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

Disparities in Transitions From E-cigarette Use to Other Tobacco Use Patterns Among Sexual Minority Versus Heterosexual Women and Men in the United States

INTRODUCTION

Despite elevated rates of e-cigarette use among sexual minority versus heterosexual young adults, limited research has examined sexual identity in relation to transitions from e-cigarette use to other tobacco use patterns.

METHODS

We analyzed data from 608 US young adults in a 2-year study (2018-2020) who reported using e-cigarettes in the past 6 months (time period between assessments) but no other tobacco product at baseline (Fall 2018). Multinomial logistic regressions among women and men, separately, examined associations between sexual identity and past 6-month tobacco use in Fall 2020 (nonuse [referent group] vs e-cigarette only, other tobacco product only, e-cigarette and other tobacco product dual use), controlling for age and race/ethnicity.

RESULTS

Among women (n = 340; mean [M]age = 23.42; n = 147 [43.4%] sexual minority; 29.4% racial/ethnic minority), 34.4% reported nonuse at follow-up, 26.8% e-cigarette only, 10.3% other tobacco product only, and 28.5% e-cigarette and other tobacco product dual use. Sexual minority (vs heterosexual) women displayed greater odds of e-cigarette-only use, as well as dual use relative to nonuse at follow-up. Among men (n = 244; Mage = 24.30; n = 51 [20.9%] sexual minority; 36.1% racial/ethnic minority), 25.4% reported no use, 20.9% e-cigarette only, 17.2% other tobacco product only, and 36.5% dual use at follow-up. Sexual minority (vs heterosexual) men displayed lower odds of e-cigarette only, other tobacco product only, and dual use relative to nonuse at follow-up.

CONCLUSIONS

Research is needed to assess and intervene on tobacco/nicotine product perceptions (eg, harm, social acceptability) and reasons for use (eg, mood regulation) associated with high-risk tobacco use patterns and trajectories, particularly among sexual minority young adult women who may have distinct profiles and risks associated with use.

Come for the Tobacco, Stay for the Flavor: Flavored Cigarillo-Use Trajectories Among Young Adult Sexual Gender Minority Women

INTRODUCTION

The purpose of this research was to identify how young adult sexual gender minority (SGM) women who use cigarillos may respond to cigar flavor restrictions.

AIMS AND METHODS

Young adults aged 21-28 years in the United States who currently use cigarillos were recruited between October 2020 and April 2021 to participate in an online survey. Due to high prevalence of cigarillo use among individuals who identify as sexual and/or gender minority (SGM) women, their (n = 192) flavored tobacco-use behaviors and anticipated responses to cigarillo flavor restrictions were compared to cisgender heterosexual (CisHet) women (n = 110). Logistic regression was used to model cigarillo cessation and product-switching behaviors (flavored and unflavored).

RESULTS

SGM women were significantly less likely to report the use of flavor at the initiation of cigarillo use (61.7% vs. 86.1%) but were no different in current flavor use compared to CisHet women, with more than 80% of all women using any flavor. SGM women were 2.36 times as likely to say they would discontinue using cigarillos if flavors were unavailable. Among those who would continue using cigarillos, SGM women were 4.53 times as likely to endorse switching to an unflavored tobacco product but had the same likelihood of saying they would switch to flavored product compared to CisHet women.

CONCLUSIONS

Flavor restriction policies may not reduce the initiation of cigarillos among SGM women and may elicit differential cigarillo use and tobacco product substitution by SGM identity. Flavor restriction policies should be coupled with targeted cessation resources to address potential remaining disparities.

IMPLICATIONS

SGM US women have a unique cigarillo-use trajectory. These women are more likely to initiate cigarillos without flavor and then later integrate it into their behavior. National cigar flavor restrictions are expected to have a greater impact decreasing cigarillo initiation among CisHet women and decreasing current cigarillo use among SGM women. However, for those who would continue using unflavored cigarillos, SGM women may remain at risk for nicotine dependence due to increased product substitution. SGM women should be prioritized for cessation resources to reduce tobacco-use disparities leading up to and following the implementation of cigar flavor restrictions.

A Scoping Review of Trends in the Size of Lesbian, Gay, and Bisexual Tobacco Use Disparities, 1996-2020, United States and Canada

Purpose: Tobacco use is a major health disparity for lesbian, gay, bisexual, and transgender (LGBT) populations compared with heterosexual/cisgender populations. In this scoping review, we aimed to determine if LGBT tobacco use disparities are improving or worsening over time and if trends in disparities differed across subgroups. Methods: We included articles that longitudinally explored youth and adult LGB tobacco use in the United States and Canada after searching four databases and capturing records through July 2022. Two reviewers independently screened the title/abstract and full text of 2326 and 45 articles, respectively. Eleven articles from 18 larger assessments met inclusion criteria, spanning data collection from 1996 to 2020. Results: All studies consistently demonstrated tobacco disparities for LGB populations. No articles examined longitudinal transgender tobacco disparities. Most studies focused on smoking combustible cigarettes. Disparities in heavy or daily use for all LGB youth subgroups compared with heterosexual samples appear to be shrinking longitudinally. Results for early-onset, current, and lifetime smoking were less consistent. Adult evidence was relatively sparse; however, after 2010, studies show diminishing disparities over time, except for current smoking by bisexual women. Conclusions: Large tobacco use disparities persist for LGB populations, although the size of disparities may be decreasing for some groups. Initiatives for lesbian and bisexual women and girls should be prioritized, in addition to interventions addressing LGB smoking broadly. Surveillance instruments should uniformly and consistently assess LGBT identities and tobacco use behaviors.

