Dual and poly-nicotine and tobacco use among adolescents in the United States from 2011 to 2022

BACKGROUND

Adolescent nicotine and tobacco product use remains common despite declining smoking rates in the United States, likely due to the emergence of novel products. Concurrent use of multiple products may increase the risk of nicotine dependency and subsequent substance use.

AIM

To identify patterns and trends of dual and poly nicotine and tobacco use among adolescents in the US and explore associations of dual and poly nicotine and tobacco use with sociodemographic factors.

METHODS

12 years of annual National Youth Tobacco Survey data (2011-2022) from 242,637 respondents were used to examine prevalence trends of different combinations of nicotine or tobacco product use among adolescents in the US using weighted point estimates for each year. Poisson regression models examined sociodemographic factors associated with different patterns of dual and poly-product use from 2011 to 2022.

RESULTS

Overall, the prevalence of dual (i.e. at least two products) and poly (i.e. at least three products) use decreased between 2011 and 2021 (from 9.5 % to 2.8 % and from 5.1 % to 1.1 %, respectively), but showed signs of increase between 2021 and 2022 (3.7 % for dual and 1.7 % for poly use). The most common combinations included a combustible product with either a novel or noncombustible product. The risk for dual and poly-product use was higher among non-Hispanic Whites, males, and high school students.

CONCLUSIONS

Previously declining trends in the prevalence of tobacco/nicotine dual and poly use may have been reversed. Close monitoring and targeted tobacco control policies are essential to tackle multiple product use among adolescents.

A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: implications for tobacco control in the Southeast Asia region

Background

In Southeast Asia, tobacco use is a major public health threat. Tobacco users in this region may switch between or concurrently use smoked tobacco and smokeless tobacco (SLT), which makes effective tobacco control challenging. This study tracks transitions of use among different product users (cigarettes, bidis, and SLT) in Bangladesh, one of the largest consumers of tobacco in the region, and examines factors related to transitions and cessation.

Methods

Four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey with a cohort sample of 3245 tobacco users were analysed. Generalized Estimating Equations (GEE) models were used to explore the socioeconomic correlates of transitions from the exclusive use of cigarettes, bidis, or SLT to the use of other tobacco products or quitting over time.

Findings

Among exclusive cigarette users, most remained as exclusive cigarette users (68.1%). However, rural smokers were more likely than urban smokers to transition to bidi use (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.29); to SLT use (OR = 2.68, 95% CI = 1.79-4.02) and to quit tobacco (OR = 1.57, 95% CI = 1.06-2.33). Among exclusive bidi users, transitional patterns were more volatile. Fewer than half (43.3%) of the exclusive bidi users maintained their status throughout the waves. Those with higher socio-economic status (SES) were more likely to quit (OR = 4.16, 95% CI = 1.08-13.12) compared to low SES smokers. Exclusive SLT users either continued using SLT or quit with minimal transitions to other products (≤2%). Nevertheless, males were more likely to switch to other tobacco products; younger (OR = 2.94, 95% CI = 1.23-6.90 vs. older), more educated (OR = 1.55, 95% CI = 1.77-3.12 vs. less educated), and urban SLT users (OR = 0.52, 95% CI = 0.30-0.86 for rural vs. urban users) were more likely to quit.

Interpretation

Complex transitional patterns were found among different types of tobacco product users over time in Bangladesh. These findings can inform more comprehensive and multi-faceted approaches to tackle diversified tobacco use in Bangladesh and neighbouring countries in the Southeast Asia region with similar tobacco user profiles of smoked tobacco and SLT products.

Funding

This is an unfunded observational study with the use the ITC Bangladesh datasets. The ITC Bangladesh Surveys were supported by grants from the US National Cancer Institute (P01 CA138389), the International Development Research Centre (IDRC Grant 104831-003), and Canadian Institutes of Health Research (MOP-79551, MOP-115016).

Tobacco control is integral to global COVID-19 response: an opportunity to accelerate toward SDGs

Issue

Tobacco use intersects with the COVID-19 pandemic not only in terms of health consequences, but also on public health systems, economies, and the environment.

