Awareness, perceptions and use of snus among young adults from the upper Midwest region of the USA

Electronic Nicotine Delivery Systems and Cardiovascular/Cardiometabolic Health

The use of electronic nicotine delivery systems, specifically electronic cigarettes (e-cig), has risen dramatically within the last few years; the demographic purchasing these devices is now predominantly adolescents that are not trying to quit the use of traditional combustible cigarettes, but rather are new users. The composition and appearance of these devices has changed since their first entry into the market in the late 2000s, but they remain composed of a battery and aerosol delivery system that is used to deliver breakdown products of propylene glycol/vegetable glycerin, flavorings, and potentially nicotine or other additives. Manufacturers have also adjusted the type of nicotine that is used within the liquid to make the inhalation more palatable for younger users, further affecting the number of youth who use these devices. Although the full spectrum of cardiovascular and cardiometabolic consequences of e-cig use is not fully appreciated, data is beginning to show that e-cigs can cause both short- and long-term issues on cardiac function, vascular integrity and cardiometabolic issues. This review will provide an overview of the cardiovascular, cardiometabolic, and vascular implications of the use of e-cigs, and the potential short- and long-term health effects. A robust understanding of these effects is important in order to inform policy makers on the dangers of e-cigs use.

Swedish Snuff (Snus), Cigarette Smoking, and Risk of Type 2 Diabetes

INTRODUCTION

Cigarette smoking is a known risk factor for Type 2 diabetes, but evidence regarding former smoking and moist snuff (snus) use and Type 2 diabetes risk is inconclusive. This study investigated the relationships of cigarette smoking and Swedish snus use with the risk of Type 2 diabetes in a cohort of middle-aged and elderly participants.

METHODS

Participants (N=36,742; age range=56-95 years) were followed for incident Type 2 diabetes and death between 2009 and 2017 through linkage to the Swedish National Patient, Prescribed Drug and Death Registers. Cox proportional hazards regression was used to obtain hazard ratios and 95% CIs adjusted for potential confounders, including physical activity, education, BMI, and alcohol intake. Analyses were conducted in 2021‒2022.

RESULTS

Former and current smoking was associated with an increased risk of Type 2 diabetes (hazard ratios [95% CI]=1.17 [1.07, 1.29] and 1.57 [1.36, 1.81], respectively). In those who stopped smoking, Type 2 diabetes risk remained elevated up to approximately 15 years after cessation. In participants who have never smoked, snus use was linked to a higher risk of Type 2 diabetes in the model adjusted for age and sex (hazard ratio [95% CI]=1.49 [1.04, 2.15]), but this was attenuated after multivariable adjustment (hazard ratio [95% Cl]=1.29 [0.89, 1.86]).

CONCLUSIONS

This study indicates that current and former smoking are associated with an increased risk of Type 2 diabetes in middle-aged and older individuals. There was less evidence of an association of snus use with the risk of Type 2 diabetes, suggesting that compounds other than nicotine may underlie the detrimental association of smoking with the risk of Type 2 diabetes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Reasons for Using Smokeless Tobacco: A Review

Background:

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

Methods:

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

Results:

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

Conclusion:

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

Use of internal documents to investigate a tobacco company's strategies to market snus in the United States

INTRODUCTION

Prior studies indicate that cigarette manufacturers have been interested for decades in developing a smokeless tobacco (SLT) product for smokers and non-users of SLT. The current study aims to assess a tobacco company’s use of novel marketing strategies and intent to promote snus in the US as either a replacement or situational substitute for the cigarette.

METHODS

A Boolean search string was used to search R. J. Reynolds’ (RJR) Records in UCSF’s Truth Tobacco Industry Documents Library. A total of 358 documents, from 2005–2009, met our initial search criteria and were selected for their relevance to the marketing of Camel Snus. A content analysis was subsequently conducted using the Framework Method to identify themes and strategies for promoting Camel Snus.

RESULTS

Four major themes about Camel Snus emerged from the documents: 1) promotion by third parties including retailers, snus ambassadors and secret shoppers, 2) expansion of the target population of SLT users to include female smokers and dual users of cigarettes and SLT, 3) emphasis on the difference between Camel Snus and other SLT, and 4) a shift from promoting the practical uses of Camel Snus to using emotional messages conveying freedom.

