Harm Perceptions of Alternative Tobacco Products among US Adolescents

Initial experimentation with tobacco is associated with subsequent tobacco use patterns among youth in the United States

Understanding the association between initial experimentation with a tobacco product and subsequent patterns of tobacco use among youth is important to informing prevention activities for youth in the US. We conducted an online survey from August to October 2017 among youth aged 13-18 years. The current analysis focused on respondents reporting initial experimentation with any tobacco product (n = 2,022). Using multinomial logistic regression, we examined the association between first tobacco product tried (cigarettes; cigars including cigarillos, little cigars, and bidis; electronic nicotine delivery systems (ENDS); smokeless and chewing tobacco; or hookah) with subsequent patterns of tobacco use while adjusting for covariates. Of the youth who experimented, 56.8% were non-current tobacco users. Of current tobacco users (n = 934), 13% were exclusive ENDS users, 5.3% exclusive combustible mono-users, 13.4% ENDS plus combustible poly-users, 3.3% combustible product only poly-users, and 8.2% other tobacco poly-users. The most common type of first tobacco product tried was ENDS (44.7%), followed by cigarettes (35.0%) and cigars (8.6%). Those who experimented with combustible tobacco products were less likely to be exclusive ENDS users [Relative Risk Ratio (RRR) = 0.46; 95% CI = 0.28, 0.73 for cigarettes; RRR = 0.32; 95% CI = 0.13, 0.81 for cigars; and RRR = 0.33; 95% CI = 0.14, 0.79 for hookah] when compared to non-current tobacco users (reference group). Tobacco product choices for initial experimentation appear to play a role in subsequent tobacco use patterns among youth. Understanding the reasons behind initial product choice may inform our understanding regarding the reasons for subsequent current tobacco product use, thus informing youth prevention efforts.

Perceptions of Harm and Addictiveness for Nicotine Products, THC e-Cigarettes, and e-Cigarettes with Other Ingredients Among Adolescents, Young Adults, and Adults

BACKGROUND

Perceptions of health harms and addictiveness related to nicotine products, THC e-cigarettes, and e-cigarettes with other ingredients are an important predictor of use. This study examined differences in perceived harm and addiction across such products among adolescents, young adults, and adults.

METHODS

We conducted a cross-sectional survey (N = 6,131, ages 13-40 years old) in which participants reported perceived harm and addictiveness for 11 products (cigarettes, disposable nicotine e-cigarettes, pod-based nicotine e-cigarettes, other nicotine e-cigarettes, THC e-cigarettes, e-cigarettes with other ingredients, nicotine pouches, nicotine lozenges, nicotine gums, nicotine tablets, nicotine toothpicks). We applied adjusted regression models and conducted pairwise comparisons between age groups (13-17, 18-20, 21-25, and 26-40) and product use status (never, ever, and past-30-day use), adjusting for gender, race/ethnicity, sexual orientation, and financial comfort.

RESULTS

Overall, participants in younger age groups perceived products to be more harmful and addictive than those in older age groups, with the exception of e-cigarettes with other ingredients. For all products, participants who never used perceived each product to be more harmful than those who ever used. For all products, participants who used the products in the past 30-days had lower perceived harm and addictiveness compared to never and ever use. Certain sociodemographic groups, such as people who identify as LGBTQ+, Non-Hispanic Black, or Hispanic, had lower perceived harm and addictiveness for most products.

DISCUSSION

Efforts should be made to educate all age groups and minoritized groups on harms and addictiveness of all nicotine products, THC e-cigarettes, and e-cigarettes with other ingredients.

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.

Disparities in E-Cigarette Harm and Addiction Perceptions Among Adolescents in the United States: a Systematic Review of the Literature

BACKGROUND

Health disparities associated with e-cigarette use are increasingly apparent among US adolescents. Perceptions of e-cigarette harm and addiction play an important role in understanding adolescents' e-cigarette use behavior. The objective of this systematic review is to examine racial/ethnic and socio-economic disparities in e-cigarette harm and addiction perceptions among US adolescents.

METHODS

We searched five databases to identify cross-sectional or longitudinal studies that focused on adolescents (≤ 18 years of age) who were ever, current, or never e-cigarettes users; we then examined how race/ethnicity and/or socio-economic status (SES) impacted e-cigarette harm and/or addiction perceptions. Two co-authors independently identified relevant studies, extracted data, and assessed the risk of bias.

