New Estimates of Smoking-Attributable Mortality in the U.S. From 2020 Through 2035

INTRODUCTION

The often-cited Centers for Disease Control and Prevention (CDC) estimate of 480,000 annual U.S. smoking-attributable deaths (SADs), including 439,000 first-hand smoke deaths, derives from 2005 to 2009 data. Since then, adult smoking prevalence has decreased by 40%, while the population has grown and the smoking population aged. An updated estimate is presented to determine whether the CDC figure remains accurate or has changed substantially. In addition, the likely annual smoking-related mortality toll is projected through 2035.

METHODS

A well-established model of smoking prevalence and health effects is employed to estimate annual SADs among individuals exposed to first-hand smoke in the U.S. for two distinct periods: 2005-2009 and 2020-2035. The estimate for 2005-2009 serves as a benchmark to evaluate the reliability of the model's estimate in comparison to CDC's. The projections for 2020-2035 provide up-to-date figures for SADs, predicting how annual SADs are likely to change in the coming years. Data were collected between 2005 and 2020. The analysis was conducted in 2023.

RESULTS

This study's estimate of 420,000 first-hand smoke deaths over 2005-2009 is 95.7% of CDC's estimate during the same period. The model projections indicate that SADs among individuals who currently smoke or formerly smoked have increased modestly since 2005-2009. Beginning in 2020, annual SADs will remain relatively stable at approximately 450,000 before starting to decline around 2030.

CONCLUSIONS

These findings suggest that the CDC estimate of the annual mortality burden of smoking remains valid. Despite U.S. population growth and the aging of the smoking population, substantial reductions in smoking will finally produce a steady, if gradual, decline in SADs beginning around 2030.

The association between cannabis vaping and other substance use

Introduction

The popularity of cannabis vaping has increased rapidly, especially among adolescents and young adults. We posit some possible explanations and, to evaluate them, examine whether cannabis vapers differ from non-vaping cannabis users in other substance use.

Methods

Using nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study wave 5 (Dec. 2018-Nov. 2019), we assessed the association between cannabis vaping and other substance use. A total of 1,689 adolescents and 10,620 adults who reported cannabis use in the past 12 months were included in the study. We employed multivariable logistic regressions to assess the association between cannabis vaping and other substance use.

Results

Among past 12-month cannabis users, compared with those who do not vape cannabis, participants who vape cannabis had higher risks of using alcohol (adjusted relative risk [aRR] = 1.04, 95 % CI, 1.01-1.07), cigarettes (aRR = 1.09, 95 % CI, 1.02-1.15), cigars (aRR = 1.17, 95 % CI, 1.06-1.30), other tobacco products (aRR = 1.29, 95 % CI, 1.14-1.45), electronic nicotine products (aRR = 4.64, 95 % CI, 4.32-4.99), other illicit drugs (aRR = 1.53, 95 % CI, 1.29-1.80), and misuse of prescription drugs (aRR = 1.43, 95 % CI, 1.19-1.72). Compared to older cannabis vapers, younger cannabis vapers were at risk of using more other substances. Cannabis vaping was associated with all seven measures of substance use among young adults.

Conclusions

Compared to non-vaping cannabis users, cannabis vapers have higher likelihood of using other substances. Research is needed to understand why, as well as the implications of the association.

Trends in US Adult Smoking Prevalence, 2011 to 2022

Importance

President Biden recently prioritized the fight against smoking as key to reducing cancer mortality.

Objective

To assess trends in smoking and illuminate the association between smoking and reducing deaths due to cancer.

Design, Setting, and Participants

This cross-sectional study used responses to National Health Interview Surveys from January 1, 2011, to December 31, 2022, to characterize trends in current smoking for key sociodemographic groups among US adults.

Exposures

Age (18-24, 25-39, 40-64, and ≥65 years), family income (<200%, 200%-399%, and ≥400% of the federal poverty level [FPL]), educational level (less than high school, high school degree or General Educational Development, some college, and college degree or above), and race and ethnicity (Black, Hispanic, White, and other).

Main Outcomes and Measures

Weighted current smoking prevalence with 95% CIs by analysis group from 2011 to 2022. Average annual percentage change (AAPC) in smoking prevalence by analysis group is calculated using Joinpoint regression.

Results

Data from 353 555 adults surveyed by the National Health Interview Surveys from 2011 to 2022 were included (12.6% Black, 15.0% Hispanic, 65.2% White, and 7.3% other race or ethnicity). Overall, smoking prevalence decreased among adults aged 18 to 24 years from 19.2% (95% CI, 17.5%-20.9%) in 2011 to 4.9% (95% CI, 3.7%-6.0%) in 2022 at an AAPC of -11.3% (95% CI, -13.2% to -9.4%), while it remained roughly constant among adults 65 years or older at 8.7% (95% CI, 7.9%-9.5%) in 2011 and 9.4% (95% CI, 8.7%-10.2%) in 2022 (AAPC, -0.1% [95% CI, -0.8% to 0.7%]). Among adults 65 years or older, smoking prevalence increased from 13.0% (95% CI, 11.2%-14.7%) in 2011 to 15.8% (95% CI, 14.1%-17.6%) for those with income less than 200% FPL (AAPC, 1.1% [95% CI, 0.1%-2.1%]) and remained roughly constant with no significant change for those of higher income. Similar age patterns are seen across educational level and racial and ethnic groups.

Conclusions and Relevance

This cross-sectional study found that smoking prevalence decreased from 2011 to 2022 in all age groups except adults 65 years or older, with faster decreases among younger than older adults. These findings suggest that the greatest gains in terms of reducing smoking-attributable morbidity and mortality could be achieved by focusing on individuals with low socioeconomic status, as this population has the highest smoking rates and the worst health prospects.

