Overview of tobacco use transitions for population health

National longitudinal tobacco product discontinuation rates among US youth from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

Determine longitudinal tobacco product discontinuation rates among youth (ages 12-17 years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study, was used to determine annual/biennial rates of tobacco product discontinuation behaviours among youth across 2013-2019: (1) discontinuing product use (transition from past 30-day use to no past 30-day use), (2) attempting to quit product use and (3) discontinuing product use among those who attempted to quit. Discontinuing use was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah, smokeless tobacco and any tobacco. Attempting to quit and discontinuing use among those who attempted were each evaluated for cigarettes and ENDS. Generalised estimating equations were used to evaluate linear and non-linear trends in rates across the study period.

RESULTS

Between 2013 and 2019, biennial rates of discontinuing tobacco product use among youth increased for cigarettes from 29% to 40%, increased for smokeless tobacco from 39% to 60%, and decreased for ENDS from 53% to 27%. By 2018/2019, rates of discontinuing use among attempters were 30% for those who used ENDS and 30% for those who smoked cigarettes.

CONCLUSIONS

Findings show decreasing rates of discontinuing ENDS use among youth in the USA alongside the changing ENDS marketplace and increasing rates of discontinuing cigarette smoking and smokeless tobacco use. Findings will serve as benchmarks against which future tobacco product discontinuation rates can be compared with evaluating impacts of subsequent tobacco regulatory policies, ENDS product development and public education campaigns.

National longitudinal tobacco product cessation rates among US adults from the PATH Study: 2013-2019 (waves 1-5)

OBJECTIVE

To report on longitudinal tobacco product cessation rates, by product type, among adults (ages 18+ years) in the USA between 2013 and 2019.

METHODS

The Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study was used to report on annual and biennial rates of the following three cessation behaviours across 2013-2019: (1) discontinuing tobacco product use (ie, transition from past 30-day use to no past 30-day use), (2) attempting to quit tobacco product use and (3) quitting tobacco product use among those who attempted to quit. Each cessation behaviour was evaluated separately for cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco. Generalised estimating equations were used to evaluate linear and nonlinear trends in cessation rates across the study period.

RESULTS

Between 2013 and 2019, rates of discontinuing cigarette smoking among adults in the USA statistically increased from 16% to 18%, though these were consistently lower than rates of discontinuing use of other tobacco products. Similarly, quit attempt rates and rates of quitting among attempters increased for cigarette smokers. However, rates of discontinuing ENDS use sharply declined across the study period, from 62% to 44%.

CONCLUSIONS

Findings show that tobacco product cessation rates have been changing in recent years in the USA alongside the changing tobacco product marketplace and regulatory environment, though rates of discontinuing cigarette smoking remain relatively low. Findings can serve as a benchmark against which future cessation rates can be compared to evaluate the impacts of future tobacco regulatory policies.

Tobacco Whack-A-Mole: A Consumption Taxonomy of Cigar & Other Combustible Tobacco Products among a Nationally Representative Sample of Young Adults

INTRODUCTION

Little filtered cigars and cigarillos (LCCs) are consumed infrequently, co-administered with marijuana, and concurrently used with other tobacco products. Reliance on the past 30-day use estimate, a marker of tobacco user status, may underestimate the dynamic nature of intermittent LCC and other tobacco product use. We developed a framework to capture the intermittent nature of exclusive LCC use and dual/poly use with cigarettes and large cigars using broader timing of last product use categories and product use modality (e.g., with marijuana).

METHODS

Data come from the baseline C'RILLOS study, a U.S. nationally representative sample of young adults aged 18-34 (n = 1063) collected in October 2019. We developed a consumption taxonomy framework that accounted for respondents' modality of LCC use (i.e., use with tobacco, LCC-T, or use with marijuana as blunts, LCC-B), the exclusive use of LCCs and other tobacco products (i.e., cigarettes, and large cigars) or their co-use and the timing of last product use (i.e., ever and past 30 days, past 3 months, past 6 months, greater than 6 months).

RESULTS

Seventy-five percent of our sample reported ever use of any combustible tobacco product, including LCCs. The most common ever use pattern was poly use of LCC-T + LCC-B + cigarettes (16%). Our consumption taxonomy framework demonstrated the fluid nature of combustible tobacco product use among LCC users. For instance, among past 30-day cigarette users, 48% reported using LCC-T, 39% reported using LCC-B, and 32% reported using large cigars in the past 3 months or more.

