State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Accessing Treatments - United States, 2018-2022

The prevalence of cigarette smoking among U.S. adults enrolled in Medicaid is higher than among adults with private insurance; more than one in five adults enrolled in Medicaid smokes cigarettes. Smoking cessation reduces the risk for smoking-related disease and death. Effective treatments for smoking cessation are available, and comprehensive, barrier-free insurance coverage of these treatments can increase cessation. However, Medicaid treatment coverage and treatment access barriers vary by state. The American Lung Association collected and analyzed state-level information regarding coverage for nine tobacco cessation treatments and seven access barriers for standard Medicaid enrollees. As of December 31, 2022, a total of 20 state Medicaid programs provided comprehensive coverage (all nine treatments), an increase from 15 as of December 31, 2018. Only three states had zero access barriers, an increase from two; all three also had comprehensive coverage. Although states continue to improve smoking cessation treatment coverage and decrease access barriers for standard Medicaid enrollees, coverage gaps and access barriers remain in many states. State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based cessation treatments and by promoting this coverage to enrollees and providers.

Chemical Composition of Electronic Vaping Products from School Grounds in California

INTRODUCTION

The use of electronic vaping products (EVPs) containing nicotine, marijuana, and/or other substances remains prominent among youth; with EVPs containing nicotine being the most commonly used tobacco product among youth since 2014. However, a detailed understanding of the chemical composition of these products is limited.

METHODS

During February 25th-March 15th, 2019, a total of 576 EVPs, including 233 e-cigarette devices (with 43 disposable vape pens) and 343 e-liquid cartridges/pods/bottled e-liquids, were found or confiscated from a convenience sample of 16 public high schools in California. Liquids inside 251 vape pens and cartridges/pods/bottled e-liquids were analyzed using a gas chromatography/mass spectrometry (GC/MS). For comparison, new JUUL pods, the most commonly used e-cigarette among youth during 2018-2019, with different flavorings and nicotine content were purchased and analyzed.

RESULTS

For e-cigarette cartridges/pods/bottled e-liquids, nicotine was detected in 204 of 208 (98.1%) samples. Propylene glycol (PG) and vegetable glycerin (VG) were dominant solvents in nicotine-containing EVPs. Among 43 disposable vape pen devices, cannabinoids such as tetrahydrocannabinol (THC) or cannabidiol (CBD) were identified in 39 of 43 (90.1%) samples, of which 3 contained both nicotine and THC. Differences in chemical compositions were observed between confiscated or collected JUULs and purchased JUULs. Measured nicotine was inconsistent with labels on some confiscated or collected bottled e-liquids.

CONCLUSIONS

EVPs from 16 participating schools were found to widely contain substances with known adverse health effects among youth, including nicotine and cannabinoids. There was inconsistency between labeled and measured nicotine on the products from schools.

IMPLICATIONS

This study measured the main chemical compositions of EVPs found at 16 California public high schools. Continued efforts are warranted, including at the school-level, to educate, prevent and reduce youth use of EVPs.

E-cigarette Unit Sales by Product and Flavor Type, and Top-Selling Brands, United States, 2020-2022

E-cigarette products, related policies, and use patterns change rapidly. In the United States, the prevalence of e-cigarette use is markedly higher among youths and young adults than it is among adults overall. In 2021, 4.5% of all adults aged ≥18 years (an estimated 11.1 million) and 11.0% of young adults aged 18-24 years (an estimated 3.1 million) currently (≥1 day during the previous 30 days) used e-cigarettes; during 2022, 14.1% of high school students (an estimated 2.14 million) currently used e-cigarettes (1,2). E-cigarettes often contain high concentrations of nicotine. Nicotine is highly addictive and can harm the adolescent brain, which continues to develop through approximately age 25 years (3). Since 2020, the availability of e-cigarette products has changed in response to multiple factors, including local and state policies to address flavored e-cigarette sales, actions undertaken by the Food and Drug Administration (FDA), COVID-19-related closures, and global supply chain disruptions. To assess trends in unit sales of e-cigarettes in the United States, by product and flavor, and top-selling brands, the CDC Foundation, Truth Initiative,* and CDC analyzed retail scanner data during January 26, 2020-December 25, 2022, from Information Resources, Inc. (IRI), a U.S. data analytics and market research company. Overall, unit sales increased by 46.6% during the study period. The unit share of menthol-flavored product sales remained relatively stable during this period, whereas nonmenthol flavor unit shares changed. During January 26, 2020-December 25, 2022, unit shares of tobacco-flavored and mint-flavored products decreased (from 28.4% to 20.1% and from 10.1% to 5.9%, respectively), whereas shares of other flavor sales increased (from 29.2% to 41.3%). In addition, during January 2020-December 2022, unit shares of prefilled cartridges decreased from 75.2% to 48.0%, and disposable e-cigarette unit share increased from 24.7% to 51.8% of total unit sales. The five top-selling e-cigarette brands for the 4-week period ending December 25, 2022, were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. Analysis of information on e-cigarette retail sales can guide strategies to prevent youth access to and use of e-cigarettes, including restrictions on flavored tobacco products (4).