RESULTS

Adhering to PRISMA guidelines, eight of 226 identified studies met the inclusion criteria. These eight studies examined either perceptions regarding absolute e-cigarette harm and/or addiction (i.e., assessing perception of only e-cigarette) or relative e-cigarette harm and/or addiction (i.e., comparative perceptions to traditional cigarettes) by race and ethnicity. Two of the eight studies assessed absolute harm and/or addiction perceptions of e-cigarettes by SES. Our results indicate that, compared to all other racial/ethnic groups, relative e-cigarette harm and addiction perceptions were lower among Non-Hispanic White adolescents; however, absolute e-cigarette harm perception was higher among these groups. No clear patterns of racial/ethnic differences in absolute e-cigarette addiction perceptions and SES differences in absolute e-cigarette harm perceptions were reported.

CONCLUSION

More research is needed to explicitly assess perceptions of e-cigarette harm and addiction among US adolescents by race/ethnicity and SES to develop subgroup appropriate public health messaging.

Patterns of use, perceptions, and cardiopulmonary health risks of cigar products: a systematic review

OBJECTIVE

A systematic review was conducted to evaluate the use patterns, health perceptions, and cardiopulmonary health effects of cigars.

DATA SOURCES

PubMed and Google Scholar were searched for peer-reviewed articles published between June 2014 and February 2021. Search keywords included cigars, cigarillos, little cigars, and cardiopulmonary health outcomes.

STUDY SELECTION

Of 782 papers identified, we excluded non-English articles, review articles, commentaries, and those without empirical data on cigars. Three coders independently reviewed all articles and compared codes to resolve discrepancies. 93 articles met the inclusion criteria and were included.

DATA SYNTHESIS

Cigars have evolved from premium cigars to encompass little cigars and cigarillos (LCCs). LCCs are available in an array of flavors and at a price advantage, and as a result, are used by different groups compared to premium cigars. LCCs are more frequently used by youth, young adults, and those who identify as Black/African American. LCCs are often used in combination with other tobacco products, alcohol, and cannabis. Despite limited regulation, cigars generate smoke of a similar composition as cigarettes. Among the studies identified, evidence suggests that cigar use is associated with cardiovascular and pulmonary toxicity. Higher all-cause and cancer-related mortalities are associated with cigar use, particularly with more frequent and deeper inhalation, compared to non-tobacco users.

CONCLUSIONS

LCCs are used more frequently by at-risk groups compared to premium cigars. Recent studies evaluating cigar cardiopulmonary health effects are limited but suggest cigars have similar health risks as conferred by cigarette smoking. With the use of LCCs and targeted marketing on the rise among high-risk groups, there is a critical need for continued research in this area.

Latent class trajectories: U.S. adolescents' nicotine use and its association with nicotine dependence

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Youth’s 30-day nicotine/tobacco use increased across three waves of PATH: 2013–2017.

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Cigarette use associated with greater nicotine/tobacco dependence than e-cigarettes.

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LCA revealed variability in youths’ nicotine/tobacco use & dependence trajectories.

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Findings have relevance for prevention messages with high-risk youth.

Introduction

Twenty-seven percent of adolescents used a nicotine/tobacco product in 2018. Our study analyzed three waves from the Population Assessment of Tobacco and Health (PATH) Study and examined adolescent nicotine/tobacco use trajectories over time to determine which latent classes were associated with symptoms of nicotine dependence.

Methods

The PATH Study used a four-stage, stratified area probability sample and annual household interviews with adolescents (12–17 years). Adolescents who indicated past 30-day nicotine/tobacco use at least once were included (n = 1101). We used latent class analysis (LCA) to identify nicotine/tobacco trajectories across three waves of PATH data and their association with six symptoms consistent with nicotine dependence from the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68).

