Prevalence and correlates of flavored novel oral nicotine product use among a national sample of youth

BACKGROUND

Flavored novel oral nicotine products (ONP), such as pouches, gum, lozenges, tablets, and gummies, have recently entered the US market but have not been authorized for smoking cessation. This study assessed the prevalence and correlates of ONPs in a national sample of youth who smoked little filtered cigars or cigarillos (LCCs) or were susceptible to LCCs.

METHODS

We conducted a national online survey from September-October 2022, as part of a study to develop cigar warnings among youth. Those aged 15-20 years old who reported using (ever or current) or susceptibility to little filtered cigars or cigarillos (LCCs) were eligible. Descriptive statistics and chi-square analyses assessed the prevalence of flavored ONP use and associations with other past 30-day tobacco product use and participant characteristics.

RESULTS

Approximately one-fifth (17.1 %) of the sample (n = 680) reported past month flavored ONP use. Any past month tobacco use was correlated with past month flavored ONP use (ps < 0.001), increasing from 17.1 % in the overall sample to 26.8 % among those reporting e-cigarette use, 41.4 % (LCCs), 47.8 % (waterpipe tobacco), 61.8 % (large cigars), and 69.1 % (smokeless tobacco). The number of products used in the past month was significantly associated with higher odds of ONPs in the past month in a multivariable logistic regression model (aOR2.26; 95 % CI: 1.92, 2.65).

DISCUSSION

Almost one-fifth of participants who use or are susceptible to cigar use in our national sample of youth use ONPs. Dual/poly use of other tobacco products and ONPs among youth suggests that many of these youth may be addicted to nicotine. Additional surveillance and regulation of ONPs that exhibit enticing characteristics, such as flavors, kid-friendly formulations, and targeted marketing/branding may be needed.

Perceived Effectiveness of Cigar Warnings in Discouraging Blunt Use

INTRODUCTION

Many people remove the tobacco leaf from cigars and replace it with cannabis (ie, blunts), but few studies have examined whether messages about the risks of cigars, like warnings on cigar packages, can affect blunt use.

METHODS

Participants were 438 U.S. adults who reported past 30-day cigar use and ever blunt use, recruited from a probability-based national panel to take an online survey. In a 2 × 2 experiment with a between-subjects design, we manipulated two cigar warning characteristics: (1) warning type: text-only versus pictorial (ie, text + image) and (2) warning size: 30% (smaller) versus 50% (larger) of the product package. Participants then viewed six different warnings on a fictious cigarillo package, within their randomly assigned condition. After evaluating all stimuli, participants were asked the extent to which the warnings discouraged them from wanting to use cigars to smoke cannabis (ie, blunt perceived warning effectiveness). Response options ranged from "not at all" (1) to "a great deal" (5).

RESULTS

We observed no main effects of warning type or size on blunt perceived warning effectiveness. However, a significant interaction existed between the two experimental manipulations (p = .009). Whereas adding images made no difference to blunt perceived warning effectiveness when warnings were smaller (simple effect: -0.22, p = .28), images mattered for larger warnings. Specifically, adding images increased blunt perceived warning effectiveness when warnings were 50% of the product package (simple effect: 0.52, p = .008).

CONCLUSIONS

This experiment provides preliminary evidence that larger pictorial cigar warnings may discourage blunt use relative to larger but text-only warnings.

IMPLICATIONS

Blunts, which are hollowed out cigars with tobacco leaf wrappers that are filled with cannabis leaf, are one of the most common ways in which tobacco and cannabis are used simultaneously, yet few studies have examined whether messages about the risks of cigars can affect blunt use. We conducted an online experiment concerning the perceived effectiveness of cigar warnings among people who use blunts recruited from a probability-based panel. Results provide novel, preliminary evidence that larger pictorial cigar warnings may discourage blunt use, relative to larger but text-only warnings. More research evaluating cigar warnings on blunt use is needed.

Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina

BACKGROUND

Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches.

METHODS

We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis.

RESULTS

Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches.

CONCLUSIONS

Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.

Perceived message effectiveness of cigar warning themes among adults in the United States

Most tobacco warnings focus on health harms to the consumer, but other message themes may be promising. We assessed perceived message effectiveness (PME) among adults who smoke cigars for 12 cigar warning statements to discourage smoking, and measured PME across four message themes: explicit health effects to the consumer, secondhand smoke effects, chemicals/constituents, and toxicity. Between April 23 and May 7, 2020, we conducted an online study with U.S. adults who used any cigar type in the past 30 days (n = 777). Participants were randomly assigned to view two out of 12 warnings and rate each one on PME. We analyzed PME mean ratings (range 1 [low] to 5 [high]). The warning statements for lung cancer (M = 3.91) and heart disease (M = 3.77) had the highest PME ratings; secondhand smoke (M = 3.50) and formaldehyde (M = 3.48) had the lowest PME ratings. Multilevel analyses showed that the explicit health effects theme was associated with higher PME ratings compared to other warning themes (ps < 0.05 for chemicals/constituents and secondhand smoke effects) except toxicity (p =.16). Higher awareness of consequences was associated with higher PME ratings (p <.001). Higher nicotine dependence was also associated with higher PME ratings (p = .004). Warning statements with information addressing the themes of health harms and toxicity could potentially inform those who smoke cigars about the broader harms of cigar use and should be considered in FDA labeling regulations for cigars.

Improving Point-of-Sale Warnings for Single Cigars: Implications for Premium Cigars

INTRODUCTION

For cigars sold individually without packaging, including many premium cigars, the US Food and Drug Administration (FDA) proposed that retailers display six warning statements on a sign at the point-of-sale (POS).

AIMS AND METHODS

To examine the potential effectiveness of cigar warning signs, we conducted a between-subjects online experiment. Participants were 809 U.S. adults who reported using cigars (78% ever large cigar use, 49% past 30-day large cigar use) recruited from a probability-based panel. Participants viewed an image of a cigar store countertop with randomization to one of four conditions: (1) no warning sign, (2) a sign with six FDA proposed text-only warnings, (3) a sign with six novel text-only warnings, or (4) a sign with six novel text + image warnings. We used analysis of variance (ANOVA) models and post hoc Tukey tests to examine the results.

RESULTS

The FDA-proposed text-only warning sign was perceived as less effective in discouraging participants from smoking cigars (M: 3.26, SD: 1.39; scale range: 1-5, where five indicates higher discouragement) compared with the novel text-only warning sign (M = 3.38, SD = 1.40) and the novel text + image warning sign (M = 3.65, SD = 1.34). The novel text + image warning sign increased discouragement from smoking cigars versus the FDA-proposed text-only warning sign (p = .02) and decreased the perceived satisfaction of smoking cigars versus no warning sign (p = .04). In a sensitivity analysis, the novel text + image warning sign decreased the perceived satisfaction of smoking cigars (p = .01), decreased cigar purchase intentions (p = .03), decreased the urge to smoke (p = .03), and increased discouragement from smoking cigars (p = .006) compared with all other study conditions.

CONCLUSIONS

Results provide new evidence that policymakers, such as the FDA, could use when proposing POS warning signs for cigars.

IMPLICATIONS

The US FDA proposed that retailers display a warning sign at the POS for cigars sold individually without packaging. We conducted an online experiment concerning the potential effectiveness of this regulatory policy with people who use cigars recruited from a probability-based panel. Results provide the first evidence that the FDA-proposed text-only warning sign was perceived as less effective than other types of warning signs and that adding images could potentially increase the effectiveness of warning signs. These findings are particularly relevant for premium cigars, which are often sold individually in brick-and-mortar retail settings.

How do current tobacco warnings compare to the WHO FCTC guidelines: a content analysis of combustible tobacco warnings worldwide

OBJECTIVE

Many countries have adopted warning labels for combustible tobacco products, yet little research exists describing tobacco warning characteristics globally and to what extent they meet the WHO Framework Convention for Tobacco Control (FCTC) Guidelines. This study evaluates characteristics of combustible tobacco warnings.

DESIGN

We conducted a content analysis to describe the overall landscape of warnings using descriptive statistics and compared to the WHO FCTC Guidelines.

SETTING

We searched existing warning databases for combustible tobacco warnings from English-speaking countries. We compiled warnings meeting inclusion criteria and coded for message and image characteristics using a pre-defined codebook.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Characteristics of combustible tobacco warning text statements and warning images were the primary study outcomes. There were no secondary study outcomes.

RESULTS

We identified a total of 316 warnings from 26 countries or jurisdictions worldwide. Of these warnings, 94% included warning text and an image. Warning text statements most often described health effects to the respiratory (26%), circulatory (19%) and reproductive systems (19%). Cancer was the most frequently mentioned health topic (28%). Fewer than half of warnings included a Quitline resource (41%). Few warnings included messages about secondhand smoke (11%), addiction (6%) or cost (1%). Of warnings with images, most were in colour and showed people (88%), mostly adults (40%). More than 1 in 5 warnings with images included a smoking cue (ie, cigarette).