Cannabis Use Differences Among Sexual Minority Versus Heterosexual Females and Males in Oklahoma: The Roles of Mental Health, Cannabis Perceptions, and Cannabis Marketing Exposure

INTRODUCTION

Despite the high cannabis use rates among sexual minority (SM) individuals, less research has examined factors related to cannabis use among SM (vs. heterosexual) individuals, especially in places with legal medical cannabis retail markets and high structural stigma, like Oklahoma.

METHODS

Data were from a survey of Oklahoma adults, including 3020 females (18.6% SM) and 2279 males (10.1% SM). Bivariate analyses examined associations of sexual identity with cannabis-related factors (i.e., perceived harm, positive attitudes, marketing exposure, depressive symptoms, anxiety symptoms) and cannabis use and use severity (i.e., past 30-day use, daily/near-daily use, cannabis use disorder [CUD] symptoms). Logistic regression examined associations of sexual identity and cannabis-related factors with cannabis use and use severity among females and males, separately.

RESULTS

SM (vs. heterosexual) females reported greater odds of past 30-day cannabis use and daily/near-daily use, lower harm perceptions, greater marketing exposure, and higher rates of depressive/anxiety symptoms. Lower harm perceptions and greater marketing exposure were associated with greater odds of past 30-day use, whereas marketing exposure was associated with greater odds of daily/near-daily use. SM (vs. heterosexual) males reported greater odds of daily/near-daily use and higher rates of depressive/anxiety symptoms.

CONCLUSIONS

SM (vs. heterosexual) females reported higher rates of cannabis use, whereas SM (vs. heterosexual) females and males reported higher rates of daily/near-daily cannabis use. Potential targets for cannabis-related health campaigns aimed at reducing use differences include correcting misinterpretations of harm that may emanate from cannabis marketing efforts among females and addressing depressive symptoms among males.

Awareness of electronic cigarette industry practices and their associations with anti-electronic cigarette attitudes among susceptible US young adults

BACKGROUND

Public education exposing cigarette industry practices have been effective in changing attitudes and preventing smoking among young people. It is unclear how much young adults are aware of e-cigarette industry practices, and how this awareness relates to anti-e-cigarette attitudes. We examined demographic correlates of awareness of e-cigarette industry practices and anti-e-cigarette attitudes, and the association between awareness of these practices with anti-e-cigarette attitudes.

METHODS

A US sample of young adults aged 18-30 years who do not use commercial tobacco products but are susceptible to e-cigarette use were cross-sectionally surveyed through online panel services from August 2021 to January 2022. Respondents reported their demographics, awareness of cigarette industry practices, awareness of e-cigarette industry practices and their level of agreement with four anti-e-cigarette attitude statements. We used multivariable linear regressions to examine demographic associations and the relationship between awareness of e-cigarette industry practices with each anti-e-cigarette attitude, adjusting for demographics and awareness of cigarette industry practices.

RESULTS

Generally, Hispanic and Black young adults (vs White) and those with

DISCUSSION

Public education exposing e-cigarette industry practices may promote anti-e-cigarette attitudes among susceptible young adults who do not use commercial tobacco products. Future research should investigate the utility of anti-e-cigarette industry messaging.

Collapse

Key Words

• Denormalization
• Electronic nicotine delivery devices
• Prevention

Collapse

MESH Headings Collapse

Grants

• R00 CA272919 NCI NIH HHS
• U54 CA267735 NCI NIH HHS
• ZIA MD000006 Intramural NIH HHS

Collapse

Affiliation(s)

Lilianna Phan Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA Department of Community Health and Prevention, Dornsife School of Public Health and Division of Graduate Nursing, College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania, USA
Kelvin Choi Division of Intramural Research, National Institute on Minority Health and Health Disparities, Bethesda, Maryland, USA

Collapse

Flavored electronic nicotine delivery systems ads (2019-2020) on traditional U.S. Media by audience demographics

