Cigarette advertising and teen smoking initiation

Trends in smoking initiation and cessation over a century in two Australian cohorts

BACKGROUND

Historical data on smoking can enhance our comprehension of the effectiveness of past tobacco control policies and play a key role in developing targeted public health interventions. This study was undertaken to assess trends in smoking initiation and cessation in Australia for the period 1910-2005.

METHODS

Rates of smoking initiation and cessation were calculated for participants in two population-based cohorts, the Busselton Health Study and the Tasmanian Longitudinal Health Study. The effects of time trends, gender and age group were evaluated.

RESULTS

Of the 29,971 participants, 56.8% ever smoked. In males, over the period 1910-1999, the rate of smoking initiation in young adolescents remained high with a peak in the 1970s; in older adolescents it peaked in the 1940s and then declined; in young adults it showed a steady decline. In females, the rate of smoking initiation in young adolescents rose sharply in the 1960s and peaked in the 1970s, in older adolescents it increased throughout the period, and in young adults it declined after 1970. In the period 1930-2005, 27.3% of 9,605 people aged 36-50 years who smoked ceased smoking. Rates of cessation in this age group increased throughout but decreased in males after 1990 and plateaued around 2000 in females.

CONCLUSION

Our findings show substantial variation in the efficacy of tobacco control policies across age groups, with a notable lack of success among the younger population.

Sociodemographic inequalities in cigarette, smokeless tobacco, waterpipe tobacco, and electronic cigarette use among adolescents aged 12-16 years in 114 countries: A cross-sectional analysis

INTRODUCTION

The majority of users of tobacco and nicotine products start using them in adolescence. In order to keep equity considerations at the forefront of tobacco control, it is crucial to assess whether inequalities in prevalence of tobacco and nicotine use exist among adolescents globally.

METHODS

We conducted a secondary analysis of Global Youth Tobacco Survey (GYTS) data from 538644 school-based adolescents (79.3% aged 13-15 years) in 114 countries (2013-2019). Data were collected on current (past 30-day) use of cigarettes, smokeless tobacco, waterpipe tobacco and electronic cigarettes. We used weighted Poisson regression models adjusted for sex, pocket money, and age to assess differences in prevalence of current use between boys and girls, and between students with high versus low pocket money.

RESULTS

Although there was substantial regional variation, in most countries boys were statistically significantly more likely to report current use of all assessed products (ranging from 50.0% of countries for waterpipe tobacco to 73.3% of countries for electronic cigarettes). Inequalities by sex were less pronounced in Europe compared to other regions. Inequalities by pocket money were less consistent; students with more pocket money were more likely to report current use of cigarettes (vs those with less pocket money) in 61.8% of the countries, but more likely to report current use of smokeless tobacco in only 18.3% of countries.

CONCLUSIONS

Globally, boys and adolescents with more pocket money are generally more likely to use a range of tobacco and nicotine products. However, these patterns are not universal and local variations should be taken into consideration to design effective and equitable tobacco control policies.

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the "Präventionsradar" from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

Socioecological factors associated with multiple nicotine product use among U.S. youth: Findings from the population assessment of tobacco and health (PATH) study 2013-2018

OBJECTIVE

This study utilized a socioecological approach to prospectively identify intrapersonal, familial, and environmental factors associated with single nicotine product use (NPU) and multiple NPU among U.S. youth.

METHODS

Participants were 10,029 youths (ages 12-17 years) who had completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments and data on past 30-day nicotine product use. Multinomial logistic regression was fit for the 3-level outcome (no use, single NPU, multiple NPU) to estimate adjusted associations between the predictors and the outcome.

RESULTS

The current study found that intrapersonal (sex, age, race/ethnicity, internalizing symptoms, sensation seeking, harm perceptions, lifetime history of using two or more tobacco products), familial (parental discussion about not using tobacco and living with someone who uses tobacco products) and environmental factors (exposure to tobacco advertising) commonly associated with tobacco use differentiated between individuals who later reported past 30-day NPU (either multiple or single NPU) from those who did not report past 30-day NPU. One familial factor only differentiated between lifetime users who were single NPUs from those who reported no NPU: non-combustible tobacco product use allowed anywhere in the home. Intrapersonal factors differentiated multiple NPU from single NPU: older age, being male, lifetime history of using nicotine product and less harm perceptions.

CONCLUSIONS

This study identified factors that may be studied to prevent any NPU, along with factors that may be studied to promote harm reduction by preventing escalation of single NPU to problematic patterns of multiple NPU.

Patterns in Tobacco, E-Cigarette, and Cannabis Advertising Exposure Among California Adolescents and Associations With Future Use Expectations

BACKGROUND

Exposure to tobacco, e-cigarette, or cannabis marketing is associated with adolescent use. Few studies have examined advertising exposure prevalence and patterns across these products concurrently.

METHODS

This study assessed past 30-day recalled exposure to promotional messages about tobacco, e-cigarettes ("vapes" on the survey), and cannabis ("marijuana") from various sources among California adolescents (ages 12-17) in the 2022 Teens, Nicotine, and Tobacco Online Survey (N = 2530). Principal components analysis (PCA) was conducted to examine the underlying structure and patterns in advertising exposure sources. Multivariable logistic regression was used to evaluate associations between any advertising exposure and future use expectations (a susceptibility measure) in one year and at age 25 among current never-users.

RESULTS

Overall, 65.9% of participants recently noticed at least one tobacco (52.5%), vape (51.5%), or marijuana (45.6%) advertisement. Gas stations or convenience stores were the most common source for tobacco or vape ads; billboards were for marijuana ads. In PCA, advertising exposure patterns correlated with advertising source, not the type of product. Exposures from tobacco-specific sources and nearer point of sale were associated with current use, older age, LGBTQ + identity, and sensation seeking. Among never-users, advertising exposure was associated with one-year and age-25 use expectations for cigarettes (one-year expectations adjusted odds ratio: 1.7; 95% CI: 1.1, 2.5), vapes (2.3; 1.5, 3.5), and marijuana (2.1; 1.5, 3.0).

CONCLUSION

California adolescents' exposure to tobacco, e-cigarette, and cannabis marketing is common, follows similar patterns, and is associated with use susceptibility. Comprehensive restrictions on marketing accessible to adolescents could help prevent youth use.

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the 'Präventionsradar' from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

The effect of exposure to tobacco smoking-related media messages on youths' smoking behavior in Jordan: A longitudinal, school-based study

Only a few studies investigated the link between tobacco smoking-related media and youth smoking in the Eastern Mediterranean Region (EMR). This study aimed to assess the influence of both promotional and control messages on cigarette smoking behavior among young Jordanian students. Generalized Linear Mixed Models were analyzed using data from the Irbid Longitudinal Smoking Study that followed a random sample of 2174 students (2008-2011). We examined the associations of media messaging with smoking behavior, as well as intention-to-quit smoking, and intention-to-start smoking, among young adolescents. At baseline, 12.2% and 43.7% of students were exposed to only pro-smoking or only anti-smoking messages, while 41.8% were equally exposed to both. Exposure to anti-smoking messages was associated with lower odds of ever smoking at baseline among girls (AOR = 0.4; 95% CI: 0.2, 0.8). Boys who were exposed to anti-smoking messages were more likely to report an intention to quit, with borderline significance (AOR = 2.0; 95% CI: 0.9, 4.1). The cumulative exposure to anti-smoking messages over time was associated with lower odds of intention to smoke among girls (AOR = 0.5; 95% CI: 0.3, 0.9) but with higher odds among boys (AOR = 1.8; 95% CI: 1.0, 3.1). In both sexes, media messaging was not associated with progression of the smoking habit. In conclusion, this comprehensive analysis of both pro- and anti-smoking messages advances our understanding of their role in influencing youths' smoking behaviors, and could guide the development of evidence-based interventions to address adolescent tobacco smoking in Jordan and the EMR.