Potential Implications for Tobacco Industry Transformation of the Acquisition of Swedish Match by Philip Morris International

Philip Morris International's recent purchase of Swedish Match may prove to be a vital tobacco industry development. We focus on PMIs potential progress in moving from primarily selling cigarettes toward primarily selling noncombustible nicotine delivery products (NCNDPs). We also consider the potential contribution of the acquisition to industry transformation whereby other cigarette firms may potentially move toward primarily selling NCNDPs. We examine the potential impact on noncombustible nicotine delivery product use, including nicotine pouches (a major Swedish Match product), e-cigarettes, heated tobacco products, and, most importantly, on sales of the industry's staple, combustible cigarettes. We focus on the United States as a special case, where PMI is limited from entering the cigarette market. Implications: Philip Morris International's purchase of Swedish Match and policies regarding nicotine pouches (NPs) have been overlooked in the tobacco control literature. The acquisition indicates the importance of the NP market to the largest nonstate-owned tobacco company. The acquisition has the potential through pricing and marketing tactics to either encourage or discourage the use of NPs, e-cigarettes, heated tobacco products, and most importantly cigarettes. Due to its inability to sell cigarettes in the United States, PMI will have incentives to use its alternative nicotine delivery products, including its newly acquired NPs, to reduce the sale of cigarettes by other companies. However, the potential effects in other countries, where PMI does sell cigarettes, are less clear. Monitoring and analyzing tobacco company acquisitions is essential to studying future transitions in using different kinds of tobacco products, especially from cigarettes to lower-risk alternative nicotine delivery products.

The evolution of age-specific smoking cessation rates in the United States from 2009 to 2017: a Kalman filter based approach

BACKGROUND

Tracking the US smoking cessation rate over time is of great interest to tobacco control researchers and policymakers since smoking cessation behaviors have a major effect on the public's health. Recent studies have employed dynamic models to estimate the US cessation rate through observed smoking prevalence. However, none of those studies has provided annual estimates of the cessation rate by age group. Hence, the primary objective of this study is to estimate annual smoking cessation rates specific to different age groups in the US from 2009 to 2017.

METHODS

We employed a Kalman filter approach to investigate the annual evolution of age-group-specific cessation rates, unknown parameters of a mathematical model of smoking prevalence, during the 2009-2017 period using data from the 2009-2018 National Health Interview Surveys. We focused on cessation rates in the 25-44, 45-64 and 65 + age groups.

RESULTS

The findings show that cessation rates followed a consistent u-shaped curve over time with respect to age (i.e., higher among the 25-44 and 65 + age groups, and lower among 45-64-year-olds). Over the course of the study, the cessation rates in the 25-44 and 65 + age groups remained nearly unchanged around 4.5% and 5.6%, respectively. However, the rate in the 45-64 age group exhibited a substantial increase of 70%, from 2.5% to 2009 to 4.2% in 2017. The estimated cessation rates in all three age groups tended to converge to the weighted average cessation rate over time.

CONCLUSIONS

The Kalman filter approach offers a real-time estimation of cessation rates that can be helpful for monitoring smoking cessation behavior.

The Association Between Cannabis Use and Subsequent Nicotine Electronic Cigarette Use Among US Adolescents

PURPOSE

The current study assessed the association between cannabis use among youth never e-cigarette users and subsequent e-cigarette use.

METHODS

The Population Assessment of Tobacco and Health Study is a nationally representative cohort study. Participants aged 12 years and older were selected using a 4-stage, stratified probability sample design from the US civilian, noninstitutionalized population. We included adolescents who participated in both wave 4.5 (2017-2018) and wave 5 (2018-2019) of Population Assessment of Tobacco and Health, and were never e-cigarette users at baseline (N = 9,925). Through multivariable logistic regressions, we examined the prospective association between cannabis use and subsequent e-cigarette use.

RESULTS

E-cigarette use at wave five was significantly more common among youth cannabis users at wave 4.5. The adjusted relative risks between ever cannabis use and subsequent past 12-month, past 30-day, and frequent e-cigarette use (≥20 days per month) were 1.53 (95% CI, 1.26-1.81), 1.70 (95% CI, 1.25-2.15), and 2.10 (95% CI, 1.17-3.03), respectively. The adjusted relative risks between past 30-day cannabis use and subsequent past 12-month, past 30-day, and frequent e-cigarette use were 1.54 (95% CI, 1.04-2.28), 2.01 (95% CI, 1.23-3.29), and 2.87 (95% CI, 1.44-5.71), respectively. We also found significant associations between ever cannabis vaping with subsequent e-cigarette use.

DISCUSSION

While previous research associates e-cigarette use with subsequent onset of cannabis use, we identify a reverse directional effect, where adolescent cannabis use is associated with increased likelihood of future e-cigarette use.

The Evolution of Age-Specific Smoking Cessation Rates in the United States From 2009 to 2018

Objective

Tracking the US smoking cessation rate over time is of great interest to tobacco control researchers and policymakers since smoking cessation behaviors have a major effect on the public's health. A couple of recent studies have employed dynamic models to estimate the US cessation rate through observed smoking prevalence. However, none of those studies has provided recent annual estimates of the cessation rate by age group.

Methods

We employed a Kalman filter approach to investigate the annual evolution of age-group-specific cessation rates, unknown parameters of a mathematical model of smoking prevalence, during the 2009-2018 period using data from the National Health Interview Survey. We focused on cessation rates in the 24-44, 45-64 and 65 + age groups.

Results

The findings show that cessation rates follow a consistent u-shaped curve over time with respect to age (i.e., higher among the 25-44 and 65 + age groups, and lower among 45-64-year-olds). Over the course of the study, the cessation rates in the 25-44 and 65 + age groups remained nearly unchanged around 4.5% and 5.6%, respectively. However, the rate in the 45-64 age group exhibited a substantial increase of 70%, from 2.5% in 2009 to 4.2% in 2017. The estimated cessation rates in all three age groups tended to converge to the weighted average cessation rate over time.

Conclusions

The Kalman filter approach offers a real-time estimation of cessation rates that would be helpful for monitoring smoking cessation behavior, of interest in general but also for tobacco control policymakers.

Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study

INTRODUCTION

The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs).

METHODS

After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060.

RESULTS

As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications.

CONCLUSIONS AND RELEVANCE

Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.

The Role of Flavored Electronic Nicotine Delivery Systems in Smoking Cessation: A Systematic Review

Background

Electronic nicotine delivery systems (ENDS) come in numerous flavors and may aid smoking cessation. This systematic review examines evidence on the role of ENDS flavors in smoking cessation.