Description of the problem

The global tobacco supply contributes significantly to environmental pollution of the natural ecosystems. The damage is compounded by tobacco consumption and its resultant waste, which leaves a significant carbon footprint on the environment, undermining the planet’s ecological stability and intensifying climate change. Furthermore, tobacco use exacerbates inequalities and adds burdens to COVID-19-related mortality, which are major challenges to recovery from the COVID-19 pandemic.

Results

he pandemic has provided a chance to combat tobacco use and accelerate efforts to alleviate these challenges and accelerate progress toward Sustainable Development Goals (SDGs). The MPOWER measures from the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) can play an integral part to boost sustainable and equitable COVID-19 recovery — Monitor tobacco use (article 20); Protection from tobacco smoke (article 8); Offer help for tobacco cessation (article 14); Warn about the dangers of tobacco (article 11); Enforcing bans on tobacco advertising, promotion, and sponsorship (TAPS) (article13); and Raise tobacco taxes (article 6).

Lessons

To accelerate recovery, it is critical to call for actions for governments and policy-makers to strengthen synergies and policy actions to emphasise tobacco control across equity, public health, climate actions, and counteract against the tobacco industry during and beyond COVID-19 as global authorities pledge to achieve the SDGs.

Key messages

• Global authorities must create better synergies on policies with a prime focus on reinforcing tobacco control to recover from the pandemic.

• The WHO FCTC MPOWER measures can play an integral part in COVID-19 recovery to fight tobacco use and accelerate progress toward SDGs.

Tobacco control measures in COVID-19 recovery: an opportune time to restore equity and planetary health

Tobacco intersects with the COVID-19 pandemic not only in terms of health consequences, but also environmental change and planetary health. Tobacco use exacerbates inequalities, causes catastrophic environmental degradation and climate change and adds burdens to COVID-19-related mortality, which are major challenges to recovery from the COVID-19 pandemic. However, the pandemic has provided a chance to combat tobacco use and accelerate efforts to alleviate these challenges in response. The MPOWER measures introduced by the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) can play a crucial role in COVID-19 recovery to fight tobacco use and contribute to sustainable and equitable development. To accelerate recovery, it is critical to call for actions for governments and policy-makers to strengthen synergies and coordinate policy actions emphasising tobacco control and cessation across equity, public health, and climate actions as global authorities pledge to achieve the Sustainable Development Goals (SDGs) and net zero emissions targets as part of the Climate Change Conference 2021 (COP26).

Global Patterns and Prevalence of Dual and Poly-Tobacco Use: A Systematic Review

INTRODUCTION

Improving understanding of the epidemiology of dual and poly-tobacco product use is essential for tobacco control policy and practice. The present study aimed to systematically review existing epidemiologic evidence on current dual and poly-tobacco use among adults globally.

METHODS

We systematically searched online databases for studies published up to June 30, 2020. We included quantitative studies with measures of nationally representative prevalence of current dual or poly-tobacco use among adults. Prevalence estimates for each country were extracted manually and stratified by WHO regions and World Bank income classifications.

RESULTS

Twenty studies with nationally representative prevalence data on current dual or poly-tobacco use in the adult population across 48 countries were included. Definitions of dual and poly-tobacco use varied widely. Prevalence of dual and poly-tobacco use was higher in low- and lower-middle-income countries compared to other higher-income countries. Current dual use of smoked and smokeless tobacco products among males ranged from 0.2% in Ukraine (2010) and Mexico (2009) to 17.9% in Nepal (2011). Poly-tobacco use among males ranged from 0.8% in Mexico (2009) and 0.9% in Argentina (2010) to 11.4% in the United Kingdom and 11.9% in Denmark in 2012. Dual tobacco use was generally higher in South-East Asia; poly-tobacco use was prevalent in Europe as well as in South-East Asia.

CONCLUSIONS

This is the first systematic review of the prevalence estimates of dual and poly-tobacco use among adults globally. The results of the current study could significantly help health policy makers to implement effective tobacco control policies.

IMPLICATIONS

This study demonstrates that dual/poly-tobacco use is common in many countries of the world, and highlights the need for in-depth exploration of this field in future studies, especially in high prevalence regions such as South-East Asian and European countries. In light of this, the global tobacco control community and health authorities should also agree upon a consistent operational definition of dual and poly-tobacco use to propel research and improve surveillance of dual/poly-use in health surveys for better communication and understanding of these phenomena.