What happens in Vegas, stays in your lungs: an assessment of fine particulate matter in casinos that prohibit and allow smoking in Las Vegas, Nevada, USA

INTRODUCTION

Despite progress in adoption of smoke-free policies, smoking in casinos is allowed in some US states, including Nevada. In 2020, for the first time, a resort-style casino in Las Vegas prohibited smoking voluntarily. This study is the first to assess air quality in this casino and compare results with similar casinos that allow smoking.

METHODS

A real-time personal aerosol monitor evaluated particulate matter with a diameter <2.5 µm (PM2.5), a surrogate for secondhand smoke (SHS). PM2.5 was measured at eight Las Vegas casinos, including the smoke-free casino. Each casino was visited twice, and PM2.5 was assessed in smoking-permitted gaming areas and areas where smoking is otherwise prohibited.

RESULTS

Average PM2.5 levels were significantly higher in casinos that allow smoking, for both casino gaming areas and areas where smoking is otherwise prohibited (p<0.05). Mean PM2.5 in gaming areas was 164.9 µg/m3 in casinos that allow smoking and 30.5 µg/m3 in the smoke-free casino. Mean PM2.5 in areas where smoking is otherwise prohibited was 83.2 µg/m3 in casinos which allowed smoking in gaming areas, and 48.1 µg/m3 in the smoke-free casino.

CONCLUSION

Despite robust evidence about the harms of SHS, tens of thousands of casino employees and tens of millions of tourists are exposed to high levels of SHS in Las Vegas casinos annually, with PM2.5 levels 5.4 times higher in gaming areas when compared with a smoke-free casino. The only way to protect people from SHS exposure is to prohibit smoking in all indoor areas.

Changes in Sales of E-Cigarettes, Cigarettes, and Nicotine Replacement Therapy Products Before, During, and After the EVALI Outbreak

INTRODUCTION

In 2019, an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in the US. We used Nielsen retail sales data to assess trends in sales of e-cigarettes, cigarettes, and nicotine replacement therapy (NRT) products before, during, and after the EVALI outbreak.

METHODS

Monthly unit sales of e-cigarettes, cigarettes, and NRT products overall and by product type were assessed during January 2019 through June 2020 by using an interrupted time series model. Two time points were specified at the period ending July 13, 2019, and the period ending February 22, 2020, to partition before, during, and after the outbreak period. Sales trends by aggregated state-level EVALI case prevalence (low, medium, and high) were assessed to investigate interstate variations in changes of sales coinciding with the EVALI outbreak.

RESULTS

Monthly e-cigarette sales increased 3.5% (P < .001) before the outbreak and decreased 3.1% (P < .001) during the outbreak, with no significant changes after the outbreak. Monthly cigarette sales increased 1.6% (P < .001) before the outbreak, decreased 1.8% (P < .001) during the outbreak, and increased 2.7% (P < .001) after the outbreak. NRT sales did not change significantly before or during the outbreak but decreased (2.8%, P = .01) after the outbreak. Sales trends by state-level EVALI case prevalence were similar to national-level sales trends.

CONCLUSION

Cigarette and e-cigarette sales decreased during the EVALI outbreak, but no changes in overall NRT sales were observed until after the outbreak. Continued monitoring of tobacco sales data can provide insight into potential changes in use patterns and inform tobacco prevention and control efforts.

Youth Indoor and Outdoor Exposure to Secondhand Smoke and Secondhand Aerosol

INTRODUCTION

Secondhand smoke and secondhand aerosol exposure are important public health concerns. This is the first study to present separate estimates of public indoor and outdoor secondhand smoke and secondhand aerosol exposure among U.S. youth.

METHODS

Data came from the 2020 National Youth Tobacco Survey, an annual cross-sectional survey of U.S. students in Grades 6-12. Self-reported past 30-day indoor and outdoor secondhand smoke and secondhand aerosol exposures were assessed separately. Weighted prevalence and adjusted prevalence ratios for each outcome were assessed among students overall and stratified by sex, school level, race/ethnicity, sexual orientation, and current tobacco product use; prevalence also was calculated among those who did not currently use tobacco.

RESULTS

Exposure to secondhand smoke and secondhand aerosol was reported by 60.6% (95% CI=58.7, 62.4) and 44.5% (95% CI=42.1, 46.9) of U.S. youth, respectively. Among all students, 37.6% (95% CI=36.0, 39.2) and 53.3% (95% CI=51.4, 55.2) reported indoor and outdoor secondhand smoke exposure, respectively; 34.9% (95% CI=32.9, 37.4) and 36.8% (95% CI=34.6, 38.9) reported indoor and outdoor secondhand aerosol exposure, respectively. After adjustment, female versus male students (adjusted prevalence ratio=1.15-1.30) and those who currently use versus do not use combustible tobacco products (adjusted prevalence ratio=1.15-1.36) were more likely to report exposure to all outcomes.