CONCLUSIONS

While most tobacco warnings followed WHO FCTC guidance on effective tobacco warnings, such as communicating health risks and inclusion of images, many did not include local Quitline or cessation resources. A sizeable minority include smoking cues that could inhibit effectiveness. Full alignment with WHO FCTC guidelines will improve warnings and better achieve the WHO FCTC objectives.

Communicating the risks of tobacco and alcohol co-use

BACKGROUND

While tobacco and alcohol co-use is highly prevalent across the United States, little experimental research has examined ways to counter such dual use. We developed and tested messages about the risks of co-using tobacco and alcohol among adults who used a combustible tobacco product and drank alcohol within the 30 days.

METHODS

In an online experiment, 1,300 participants were randomly assigned to read different messages about tobacco and alcohol co-use (e.g., Alcohol and tobacco cause throat cancer). Three between-subjects experiments manipulated the presence of: 1) a marker word (e.g., Warning), 2) text describing the symptoms of health effects and a quitting self-efficacy cue, and 3) an image depicting the health effect. Participants rated each message using a validated Perceived Message Effectiveness (PME) scale. We used independent samples t-tests to examine differences between experimental conditions. Results include effect sizes (Cohen's d) to compare standardized mean differences.

RESULTS

Our sample was 64% male, 70% white, 23% Black, and 17% Hispanic/Latino with a mean age of 42.4 (SD = 16.4) years. Messages that described the symptoms of the health effect (d = 0.17, p = 0.002) and included an image (d = 0.11, p = 0.04) were rated significantly higher in PME compared with messages that did not describe symptoms and were text-only. We found no significant effects of a marker word or self-efficacy cue on PME.

CONCLUSIONS

Messages that describe the symptoms of health effects and include text and images may be particularly effective for communicating the risks of tobacco and alcohol co-use and decreasing adverse health effects from co-use.

The Impact of Cannabis Packaging Characteristics on Perceptions and Intentions

INTRODUCTION

As cannabis increasingly becomes a consumer product in the U.S., its product packaging has become critically important to regulators. This study examined the influence of recreational cannabis packaging characteristics.

METHODS

Five online between-subjects experiments were conducted in April 2021, and data were analyzed in May 2021-July 2021. Experiments randomized participants to view different (1) types of cannabis, (2) visual displays of tetrahydrocannabinol content, (3) cannabis packages designed around brand personality research, (4) health warnings, and (5) health claims. Outcomes included cognitive, affective, and behavioral responses.

RESULTS

A total of 841 adults from the U.S. (49% male, 50% young adults, 44% White, 17% Hispanic) were included in the study. Edible gummies were perceived as healthier (β=0.32, 95% CI=0.03, 0.62), less grown up (β= -0.58, 95% CI= -0.86, -0.28), and more socially acceptable to consume (β=0.30, 95% CI=0.01, 0.59) than cannabis concentrate in a medical dropper. Participants also had more interest in trying edible gummies (β=1.33, 95% CI=1.04, 1.62) and trying a free sample (β=1.30, 95% CI=1.01, 1.60) than trying cannabis concentrate. Cannabis packages with a helps-you-relax health claim elicited more happy (β=0.34, 95% CI=0.04, 0.64) and good (β=0.37, 95% CI=0.07, 0.67) feelings than cannabis packages without this claim. Minimal effects were found for visual displays of tetrahydrocannabinol content and health warnings.

CONCLUSIONS

Edibles are a unique type of cannabis that should be given special consideration under state laws, and lawmakers should consider limiting and governing the use of both implicit and explicit health claims on recreational cannabis packages when implementing laws.

A Mixed Methods Approach to Improving Provider Counseling of Patients Who Vape

Significance

Vaping is an epidemic among young people, but there is little guidance on how medical providers should counsel young adults about vaping. To address this gap, we examined how electronic health record (EHR) systems prompt providers to collect vaping data and interviewed young adults about vaping communications with providers and preferred information sources.

Methods

In this mixed methods study, we used survey research methods to explore if prompts exist in EHR systems to guide discussions about vaping with youth seen in primary care. We collected primary care practice information about EHR prompts regarding e-cigarette use from 10 rural North Carolina practices from August 2020 through November 2020 and interviewed 17 young adults (age 18-21 years) who reviewed resources and provided their opinion on the resource's relevance for their age group. Interviews were stratified by vaping status, transcribed, coded, and thematically analyzed.

Results

Only 5 of 10 EHR systems included prompts to capture information about vaping and data capture was optional in all 5 cases. Of the 17 interviewees, 10 were female, 14 were White, 3 were non-White and the mean age was 19.6 years. Two central themes emerged. Young adults: 1) were open to confidential, non-confrontational interactions with trusted providers and supported the use of a 2-page resource/discussion guide, questionnaires about vaping, and other waiting room resources, and 2) wanted prevention and cessation resources to be age-appropriate, including medical facts from a trusted source, and to be disseminated via social media platforms used by young adults.

Conclusions

We found a lack of EHR functionalities in screening for vaping status hindered patients from receiving counseling on use. Young adults report a willingness to communicate with and learn from trusted providers and to gain understanding from information accessed via social media.

Reducing Misperceptions About Very Low Nicotine Content Cigarettes: Insights From Adults Who Smoke

INTRODUCTION

Many people incorrectly think that very low nicotine content (VLNC) cigarettes are less carcinogenic than current cigarettes. This risk misperception by people who smoke could reduce motivation to quit under a nicotine reduction policy. We qualitatively examined perspectives on campaign messages designed to reduce misperceptions.

AIMS AND METHODS

Adults who smoke from North Carolina participated in online interviews. After being introduced to the idea of a VLNC policy, participants were shown VLNC messages and asked about their perceptions on the clarity, understandability, persuasiveness, and meaning of the messages. We conducted a thematic content analysis of the transcripts.

RESULTS

Thirty adults who smoke cigarettes participated (15 females, 13 males, 2 nonbinary) with a mean age of 43 years. Central themes that emerged were: (1) Confusion about the proposed VLNC cigarette policy affected how messages were interpreted; (2) Messages that promote self-efficacy for quitting rather than guilt or fear were better received; and (3) Direct and succinct messages were seen as more able to grab attention and inform people who smoke. Some participant concerns focused on whether VLNC cigarettes would relieve their nicotine cravings and whether they would need to smoke more VLNC cigarettes to feel satisfied.

CONCLUSION

Campaign messages to educate the public about the harmful effects of smoking VLNC cigarettes may be more effective if people who smoke are informed about the policy's rationale to understand why nicotine is removed rather than the other harmful chemicals. Messages should also acknowledge the difficulty of quitting and be short and direct to capture attention.

IMPLICATIONS

Adults who smoke have some confusion about nicotine reduction in cigarettes and this affects how they perceive potential communication campaign messages about the risk of smoking VLNC cigarettes. In our qualitative research, we found that adults who smoke prefer messages about VLNC cigarettes that acknowledge the challenge of quitting and that are direct and succinct. With further development, campaign messages may be able to reduce misperceptions about VLNC cigarettes and maximize the public health benefit of a nicotine reduction policy.

Impact of an e-cigarette tax on cigarette and e-cigarette use in a middle-income country: a study from Indonesia using a pre-post design

OBJECTIVES

Indonesia implemented its first e-cigarette regulation in 2018, a 57% tax on the retail price of e-cigarette liquid (e-liquid), exceeding the 40% average tax on cigarettes. Economic research suggests that this tax could unintentionally increase cigarette smoking among dual users, but this has not been examined in a low-income or middle-income country. We therefore investigated the effects of the e-liquid tax among adults in Indonesia.

DESIGN

Pre-post study.

SETTING

Indonesia.

PARTICIPANTS

Adults who currently used e-cigarettes and either currently or occasionally smoked cigarettes or recently quit were recruited using Facebook and Instagram ads. Our follow-up response rate was 79%. A final sample of 1039 adults participated.

PRIMARY OUTCOME MEASURES

E-cigarette and cigarette use.

RESULTS

Following the e-liquid tax, participants reported paying a 4.4% higher price for e-liquid (p=0.02). Participants also reported an average 0.5-day decrease in the number of days they used e-cigarettes in the past week (p<0.001), and the proportion of daily e-cigarette users decreased (75.9% to 63.6%; p<0.001). Overall, reported use of cigarettes also declined, on average, by nine cigarettes per week. Participants who reported decreasing their e-cigarette use had higher odds of reporting increasing their cigarette use rather than reporting no change (adjusted OR: 2.99; 95% CI: 1.95 to 4.59). Further, as participants reported using e-cigarettes less frequently, they reported using cigarettes more frequently (β=-2.41, p=0.007).

CONCLUSIONS

Following an e-liquid tax in Indonesia, prices of e-liquid increased slightly, e-cigarette and cigarette use declined, and people who reported decreasing their e-cigarette use reported increasing their cigarette use. To avoid encouraging cigarette use, a prudent approach would be to raise cigarette taxes concurrently with e-cigarette taxes.

