Racial and Ethnic Differences in What Smokers Report Paying for Their Cigarettes

Relationship Between Chronic Stress Measured by Allostatic Load and Age-Related Macular Degeneration in the All of Us Research Program

PURPOSE

To assess the longitudinal relationship between age-related macular degeneration (AMD) and allostatic load (AL), an established framework for quantifying the physiologic effects of chronic stress through measurements of systemic biomarkers.

DESIGN

Retrospective case-control study.

METHODS

Participants of the National Institutes of Health All of Us (AoU) Research Program with complete AL biomarker data between February 1985 to May 2022 and with (cases) or without (controls) AMD were identified. AL scores were calculated using the adapted Seeman AL scale consisting of 10 systemic biomarkers: body mass index, systolic blood pressure, diastolic blood pressure, total cholesterol, triglycerides, glomerular filtration rate, albumin, C-reactive protein, and homocysteine. AL score was defined as the number of biomarkers with measurements in the highest risk quartiles. Age was calculated as the median age at time of earliest or latest biomarker measurements. The main outcome was AMD status (AMD or non-AMD). Logistic regression models assessed the association between AL score and AMD after standardization of age and sex and adjustment for race/ethnicity and pack-years of cigarette smoking. Mediation analysis estimated the relationship between race/ethnicity and AMD as mediated by AL score.

RESULTS

Among 1530 participants (221 cases, 1309 controls) with complete biomarker data, there were 44.6% males, 76.1% non-Hispanic Whites (NHWs), 18.6% other specified race/ethnicity (Asian, Black, or Hispanic race/ethnicity), and 5.3% unspecified race/ethnicity. AL scores measured a median of 9.0 (IQR=5.0-14.0) years prior to diagnosis were higher among cases compared to controls (Median [IQR] = 2 [2-4] versus 2 [1-3]; P = .02). On multivariable analysis, higher baseline AL score (OR=1.11) and greater pack-years (OR=1.15 per 10 pack-years) conferred higher risk of AMD (P ≤ .02). Mediation analysis revealed a significant indirect effect that increased risk of AMD among other specified race/ethnicity participants compared to NHW participants through higher AL score (OR=1.07 per unit [1.01-1.15]).

CONCLUSION

All of Us participants diagnosed with AMD had greater AL score 9.0 years prior to AMD diagnosis. Chronic stress appears to increase risk for AMD and may contribute to racial/ethnic differences in disease prevalence.

Use of tobacco price-minimization strategies among public housing residents compared to U.S. low-income adults

BACKGROUND

Price minimization strategies (PMS) are ways for people to save money on tobacco purchases especially among those of lower socioeconomic status. This study assesses PMS and coupon receipt among public housing residents compared to U.S. low-income adults.

METHODS

Data were from adults who currently use tobacco and live in District of Columbia Housing Authority (DCHA) public housing (n=270) and a US nationally representative sample of low-income adults who currently use tobacco (n=820). We examined the prevalence of PMS use across demographic characteristics and smoking behaviors, and qualitatively compared them across the two datasets.

RESULTS

Most DCHA resident participants (84.2 %) and US low-income adults who currently use tobacco (91.5 %) recently used at least one PMS to save money on tobacco. The top-three most common strategies among DCHA residents were saving cigarettes to finish later (35.6 %), smoking fewer cigarettes (32.2 %), and finding cheaper places to buy cigarettes (30.4 %), while among U.S. low-income adults these strategies were using coupons or promotions (62.7 %), purchasing by bulk (55.5 %), and finding cheaper places to buy tobacco products (53.6 %). People who lightly smoke in DCHA were more likely than people who heavily smoke to use PMS in general (25.0 % vs. 13.7 %) and smoke fewer cigarettes to save money (35.8 % vs. 19.2 %). US low-income people who lightly smoke were more likely than people who heavily smoke to cut back on tobacco use (61.9 % vs. 39.8 %).

CONCLUSION

Most U.S. low-income individuals and DCHA residents who smoke engaged in PMS. Regulating these strategies while supporting tobacco use cessation may reduce the impact of tobacco in these populations.

Impact of New York City Cigarette Floor Price Policy on Reducing Smoking Disparities

INTRODUCTION

In 2017, New York City (NYC) passed a minimum floor price law (MFPL) to raise the minimum price of a pack of cigarettes to $13.00. Evaluation of the MFPL in NYC is limited and has yet to examine its potential as a proequity policy.