CONCLUSIONS

Approximately 1 in 2 students overall reported outdoor secondhand smoke exposure, and 1 in 3 students reported exposures to each indoor secondhand smoke, indoor secondhand aerosol, and outdoor secondhand aerosol. Separate estimates of indoor and outdoor secondhand smoke and secondhand aerosol exposure, along with data on correlates of exposure, provide information to support comprehensive indoor and outdoor smoke-free policies.

Trends in Cigar Sales and Prices, by Product and Flavor Type-the United States, 2016-2020

INTRODUCTION

Cigar smoking has increased in recent decades as the cigar product landscape has diversified. This study assessed trends in US cigar sales during 2016-2020.

AIMS AND METHODS

Unit sales and average unit price for cigars were assessed during January 3, 2016-June 13, 2020, overall and by product and flavor type, for the 48 contiguous US states and D.C. Assessed cigar types were large cigars, little cigars, and cigarillos; assessed flavor types were tobacco/unflavored, candy/sweets, fruit, menthol, alcohol, coffee, other flavors, and no flavor stated. A joinpoint regression model was used to assess the magnitude and significance of sales trends.

RESULTS

During January 3, 2016-June 13, 2020, unit sales of cigarillos increased (average monthly percentage change [AMPC] = 0.7%, p < .001), while unit sales of large cigars (AMPC = -0.8%, p < .001) and little cigars decreased (AMPC = -0.2%, p < .001). The average price of cigarillos gradually decreased since mid-August 2017 (AMPC = -0.1%, p < .001), and the average price of little cigars decreased from mid-June 2016 to mid-June 2019 (AMPC = -0.3%, p < .001). In contrast, the average price of large cigars increased during the entire study period (AMPC = 0.6%, p < .001). Irrespective of cigar type, tobacco-flavored/unflavored products were the most commonly sold cigars during the assessed period; however, sales of other flavors varied by cigar type.

CONCLUSIONS

Cigar sales and price vary by type over time in the United States, including sales of cigarillos (94.2% of unit sales) increasing as their prices have decreased in recent years. Public health strategies are warranted to address the full scope of cigar types being used in the United States.

IMPLICATIONS

Surveillance of cigar sales data, including product characteristics, can provide a timely complement to self-reported survey data of cigar use. This study assessed trends in US cigar sales during 2016-2020, including by product and flavor type. The findings indicate that sales of cigarillos, which comprise most cigar sales in the United States during the assessed period, increased as their prices decreased. Sales of certain flavors, such as candy/sweet cigarillos and coffee large cigars, increased significantly. These findings reinforce the importance of evidence-based strategies, including increasing price and restricting flavors, to reduce the affordability and consumption of cigars in the United States.

Evaluation of Statewide Restrictions on Flavored e-Cigarette Sales in the US From 2014 to 2020

IMPORTANCE

e-Cigarettes are the most commonly used tobacco product among US youths. Flavors are among the most cited reasons for use of e-cigarettes among youths, and therefore, some states have imposed restrictions on flavored e-cigarette sales. To our knowledge, no study has compared e-cigarette sales between states with statewide flavored e-cigarette restrictions and states without such restrictions while controlling for co-occurring events.

OBJECTIVE

To assess whether implementation of statewide restrictions on flavored e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington was associated with a reduction in total e-cigarette unit sales from 2014 to 2020.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study with difference-in-differences analysis used e-cigarette retail sales data from Massachusetts, Rhode Island, and Washington, which implemented restrictions on flavored e-cigarette sales in October 2019; New York, which implemented these restrictions in May 2020; and 35 states without these restrictions (control states). Sales were summed into 4-week periods from August 24, 2014, to December 27, 2020, for a total of 2988 state-period observations.

MAIN OUTCOMES AND MEASURES

A difference-in-differences analysis was conducted to compare e-cigarette unit sales in the 4 states with flavor restrictions (before and after implementation) with those in the 35 control states. The model controlled for other population-based policies and emergent events (eg, the COVID-19 pandemic). Data on 4-week e-cigarette unit sales were sorted into 4 flavor categories (tobacco, menthol, mint, and other). Unit sales were standardized to reflect the most common package sizes for each product type.

RESULTS

Statewide restrictions on non-tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% (95% CI, 24.08%-36.66%) in New York, 31.26% (95% CI, 11.94%-46.34%) in Rhode Island, and 25.01% (95% CI, 18.43%-31.05%) in Washington. In Massachusetts, the comprehensive sales prohibition of all e-cigarette products was associated with a 94.38% (95% CI, 93.37%-95.23%) reduction in 4-week sales compared with control states. Except in Massachusetts, where all sales of flavored e-cigarettes decreased, reductions were found only for non-tobacco-flavored e-cigarette sales in the other states with restrictions. Among control states, mean sales decreased by 28.4% from August 2019 to February 2020 but then increased by 49.9% from February through December 2020.