CONCLUSIONS

The findings align with other studies suggesting that RJR intended to market snus to non-users of SLT. The findings also reveal that RJR employed creative marketing strategies (e.g. snus ambassadors) and may have intended to promote snus as a situational substitute for the cigarette, as evidenced by the company’s recruitment of dual tobacco users.

Beliefs about the Harmfulness of Heated Tobacco Products Compared with Combustible Cigarettes and Their Effectiveness for Smoking Cessation among Korean Adults

Heated tobacco products (HTPs) have been widely used in Korea since their introduction in 2017. In this study, we investigated the perceptions of their relative harmfulness and smoking cessation effects. We performed an online survey in 7000 Koreans in 2018 (2300 males and 4700 females aged 20-69 years) by matching their age, sex, and provincial distribution. To investigate the factors causing HTPs to be perceived as less harmful than combustible cigarettes (CCs) and helpful for smoking cessation, we used multivariable logistic regression analyses. HTPs were less harmful than CCs in 16.8% of participants, particularly among HTP-only users and dual and triple users of HTPs, electronic cigarettes (ECs), or CCs than among CC-only users, those who were aged ≤ 34 years, males, and those with higher incomes. HTPs were reportedly helpful for smoking cessation in 11.2% of participants. Similar perceptions were more likely among HTP-only users, as well as dual and triple users than among CC-only users and adults with higher education/incomes. Although Korean adults generally had negative perceptions of the harmfulness and smoking cessation effects of HTPs compared with CCs, dual and triple users were more likely to have positive perceptions. Monitoring the use of multiple tobacco products and HTPs is a new challenge for Korean policymakers.

Alarming development of dual snus and cigarette usage among young Finnish males

Background

The consumption of tobacco products has evolved to include more complex combinations of different products. We investigated the tobacco habits of a representative population of young Finnish male conscripts in order to evaluate the prevalence of dual use of cigarettes and snus as well as the transition from one tobacco product to another. In addition, we evaluated the correlation between the level of education and the use of cigarettes and snus.

Methods

A questionnaire-based survey was carried out in three out of 17 garrisons among conscripts during their first week of service in 2014. A total of 1971 male conscripts were selected by simple random sampling of the 9013 males in the selected garrisons. Of them 1916 participated and filled in the questionnaire. The response rate was 97.2%. The questionnaire consisted of 25 questions including age, gender, basic education, use of tobacco products as well as questions assessing nicotine dependency.

Results

The amount of dual users of cigarettes and snus was 21%. There was a higher probability of dual use of cigarettes and snus among smokers compared to snus users (p < 0.001). One third (35%) of former smokers reported daily snus use and over 40% of the former snus users smoked daily. One third (34%) of the participants reported snus usage and 14% of the study subjects used snus daily. 40% of the study population were smokers and over 25% smoked daily. Of the participants with basic educational background 57% smoked daily (p < 0.001), however, no association between snus and level of education was found (p = 0.69).

Conclusions

This study provides better understanding of the complex tobacco habits of young adult males. The simultaneous usage of multiple tobacco products as well as the high tendency to transition from one tobacco product to another should be taken into consideration when planning cessation interventions in health care settings and tobacco control policies at societal levels.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7519-1) contains supplementary material, which is available to authorized users.

Trends in Awareness, Use of, and Beliefs About Electronic Cigarette and Snus Among a Longitudinal Cohort of US Midwest Young Adults

Introduction

Few longitudinal studies have examined how awareness, use of, and beliefs about electronic cigarettes (e-cigarettes) and snus change over time. We assessed these trends in a cohort of young adults from the US Midwest.

Methods

Data were from the Minnesota Adolescent Community Cohort (MACC) Study, collected annually during 2010-2013 when participants were 21-29 years old (n = 2622). Participants were asked if they had heard of and ever used e-cigarettes and snus, and the number of days they used these products in the past 30 days. Beliefs about whether these products are less harmful than cigarettes, less addictive than cigarettes, and could help people quit smoking were assessed. Repeated measures multiple linear and logistic regression models, adjusting for demographics, peer smoking and smoking status, were used to assess trends.

Results

Compared to 2010-2011, participants in 2012-2013 were five times more likely to be aware of e-cigarettes, report ever used them, and report using them in the past 30-days. Increases in e-cigarette use were observed in all smoking status. Participants were also increasingly likely to believe that e-cigarettes are less harmful than combustible cigarettes and could help people quit smoking. There was only a modest increase in awareness of and ever using snus, as well as believing snus is less harmful than combustible cigarettes. These trends did not differ by smoking status.