Methods

We searched EMBASE OVID, PsychInfo, and Medline databases for studies that: 1) examined cigarette cessation outcomes for persons using ENDS (intent, attempts, and success) and 2) reported results separated by respondent's ENDS flavor used. We extracted crude and adjusted odds ratios for associations between cessation outcomes and types of ENDS flavors used (nontobacco vs. tobacco/unflavored; nontobacco and nonmenthol vs. tobacco/unflavored and menthol). We did not consider cessation outcomes among people not using ENDS. We evaluated the evidence using the GRADE approach, focusing on consistency and reliability of findings across studies.

Results

29 studies met inclusion criteria, producing 36 odds ratios (ORs) comparing cessation outcomes across ENDS flavor groups. Three ORs examined quit intent, five examined quit attempts, and 28 examined quit success. Using GRADE, we reached Low levels of certainty that there was not an association between ENDS flavor use and intention to quit smoking or making a quit attempt. There were Very Low levels of certainty that nontobacco flavored versus tobacco/unflavored ENDS use was not associated with smoking cessation success, with similar findings for nonmenthol and nontobacco compared to tobacco and menthol flavored ENDS.

Conclusion

The evidence about the role of different flavored ENDS use and smoking cessation outcomes is inconclusive, reflecting highly heterogeneous study definitions and methodological limitations. More high-quality evidence, ideally from randomized controlled trials, is required.

Association of Electronic Cigarette Use by US Adolescents With Subsequent Persistent Cigarette Smoking

Importance

Many studies have reported a positive association of youth electronic cigarette (e-cigarette) use with subsequent cigarette smoking initiation, but it remains unclear whether e-cigarette use is associated with continued cigarette smoking after initiation.

Objective

To assess the association of youth baseline e-cigarette use with their continued cigarette smoking 2 years after initiation.

Design, Setting, and Participants

The Population Assessment of Tobacco and Health (PATH) Study is a national longitudinal cohort study. This sample consisted of youth who participated in waves 3, 4, and 5 of the study (wave 3 was from October 2015 to October 2016, wave 4 was from December 2016 to January 2018, and wave 5 was from December 2018 to November 2019) and had never used cigarettes (cigarette-naive) by wave 3. The current analysis used multivariable logistic regressions in August 2022 to assess the association between e-cigarette use among cigarette-naive adolescents aged 12 to 17 years in 2015 and 2016 and subsequent continued cigarette smoking. PATH uses audio computer-assisted self-interviewing and computer-assisted personal interviewing to collect data.

Exposures

Ever and current (past 30-day) use of e-cigarettes in wave 3.

Main Outcomes and Measures

Continued cigarette smoking in wave 5 after initiating smoking in wave 4.

Results

The current sample included 8671 adolescents who were cigarette naive in wave 3 and also participated in waves 4 and 5; 4823 of the participants (55.4%) were aged 12 to 14 years, 4454 (51.1%) were male, and 3763 (51.0%) were non-Hispanic White. Overall, regardless of e-cigarette use, few adolescents (362 adolescents [4.1%]) initiated cigarette smoking at wave 4, and even fewer (218 participants [2.5%]) continued smoking at wave 5. Controlling for multiple covariates, the adjusted odds ratio of baseline ever e-cigarette use, compared with never e-cigarette use, was 1.81 (95% CI, 1.03 to 3.18) for continued smoking measured as past 30-day smoking at wave 5. However, the adjusted risk difference (aRD) was small and not significant. The aRD was 0.88 percentage point (95% CI, -0.13 to 1.89 percentage points) for continued smoking, with the absolute risk being 1.19% (95% CI, 0.79% to 1.59%) for never e-cigarette users and 2.07% (95% CI, 1.01% to 3.13%) for ever e-cigarette users. Similar results were found using an alternative measure of continued smoking (lifetime ≥100 cigarettes and current smoking at wave 5) and using baseline current e-cigarette use as the exposure measure.

Conclusions and Relevance

In this cohort study, absolute and relative measures of risks yielded findings suggesting very different interpretations of the association. Although there were statistically significant odds ratios of continued smoking comparing baseline e-cigarette users with nonusers, the minor risk differences between them, along with the small absolute risks, suggest that few adolescents are likely to continue smoking after initiation regardless of baseline e-cigarette use.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review

Objective

To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions.

Data sources

PubMed, Scopus, Embase and Web of Science before May 3, 2022.

Study selection

Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions.

Data extraction

Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance.

Data synthesis

We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6–39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products.

Conclusion

Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14440-x.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation

INTRODUCTION

Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation.

AIMS AND METHODS

We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias.

RESULTS

Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies.

CONCLUSIONS

Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point.

IMPLICATIONS

A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

A Proposed Policy Agenda For Electronic Cigarettes In The US: Product, Price, Place, And Promotion

Growth in the market for electronic cigarettes (e-cigarettes) raises complex questions about the devices' public health implications and, hence, challenging policy issues. We propose a policy agenda addressing concerns about preventing youth uptake of e-cigarettes and the desire to realize the potential of e-cigarettes to increase adult cigarette smoking cessation. We organize interventions according to the "four Ps" of marketing: product, price, place, and promotion. Policies include decreasing the addictiveness of combusted tobacco products while ensuring the availability of consumer-acceptable reduced-risk nicotine products, imposing large taxes on combustible products and smaller taxes on e-cigarettes, limiting the sale of all tobacco and (nonmedicinal) nicotine products to adult-only retailers, and developing communications that accurately portray e-cigarettes' risks to youth and benefits for inveterate adult smokers. All members of the public health community should unite to pursue a shared commitment to the principle that both youth and adults deserve a future free of tobacco-related disease.

Use of Electronic Cigarettes Among Cannabis-Naive Adolescents and Its Association With Future Cannabis Use

IMPORTANCE

Electronic cigarette (e-cigarette) use has been reported to increase the likelihood of future cigarette smoking among adolescents. The prospective association between e-cigarette use and cannabis use has been less clear, especially in recent years.

