and consumption of combustible tobacco in the United States.

Implications

This study highlights the prevalence and provides a baseline of price-discounted cigarettes, large cigars, little cigars, and cigarillos. Surveillance of tobacco sales data, including state-level trends and additional product types, is critical for informing approaches to reduce tobacco consumption. These approaches include countering tobacco product price-discounting practices and raising and maintaining a high sales price for all tobacco products. The implementation of evidence-based population-level interventions, together with local, state, and federal regulation of tobacco products, could prevent tobacco initiation, increase tobacco cessation, and reduce overall tobacco use among US youth and adults.

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.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

Pro-tobacco marketing and anti-tobacco campaigns aimed at vulnerable populations: A review of the literature

INTRODUCTION

We reviewed research literature on pro-tobacco marketing and anti-tobacco campaigns targeting eight vulnerable populations to determine key findings and research gaps. Results can inform tobacco policy and control efforts and the design of public education campaigns for these groups.

METHODS

Five journal databases in medicine, communication, and science, were used to identify 8875 peer-reviewed, original articles in English, published in the period 2004-2018. There were 144 articles that met inclusion criteria on pro-tobacco marketing or anti-tobacco campaigns aimed at eight US groups: women of reproductive age, racial/ethnic minority groups (African American, Hispanic/Latino, Asian/Pacific Islander and American Indian/Alaska Native), Lesbian/Gay/Bisexual/Transgender (LGBT) populations, groups with low socioeconomic status, rural/inner city residents, military/veterans, and people with mental health or medical co-morbidities. We summarized the number of articles for each population, type of tobacco, and pro-tobacco or anti-tobacco focus. Narrative summaries were organized by population and by pro-tobacco or anti-tobacco focus, with key strategies and gaps by group.

RESULTS

There were more studies on pro-tobacco marketing rather than anti-tobacco campaigns, and on cigarettes rather than other tobacco products. Major gaps included studies on Asian Americans, American Indian/Alaska Natives, pregnant women, LGBT populations, and those with mental health or medical co-morbidities. Gaps related to tobacco products were found for hookah, snus, and pipe/roll-your-own tobacco in the pro-tobacco studies, and for all products except cigarettes in anti-tobacco studies. Common tobacco industry methods used were tailoring of product and package design and messages that were used to reach and appeal to different sociodemographic groups. Studies varied by research design making it difficult to compare results.

CONCLUSIONS

We found major research gaps for specific groups and tobacco products. Public education campaigns need a stronger foundation in empirical studies focused on these populations. Research and practice would benefit from studies that permit comparisons across studies.

Evaluating the influence of racially targeted food and beverage advertisements on Black and White adolescents' perceptions and preferences

INTRODUCTION

The present study measures how racially-targeted food and beverage ads affect adolescents' attitudes toward ads and brands, purchase intentions for advertised products, and willingness to engage with brands on social media.

METHODS

Black and White adolescents were recruited through Survey Sampling International in 2016. Participants completed an online survey in which they were randomized to view either four food and beverage ads (e.g., soda, candy commercials) featuring Black actors or four food and beverage ads featuring White actors.

RESULTS

For the two components of the attitudinal outcome, Black participants were more likely to report a positive affective response toward racially-similar ads compared to Whites. However, White participants were more likely to like ads that were racially-dissimilar compared to Black participants. Data were analyzed in 2016-2017, and we used an alpha level of 0.05 to denote statistical significance.

CONCLUSIONS

Both Black and White adolescents reported more positive affective responses to ads that featured Blacks compared to ads that featured Whites. Because there were no differences on two outcomes, future research should examine the influence of racially-targeted marketing in real-world contexts (e.g., social media) and longitudinal exposure to targeted advertising on dietary behavior.

Patterns of Alcohol, Tobacco, and Substance Use Among Young Adult Peer Crowds

INTRODUCTION

The association between peer crowd identification and substance use is well documented among adolescents, but less is known about substance use among young adult peer crowds.