Conclusions

The increasingly favorable beliefs about e-cigarettes may explain the increasing prevalence of their use particularly among young adults, both among smokers and nonsmokers.

Implications

Awareness and use of e-cigarettes have increased substantially over the past few years, and positive beliefs of e-cigarettes have also become more prevalent among young adults. Meanwhile, little changes in awareness, use of, and beliefs about snus among young adults. Given the potential of these products to have both positive and negative impact on public health depending on who use them and how they are used, strategically communicating the risks associated with e-cigarettes and snus use may help minimize the burden of tobacco use at the population level.

Efficiency and adverse events of electronic cigarettes: A systematic review and meta-analysis (PRISMA-compliant article)

BACKGROUND

Electronic cigarettes (e-cigarettes) are a prevalent smoking cessation aid worldwide; however, a consensus regarding their efficacy and safety has yet to be reached.

METHODS

We conducted a systematic review of the literature from related studies written in English or Chinese and published between January 1, 2003, and July 30, 2017. Eligible studies reporting the number of smokers who reduced or quit smoking and suffered from adverse events after e-cigarette use were selected according to predefined criteria; pertinent data were then extracted for a meta-analysis.

RESULTS

Our search produced 198 articles; of these publications, 14 including 35,665 participants were analyzed. The pooled efficacy rate of e-cigarettes ranged from 48.3% to 58.7% for smoking reduction and from 13.2% to 22.9% for smoking cessation. The pooled rate of adverse events associated with e-cigarettes ranged from 49.1% to 51.6% based on 11 studies including 16,406 participants. The most prevalent adverse events were mouth or throat irritation, anxiety, depressed mood, nausea, and insomnia. No significant differences in overall CO2 exhalation (eCO) levels were observed after e-cigarette use according to the data from 5 studies.

CONCLUSION

Our findings suggest that e-cigarettes are moderately effective with regard to smoking reduction and smoking cessation. eCO levels are unreliable for evaluating the efficacy of e-cigarettes. E-cigarette related adverse events frequently occur, especially due to high-dose nicotine-containing cartridges.

US adult tobacco users' absolute harm perceptions of traditional and alternative tobacco products, information-seeking behaviors, and (mis)beliefs about chemicals in tobacco products

INTRODUCTION

Harm perceptions about tobacco products may influence initiation, continued use, and cessation efforts. We assessed associations between adult traditional tobacco product use and absolute harm perceptions of traditional and alternative tobacco products. We also described the topics individuals looked for during their last search for information, their beliefs about chemicals in cigarettes/cigarette smoke, and how both relate to harm perceptions.

METHODS

We ran multivariable models with jackknife replicate weights to analyze data from the 2015 administration of the National Cancer Institute's Health Information National Trends Survey (N=3376).

RESULTS

Compared to never users, individuals reported lower perceived levels of harm for products they use. Among current tobacco users, ethnicity, thinking about chemicals in tobacco, and information-seeking were all factors associated with tobacco product harm perceptions. In the full sample, some respondents reported searching for information about health effects and cessation and held misperceptions about the source of chemicals in tobacco.

CONCLUSIONS

This study fills a gap in the literature by assessing the absolute harm perceptions of a variety of traditional and alternative tobacco products. Harm perceptions vary among tobacco products, and the relationship among tobacco use, information seeking, thoughts about chemicals in tobacco products, and harm perceptions is complex. Data suggest that some individuals search for information about health effects and cessation and hold misperceptions about chemicals in tobacco products. Future inquiry could seek to understand the mechanisms that contribute to forming harm perceptions and beliefs about chemicals in tobacco products.