Prevalence of Cigarette Smoking among Professionally Active Adult Population in Poland and Its Strong Relationship with Cardiovascular Co-Morbidities-POL-O-CARIA 2021 Study

Smoking is a leading cause of preventable mortality. It affects both the health and economic situation within societies. The aim of the study is to perform an epidemiological analysis of smoking among professionally active adults in Poland in the years 2016–2020 and its Strong Relationship with Cardiovascular Co-morbidities. The article retrospectively analyzed the records of 1,450,455 who underwent occupational medicine examinations between 2016 and 2020. Statistical analyses performed using IBM SPSS Statistics 25 software were performed. In general, irrespective of the year of measurement, 11.6% of women and 17.1% of men declared smoking. After sorting by year of measurement, we found that the percentage of female smokers was decreasing, while that of males remained relatively consistent. In the case of BMI, it was found that among tobacco smokers the percentage of people with normal body weight decreases with successive years of measurement, while the percentage of overweight and level I obesity increases. Moreover, we analyzed in detail the occurrence of particular comorbidities in the group of people who declared smoking. The most common diseases in this group were: arterial hypertension (39%), lipid disorders (26.7%), and hypertension and lipid disorders (16.5%). Active preventive measures are necessary to reduce the number of smokers and the negative impact of smoking on the occurrence of comorbid diseases.

Longitudinal Trajectories of Multiple Nicotine Product Use Among Youths in the Population Assessment of Tobacco and Health Study

Importance

Multiple nicotine product use (MNPU) among youths is a significant public health concern. Much remains unknown about the patterns of MNPU in youths, including how socioecological factors influence trajectories of MNPU, which may inform targeted prevention.

Objective

To identify longitudinal trajectories of MNPU and characterize them according to socioecological factors associated with tobacco use.

Design, Setting, and Participants

This US-based longitudinal survey study used data from waves 1 (September 12, 2013, to December 14, 2014) through 4 (December 1, 2016, to January 3, 2018) of the Population Assessment of Tobacco and Health (PATH) study. Participants included 10 086 youths (aged 12-17 years) at wave 1, with follow-up data at waves 2 to 4 (assessed approximately 1 year apart) in the youth or adult data sets. Data were analyzed from January 15, 2020, to December 22, 2021.

Exposures

Socioecological factors at wave 1.

Main Outcomes and Measures

Outcome variables were days of use in the past 30 days of 4 products: cigarettes, e-cigarettes, cigars, and smokeless tobacco. Factors associated with use of the nicotine products that were collected at wave 1 included sociodemographic factors, internalizing and externalizing symptoms, living with a tobacco user, rules about tobacco use at home, conversations with parents about not using tobacco, tobacco accessibility, and exposure to advertising. Multitrajectory latent class growth analysis was used to identify distinct subgroups with similar patterns of use over time. Multinomial logistic regression models were used to investigate factors associated with class membership. Weights were applied to all data except frequencies to account for the complex survey design.

Results

Of the 10 086 youths included in the analysis, 5142 (51.2%) self-identified as male; 4792 (54.7%) were non-Hispanic White; and 5315 (50.6%) were aged 12 to 14 years. Six latent trajectory classes were identified: nonuse (8056 [78.2%]), experimentation (908 [9.8%]), increasing e-cigarette/cigarette use (359 [4.0%]), increasing cigarette/cigar use (320 [3.3%]), decreasing cigarette/e-cigarette/cigar use (302 [3.2%]), and stable smokeless tobacco/cigarette use (141 [1.6%]). Compared with the nonuse class, being older (odds ratio [OR] range, 2.54 [95% CI, 1.94-3.32] to 9.49 [95% CI, 6.03-14.93]), being female (OR range, 0.06 [95% CI, 0.03-0.14] to 0.71 [95% CI, 0.53-0.94]), living with a tobacco user (OR range, 1.43 [95% CI, 1.11-1.83] to 4.94 [95% CI, 3.43-7.13]), and having relaxed rules about noncombustible tobacco product use at home (OR range, 1.41 [95% CI, 1.02-1.94] to 3.42 [95% CI, 1.74-6.75]) were associated with classification in all the use classes. A high degree of difficulty accessing tobacco was associated with lower odds of membership in the increasing cigarette/cigar use vs nonuse classes (OR, 0.62 [95% CI, 0.40-0.98]).

Conclusions and Relevance

These survey results highlight the heterogeneity of longitudinal pathways of MNPU in US youths and suggest directions for future prevention and regulatory efforts directed at tobacco use behaviors in this population.

Sociodemographic differences in young adults' recall of tobacco and cannabis marketing online and in television/film

Young adults (YA) who report viewing pro-tobacco and cannabis marketing are at increased risk for using tobacco and cannabis. However, there is a growing diversity of tobacco and cannabis products on the market, as well as methods for marketing them. Prevalence of, and sociodemographic differences in, YA's recall of various types of tobacco and cannabis marketing is not well-characterized. Data were from a cohort of YA (mean age: 19.8) from Southern California in 2019. Respondents were asked whether they recalled having seen two types of marketing (online advertisements and portrayals of product use in TV/movies) for 5 tobacco and 3 cannabis products among never-users of tobacco (N = 954) and cannabis (N = 1,046), respectively. Sociodemographic differences in marketing recall were subsequently assessed. Among tobacco-naïve respondents, 31.3% and 49.3% recalled seeing online advertisements and tobacco use in TV/movies, respectively. Among cannabis-naïve respondents, 18.7% and 31.0% recalled seeing online advertisements and cannabis use in TV/movies, respectively. Overall, respondents recalled seeing tobacco and cannabis products on TV/movies at higher rates than seeing online advertisements, with the exception of electronic cigarettes, for which online advertisements were seen at higher rates. Women (vs. men) had higher odds of seeing tobacco (aOR = 1.9) and cannabis use in TV/movies (aOR = 1.4) and cannabis marketing online (aOR = 1.4). LGB (vs. straight) respondents had higher odds of seeing cannabis marketing online (aOR = 1.7). Efforts to regulate exposure to tobacco and cannabis marketing among young women and LGB people merit further consideration.

Health Informatics on Adolescents Smoking Based on the Miryoku Engineering Analysis Framework

Smoking among young people has aroused widespread concern in society. The number of young people who smoke has increased year by year, which has largely affected their health. Therefore, how to improve the prevention and control rate of tobacco harm, thereby reducing the smoking rate of young people has become an important issue. Based on the glamour engineering research method that can specifically solve the problem of attractiveness between users and products, the user preference of young people's smoking behavior is studied through the evaluation structure method and quantitative type I analysis, and the potential attractive factors are analyzed. Among them, there are 7 important attractive characteristics that affect the first attempt to smoke. These seven factors are divided into two aspects, namely, personal preference factors and environmental factors. The statistical data obtained through data analysis will be tested in the KMO field. The KMO values are 0.827 and 0.687, respectively, and the statistical results have obvious scores, so this study is effective. By quantifying one category, the partial correlation coefficients of different categories can be found, that is, specific solutions. This method provides a reference for ways and means to curb smoking behavior and also provides a case study for studying user perception. According to the research results, we seek ways to influence the smoking preferences of young people and then adopt some artificial methods to intervene in the generation of these factors, so as to achieve the purpose of reducing smoking among young people.

[Use of Electronic Cigarettes (e-cigs) and e-Shishas by Children and Adolescents: Evidence Paper of the Joint Addiction Commission of the German Societies and Professional Associations of Child and Adolescent Psychiatry and Psychotherapy]

Use of Electronic Cigarettes (e-cigs) and e-Shishas by Children and Adolescents: Evidence Paper of the Joint Addiction Commission of the German Societies and Professional Associations of Child and Adolescent Psychiatry and Psychotherapy Abstract. The particular risks associated with the consumption of electronic cigarettes (e-cigs) in children and adolescents are not sufficiently considered in the health policy discourse. The present article evaluates the current dissemination and consumption patterns of e-cigarettes as well as the health risks attached to children and adolescents. Based on data from current national and international studies, there has been a clear increase in the consumption of e-cigarettes over the past years. This stands in sharp contrast to the overall decline in tobacco consumption among both children and adolescents in Germany. Young people without tobacco experience are now consuming more frequently e-cigarettes than those who occasionally or regularly use tobacco. They also are experimenting more frequently with conventional cigarettes if they have previously consumed e-cigarettes. The largely unregulated availability of e-cigarette products to the newest generation, such as JUUL, led to a dramatic increase in their prevalence among high-school students in the USA. Products with high nicotine content and multiple flavors are being marketed intensively as trendy lifestyle products to young user groups via advertising and social media campaigns. These products are also becoming increasingly relevant in Germany. The success of tobacco prevention in recent years is presently jeopardized by the ongoing effective advertising for e-cigarettes. The Addiction Commission of the German Child and Youth Psychiatric Federations and Scientific Societies therefore call for an immediate, strict, and comprehensive ban of e-cigarette advertising.