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales. These findings suggest that not all e-cigarette users who purchased non-tobacco-flavored e-cigarettes switched to purchasing tobacco-flavored e-cigarettes after policy implementation.

Nicotine Pouch Unit Sales in the US, 2016-2020

This study uses retail scanner data to assess nicotine pouch sales in the US between 2016 and 2020.

Differences in rapid increases in county-level COVID-19 incidence by implementation of statewide closures and mask mandates - United States, June 1-September 30, 2020

BACKGROUND AND OBJECTIVE

Community mitigation strategies could help reduce COVID-19 incidence, but there are few studies that explore associations nationally and by urbanicity. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity.

METHODS

We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value< .05); associations were adjusted for county population size.

RESULTS

Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio = 0.57; 95% confidence intervals = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas.

CONCLUSIONS

These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

Timing of State and Territorial COVID-19 Stay-at-Home Orders and Changes in Population Movement - United States, March 1-May 31, 2020

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

Timing of State and Territorial COVID-19 Stay-at-Home Orders and Changes in Population Movement - United States, March 1-May 31, 2020

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

Self-reported exposure to, perceptions about, and attitudes about public marijuana smoking among US adults, 2018

BACKGROUND AND AIMS

Eleven US states and the District of Columbia have legalized the non-medical use of marijuana. Public marijuana smoking is generally prohibited, although some states have considered exemptions. This study assessed attitudes about public marijuana smoking, perceptions of harm from marijuana second-hand smoke (SHS) and self-reported marijuana SHS exposure.

DESIGN

Internet panel survey fielded in June-July 2018.

SETTING

United States.

PARTICIPANTS

US adults aged ≥ 18 years (n = 4088).

MEASUREMENTS

Current (past-30 day) tobacco product use, current marijuana use, opinions about public indoor marijuana smoking, perceptions of harm from marijuana SHS and self-reported past-7 day exposure to marijuana SHS in public indoor or outdoor areas were assessed. Weighted prevalence estimates were computed and correlates were assessed using logistic and multinomial regression.

FINDINGS

Overall, 27.4% [95% confidence interval (CI) = 25.7, 29.1] of adults reported past-week marijuana SHS exposure in indoor and/or outdoor public areas; younger adults, blacks, Hispanics, those in the Northeast or West, and current marijuana and/or tobacco users were more commonly exposed (Ps < 0.0001). More than half of adults (52.4%; 95% CI = 50.7, 54.2) regarded marijuana SHS as harmful, and most (81.0%; 95% CI = 79.5, 82.4) opposed public marijuana smoking. Correlates of favoring public marijuana smoking included being male, younger (Ps < 0.01), black or Hispanic, past-month tobacco and/or marijuana users and perceiving no/low harm from marijuana SHS (Ps < 0.0001).

CONCLUSION

While one in four US adults report recent marijuana second-hand smoke exposure, a majority believe marijuana second-hand smoke is harmful and most oppose public marijuana smoking.

Public Attitudes, Behaviors, and Beliefs Related to COVID-19, Stay-at-Home Orders, Nonessential Business Closures, and Public Health Guidance - United States, New York City, and Los Angeles, May 5-12, 2020

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to be transmitted mainly by person-to-person contact (1). Implementation of nationwide public health orders to limit person-to-person interaction and of guidance on personal protective practices can slow transmission (2,3). Such strategies can include stay-at-home orders, business closures, prohibitions against mass gatherings, use of cloth face coverings, and maintenance of a physical distance between persons (2,3). To assess and understand public attitudes, behaviors, and beliefs related to this guidance and COVID-19, representative panel surveys were conducted among adults aged ≥18 years in New York City (NYC) and Los Angeles, and broadly across the United States during May 5-12, 2020. Most respondents in the three cohorts supported stay-at-home orders and nonessential business closures* (United States, 79.5%; New York City, 86.7%; and Los Angeles, 81.5%), reported always or often wearing cloth face coverings in public areas (United States, 74.1%, New York City, 89.6%; and Los Angeles 89.8%), and believed that their state's restrictions were the right balance or not restrictive enough (United States, 84.3%; New York City, 89.7%; and Los Angeles, 79.7%). Periodic assessments of public attitudes, behaviors, and beliefs can guide evidence-based public health decision-making and related prevention messaging about mitigation strategies needed as the COVID-19 pandemic evolves.

Tobacco and Marijuana Use Among US College and Noncollege Young Adults, 2002-2016

OBJECTIVES

To assess trends and behavioral patterns of marijuana and cigarette and/or cigar (ie, smoked tobacco) use among 18- to 22-year-old US young adults who were in or not in college.