Perceptions of harm and addiction of snus: An exploratory study

Tobacco companies in the United States are prohibited from making reduced harm claims without filing a modified risk tobacco product application with the Food and Drug Administration and obtaining an order to market as such. However, it is possible that product marketing may suggest reduced risk to individuals. This study examines perceptions, in particular those related to harm and addiction, of snus print advertisements using a combination of eye-tracking, survey, and semistructured interviews. Participants were 22 male smokers ages 19-29 (M = 26.64, SD = 2.92). Five snus advertisements were each displayed for 20 s and eye movements were tracked. Participants responded to questions about harm and addiction after each advertisement and interviews were conducted after seeing all advertisements. For each advertisement, descriptive statistics were calculated and regression analyses predicted harm and addiction perceptions from eye tracking areas of interest (e.g., warning label). Qualitative data were analyzed using inductive/deductive thematic analysis. For certain advertisements, areas of interest were significantly associated with harm and/or addiction perceptions. For example, higher total fixation duration on the graphic in the Smokeless for Smokers advertisement was associated with decreased perceptions of addiction (B = -.360, p = .048). Qualitative themes emerged and in many instances corroborated quantitative results. This study indicates that for some advertisements, attention on certain areas (measured through eye tracking) is associated with perceptions among young male smokers. Understanding how smokers perceive and understand products after viewing advertisements may inform regulations regarding claims about product harm and addiction and may guide public health efforts to educate smokers on the risks of emerging products. (PsycINFO Database Record

Acute effects of snus in never-tobacco users: a pilot study

BACKGROUND

Snus tobacco characteristics may attract non-tobacco users, including relatively low, but pharmacologically active, doses of nicotine. Lower nicotine doses may limit adverse drug effects while also producing a physiologically active response.

OBJECTIVES

This pilot study is the first to profile the acute effects of snus on physiological and subjective assessments in a sample of never-tobacco users.

METHODS

Eleven never-tobacco users (five women; <100 uses/lifetime) were recruited from the community via university-approved advertisements. Using a within-subject design, participants consumed six pouches in ascending dose order (0, 1.6, 3.2, 4.8, 6.4, and 8.0 mg nicotine) within one session. The start of each snus bout was separated by 45 minutes, and pre- and post-pouch assessments included ratings of drug effects and physiological response.

RESULTS

The average heart rate and systolic blood pressure increased significantly from pre- to post-pouch use as a function of dose, though these increases were reliable for 8.0 mg nicotine only (p < .05). Collapsed across time, diastolic blood pressure was significantly higher for 8.0 mg nicotine than for all other doses (p < .05). Subjective ratings for "excessive salivation" and "satisfying" increased significantly from pre- to post-pouch use (p < .05), independent of dose.

CONCLUSION

Significant increases in physiological response at some doses suggest that users were exposed to pharmacologically active doses of nicotine. The lack of reliable subjective effects may be the product of the dosing regimen or the relatively small sample size. Findings highlight the need for identification of doses of snus that may promote abuse among naïve users.

A longitudinal, naturalistic study of U.S. smokers' trial and adoption of snus

To refine public health policy amidst a changing landscape of tobacco products in the United States, it is first necessary to describe fully the nature of smokers' alternative product use. Little research addresses smokers' snus use, and most studies are limited by small samples, cross-sectional designs, and crude outcome measurement. This study sample includes 626 adult US smokers who denied intention to quit in the next month and were randomized to receive free snus during a 6-week sampling period, after which no snus was provided. Participants were then followed for one year. Outcome data were collected via phone. Participants (mean age: 48.7years) were predominately female, White non-Hispanic. Eighty-four percent reported trial of snus. Eleven percent reported purchase (i.e., adoption). Current use declined from 47.1% at the end of the sampling period to 6.5% at the end of follow-up. Frequency and quantity of snus use among current users was low. Among snus users, 79.3% said it functioned as an alternative to smoking and 58.4% said it provided a means of coping with smoking restrictions; options not mutually exclusive. In logistic regressions, men were more likely to report trial (odds ratio [OR]=2.33, p<0.01) and adoption (OR=1.84, p<0.05) than women. Baseline expectations about the nature of snus use also predicted snus outcomes (OR=1.28-1.78, p<0.05). Smokers showed willingness to try snus, but product interest waned over time. Snus as currently marketed is unlikely to play a prominent role in US tobacco control efforts.

Openness to Using Non-cigarette Tobacco Products Among U.S. Young Adults

INTRODUCTION

National data indicate that the prevalence of non-cigarette tobacco product use is highest among young adults; however, little is known about their openness to use these products in the future and associated risk factors. This study sought to characterize openness to using non-cigarette tobacco products and associated factors among U.S. young adults.