DISCUSSION

The tobacco use field currently classifies 'tobacco users' based on the product they smoked in the past 30 days. Any tobacco product use beyond the past 30-day period is considered 'discontinued use' and not the focus of intervention or tobacco regulatory science decisions. We documented the substantial proportion of young adult LCC, cigarette, and large cigar users who either exclusively or dual/poly used these combustible products in recent (e.g., past 3 months) periods. To prevent underestimation of use, surveillance measures should assess the use modality, timing of last product use, and exclusive/multiple product use to more accurately identify the smoking status of young adult LCC users.

Smoking trajectory and cancer risk: A population-based cohort study

INTRODUCTION

Smoking behavior can change with time and lead to different health outcomes. This study explored the trajectory of smoking and its relationship with cancer incidence and mortality among Korean male adults.

METHODS

We used 2002–2018 data from the National Health Insurance Service (NHIS). Smoking status was repeatedly measured in four waves of general health examinations provided by the NHIS between 2002 and 2009. Cancer incidence and mortality were tracked from 2010 to 2018. Trajectory analysis was used to identify the patterns of smoking. The hazard ratio was calculated using Cox proportional regression models.

RESULTS

For the 2448548 men (≥20 years), 137788 cases of cancers and 41146 cancer deaths were found. We identified six trajectory groups: never smokers, former smokers, new current smokers, decreasing light smokers, steady moderate smokers, and steady heavy smokers. All smoking groups had an increased risk of cancer. The steady heavy smokers showed higher cancer incidence and mortality rate than the steady non-smokers (hazard ratio, HR=1.53; 95% CI: 1.49–1.58 and HR=2.64; 95% CI: 2.50–2.79, respectively). The cancer-specific analysis showed that the larynx and lung cancer incidence and mortality rate of the smoking group were higher than in never smokers.

CONCLUSIONS

Smoking, even at low doses, increases the risk of most cancers in men. Quitting or reducing smoking, especially at a young age, can lower cancer incidence and mortality. This study may provide more objective results on the relationship between smoking and cancer, because smoking behavior was examined at multiple time points.

Electronic nicotine delivery systems use predicts transitions in cigarette smoking among young adults

BACKGROUND

Although cigarette smoking during young adulthood is characterized by volatility, few studies examine if use of electronic nicotine delivery systems (ENDS) impacts transitions in cigarette use behaviors across this developmental period. The purpose of this longitudinal study was to examine the role of ENDS use on three transitions in cigarette smoking among young adults; initiation, desistance, and re-uptake.

METHODS

Participants were 5029 18-29-year-olds (64.2% female) enrolled in one of 24 Texas colleges at baseline and involved in an eight-wave, 4.5-year study. A multi-state, continuous time Markov model was used to assess the role of current/past 30-day and ever ENDS use on three transitions, spanning at least six months 1) never to current smoking (initiation); 2) current to non-current smoking (desistance); and 3) non-current to current smoking (re-uptake). The model also contained time-invariant socio-demographic, and time-varying intrapersonal (other tobacco use, nicotine dependence, sensation seeking, depressive symptoms) and interpersonal (peer cigarette use) covariates.

RESULTS

Both current and ever ENDS use increased the probability of transitioning from never to current cigarette use (initiation) and decreased the probability of transitioning from current to non-current use (desistance). Current, but not ever, ENDS use also increased the probability of transitioning from non-current to current use (re-uptake). Adjustment for socio-demographic, intrapersonal, and interpersonal covariates did not alter these findings.

DISCUSSION

ENDS use in young adulthood increases the risk for cigarette smoking behaviors across the continuum of uptake and progression. Prevention and cessation efforts targeting both ENDS and cigarette use during young adulthood are needed.

E-Cigarette Toxicology

Since the spread of tobacco from the Americas hundreds of years ago, tobacco cigarettes and, more recently, alternative tobacco products have become global products of nicotine addiction. Within the evolving alternative tobacco product space, electronic cigarette (e-cigarette) vaping has surpassed conventional cigarette smoking among adolescents and young adults in the United States and beyond. This review describes the experimental and clinical evidence of e-cigarette toxicity and deleterious health effects. Adverse health effects related to e-cigarette aerosols are influenced by several factors, including e-liquid components, physical device factors, chemical changes related to heating, and health of the e-cigarette user (e.g., asthmatic). Federal, state, and local regulations have attempted to govern e-cigarette flavors, manufacturing, distribution, and availability, particularly to underaged youths. However, the evolving e-cigarette landscape continues to impede timely toxicological studies and hinder progress made toward our understanding of the long-term health consequence of e-cigarettes.