Preferences for different features of ENDS products by tobacco product use: a latent class analysis

BACKGROUND

From a public health perspective, electronic nicotine delivery devices (ENDS) use may be beneficial for some populations (e.g., smokers who fully switch to ENDS) but detrimental for others (e.g., nonsmokers). Understanding the importance placed on different ENDS product features by user groups can guide interventions and regulations.

METHODS

Participants were US adults who had used ENDS at least once and from a convenience sample drawn from a market research software in 2016. Participants chose between 9 different ENDS product features (harms of use, general effects of use, use as a cessation aid, initial purchase price, monthly cost, nicotine content, flavor availability, device design, and modifiability). A latent class analysis (LCA) identified subgroups of feature preferences and examined differences between groups by socio-demographics and tobacco product use.

RESULTS

Of the 636 participants, 81% were White, the median age was 42, and 65% were current cigarette smokers. The LCA identified a 4-class solution as the most appropriate model: (1) people with high nicotine dependence who preferred ENDS similar to combustible cigarettes, (2) people with moderate tobacco use who were interested in low nicotine ENDS (3) people who use ENDS and combustible tobacco who preferred lower price and flavored ENDS products, and (4) people who used ENDS predominantly, without a strong preference for any of the features presented.

CONCLUSIONS

Tobacco use classes were associated with differences in preferences for ENDS features. These findings can inform regulations to reduce ENDS use among specific groups of people who use ENDS products.

Designing more effective cigar warnings: an experiment among adult cigar smokers

INTRODUCTION

Little systematic evidence exists about the effectiveness of cigar warnings. This study examined the perceived message effectiveness (PME) of warning statements about different health consequences caused by cigars. PME is a validated self-report scale of how effectively a health message discourages smoking.

METHODS

We conducted an online study from April-May 2020 with adults in the United States who used cigars in the past 30 days (n=777). Participants were randomly assigned to view and rate PME (3 items, range 1 to 5) for 7 out of 37 text warning statements about different health consequences from cigar use. Linear mixed effects models evaluated the most effective warning characteristics (e.g., type of health consequence), controlling for repeated measures and participant demographics.

RESULTS

Analyses showed that health consequences about the cardiovascular system (B=0.38), mouth (B=0.40), other digestive (B=0.45), respiratory system (B=0.36), and early death (B=0.36) were associated with higher PME scores than reproductive health consequences (all p-values <0.001). Similar results were found for these health consequences compared to addiction (all p-values p<0.001). We also observed that awareness of the health consequence was associated with higher PME scores (B=0.19, p<0.001) and length of the warning message (number of characters) was associated with lower PME scores (B=-0.007, p=0.03). No differences were observed between cancer and non-cancer health consequences (p=0.27) or health consequences that used plain language vs. medical jargon (p=0.94).

CONCLUSIONS

Our study provides new evidence about the perceived effectiveness of different cigar health warning statements and identifies features that may strengthen statements.

IMPLICATIONS

Our study with cigar smokers from across the United States provides much-needed evidence concerning the perceived effectiveness of different cigar health warning statements and features that may strengthen such statements. Mandated cigar warnings in the United States could be strengthened by including health consequences that were perceived as more effective in our study (e.g., early death), using health consequences that participants were aware of, and using short warning statements.

Youth Exposure to Warnings on Cigar, E-Cigarette, and Waterpipe Tobacco Packages

INTRODUCTION

Studies of tobacco product warnings have focused primarily on the reach and effectiveness of cigarette warnings for adult smokers, whereas few observational studies have examined noncigarette tobacco product warnings among youth.

METHODS

High school students from the 2019 National Youth Tobacco Survey (n=10,094) reported the frequency of exposure to warnings on cigar, e-cigarette, and waterpipe tobacco packages and the perceived harm of occasionally using e-cigarettes and waterpipe tobacco. In 2020, results were analyzed for the entire sample and among subgroups, including never users, ever users, youth susceptible to using tobacco, and current users.

RESULTS

Reported high exposure to warnings was highest for cigars (22.3%), followed by that for e-cigarettes (20.8%) and that for waterpipe tobacco (7.0%). Youth who were susceptible to using cigars (AOR=1.53, 95% CI=1.29, 1.82), who ever used cigars (AOR=4.32, 95% CI=3.57, 5.22), or who currently used cigars (AOR=8.90, 95% CI=6.95, 11.39) were more likely to report high exposure to cigar warnings than youth who never used cigars. Similar findings were observed for e-cigarette and waterpipe tobacco warnings. For youth who ever used e-cigarettes, high exposure to warnings was associated with higher odds of perceiving e-cigarettes as harmful for occasional product use (AOR=1.50, 95% CI=1.05, 2.15), and high exposure to waterpipe tobacco warnings was associated with higher odds of perceiving waterpipe tobacco as harmful (AOR=1.21, 95% CI=1.00, 1.45).

CONCLUSIONS

Warnings on noncigarette tobacco products reach some youth at risk for using these products, but these warnings may need to be strengthened to further reduce their use.

Effect of Cigarette Constituent Messages With Engagement Text on Intention to Quit Smoking Among Adults Who Smoke Cigarettes: A Randomized Clinical Trial

IMPORTANCE

The US Food and Drug Administration (FDA) is required to communicate the risks of tobacco constituents to the public. Few studies have addressed how FDA media campaigns can effectively communicate about cigarette smoke constituents.

OBJECTIVE

To examine whether messages about cigarette smoke constituents are effective in reducing smoking intentions and behaviors among adults who smoke.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial enrolled participants who were aged between 18 and 65 years, were English speakers, were living in the United States, and who smoked at least 100 cigarettes during their lifetime and now smoked every day or some days. Participants received daily messages via email for 15 days. Participants were randomized to 1 of 2 message conditions or a control group and reported their previous-day smoking behaviors daily. Follow-up surveys were conducted on days 16 and 32. Data were collected from June 2017 to April 2018 and analyzed from April to September 2018.

INTERVENTIONS

The 3 groups were (1) constituent plus engagement messages (eg, "Cigarette smoke contains arsenic. This causes heart damage.") that included the FDA as the source and engagement text (eg, "Within 3 months of quitting, your heart and lungs work better. Ready to be tobacco free? You can quit. For free nicotine replacement, call 1-800-QUIT-NOW"); (2) constituent-only messages that did not list the FDA as the source or include engagement text; and (3) a control condition with messages about littering cigarette butts.

MAIN OUTCOMES AND MEASURES

The primary outcome was the change in quit intentions (range, 1-4, with higher scores indicating stronger intentions) from pretest to day 16. Secondary outcome measures included daily smoking behaviors and quit attempts.

RESULTS

A total of 789 participants (mean [SD] age, 43.4 [12.9] years; 483 [61.2%] women; 578 [73.3%] White; 717 [90.9%] non-Hispanic) were included in the study. The mean (SD) quit intention score was 2.5 (0.9) at pretest. Mean (SE) change in quit intention score from pretest to day 16 was 0.19 (0.07) points higher in the constituent plus engagement condition than in the control condition (P = .005) and 0.23 (0.07) points higher in the constituent-only condition compared with the control condition (P = .001). Participant reports of cigarettes smoked, forgone, and butted out were similar across study conditions at baseline and did not differ significantly at days 16 and 32 across study conditions. Viewing more messages was associated with an estimated decrease of 0.15 (SE, 0.01) cigarettes smoked per day per message viewed overall across conditions.

CONCLUSIONS AND RELEVANCE

To our knowledge, this is the first longitudinal test of cigarette constituent campaign messages in a national sample of adults who currently smoke. Messages about cigarette smoke constituents, with or without engagement text and source information, increased participants' intentions to quit, lending support to FDA efforts to educate consumers about such constituents.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03339206.

Public Understanding of Cigarette Smoke Chemicals: Longitudinal Study of US Adults and Adolescents

INTRODUCTION

The US Food and Drug Administration has increased communication efforts that aim to raise public awareness of the harmful constituents (ie, chemicals) in cigarette smoke. We sought to investigate whether the public's awareness of these chemicals has increased in light of such efforts.

METHODS

Participants were national probability samples of 11 322 US adults and adolescents recruited in 2014-2015 (wave 1) and 2016-2017 (wave 2). Cross-sectional telephone surveys assessed awareness of 24 cigarette smoke chemicals at both timepoints.

RESULTS

The proportion of US adults aware of cigarette smoke chemicals did not differ between waves 1 and 2 (25% and 26%, p = .19). In contrast, awareness of chemicals among adolescents fell from 28% to 22% (p < .001), mostly due to lower awareness of carbon monoxide, arsenic, benzene, and four other chemicals. Belief that most of the harmful chemicals in cigarette smoke come from burning the cigarette also fell from waves 1 to 2 (adults: 31% vs. 26%; adolescents: 47% vs. 41%, both ps < .05). Participants were more likely to be aware of cigarette smoke chemicals if they had been exposed to anti-smoking campaign advertisements (p < .05) or had previously sought chemical information (p < .05). Cigarette smoke chemical awareness did not differ between smokers and nonsmokers.