METHODS

In 2014, National Adult Tobacco Survey data (2012-2013) were analyzed to characterize openness to using the following tobacco products among all young adults aged 18-29 years (N=5,985): cigars; electronic cigarettes ("e-cigarettes"); hookah; pipe tobacco; chew, snuff, or dip; snus; and dissolvables. Among those who were not current users of each product, multivariable logistic regression was used to examine associations between demographics, cigarette smoking status, lifetime use of other non-cigarette products, perceived harm and addictiveness of smoking, and receipt of tobacco industry promotions and openness to using each product.

RESULTS

Among all young adults, openness to using non-cigarette tobacco products was greatest for hookah (28.2%); e-cigarettes (25.5%); and cigars (19.1%). In multivariable analyses, which included non-current users of each product, non-current ever, current, and former smokers were more likely than never smokers to be open to using most examined products, as were men and adults aged 18-24 years. Receipt of tobacco industry promotions was associated with openness to using e-cigarettes; chew, snuff, or dip; and snus.

CONCLUSIONS

There is substantial openness to trying non-cigarette tobacco products among U.S. young adults. Young adults are an important population to consider for interventions targeting non-cigarette tobacco product use.

Use of electronic nicotine delivery systems and other tobacco products among USA adults, 2014: results from a national survey

OBJECTIVES

This study assessed the awareness and use of traditional and novel tobacco products and dual use of cigarettes with electronic nicotine delivery systems (ENDS) among USA adults.

METHODS

Data were obtained from the 2014 Tobacco Products and Risk Perceptions Survey of a probability sample of 5717 USA adults conducted June-November, 2014.

RESULTS

Use of ENDS varied by demography and by cigarette and other tobacco use. Adults aged 25-34, non-heterosexual adults, and those reporting poorer health reported higher rates of current ENDS use. Current cigarette smokers had much greater odds of ENDS ever use than never smokers, with one-half of all cigarette smokers having used ENDS and 20.7 % currently using them. However, 22.0 % of current ENDS users were former cigarette smokers, and 10.0 % were never cigarette smokers.

CONCLUSIONS

Patterns of ENDS use are evolving rapidly and merit continued surveillance. Nearly 10 % of adult ENDS usage is among never smokers. The public health challenge is how to enhance the potential that ENDS can replace combusted tobacco products without expanding nicotine use among youth, long-term ex-smokers, and other vulnerable populations.

Communicating tobacco product harm: Compared to what?

With the expansion of tobacco product options, a better understanding is needed of how information about the known and unknown risks of products is communicated to the public. Engaging in comparative processes is an common way for people to understand novel products, but the referent of comparison matters and can influence perceptions and behavior. This paper builds awareness of research from other disciplines, including decision science, marketing, and psychology, which can help inform research and tobacco control efforts.

A Content Analysis of Electronic Cigarette Portrayal in Newspapers

OBJECTIVE

To determine how electronic cigarettes (e-cigarettes) are portrayed in newspaper informative articles and opinion pieces.

METHODS

A content analysis was conducted on 450 articles published in the United States from 1997 to mid-2014 and obtained by a Newsbank search. The articles were reliably coded for overall frame, type of article, first topic and main topics addressed.

RESULTS

The article topics have changed over time and suggest significant differences between news articles and opinion pieces. Informative articles focused on e-cigarette regulation, while opinion pieces highlighted their increasing popularity and perceived health benefits.

CONCLUSIONS

This content analysis uncovered significant interest in e-cigarettes, particularly in their regulation. The FDA should consider public perceptions of e-cigarettes when developing regulations.

Youth tobacco use type and associations with substance use disorders

AIMS

To examine the associations between youth poly-tobacco use and substance use disorders.

DESIGN

Analysis of data from the 2007-11 US National Survey on Drug Use and Health.

SETTING

Randomly selected, household-dwelling adolescents from the non-institutionalized, civilian population of the United States.

PARTICIPANTS

A total of 91 152 adolescents (aged 12-17 years).

METHODS

Logistic regression models were used to examine the associations between type of tobacco user (non-user, users of alternative tobacco products only, users of cigarettes only and users of cigarettes plus alternative tobacco products) with past year alcohol, marijuana or other illicit drug use disorders, adjusting for demographic and social variables.