AIMS AND METHODS

Data (n = 20 241; prepolicy n = 15 037, postpolicy n = 5204) were obtained from the New York State Adult Tobacco Survey, a quarterly repeated cross-sectional survey. Using the Difference-in-Differences approach, we compared changes in reported cigarette prices, cigarette consumption, and smoking status among NYC residents before and after policy implementation to changes in the same outcomes among residents in the rest of the state (ROS) over the same period.

RESULTS

For some smokers, cigarette price increased in NYC for the postpolicy period; moreover, prices increased more in NYC than in ROS. NYC smokers who reported higher income, more education, or White or "Other" race, reported a bigger price increase than their ROS counterparts. Cigarette consumption decreased more in the postpolicy period for people in the ROS, in general and among certain groups. Everyday smoking status decreased similarly in both NYC and ROS, whereas someday smoking status decreased primarily in the ROS during the analysis period.

CONCLUSIONS

Cigarette prices in NYC increased after the 2017 MFPL; these increases were greater than those occurring elsewhere in the state, suggesting the policy might be a factor in the change. However, the increases were concentrated among relatively higher-priced purchases, and groups with lower smoking prevalence. Changes in smoking status and cigarette consumption did not correspond to study hypotheses.

IMPLICATIONS

This study provides an empirical analysis of a real-world policy in tobacco control. It examines the potential of the MFPL in NYC as a proequity policy. Findings extend the current MFPL literature and suggest that they may be able to raise cigarette prices for some purchases, but also may have a limited impact on smoking behaviors.

Cigarette Prices and Disparities in Smoking Cessation in the United States

INTRODUCTION

Achieving cessation in people with established smoking patterns remains a challenge. Increasing cigarette prices has been one of the most successful strategies for lowering smoking rates. The extent to which it has remained effective in encouraging cessation among adults in recent years and how the effectiveness has varied by sociodemographic characteristics is unclear.

AIMS AND METHODS

Using repeated cross-sectional data collected by the Tobacco Use Supplement of the Current Population Survey, we investigate the relationship between cigarette prices and cessation from 2003 to 2019 in adults at least 25 years old. We examine the associations between price and cessation in the population overall and by sex, race and ethnicity, and socioeconomic status.

RESULTS

We found mixed support for associations between greater local prices and cessation. Unadjusted models showed that greater local prices were associated with greater odds of cessation, but the associations did not persist after controlling for sociodemographic characteristics. The associations did not significantly differ by respondent characteristics. Sensitivity analysis using alternative specifications and retail state price as the main predictor showed similar results. Sensitivity analysis with controls for e-cigarette use in the 2014-2019 period showed that greater local price was associated with cessation among adults with less than a high school degree. When stratified by year of data collection, results show that greater local prices were associated with cessation after 2009.

CONCLUSIONS

Overall, the study adds to the conflicting evidence on the effectiveness of increasing prices on smoking cessation among adults with established smoking patterns.

IMPLICATIONS

Higher cigarette prices have been one of the most successful tools for lowering smoking prevalence. It remains unclear how effective they have been in recent years in encouraging adults with established smoking patterns to quit. The study's results show that greater local prices were associated with higher odds of cessation, but the association did not persist after sociodemographic adjustment. In a sensitivity analysis, greater local price was associated with cessation among people with less than a high school degree in models controlling for e-cigarette use. We also found evidence that greater local price was associated with cessation after 2009. More comprehensive smoke-free coverage was also associated with greater odds of cessation. The study's results highlight that encouraging cessation among adults with an established smoking pattern remains a challenging policy problem even when cigarette prices rise.

Changes in retail tobacco product sales and market share among retail payroll establishments in the U.S. Economic Census between 1997 and 2017

The tobacco industry spends the vast majority of their marketing and promotional budget at retail outlets. However, few studies have used publicly available data to examine trends in the number and types of retail establishments where tobacco products are sold. Using the U.S. Economic Census for 1997, 2002, 2007, 2012 and 2017 (the latest year), we examined the number, type, and sales of payroll establishments selling tobacco products. Nine store types accounted for 94% - 99% of tobacco product sales between 1997 and 2017. Gas/convenience stores had the greatest market share (33% - 49% of tobacco sales). The number of warehouse clubs selling tobacco quadrupled; however, market share only increased from 9.6% to 10.3%. Supermarkets experienced the largest decrease in percent of stores selling tobacco. Pharmacy tobacco sales increased in 2012 then decreased in 2017; per store sales volume more than doubled between 1997 and 2012. Online shopping accounted for less than 1% of the market share between 1997 and 2012, but rose to 6.3% in 2017. Between 1997 and 2017, consumers shifted where they purchased tobacco products. Declining tobacco sales in supermarkets is a promising trend for consumers seeking healthy food without exposure to tobacco product marketing; however, the consistently large number of tobacco retailers, and thus widespread tobacco availability, is concerning. Consumer tobacco purchase changes over time support the case for point-of-sale policies that affect different retail types, including pharmacy bans, to reduce tobacco retailer density. Additionally, the rapid shift to online tobacco purchasing in 2017 identifies a new target for enhanced regulation and enforcement.