Cumulative disadvantage as a framework for understanding rural tobacco use disparities

Traditional tobacco product (cigarettes and smokeless tobacco) and polytobacco use rates are significantly higher among rural adolescents and adults compared to their nonrural counterparts. Such disparities are due to several factors that promote tobacco use initiation and continuation, including individual-level psychopharmacological factors and structural-level factors such as fewer tobacco control efforts (e.g., fewer smoke-free policies and lower tobacco excise taxes), targeted tobacco marketing, less access to health-relevant resources, and more positive cultural norms surrounding tobacco use in rural communities. In this review, we use cumulative disadvantage theory as a framework for understanding how psychopharmacological and structural-level factors serve as drivers of tobacco use in rural areas. We start by describing how structural-level differences between rural-nonrural communities impact psychopharmacological influences and, when available, how these factors influence tobacco use. We conclude by discussing the interplay between factors, providing suggestions for ways to assess our application of cumulative disadvantage theory empirically and making recommendations for research and policy implementation in rural areas. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Effects of Cigarette Advertisement and Peer Influence on Adolescent’s Smoking Intention in Indonesia

BACKGROUND: The occurrence of smoking among adolescents keeps increasing. Based on data from the Regional Health Research 2013, the prevalence of child smokers aged 10–18 years old was 7.2–9.1% in 2018. In fact, it exceeds the government’s target to reduce the number of child smokers in 2019 to 5.4%. Cigarette advertising is one of the reasons children are attracted to smoking, and Indonesia ranks first in ASEAN for youth exposure to tobacco advertisement and promotion. AIM: The aim of the study is to determine the factors that affect the urge to smoke in adolescents, specifically the influence of friends who smoke and exposure to cigarette advertisements in Sleman, Indonesia. METHODOLOGY: A non-experimental study with a correlation study and a cross-sectional approach. The sample was 318 respondents with a total sampling technique on first-grade junior high school students from three schools. The research instruments used were a questionnaire on exposure to cigarette advertisements, smoker friends, and the intention to smoke. The bivariate analysis used was the chi-square correlation test. RESULTS: Most of the respondents were exposed to cigarette advertisements in the medium category (56.6%), most of the respondents had smoking friends (57.2%), 11% of respondents had the desire to smoke shortly, and 15.1% of respondents had a desire to smoke for an extended period. The correlation test results between exposure to cigarette advertisements and smoking friends and the desire to smoke in the near and long term showed a p-value of <0.001. CONCLUSION: There was a significant relationship between exposure to cigarette advertisements and friends who smoke and the intention to smoke in the near and long term among adolescents in Sleman Regency, Indonesia.

Influence of Tobacco Marketing on Nepalese Adolescents: Cigarette Use and Susceptibility to Cigarette Use

Background:

Tobacco advertising, promotion, and sponsorship (TAPS) are common tactics of the tobacco industry to encourage adolescents to use tobacco products.

Objective:

The objective of the study is to assess the influence of TAPS on cigarette use and susceptibility to cigarette use among Nepalese adolescents.

Materials and Methods:

Data (n=2,878) were drawn from the Global Youth Tobacco Survey for Nepal (GYTS, 2011). Channel-specific and cumulative TAPS exposure were the primary exposures of the study. Six multivariate logistic regression analyses were performed to examine current and ever cigarette use outcome with exposure to TAPS. Six binary logistic regression analyses were applied to determine the susceptibility to cigarette use when exposed to TAPS.

Results:

Channel-specific TAPS analyses show that indirect TAPS increases the odds of all the three outcomes; current cigarette use (OR=1.68, 95% CI=1.10-2.58), ever cigarette use (OR=1.81, 95% CI=1.23-2.65) and susceptibility to cigarette use (OR=1.65, 95% CI=1.25-2.19) after adjusting for the covariates. Television (TV) and movies exposure decreases the odds of susceptibility to cigarette use (OR=0.55, 95% CI=0.31-0.97). Cumulative TAPS analyses show that exposure to 5 sources of TAPS increases the odds of current cigarette use (OR=2.53, 95% CI=1.21-5.29). Being male increases the odds of all the three outcomes; current (OR=3.52, 95% CI=2.11-5.87), ever (OR=2.51, 95% CI=1.69-3.73) and susceptibility to cigarette use (OR=1.31, 95% CI=1.01-1.69). Social influence is likely to increase current (OR=6.47, 95% CI=2.50-16.74), ever (OR=1.79, 95% CI=1.10-2.93) and susceptibility to cigarette use (OR=1.66, 95% CI=1.25-2.21).

Conclusion:

Indirect TAPS exposure increased the current, ever, and susceptibility to cigarette use among Nepalese adolescents. Overall, the current use of cigarettes followed a dose-response relationship with TAPS exposure. The result implies a requirement of active surveillance of tobacco products and future research on adolescent-focused tobacco marketing in Nepal.

Cigarette Packs With URLs Leading to Tobacco Company Websites: Content Analysis

BACKGROUND

Tobacco companies include on the packaging of their products URLs directing consumers to websites that contain protobacco messages. Online media tend to be underregulated and provide the industry with an opportunity to present users with protobacco communication.

OBJECTIVE

The objective of our study was to document the content of websites that were advertised on tobacco packs in 14 low- and middle-income countries.

METHODS

We purchased tobacco packs from 14 low- and middle-income countries in 2013 and examined them for the presence of URLs. We visited unique URLs on multiple occasions between October 1, 2016 and August 9, 2017. We developed a coding checklist and used it to conduct a content analysis of active corporate websites to identify types of protobacco communication. The coding checklist included the presence of regulatory controls and warnings, engagement strategies, marketing appeals (eg, description of product popularity, luxury/quality, taste), corporate social responsibility programs, and image management. We coded brand websites separately and also described social media and other website types.

RESULTS

We identified 89 unique URLs, of which 54 were active during the search period. We assessed 26 corporate websites, 21 brand websites, 2 nontobacco websites, and 5 social media pages. We excluded 2 corporate websites and 14 brand websites due to limited accessible content or incomplete content. Corporate social responsibility was discussed on all corporate websites, and marketing appeals were also common. Corporate websites were also more likely to include more nonspecific (12/24, 50%) than specific (7/24, 29%) health warnings. Promotions (6/7, 86%) and sociability appeals (3/7, 43%) were common on brand websites. The small number of social media webpages in our sample used gendered marketing.

CONCLUSIONS

URLs appearing on tobacco packs direct consumers to websites where users are exposed to marketing that highlights the "positive" contributions of tobacco companies on corporate websites, and extensive promotions and marketing appeals on brand websites and social media pages. It is essential that marketing regulations become more comprehensive and ban all protobacco communication, a policy that is in line with articles 5.3 and 13 of the World Health Organization Framework Convention on Tobacco Control. For countries that already ban internet tobacco advertising, enforcement efforts should be strengthened. Tobacco companies' use of URLs on packs may also be compelling for plain packaging advocacy, where all branding is removed from the pack and large graphic health warning labels are the only communication on the tobacco packaging. Future research should consider including tobacco websites in marketing surveillance.

Tobacco Marketing and Subsequent Use of Cigarettes, E-Cigarettes, and Hookah in Adolescents

INTRODUCTION

Tobacco marketing has expanded from cigarettes to other tobacco products through many promotional channels. Marketing exposure is associated with use of that tobacco product. However, it is unclear if marketing for one product leads to subsequent use of other tobacco products.