OBJECTIVE

To examine the association between e-cigarette use among cannabis-naive adolescents and cannabis use 1 year later.

DESIGN, SETTING, AND PARTICIPANTS

The Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study, uses a 4-stage, stratified probability sample design to select participants aged 12 years or older from the US civilian, noninstitutionalized population. This study sample included 9828 cannabis-naive adolescents at the baseline survey who participated in both wave 4.5 (2017-2018) and wave 5 (2018-2019) of PATH.

EXPOSURES

e-Cigarette use, assessed by ever use, past 12-month use, and past 30-day use.

MAIN OUTCOMES AND MEASURES

Cannabis use in wave 5, assessed by past 12-month and past 30-day use. Multivariable logistic regressions assessed the association between e-cigarette use and cannabis use 1 year later. Results were weighted to produce nationally representative findings.

RESULTS

Of the 9828 adolescents included in the analysis, 5361 (57.3%) were aged 12 to 14 years, 5056 (50.7%) were male, and 4481 (53.0%) were non-Hispanic White. After adjustment for sociodemographic characteristics, environmental factors, other substance use, and sensation seeking, e-cigarette use among cannabis-naive adolescents was associated with increased likelihoods of both self-reported past 12-month and past 30-day cannabis use 1 year later. The adjusted relative risks (aRRs) of subsequent past 12-month cannabis use with ever use of e-cigarettes was 2.57 (95% CI, 2.04-3.09), with past 12-month use of e-cigarettes was 2.62 (95% CI, 2.10-3.15), and with past 30-day use of e-cigarettes was 2.18 (95% CI, 1.50-2.85). The aRRs of subsequent past 30-day cannabis use with ever use of e-cigarettes was 3.20 (95% CI, 2.10-4.31), with past 12-month use of e-cigarettes was 3.40 (95% CI, 2.17-4.63), and with past 30-day use of e-cigarettes was 2.96 (95% CI, 1.52-4.40).

CONCLUSIONS AND RELEVANCE

This cohort study's findings suggest a strong association between adolescent e-cigarette use and subsequent cannabis use. However, despite the strong association at the individual level, e-cigarette use seems to have had a minimal association with the prevalence of youth cannabis use at the population level.

Can PATH Study susceptibility measures predict e-cigarette and cigarette use among American youth 1 year later?

AIMS

To investigate whether e-cigarette and cigarette susceptibility predict e-cigarette and cigarette use among American youth 1 year later.

DESIGN AND SETTING

Longitudinal data from the Population Assessment of Tobacco and Health (PATH) Study-a four-stage, stratified probability cohort study of youth (12-17 years old) sampled from the United States civilian, non-institutionalized population. Multivariable logistic regression was used to estimate the association between initial product-specific susceptibility and subsequent cigarette smoking and e-cigarette use while controlling for sociodemographic characteristics, exposure to nicotine users, and behavioral risk factors.

PARTICIPANTS

The sample included 8841 adolescent never nicotine users at initial survey who participated in both wave 4 (2016-2017) and wave 4.5 (2017-2018) of PATH.

MEASUREMENTS

We measured cigarette and e-cigarette susceptibility (defined as a lack of a firm commitment to not use cigarettes or e-cigarettes) among never nicotine users at baseline (wave 4) as well as cigarette and e-cigarette use at 12-month follow-up (wave 4.5).

FINDINGS

Youth e-cigarette susceptibility was statistically significantly (P < 0.05) associated with e-cigarette use 1 year later, for both past 12-month (adjusted odds ratio [aOR], 2.99; 95% CI, 2.29-3.90) and past 30-day e-cigarette use (aOR, 2.73; 95% CI, 1.78-4.16), but not with cigarette smoking (aOR, 1.05; 95% CI, 0.64-1.73 for past 12-month smoking and aOR, 0.65; 95% CI, 0.29-1.45 for past 30-day smoking. Smoking susceptibility predicted subsequent smoking in the past 12 months (aOR, 1.82; 95% CI, 1.09-3.03) and past 30 days (aOR, 3.32; 95% CI (1.33-8.29), but not e-cigarette use in the past 12 months (aOR, 0.96; 95% CI, 0.77-1.19) or past 30 days (aOR, 1.11; 95% CI, 0.82-1.51).

CONCLUSION

E-cigarette and cigarette susceptibility measures appear to predict product-specific use among youth 1 year later.

Monitoring the Increase in the U.S. Smoking Cessation Rate and its Implication for Future Smoking Prevalence

INTRODUCTION

We calculate the U.S. adult smoking cessation rate for 2014-2019, compare it to the historical trend, and estimate the implication for future smoking prevalence.

METHODS

We repeated an earlier analysis, which examined the cessation rate from 1990-2014, extending the period to 2019. Employing National Health Interview Survey (NHIS) and National Survey on Drug Use and Health (NSDUH) data, we estimated the adult cessation rate in six-year intervals, using weighted non-linear least squares. We then employed a meta-regression model to test whether the cessation rate has increased beyond expectation. We used cessation rate estimates and smoking initiation rate estimates to project smoking prevalence in 2030 and eventual steady-state prevalence.

RESULTS

The annual cessation rate increased 29% using NHIS data (from 4.2% in 2008-2013 to 5.4% in 2014-2019) and 33% with NSDUH data (4.2% to 5.6%). The cessation rate increase accounts for 60% of a smoking prevalence decline in the most recent period exceeding the 1990-2013 predicted trend. The remaining 40% owes to declining smoking initiation. With current initiation and cessation rates, smoking prevalence should fall to 8.3% in 2030 and eventually reach a steady state of 3.53%.

CONCLUSIONS

The smoking cessation rate continued to increase during 2014-2019. NHIS and NSDUH results are practically identical. The larger share (60%) of the smoking prevalence decrease, beyond expectation, attributable to the increased cessation rate is encouraging since the positive health effects of cessation occur much sooner than those derived from declining initiation.

IMPLICATIONS

The smoking cessation rate in the U.S. continues to increase, accelerating the decline in smoking prevalence. This increase suggests that the Healthy People 2030 goal of 5% adult smoking prevalence, while ambitious, is attainable. Our findings can be used in simulation and statistical models that aim to predict future prevalence and population health effects due to smoking under various scenarios.