"That's Pot Culture Right There": Purchasing Behaviors of People Who Use Cannabis Without a Medical Cannabis Card

Introduction

The legal landscape surrounding purchasing cannabis without a medical cannabis card (i.e., without MCC) is changing rapidly, affecting consumer access and purchasing behaviors. Cannabis purchasing behaviors are related to subsequent use and experiencing greater cannabis-related negative consequences. However, purchasing behaviors of individuals who use cannabis without MCC are understudied.

Methods

The current study analyzed qualitative data from focus groups with adults who use cannabis without MCC (n = 5 groups; 6-7 participants/group; n = 31 total participants). Focus groups followed a semi-structured agenda, and were audio recorded and transcribed. Two coders applied thematic analysis to summarize topics pertaining to cannabis purchasing attitudes and behaviors. Focus groups occurred in 2015 and 2016 in Rhode Island, when purchasing and use of cannabis without MCC was decriminalized but still considered illegal.

Results

On average, participants (72% male) were 26 years old (SD = 7.2) and reported using cannabis 5 days per week (SD = 2.1). Thematic analysis revealed three key themes related to cannabis purchasing behaviors: (1) regular purchasing routines (i.e., frequency, schedule, amount of purchases), (2) economic factors (i.e., financial circumstances), and (3) contextual factors (i.e., quality of cannabis, convenience/availability) were perceived to influence purchasing decisions. Dealers' recommendations affected participants' purchases, who also reported minimal legal concerns. Participants reported saving money and using more cannabis when buying in bulk.

Discussion

Purchasing behaviors were found to vary and were perceived to be affected by individual-level (e.g., routines) and contextual factors (e.g., availability) that, in turn, may impact use patterns. Future research should consider how factors (e.g., availability) that differ across contexts (e.g., location) and demographic groups interact to affect purchasing behaviors.

Association between maternal e-cigarette use during pregnancy and low gestational weight gain

OBJECTIVE

To evaluate the risk of low gestational weight gain (GWG) in women who use electronic cigarettes (e-cigarettes), combustible cigarettes, or both e-cigarettes and combustible cigarettes (dual use) during pregnancy.

METHODS

We conducted a secondary analysis of the data from 176 882 singleton pregnancies in the 2016-2020 US Pregnancy Risk Assessment Monitoring System (PRAMS). Postpartum women self-reported their use of e-cigarettes and/or cigarettes during the last 3 months of pregnancy. Low GWG was defined as the total GWG less than 12.7 kg, less than 11.3 kg, less than 6.8 kg, and less than 5.0 kg (<28, <25, <15, and < 11 lb) for women with underweight, normal weight, overweight, and obesity, respectively. We used multivariable logistic regression to estimate the odds ratios (ORs) of low GWG, adjusting for confounders.

RESULTS

In this national sample, 921 (weighted percentage, 0.5%) of women were e-cigarette users and 1308 (0.7%) were dual users during late pregnancy. Compared with non-users during late pregnancy (40 090, 22.1%), cigarette users (4499, 28.0%) and dual users (427, 26.0%) had a higher risk of low GWG, but e-cigarette users had a similar risk (237, 22.1%). Adjustment for sociodemographic and pregnancy confounders moderately attenuated these associations: confounder-adjusted ORs 1.26 (95% confidence interval [CI] 1.18-1.35) for cigarette users, 1.18 (95% CI 0.96-1.44) for dual users, and 0.99 (95% CI 0.78-1.27) for e-cigarette users.

CONCLUSIONS

Unlike combustible cigarette use, e-cigarette use during late pregnancy does not appear to be a risk factor for low GWG.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Using point-of-sale data to examine tobacco pricing across neighbourhoods in Scotland

OBJECTIVES

To assess the geographical variation in tobacco price (cigarettes and roll-your-own (RYO) tobacco) in convenience stores across Scotland and how this relates to neighbourhood income deprivation, tobacco retail outlet density and urban/rural status.