METHODS

This prospective cohort study assessed self-reported marketing exposure for six tobacco products across five marketing channels in 11th and 12th grade students in 2014. Approximately 16 months later, a follow-up survey was conducted online (N = 1553) to assess initiation of cigarettes, electronic cigarettes (e-cigarettes), and hookah.

RESULTS

Adolescent never-smokers with frequent exposure to cigarette marketing on the Internet and in stores are more than two times as likely to begin smoking as young adults (Internet OR = 2.98 [95% CI = 1.56 to 5.66]; stores OR = 2.83 [95% CI = 1.23 to 6.50]). Never users of e-cigarettes were significantly more likely to initiate use, if exposed to Internet, store, and outdoor e-cigarette marketing. Never users of hookah were more likely to use hookah after seeing it marketed in stores. Youth exposed to marketing of e-cigarettes, hookah, cigars, smokeless tobacco, and pipe tobacco in stores were two to three times more likely to begin smoking cigarettes even though the marketed products were not cigarettes.

CONCLUSIONS

Adolescent exposure to marketing of tobacco products is associated with initiation of those products as young adults. Exposure to marketing for non-cigarette tobacco products is associated with subsequent cigarette smoking, even when the promoted products are not cigarettes. Future research and interventions should consider the influence of marketing from multiple tobacco products on adolescent tobacco use.

IMPLICATIONS

Adolescents grow up in a rich media environment with exposure to tobacco marketing in both their homes (eg, through the Internet and television) and their communities (eg, stores and billboards). This prospective study provides evidence that adolescents exposed to tobacco marketing for multiple tobacco products are more likely to subsequently begin using those products and to begin smoking cigarettes even when the marketing they recall is for different tobacco products. Adolescent exposure to tobacco marketing can increase likelihood of cigarette smoking, e-cigarette, and hookah use with potential lifelong health effects.

Electronic cigarette advertising and teen smoking initiation

INTRODUCTION

The objective of this study was to investigate the associations between recall of exposure to e-cigarette advertisements and initial use of e-cigarettes, conventional cigarettes and hookahs one year later among German adolescents.

METHODS

Longitudinal school-based survey with a sample of 4,529 German adolescents (mean age = 12.5 years, SD = 1.55). Baseline assessment took place in the fall/winter 2016/2017, and a follow-up assessment 12 months later. Exposure to e-cigarette advertisements was measured at baseline with self-rated contact frequency to three advertising images. Multilevel mixed-effect logistic regression models were used to assess associations between exposure to e-cigarette advertisements at baseline and adolescents' initiation of e-cigarette, smoking and hookah use one year later.

RESULTS

About 14% (N = 472) baseline never-users initiated e-cigarette use within one year, about 11% (N = 384) initiated cigarette use, and 12% (N = 406) used a hookah for the first time within the observation period. After statistical control for age, gender, school type, subjective socioeconomic status, sensation seeking, lifetime smoking behavior and peer substance use, adolescents with higher contact to e-cigarette advertisements had higher proportion of subsequent e-cigarette (aOR = 1.37 (CI = 1.04-1.81) p = .024), cigarette (aOR = 1.44 (CI = 1.09-1.91) p = .010), and hookah use (aOR = 1.82 (CI = 1.37-2.42) p < .001).

CONCLUSIONS

This longitudinal study demonstrates that exposure to e-cigarette advertisements may increase the likelihood of initial use of e-cigarettes, cigarettes, and hookahs. Findings raise concerns about e-cigarette marketing regulations in Germany, and about the broader impact of e-cigarette advertising on traditional smoking.

Association of energy drink consumption with substance-use initiation among adolescents: A 12-month longitudinal study

BACKGROUND

Aggressive marketing has resulted in exponential growth of energy drink sales in recent years. Despite growing concerns about the negative health effects of energy drinks, they are increasingly popular among young people. Little is known about temporal associations between energy drink consumption and other drug use, though some researchers have suggested that energy drink consumption reflects an entry into a drug-using lifestyle.

AIMS

The purpose of this study was to evaluate whether energy drink use among adolescents who have never tried substances is associated with a risk of initiating tobacco (i.e. cigarettes, e-cigarettes, and hookah) and alcohol use.

METHODS

A school-based longitudinal study of 3071 adolescents ages 9-17 years was conducted in six federal states of Germany. Data analyses involved two assessment waves that took place approximately 12 months apart: baseline (fall-winter of school year 2016-2017), and 12-month follow-up (fall-winter of school year 2017-2018).

RESULTS

Multilevel models revealed that energy drink use at baseline was associated with cigarette (odds ratio for energy drink ever use, 3.15 (95% confidence interval, 2.07-4.78 )), e-cigarette (odds ratio, 4.32 (95% confidence interval, 2.87-6.51)), hookah smoking (odds ratio, 3.15 (95% confidence interval, 2.06-4.82)), and alcohol use (odds ratio, 2.26 (95% confidence interval, 1.75-2.93)) initiation within 12 months.

CONCLUSIONS

These results raise the possibility that energy drinks may potentially act as a gateway drug to other substances. However, inferences regarding whether this association is or is not causal cannot yet be made.

Risk factors associated with subsequent initiation of cigarettes and e-cigarettes in adolescence: A structural equation modeling approach

BACKGROUND

Previous youth tobacco research has identified multiple correlated risk factors for initiation of cigarette and e-cigarette use; whether these factors are independently associated with initiation is not known, due to challenges with disentangling the independent effects of these correlated risk factors.

METHODS

Students in 11th/12th grade enrolled in the Southern California Children's Health Study were surveyed in 2014 (baseline) and again in 2015 (N = 1553). Structural equation models (SEM) were developed to investigate associations of susceptibility, marketing, and the social environment (as latent factors), and other tobacco use at baseline with cigarette or e-cigarette initiation between baseline and follow-up. Analyses were restricted to baseline never cigarette users (N = 1293) for models evaluating cigarette initiation, and to never e-cigarette users (N = 1197) for models evaluating e-cigarette initiation.

RESULTS

In fully-adjusted prospective SEM models, latent factors for cigarette susceptibility, marketing, and the social environment, along with ever e-cigarette use and ever hookah use at baseline were independently associated with cigarette initiation between baseline and follow-up (P < 0.05). Similarly, latent factors for e-cigarette susceptibility, marketing, and the social environment, along with ever hookah use at baseline were associated with e-cigarette initiation between baseline and follow-up (P < 0.05); however, cigarette use at baseline was not associated with e-cigarette initiation in SEM models (P = 0.16).

CONCLUSIONS

We identified independent effects of multiple risk factors in SEM models on initiation of cigarettes and e-cigarettes. E-cigarette use was associated with cigarette initiation, but cigarette use was not associated with e-cigarette initiation in fully adjusted models. Research to identify underlying causal mechanisms is warranted.

The influence and interaction of exposure to pro-smoking and anti-smoking messaging on youth smoking behaviour and susceptibility

INTRODUCTION

Exposure to tobacco-related information is an important factor in youth smoking initiation. This study aims to explore the relationship between exposure to pro-smoking and anti-smoking media and adolescents’ current smoking status and susceptibility to smoking, as well as the interaction between exposure to pro-smoking and anti-smoking media information.

METHODS

This cross-sectional study was conducted in 2017. We recruited 12278 students from junior, senior and vocational high schools located in Shanghai, China. The exposure of participants to tobacco promotional and control messages over the past 30 days was examined, as well as current smoking and susceptibility to never smokers’ initiation. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using complex samples procedure logistic regression, adjusting for related covariables.

RESULTS

There were 89.3% and 91.5% of adolescents exposed to tobacco pro-smoking and anti-smoking messages. Exposure was more prevalent among males, suburb school and vocational school students. Exposure to pro-tobacco and antitobacco messages, separately, increased and decreased the risk of current smoking and susceptibility to never-smokers’ smoking, respectively, especially among males and junior high school students. Risk was associated with the exposure level (p-trend<0.001). Tobacco control messaging was found to mitigate the influences of tobacco promotion on the risk of both current smoking (AOR=0.64; 95% CI: 0.41–0.99) and susceptibility to smoking (AOR=0.65; 95% CI: 0.46–0.93).