CONCLUSION

Awareness of cigarette smoke chemicals remains low and unchanged among adults and decreased somewhat among adolescents. The association of chemical awareness with information exposure via campaigns and information seeking behavior is promising. More concerted communication efforts may be needed to increase public awareness of cigarette smoke chemicals, which could potentially discourage smoking.

IMPLICATIONS

Awareness of the toxic chemicals in cigarette smoke may contribute to quitting. The US Food and Drug Administration is making efforts to increase public awareness of these chemicals. Two national surveys (2014-2017) found that chemical awareness was low among adults and adolescents. Although awareness did not change among adults, awareness among adolescents dropped over time. In addition, exposure to anti-smoking campaigns and chemical information seeking behavior were associated with higher awareness of chemicals in cigarette smoke. Campaigns and other efforts may be needed to increase awareness of cigarette smoke chemicals.

Tobacco Quit Intentions and Behaviors among Cigar Smokers in the United States in Response to COVID-19

Combustible tobacco users appear to be at greater risk for serious complications from COVID-19. This study examined cigar smokers' perceived risk of COVID-19, quit intentions, and behaviors during the current pandemic. We conducted an online study between 23 April 2020 to 7 May 2020, as part of an ongoing study examining perceptions of different health effects of cigars. All participants used cigars in the past 30 days (n = 777). Three-quarters of the sample (76.0%) perceived they had a higher risk of complications from COVID-19 compared to non-smokers. The majority of participants (70.8%) intended to quit in the next six months due to COVID-19, and almost half of the sample (46.5%) reported making a quit attempt since the start of the COVID-19 pandemic. Far more participants reported increasing their tobacco use since COVID-19 started (40.9%) vs. decreasing their tobacco use (17.8%). Black or African American participants, participants who reported using a quitline, and participants with higher COVID-19 risk perceptions had higher intentions to quit using tobacco due to COVID-19, and higher odds of making a quit attempt since COVID-19 started. More research is needed to understand how tobacco users are perceiving COVID-19 risks and changing their tobacco use behaviors.

Cigarette Constituent Health Communications for Smokers: Impact of Chemical, Imagery, and Source

INTRODUCTION

Communication campaigns are incorporating tobacco constituent messaging to reach smokers, yet there is a dearth of research on how such messages should be constructed or will be received by smokers.

METHODS

In a 2 × 2 × 2 experiment, we manipulated three cigarette constituent message components: (1) the toxic constituent of tobacco (arsenic vs. lead) with a corresponding health effect, (2) the presence or absence of an evocative image, and (3) the source of the message (FDA vs. no source). We recruited smokers (N = 1669, 55.4% women) via an online platform and randomized them to one of the eight message conditions. Participants viewed the message and rated its believability and perceived effectiveness, the credibility of the message source, and action expectancies (ie, likelihood of seeking additional information and help with quitting as a result of seeing the message).

RESULTS

We found significant main effects of image, constituent, and source on outcomes. The use of arsenic as the constituent, the presence of an evocative image, and the FDA as the source increased the believability, source credibility, and perceived effectiveness of the tobacco constituent health message.

CONCLUSIONS

Multiple elements of a constituent message, including type of constituent, imagery, and message source, impact their reception among smokers. Specifically, communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes that are associated with subsequent attitude and behavioral changes.

IMPLICATIONS

This article describes how components of communication campaigns about cigarette constituents are perceived. Multiple elements of a tobacco constituent message, including type of constituent, image, and message source may influence the reception of messages among current smokers. Communication campaigns targeting smokers that utilize arsenic as the tobacco constituent, visual imagery, and the FDA logo may be particularly effective in changing key outcomes among smokers. The effects of such campaigns should be examined, as well as the mechanisms through which such campaigns affect change.

Risk, Resilience, and Smoking in a National, Probability Sample of Sexual and Gender Minority Adults, 2017, USA

Background. There are well-documented inequities in smoking between sexual and gender minority (SGM; e.g., lesbian, gay, bisexual, and transgender [LGBT]) and straight and cisgender people. However, there is less information about risk for and resilience against smoking among SGM people. Such information is critical for understanding etiology and developing interventions. Aims. To conduct a within-group assessment of risks and resiliencies relating to smoking status. Method. In 2017, we conducted a cross-sectional telephone survey with a national, probability-based sample of SGM adults (N = 453). We assessed theory-informed risks (adverse childhood events, substance use-oriented social environment, mental distress, stigma, discrimination, social isolation, and identity concealment) and resiliencies (advertising skepticism, identity centrality, social support, and SGM community participation). We applied survey weights, standardized predictor variables, and fit logistic regression models predicting smoking status. We stratified by age and SGM identity. Results. Patterns of risk and resilience differ by age and identity. Effects were consistently in the same direction for all groups for participating in substance use-oriented social environments, pointing to a potential risk factor for all groups. Advertising skepticism and having people you can talk to about being LGBTQ were potential protective factors. Discussion. Intervention development should address risk and resilience that differs by SGM identity. Additionally, our findings suggest interventionists should consider theoretical frameworks beyond minority stress. Conclusion. While much of the literature has focused on the role of stress from stigma and discrimination in tobacco use, addressing social norms and bolstering protective factors may also be important in SGM-targeted interventions.

An Eye Tracking Study of Anti-Smoking Messages on Toxic Chemicals in Cigarettes

The US Food and Drug Administration is tasked with communicating information to the public about the harmful chemicals in cigarette smoke. Our study used eye tracking method to test the effectiveness of messages about the harmful chemicals in cigarettes smoke among adult smokers. A sample size of 211 current cigarette smokers viewed four communication messages that included: Health effects of a chemical in cigarette smoke and an image depicting the health effect. The messages focused on arsenic, formaldehyde, uranium, and general health. Eye tracking recorded the length of time participants viewed the text and the image. After each message, the participants were asked about the messages' effectiveness in changing attitudes towards smoking. We analyzed the data using multilevel modeling, and of the 211 smokers, 59.7% were female, 36.5% were Black, and 21.3% had a high school degree or less. Compared to the general message, the messages about formaldehyde and uranium were more discouraging to smoking (p < 0.05). Messages about formaldehyde were more believable and made participants want to quit more than the general messages. Increasing message dose was significantly associated with discouraging participants from smoking and made participants want to quit (p < 0.05). Our findings suggest that anti-smoking messages, containing chemical information, can successfully increase negative attitudes toward smoking cigarettes and potentially encourage quitting.

Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial

INTRODUCTION

Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings' effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases.

STUDY DESIGN

Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019.

SETTING/PARTICIPANTS

Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).

INTERVENTION

Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label).

MAIN OUTCOME MEASURES

The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness).

RESULTS

All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, -31.4 calories; 95% CI= -57.9, -5.0). Unadjusted analyses yielded similar results (difference, -32.9 calories; 95% CI= -58.9, -7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages' added sugar content, healthfulness, appeal/coolness, or disease risk.

CONCLUSIONS

Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03511937.

Impact of non-menthol flavours in e-cigarettes on perceptions and use: an updated systematic review

OBJECTIVES

Given the exponential increase in the use of e-cigarettes among younger age groups and in the growth in research on e-cigarette flavours, we conducted a systematic review examining the impact of non-menthol flavoured e-cigarettes on e-cigarette perceptions and use among youth and adults.

DESIGN

PubMed, Embase, PyscINFO and CINAHL were systematically searched for studies published and indexed through March 2018.

ELIGIBILITY CRITERIA

Quantitative observational and experimental studies that assessed the effect of non-menthol flavours in e-cigarettes on perceptions and use behaviours were included. Specific outcome measures assessed are appeal, reasons for use, risk perceptions, susceptibility, intention to try, initiation, preference, current use, quit intentions and cessation.

DATA EXTRACTION AND SYNTHESIS

Three authors independently extracted data related to the impact of flavours in tobacco products. Data from a previous review were then combined with those from the updated review for final analysis. Results were then grouped and analysed by outcome measure.

RESULTS

The review included 51 articles for synthesis, including 17 published up to 2016 and an additional 34 published between 2016 and 2018. Results indicate that non-menthol flavours in e-cigarettes decrease harm perceptions (five studies) and increase willingness to try and initiation of e-cigarettes (six studies). Among adults, e-cigarette flavours increase product appeal (seven studies) and are a primary reason many adults use the product (five studies). The role of flavoured e-cigarettes on smoking cessation remains unclear (six studies).

CONCLUSION

This review provides summary data on the role of non-menthol flavours in e-cigarette perceptions and use. Consistent evidence shows that flavours attract both youth and adults to use e-cigarettes. Given the clear findings that such flavours increase product appeal, willingness to try and initiation among youth, banning non-menthol flavours in e-cigarettes may reduce youth e-cigarette use. Longitudinal research is needed to examine any role flavours may play in quit behaviours among adults.

Public Knowledge and Credibility Perceptions of the FDA as a Tobacco Regulator

Introduction

Since the U.S. Food and Drug Administration (FDA) was granted regulatory authority over tobacco products in 2009, few studies have examined perceived credibility of the FDA in this role. The current study assessed knowledge and credibility of the FDA as a regulator of tobacco products.