The tobacco industry has historically targeted flavored products to specific U.S. consumer segments, including young people, women, and systemically marginalized groups based on race, ethnicity, or sexual/gender identity. Existing research on target marketing is focused on cigarettes and smokeless tobacco. In contrast, studies of target marketing of electronic nicotine delivery systems (ENDS)-a growing segment of the U.S. tobacco product market - are much more limited. We analyzed data on 496 ENDS ads and audience demographics to explore the extent to which flavored ENDS ads on cable television (n = 25 ads), terrestrial radio (n = 412 ads), and in print consumer magazines (n = 59 ads) are targeted to different demographic groups based on age, sex, and race/ethnicity. We observed flavor-related content in one-quarter to one-third of ENDS ad occurrences during 2019-2020. Across all media outlets examined, audience age was an important factor in explaining the likelihood of ENDS ads containing flavor-related content. For example, within a television channel, there were 3.82 [95% confidence interval (CI): 1.39-10.49] times greater odds that an ENDS ad contained flavor-related content versus not for every 1% increase in the proportion of U.S. youth ages 6-17 watching a television show. In addition, there were 2.13 [95 %CI: 1.30-3.51] and 1.61 [95 %CI:1.60-1.63] times greater odds that an ENDS ad contained flavor-related content versus not in cable television and radio stations, respectively, for every 1% increase in the proportion of male audience members. Race/ethnicity was an important explanatory factor for the presence of flavor-related content on radio but not television ENDS ads. Our findings suggest differences in target marketing of flavored ENDS by media outlet and audience demographics.

Sexual orientation and gender identity differences in perceptions and product appeal in response to e-cigarette advertising

INTRODUCTION

E-cigarette use is disparately high among sexual minoritized populations. As e-cigarette advertising may influence product appeal, this study tested sexual orientation- and gender-based differences in response to e-cigarette advertisement exposure on advertisement perceptions and product appeal.

METHODS

We recruited 497 adults (mean age=31.9 years, 45.1% women, 54.3% heterosexual, 71.2% Non-Hispanic White) living in the United States via the crowdsourcing platform Prolific. Participants viewed two randomly selected e-cigarette advertisements (from n=173 advertisements). Post-exposure, participants rated the perceived advertisement effectiveness, relevance, and product use intention. Associations between sexual orientation and outcomes were estimated using multivariable linear mixed-effects models. We tested interaction effects between sexual orientation, gender, and advertisement feature (e.g. presence of humans, flavors, and product packaging), and ran Tukey post hoc tests for pairwise comparisons.

RESULTS

Post-exposure, heterosexual women, sexual minoritized men, and sexual minoritized women (reference group: heterosexual men) rated perceived advertisement effectiveness and relevance lower after viewing advertisements featuring flavors (vs no flavors; all p<0.001). Sexual minoritized men and sexual minoritized women rated perceived advertisement relevance lower after viewing advertisements featuring humans (all p<0.001) or fruit (all p<0.001). Heterosexual women, sexual minoritized men, and sexual minoritized women reported lower product use intention after viewing advertisements featuring an e-liquid bottle (vs no e-liquid bottle; all p<0.05).

CONCLUSIONS

Sexual minoritized women and men reported lower e-cigarette advertisement appeal and product use intentions than heterosexual men. More evidence is needed to understand advertisement perceptions and product appeal in this group to inform e-cigarette advertising regulations and anti-tobacco messaging campaigns that aim to reduce tobacco-related health inequities.

E-Cigarette Use among Sexual Minoritized Women and Nonbinary People Assigned Female at Birth: Assessing the Roles of Discrimination, Perceived Stress, and Social Support

Background: Young adult sexual minoritized women (SMW) are at disproportionate risk for e-cigarette use, which may in part be due to excess minority stress imposed by discrimination exposure. While discrimination exposure is associated with risk for combustible tobacco/nicotine use among SMW, similar associations have yet to be tested with e-cigarettes. Moreover, it is unknown if discrimination-related risk may be mitigated by protective factors such as social support. This study examined concurrent associations of discrimination, perceived stress, and social support with past 30-day e-cigarette use in a sample of young adult SMW during the COVID-19 pandemic. Methods: N = 501 SMW and nonbinary people assigned female at birth (AFAB) aged 18-30 completed an online survey. A series of logistic regressions examined associations of discrimination, perceived stress, and four forms of social support received during the COVID-19 pandemic with past-30-day e-cigarette use. Results: Among SMW, greater perceived stress (OR = 1.10, p = .03), but not discrimination exposure, was associated with e-cigarette use. Associations of discrimination with e-cigarette use were nonsignificant when most forms of social support (emotional, material/financial, and virtual) were accounted for. Associations of perceived stress with e-cigarette use were strongest among those who needed but did not receive material support. Conclusions: Perceived stress, but not discrimination exposure, was associated with risk for e-cigarette use among young SMW during the COVID-19 pandemic. Effects of nonspecific stress may be compounded by insufficient material/financial support.

U.S. young adults' awareness of the Master Settlement Agreement and cigarette industry practices and their associations with electronic cigarette industry and health risk perceptions

BACKGROUND

The lawsuit that led to the U.S. Master Settlement Agreement (MSA) exposed the cigarette industry's deceptive marketing practices, which changed population perceptions about the cigarette industry and helped prevent cigarette smoking. The cigarette industry now owns many electronic cigarette (e-cigarette) companies and make their own e-cigarettes. Given that the MSA occurred in previous decades, many millennial and generation Z young adults may not know about the MSA and the cigarette industry's marketing practices. It is unknown whether awareness about the MSA and cigarette industry practices may influence these young adults' e-cigarette industry and e-cigarette health risk perceptions, which may inform e-cigarette prevention efforts.