METHODS

This study leverages data from the Truth Initiative Young Adult Cohort Study (Wave 8, June-July 2015), a nationally representative cohort sample of young adults aged 18-34 years. The current cross-sectional analyses (conducted in 2018) focused on 1,341 individuals aged 18-24 years in this sample. Participants reported their peer crowd identification and current use of alcohol, marijuana, other drugs, and tobacco (cigarettes, little cigars/cigarillos, e-cigarettes, hookah, smokeless tobacco). Adjusted logistic regression models assessed associations between peer crowd identification and substance use.

RESULTS

In general, young adults who identified as homebody, young professional, or religious had lower odds of substance use than their counterparts. Young adults who identified as social/partier were more likely to be current users of alcohol, marijuana, any tobacco, cigarettes, and e-cigarettes than those who did not identify as social/partier. Those who identified as alternative were more likely to be current users of marijuana and other drugs than those not identified as alternative. Those who identified as country were more likely than those not identified as country to be current users of cigarettes and smokeless tobacco. Those who identified as hip hop were more likely to be current users of marijuana and e-cigarettes.

CONCLUSIONS

Peer crowd identification is associated with substance use among young adults. These findings can help identify target populations for prevention and cessation interventions and inform intervention design and delivery.

A cigarette pack by any other color: Youth perceptions mostly align with tobacco industry-ascribed meanings

•Youth interpret cigarette pack-colors in line with industry-intended associations.•Product-packaging restrictions may be circumvented by use of colors that misrepresent product harms.•43.2% of participants attributed extra strong to the black cigarette pack.•35.6% of participants ascribed rich to gold.•31.1% of participants ascribed menthol to green.

Peer crowd segmentation for targeting public education campaigns: Hip hop youth and tobacco use

This study examines the potential association between strength of Hip Hop peer crowd identification and tobacco use in one of the first large samples of Hip Hop youth in the United States. Data are from a geographically-targeted, address-based convenience sample of 2194 youths aged 12–17 who identify with the Hip Hop peer crowd collected via in-person and web interviews in 30 U.S. media markets in 2015. We examined strength of Hip Hop peer crowd identification, perceived peer tobacco use, and tobacco use outcomes. Overall, 18.3% of Hip Hop youth reported current blunt (cigar with added marijuana) use, followed by electronic cigarettes (e-cigarettes) (11.6%), cigar (without added marijuana) (8.8%), hookah (6.5%), and cigarette (5.6%) use. Stronger Hip Hop peer crowd identification was associated with increased odds of using cigarettes (OR = 2.25, p < 0.05), cigars (OR = 2.14, p < 0.05), and blunts (OR = 1.61, p < 0.05), controlling for demographic characteristics and perceived peer tobacco use. Results suggest that a Hip Hop peer crowd–targeted public education prevention campaign for youth can be promising for a variety of tobacco products.

Menthol Smoking Patterns and Smoking Perceptions Among Youth: Findings From the Population Assessment of Tobacco and Health Study

INTRODUCTION

Youth may be attracted to menthol cigarettes because they are perceived as less harmful and harsh to smoke relative to non-menthol cigarettes. This study examined demographic factors and menthol cigarette smoking patterns as correlates of youth harm perceptions of cigarette smoking and ease of smoking menthol versus non-menthol cigarettes.

METHODS

Data were from the Wave 1 (2013-2014) youth sample of the Population Assessment of Tobacco and Health Study. Weighted multivariable logistic regression models were used to examine correlations between demographic factors and menthol cigarette smoking patterns (menthol initiation, past 30-day menthol cigarette smoking, and menthol cigarette brand preference), with harm perceptions of cigarette smoking and ease of smoking a menthol cigarette.

RESULTS

Nearly half of ever cigarette smoking youth (43%) first used a menthol cigarette; 21% reported past 30-day menthol cigarette smoking; and 42% of past 30-day smokers providing brand information used a menthol cigarette as their preferred brand. In bivariate analyses, initiation with a menthol cigarette and menthol brand preference (versus non-menthol) were correlated with black race, older age at initiation, and past 30-day menthol cigarette smoking. In adjusted models, past 30-day menthol cigarette smoking and menthol cigarette brand preference, but not menthol initiation, were correlated with the perception that menthol cigarettes are easier to smoke.