The association of migration with multiple tobacco product use among male adults in 15 low- and middle-income countries

Little is known about the impact of migration on tobacco use patterns among men in low- and middle-income countries (LMICs). This study aims to explore the association between migration and tobacco use among men in LMICs. We used multilevel regression models to analyze data of 154 425 men from 15 countries from the latest wave of the Demographic and Health Survey. Results showed higher risk of single tobacco product use [relative risk ratio (RRR) = 1.22; 95% confidence interval (CI): 1.19-1.26], but importantly of dual (RR = 1.41, 95% CI: 1.36-1.49) and poly-tobacco use (RR = 1.71, 95% CI: 1.57-1.86) among migrant men compared with non-migrants.

Cigarette and E-Cigarettes Dual Users, Exclusive Users and COVID-19: Findings from Four UK Birth Cohort Studies

INTRODUCTION

The relationship between current cigarette and electronic cigarette (e-cigarette) dual use, exclusive use and COVID-19-related measures are still unclear. This study aims to assess the association between different tobacco use patterns and coronavirus disease 2019 (COVID-19) symptoms, testing, self-reported infection and social distancing behaviors in the United Kingdom (UK).

METHODS

Data come from the first wave of the Centre for Longitudinal Studies (CLS) COVID-19 survey, comprising four birth cohorts (N = 13,077, aged 20-63 years) surveyed between 2 to 31 May 2020, during the COVID-19 pandemic. Sociodemographic characteristics and COVID-19-related outcomes (symptoms, testing, diagnosis and social distancing behaviors) were compared across different product user groups (non-users, exclusive cigarette users, exclusive e-cigarettes users and dual use) using Cochran-Mantel-Haenszel χ2 test. Multivariable logistic regression models were used to explore associations between COVID-19-related outcomes and different smoking patterns.

RESULTS

Across all four cohorts, 12.6% and 4.9% of the respondents were current exclusive cigarette and e-cigarette users, respectively, with approximately 3% of the respondents being dual users. Significant differences in prevalence were observed between different tobacco use patterns and COVID-19 symptoms (p = 0.02), self-reported infection (p = 0.04) and social distancing behaviors (p < 0.001). Current cigarette and e-cigarette dual use was associated with 2.15-fold higher odds for reporting COVID-19 infection (aOR = 2.15; CI [1.15-4.05]). Compliance of social distancing behaviors were the lowest for current dual users (aOR = 0.58; CI [0.41-0.83]) and exclusive cigarette users (aOR = 0.72; CI [0.63-0.92]).

CONCLUSIONS

The findings highlight dual users' higher prevalence of having COVID-19 symptoms, infection and incompliance of social distancing behaviors. Self-reported infection was associated with dual product use; dual users and exclusive cigarette users were linked to poor adherence to social distancing behaviors. Smoking cessation support and further monitoring on multiple tobacco use among these populations should be reinforced as preventive measures to tackle the pandemic.

Inequality-Related Health and Social Factors and Their Impact on Well-Being during the COVID-19 Pandemic: Findings from a National Survey in the UK