METHODS

Cross-sectional data were collected from a U.S. sample of tobacco-naïve young adults, 18-30 years-old, susceptible to e-cigarette use (n = 1,329) through an online panel service in August 2021-January 2022. Participants reported their demographic characteristics, awareness of the MSA, awareness of cigarette industry practices, e-cigarette industry perceptions, and e-cigarette health risk perceptions. We examined the relationships between awareness of the MSA and cigarette industry practices with e-cigarette industry and e-cigarette health risk perceptions using multivariable linear regressions, adjusted for demographic characteristics.

RESULTS

Overall, 36.2%, 24.1%, and 39.3% of participants had heard of the MSA and knew a lot about it, had heard of the MSA, but did not know much about it, and did not hear of the MSA, respectively. On average, participants were aware of 5.2 (SD = 3.0) of the 11 cigarette industry practices included. Hearing about the MSA and knowing a lot about it and awareness of more cigarette industry practices were associated with less positive e-cigarette industry and higher e-cigarette health risk perceptions, whereas having heard of the MSA but not knowing much about it was associated with more positive e-cigarette industry and lower e-cigarette health risk perceptions.

CONCLUSIONS

Findings suggest that increasing comprehensive awareness of the MSA and cigarette industry practices may influence young adults' e-cigarette-related perceptions, and may importantly prevent detrimental information gaps about the cigarette industry. Future research should investigate the potential impact of increasing awareness of the MSA and cigarette industry practices in changing e-cigarette-related perceptions, which may help prevent e-cigarette use.

A double disparity: Rural sexual minorities and tobacco use among U.S. adults

BACKGROUND

Marginalized groups continue to face an uneven distribution of the risks and consequences of smoking cigarettes, with rural/urban geography and sexual orientation status examined independently. However, little is known about the intersection of rural/urban geography and sexual orientation regarding tobacco use disparities. This study examined rural-urban sexual minority differences in tobacco use in the United States.

METHODS

Data came from the 2018-2020 Behavioral Risk Factor Survey System (N = 675,221). We estimated cigarette smoking prevalence for each year of survey data by rural/urban status and sexual orientation. Multivariable logistic regressions were used to assess associations of rural/urban location and sexual orientation status with cigarette use. Additional Multivariable logistic regressions were conducted, including stratified analyses by sex on multiple sexual orientation categories.

FINDINGS

Cigarette smoking was higher among participants who lived in rural areas and identified as lesbian or gay and bisexual. Furthermore, the disparities in smoking rates were significantly different, with 38 % higher odds of smoking among rural sexual minorities than urban sexual minorities (aOR = 1.38, 95 % CI = 1.19, 1.60). Stronger odds of cigarette smoking were found among rural gays or lesbians (aOR = 1.83, 95 % CI = 1.47, 2.28) and rural bisexuals (aOR = 2.40, 95 % CI = 2.03, 2.84) compared to urban straight counterparts.

CONCLUSION

Findings highlight rural populations, particularly sexual minorities, might have an elevated risk of cigarette use. Prevention and cessation efforts that help these especially disadvantaged groups will be beneficial in addressing tobacco use disparities.

The Landscape of Cigar Marketing in Print Magazines from 2018-2021: Content, Expenditures, Volume, Placement and Reach

Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018-2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences (i.e., appearances in magazines), translating to $46,504,578 in expenditures. All ads featured the word "enjoy/enjoyment" and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA's efforts to reduce health disparities through regulations and public education.

Intersectionality of Sexual Orientation With Race and Ethnicity and Associations With E-Cigarette Use Status Among U.S. Youth

INTRODUCTION

Although structural discrimination against sexual and racial/ethnicity minorities is a putative risk factor for youth tobacco use, understanding health disparities in youth E-cigarette use at the intersection of sexual orientation, race, and ethnicity is still lacking. This study aims to examine the differences in E-cigarette use prevalence among U.S. youth at the intersections of sexual orientation with race and ethnicity.

METHODS

E-cigarette use status (never, experimental, or current use) was analyzed among 38,510 U.S. youth using a pooled data set from the Youth Risk Behavior Surveillance System 2015-2019. The weighted E-cigarette use status between youth at the intersections of sexual orientation with race and ethnicity was reported, stratified by sex. Multivariable multinomial regression adjusting for relevant covariates was further conducted. Data analyses were performed in April 2022.

RESULTS

After controlling for other covariates, the RRR of current E-cigarette use compared with never use between lesbian Black girls (and heterosexual Black girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=6.99; 95% CI=2.21, 22.14). The RRR of current E-cigarette use compared with never use between lesbian other race/multiracial girls (and heterosexual other race/multi-racial girls) was higher than between lesbian White girls (and heterosexual White girls) (adjusted RRR=3.60; 95% CI=1.06, 12.26).