Methods

In a nationally representative survey of U.S. adults (N = 4758), we assessed knowledge that the FDA regulates the manufacture, distribution, and marketing of cigarettes, and credibility of the FDA as a tobacco regulator. We examined demographic differences in knowledge and credibility, and associations of knowledge and trust in government with credibility perceptions.

Results

Less than half of respondents reported knowing the FDA regulates how cigarettes are sold (46.8%) and advertised (49.7%), and only 36.0% knew the FDA regulates how cigarettes are made, with few demographic differences. Respondents reported that the FDA was moderately credible in regulating tobacco. Knowledge of the FDA as a tobacco regulator and trust in government were the strongest predictors of credibility. Being of younger age, being White (compared to African American), and being male were associated with higher credibility ratings of the FDA.

Conclusions

Much of the public still does not know that the FDA regulates tobacco products, and credibility perceptions are moderate. Greater knowledge of the FDA's regulatory role was associated with higher credibility; efforts that increase the public's understanding of the FDA's role as a tobacco regulator may positively impact views of the agency's credibility. This may in turn improve public reception to the FDA's messages and regulations.

Implications

This study is the first to show nationally representative estimates of both knowledge and credibility of the FDA as a tobacco regulator. Our research shows further that knowledge of the FDA's tobacco regulatory roles is likely to be an important factor related to perceived credibility of the FDA. Increasing the public's knowledge of the FDA's roles may enhance the agency's credibility, which can improve public reception to messages and regulations.

Product attributes important to US adult consumers' use of electronic nicotine delivery systems: a discrete choice experiment

OBJECTIVE

To understand the importance of electronic nicotine delivery systems (ENDS) product attributes to adult consumers in the USA by age and gender.

DESIGN

Cross-sectional survey with a discrete choice experiment (best-worst, case 2, scaling) of 19 choice tasks in which participants answered what would make them most want to use and least want to use an ENDS product.

SETTING AND PARTICIPANTS

A national sample of adults (aged 18+ years) in the USA who had tried an ENDS product at least once.

MEASURES

We included 9 ENDS attributes with levels that varied across 19 choice tasks. We performed a multinomial logistic regression to obtain overall importance scores, attribute-level part-worth utilities and most important attribute.

RESULTS

Of 660 participants, 81% were white, 51% women and 37% had at least a 4-year college degree with an average age of 42.0 years (SD ±19.4). The attributes had the following importance: harms of use 17.6%; general effects 14.1%; cessation aid 12.6%; purchase price 12.1%; monthly cost 12.0%; nicotine content 11.4%; flavour availability 8.4%; device design 7.2%; modifiability 4.6%. Harms of use was the most important attribute for all ages and genders (p<0.05); variation in other important attributes existed by age though not by gender.

CONCLUSION

This study identified the importance of nine ENDS attributes. Perceived harms of use of ENDS use appeared most important, and modifiability was least important. Variation by consumer group existed, which may allow for targeted interventions to modify ENDS use.

Vaping cannabis among adolescents: prevalence and associations with tobacco use from a cross-sectional study in the USA

OBJECTIVE

Previous research suggests that some adolescents are using e-cigarette devices to vaporise ('vaping') cannabis in the form of hash oil, tetrahydrocannabinol (THC) wax or oil, or dried cannabis buds or leaves. However, it is unclear how adolescents who vape cannabis use other tobacco products. This study examined the extent to which adolescents reported ever vaping cannabis and investigated how demographic variables and tobacco behaviours were associated with use.

DESIGN

We used cross-sectional data from adolescents (total response rate 64.5%) who participated in the 2017 North Carolina Youth Tobacco Survey. SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

SETTING

North Carolina, USA.

PARTICIPANTS

Adolescents in high school (n=2835).

PRIMARY OUTCOME AND MEASURE

Adolescents were asked to indicate whether they had ever used an e-cigarette device with marijuana, THC or hash oil, or THC wax.

RESULTS

Approximately 1 in 10 high school students reported ever vaping cannabis in the overall sample (9.6%). In multivariable models, adolescents who reported using cigars (adjusted OR (aOR) 3.76, 95% CI 2.33 to 6.07), waterpipe (aOR 2.32, 95% CI 1.37 to 3.93) or e-cigarettes (aOR 3.18, 95% CI 2.38 to 4.25) in the past 30 days had higher odds of reporting ever vaping cannabis compared with their counterparts. There was no significant association between use of smokeless tobacco (aOR 0.89, 95% CI 0.42 to 1.91) or use of cigarettes (aOR 1.27, 95% CI 0.71 to 2.29) in the past 30 days and odds of reporting ever vaping cannabis.

CONCLUSIONS

These findings provide evidence that large numbers of high school students who use tobacco products have vaped cannabis. As tobacco control policies-such as communication campaigns or smoke-free laws-increasingly focus on e-cigarettes, attention to understanding how adolescents use e-cigarettes to vape substances other than nicotine is essential.

Do Smokers Recall Source or Quitline on Cigarette Constituent Messages?

OBJECTIVES

The Food and Drug Administration (FDA) is required under the Family Smoking Prevention and Tobacco Control Act to communicate the risks of tobacco use to the public. Little research exists about methods to communicate the constituents of tobacco in a media campaign. This research examines specific strategies to increase effectiveness of a media campaign for cigarette smoking adults about tobacco constituents by including engagement text about smoking cessation and FDA as the source of the campaign.

METHODS

In an eye tracking study of 211 current cigarette smokers, participants randomly viewed 4 cigarette constituent messages that varied engagement text for quitting (benefits of quitting and quitline number, presence, absence) and by FDA source (presence, absence). After the eye tracking session, participants were asked about recall of the national quitline number and the source of message.

RESULTS

Participants in conditions with engagement text were significantly more likely than those in the no engagement conditions to recall the national quitline number. Few participants saw or recalled the FDA source.

CONCLUSIONS

Engagement text for smoking cessation on constituent communication campaign messages significantly increases recall of the quitline, an important resource for smokers.

Trends and Racial Disparities in Mono, Dual, and Poly Use of Tobacco Products Among Youth

Introduction

We examined racial disparities in mono, dual, and poly use of tobacco products including whether racial disparities changed over time.

Methods

We analyzed data on high school students from the North Carolina Youth Tobacco Survey collected in 2011, 2013, and 2015. Dual and poly use included use of two and three or more tobacco products, respectively, in the past month. Multinomial regression models assessed racial differences and changes over time in mono, dual, and poly use. Data include product combinations most commonly used by youth from different racial groups.

Results

In total, 24% (in 2011) and 26% (in 2013 and 2015) of students used tobacco products. No significant changes over time were observed in mono (12%) or dual use (6%). Poly use was 6%, 8%, and 7% in 2011, 2013, and 2015, respectively. Relative to nonuse of tobacco, White students had a higher relative risk than Blacks for mono use. Whites and Hispanics had a higher relative risk than Blacks for dual and poly use. Observed racial differences in tobacco use did not change over time. Types of tobacco products used varied by year and race. In 2015, e-cigarette was the most commonly used product among mono users from all racial groups.

Conclusions

Substantial racial variation persists over time in mono and multiple tobacco product use among North Carolina youth, including racial variation in the types of tobacco products used. Research and policy efforts should examine and eliminate factors that drive multiple tobacco use and racial disparities in use among youth.

Implications

This study reports on racial disparities in mono and multiple tobacco product use among youth. White and Hispanic youth have higher relative risk for dual and poly use of tobacco products than Black youth. In addition, significant racial variation exists in the types of tobacco products used among youth mono, dual, and poly users, with cigarettes, cigars, smokeless tobacco, and e-cigarettes being the most commonly used products. Patterns of multiple tobacco product use vary by race and may warrant tailored prevention efforts. Strengthening tobacco control regulations for other tobacco products than cigarettes is critical to reduce multiple tobacco product use among youth.

The effect of cigarillo packaging elements on young adult perceptions of product flavor, taste, smell, and appeal

Introduction

Product packaging has long been used by the tobacco industry to target consumers and manipulate product perceptions. This study examines the extent to which cigarillo packaging influences perceptions of product flavor, taste, smell, and appeal.

Methods

A web-based experiment was conducted among young adults. Participants viewed three randomly selected cigarillo packs, varying on pack flavor descriptor, color, type, branding, and warning—totaling 180 pack images. Mixed-effects models were used to estimate the effect of pack elements on product perceptions.

Results

A total of 2,664 current, ever, and never little cigar and cigarillo users participated. Cigarillo packs with a flavor descriptor were perceived as having a more favorable taste (β = 0.21, p < .001) and smell (β = 0.14, p < .001) compared to packs with no flavor descriptor. Compared to packs with no color, pink and purple packs were more likely to be perceived as containing a flavor (β = 0.11, p < .001), and were rated more favorably on taste (β = 0.17, p < .001), smell (β = 0.15, p < .001), and appeal (β = 0.16, p < .001). While warnings on packs decreased favorable perceptions of product taste (pictorial: β = -0.07, p = .03) and smell (text-only: β = -0.08, p = .01; pictorial: β = -0.09, p = .007), warnings did not moderate the effects of flavor descriptor or color.