CONCLUSIONS

Exposure to tobacco-related messages was highly prevalent and associated with youth smoking and susceptibility to smoking. It is therefore important to enhance the comprehensiveness and enforcement of promotion bans. Given that tobacco control information can counter the impact of tobacco promotion information on smoking risk, the publicity and dissemination of tobacco control information should be consistently strengthened.

Convenience store visitors recall cigarette advertisements even if they do not purchase cigarettes

Background

This study examined the extent to which visitors to convenience stores remember the cigarette advertisements they encounter in these stores and investigated the relationships between how advertisements are recalled and attitudes toward them.

Methods

Exit surveys of 1007 visitors to three convenience stores located in Seoul, Korea, were conducted between 25 November 2015 and 7 December 2015.

Results

Of the respondents, 23.4% (n = 236) freely recalled the cigarette advertisement in the store just visited. However, the percentage of participants who correctly recalled the advertisement increased to 55.2% (n = 556) after we presented them with a card showing options for the advertisement (i.e. a cued recall task). Regardless of sex or purchasing cigarettes, free recall performance was significantly associated with age, number of weekly visits to the convenience store and current smoking status. In addition, free recall increased with having a positive attitude toward cigarette advertisements.

Conclusions

Repeated visits to convenience stores may continue to expose individuals to cigarettes and their advertisements; such exposure may subconsciously affect recall of the advertisements and maintenance of a positive attitude toward cigarette advertisements. Therefore, to denormalize smoking in society, cigarette advertising and displays at points of sale including convenience stores, should be banned.

Retail outlets prompt associative memories linked to the repeated use of nicotine and tobacco products among alternative high school students in California

Numerous studies have examined how youth are influenced by the presence of tobacco retail outlets that use point-of-sale marketing tactics to promote nicotine and tobacco products. The current investigation extends this research by assessing whether tobacco retail outlets function as environmental cues that prompt associative memories linked to the repeated use of cigarettes, electronic cigarettes, and cigars. Students (N = 1060) from 29 alternative high schools in California were recruited into a three-year cohort study. A repeated measures latent profile analysis was conducted to identify latent subgroups of students. Analyses suggested the presence of one subgroup of students that did not use nicotine and tobacco products and five subgroups of students that used multiple products. A multinomial logistic regression revealed that images of gas stations, convenience stores, and liquor stores presented in the first year of the study prompted spontaneous associations in memory that increased the odds a student would belong to one of the five subgroups that repeatedly used nicotine and tobacco products over a three-year period. These findings suggest that tobacco retail outlets may act as environmental cues that prompt the use of addictive products among at-risk youth. Policymakers should consider implementing strategies that reduce the potency and prevalence of these cues.

Electronic cigarette marketing and smoking behaviour in adolescence: a cross-sectional study

The aim of this study was to investigate the association between exposure to electronic cigarette (e-cigarette) advertisements and use of e-cigarettes, combustible cigarettes and hookahs. A cross-sectional survey of 6902 German students (mean age 13.1 years, 51.3% male) recruited in six German states was performed. Exposure to e-cigarette advertisements was measured with self-rated contact frequency to three advertising images. Multilevel mixed-effect logistic regression models were used to assess associations between exposure to e-cigarette advertisement and use of e-cigarettes, combustible cigarettes and hookahs (ever and past 30 days). Overall, 38.8% of the students were exposed to e-cigarette advertisements; ever-use of e-cigarettes was 21.7%, of combustible cigarettes was 21.8% and of hookahs was 23.2%, and poly-use of all three products was 12.4%. Exposure to e-cigarette advertisements was positively related to ever and past 30-day use of e-cigarettes, combustible cigarettes, hookahs and combined use. We concluded that a considerable number of German teenagers are exposed to e-cigarette advertisement. There was a clear exposure-behaviour link, indicating that advertising contact was associated with different kinds of "vaping" and also smoking behaviour. Although causal interpretation is not possible due to the cross-sectional design, findings raise concerns about the current tobacco control policies.

Attitudes toward Tobacco, Alcohol, and Non-Alcoholic Beverage Advertisement Themes among Adolescent Boys

BACKGROUND

Previous studies have examined what adolescents find appealing in tobacco and alcohol advertisements and how different themes in advertisements are used to manipulate consumer behaviors. Yet, we know little about the relationship between the themes portrayed in advertisements and youth attitudes towards those themes.

OBJECTIVES

This study compared attitudes towards advertisements for different consumer products in a sample of urban and rural adolescent boys in order to examine how key marketing themes impact adolescent attitudes towards those advertisements.

METHODS

Participants were 11- to 16-year-old boys (N = 1220) residing in either urban or rural Ohio Appalachian counties. Each participant viewed five print advertisements (one each for cigarettes, electronic cigarettes (e-cigarettes), smokeless tobacco (SLT), non-alcoholic beverages, and alcohol), presented in a random order, for eight seconds each. All advertisements had appeared in magazines that adolescent males commonly read. Attitudes towards each of the five advertisements were assessed. The advertisements were then coded for the presence of various themes, including social acceptance and masculinity. Analyses were conducted to determine associations between advertisement type and the attitude measure, and between the presence of a theme and the attitude measure.

RESULTS

Overall, participants preferred non-tobacco advertisements to tobacco advertisements, rural participants had less positive attitudes and participants who had peers who used tobacco had more positive attitudes. Social acceptance and entertainment themes increased the appeal of SLT advertisements, and sex appeal increased the appeal of e-cigarette advertisements. Conclusions/Importance: Findings suggest that advertisements that promote the social nature of use in SLT advertisements may be of particular concern for their influence on adolescent boys.

Trends in smoking initiation in Europe over 40 years: A retrospective cohort study

Background

Tobacco consumption is the largest avoidable health risk. Understanding changes of smoking over time and across populations is crucial to implementing health policies. We evaluated trends in smoking initiation between 1970 and 2009 in random samples of European populations.

Methods

We pooled data from six multicentre studies involved in the Ageing Lungs in European Cohorts consortium, including overall 119,104 subjects from 17 countries (range of median ages across studies: 33–52 years). We estimated retrospectively trends in the rates of smoking initiation (uptake of regular smoking) by age group, and tested birth cohort effects using Age-Period-Cohort (APC) modelling. We stratified all analyses by sex and region (North, East, South, West Europe).

Results

Smoking initiation during late adolescence (16–20 years) declined for both sexes and in all regions (except for South Europe, where decline levelled off after 1990). By the late 2000s, rates of initiation during late adolescence were still high (40–80 per 1000/year) in East, South, and West Europe compared to North Europe (20 per 1000/year). Smoking initiation rates during early adolescence (11–15 years) showed a marked increase after 1990 in all regions (except for North European males) but especially in West Europe, where they reached 40 per 1000/year around 2005. APC models supported birth cohort effects in the youngest cohorts.

Conclusion

Smoking initiation is still unacceptably high among European adolescents, and increasing rates among those aged 15 or less deserve attention. Reducing initiation in adolescents is fundamental, since youngsters are particularly vulnerable to nicotine addiction and tobacco adverse effects.

A fMRI study on the impact of advertising for flavored e-cigarettes on susceptible young adults

BACKGROUND

E-cigarettes are sold in flavors such as "skittles," "strawberrylicious," and "juicy fruit," and no restrictions are in place on marketing e-cigarettes to youth. Sweets/fruits depicted in e-cigarette advertisements may increase their appeal to youth and interfere with health warnings. This study tested a brain biomarker of product preference for sweet/fruit versus tobacco flavor e-cigarettes, and whether advertising for flavors interfered with warning labels.

METHODS

Participants (N = 26) were college-age young adults who had tried an e-cigarette and were susceptible to future e-cigarette use. They viewed advertisements in fMRI for sweet/fruit and tobacco flavor e-cigarettes, menthol and regular cigarettes, and control images of sweets/fruits/mints with no tobacco product. Cue-reactivity was measured in the nucleus accumbens, a brain biomarker of product preference. Advertisements randomly contained warning labels, and recognition of health warnings was tested post-scan. Visual attention was measured using eye-tracking.