METHODS

Tobacco price data from 124 566 shopping baskets purchased in 274 convenience stores during 1 week in April 2018 were obtained through an electronic point-of-sale system. These data were combined with neighbourhood-level measures of income deprivation, tobacco retail outlet density and urban/rural status. We examined brand price for 12 of the most popular cigarette brands and 3 RYO brands and variations in purchases by price segment; multivariable regression analysis assessed associations between area variables and tobacco price.

RESULTS

Most stores sold tobacco in all price segments. The lowest priced subvalue brands were the most popular in all neighbourhoods but were most dominant in shops in more deprived neighbourhoods. When total sales were assessed, overall purchase price varied significantly by neighbourhood income deprivation; packets of 20 cigarettes were 50 pence (5.6%) lower and RYO 34 pence (2.7%) lower among shops in the two highest income deprivation quintiles relative to the lowest. Analysis of individual brands showed that for 3 of the 12 cigarette brands considered, average prices were 12-17 pence lower in more deprived neighbourhoods with the most popular RYO brand 15 pence lower. There was limited evidence of a relationship with tobacco retail outlet density.

CONCLUSION

Across Scottish convenience stores, the purchase price of cigarettes and RYO was lower in more income-deprived neighbourhoods. The lower prices primarily reflect greater sales of cheap brands in these areas, rather than retailers reducing the prices of individual brands.

Simulating the Impact of a Cigarette Minimum Floor Price Law on Adult Smoking Prevalence in California

INTRODUCTION

Minimum floor price laws (MFPLs) are an emerging tobacco control policy that sets a minimum price below which a specific tobacco product cannot be sold. MFPLs target cheaper products and may disproportionately impact consumers choosing low price brands or using discounts to reduce prices. We developed a static microsimulation model for California, United States to project short-term effects of different MFPL options for a 20-stick pack of cigarettes on adult smoking behaviors.

AIMS AND METHODS

We simulated 300 000 individuals defined by race and ethnicity, sex, age, and poverty status. Smoking behaviors and cigarette prices were assigned based on demographic distributions in the 2014-2016 California Behavioral Risk Factor Surveillance System. We drew 100 random samples (n = 30 000), weighted to state-level California demographic characteristics. We simulated six MFPL options and modeled impacts on smoking prevalence and cigarette consumption, in general, and separately for those in households below or above 250% of the federal poverty level, assuming a price elasticity of -0.4.

RESULTS

Predicted changes in prices, prevalence, and consumption increased exponentially as the floor price increased from $7.00 to $9.50. Assuming 15% policy avoidance, projected increases in average cigarette prices ranged from $0.19 to $1.61. Decreases in smoking prevalence ranged from 0.05 to 0.43 percentage points, and decreases in average monthly cigarette consumption ranged from 1.4 to 12.3 cigarettes. Projected prices increased, and prevalence and consumption decreased, more among individuals in households below 250% federal poverty level.

CONCLUSIONS

MFPLs are a promising tobacco control strategy with the potential to reduce socioeconomic disparities in cigarette smoking prevalence and consumption.

IMPLICATIONS

Despite reductions in adult smoking prevalence, significant socioeconomic disparities remain, with lower-income groups smoking at substantially higher levels than higher-income groups. Policies that set a floor price below which a tobacco product cannot be sold could reduce socioeconomic disparities in smoking, depending on variation in prices paid by smokers prepolicy. By using a microsimulation model to predict changes in smoking for different population groups in California under several floor price scenarios, this study demonstrates that MFPLs have the potential to reduce adult smoking prevalence overall, and especially for lower-income tobacco users.

Design-based single-mediator approach for complex survey data

We discuss a two-step approach to test for a mediated effect using data gathered via complex sampling. The approach incorporates design-based multiple linear regressions and a generalized Sobel’s method to test for significance of a mediated effect. We illustrate the applications to a study of nicotine dependence, race/ethnicity and cigarette purchase price among daily smokers in the U.S. The study goal was to assess significance of cigarette purchase price as a mediator in the association between race/ethnicity (non-Hispanic Black/African American, non-Hispanic White) and nicotine dependence measured in terms of the average number of cigarettes smoked per day. The single-mediator model incorporated 18 covariates as control factors. The results indicated a significant mediated effect of cigarette purchase price on the association. However, the relative effect size of 5% indicated low practical significance of the cigarette purchase price as a mediator in the association between race/ethnicity and nicotine dependence. The approach can be modified to studies where data are gathered via other types of complex sampling.

Patterns and correlates of purchasing cigarettes on Indian reservations among daily smokers in the United States

INTRODUCTION

We described the population of daily smokers purchasing cigarettes on Indian reservations (IRs), estimated the rates of cigarette purchasing on IRs for diverse populations of daily smokers in the U.S., and assessed the trends in the period from 2010-11 to 2014-15.