METHODS

Data were from the 2002-2016 National Survey on Drug Use and Health. Past-30-day and past-12-month use of marijuana and smoked tobacco were assessed by college enrollment status. χ² tests were used to examine within- and between-group differences. Trends were assessed by using logistic regression and relative percentage change (RPC).

RESULTS

Among both college and noncollege individuals during 2002 to 2016, exclusive marijuana use increased (faster increase among college students; RPC = 166.6 vs 133.7), whereas exclusive smoked tobacco use decreased (faster decrease among college students; RPC = -47.4 vs -43.2). In 2016, 51.6% of noncollege and 46.8% of college individuals reported past-12-month usage of marijuana and/or smoked tobacco products (P < .05). Exclusive marijuana use was higher among college than noncollege individuals, both for past-30-day (11.5% vs 8.6%) and past-12-month use (14.6% vs 10.8%). Exclusive smoked tobacco use was higher among noncollege than college individuals, both for past-30-day (17.7% vs 10.4%) and past-12-month (17.4% vs 12.2%) use (P < .05).

CONCLUSIONS

Exclusive marijuana use is increasing among young adults overall, whereas exclusive smoked tobacco use is decreasing: faster rates are seen among college students. Exclusive marijuana use is higher among college students, whereas exclusive smoked tobacco use is higher among noncollege individuals. Surveillance of tobacco and marijuana use among young people is important as the policy landscape for these products evolves.

Use and reasons for use of electronic vapour products shaped like USB flash drives among a national sample of adults

OBJECTIVES

Assess use and reasons for use of electronic vapour products (EVPs) shaped like universal serial bus (USB) flash drives among adults in the USA.

METHODS

Data came from SummerStyles, an internet survey of US adults aged ≥18 (N=4088) fielded in June to July 2018. Respondents were shown product images and asked about ever use, current (past 30 days) use and reasons for use. Weighted point estimates and adjusted ORs were assessed.

RESULTS

In 2018, 7.9% of participants had ever used flash drive-shaped EVPs, including 25.7% of current cigarette smokers and 45.9% of current EVP users. Moreover, 2.0% reported current use, including 6.8% of cigarette smokers and 34.3% of EVP users. Leading reasons for ever use were 'to deliver nicotine' (30.7%) and 'friend or family member used them' (30.2%).

CONCLUSIONS

About one in 13 US adults have ever used flash drive-shaped EVPs, with use being highest among current EVP users. Nicotine content and friend/family use are drivers of ever use.

PUBLIC HEALTH IMPLICATIONS

Understanding use of emerging EVP types can inform strategies to maximise any potential benefits for adult cessation and minimise risks of youth initiation.

Attitudes Toward Smoke-Free Casino Policies Among US Adults, 2017

Research shows that there is no risk-free level of exposure to secondhand smoke (SHS) and that eliminating smoking indoors fully protects nonsmokers from indoor SHS exposure. Casinos often allow smoking indoors and can be a source of involuntary SHS exposure for employees and visitors. We examined attitudes toward smoke-free casino policies among US adults. During June and July 2017, we used a web-based survey to ask a nationally representative sample of 4107 adults aged ≥18 about their attitudes toward smoke-free casinos. Among 4048 respondents aged ≥18, a weighted 75.0% favored smoke-free casino policies, including respondents who visited casinos about once per year (74.1%), several times per year (75.3%), and at least once per month (74.2%). Although the sociodemographic characteristics of respondents who favored smoke-free casino policies varied, the majority in each group, except current smokers (45.4%), supported smoke-free policies. Allowing smoking inside casinos involuntarily exposes casino employees and visitors to SHS, a known and preventable health risk. Further assessment of public knowledge and attitudes toward smoke-free casinos at state and local levels may help inform tobacco control policy, planning, and practice.

Prevalence of Cannabis Use in Electronic Cigarettes Among US Youth

This Research Letter examines the prevalence of electronic cigarette use and association with cannabis use among US middle and high school students.

Use of Price Promotions Among U.S. Adults Who Use Electronic Vapor Products

INTRODUCTION

Sales of electronic vapor products have increased in recent years. This increase in use may be related to manufacturer price promotions. This study assessed the use of price-related promotions among current electronic vapor product users.

METHODS

Data from the 2015 and 2016 Summer Styles, an Internet survey of U.S. adults aged ≥18 years, were analyzed in 2017. Current electronic vapor product users (n=300) were those who reported past 30-day electronic vapor product use. Price-related promotion use was defined as reported use of coupons, rebates, discount codes, or other special price-related promotions when purchasing electronic vapor products (e.g., electronic cigarettes [e-cigarettes], electronic hookah [e-hookah], or vape pens). Associations between price-related promotion use and sex, age, race/ethnicity, educational attainment, U.S. region, cigarette smoking status, electronic vapor product use frequency, place electronic vapor products were obtained, and survey year were assessed using multivariable logistic regression.