Evaluation of Self-reported Cannabis Vaping Among US Youth and Young Adults Who Use e-Cigarettes

This cross-sectional study examines the prevalence and frequency of cannabis vaping, which is distinct from nicotine vaping, among young people aged 12 to 24 years.

Is Adolescent E-Cigarette Use Associated With Subsequent Smoking? A New Look

INTRODUCTION

Prospective studies have consistently reported a strong association between e-cigarette use and subsequent cigarette smoking, but many failed to adjust for important risk factors.

METHODS

Using longitudinal data from the Population Assessment of Tobacco and Health (PATH) Study, we employed multivariable logistic regressions to assess the adolescent vaping-to-smoking relationship, with four regressions (Models 1-4) sequentially adding more risk factors.Our sample included all waves (waves 1-5) of the PATH Study.

RESULTS

The association between ever e-cigarette use and subsequent cigarette smoking decreased substantially in magnitude when adding more control variables, including respondents' sociodemographic characteristics, exposure to tobacco users, cigarette susceptibility, and behavioral risk factors. Using the most recent data (waves 4-4.5 and waves 4.5-5), this association was not significant in the most complete model (Model 4). Using wave 4.5-5 data, the adjusted odds ratio (aOR) for ever e-cigarette use at initial wave and subsequent past 12-month smoking declined from 4.07 (95% confidence interval [CI, 2.86-5.81) in Model 1, adjusting only for sociodemographic characteristics, to 1.35 (95% CI, 0.84-2.16) in Model 4, adjusting for all potential risk factors. Similarly, the aOR of ever e-cigarette use and past 30-day smoking at wave 5 decreased from 3.26 (95% CI, 1.81-5.86) in Model 1 to 1.21 (95% CI, 0.59-2.48) with all covariates (Model 4).

CONCLUSIONS

Among adolescent never cigarette smokers, those who had ever used e-cigarettes at baseline, compared with never e-cigarette users, exhibited modest or non-significant increases in subsequent past 12-month or past 30-day smoking when adjusting for behavioral risk factors.

The Potential Impact of Widespread Cessation Treatment for Smokers With Depression

INTRODUCTION

Experts recommend integrating smoking-cessation treatments within U.S. mental health settings, but the population health benefits of doing so have not been estimated. This study simulates the impact of widespread cessation treatment for patients with depression under best-case treatment and maximum potential cessation scenarios.

METHODS

Cessation interventions were simulated for U.S. adult smokers seeing a health professional for depression from 2020 to 2100. Interventions included (1) Any Treatment (behavioral counseling, pharmacological, combination) and (2) Pharmacological Treatment (including counseling), combined with increased mental health service utilization each. These were compared with a maximum potential cessation scenario where all patients with major depression quit smoking. Analyses were conducted in 2016-2020.

RESULTS

Widespread uptake of Any Treatment among patients with depression would avert 32,000 deaths and result in 138,000 life-years gained by 2100; Any Treatment combined with 100% mental health service utilization would result in 53,000 and 231,000, respectively. Pharmacological Treatment would avert 125,000 deaths, with 540,000 life-years gained. Pharmacological Treatment combined with 100% mental health service utilization would result in 203,000 deaths averted and 887,000 life-years gained. Health gains under best-case treatment scenarios represent modest fractions of those projected under maximum potential cessation scenarios at current mental health service utilization levels (835,000 deaths averted, 3.73 million life-years gained) and at 100% utilization (1.11 million deaths averted, 5.07 million life years gained).

CONCLUSIONS

Providing smoking-cessation treatment to patients with depression and increasing mental health service utilization would reduce the toll of tobacco on this population. These gains would be considerably larger if cessation treatments were more effective.

Balancing Consideration of the Risks and Benefits of E-Cigarettes

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes' risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public-including most smokers-now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers' use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay's authors, encourage the health community, media, and policymakers to more carefully weigh vaping's potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

Trends in Nicotine Product Use Among US Adolescents, 1999-2020

IMPORTANCE

With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications.

OBJECTIVE

To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants.

EXPOSURES

Nicotine product use in the past 30 days.

MAIN OUTCOMES AND MEASURES

Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products.

RESULTS

This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students.

CONCLUSIONS AND RELEVANCE

This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.

An Expert Elicitation on the Effects of a Ban on Menthol Cigarettes and Cigars in the United States

INTRODUCTION

The US FDA announced its intention to ban menthol in cigarettes. However, information is needed on how a federal ban would affect population health. We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the US.

METHODS

We developed and pilot tested a questionnaire that focused on tobacco use transitions of current smokers (age 18-24 menthol, age 35-54 menthol, and age 35-54 non-menthol) and potential menthol smokers (age 12-24). Using a structured expert elicitation, we estimated mean net transitions under a ban from cigarette use to combustible tobacco product, smokeless tobacco, novel nicotine delivery product (NNDPs, such as e-cigarettes) use, or no tobacco use.

RESULTS

Eleven experts provided responses. Of those ages 12-24 who would have initiated menthol cigarette use in the absence of a ban, the experts estimated that 41% would still initiate combustible products under a ban, while 18% would initiate with NNDPs and 39% would not initiate regular tobacco use. Combustible use by menthol smokers ages 35-54 was expected to decline by 20% post-ban relative to pre-ban rates, half switching to NNDPs and half quitting all tobacco use. Menthol smokers ages 18-24 were expected to reduce combustible use by 30%, with 16% switching to NNDPs. Greater reductions in combustible use were estimated for African-Americans across the three age groups. Negligible impacts were expected for current adult non-menthol smokers.

CONCLUSIONS

According to expert opinion, a menthol ban is expected to substantially reduce smoking initiation and combustible tobacco product use among current menthol smokers.

A Magic Bullet? The Potential Impact of E-Cigarettes on the Toll of Cigarette Smoking

INTRODUCTION

We examine the proportion of US smoking-produced mortality that e-cigarettes might eliminate under assumptions regarding vaping's ability to increase smoking cessation, vaping's health risks, and the possibility that vaping will increase smoking among young people.