RESULTS

There was a significant effect of e-cigarette condition (sweet/tobacco/control) on nucleus accumbens activity, that was not found for cigarette condition (menthol/regular/control). Nucleus accumbens activity was greater for sweet/fruit versus tobacco flavor e-cigarette advertisements and did not differ compared with control images of sweets and fruits. Greater nucleus accumbens activity was correlated with poorer memory for health warnings.

CONCLUSIONS

These and exploratory eye-tracking findings suggest that advertising for sweet/fruit flavors may increase positive associations with e-cigarettes and/or override negative associations with tobacco, and interfere with health warnings, suggesting that one way to reduce the appeal of e-cigarettes to youth and educate youth about e-cigarette health risks is to regulate advertising for flavors.

Online Tobacco Marketing and Subsequent Tobacco Use

BACKGROUND

Nearly 2.9 million US adolescents engaged with online tobacco marketing in 2013 to 2014. We assess whether engagement is a risk factor for tobacco use initiation, increased frequency of use, progression to poly-product use, and cessation.

METHODS

We analyzed data from 11 996 adolescents sampled in the nationally representative, longitudinal Population Assessment for Tobacco and Health study. At baseline (2013-2014), we ascertained respondents' engagement with online tobacco marketing. At follow-up (2014-2015), we determined if respondents had initiated tobacco use, increased frequency of use, progressed to poly-product use, or quit. Accounting for known risk factors, we fit a multivariable logistic regression model among never-users who engaged at baseline to predict initiation at follow-up. We fit similar models to predict increased frequency of use, progression to poly-product use, and cessation.

RESULTS

Compared with adolescents who did not engage, those who engaged reported higher incidences of initiation (19.5% vs 11.9%), increased frequency of use (10.3% vs 4.4%), and progression to poly-product use (5.8% vs 2.4%), and lower incidence of cessation at follow-up (16.1% vs 21.5%). Accounting for other risk factors, engagement was positively associated with initiation (adjusted odds ratio [aOR] = 1.26; 95% confidence interval [CI]: 1.01-1.57), increased frequency of use (aOR = 1.58; 95% CI: 1.24-2.00), progression to poly-product use (aOR = 1.70; 95% CI: 1.20-2.43), and negatively associated with cessation (aOR = 0.71; 95% CI: 0.50-1.00).

CONCLUSIONS

Engagement with online tobacco marketing represents a risk factor for adolescent tobacco use. FDA marketing regulation and cooperation of social-networking sites could limit engagement.

Exposure to Advertisements and Marijuana Use Among US Adolescents

Introduction

This study examined whether exposure to marijuana advertisements was associated with current marijuana use and frequency of use among US adolescents in grades 8, 10, and 12.

Methods

Weighted estimates of exposure to marijuana advertisements and marijuana use from the 2014 and 2015 Monitoring the Future studies were investigated. Factors associated with the prevalence and frequency of marijuana use were analyzed by using logistic regression and linear regression models, respectively.

Results

Of all respondents (n = 12,988), 13.8% reported marijuana use in the past 30 days. Exposure to marijuana advertisements was prevalent among adolescents, with 52.8% reporting exposure from internet advertisements, 32.1% from television advertisements, 24.1% from magazine or newspaper advertisements, 19.7% from radio advertisements, 19.0% from advertisements on storefronts, and 16.6% from billboards. In the multivariable analysis, current use of marijuana among adolescents was associated with exposure to marijuana advertisements on storefronts (adjusted odds ratio [OR] = 1.4, P < .001), magazines or newspapers (adjusted OR = 1.6, P < .001), billboards (adjusted OR = 1.4, P = .002), internet (adjusted OR = 1.8, P < .001), television (adjusted OR = 1.4, P < .001) and radio (adjusted OR = 1.7, P < .001). Exposure to marijuana advertisements from the internet was associated with increased use of marijuana (β = 0.3, P = .04).

Conclusion

Exposure to marijuana advertisements was associated with higher odds of current marijuana use among adolescents. Regulations that limit marijuana advertisements to adolescents and educational campaigns on harmfulness of illicit marijuana use are needed.

"It Feels More Real": An Interpretive Phenomenological Study of the Meaning of Video Games in Adolescent Lives

The pervasiveness of video gaming among adolescents today suggests a need to understand how gaming affects identity formation. We interviewed 20 adolescents about their experiences of playing, asking them to describe how they used games and how game playing affected their real-world selves. Adolescents presented a complicated developmental picture: gaming placed players into virtual worlds that felt "real"; games were used to practice multiple identities; and gaming, often undertaken within a world of hyperviolence, provided stress relief, feelings of competence, and relaxation. Gaming occurred in complex "virtual" but "real" social arenas where adolescents gathered to interact, emulate, and develop identities.

The relationships between sensation seeking and a spectrum of e-cigarette use behaviors: Cross-sectional and longitudinal analyses specific to Texas adolescents

INTRODUCTION

Sensation seeking is strongly associated with cigarette use in adolescents. However, few studies have investigated its relationship with adolescent e-cigarette use. This study examined cross-sectional and longitudinal associations between sensation seeking and a variety of e-cigarette use behaviors among Texas adolescents.

METHODS

This study utilized two waves of data collected 6months apart through the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS) in 2014-2015 (n=2,488/N=461,069). TATAMS employs a complex probability-sampling design and is representative of students in 6th, 8th and 10th grades from five counties surrounding the four largest cities in Texas (Houston, Dallas/Ft. Worth, San Antonio, Austin). Weighted multivariable logistic regression was used to examine the cross-sectional and longitudinal associations between sensation seeking and susceptibility to e-cigarette use, ever e-cigarette use, and current (past 30day) e-cigarette use.

RESULTS

In the cross-sectional analyses, higher mean sensation seeking scores were associated with higher odds of both susceptibility to e-cigarette use and ever e-cigarette use (AOR=1.25, 95% CI=1.07, 1.47; AOR=1.24, 95% CI=1.08, 1.43, respectively). For the longitudinal analyses, only the association between higher mean sensation seeking scores and transition to ever e-cigarette use remained statistically significant (AOR=1.45, 95% CI=1.01, 2.08). There were no significant associations between sensation seeking and current e-cigarette use in either the cross-sectional or longitudinal analyses.

CONCLUSIONS

Higher sensation seeking scores were consistently and significantly related to experimentation with e-cigarette use among Texas adolescents. Future interventions (e.g., communication campaigns) should target high sensation seeking adolescents to reduce initiation of e-cigarette use among this population.

Comparison of Measures of E-cigarette Advertising Exposure and Receptivity

OBJECTIVES

We tested how various measures of e-cigarette advertising exposure and receptivity are related to each other and compare to each other in their associations with e-cigarette use susceptibility and behavior.

METHODS

Cross-sectional data were collected from young adult college students (N = 470; Mage = 20.9, SD = 2.1; 65% women). Measures of e-cigarette advertising exposure/receptivity compared included a cued recall measure, measures of marketing receptivity, perceived ad exposure, liking of e-cigarette ads, and frequency of convenience store visit, which is considered a measure of point-of-sale ad exposure.

RESULTS

The cued-recall measure was associated with e-cigarette use experimentation but not current e-cigarette use. Marketing receptivity was associated with current e-cigarette use but not e-cigarette use experimentation. Liking of e-cigarette ads was the only measure associated with e-cigarette use susceptibility. Frequency of convenience store visit was associated with current e-cigarette use but not e-cigarette use experimentation or susceptibility.

CONCLUSION

Inclusion of multiple measures of marketing exposure and receptivity is recommended for regulatory research concerning e-cigarette marketing. Marketing receptivity and cued recall measures are strong correlates of current and ever e-cigarette use, respectively.