RESULTS

Among current electronic vapor product users, 15.0% reported using price-related promotions. The adjusted odds of using price-related promotions was significantly higher among respondents who obtained electronic vapor products from a gas station, grocery or drug store, or the Internet (AOR=2.65, 95% CI=1.22, 5.74) versus anywhere else (i.e., mall kiosks, vape shop, friends/family) and among those who used electronic vapor products ≥15 days in the past 30 days (AOR=2.57, 95% CI=1.18, 5.56) versus ≤14 days.

CONCLUSIONS

Nearly one in seven current U.S. adult electronic vapor product users reported using price promotions during 2015-2016, and variations in price promotion use existed by electronic vapor product use frequency and where electronic vapor products were obtained. Continued monitoring of the use of price-related promotions could help inform public health policy, planning, and practice.

Smoke-Free and Tobacco-Free Policies in Colleges and Universities - United States and Territories, 2017

Each year in the United States, cigarette smoking causes an estimated 480,000 deaths, including approximately 41,000 deaths from secondhand smoke exposure among nonsmoking adults (1). Smoke-free policies protect nonsmokers from secondhand smoke exposure, reduce the social acceptability of smoking, help in preventing youth and young adult smoking initiation, and increase smokers' efforts to quit smoking (1,2). Given that 99% of adult cigarette smokers first start smoking before age 26 years and many smokers transition to regular, daily use during young adulthood (2),* colleges and universities represent an important venue for protecting students, faculty, staff members, and guests from secondhand smoke exposure through tobacco control policies (3). To assess smoke-free and tobacco-free policies in U.S. colleges and universities, CDC and the American Nonsmokers' Rights Foundation (ANRF) determined the number of campuses nationwide that completely prohibit smoking (smoke-free) or both smoking and smokeless tobacco product use (tobacco-free) in all indoor and outdoor areas. As of November 2017, at least 2,082 U.S. college and university campuses had smoke-free policies. Among these campuses, 1,743 (83.7%) were tobacco-free; 1,658 (79.6%) specifically prohibited electronic cigarette (e-cigarette) use; and 854 (41.0%) specifically prohibited hookah smoking. Smoke-free and tobacco-free policies on college and university campuses can help reduce secondhand smoke exposure, tobacco use initiation, and the social acceptability of tobacco use (1-3).

Smoke-Free Policies in the World's 50 Busiest Airports - August 2017

Exposure to secondhand smoke from burning tobacco products causes premature death and disease, including coronary heart disease, stroke, and lung cancer among nonsmoking adults and sudden infant death syndrome, acute respiratory infections, middle ear disease, exacerbated asthma, respiratory symptoms, and decreased lung function in children (1,2). The U.S. Surgeon General has concluded that there is no risk-free level of exposure to secondhand smoke (1). Previous CDC reports on airport smoke-free policies found that most large-hub airports in the United States prohibit smoking (3); however, the extent of smoke-free policies at airports globally has not been assessed. CDC assessed smoke-free policies at the world's 50 busiest airports (airports with the highest number of passengers traveling through an airport in a year) as of August 2017; approximately 2.7 billion travelers pass through these 50 airports each year (4). Among these airports, 23 (46%) completely prohibit smoking indoors, including five of the 10 busiest airports. The remaining 27 airports continue to allow smoking in designated smoking areas. Designated or ventilated smoking areas can cause involuntary secondhand smoke exposure among nonsmoking travelers and airport employees. Smoke-free policies at the national, city, or airport authority levels can protect employees and travelers from secondhand smoke inside airports.

Tobacco Use in Top-Grossing Movies - United States, 2010-2016

The Surgeon General has concluded that there is a causal relationship between depictions of smoking in the movies and the initiation of smoking among young persons (1). The more youths see smoking on screen, the more likely they are to start smoking; youths who are heavily exposed to onscreen smoking imagery are approximately two to three times as likely to begin smoking as are youths who receive less exposure (1,2). A Healthy People 2020 objective is to reduce the proportion of youths exposed to onscreen tobacco marketing in movies and television (Tobacco Use Objective 18.3) (3). To assess the recent extent of tobacco use imagery in youth-rated movies (G, PG, PG-13*), 2010-2016 data from Thumbs Up! Thumbs Down! (TUTD), a project of Breathe California of Sacramento-Emigrant Trails were analyzed and compared with previous reports.† In 2016, 41% of movies that were among the 10 top-grossing movies in any calendar week included tobacco use, compared with 45% in 2010. Among youth-rated movies, 26% included tobacco use in 2016 (including 35% of PG-13 movies) compared with 31% in 2010 (including 43% of PG-13 movies). The steady decline in the number of tobacco incidents in youth-rated movies from 2005-2010 stopped after 2010. The total number of individual occurrences of tobacco use in a movie (tobacco incidents) in top-grossing movies increased 72%, from 1,824 in 2010 to 3,145 in 2016, with an increase of 43% (from 564 to 809) occurring among PG-13 rated movies. Reducing tobacco use in youth-related movies could help prevent the initiation of tobacco use among young persons.