CONCLUSIONS

This study has shown that sexual minority Black girls were more likely to currently use E-cigarettes than heterosexual Black girls. Future studies should examine the underlying reasons for current E-cigarette use among girls with intersectional identities, including race and sexual orientation.

Progress, challenges and the need to set concrete goals in the global tobacco endgame

The tobacco endgame is rapidly moving from aspirational and theoretical toward a concrete and achievable goal and, in some cases, enacted policy. Endgame policies differ from traditional tobacco control measures by explicitly aiming to permanently end, rather than simply minimize, tobacco use. The purpose of this paper is to outline recent progress made in the tobacco endgame, its relationship to existing tobacco control policies, the challenges and how endgame planning can be adapted to different tobacco control contexts. Examples of implemented policies in three cities in the United States and national policies in the Netherlands and New Zealand are outlined, as well as recent endgame planning developments in Europe. Justifications for integrating endgame targets into tobacco control policy and the need to set concrete time frames are discussed, including planning for ending the sale of tobacco products. Tobacco endgame planning must consider the jurisdiction-specific tobacco control context, including the current prevalence of tobacco use, existing policies, implementation of the World Health Organization’s Framework Convention on Tobacco Control, and public support. However, the current tobacco control context should not determine whether endgame planning should happen, but rather how and when different endgame approaches can occur. Potential challenges include legal challenges, the contested role of e-cigarettes and the tobacco industry’s attempt to co-opt the rhetoric of smoke-free policies. While acknowledging the different views regarding e-cigarettes and other products, we argue for a contractionary approach to the tobacco product market. The tobacco control community should capitalize on the growing theoretical and empirical evidence, political will and public support for the tobacco endgame, and set concrete goals for finally ending the tobacco epidemic.

Discrimination experiences, resilience, and cardiovascular disease risk factors among sexual minority women

Resilience, or the process of adapting to adversity, may protect against the harmful effects of minority-related stressors on the cardiovascular health of sexual minority women (SMW). An online survey was conducted in a sample of cisgender, non-heterosexual women to evaluate resilience as a moderator of the association between discrimination experiences and key cardiovascular disease (CVD) risk factors: stress, tobacco-smoking, hazardous alcohol consumption, poor diet quality, physical inactivity, and sedentary behaviors. Overall, 191 women (mean age = 29.34, SD = 6.92; 84.5% White) completed the survey and met eligibility to be included in the data analysis. White race (b = - 6.71, SE = 2.49) and education (b = - 3.36, SE = 0.56) were each independently associated with fewer discrimination experiences. Latinx ethnicity was associated with more discrimination experiences (b = 9.34, SE = 2.61). Education was associated with greater resilience (b = 4.57, SE = 0.83). Multivariable regression models were adjusted for race, ethnicity, and education. Discrimination was associated with a higher likelihood of smoking in the past month (b = 0.04, SE = 0.02) and drinking at hazardous levels (b = 0.09, SE = 0.02). Resilience was associated with less stress (b =  - 0.15, SE = 0.02), a lower likelihood of hazardous alcohol consumption (b =  - 0.02, SE = 0.01) and less time spent engaging in sedentary behaviors (b =  - 0.02, SE = 0.01). One moderation emerged, such that discrimination was negatively associated with stress for those low in resilience (b =  - 1.75, SE = 0.58), and not associated with stress for those high in resilience. These findings may inform the development of CVD-risk reduction interventions for SMW, which could include both strategies to mitigate the effects of discrimination on substance use and coping skills to promote resilience.

Evaluating tobacco industry 'transformation': a proposed rubric and analysis

Some tobacco companies claim they are 'transforming' by adopting harm reduction goals or even seeking to achieve a 'smokefree' world. What characterises transformation and whether companies can or are transforming is unclear. Nevertheless, such claims are gaining traction. We critically investigated tobacco industry transformation by exploring the definition and criteria for evaluating transformation, and assessed whether transformation is occurring and feasible.Companies' transformation claims centre on increasing sales of new tobacco and nicotine products like e-cigarettes ('new products') with little attention to reducing sales of more hazardous smoked and oral products ('conventional products').We define a transforming tobacco company as one demonstrating substantial, rapid and verifiable progress towards eliminating the production and sale of conventional tobacco products within 5 years in all markets where it operates.We found no evidence any tobacco company is meeting the three essential criteria of rapidly progressing towards eliminating conventional products, ceasing to obstruct effective tobacco control measures and taking action to minimise smoking uptake and disparities. While some companies are developing new product portfolios, their actions are more consistent with profit maximisation than eliminating conventional product use. This approach is best described as 'pseudo-transformation', designed to delay implementation of effective tobacco control policies. In addition, our analysis suggests replacing conventional products with new nicotine products is unlikely to be a viable long-term business model.Public health practitioners should not rely on tobacco industry claims but should lead the transformation debate, establish credible definitions and criteria, and monitor and assess whether transformation is occurring.