Results

All types of past 30-day nicotine/tobacco use increased across the three waves. An LCA model fit was assessed using both the CIV and entropy measures in conjunction with the Vuong-Lo-Mendell-Rubin LRT. A five latent class solution had the lowest BIC value (BIC = 9784.272), and resulted in: (1) “Stable/consistent multiproduct use trajectory”, (2) “Increasing cigarette use trajectory”, (3) “Increasing e-cigarette use trajectory”, (4) “Experimental (poly-nicotine/tobacco) use trajectory”, and (5) “Increasing other nicotine/tobacco use trajectory”. The most prevalent was the “Experimental (poly-nicotine/tobacco) use trajectory” (33.8%) although sex, race, and social class were associated with different trajectories. Those represented by the “Increasing cigarette use trajectory” (19.4%) reported significantly more past-year nicotine dependence symptoms (b = 1.73, p < 0.001) compared to the “Increasing e-cigarette use trajectory”. Findings varied by sex and race.

Conclusions

Results indicate that the relationship between e-cigarette use and other forms of nicotine/tobacco and substance use is complex and that adolescent nicotine/tobacco users are a heterogenous group with different risks for nicotine dependence. Findings can inform tailored prevention education and messaging for different groups of youth.

Impact of Graphic Warning Messages on Intentions to Use Alternate Tobacco Products

Graphic cigarette warnings increase quit attempts. Perceived message effectiveness and message avoidance are predictive of later quit attempts. We sought to examine whether randomized exposure to warning messages would inadvertently increase intentions to use alternate tobacco products while enhancing attempts to quit cigarettes. An online survey of 1392 adult smokers in the US asked participants to rate six randomly selected tobacco warnings (from a set of 319) on perceived effectiveness and avoidance intentions. These two indicators of message effectiveness were calculated at the message-level and then at the individual campaign-level to facilitate causal inference. After viewing a message campaign of six warning messages, participants indicated their intentions to use alternate tobacco products. Sixty-eight percent of participants reported some intention to use e-cigarettes and intentions to use other alternate tobacco products ranged from 31% to 40%. Campaigns of messages eliciting higher avoidance increased the odds of intending to use hookah (aOR: 4.32), smokeless tobacco (aOR: 4.88), and snus (aOR: 8.06), but not the intention to use electronic cigarettes. These relationships are mediated by intentions to quit smoking (all p <.05). Viewing campaigns with higher campaign-level perceived effectiveness increased the intentions to quit, which in turn increased intentions to try alternate tobacco products. Our findings increase the tobacco control community's understanding of unintended consequences of graphic tobacco warnings.

Attitudes and Perceptions of Tobacco-Related Products in College Students

BACKGROUND

Despite the highly publicized health consequences, some college students do not perceive tobacco consumption as harmful. Historically-Black College and Universities (HBCUs) have the lowest rates of tobacco-free policies compared to other colleges, universities, and minority-serving institutions, making their students at higher risk for tobacco abuse. A campus Alcohol, Tobacco, and Other Drug Prevention Committee (ATDP) was formed and led by a pharmacist to develop all tobacco cessation policies at the HBCU.

OBJECTIVES

(1) To determine the knowledge and attitudes of cigarettes, cigars, smokeless tobacco, electronic cigarettes, and hookah among college students in a rural area with high tobacco usage; (2) To assess perceptions on the effectiveness of smoking cessation resources on the college campus led by the ATDP committee.

METHODS

A cross-sectional study was conducted on 99 students between 18 - 26 years attending a HBCU in Maryland. The online survey was disseminated to assess student's health behaviors and attitudes towards tobacco products and their successfulness in abstinence using campus resources with the Health Belief Model.

RESULTS

Participants had more perceived harms with smoking tobacco (cigarettes and cigars) and smokeless tobacco, and greater perceived benefits with using electronic cigarettes and hookah (P < 0.001). Most students had limited knowledge of the four tobacco categories (5.8 ± 2.6 on a 10-point Likert scale). Self-efficacy to quit was 4.2 ± 1.7 on a 10-point Likert scale despite the current resources at the HBCU.

CONCLUSION

Students had a perceived benefits sequential rank order with hookah, e-cigarettes, smokeless tobacco, followed by smoking tobacco. Campuses should investigate barriers for abstinence, raise awareness about the dangers of tobacco, and create programs that enhance self-efficacy when quitting.

INNOVATION AND PRACTICE IMPLICATION

This is the first study of its kind that compares all major tobacco products head-to-head in a rural and underrepresented population. Additionally, the development of a campus-wide tobacco policy was novel as it was pharmacist-led. The results show this population has limited knowledge of tobacco products with more perceived benefits among newer nicotine delivery systems. Targeted education and public health programs should be implemented to prevent this susceptible group from initiating and continuing tobacco products.