Estimating the Impact of Raising Prices and Eliminating Discounts on Cigarette Smoking Prevalence in the United States

The average retail price per pack of cigarettes is less than $6, which is substantially lower than the $10 per-pack target established in 2014 by the Surgeon General to reduce the smoking rate. We estimated the impact of three cigarette pricing scenarios on smoking prevalence among teens aged 12-17 years, young adults aged 18-25 years, and adults aged ≥26 years, by state: (1) $0.94 federal tax increase on cigarettes, as proposed in the fiscal year 2017 President's budget; (2) $10 per-pack retail price, allowing discounts; and (3) $10 per-pack retail price, eliminating discounts. We conducted Monte Carlo simulations to generate point estimates of reductions in cigarette smoking prevalence by state. We found that each price scenario would substantially reduce cigarette smoking prevalence. A $10 per-pack retail price eliminating discounts could result in 637,270 fewer smokers aged 12-17 years; 4,186,954 fewer smokers aged 18-25 years; and 7,722,460 fewer smokers aged ≥26 years. Raising cigarette prices and eliminating discounts could substantially reduce cigarette smoking prevalence as well as smoking-related death and disease.

Tax Avoidance and Evasion: Cigarette Purchases From Indian Reservations Among US Adult Smokers, 2010-2011

Excise taxes are the primary public health strategy used to increase the price of cigarettes in the United States. Rather than quitting or reducing consumption of cigarettes, some price-sensitive smokers may avoid state and local excise taxes by purchasing cigarettes from Indian reservations. The objectives of this study were to (1) provide the most recent state-specific prevalence of purchases made on Indian reservations by non-American Indians/Alaska Natives (non-AI/ANs) and (2) assess the impact of these purchases on state tax revenues. We used data from a large national and state-representative survey, the 2010-2011 Tobacco Use Supplement to the Current Population Survey, which collects self-reported measures on cigarette use and purchases. Nationwide, 3.8% of non-AI/AN smokers reported purchasing cigarettes from Indian reservations. However, in Arizona, Nevada, New Mexico, New York, Oklahoma, and Washington State, about 15% to 30% of smokers reported making such purchases, resulting in annual tax revenue losses ranging from $3.5 million (Washington State) to $292 million (New York) during 2010-2011. Strategies to reduce the sale of non- or lower-taxed cigarettes to non-AI/ANs on Indian reservations have the potential to decrease smoking prevalence and recoup lost revenue from purchases made on reservations.

Consumption of Combustible and Smokeless Tobacco - United States, 2000-2015

Combustible and smokeless tobacco use causes adverse health outcomes, including cardiovascular disease and multiple types of cancer (1,2). Standard approaches for measuring tobacco use include self-reported surveys of use and consumption estimates based on tobacco excise tax data (3,4). To provide the most recently available tobacco consumption estimates in the United States, CDC used federal excise tax data to estimate total and per capita consumption during 2000-2015 for combustible tobacco (cigarettes, roll-your-own tobacco, pipe tobacco, small cigars, and large cigars) and smokeless tobacco (chewing tobacco and dry snuff). During this period, total combustible tobacco consumption decreased 33.5%, or 43.7% per capita. Although total cigarette consumption decreased 38.7%, cigarettes remained the most commonly used combustible tobacco product. Total noncigarette combustible tobacco (i.e., cigars, roll-your-own, and pipe tobacco) consumption increased 117.1%, or 83.8% per capita during 2000-2015. Total consumption of smokeless tobacco increased 23.1%, or 4.2% per capita. Notably, total cigarette consumption was 267.0 billion cigarettes in 2015 compared with 262.7 billion in 2014. These findings indicate that although cigarette smoking declined overall during 2000-2015, and each year from 2000 to 2014, the number of cigarettes consumed in 2015 was higher than in 2014, and the first time annual cigarette consumption was higher than the previous year since 1973. Moreover, the consumption of other combustible and smokeless tobacco products remains substantial. Implementation of proven tobacco prevention interventions (5) is warranted to further reduce tobacco use in the United States.

State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars - United States, 2015

Exposure to secondhand smoke from burning tobacco products causes stroke, lung cancer, and coronary heart disease in adults (1,2). Children who are exposed to secondhand smoke are at increased risk for sudden infant death syndrome, acute respiratory infections, middle ear disease, more severe asthma, respiratory symptoms, and slowed lung growth (1,2). Secondhand smoke exposure contributes to approximately 41,000 deaths among nonsmoking adults and 400 deaths in infants each year (2). This report updates a previous CDC report that evaluated state smoke-free laws in effect from 2000-2010 (3), and estimates the proportion of the population protected by comprehensive smoke-free laws. The number of states, including the District of Columbia (DC), with comprehensive smoke-free laws (statutes that prohibit smoking in indoor areas of worksites, restaurants, and bars) increased from zero in 2000 to 26 in 2010 and 27 in 2015. The percentage of the U.S. population that is protected increased from 2.72% in 2000 to 47.8% in 2010 and 49.6% in 2015. Regional disparities remain in the proportions of state populations covered by state or local comprehensive smoke-free policies, as no state in the southeast has a state comprehensive law. In addition, nine of the 24 states that lack state comprehensive smoke-free laws also lack any local comprehensive smoke-free laws. Opportunities exist to accelerate the adoption of smoke-free laws in states that lack local comprehensive smoke-free laws, including those in the south, to protect nonsmokers from the harmful effects of secondhand smoke exposure.