CONCLUSIONS

Youth who smoke menthol cigarettes perceive them as easier to smoke, even after adjusting for other factors. Age of initiation and black race emerged as correlates of menthol cigarette initiation, brand preference, and cigarette harm perceptions, and may inform future prevention campaigns.

Ethnic and Socioeconomic Disparities in Recalled Exposure to and Self-Reported Impact of Tobacco Marketing and Promotions

The role of tobacco marketing in tobacco use, particularly among the vulnerable ethnic and socioeconomic sub-populations is a regulatory priority of the U.S. Food and Drug Administration. There currently exist both ethnic and socioeconomic disparities in the use of tobacco products. Monitoring such inequalities in exposure to tobacco marketing is essential to inform tobacco regulatory policy that may reduce known tobacco-related health disparities. We use data from the Population Assessment of Tobacco and Health (PATH) Wave 1 youth survey to examine (1) recalled exposure to and liking of tobacco marketing for cigarettes, non-large cigars, and e-cigarettes, (2) self-reported exposure to specific tobacco marketing tactics, namely coupons, sweepstakes, and free samples, and (3) self-reported impact of tobacco marketing and promotions on product use. Findings indicate that African Americans and those of lower SES were more likely to recall having seen cigarette and non-large cigar ads. Reported exposure to coupons, sweepstakes and free samples also varied ethnically and socioeconomically. African Americans and those of lower SES were more likely than other respondents to report that marketing and promotions as played a role in their tobacco product use. Better understanding of communication inequalities and their influence on product use is needed to inform tobacco regulatory action that may reduce tobacco company efforts to target vulnerable groups. Tobacco education communication campaigns focusing on disproportionately affected groups could help counter the effects of targeted industry marketing.

Combustible and Electronic Tobacco and Marijuana Products in Hip-Hop Music Videos, 2013-2017

IMPORTANCE

Hip-hop is the leading music genre in the United States and its fan base includes a large proportion of adolescents and young adults of all racial and ethnic groups, particularly minorities. The appearance of combustible and electronic tobacco and marijuana products, especially brand placement and use by popular and influential artists, may increase the risk of tobacco and marijuana use and decrease perceptions of harm.

OBJECTIVE

To assess the prevalence of the appearance and use of combustible and electronic tobacco and marijuana products, including brand placement, in leading hip-hop songs.

DESIGN, SETTING, AND PARTICIPANTS

Analysis of top 50 songs from 2013 to 2017 of Billboard magazine's weekly Hot R&B/Hip-Hop Songs with videos that included the appearance or use of combustible tobacco and marijuana products (manufactured cigarettes, cigars, hookah or waterpipe, pipe, hand-rolled tobacco and marijuana products, marijuana buds); appearance of exhaled smoke or vapor without an identifiable source product; appearance or use of electronic tobacco and marijuana products (eg, electronic cigarettes); tobacco or marijuana brand placement; appearance or use of combustible and electronic tobacco and marijuana by main or featured artist. Data were collected from December 6, 2017, to June 4, 2018.

MAIN OUTCOMES AND MEASURES

Prevalence of (1) appearance or use of combustible tobacco and marijuana products, (2) appearance of smoke or vapor, (3) appearance or use of electronic tobacco and marijuana products, (4) tobacco or marijuana brand placement, and (5) appearance or use of combustible and electronic tobacco and marijuana by main or featured artist. Probability of appearance or use of combustible and electronic tobacco and marijuana products by quartile of viewership of videos.

RESULTS

The proportion of leading hip-hop videos containing combustible use, electronic use, or smoke or vapor ranged from 40.2% (76 of 189) in 2015, to 50.7% (102 of 201) in 2016. For each year, the leading category of combustible use was hand-rolled products. The appearance of branded products increased from 0% in 2013 (0 of 82) to 9.9% in 2017 (10 of 101) for combustible products, and from 25.0% in 2013 (3 of 12) to 87.5% in 2017 (14 of 16) for electronic products. The prevalence of combustible or electronic product use or exhaled smoke or vapor increased by quartile of total number of views: 41.9% (8700 to 19 million views) among songs in the first quartile of viewership and 49.7% among songs in the fourth quartile of viewership (112 million to 4 billion views).