Global tobacco advertising, promotion and sponsorship regulation: what's old, what's new and where to next?

Tobacco advertising, promotion and sponsorship (TAPS) bans are a cornerstone of comprehensive tobacco control laws. Global progress in implementing TAPS bans has been enabled by the adoption of the WHO Framework Convention on Tobacco Control. Innovative TAPS policies are in place internationally and include: point-of-sale display bans, plain packaging of products, industry spending on TAPS disclosure reporting, bans on retailer incentive programmes, and regulation of TAPS in entertainment and online media. However, there is an over-reliance on entertainment and digital content producers and platforms to self-regulate TAPS. Ensuring TAPS laws are regularly examined to limit loopholes and remove exemptions is crucial to continued success. The definition of what constitutes TAPS can allow the tobacco industry to deploy corporate communication and political campaigns that skirt TAPS bans. TAPS laws must also maintain pace with the changing media landscape, which includes monitoring and reporting TAPS that cross international borders, primarily through digital media platforms. Limiting tobacco retail supply will also serve to prevent the continued undermining of TAPS bans. Leveraging global corporation to ensure enforcement of TAPS bans across borders is urgently needed.

Associations of race and ethnicity with tobacco messaging exposures and tobacco use among bisexual and pansexual women

Within the lesbian and bisexual community, bisexual women have the highest prevalence of tobacco use, and Black and Latina women are much more likely to use tobacco than their heterosexual peers. Research on tobacco use among bisexual women is limited to descriptions of prevalence in this population. We evaluated associations between race/ethnicity, exposure to pro- and anti-tobacco messages, and tobacco use outcomes among bisexual and pansexual women. We recruited a sample of N = 382 bisexual and pansexual women in the United States using the online survey platform, Prolific. Participants reported sociodemographics, exposure to pro- and anti-tobacco messaging, receipt of coupons, and ever and current use of cigarettes, e-cigarettes, and other tobacco products. We modeled associations between race/ethnicity, pro- and anti-tobacco messaging exposures, and tobacco use outcomes. Unadjusted results indicated differences in prevalence of tobacco use by race/ethnicity, with White women having the highest prevalence of ever using each product, but Black women having the highest prevalence of current cigar smoking and any tobacco use. Associations between race and tobacco use were attenuated in adjusted analyses. Receiving coupons was strongly associated with current use of cigarettes (aOR = 8.02; 95% CI [3.55, 18.1]), e-cigarettes (aOR = 7.26; 95% CI [3.55, 14.9]), and any tobacco (aOR = 5.04; 95% CI [2.44, 10.4]). In conclusion, unadjusted differences in prevalence of tobacco use across race/ethnic groups were attenuated after controlling for pro- and anti-tobacco messaging exposures. Receiving tobacco coupons was consistently associated with current tobacco use among bisexual and pansexual women. Restrictions on coupons could promote health equity.

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda

Background

Disparities in exposure to and density of tobacco advertising are well established; however, it is still unclear how e-cigarette and heated tobacco product (HTP) advertising vary by age, education, sex, gender identity, race/ethnicity, sexual orientation, socioeconomic status (SES), and/or urban/rural area. Through a scoping review, we sought to identify potential disparities in exposure to e-cigarette and HTP advertising and promotion across populations.

Methods

In January 2020, a systematic literature search was conducted in five databases: PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. The search was updated in October 2020. Articles reporting on exposure to e-cigarette and/or HTP advertising and promotion across age, education, sex, gender identity, race/ethnicity, sexual orientation, SES, and/or urban/rural areas were included for full-text review (n = 25). Of those, 15 were deemed relevant for data extraction.

Results

The majority of the studies were from the U.S. (n = 12) and cross-sectional (n = 14). Studies were published between 2014 and 2020 and focused on determining causal relationships that underlie disparities; only one study assessed HTP advertising and promotion. Exposure to e-cigarette and HTP advertising was assessed at the individual-level (e.g., recall seeing ads on television) and at the neighborhood-level (e.g., ad density at the point-of-sale). Studies addressed differences across age (n = 6), education (n = 2), sex (n = 6), gender identity and sexual orientation (n = 3), race/ethnicity (n = 11), SES (n = 5), and urban/rural (n = 2). The following populations were more likely to be exposed to e-cigarette advertising: youth, those with more than a high school diploma, males, sexual and gender minorities, Whites, and urban residents. At the neighborhood-level, e-cigarette advertisements were more prevalent in non-White neighborhoods.

Conclusions

Exposure to e-cigarette/HTP advertising varies based on sociodemographic characteristics, although the literature is limited especially regarding HTPs. Higher exposure among youth might increase tobacco-related disparities since it can lead to nicotine/tobacco use. Research should incorporate and apply a health equity lens from its inception to obtain data to inform the elimination of those disparities.