FINDINGS

Compared with non-users of tobacco, the greatest risk for substance use disorders was among users of cigarettes plus alternative tobacco products [alcohol disorder adjusted odds ratio (aOR) = 18.3, 95% confidence interval (CI) = 16.2-20.6; marijuana disorder aOR = 37.2, 95% CI = 32.5-42.7; other drug disorder aOR = 18.4, 95% CI = 15.4-21.8], followed by users of cigarettes only (alcohol disorder aOR = 9.6, 95% CI = 8.8-10.6; marijuana disorder aOR = 20.4, 95% CI = 18.1-23.0; other drug disorder aOR = 9.4, 95% CI = 7.8-11.4), then users of alternative tobacco products only (alcohol disorder aOR = 8.1, 95% CI = 6.7-9.6; marijuana disorder aOR = 9.2, 95% CI = 7.5-11.4; other drug disorder aOR = 3.2, 95% CI = 2.4-4.3).

CONCLUSIONS

Tobacco use in adolescence is associated with higher rates of substance use disorders across all tobacco users, especially among those who use cigarettes plus other tobacco products.

A qualitative study of smokers' responses to messages discouraging dual tobacco product use

Cigarette companies increasingly promote novel smokeless tobacco products to smokers, encouraging them to use smokeless tobacco in smoke-free environments. New messages may counteract this promotion. We developed 12 initial anti-smokeless message ideas and tested them in eight online focus groups with 75 US smokers. Those smokers who never tried smokeless tobacco were unaware of health risks of novel smokeless tobacco products, perceived scary messages as effective and acknowledged the addictive nature of nicotine. Smokers who had tried smokeless tobacco shared their personal (mainly negative) experiences with smokeless tobacco, were aware of health risks of novel smokeless tobacco products, but denied personal addiction, and misinterpreted or disregarded more threatening messages. Portraying women as smokeless tobacco users was perceived as unbelievable, and emphasizing the lack of appeal of novel smokeless tobacco products was perceived as encouraging continued smoking. Future ads should educate smokers about risks of novel smokeless tobacco products, but past users and never users may require different message strategies.

Latent classes of young adults based on use of multiple types of tobacco and nicotine products

INTRODUCTION

New tobacco and nicotine products such as snus, hookah, and electronic cigarettes have risen in popularity in recent years. Use of these products among young adults is of particular interest given that experimentation with new products is common in young adulthood.

METHODS

We conducted latent class analysis among a population-based sample of young adults to identify separate classes based on use of 6 types of tobacco or nicotine products: snus, hookah, electronic cigarettes, cigarillos, snuff, and cigarettes. We then examined how identified classes differed on demographic characteristics and marijuana and alcohol use.

RESULTS

We identified 5 classes: the largest group (60%) was characterized as reporting no or limited use of any of the products, while the smallest group (7%) was characterized by use of many types of products (poly-users). Of the 3 middle classes, 2 were the same size (10%) and were characterized by primarily using 2 of the products: one class used snus and snuff, and the other used cigarillos and hookah; the third class (13%) was characterized by primarily cigarette smoking. Numerous differences were seen across classes, including the poly-users being less likely to be college students/graduates and more likely to be male and use marijuana and alcohol.

CONCLUSIONS

We found that young adults can be grouped into 5 subgroups based on types of tobacco/nicotine products they do and do not use. A poly-use group that uses all types of tobacco products is concerning, particularly given high levels of marijuana and alcohol use reported in this group.

Beliefs and experimentation with electronic cigarettes: a prospective analysis among young adults

BACKGROUND

Previous cross-sectional studies found that positive beliefs about electronic nicotine delivery systems (commonly known as electronic cigarettes or e-cigarettes) were associated with use of these products. However, the prospective association between these beliefs and subsequent use of e-cigarettes is unclear.

PURPOSE

To identify the beliefs predicting subsequent use of e-cigarettes.

METHODS

A total of 1379 young adults (mean age=24.1 years) from the Minnesota Adolescent Community Cohort who reported never using e-cigarettes at baseline (collected Oct 2010-Mar 2011) and completed follow-up data collection (during Oct 2011-Mar 2012) were included in this analysis. Participants' beliefs about e-cigarettes (potential as quit aids, harmfulness and addictiveness relative to cigarettes) were asked at baseline (yes/no). At follow-up, participants were asked if they had ever used e-cigarettes. Logistic regression models were used to assess the associations between beliefs about e-cigarettes and subsequent experimentation. Analysis was conducted in 2012.