METHODS

We employ a dynamic population simulation model that tracks individuals from ages 0 to 110, differentiated by gender and smoking status. Using data from the US Census, the National Vital Statistics Reports, Cancer Prevention Study II, and the National Health Interview Survey, we estimate the number of smoking-related life-years lost (LYL) from 2018 to 2100 in a no-vaping scenario. We then compare results for model runs that assess the impact of vaping under a variety of assumptions.

RESULTS

The combination of assumptions produces 360 possible scenarios. 357 (99%) yield positive estimates of life-years saved (LYS) due to vaping by 2100, from 143 000 to 65 million. Most scenarios result in millions of individuals quitting smoking due to vaping. On average, vaping-induced quitters gain an extra 1.2-2.0 years of life compared to smokers who quit without vaping. The impact of vaping is greatest when it most helps smokers who otherwise have the greatest difficulty quitting smoking. While the numbers of LYS are generally large across all scenarios, they often represent a small fraction of the toll of smoking.

CONCLUSIONS

Vaping is highly likely to reduce smoking-produced mortality. Still, vaping is not "the" answer to the public health crisis created by smoking. Rather, it may well be a tool to add to the armamentarium of effective tobacco control measures.

IMPLICATIONS

E-cigarettes hold the potential to reduce cigarette smoking's enormous toll. By itself, however, tobacco harm reduction, as embodied in vaping, is no magic bullet. Going forward, tobacco control will require vigilant application of the evidence-based measures that have brought us so much success in combatting smoking. It will require, as well, the search for and adoption of novel means of attacking the remaining problem. Harm reduction can, and many would say should, be a part of the complex formula that will eventually bring about the demise of smoking.

Toward a More Comprehensive Index of Youth Cigarette Smoking: Average Number of Cigarettes Smoked per Day among Students in the United States over Two Decades

Reliance on 30-day prevalence as the principal means of assessing trends in youth cigarette smoking may understate the magnitude of the decrease in youth smoking, because prevalence does not account for smoking frequency or intensity. We analyzed Youth Risk Behavior Survey (YRBS) data from 1997 through 2017 and estimated cigarette smoking prevalence (any smoking in the previous 30 days), frequency (number of smoking days in the previous 30 days), and intensity (cigarettes per day on smoking days). We calculated average cigarettes smoked per day (ACSD) as the product of frequency and intensity, divided by 30. We estimated ACSD among all high school students and by smoking frequency group (i.e., 1–5, 6–9, 10–19, 20–29, or 30 of the previous 30 days), sex, grade level, and race/ethnicity. Among US high school students, ACSD declined by 86.7% from 1997 to 2017, while prevalence declined by 75.8%. Within smoking frequency groups, smoking intensity remained similar over the two decades. However, changes in ACSD over time varied by race/ethnicity; ACSD increased among Hispanic and non-Hispanic Black daily smokers while it decreased among daily smokers of other race/ethnicity groups. ACSD declined more substantially than smoking prevalence over two decades but remained virtually unchanged within smoking frequency groups, indicating that changes in frequency, rather than intensity, drove this decline. Prevalence estimates alone understate the degree to which youth in the United States have rejected smoking, and racial/ethnic disparities in smoking intensity are hidden when we limit our lens to prevalence-only measures.

Modeling smoking-attributable mortality among adults with major depression in the United States

Tobacco-related health disparities disproportionately affect smokers with major depression (MD). Although tobacco simulation models have been applied to general populations, to date they have not considered populations with a comorbid mental health condition. We developed and calibrated a simulation model of smoking and MD comorbidity for the US adult population using the 2005-2018 National Surveys on Drug Use and Health. We use this model to evaluate trends in smoking prevalence, smoking-attributable mortality and life-years lost among adults with MD, and changes in smoking prevalence by mental health status from 2018 to 2060. The model integrates known interaction effects between smoking initiation and cessation, and MD onset and recurrence. We show that from 2018 to 2060, smoking prevalence will continue declining among those with current MD. In the absence of intervention, people with MD will be increasingly disproportionately affected by smoking compared to the general population; our model shows that the smoking prevalence ratio between those with current MD and those without a history of MD increases from 1.54 to 2.42 for men and from 1.81 to 2.73 for women during this time period. From 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with current MD, leading to 11.3 million life-years lost. Ambitious tobacco control efforts could alter this trajectory. With aggressive public health efforts, up to 264,000 of those premature deaths could be avoided, translating into 7.5 million life years gained. This model can compare the relative health gains across different intervention strategies for smokers with MD.

How much of the future mortality toll of smoking can be avoided?

OBJECTIVE

To determine how much future smoking-related mortality in the USA can be prevented, recognising that some of that future mortality results from past smoking.

METHODS

Employing a dynamic population simulation model, we estimate smoking's expected mortality burden in the USA, measured as life-years lost (LYL), in a status-quo scenario run from 2018 through 2100. We then estimate LYL attributable to past smoking assuming that all smoking ceases at the end of 2017. We calculate the potential avoidable LYL, which we call the maximum potential reduction in premature mortality (MPRPM), as the difference between the two. We use data from the US Census Bureau, National Vital Statistics Reports, the National Health Interview Survey and Cancer Prevention Study II.

RESULTS

Under status-quo assumptions, smoking will claim 305 million LYL in the US from 2018 to 2100. If all smoking ceased at the end of 2017, past smoking would be responsible for 191.8 million LYL. Thus, avoidable LYL by 2100-the MPRPM-would be 113.2 million, 37% of the expected toll of smoking. A sensitivity analysis finds that were the annual smoking initiation rate 3% instead of 7.8%, the MPRPM would be 13-14% lower. Were the annual permanent smoking cessation rate twice our status-quo estimate of 4.35%, the MPRPM would be 38-39% lower.

CONCLUSIONS

Public health can address only the future toll of future smoking. Smoking's MPRPM is the reduction in the mortality burden of smoking that tobacco control can strive to achieve.