How the Expansion of the U.S. Preventive Services Task Force Lung Cancer Screening Eligibility May Improve Health Equity Among Diverse Sexual and Gender Minority Populations

This article discusses the potential implications of addressing lung cancer disparities among diverse sexual and gender minority (SGM) populations based on the recently expanded U.S. Preventive Services Task Force 2021 guidelines on lung cancer screening using low-dose computed tomography to include adults aged 50-80 years who have a 20 pack-year smoking history (one pack-year equals smoking one pack or 20 cigarettes per day for 1 year) and currently smoke or have quit within the past 15 years. Research on lung cancer screening barriers and facilitators and efforts to increase awareness and screening uptake among SGM populations are proposed.

Targeted Truth: An Experiment Testing the Efficacy of Counterindustry Tobacco Advertisements Targeted to Black Individuals and Sexual and Gender Minority Individuals

INTRODUCTION

Some groups disproportionately suffer from tobacco-related illnesses-in part, because the tobacco industry has strategically targeted these groups. To combat industry targeting, antitobacco media campaigns (eg, the truth campaign) have used analogous messaging strategies, describing the industry's targeted marketing practices to reach these vulnerable groups. We tested the efficacy of counterindustry tobacco advertisements targeted to vulnerable groups (Black individuals and sexual and gender minority [SGM] individuals).

AIMS AND METHODS

From March to July 2020, we recruited N = 1161 young adults in the United States, including n = 430 Black young adults and n = 452 SGM young adults (with n = 108 identifying as Black and SGM). In a web-based, between-subjects experiment, participants were randomized to watch one of four types of advertisement ("ad"): (1) ads from the truth antismoking campaign not targeted toward a specific vulnerable group, (2) Black-targeted truth ads, (3) SGM-targeted truth ads, or (4) unrelated control ads. We examined effects on support for tobacco control policies, counterindustry motivation, counterindustry beliefs, perceived effectiveness, and anger toward the industry.

RESULTS

Relative to control, non-targeted ads increased policy support, and Black-targeted ads increased motivation and beliefs. Targeted ads elicited anger regardless of the audience targeted. However, in general, neither Black identity nor SGM identity moderated the effects of the targeted ads.

CONCLUSIONS

We offer little evidence that targeted counterindustry ads are especially influential for their intended group. However, targeted counterindustry appeals may be successful at evoking industry anger regardless of the audience targeted.

IMPLICATIONS

Counterindustry advertisements from the truth campaign targeting Black individuals and SGM individuals had limited effect on tobacco control policies, counterindustry motivation, and counterindustry beliefs. However, counterindustry ads evoked anger toward the industry regardless of ingroup status, which in turn was positively associated with anti-industry outcomes. These results, considered alongside the extant literature, suggest little benefit to developing targeted counterindustry tobacco campaigns for specific groups and instead point to the utility of developing campaigns that appeal to broader audiences.

Tobacco Advertising Features That May Contribute to Product Appeal Among US Adolescents and Young Adults

INTRODUCTION

Cigarette advertising is a causal agent of smoking uptake among young people. Although prior research links ad receptivity to tobacco product interest and use, little is known regarding the specific advertising tactics associated with increased product appeal among young people.

METHODS

A national sample of 13-20 year-olds (N = 3688, youth) and 21-24 year-olds (N = 1556, young adults) in the US participated in an online survey in 2017 (mean age 18.1 years). The majority (72.0%) of youth and nearly half (44.8%) of young adults were never smokers. Participants were shown a cigarette ad, randomly assigned from a pool of 50 advertisements, and reported how much they liked the ad, and were curious about and interested in using the advertised product. All 50 advertisements were content analyzed for a variety of features. Data from the survey and content analysis were merged and mixed effects analyses used to identify the features associated with increased liking, curiosity, and interest in using, referred to collectively as product appeal.

RESULTS

Presence of a sweepstakes offer was associated with increased liking, curiosity and interest among youth and curiosity and interest among young adults. Outdoors settings, flora imagery, natural descriptors, and environmental themes were associated with increased appeal. Price reductions (eg, coupons) were associated with decreased appeal among youth.

CONCLUSIONS

This study identified several advertising tactics associated with increased appeal among youth and young adults. If additional research confirms these findings, the U.S. Food and Drug Association should consider restricting use of these tactics in tobacco advertising.

IMPLICATIONS

This study's findings provide insight into features of cigarette ads that appeal to youth and young adults. Overall, the presence of sweepstakes appealed to youth and young adults and outdoors and environmental themes were particularly appealing to young adults. Such tactics could serve to further brand engagement, improve brand image and lead to initiation or escalation of use. If confirmatory studies further demonstrate the effects of the tactics identified in this study on youth product appeal, U.S. Food and Drug Administration should consider using its authority to restrict the use of youth-appealing tactics.