Background: Lower socioeconomic groups and disadvantaged populations across the world suffer disproportionately from the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to examine the impact of health- and social-inequality-related factors on well-being in order to further distinguish each of their effects during the pandemic. Methods: A nationally-representative sample of 5077 UK respondents aged 18 years or older was recruited through an online survey panel during the COVID-19 pandemic. Their subjective well-being was measured using the 11-point Cantril Ladder of Life Scale. The impact of inequality-related health and social factors (pre-existing medical conditions, household size and occupation), as well as COVID-19-related risk factors (symptoms, confirmed infections, and social distancing behaviours) on well-being were analysed using multiple linear regression models. The associations between the COVID-19-related risk factors and well-being according to the respondents' household size and occupation were modelled in order to test the differences by their socioeconomic profile. Results: We identified inverted V-shaped associations between household size and subjective well-being during the COVID-19 pandemic. Compared to single-person households, respondents from households of two to four persons showed better well-being (β = 0.57; CI (0.44, 0.72)), whereas living in crowded households of five persons or more was associated with decreased well-being (β = -0.48; CI (-0.71, -0.25)). Furthermore, lower-skilled occupations (elementary occupations: β = -0.31; CI (-0.58, -0.03); logistics and transport services: β = -0.37; CI (-0.74, -0.01)) and chronic medical conditions (cardiometabolic or respiratory diseases: β = -0.25; CI (-0.41, -0.1); and mental health conditions: β = -1.12; CI (-1.28, -0.96)) were factors associated with reduced well-being during the pandemic. Interactions between a positive COVID-19 diagnosis, symptoms, and crowded households were identified (β = -0.95; CI (-1.76, -0.14) and β = -4.74; CI (-9.87, -1.61), respectively). Conclusions: In a national sample, the levels of general subjective well-being during the COVID-19 pandemic and lockdowns were disproportionately distributed across different groups within society. Preventive policies should explicitly focus on reaching lower socioeconomic groups; more emphasis should be placed on the coordination of multisectoral support in order to tackle existing health and social inequalities.

Prevalence and determinants of dual and poly-tobacco use among males in 19 low-and middle-income countries: Implications for a comprehensive tobacco control regulation

Despite their implications for tobacco control, data on concurrent dual (using two tobacco products) and poly-tobacco use (using more than two products) are relatively scarce globally. This study aimed to estimate the prevalence of dual and poly-tobacco use among men in 19 low-and middle-income countries (LMICs) and assess potential associations with individual and country level factors. Data from 19 LMICs were obtained from the most recent wave of the Demographic and Health Survey (DHS), collected between 2015 and 2016 comprising 235,975 men aged 15-49 years. The prevalence of current single, dual and poly-tobacco use were estimated using available sample weights. Mixed-effect multilevel models were used to estimate associations of individual and country level factors with tobacco use. Results showed that the prevalence of dual or poly-tobacco use among men was highest in Timor Leste (27.1%), Nepal (18.3%), Lesotho (13.2%) and India (9.3%). Factors associated with dual and poly-tobacco use were older age, low academic achievement, low income status, being divorced, living in urban areas and high frequency of media use. Among country-level characteristics, national wealth was not associated with dual and poly-tobacco use. Implementation of MPOWER measures was inversely associated with single tobacco use; this was not the case for dual and poly-tobacco use. Findings suggest that dual and poly-tobacco use are common among men especially in South-East Asian countries. This study highlights the need for MPOWER measures to be expanded and strengthened to address all tobacco products and explicitly consider dual and poly use.

The psychosocial impact of the COVID-19 pandemic on changes in smoking behavior: Evidence from a nationwide survey in the UK

INTRODUCTION

The stress and anxiety during this unprecedented public health crisis may lead current smokers to increase tobacco use or former smokers to relapse. Thus, this study aims to provide epidemiological evidence of the changes in smoking behavior among British smokers in response to the COVID-19 pandemic and assess the impact of psychosocial factors on these behaviors.

METHODS

A nationwide survey of a representative sample of 4075 UK respondents aged >16 years was conducted between 27 April and 24 May 2020 during the COVID-19 pandemic. Psychosocial and demographic variables between different smoking behavior groups were compared using Pearson’s χ² test and Cramer’s V.

RESULTS

Among current smokers (n=329), one-quarter (25.2%, n=86) reported smoking more than usual, 50.9% (n=174) reported smoking the same amount, and 20.2% (n=69) reported smoking less. Significant associations were observed between different smoking behavior groups and psychosocial factors. Pearson’s χ² test revealed significant differences between different smoking behavior groups in their concerns about mental health (p<0.001), anxiety (p<0.001) and stress (p<0.001), state of low mood (p=0.012), in the Patient Health Questionnaire (PHQ) score (p=0.018) and ranking on the Cantril Ladder scale (p<0.001). Many respondents expressed that the pandemic had a more negative impact on their mental health and the impact was more pronounced among those who smoked more.

CONCLUSIONS

Deterioration of mental health and psychosocial well-being were linked to increased smoking. Public health authorities should take proactive measures to provide mental healthcare and smoking cessation support as preventive measures to tackle the pandemic.