Transitions in Frequent to Daily Tobacco and Nicotine Use among Youth and Young Adults

Objective: To examine use and frequency patterns across e-cigarettes, cigarettes, and little cigars, cigarillos, and cigars (LCCs) over time. Methods: Data were obtained from the Truth Longitudinal Cohort (TLC), a nationally representative longitudinal cohort of youth and young adults. Latent class analysis was conducted to classify participants (n = 5274) into subgroups based upon frequency of use of cigarettes, e-cigarettes, and little cigars, cigarillos, and cigars (LCCs) in the past 30 days. Latent transition analysis was used to estimate the probability of use pattern transitions across 23 months (February 2018 to December 2019), adjusted for the effects of gender, race/ethnicity, financial situation, sensation seeking, parent education, and household smoking. Findings: Findings reveal four groups of tobacco product users: (1) frequent to daily cigarette users (9%), (2) frequent to daily cigarette and LCC users (3%), (3) frequent to daily e-cigarette users (10%), and (4) former or noncurrent tobacco users (78%). Although most respondents (69-94%) retained their initial user patterns during the observation period, results also indicate shifts between user groups. Notably, 14% of frequent to daily cigarette and LCC users transitioned to frequent to daily cigarette use, while 6% of frequent to daily cigarette and LCC users, 9% of frequent to daily cigarette users, and 4% of former or noncurrent tobacco users transitioned to frequent to daily e-cigarette use. Conclusion: Although most frequent to daily tobacco users stay with their primary product, there are transitions between frequent to daily cigarette, e-cigarette, and LCC use. Transition patterns may influence risk for nicotine addiction among youth and young adults. Thus, policies focused on preventing and reducing all tobacco use are needed to curb the risk of nicotine addiction among youth and young adults.

The Influence of Increasing Levels of Provider-Patient Discussion on Quit Behavior: An Instrumental Variable Analysis of a National Survey

Objective: We aimed to examine the influence of increasing levels of discussion (both asked and advised, either asked or advised but not both, and neither asked nor advised) on quit behavior. Methods: We included 4133 adult current smokers from the 2015 National Health Interview Survey. The primary outcomes were quit intent and quit attempt, and the secondary outcomes were methods used for quitting. We used an instrumental variable analysis, as well as propensity score weighted and multivariable logistic regressions. Results: Compared to no discussion, having both or only one discussion, respectively, increased quit intent (OR = 1.65, 95% CI = 1.63–1.66 and OR = 1.02, 95% CI = 0.99–1.05), quit attempt (OR = 1.76, 95% CI = 1.75–1.77 and OR = 1.60, 95% CI = 1.57–1.63). Among those who attempted to quit (n = 1536), having both or only one discussion increased the use of pharmacologic (OR = 1.99, 95% CI = 1.97–2.02 and OR = 1.56, 95% CI = 1.49–1.63) or behavioral (OR = 2.01, 95% CI = 1.94–2.08 and OR = 2.91, 95% CI = 2.74–3.08) quit methods. Conclusions: Increasing levels of provider–patient discussion encourages quit behavior, and should be an integral part of reducing the health and economic burden of smoking. Strategies that promote the adherence and compliance of providers to communicate with patients may help increase the success of smoking cessation.