METHODS

We used the 2010-11 and 2014-15 Tobacco Use Supplement to the Current Population Survey data for adult daily smokers as well as additional information, e.g., state excise tax on tobacco (n = 33,871).

RESULTS

Daily smokers who purchased cigarettes on IRs were primarily 45+ years old, non-Hispanic (NH) White, resided in a state with an IR, paid less than $4.50 per pack, and purchased cigarettes in the state of their residency. The majority of purchases on IRs were made in New York (28%), Oklahoma (14%), Washington (10%), Arizona (9%), and Florida (6%). The rate of purchasing cigarettes on IRs decreased from 4% in 2010-11 to 3% in 2014-15 (p = 0.012). The rates were higher for females than males (OR = 1.23, CI = 1.09:1.40) and heavy than non-heavy smokers (OR = 1.35, CI = 1.17:1.55). Higher state excise tax on tobacco, on average, was associated with purchasing cigarettes on IRs.

CONCLUSIONS

The rate of purchasing cigarettes on IRs is relatively low and has decreased in recent years. However, the rates differ across sociodemographic factors of daily smokers, including the state of residency and purchase. Purchasing cigarettes on IRs at lower prices can affect smokers' intentions to quit and can reduce federal and state efforts toward a tobacco-free nation.

Point-of-sale cigarette purchase patterns among U.S. adult smokers-National Adult Tobacco Survey, 2012-2014

Tobacco products are ubiquitous in most U.S. retail environments. Given that data on preferred point-of-sale purchase locations among U.S. adult tobacco users are limited, an enhanced understanding of tobacco purchase locations can help inform tobacco control policy, planning, and practice. We investigated prevalence and sociodemographic characteristics associated with cigarette purchase location among U.S. adult smokers. Pooled data came from the 2012-2013 (N=60,192) and 2013-2014 (N=75,233) National Adult Tobacco Surveys. Current cigarette smokers (n=18,005) aged ≥18 were asked if they purchased cigarettes within the previous 30days (n=15,182) and, if so, where they last purchased cigarettes. In 2016, logistic regression adjusted for sex, age, race/ethnicity, education level and annual household income was used to assess characteristics associated with purchase location. Among current smokers, 90.2% reported purchasing cigarettes in the past 30days. The most common purchase locations were convenience stores/gas stations (69.1%), tobacco discount stores (9.9%), drug stores (5.0%), supermarkets (4.9%), and liquor stores (3.6%). The odds of purchasing cigarettes at convenience stores/gas stations were higher among men (adjusted odds ratio (AOR)=1.4; 95% confidence interval (CI)=1.2-1.5) than women; and among adults aged 18-24 (AOR=3.1; 95% CI=2.4-3.9), 25-44 (AOR=3.1; 95% CI=2.7-3.7), and 45-64years (AOR=1.8 95% CI=1.6-2.1) than adults aged ≥65years. Over two-thirds of U.S. smokers last purchased cigarettes from convenience stores/gas stations. Understanding the relationship between purchase location and smoker characteristics may inform tobacco control strategies in the retail environment.

Chinese immigrant men smokers' sources of cigarettes in Canada: A qualitative study

Background

Immigrants often experience economic hardship in their host country and tend to belong to economically disadvantaged groups. Individuals of lower socioeconomic status tend to be more sensitive to cigarette price changes. This study explores the cigarette purchasing patterns among Chinese Canadian male immigrants.

Methods

Semi-structured in-depth interviews were conducted with 22 Chinese Canadian immigrants who were smoking or had quit smoking in the last five years.

Results

Because of financial pressures experienced by participants, the high price of Canadian cigarettes posed a significant challenge to their continued smoking. While some immigrants bought fully-taxed cigarettes from licensed retailers, more often they sought low-cost cigarettes from a variety of sources. The two most important sources were cigarettes imported during travels to China and online purchases of Chinese cigarettes. The cigarettes obtained through online transactions were imported by smoking or non-smoking Chinese immigrants and visitors, suggesting the Chinese community were involved or complicit in sustaining this form of purchasing behavior. Other less common sources included Canada-USA cross border purchasing, roll your-own pouch tobacco, and buying cigarettes available on First Nations reserves.

Conclusions

Chinese Canadian immigrant men used various means to obtain cheap cigarettes. Future research studies could explore more detailed features of access to expose gaps in policy and improve tobacco regulatory frameworks.