Will 5.6 million current American youth eventually die from smoking? The anatomy of a commonly accepted tobacco control measure

BACKGROUND

According to the 2014 Surgeon General's Report (SGR), '5.6 million (American) youth currently aged 0-17 years of age will die prematurely of a smoking-related illness.' Advocates cite this number as evidence that smoking will exact an enormous toll for decades to come. This paper examines whether the projected toll accurately portrays smoking's likely future burden.

METHODS

The SGR estimate, using 2012 state-specific data, can be closely approximated using national data by multiplying the population ages 0-17 by 2012 smoking prevalence among adults ages 18-30, and multiplying that by 32%, the 1996 estimate by the Centers for Disease Control and Prevention of the probability of future smoking-attributable mortality among young adult smokers. Repeating this process using 2018 data estimates the number of future deaths of youth ages 0-17 in 2018. A hypothetical estimate for 2024 assumes continuation of the 2012-2018 smoking prevalence decrease.

FINDINGS

Based on 2012 data, the estimated number of youth alive in 2012 who will die prematurely from smoking is 5.31 million. With lower young adult smoking prevalence in 2018, the future smoking-related mortality estimate is 3.66 million. For 2024, the estimate is 2.54 million.

CONCLUSIONS

The SGR estimate depended on assumptions that no longer held a few years later. Yet advocates for youth smoking prevention cite it frequently today. Considerations such as this paper's calculations, decreasing smoking initiation rates, increasing cessation, better screening for and treatment of smoking-related diseases, and smoking's increasing social unacceptability suggest that smoking's death toll for today's youth will be far lower than contemporary estimates. How much lower is virtually impossible to estimate.

E-cigarettes: Comparing the Possible Risks of Increasing Smoking Initiation with the Potential Benefits of Increasing Smoking Cessation

Introduction

The public health community is divided regarding electronic cigarettes. Skeptics emphasize potential vaping-induced increases in smoking among children and possible health hazards for adults. Enthusiasts consider e-cigarettes much less dangerous than smoking and believe they increase adult smoking cessation. We compare potential health benefits and costs to put these two perspectives in context.

Methods

Using a dynamic model that tracks the US adult population's smoking status and smoking-related deaths over time, we simulate the effects of vaping-induced smoking initiation and cessation on life-years saved or lost to the year 2070. The base case assumes that vaping annually increases smoking initiation by 2% and smoking cessation by 10%. Sensitivity analyses raise the initiation rate increase to 6% while decreasing the cessation rate increase to 5%. Sensitivity analyses also test vaping's reducing the health benefits of quitting smoking by 10%.

Results

With base-case assumptions, the population gains almost 3.3 million life-years by 2070. If all people who quit smoking by vaping lose 10% of the benefit of quitting smoking, the net life-year gain falls to 2.4 million. Under worst-case assumptions, in which vaping increases smoking initiation by 6% and cessation by 5%, and vaping-induced quitters lose 10% of the health benefits, the population gains over 580000 life-years.

Conclusion

Potential life-years gained as a result of vaping-induced smoking cessation are projected to exceed potential life-years lost due to vaping-induced smoking initiation. These results hold over a wide range of plausible parameters.

Implications

Our analysis strongly suggests that the upside health benefit associated with e-cigarettes, in terms of their potential to increase adult smoking cessation, exceeds their downside risk to health as a result of their possibly increasing the number of youthful smoking initiators. Public messaging and policy should continue to strive to reduce young people's exposure to all nicotine and tobacco products. But, they should not do so at the expense of limiting such products' potential to help adult smokers to quit.

How to Think-Not Feel-about Tobacco Harm Reduction

INTRODUCTION

The debate over tobacco harm reduction (THR) has divided the tobacco control community into two camps, one expressing serious reservations about THR whereas the other believes that reduced-risk products like e-cigarettes will disrupt the cigarette market. The often emotional debate would benefit from dispassionate data-based evaluation of evidence.

METHODS

After briefly discussing harm reduction in public health and specifically in tobacco control, this paper identifies major issues concerning e-cigarettes and reviews relevant evidence. Issues include: e-cigarettes' risks compared to cigarette smoking; the effect of vaping on youth smoking; vaping's impact on adult smoking cessation; the net long-term public health implications of vaping; and differences in views on policy issues. The intent is to provide a broad overview of issues and evidence, directing readers to more detailed reviews of specific issues.

FINDINGS

Principal findings include the following: (1) while longitudinal studies suggest that vaping increases never-smoking young people's odds of trying smoking, national survey data indicate that adolescents' 30-day smoking prevalence decreased at an unprecedented rate precisely whereas vaping increased. Use of all other tobacco products also declined. (2) Recent population-level studies add evidence that vaping is increasing adult smoking cessation. (3) Vaping is likely to make a positive contribution to public health.

CONCLUSIONS

THR can be a complement to, not a substitute for, evidenced-based tobacco control interventions. Tobacco control professionals need to focus on objective assessment of and discussion about the potential costs and benefits of THR.

IMPLICATIONS

Participants on both sides of the divisive THR debate need to examine the complicated issues and evidence more objectively. This entails considering both the potential benefits and costs associated with reduced-risk products like e-cigarettes. Furthermore, it requires examining different kinds of evidence when considering specific issues. For example, those concerned by longitudinal study findings that vaping increases students' trial of cigarettes should consider US national survey evidence that youth smoking has decreased at an unprecedented rate. A review of the major issues suggests that the potential of vaping to assist adult smokers to quit outweighs the potential negatives.

The Use of Excise Taxes to Reduce Tobacco, Alcohol, and Sugary Beverage Consumption

In countries around the world, tobacco use, excessive alcohol consumption, and consumption of sugar-sweetened beverages (SSBs) are significant contributors to the global epidemic of noncommunicable diseases. As a consequence, they contribute, as well, to excess health care costs and productivity losses. A large and growing body of research documents that taxes specific to such products, known as excise taxes, reduce consumption of these products and thereby diminish their adverse health consequences. Although such taxation has historically been motivated primarily by revenue generation, governments are increasingly using these taxes to discourage unhealthy consumption. We review the global evidence on the impact of taxes and prices on the consumption of these products and the health and social consequences. We then evaluate arguments commonly raised against these taxes, identify best practices in excise tax policy, and conclude with a summary of the current status of tobacco, alcohol, and SSB excise taxes globally.