Transitions in hookah (Waterpipe) smoking by U.S. sexual minority adults between 2013 and 2015: the population assessment of tobacco and health study wave 1 and wave 2

BACKGROUND

Tobacco smoking using a hookah (i.e., waterpipe) is a global epidemic. While evidence suggests that sexual minorities (SM) have higher odds of hookah use compared to heterosexuals, little is known about their hookah use patterns and transitions. We sought to examine transitions between hookah smoking and use of other tobacco and electronic (e-) products among SM adults aged 18 years of age and older versus their heterosexual counterparts.

METHODS

We analyzed nationally representative data of ever and current hookah smokers from Wave 1 (2013-2014; ever use n = 1014 SM and n = 9462 heterosexuals; current use n = 144 SM and n = 910 heterosexuals) and Wave 2 (2014-2015; ever use n = 901 SM and n = 8049 heterosexuals; current use n = 117 SM and n = 602 heterosexuals) of the Population Assessment of Tobacco and Health Study. Comparisons between groups and gender subgroups within SM identity groups were determined with Rao-Scott chi-square tests and multivariable survey-weighted multinomial logistic regression models were estimated for transition patterns and initiation of electronic product use in Wave 2.

RESULTS

Ever and current hookah smoking among SM adults (ever use Wave 1: 29% and Wave 2: 31%; current use Wave 1: 4% and Wave 2: 3%) was higher than heterosexuals (ever use Wave 1: 16% and Wave 2: 16%; current use Wave 1: 1% and Wave 2: 1%; both p < 0.0001). Among SM adults who reported hookah use at Wave 1, 46% quit hookah use at Wave 2; 39% continued hookah use and did not transition to other products while 36% of heterosexual adults quit hookah use at Wave 2 and 36% continued hookah use and did not transition to other products. Compared with heterosexuals, SM adults reported higher use of hookah plus e-products (Wave 2 usage increased by 65 and 83%, respectively).

CONCLUSIONS

Compared to heterosexuals, in addition to higher rates of hookah smoking, higher percentages of SM adults transitioned to hookah plus e-product use between 2013 and 2015. Results have implications for stronger efforts to increase awareness of the harmful effects of hookah as well as vaping, specifically tailored among SM communities.

Association of Coming Out as Lesbian, Gay, and Bisexual+ and Risk of Cigarette Smoking in a Nationally Representative Sample of Youth and Young Adults

Importance

Coming out as lesbian, gay, bisexual, or other identities besides heterosexual (LGB+) may represent a susceptible period for cigarette smoking initiation in youth and young adults.

Objective

To assess whether young people who change their sexual identity have higher risk of cigarette smoking initiation and current smoking compared with those with consistent sexual identities.

Design, Setting, and Participants

This cohort study used data from the nationally representative Population Assessment of Tobacco and Health study (wave 1, 2013-2014; wave 2, 2014-2015; wave 3, 2015-2016; wave 4, 2016-2018). Youth and young adults aged 14 to 29 years who were never smokers at wave 1 were included in this study. Analysis began October 2018 and ended June 2020.

Exposures

Consistent sexual identity (consistently heterosexual, consistently LGB+) vs changing sexual identity (coming out as LGB+, other LGB+ patterns) based on 4 waves of sexual identity data. Identities were further classified by distinguishing between bisexual and lesbian, gay, and other nonheterosexual identities.

Main Outcomes and Measures

Smoking initiation and current cigarette smoking at wave 4.

Results

Among 7843 individuals who never smoked at wave 1, 6991 (90.7%) reported a consistent sexual identity, and 852 (9.3%) changed sexual identity across waves. The mean (SE) baseline age of participants who reported consistent heterosexuality was 20.1 (0.8) years; consistently LGB+, 20.0 (3.7) years; coming out as LGB+, 18.0 (2.9) years, and other LGB+ pattern, 20.3 (3.8) years. A total of 14.1% (weighted) initiated smoking, and 6.3% were current smokers at wave 4. Compared with consistently heterosexual identities, coming out as LGB+ (23% vs 13%; odds ratio [OR], 1.72; 95% CI, 1.34-2.20), consistently LGB+ identities (17% vs 13%; OR, 1.45; 95% CI, 1.03-2.04), and other LGB+ patterns (17% vs 13%; OR, 1.47; 95% CI, 1.04-2.08) were positively associated with smoking initiation by wave 4. Compared with consistently heterosexual identities, ORs for smoking initiation were 2.24 (28% vs 13%; 95% CI, 1.72-2.92) for coming out as bisexual, 1.99 (23% vs 13%; 95% CI, 1.20-3.29) for consistently LGB+ with change to/from bisexual, and 2.20 (23% vs 13%; 95% CI, 1.40-3.46) for other LGB+ patterns with change to/from bisexual identity. Current smoking estimates were similar to those for smoking initiation.

Conclusions and Relevance

Compared with consistently heterosexual identities, changing sexual identity over follow-up was associated with smoking initiation and current smoking. The risk associated with changing sexual identities was concentrated among participants coming out as bisexual or reporting other changes in their identity to/from being bisexual. More research is needed on mechanisms underlying the association between changing sexual identity and smoking initiation to inform tailored prevention programs and tobacco regulations.