Conclusions

To our knowledge, this study provides the first quantitative evidence that cigarillo packaging alters consumers’ cognitive responses, and warnings on packs do not suffice to overcome the effects of product packaging. The findings support efforts at federal, state, and local levels to prohibit flavor descriptors and their associated product flavoring in non-cigarette products such as cigarillos, along with new data that supports restrictions on flavor cues and colors.

E-Cigarette Use Among Adolescents Not Susceptible to Using Cigarettes

Introduction

Research suggests that adolescents who use electronic cigarettes (e-cigarettes), including adolescents not susceptible to smoking cigarettes (ie, those who have never smoked cigarettes and are not attitudinally susceptible to using cigarettes), are more likely to initiate using cigarettes or other combustible tobacco products than adolescents who do not use e-cigarettes. In this study, we examined correlates of e-cigarette use and susceptibility among adolescents not susceptible to future cigarette smoking.

Methods

We used data on high school students from the 2015 North Carolina Youth Tobacco Survey (n = 1,627). SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

Results

Increasing perceived harm of e-cigarettes was associated with lower odds of susceptibility to using e-cigarettes (adjusted odds ratio [AOR] = 0.79; 95% confidence interval [CI], 0.65–0.96) and current use of e-cigarettes (AOR = 0.43; 95% CI, 0.25–0.72). Similar patterns were found for perceived harm of secondhand e-cigarette vapor. Exposure to e-cigarette vapor in indoor or outdoor public places was positively associated with susceptibility to using e-cigarettes (AOR = 1.96; 95% CI, 1.33–2.91) and with current e-cigarette use (AOR = 5.69; 95% CI, 2.57–12.61).

Conclusion

To prevent initiation of e-cigarette use, particularly among adolescents not susceptible to smoking cigarettes, educational campaigns could target harm perceptions associated with e-cigarettes. In addition, regulations that limit adolescents’ exposure to e-cigarettes in public places may decrease e-cigarette use by nonsusceptible adolescents.

Effects of Framing Proximal Benefits of Quitting and Motivation to Quit as a Query on Communications About Tobacco Constituents

INTRODUCTION

Little is known on how to communicate messages on tobacco constituents to tobacco users. This study manipulated three elements of a message in the context of a theory-based communication campaign about tobacco constituents: (1) latency of response efficacy (how soon expected health benefits would accrue), (2) self-efficacy (confidence about quitting), and (3) interrogative cue ("Ready to be tobacco-free?").

METHODS

Smokers (N = 1669, 55.4% women) were recruited via an online platform, and were randomized to a 3 (Latency of response efficacy) × 2 (Self-efficacy) × 2 (Interrogative cue) factorial design. The dependent variables were believability, credibility, perceived effectiveness of the communication message, and action expectancies (likelihood of seeking additional information and help with quitting).

RESULTS

Latency of response efficacy influenced believability, perceived effectiveness, credibility, and action expectancies. In each case, scores were higher when specific health benefits were said to accrue within 1 month, as compared to general health benefits occurring in a few hours. The interrogative cue had a marginal positive effect on perceived effectiveness. The self-efficacy manipulation had no reliable effects, and there were no significant interactions among conditions.

CONCLUSIONS

Smokers appear less persuaded by a communication message on constituents where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, smokers appeared to be more persuaded by messages with an interrogative cue. Such findings may help design more effective communication campaigns on tobacco constituents to smokers.

IMPLICATIONS

This paper describes, for the first time, how components of tobacco constituent messages are perceived. We now know that smokers appear to be less persuaded by communication messages where general health benefits accrue immediately (within a few hours) than specific benefits over a longer timeframe (1 month). Additionally, including an interrogative cue ("Ready to be tobacco free?") may make messages more effective, whereas the self-efficacy manipulation designed to increase confidence about quitting had no effect. While messages were universally impactful across smoker subpopulations, everyday smokers and smokers with less trust in the government may be less receptive to communication campaigns.

Consumers' Preferences for Electronic Nicotine Delivery System Product Features: A Structured Content Analysis

To inform potential governmental regulations, we aimed to develop a list of electronic nicotine delivery system (ENDS) product features important to U.S. consumers by age and gender. We employed qualitative data methods. Participants were eligible if they had used an ENDS at least once. Groups were selected by age and gender (young adult group aged 18–25, n = 11; middle-age group aged 26–64, n = 9; and women’s group aged 26–64, n = 9). We conducted five individual older adult interviews (aged 68–80). Participants discussed important ENDS features. We conducted a structured content analysis of the group and interview responses. Of 34 participants, 68% were white and 56% were female. Participants mentioned 12 important ENDS features, including: (1) user experience; (2) social acceptability; (3) cost; (4) health risks/benefits; (5) ease of use; (6) flavors; (7) smoking cessation aid; (8) nicotine content; (9) modifiability; (10) ENDS regulation; (11) bridge between tobacco cigarettes; (12) collectability. The most frequently mentioned ENDS feature was modifiability for young adults, user experience for middle-age and older adults, and flavor for the women’s group. This study identified multiple features important to ENDS consumers. Groups differed in how they viewed various features by age and gender. These results can inform ongoing regulatory efforts.

Public attitudes toward larger cigarette pack warnings: Results from a nationally representative U.S. sample

A large body of evidence supports the effectiveness of larger health warnings on cigarette packages. However, there is limited research examining attitudes toward such warning labels, which has potential implications for implementation of larger warning labels. The purpose of the current study was to examine attitudes toward larger warning sizes on cigarette packages and examine variables associated with more favorable attitudes. In a nationally representative survey of U.S. adults (N = 5,014), participants were randomized to different warning size conditions, assessing attitude toward "a health warning that covered (25, 50, 75) % of a cigarette pack." SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights. Across experimental groups, nearly three-quarters (72%) of adults had attitudes supportive of larger warning labels on cigarette packs. Among the full sample and smokers only (N = 1,511), most adults had favorable attitudes toward labels that covered 25% (78.2% and 75.2%, respectively), 50% (70% and 58.4%, respectively), and 75% (67.9% and 61%, respectively) of a cigarette pack. Young adults, females, racial/ethnic minorities, and non-smokers were more likely to have favorable attitudes toward larger warning sizes. Among smokers only, females and those with higher quit intentions held more favorable attitudes toward larger warning sizes. Widespread support exists for larger warning labels on cigarette packages among U.S. adults, including among smokers. Our findings support the implementation of larger health warnings on cigarette packs in the U.S. as required by the 2009 Tobacco Control Act.

Believability of Cigar Warning Labels Among Adolescents

PURPOSE

Despite high rates of cigar use among youth, little information exists about how cigar warnings are received by youth. We examined believability of different cigar warning messages with different sources among adolescents in a national phone survey.

METHODS

Adolescents (aged 13-17 years) in the US (N = 1,125; total response rate, 66%) were randomized to receive one of three health messages ("cigar smoking can cause cancers of the mouth and throat, even if you do not inhale," "cigar smoking can cause lung cancer and heart disease," and "cigars are not a safe alternative to cigarettes") and one of four warning sources (Food and Drug Administration, Surgeon General, Centers for Disease Control and Prevention, and no source). Believability was assessed with "how believable is this warning," and responses were dichotomized for "not at all or somewhat" versus "very."

RESULTS

Weighted logistic regression results indicated that most youth found the cigar warnings very believable (60.5%). Messages about mouth and throat cancer (regardless of inhalation) and the safety of cigars in comparison to cigarettes were rated as significantly less believable than messages about lung cancer and heart disease related to cigars. There were no significant differences by source or other demographics. However, youth susceptible to using cigarettes were less likely to report the cigar warnings to be very believable.

CONCLUSIONS

The messages of cigar warning labels are not viewed as equally believable among adolescents. Future studies should examine how youth process messages about health effects of cigars and the impact of different cigar warnings on youth experimentation with and use of cigars.

Impact of The Real Cost Campaign on Adolescents' Recall, Attitudes, and Risk Perceptions about Tobacco Use: A National Study

The Food and Drug Administration’s (FDA) The Real Cost campaign advertisements (ads) have targeted U.S. youth with messages designed to prevent and reduce tobacco use. This study examined exposure to The Real Cost campaign, including ad and slogan recall, and associations with attitudes and risk perceptions among U.S. adolescents. We analyzed data from a nationally representative sample of adolescents aged 13 to 17 years (n = 1125) surveyed by phone from October 2014 to June 2015. We assessed aided recall of and attitudes toward four campaign ads and the one slogan. Logistic regression models assessed whether aided recall of The Real Cost ads or slogan was associated with perceived likelihood of serious health consequences of cigarette smoking. Most (88%) adolescents reported seeing or hearing at least one of four ads for The Real Cost, and 54% recalled The Real Cost slogan. The majority of adolescents reported more negative attitudes toward tobacco products after seeing or hearing the ads. Recall of any The Real Cost ad was significantly associated with greater perceptions of serious health consequences of cigarette smoking (Adjusted Odd Ratios (AOR) = 5.58, 95% Confidence Interval (CI) = 1.20–25.90). The FDA’s The Real Cost campaign has achieved very high reach and is associated with more negative attitudes toward tobacco products and greater risk perceptions of cigarette smoking among U.S. adolescents.