Changes in Smoking and Vaping over 18 Months among Smokers and Recent Ex-Smokers: Longitudinal Findings from the 2016 and 2018 ITC Four Country Smoking and Vaping Surveys

This descriptive study of smokers (smoked at least monthly) and recent ex-smokers (quit for ≤2 years) examined transitions over an 18 month period in their smoking and vaping behaviors. Data are from Waves 1 (W1: 2016) and 2 (W2: 2018) of the ITC Four Country Smoking and Vaping Survey, a cohort study of adult (≥18+) smokers, concurrent users (smoke and vape), and recent ex-smokers from Australia, Canada, England, and the United States (US). Respondents (N = 5016) were classified according to their smoking and vaping status, which resulted in eight subgroups: (1) exclusive daily smokers (2) exclusive non-daily smokers; (3–6) concurrent users (subdivided into four groups by each combination of daily/non-daily smoking and daily/non-daily vaping); (7) ex-smokers who vape; (8) ex-smokers not vaping. The analyses focused first on describing changes between groups from W1 to W2. Second, transition outcomes were assessed based on changes in smoking and vaping between W1 and W2. Transitions focused on smoking were: no change in smoking (continued smoking at the same frequency); decreased smoking; increased smoking; discontinued smoking; relapsed (ex-smokers at W1 who were smoking at W2). Transitions focused on vaping were: initiated vaping; switched from smoking to vaping. Overall, this study found that the vast majority of smokers were smoking 18 months later. Non-daily smokers were more likely than daily smokers to have discontinued smoking (p < 0.0001) and to have switched to exclusive vaping (p = 0.034). Exclusive non-daily smokers were more likely than exclusive daily smokers to have initiated vaping (p = 0.04). Among all W1 daily smokers, there were no differences in discontinued smoking between daily smokers who vaped (concurrent users) and exclusive daily smokers; however, concurrent users were more likely than exclusive daily smokers to have decreased to non-daily smoking (p < 0.001) or to have switched to vaping by W2 (p < 0.001). Among all W1 non-daily smokers, there were no significant differences in increased smoking or discontinued smoking between concurrent users or exclusive smokers. Most ex-smokers remained abstinent from smoking, and there was no difference in relapse back to smoking between those who vaped and those who did not.

Correlates of tobacco product cessation among youth and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

To report on demographic and tobacco use correlates of cessation behaviours across tobacco products (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.

DESIGN

Data were drawn from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (ages 12-17) and adults (ages 18+) . Past 30-day (P30D) tobacco users at Wave 1 (W1) or Wave 2 (W2) were included (n=1374 youth; n=14 389 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco use characteristics at baseline, with cessation behaviours at follow-up (discontinuing use, attempting to quit, quitting), over two 1-year periods (W1-W2, W2-Wave 3).

RESULTS

Among adult users of each type of tobacco product, frequency of use was negatively associated with discontinuing use. Among adult cigarette smokers, non-Hispanic white smokers, those with lower educational attainment and those with lower household income were less likely to discontinue cigarette use; ENDS use was positively associated with making quit attempts but was not associated with cigarette quitting among attempters; smokeless tobacco use was positively associated with quitting among attempters; tobacco dependence was negatively associated with quitting among attempters. Among youth cigarette smokers, tobacco dependence was negatively associated with making quit attempts.

DISCUSSION

Demographic correlates of tobacco cessation behaviours underscore tobacco use disparities in the USA. Use of ENDS and use of smokeless tobacco products are positively associated with some adult cigarette cessation behaviours.

Correlates of tobacco product initiation among youth and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

To report on demographic and tobacco product use correlates of tobacco product initiation (cigarettes, electronic nicotine delivery systems (ENDS), cigars, hookah and smokeless tobacco) among the US population.

DESIGN

Data were from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth (aged 12-17 years) and adults (aged 18+ years). Never users of at least one type of tobacco product at Wave 1 (W1, 2013/14) or Wave 2 (W2, 2014/15) were included (n=12 987 youth; n=25 116 adults). Generalised estimating equations were used to evaluate the association between demographic and tobacco product use characteristics at baseline, and tobacco product initiation at follow-up (ever, past 30 day (P30D), frequent (use on 20 or more of thepast 30 days)) over two 1-year periods (W1-W2 and W2-Wave 3).

RESULTS

Youth aged 15-17 years were more likely than youth aged 12-14 years and adults aged 18-24 years were more likely than older adults to initiate P30D tobacco use across products; non-heterosexuals were more likely than heterosexuals to initiate P30D cigarette and ENDS use. Older adults were more likely than young adults, and males were more likely than females, to be frequent users of ENDS on initiation. Ever use of another tobacco product predicted P30D initiation of each tobacco product.

DISCUSSION

Other tobacco product use and age predict P30D tobacco initiation across products whereas associations with other demographic characteristics vary by product. Continued contemporary evaluation of initiation rates within the changing tobacco product marketplace is important.