A new measure of youth cigarette smoking

American students' 30-day smoking prevalence has decreased dramatically over the past two decades. The frequency of smoking within the 30-day measure has shifted from heavy smoking (>1/2 pack/day) toward light smoking (<1 to 5 cigarettes/day). 30-day prevalence thus understates the extent of the decline in youth smoking. To capture this shift toward less frequent smoking among the decreasing proportion of students who smoke, I develop a new index: the average number of cigarettes smoked per student per day (ACSD), using data from Monitoring the Future. To calculate ACSD I assign a specific number of cigarettes to each of 7 response options to the question, "How frequently have you smoked cigarettes during the past 30 days?" Response options range from "not at all" (assigned 0 cigarettes) to "two packs or more per day" (assigned 45 cigarettes). I then multiply these estimates by the proportion of students giving each response option. Summing across the 7 categories produces the ACSD for that survey year. I then compare time trends in 30-day prevalence and ACSD. From the mid-1990s to 2016, 30-day smoking prevalence among 12th graders declined 71.3%, while ACSD dropped 83.9% (p < 0.001). The figures were 84.0% and 90.6% (p < 0.001) for 10th graders and 87.4% and 89.0% for 8th graders (p < 0.05). Sensitivity analysis supports the finding that ACSD has decreased more than 30-day prevalence over time for both 10th and 12th grades. ACSD provides a new measure of the decline in youth smoking to complement the traditional measure of 30-day prevalence.

Examining the relationship of vaping to smoking initiation among US youth and young adults: a reality check

Background

The 2018 National Academies of Sciences, Engineering, and Medicine Report found substantial evidence that electronic cigarette use (vaping) by youth is strongly associated with an increased risk of ever using cigarettes (smoking) and moderately associated with progressing to more established smoking. However, the Report also noted that recent increases in vaping have been associated with declining rates of youth smoking. This paper examines the temporal relationship between vaping and youth smoking using multiple data sets to explore the question of whether vaping promotes smoking initiation in the USA.

Methods

Using publicly available, nationally representative data on smoking and vaping among youth and young adults, we conducted a trend line analysis of deviations from long-term trends in smoking starting from when vaping became more prevalent.

Results

There was a substantial increase in youth vaping prevalence beginning in about 2014. Time trend analyses showed that the decline in past 30-day smoking prevalence accelerated by two to four times after 2014. Indicators of more established smoking rates, including the proportion of daily smokers among past 30-day smokers, also decreased more rapidly as vaping became more prevalent.

Conclusions

The inverse relationship between vaping and smoking was robust across different data sets for both youth and young adults and for current and more established smoking. While trying electronic cigarettes may causally increase smoking among some youth, the aggregate effect at the population level appears to be negligible given the reduction in smoking initiation during the period of vaping’s ascendance.

Students' Cigarette Smoking and the Perceived Nicotine Content of Their E-cigarettes

INTRODUCTION

There is concern that youth e-cigarette use may serve as a gateway to cigarette smoking, and that nicotine exposure may harm brain development. It is therefore important to know how much nonsmoking youth perceive being exposed to nicotine through e-cigarettes.

METHODS

Data on smoking and vaping from the 2016 Monitoring the Future survey of eighth, tenth, and 12th grade students were analyzed in 2017. The weighted percentage distributions of self-reported e-cigarette mist last inhaled were calculated according to ever-smoking status and past 30-day smoking frequency. Chi-square tests of the association between smoking status and use of e-cigarettes perceived to contain nicotine, marijuana or hash oil, or just flavoring were performed. Never smokers and regular smokers were compared regarding the type of e-cigarette mist they believe they last used.

RESULTS

A significant relationship exists between smoking behavior and reportedly vaping nicotine (p<0.01) or just flavors (p<0.01). With increasing smoking intensity, an increasing proportion of students report they are vaping nicotine; a decreasing proportion report just flavors. Among 12th graders, prevalence of vaping nicotine is lowest among never smokers and non-current smokers (14.3% and 18.1%) and highest among current and frequent smokers (61.3% and 60.9%, p<0.01). Substantially larger proportions of never smokers and 30-day nonsmokers report vaping just flavors (76.0% and 69.6%) compared with regular or frequent smokers (31.0% and 29.3%, p<0.01).

CONCLUSIONS

Most nonsmoking students perceive limited nicotine exposure from vaping. Future research should evaluate the accuracy of self-reported e-cigarette nicotine content and monitor students who are consciously using nicotine-based e-cigarettes.

Has Underreporting of Cigarette Consumption Changed Over Time? Estimates Derived From US National Health Surveillance Systems Between 1965 and 2015

According to survey data, the prevalence of Americans' self-reported cigarette smoking is dropping steadily. However, the accuracy of national surveys has been questioned because of declining response rates and the increasing stigmatization of smoking. We used data from 2 repeated, cross-sectional, nationally representative health surveys (National Survey on Drug Use and Health (NSDUH), 1979-2014; and National Health Interview Survey (NHIS), 1965-2015) to determine whether self-reported cigarette consumption has changed over time as a proportion of federally taxed cigarette sales. From each survey, we calculated national equivalents of annual cigarette consumption. From 1979 to 1997, the amount of cigarettes that NSDUH and NHIS respondents reported corresponded to an average of 59.5% (standard deviation (SD), 2.3%) and 65.6% (SD, 3.2%), respectively, of taxed cigarette sales. After 1997, respondents' reported smoking data corresponded to the equivalent of an average of 64.2% (SD, 5.9%) and 63.3% (SD, 2.5%), respectively, of taxed cigarette sales. NHIS figures remained steady throughout the latter period, with a decline during 2013-2015 from 65.9% to 61.1%. NSDUH figures increased steadily, exceeding those of the NHIS after 2002. Given the consistent underreporting of cigarette consumption over time, these surveys are likely not less accurate than they were previously. The recent decrease in NHIS accuracy, however, gives pause about the magnitude of the reported decline in smoking prevalence in 2014 and 2015. Improvement in the accuracy of NSDUH data is encouraging.