Impact of non-menthol flavours in tobacco products on perceptions and use among youth, young adults and adults: a systematic review

Objective

This systematic review examines the impact of non-menthol flavours in tobacco products on tobacco use perceptions and behaviours among youth, young adults and adults.

Data sources

English-language peer-reviewed publications indexed in 4 databases were searched through April 2016.

Study selection

A search strategy was developed related to tobacco products and flavours. Of 1688 articles identified, we excluded articles that were not English-language, were not peer-reviewed, were qualitative, assessed menthol-flavoured tobacco products only and did not contain original data on outcomes that assessed the impact of flavours in tobacco products on perceptions and use behaviour.

Data extraction

Outcome measures were identified and tabulated. 2 researchers extracted the data independently and used a validated quality assessment tool to assess study quality.

Data synthesis

40 studies met the inclusion criteria. Data showed that tobacco product packaging with flavour descriptors tended to be rated as more appealing and as less harmful by tobacco users and non-users. Many tobacco product users, especially adolescents, reported experimenting, initiating and continuing to use flavoured products because of the taste and variety of the flavours. Users of many flavoured tobacco products also showed decreased likelihood of intentions to quit compared with non-flavoured tobacco product users.

Conclusions

Flavours in most tobacco products appear to play a key role in how users and non-users, especially youth, perceive, initiate, progress and continue using tobacco products. Banning non-menthol flavours from tobacco products may ultimately protect public health by reducing tobacco use, particularly among youth.

"The Job Has Become Advocating for the Job": Threats to Funding Dramatically Influence Program Outcomes

As public health funding is increasingly threatened, a better understanding is needed about how periods of funding uncertainty impact program staff, activities, and outcomes. In North Carolina, 2 years of uncertainty and threats of funding cuts for a statewide youth tobacco prevention initiative contributed to reduced grantee morale and confidence about achieving program goals, displaced focus from core program activities, and caused premature loss of personnel, resulting in substantially reduced program activities and outcomes. The range of negative impacts of funding uncertainty and threats highlights the need for programs to create an infrastructure to support ongoing sustainability planning and activities.

Electronic Cigarette Use Among High School Students and Its Association With Cigarette Use And Smoking Cessation, North Carolina Youth Tobacco Surveys, 2011 and 2013

Introduction

Although adolescent cigarette use continues to decline in the United States, electronic cigarette (e‑cigarette) use among adolescents has escalated rapidly. This study assessed trends and patterns of e‑cigarette use and concurrent cigarette smoking and the relationships between e-cigarette use and smoking cessation intentions and behaviors among high school students in North Carolina.

Methods

Data came from high school students who completed the school-based, cross-sectional North Carolina Youth Tobacco Survey in 2011 (n = 4,791) and 2013 (n = 4,092). This study assessed changes in prevalence of e-cigarette and cigarette use from 2011 through 2013, and cessation-related factors associated with those students’ current and past use of e‑cigarettes in 2013.

Results

The prevalence of current e-cigarette use (use in the past 30 days) significantly increased from 1.7% (95% CI, 1.3%–2.2%) in 2011 to 7.7% (95% CI, 5.9%–10.0%) in 2013. Among dual users, current e-cigarette use was negatively associated with intention to quit cigarette smoking for good (relative risk ratio [RRR] = 0.51; 95% CI, 0.29–0.87) and with attempts to quit cigarette smoking in the past 12 months (RRR = 0.69; 95% CI, 0.49–0.97). Current e-cigarette smokers were less likely than those who only smoked cigarettes to have ever abstained from cigarette smoking for 6 months (RRR = 0.42; 95% CI, 0.21–0.82) or 1 year (RRR = 0.21; 95% CI, 0.09–0.51) and to have used any kind of aids for smoking cessation (RRR = 0.46; 95% CI, 0.29–0.74).

Conclusion

Public health practitioners and cessation clinic service providers should educate adolescents about the risks of using any nicotine-containing products, including e-cigarettes, and provide adequate tobacco cessation resources and counseling to adolescent tobacco users.

Pilot Implementation of a Wellness and Tobacco Cessation Curriculum in North Carolina Group Homes

Despite a steady decline in smoking rates in recent decades, individuals with mental illness continue to smoke at disproportionately higher rates than the general population. Adults with mental illness are motivated to quit and quit with rates similar to the general population when evidence-based cessation interventions are used. To build an evidence base for a wellness and cessation curriculum aimed at individuals with mental illness, the Breathe Easy Live Well (BELW) program was pilot tested in two group homes in North Carolina in the spring of 2014. Evaluators conducted pre- and post-implementation site visits and interviews with program instructors to assess outcomes as well as barriers and facilitators to implementation. Qualitative analysis of the data indicated that implementation was successful in both group homes, and the following themes emerged: (1) Training and technical assistance provided throughout implementation was sufficient; (2) Instructors used prior professional experiences and goal setting to facilitate program success and participant engagement; (3) Fostering positive coping strategies contributed to reports of reduced smoking; (4) Curriculum length may be a barrier to recruitment. Additional results included an increased interest among group home residents in more diligently managing mental illness symptoms and one group home moving the designated smoking area out of the direct path of the entrance/exit. Results of this pilot project suggest that BELW could be a potentially useful tool for group home staff to address health and wellness along with smoking cessation among individuals with mental illness.

"May I Buy a Pack of Marlboros, Please?" A Systematic Review of Evidence to Improve the Validity and Impact of Youth Undercover Buy Inspections

Most smokers become addicted to tobacco products before they are legally able to purchase these products. We systematically reviewed the literature on protocols to assess underage purchase and their ecological validity. We conducted a systematic search in May 2015 in PubMed and PsycINFO. We independently screened records for inclusion. We conducted a narrative review and examined implications of two types of legal authority for protocols that govern underage buy enforcement in the United States: criminal (state-level laws prohibiting sales to youth) and administrative (federal regulations prohibiting sales to youth). Ten studies experimentally assessed underage buy protocols and 44 studies assessed the association between youth characteristics and tobacco sales. Protocols that mimicked real-world youth behaviors were consistently associated with substantially greater likelihood of a sale to a youth. Many of the tested protocols appear to be designed for compliance with criminal law rather than administrative enforcement in ways that limited ecological validity. This may be due to concerns about entrapment. For administrative enforcement in particular, entrapment may be less of an issue than commonly thought. Commonly used underage buy protocols poorly represent the reality of youths' access to tobacco from retailers. Compliance check programs should allow youth to present themselves naturally and attempt to match the community's demographic makeup.

Neighborhood Inequalities in Retailers' Compliance With the Family Smoking Prevention and Tobacco Control Act of 2009, January 2014-July 2014

Introduction

Retailer noncompliance with limited US tobacco regulations on advertising and labeling was historically patterned by neighborhood in ways that promote health disparities. In 2010, the US Food and Drug Administration (FDA) began enforcing stronger tobacco retailer regulations under the Family Smoking Prevention and Tobacco Control Act of 2009. However, recent research has found no differences in compliance by neighborhood characteristics for FDA advertising and labeling inspections. We sought to investigate the neighborhood characteristics associated with retailer noncompliance with specific FDA advertising and labeling inspections (ie, violations of bans on self-service displays, selling single cigarettes, false or mislabeled products, vending machines, flavored cigarettes, and free samples).

Methods

We coded FDA advertising and labeling warning letters (n = 718) for type of violations and geocoded advertising and labeling inspections from January 1 through July 31, 2014 (N = 33,543). Using multilevel models, we examined cross-sectional associations between types of violations and neighborhood characteristics previously associated with disparities (ie, percentage black, Latino, under the poverty line, and younger than 18 years).

Results

Retailer advertising and labeling violations are patterned by who lives in the neighborhood; regulated tobacco products are more likely to be stored behind the counter as the percentage of black or Latino residents increases, and single cigarettes are more often available for purchase in neighborhoods as the percentage of black, poor, or young residents increases.

Conclusion

Contrary to previous null findings, noncompliance with FDA advertising and labeling regulations is patterned by neighborhood characteristics, sometimes in opposite directions. Given the low likelihood of self-service violations in the same neighborhoods that have high likelihood of single cigarette sales, we suggest targeted approaches to FDA retailer inspections and education campaigns.

Single Cigarette Sales: State Differences in FDA Advertising and Labeling Violations, 2014, United States

IMPORTANCE

Single cigarettes, which are sold without warning labels and often evade taxes, can serve as a gateway for youth smoking. The Family Smoking Prevention and Tobacco Control Act of 2009 gives the US Food and Drug Administration (FDA) authority to regulate the manufacture, distribution, and marketing of tobacco products, including prohibiting the sale of single cigarettes. To enforce these regulations, the FDA conducted over 335,661 inspections between 2010 and September 30, 2014, and allocated over $115 million toward state inspections contracts.