CONCLUSIONS AND RELEVANCE

Combustible and electronic tobacco and marijuana use frequently occurred in popular hip-hop music videos. The genre's broad appeal, use of branded products by influential artists, and rise of electronic product and marijuana use may contribute to a growing public health concern of tobacco and marijuana use.

The Association Between Menthol Perceptions and Support for a Policy Ban Among US Smokers

Objective

To examine the relationship between menthol perceptions and support for a national menthol ban.

Participants

Data were collected from a nationally representative probability-based panel of adults aged ≥18 years during June 21, 2016 through July 18, 2016. A total of 1,303 respondents, including an oversample of 300 African Americans, completed the survey.

Main Outcome Measures

Weighted logistic regression models examined the relationship between menthol perceptions, specifically related to health and addiction, and the outcome measure: support for a menthol ban, by menthol smoking status. All models controlled for age, sex, education level, and race/ethnicity.

Results

The association between reporting accurate menthol health perceptions differed by menthol preference. Among non-menthol smokers, there was no association between accurate menthol health perceptions and support of a menthol ban while more accurate menthol perceptions of addiction were associated with greater support of a menthol ban (aOR=2.83, CI=1.19-6.72). Among menthol smokers, more accurate health-related menthol perceptions were associated with increased odds of supporting a menthol ban (aOR=3.90, CI=1.02-14.79) while more accurate menthol addiction perceptions were not.

Conclusions

Fewer current menthol smokers support a menthol ban than current non-menthol smokers given its effect on their preferred product. Given the large proportions of smokers who have misperceptions of the health consequences and addictive properties of menthol, there is a moral imperative to inform those who use these products. Findings suggest the need for tailored messaging strategies targeted to reach menthol smokers who will be most impacted by a ban, but also have the most to gain from such a policy change.

The Hip Hop peer crowd: An opportunity for intervention to reduce tobacco use among at-risk youth

INTRODUCTION

Peer crowds, peer groups with macro-level connections and shared norms that transcend geography and race/ethnicity, have been linked to risky health behaviors. Research has demonstrated that Hip Hop peer crowd identification, which is common among multicultural youth, is associated with increased risk of tobacco use. To address this, the FDA Center for Tobacco Products created Fresh Empire, the first national tobacco education campaign tailored for Hip Hop youth aged 12-17 who are multicultural (Hispanic, African American, Asian-Pacific Islander, or Multiracial). As part of campaign development, peer crowd (Hip Hop, Mainstream, Popular, Alternative, Country) and cigarette smoking status were examined for the first time with a nationally recruited sample.

METHODS

Youth were recruited via targeted social media advertisements. Participants aged 13-17 (n = 5153) self-reported peer crowd identification via the I-Base Survey™ and cigarette smoking status. Differences in smoking status by peer crowd were examined using chi-square and followed up with z-tests to identify specific differences.

RESULTS

Alternative youth were most at risk of cigarette smoking, followed by Hip Hop. Specifically, Hip Hop youth were significantly less likely to be Non-susceptible Non-triers than Popular, Mainstream, and Country youth, and more likely to be Experimenters than Popular and Mainstream youth.

CONCLUSIONS

Representative studies show that Alternative is relatively small compared to other high-risk crowds, such as the Hip Hop peer crowd. The current research underscores the potential utility of interventions tailored to larger at-risk crowds for campaigns like Fresh Empire.

Receipt of tobacco direct mail/email discount coupons and trajectories of cigarette smoking behaviours in a nationally representative longitudinal cohort of US adults

BACKGROUND

We assessed whether receipt of coupons-via direct mail or e-mail-was prospectively related to trajectories of smoking behaviours.

METHODS

Data were from a cohort of US adults (n=26 447) who participated in wave 1 (2013-2014) and wave 2 (2014-2015) of the Population Assessment of Tobacco and Health Study. Participants reported receipt of tobacco direct mail/email coupons in the past 6 months in wave 1 and their smoking status in both waves. Weighted multiple logistic regressions were used to examine demographic correlates of receiving tobacco direct mail/email coupons at wave 1 and to examine the prospective effect of receiving tobacco coupons on trajectories of smoking behaviours.