RESULTS

At follow-up, 7.4% of the sample reported ever using e-cigarettes (21.6% among baseline current smokers, 11.9% among baseline former smokers, and 2.9% among baseline nonsmokers). Participants who believed e-cigarettes can help people quit smoking and perceived e-cigarettes to be less harmful than cigarettes at baseline were more likely to report experimenting with e-cigarettes at follow-up (p<0.05). These associations did not differ by smoking status.

CONCLUSIONS

Given that young adults are still developing their tobacco use behaviors, informing them about the lack of evidence to support e-cigarettes as quit aids and the unknown health risk of e-cigarettes may deter young adults from trying these products.

First-year college students' interest in trying dissolvable tobacco products

BACKGROUND

Dissolvable tobacco products (DTPs) have been introduced into test markets in the U.S. We sought to gauge the level of interest in trying these products and correlates of interest among potential consumers.

METHODS

A web-based survey of freshman at 11 universities in North Carolina and Virginia was conducted in fall 2010. Multivariable logistic regression analyses were used to identify correlates of students' likelihood to try DTPs if offered a free sample.

RESULTS

Weighted prevalence of likelihood to try DTPs was 3.7%. Significant correlates of likelihood to try included male gender, current cigarette smoking, current snus use, sensation seeking, lifetime illicit drug use, and perceived health risk of using DTPs. Among current smokers, current snus use, current use of chewing tobacco, and considering quitting smoking were associated with likelihood to try DTPs.

CONCLUSIONS

While overall interest in trying these products was low, current users of cigarettes and snus were much more likely than others in trying a free sample. Some current smokers may consider DTPs to be an aid to smoking cessation, although the population-level impact of introducing these products is unknown.

Scaring the snus out of smokers: testing effects of fear, threat, and efficacy on smokers' acceptance of novel smokeless tobacco products

Novel smokeless tobacco products (such as snus) are aggressively promoted to smokers by the tobacco companies. The Extended Parallel Process Model (EPPM; Witte, 1992) was used to evaluate the current perceptions of threat, efficacy, attitudes, and behavioral intentions regarding snus in a nationally representative sample of 1,836 smokers. Participants were then exposed to messages designed to discourage smokers from trying snus. On average, smokers perceived health threat of snus as somewhat serious, but believed they can effectively avert this threat. Support was found for the EPPM's proposition that when efficacy is high, greater perceived threat is associated with greater desired outcomes (less favorable attitudes toward snus and lower behavioral intentions to try snus in the future). No support was found for the proposition that when perceived efficacy is low, greater threat is associated with greater message rejection. Instead, message rejection was explained by fear felt while exposed to the anti-smokeless ads. This finding indicates the need to more clearly distinguish between cognitive (danger control) and affective (fear control) responses posited by the EPPM.

Brief, instructional smokeless tobacco use among cigarette smokers who do not intend to quit: a pilot randomized clinical trial

INTRODUCTION

Low-nitrosamine smokeless tobacco (SLT) may have efficacy for smoking reduction and cessation, but its public health impact depends on how smokers use it.

METHODS

This pilot study explored brief, instructional low-nitrosamine SLT use among smokers unmotivated to quit. Participants (N = 57) were randomized to either a free 2-week supply of Camel Snus group or a no-supply group. Of those randomized to use Camel Snus, half were told to use it to cope with smoking restrictions (Snus to Cope), and the remaining half were advised to use it to reduce smoking (Snus to Reduce). Participants were assessed before, during, and immediately after the intervention.

RESULTS

Many Snus to Cope and Snus to Reduce participants reported daily use of Camel Snus, although the amount of use was low. Snus to Cope (18.4%) and Snus to Reduce (37.6%) participants reported a decline in number of cigarettes used per day, which was not reported by the control participants (p < .001). Intention to quit smoking and intention to quit all tobacco use (ps < .001) increased to a greater extent among Snus to Cope and Snus to Reduce participants than among control participants.

CONCLUSIONS

This study replicates previous work that shows that low-nitrosamine SLT use can lead to reduced smoking and increased intention to quit, and it adds direct evidence to suggest that the function of low-nitrosamine SLT use-either to cope with smoking restrictions or to reduce smoking-can have a differential impact on smoking behavior. Overall, the results highlight the importance of messaging and, more specifically, marketing of low-nitrosamine SLT to smokers.