OBJECTIVE

To examine differences in single cigarette violations across states and determine if likely correlates of single cigarette sales predict single cigarette violations at the state level.

DESIGN

Cross-sectional study of publicly available FDA warning letters from January 1 to July 31, 2014.

SETTING

All 50 states and the District of Columbia.

PARTICIPANTS

Tobacco retailer inspections conducted by FDA (n = 33 543).

EXPOSURES FOR OBSERVATIONAL STUDIES

State cigarette tax, youth smoking prevalence, poverty, and tobacco production.

MAIN OUTCOMES AND MEASURES

State proportion of FDA warning letters issued for single cigarette violations.

RESULTS

There are striking differences in the number of single cigarette violations found by state, with 38 states producing no warning letters for selling single cigarettes even as state policymakers developed legislation to address retailer sales of single cigarettes. The state proportion of warning letters issued for single cigarettes is not predicted by state cigarette tax, youth smoking, poverty, or tobacco production, P = .12.

CONCLUSIONS AND RELEVANCE

Substantial, unexplained variation exists in violations of single cigarette sales among states. These data suggest the possibility of differences in implementation of FDA inspections and the need for stronger quality monitoring processes across states implementing FDA inspections.

Impact of the adoption of tobacco-free campus policies on student enrollment at colleges and universities, North Carolina, 2001-2010

OBJECTIVE

College and university administrators have expressed concern that adoption of tobacco-free policies may reduce applications and enrollment. This study examines adoption and implementation of 100% tobacco-free campus policies by institutions of higher education on applications and enrollment.

PARTICIPANTS

North Carolina private colleges and universities and public community colleges. Analysis was conducted in 2011.

METHODS

Student enrollment and application data were analyzed by campus type to determine (a) if there was a difference in student applications and enrollment before and after policy implementation, and (b) if there was a difference in student applications and enrollment for campuses with versus without a policy.

RESULTS

No significant differences were found in student enrollment or applications when comparing years prior to and following policy implementation or when comparing with institutions without 100% tobacco-free campus policies.

CONCLUSIONS

The authors found no evidence that 100% tobacco-free policy adoption had an impact on student enrollment or applications.

Valuation of tobacco control policies by the public in North Carolina: comparing perceived benefit with projected cost of implementation

BACKGROUND

After 40 years of continuous decline, smoking rates in the United States have stabilized signaling a challenge for tobacco control. Renewed decline may be guided by public opinion where support for tobacco control is strong. This study sought the public's preferences about tobacco control strategies.

METHODS

This contingent valuation study investigated whether the public's valuations of 2 tobacco control policies outweighed their implementation costs. In a hypothetical referendum, a representative sample of North Carolinians aged 45-64 years (n = 644) was asked to indicate whether they would prefer a policy that would halve the youth smoking rate or one that would reduce smoking-related deaths by 10%, and to indicate how much additional tax they would be willing to pay to implement their preferred policy. This willingness-to-pay value formed the perceived "benefit" component in a cost-benefit analysis. Costs to halve youth smoking were calculated from evidence about the resources required to increase the state tobacco excise tax. Costs to reduce tobacco-related deaths were based on evidence about the resources required for a counseling quitline offering free nicotine replacement therapy.

RESULTS

The majority (85%) of respondents voted to halve the youth smoking rate. The mean maximum amount per person that voters were willing to pay in 1 year to do that was $14.90 (95% CI, $10.10-$19.60), and the maximum amount per person they were willing to pay in 1 year to reduce smoking-related deaths was $13.70 (95% CI, $2.10-$25.40). When aggregated to the North Carolina population aged 45-64 years (N = 2,400,144), the perceived benefit of halving youth smoking was $35.8 million. Implementation of a program to achieve this outcome would cost $109.8 million. Aggregating to the same population, the perceived benefit of a 10% reduction in tobacco-related deaths was $32.9 million, an amount that exceeds the $12.8 million estimated cost of achieving the outcome.

CONCLUSION

A counseling quitline with free nicotine replacement therapy would achieve a positive net benefit.

Environmental tobacco smoke and periodontitis in U.S. non-smokers

PURPOSE

The association of second hand smoke or environmental tobacco smoke (ETS) and periodontitis in non-smokers has not been confirmed using a biomarker of ETS exposure. To estimate periodontitis prevalence in non-smokers with detectable serum cotinine, and to investigate racial/ethnic and socioeconomic variation in ETS exposure in a representative sample of the U. S. adult population. Determining periodontitis risk indicators occurring with ETS appears to be a salient purpose as this study is the first of its kind to provide a link (a salivary biomarker) between second hand smoke and risk for periodontitis.

METHODS

Data were collected from the 1999 to 2004 National Health and Nutrition Examination Survey (NHANES). Subjects were 3,137 adults who had smoked fewer than 100 cigarettes and had not used other forms of tobacco. ETS exposure was classified as negligible (cotinine concentrations below sex and race/ethnicity cut-points for smokers), moderate (cotinine 0.5-<1.5 μg/mL) or high (cotinine ≥ 1.5 ng/mL). Periodontitis was classified according to the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP) case definition for moderate-severe disease. Survey estimation procedures were used to estimate prevalence and odds ratios (OR) were from multivariable logistic regression models.

RESULTS

ETS exposure was observed in 40.5% of subjects and 2.6% had periodontitis. ETS exposure was inversely associated with educational attainment and family income and was higher in non-Hispanic blacks than whites. After adjusting for age, sex and year of survey, adults with high ETS exposure (cotinine ≥ 1.5 ng/mL) had more than twice the odds of periodontitis as people with negligible exposure (OR=2.3, 95% confidence interval=1.3, 4.1).

CONCLUSION

High ETS exposure was a risk indicator for periodontitis in lifetime non-smokers.

Assessment of college and university campus tobacco-free policies in North Carolina

OBJECTIVE

To develop a reliable and efficient method for assessing prevalence and strength of college/university tobacco-related policies.

PARTICIPANTS

North Carolina (NC) public universities, community colleges, and private colleges/universities (N = 110).

METHODS

A census of policies using campus handbooks and Web sites was conducted in March 2011.

RESULTS

The rating tool is reliable and valid. Ninety-nine percent of NC college/university campuses are smoke-free in all indoor areas. The majority (94/110 [85%]) of colleges and universities regulate smoking and/or tobacco in some or all outdoor areas. Less than 20% of campuses had restrictions for industry marketing, promotion, and sales.

CONCLUSIONS

Clean indoor air policies are present at all but 1 NC college/university campus, and a growing number have enacted broad outdoor limits to protect students, faculty, and staff from secondhand smoke. Policy census approaches across all other states would quantify the national tobacco-free college campus policy environment and facilitate adoption of tobacco-free campus policies.

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses

BACKGROUND

Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.

METHODS

We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse members (n = 271) in nine clubhouses.

RESULTS

Fifty-eight percent of clubhouse participants completed surveys. Results showed tobacco users open to tobacco-free policies (62%) and perceiving more discussions about quitting tobacco with healthcare providers (69%). Analyses of staff interviews and member surveys revealed four key themes: (1) the curriculum was successfully implemented and appreciated; (2) technical assistance kept implementation on track; (3) adding wellness content and interactive components should enhance the curriculum; and, (4) the curriculum advanced other healthful policies and practices.

CONCLUSIONS

Mental health settings are important locations for implementing programs to address tobacco use. In this real-world implementation of a model curriculum in psychosocial rehabilitation clubhouses, the curriculum tested well, was feasible and well-received, and suggests potential impact on tobacco use outcomes. Revision, dissemination, and a randomized controlled trial evaluation of the model curriculum should now occur.

Successful implementation of a wellness and tobacco cessation curriculum in psychosocial rehabilitation clubhouses

Background

Tobacco remains a seemingly intractable problem for individuals living with severe and persistent mental illness. This study evaluated the implementation, technical assistance, and perceived impact of a model curriculum ("Learning About Healthy Living") to promote wellness and motivation to quit tobacco use in psychosocial rehabilitation clubhouses.

Methods

We used semi-structured interviews (n = 9) with clubhouse staff (n = 12) and a survey of participating clubhouse members (n = 271) in nine clubhouses.

Results

Fifty-eight percent of clubhouse participants completed surveys. Results showed tobacco users open to tobacco-free policies (62%) and perceiving more discussions about quitting tobacco with healthcare providers (69%). Analyses of staff interviews and member surveys revealed four key themes: (1) the curriculum was successfully implemented and appreciated; (2) technical assistance kept implementation on track; (3) adding wellness content and interactive components should enhance the curriculum; and, (4) the curriculum advanced other healthful policies and practices.

Conclusions

Mental health settings are important locations for implementing programs to address tobacco use. In this real-world implementation of a model curriculum in psychosocial rehabilitation clubhouses, the curriculum tested well, was feasible and well-received, and suggests potential impact on tobacco use outcomes. Revision, dissemination, and a randomized controlled trial evaluation of the model curriculum should now occur.