FINDINGS

At wave 1, 10.7% of never smokers, 13.9% of experimental smokers, 37.1% of current smokers and 16.5% of former smokers reported receiving tobacco direct mail/email coupons. Lower education and higher poverty adults and non-Hispanic white current smokers were more likely to have received these coupons (p<0.05). Receiving tobacco direct mail/email coupons at wave 1 was associated with increased odds of smoking initiation among never smokers (adjusted odds ratio (AOR)=2.28, 95% CI 1.36 to 3.83), becoming established smokers among experimenters (AOR=1.62, 95% CI 1.29 to 2.04), becoming daily smokers among non-daily smokers (AOR=1.56, 95% CI 1.23 to 1.99) and smoking relapse among former smokers between waves (AOR=1.91, 95% CI 1.39 to 2.65). Receiving these coupons at wave 1 was associated with reduced odds of smoking cessation ≥6 months among current smokers (AOR=0.71, 95% CI 0.58 to 0.88).

CONCLUSIONS

Tobacco direct mail/email coupons encourage and sustain smoking and disproportionately affect lower socioeconomic populations.

Mechanisms of toxicity and biomarkers of flavoring and flavor enhancing chemicals in emerging tobacco and non-tobacco products

Tobacco products containing flavorings, such as electronic nicotine delivery devices (ENDS) or e-cigarettes, cigars/cigarillos, waterpipes, and heat-not-burn devices (iQOS) are continuously evolving. In addition to increasing the exposure of teenagers and adults to nicotine containing flavoring products and flavoring enhancers, chances of nicotine addiction through chronic use and abuse also increase. These flavorings are believed to be safe for ingestion, but little information is available about their effects on the lungs. In this review, we have discussed the in vitro and in vivo data on toxicity of flavoring chemicals in lung cells. We have further discussed the common flavoring agents, such as diacetyl and menthol, currently available detection methods, and the toxicological mechanisms associated with oxidative stress, inflammation, mucociliary clearance, and DNA damage in cells, mice, and humans. Finally, we present potential biomarkers that could be utilized for future risk assessment. This review provides crucial parameters important for evaluation of risk associated with flavoring agents and flavoring enhancers used in tobacco products and ENDS. Future studies can be designed to address the potential toxicity of inhaled flavorings and their biomarkers in users as well as in chronic exposure studies.

Educational Attainment and Smoking Status in a National Sample of American Adults; Evidence for the Blacks' Diminished Return

BACKGROUND

Although higher socioeconomic status (SES) indicators such as educational attainment are linked with health behaviors, the Blacks’ Diminished Return theory posits that the protective effects of SES are systemically smaller for Blacks than Whites.

AIMS

To explore the Black/White differences in the association between education and smoking.

METHODS

This cross-sectional study used the Health Information National Trends Survey (HINTS) 2017 (n = 3217). HINTS is a national survey of American adults. The current analysis included 2277 adults who were either Whites (n = 1868; 82%) or Blacks (n = 409; 18%). The independent variable was educational attainment, and the dependent variables were ever and current (past 30-day) smoking. Demographic factors (age and gender) were covariates. Race was the focal moderator.

RESULTS

In the pooled sample, higher educational attainment was associated with lower odds of ever and current smoking. Race interacted with the effects of higher educational attainment on current smoking, suggesting a stronger protective effect of higher education against current smoking for Whites than Blacks. Race did not interact with the effect of educational attainment on odds of ever smoking.

CONCLUSIONS

In line with previous research in the United States, education is more strongly associated with health and health behaviors in Whites than Blacks. Smaller protective effects of education on health behaviors may be due to the existing racism across institutions such as the education system and labor market.