The German East-West Mortality Difference: Two Crossovers Driven by Smoking

Before the fall of the Berlin Wall, mortality was considerably higher in the former East Germany than in West Germany. The gap narrowed rapidly after German reunification. The convergence was particularly strong for women, to the point that Eastern women aged 50-69 now have lower mortality despite lower incomes and worse overall living conditions. Prior research has shown that lower smoking rates among East German female cohorts born in the 1940s and 1950s were a major contributor to this crossover. However, after 1990, smoking behavior changed dramatically, with higher smoking intensity observed among women in the eastern part of Germany. We forecast the impact of this changing smoking behavior on East-West mortality differences and find that the higher smoking rates among younger East German cohorts will reverse their contemporary mortality advantage. Mortality forecasting methods that do not account for smoking would, perhaps misleadingly, forecast a growing mortality advantage for East German women. Experience from other countries shows that smoking can be effectively reduced by strict anti-smoking policies. Instead, East Germany is becoming an example warning of the consequences of weakening anti-smoking policies and changing behavioral norms.

Up in Vapor: Exploring the Health Messages of E-Cigarette Advertisements

Electronic cigarettes (e-cigarettes) have gained popularity in the United States, and marketers are using advertising to recruit new users to their products. Despite outright bans on traditional cigarette advertisements, e-cigarettes have no specific regulations. This study uses framing theory to explore the themes in e-cigarette advertisements. Also, practical implications are discussed.

Awareness about the effects of tobacco consumption on oral health and the possibility of smoking behavior among male Saudi schoolchildren

OBJECTIVE

To investigate an association between the awareness about the effects of tobacco consumption on oral health and the likelihood of smoking among male schoolchildren.

MATERIALS AND METHODS

A cross sectional study was conducted using a multistage random sampling technique. The participants (ages 15-19 years) were recruited from male public high schools in Greater Dammam in Saudi Arabia. A pretested questionnaire inquired participants' awareness about the effects of smoking on oral health. SPSS (Released 2013, IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) was used to calculate unadjusted and adjusted odds ratio (OR) and 95% confidence interval (CI). Multiple logistic regression and interaction analyses were performed to identify the factors associated with the probability of smoking behavior among children.

RESULTS

More than 69.9% (n = 277) of participants were aware of the adverse effects of tobacco consumption on oral health which included poor oral health, bad taste and breath, periodontal disease, dental caries, oral ulcers, and oral cancers. The odds of smoking were 22%-47% lower among schoolchildren who were aware of the consequences of smoking on oral health than those who were unaware of these complications. The students who believed that smoking can cause oral ulcers and negatively affects oral health had a lower probability of smoking (OR: 0.414; CI: 0.201-0.50) and (OR: 0.433; CI: 0.194-0.965), respectively in comparison with those who thought that smoking had no such negative impacts.

CONCLUSIONS

Schoolchildren with increased awareness of smoking effects on oral health were less likely to smoke. Educating students about the complications of smoking on oral health should be the part of smoking cessation programs and policies.

Tobacco Marketing Receptivity and Other Tobacco Product Use Among Young Adult Bar Patrons

PURPOSE

Use of other tobacco products (smokeless tobacco, hookah, cigarillo, and e-cigarettes) is increasing, particularly among young adults, and there are few regulations on marketing for these products. We examined the associations between tobacco marketing receptivity and other tobacco product (OTP) use among young adult bar patrons (aged 18-26 years).

METHODS

Time-location sampling was used to collect cross-sectional surveys from 7,540 young adult bar patrons from January 2012 through March of 2014. Multivariable logistic regression analyses in 2015 examined if tobacco marketing receptivity was associated (1) with current (past 30 day) OTP use controlling for demographic factors and (2) with dual/poly use among current cigarette smokers (n = 3,045), controlling for demographics and nicotine dependence.

RESULTS

Among the entire sample of young adult bar patrons (Mean_age = 23.7, standard deviation = 1.8; 48.1% female), marketing receptivity was consistently associated with current use of all OTP including smokeless tobacco (adjusted odds ratio [AOR]= 2.56, 95% confidence interval [CI] 2.08-3.16, p < .001), hookah (AOR = 1.97, 95% CI 1.58-2.43, p < .001), cigarillos (AOR = 3.00, 95% CI 2.21-4.08, p < .001), electronic cigarettes (AOR = 2.43, 95% CI 1.93-3.04, p < .001), and multiple tobacco products (AOR = 2.93, 95% CI 2.45-3.51, p < .001). Among current smokers, marketing receptivity was significantly associated with use of smokeless tobacco (AOR = 1.63, 95% CI 1.22-2.18, p < .01), cigarillos (AOR = 1.81, 95% CI 1.22-2.70, p < .01), and multiple tobacco products (AOR = 1.58, 95% CI 1.27-1.97, p < .001).

CONCLUSIONS

OTP use is common among young adult bar patrons, and it is associated with tobacco marketing receptivity. Efforts to limit tobacco marketing should address OTP in addition to cigarettes.

Exposure to Advertisements and Susceptibility to Electronic Cigarette Use Among Youth

PURPOSE

Despite the rapid increase in e-cigarette use among youth, little is known about the social and behavioral factors that have contributed to this rise. We investigated whether young e-cigarette users are susceptible to e-cigarette advertisements.

METHODS

Estimates of e-cigarette use and exposure to e-cigarette advertisements from the 2014 National Young Tobacco Survey were investigated. Factors associated with the prevalence and levels of e-cigarette use were analyzed using multinomial logistic regression.

RESULTS

Of all respondents (n = 21,491), 19.8% had tried e-cigarettes and 9.4% were current e-cigarette users. Exposure to e-cigarette ads was prevalent among youth, with 38.6%/29.6%/53.2%/35.4% having medium to high exposure to e-cigarette ads from the Internet/newspapers/stores/TV, respectively. Current use of e-cigarettes among youth was associated with frequent exposure (high vs. low) to e-cigarette advertising from the Internet (odd ratio [OR] = 3.1, p < .0001), newspapers/magazines (OR = 2.5, p < .0001), stores (OR = 2.8, p < .0001), and TV/movies (OR = 2.1, p < .0001). In the multivariate analysis that joint analyzed four advertisement channels and covariates, greater exposure to e-cigarette ads on the Internet (adjusted OR = 1.9, p < .0001) and in retail stores (adjusted OR = 1.9, p < .0001) remained to be significantly associated with increased odds of using e-cigarettes. Vaping by other household members significantly increased the risk of adolescent e-cigarette use (OR = 8.7, p < .0001).

CONCLUSIONS

Exposure to e-cigarette ads significantly increased susceptibility to e-cigarette use among adolescents. E-cigarette advertising regulations and educational campaigns are critically needed.

Predictors of the Onset of Cigarette Smoking: A Systematic Review of Longitudinal Population-Based Studies in Youth

CONTEXT

The onset of cigarette smoking typically occurs during childhood or early adolescence. Nicotine dependence symptoms can manifest soon after onset, contributing to sustained, long-term smoking. Previous reviews have not clarified the determinants of onset.

EVIDENCE ACQUISITION

In 2015, a systematic review of the literature in PubMed and EMBASE was undertaken to identify peer-reviewed prospective longitudinal studies published between January 1984 and August 2015 that investigated predictors of cigarette smoking onset among youth aged <18 years who had never smoked.

EVIDENCE SYNTHESIS

Ninety-eight conceptually different potential predictors were identified in 53 studies. An increased risk of smoking onset was consistently (i.e., in four or more studies) associated with increased age/grade, lower SES, poor academic performance, sensation seeking or rebelliousness, intention to smoke in the future, receptivity to tobacco promotion efforts, susceptibility to smoking, family members' smoking, having friends who smoke, and exposure to films, whereas higher self-esteem and high parental monitoring/supervision of the child appeared to protect against smoking onset. Methodologic weaknesses were identified in numerous studies, including failure to account for attrition or for clustering in samples, and misidentification of potential confounders, which may have led to biased estimates of associations.

CONCLUSIONS

Predictors of smoking onset for which there is robust evidence should be considered in the design of interventions to prevent first puff in order to optimize their effectiveness. Future research should seek to define onset clearly as the transition from never use to first use (e.g., first few puffs).

How do Indonesian youth perceive cigarette advertising? A cross-sectional study among Indonesian high school students

Background

Previous studies have reported an association between cigarette advertising and smoking behavior. Although this has been reported extensively in the West, it has been reported less in Southeast Asian countries that have not completely banned tobacco advertising promotion and sponsorship (TAPS). Indonesia is the only ASEAN country that has not ratified the Framework Convention on Tobacco Control, so TAPS regulation is limited. This study aimed to assess the association between youths’ perceptions of cigarette ads and smoking initiation.