Peer Crowd Identification and Adolescent Health Behaviors: Results From a Statewide Representative Study

Purpose. Peer crowds are macro-level subcultures that share similarities across geographic areas. Over the past decade, dozens of studies have explored the association between adolescent peer crowds and risk behaviors, and how they can inform public health efforts. However, despite the interest, researchers have not yet reported on crowd size and risk levels from a representative sample, making it difficult for practitioners to apply peer crowd science to interventions. The current study reports findings from the first statewide representative sample of adolescent peer crowd identification and health behaviors. Methods. Weighted data were analyzed from the 2015 Virginia Youth Survey of Health Behaviors ( n = 4,367). Peer crowds were measured via the I-Base Survey™, a photo-based peer crowd survey instrument. Frequencies and confidence intervals of select behaviors including tobacco use, substance use, nutrition, physical activity, and violence were examined to identify high- and low-risk crowds. Logistic regression was used to calculate adjusted odds ratios for each crowd and behavior. Results. Risky behaviors clustered in two peer crowds. Hip Hop crowd identification was associated with substance use, violence, and some depression and suicidal behaviors. Alternative crowd identification was associated with increased risk for some substance use behaviors, depression and suicide, bullying, physical inactivity, and obesity. Mainstream and, to a lesser extent, Popular, identities were associated with decreased risk for most behaviors. Conclusions. Findings from the first representative study of peer crowds and adolescent behavior identify two high-risk groups, providing critical insights for practitioners seeking to maximize public health interventions by targeting high-risk crowds.

Social Disparities in Exposure to Point-of-Sale Cigarette Marketing

While most ecological studies have shown that higher levels of point-of-sale (POS) cigarette marketing are associated with larger proportions of residents from lower socioeconomic and minority backgrounds in neighborhoods, there are no studies that examine individual-level social disparities in exposure to POS cigarette marketing among smokers in the United States. Our aim was to examine these disparities in a Midwestern metropolitan area in the United States. We conducted a telephone survey to collect data on 999 smokers. Cigarette marketing was measured by asking respondents three questions about noticing advertisements, promotions, and displays of cigarettes within their respective neighborhoods. The questions were combined to create a summated scale. We estimated ordered logistic regression models to examine the association of sociodemographic variables with exposure to POS cigarette marketing. Adjusted results showed that having a lower income (p < 0.003) and belonging to a race/ethnicity other than "non-Hispanic White" (p = 0.011) were associated with higher levels of exposure to POS cigarette marketing. The results highlight social disparities in exposure to POS cigarette marketing in the United States, which can potentially be eliminated by banning all forms of cigarette marketing.

Understanding how perceptions of tobacco constituents and the FDA relate to effective and credible tobacco risk messaging: A national phone survey of U.S. adults, 2014-2015

BACKGROUND

The passage of the 2009 Family Smoking Prevention and Tobacco Control Act has necessitated the execution of timely, innovative, and policy-relevant tobacco control research to inform Food and Drug Administration (FDA) regulatory and messaging efforts. With recent dramatic changes to tobacco product availability and patterns of use, nationally representative data on tobacco-related perceptions and behaviors are vital, especially for vulnerable populations.

METHODS

The UNC Center for Regulatory Research on Tobacco Communication conducted a telephone survey with a national sample of adults ages 18 and older living in the United States (U.S.). The survey assessed regulatory relevant factors such as tobacco product use, tobacco constituent perceptions, and tobacco regulatory agency credibility. The study oversampled high smoking/low income areas as well as cell phone numbers to ensure adequate representation among smokers and young adults, respectively. Coverage extended to approximately 98 % of U.S. households.

RESULTS

The final dataset (N = 5,014) generated weighted estimates that were largely comparable to other national demographic and tobacco use estimates. Results revealed that over one quarter of U.S. adults, and over one third of smokers, reported having looked for information about tobacco constituents in cigarette smoke; however, the vast majority was unaware of what constituents might actually be present. Although only a minority of people reported trust in the federal government, two thirds felt that the FDA can effectively regulate tobacco products.

CONCLUSIONS

As the FDA continues their regulatory and messaging activities, they should expand both the breadth and availability of constituent-related information, targeting these efforts to reach all segments of the U.S. population, especially those disproportionately vulnerable to tobacco product use and its associated negative health outcomes.