Design

We conducted a cross-sectional survey among 2,115 high school students aged 13–18 years in Yogyakarta, Indonesia. A self-administered questionnaire was distributed to gauge the perception of cigarette ads and initiation to smoking. We calculated the odds ratio (OR) between the perception of cigarette ads and smoking initiation, adjusting for sociodemographic and psychosocial variables. The sociodemographic variables included in the final model were age and sex.

Results

The final multivariate model showed an association between perception of tobacco ads encouraging youths to smoke and smoking initiation (OR 2.70) and current smoking (OR 7.63). Attitude toward TAPS was associated with smoking initiation (OR 1.51) and current smoking (OR 3.32). Exposure to cigarette ads had an association with smoking initiation only (OR 1.27) and did not have an association with current smoking. Having friends and family who smoked was associated with smoking initiation and current smoking in the final multivariate model. Smoking initiation and current smoking were also related to the susceptibility to smoke.

Conclusions

This study revealed that cigarette ads were perceived as encouraging youths to smoke and that smoking status was consistently associated with perception of cigarette ads targeted at youths, attitude toward TAPS, and susceptibility as well as smoking friends and family. Regulations to ban TAPS, particularly cigarette ads for preventing youths from smoking, should be adopted rapidly in Indonesia, where tobacco control remains limited.

Why Bariatric surgery should be given high priority: an argument from law and morality

In recent years, bariatric surgery has become an increasingly popular treatment of obesity. The amount of resources spent on this kind of surgery has led to a heated debate among health care professionals and the general public, as each procedure costs at minimum $14,500 and thousands of patients undergo surgery every year. So far, no substantial argument for or against giving this treatment a high priority has, however, been presented. In this article, I argue that regardless which moral perspective we consider--greatest need, utility or personal responsibility--the conclusion is that we should give bariatric surgery a high priority when allocating scarce resources in health care.

Point-of-sale tobacco promotion and youth smoking: a meta-analysis

INTRODUCTION

Previous systematic reviews have found consistent evidence of a positive association between exposure to point-of-sale (POS) tobacco promotion and increased smoking and smoking susceptibility among children and adolescents. No meta-analysis has been conducted on these studies to date.

METHODS

Systematic literature searches were carried out to identify all quantitative observational studies that examined the relationship between POS tobacco promotion and individual-level smoking and smoking-related cognitions among children and adolescents, published between January 1990 and June 2014. Random-effects meta-analyses were used. Subgroup analyses were conducted according to extent of tobacco POS advertising environment in the study environment. Sensitivity analyses were performed according to study size and quality.

RESULTS

13 studies met the inclusion criteria; 11 reported data for behavioural outcomes, 6 for cognitive outcomes (each of these assessed smoking susceptibility). The studies were cross-sectional, with the exception of 2 cohort studies. For the behavioural outcomes, the pooled OR was 1.61 (95% CI 1.33 to 1.96) and for smoking susceptibility the pooled OR was 1.32 (95% CI 1.09 to 1.61).

CONCLUSIONS

Children and adolescents more frequently exposed to POS tobacco promotion have around 1.6 times higher odds of having tried smoking and around 1.3 times higher odds of being susceptible to future smoking, compared with those less frequently exposed. Together with the available evaluations of POS display bans, the results strongly indicate that legislation banning tobacco POS promotion will effectively reduce smoking among young people.

'Klar bleiben': a school-based alcohol prevention programme for German adolescents-study protocol for a cluster randomised controlled trial

INTRODUCTION

There is a noticeable increase in hazardous alcohol use during adolescence, which is significantly associated with adverse consequences. In Germany, up to 30% of adolescents report regular heavy episodic drinking. However, only a few German prevention programmes target adolescents of legal drinking age (16 years and above); thus, this trial aims to develop, implement and evaluate 'Klar bleiben' ('Stay clearheaded'), a school-based prevention programme for grade 10 students.

METHODS AND ANALYSIS

'Klar bleiben' consists of a class commitment to drink responsibly and refrain from hazardous consumption patterns for 9 weeks. The commitment is accompanied by educational lessons on alcohol-related cognitions and consequences. It will be evaluated in a sample of approximately 3000 students (150 classes) from two German federal states (Schleswig-Holstein and Lower Saxony) via a two-armed cluster randomised controlled trial with baseline and postassessment 6 months apart. The intervention group (75 classes) will participate in 'Klar bleiben', whereas the control group (75 classes) will receive education as usual. 'Klar bleiben' addresses classes, individuals, teachers and parents. It is based on a social norms approach and aims to reduce hazardous drinking and drinking-related consequences in adolescents. Secondary outcomes include general drinking behaviour, use of other substances, alcohol-related cognitions and social factors. Covariates include sociodemographic characteristics, environmental and individual (vulnerability) factors.

ETHICS AND DISSEMINATION

'Klar bleiben' provides a multicomponent school-based programme that bridges a gap in alcohol prevention. Similar class-level and social norms-based prevention programmes have already been proven to be successful for other substances among adolescents. Thus, dissemination to other federal states as well as longer term follow-up testing of the robustness of effects is to be anticipated. The study was approved by the Ethics Committee of the German Psychological Society (RH_0620152), and study findings will be disseminated through peer-reviewed publications and conference contributions.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register: DRKS00009424.

Exposure to pro-tobacco messages and smoking status among Mexican origin youth

Though several studies have found a positive relationship between exposure to tobacco advertising and/or promotional marketing and smoking status among youth, few have examined these relationships specifically for youth of Mexican origin. The current analysis examines the relationship between perceived exposure to pro-tobacco messages and progression through the smoking continuum from trying to repeated use in a cohort of Mexican origin youth ages 14-19. Data were collected via personal in-home interviews at two time points-in 2008-2009 and 2010-2011 (N = 942). Smoking status, exposure to pro-tobacco messages from five major media sources, demographic variables and established risk factors for adolescent smoking were measured at both waves. Data were analyzed using Pearson's Chi square tests, ANOVA, and multinomial logistic regression. Adolescent perception of the number of pro-tobacco messages seen in 2008-2009 was unrelated to smoking less than one cigarette assessed in 2010-2011. However, having seen a higher number of pro-tobacco messages was significantly associated with being more likely to have smoked more than one cigarette (OR = 1.21; 95% CI 1.03-1.42) controlling for demographic factors and known psychosocial risk factors of smoking behavior. Results suggest that the more pro-tobacco messages Mexican origin youth are able to recall, the further their progression through the smoking trajectory a year later. These youth are clearly susceptible to pro-tobacco messaging, and our results underscore the need to restrict all forms of messaging that promote tobacco use.

Content Analysis of Trends in Print Magazine Tobacco Advertisements

OBJECTIVES

To provide a descriptive and comparative content analysis of tobacco print magazine ads, with a focus on rhetorical and persuasive themes.

METHODS

Print tobacco ads for cigarettes, cigars, e-cigarettes, moist snuff, and snus (N = 171) were content analyzed for the physical composition/ad format (e.g., size of ad, image, setting, branding, warning label) and the content of the ad (e.g., rhetorical themes, persuasive themes).

RESULTS

The theme of pathos (that elicits an emotional response) was most frequently utilized for cigarette (61%), cigar (50%), and moist snuff (50%) ads, and the theme of logos (use of logic or facts to support position) was most frequently used for e-cigarette (85%) ads. Additionally, comparative claims were most frequently used for snus (e.g., "spit-free," "smoke-free") and e-cigarette ads (e.g., "no tobacco smoke, only vapor," "no odor, no ash"). Comparative claims were also used in cigarette ads, primarily to highlight availability in different flavors (e.g., "bold," "menthol").

CONCLUSIONS

This study has implications for tobacco product marketing regulation, particularly around limiting tobacco advertising in publications with a large youth readership and prohibiting false or misleading labels, labeling, and advertising for tobacco products, such as modified risk (unless approved by the FDA) or therapeutic claims.