The African American Youth Smoking Experience: An Overview

INTRODUCTION

Beginning in the late 1970s, a very sharp decline in cigarette smoking prevalence was observed among African American (AA) high school seniors compared with a more modest decline among whites. This historic decline resulted in a lower prevalence of cigarette smoking among AA youth that has persisted for several decades.

METHODS

We synthesized information contained in the research literature and tobacco industry documents to provide an account of past influences on cigarette smoking behavior among AA youth to help understand the reasons for these historically lower rates of cigarette smoking.

RESULTS

While a number of protective factors including cigarette price increases, religiosity, parental opposition, sports participation, body image, and negative attitudes towards cigarette smoking may have all played a role in maintaining lower rates of cigarette smoking among AA youth as compared to white youth, the efforts of the tobacco industry seem to have prevented the effectiveness of these factors from carrying over into adulthood.

CONCLUSION

Continuing public health efforts that prevent cigarette smoking initiation and maintain lower cigarette smoking rates among AA youth throughout adulthood have the potential to help reduce the negative health consequences of smoking in this population.

IMPLICATIONS

While AA youth continue to have a lower prevalence of cigarette smoking than white youth, they are still at risk of increasing their smoking behavior due to aggressive targeted marketing by the tobacco industry. Because AAs suffer disproportionately from tobacco-related disease, and have higher incidence and mortality rates from lung cancer, efforts to prevent smoking initiation and maintain lower cigarette smoking rates among AA youth have the potential to significantly lower lung cancer death rates among AA adults.

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity). Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities. There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.

"Gone are the days of mass-media marketing plans and short term customer relationships": tobacco industry direct mail and database marketing strategies

BACKGROUND

As limitations on traditional marketing tactics and scrutiny by tobacco control have increased, the tobacco industry has benefited from direct mail marketing which transmits marketing messages directly to carefully targeted consumers utilising extensive custom consumer databases. However, research in these areas has been limited. This is the first study to examine the development, purposes and extent of direct mail and customer databases.

METHODS

We examined direct mail and database marketing by RJ Reynolds and Philip Morris utilising internal tobacco industry documents from the Legacy Tobacco Document Library employing standard document research techniques.

RESULTS

Direct mail marketing utilising industry databases began in the 1970s and grew from the need for a promotional strategy to deal with declining smoking rates, growing numbers of products and a cluttered media landscape. Both RJ Reynolds and Philip Morris started with existing commercial consumer mailing lists, but subsequently decided to build their own databases of smokers' names, addresses, brand preferences, purchase patterns, interests and activities. By the mid-1990s both RJ Reynolds and Philip Morris databases contained at least 30 million smokers' names each. These companies valued direct mail/database marketing's flexibility, efficiency and unique ability to deliver specific messages to particular groups as well as direct mail's limited visibility to tobacco control, public health and regulators.

CONCLUSIONS

Database marketing is an important and increasingly sophisticated tobacco marketing strategy. Additional research is needed on the prevalence of receipt and exposure to direct mail items and their influence on receivers' perceptions and smoking behaviours.

Using peer crowds to segment Black youth for smoking intervention

Studies of peer crowds show promise for enhancing public health promotion and practice through targeting. Distinct images, role models, and social norms likely influence health behaviors of different peer crowds within health disparity groups. We describe peer crowds identified by Black young people and determine whether identification with them is associated with smoking. Data from Black young people aged 13 to 20 years in Richmond, Virginia, were collected via interview and online survey (N = 583). We identified the number and type of peer crowds using principal components analysis; associations with smoking were analyzed using Pearson chi-square tests and logistic regression. Three peer crowds were identified--"preppy," "mainstream," and "hip hop." Youth who identify with the hip hop peer crowd were more likely to smoke and have friends who smoke and less likely to hold antitobacco attitudes than those identifying with preppy or mainstream crowds. Identifying with the hip hop crowd significantly increased the odds of smoking, controlling for demographic factors (odds ratio = 1.97; 95% confidence interval = 1.03-3.76). Tobacco prevention efforts for Black youth and young adults should prioritize the hip hop crowd. Crowd identity measures can aid in targeting public health campaigns to effectively engage those at highest risk.