Continued implications of taxing roll-your-own tobacco as pipe tobacco in the USA

BACKGROUND

In 2009, a US$21.95 per pound disparity was created in the Federal excise tax between roll-your-own cigarette tobacco (RYO) and pipe tobacco in the USA. After this disparity was created, pipe tobacco sales increased and RYO sales declined as some manufacturers repackaged roll-your-own tobacco as pipe tobacco and retailers began to offer cigarette rolling machines for consumers to use. A Federal law was passed in 2012 limiting the availability of these machines, however, it was unclear what impact this law had on the sales of roll-your-own tobacco labelled as pipe tobacco.

METHODS

The quantity of RYO sold as pipe tobacco each month was estimated using objective data on Federal excise taxes.

RESULTS

From April 2009 through June 2013, 107 million pounds of RYO were sold as pipe tobacco, reducing Federal excise tax collections by US$2.36 billion. The amount of RYO taxed as pipe tobacco climbed steadily and then levelled off following the July 2012 Federal law.

CONCLUSIONS

The Federal law did not correct the market shift that occurred in pipe and RYO sales beginning in 2009. Even without access to commercial rolling machines, smokers are continuing to take advantage of the tax disparity. Without a solution, states will continue to lose revenue, and smokers who would otherwise quit will continue to have a low-cost alternative product available for purchase. Potential solutions include: (1) US Treasury Department distinguishing between RYO and pipe tobacco based on physical characteristics and (2) changing the Federal excise tax so that RYO and pipe tobacco are taxed at the same rate.

Per-pack price reductions available from different cigarette purchasing strategies: United States, 2009-2010

OBJECTIVE

Following cigarette excise tax increases, smokers may use cigarette price minimization strategies to continue their usual cigarette consumption rather than reducing consumption or quitting. This reduces the public health benefits of the tax increase. This paper estimates the price reductions for a wide-range of strategies, compensating for overlapping strategies.

METHOD

We performed regression analysis on the 2009-2010 National Adult Tobacco Survey (N=13,394) to explore price reductions that smokers in the United States obtained from purchasing cigarettes. We examined five cigarette price minimization strategies: 1) purchasing discount brand cigarettes, 2) using price promotions, 3) purchasing cartons, 4) purchasing on Indian reservations, and 5) purchasing online. Price reductions from these strategies were estimated jointly to compensate for overlapping strategies.

RESULTS

Each strategy provided price reductions between 26 and 99cents per pack. Combined price reductions were possible. Additionally, price promotions were used with regular brands to obtain larger price reductions than when price promotions were used with generic brands.

CONCLUSION

Smokers can realize large price reductions from price minimization strategies, and there are many strategies available. Policymakers and public health officials should be aware of the extent that these strategies can reduce cigarette prices.

Flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students

PURPOSE

Flavors can mask the harshness and taste of tobacco, making flavored tobacco products appealing to youth. We assessed the prevalence and correlates of flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students in 2011.

METHODS

Data were obtained from the 2011 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6-12. National estimates of current flavored-little-cigar use, flavored-cigarette use, and combined use of either product were calculated overall and among current smokers by respondent characteristics, including sex, race/ethnicity, school level, and grade. Additionally, intention to quit tobacco and smoking frequency were assessed by flavored product use.

RESULTS

The overall prevalence of current use was 4.2% for flavored cigarettes, 3.3% for flavored little cigars, and 6.3% for either product. Among current cigar smokers, 35.9% reported using flavored little cigars, and among current cigarette smokers, 35.4% reported using flavored cigarettes. Among current cigar or cigarette smokers, 42.4% reported using flavored little cigars or flavored cigarettes. Flavored product use among current smokers was higher among non-Hispanic whites than among blacks and Hispanics, higher among high school students than middle school students, and increased with grade. Among cigar smokers, prevalence of no intention to quit tobacco was higher among flavored-little-cigar users (59.7%) than nonusers (49.3%).

CONCLUSIONS

More than two fifths of U.S. middle and high school smokers report using flavored little cigars or flavored cigarettes, and disparities in the use of these products exist across subpopulations. Efforts are needed to reduce flavored tobacco product use among youth.

Impact of cigarette minimum price laws on the retail price of cigarettes in the USA

INTRODUCTION

Cigarette price increases prevent youth initiation, reduce cigarette consumption and increase the number of smokers who quit. Cigarette minimum price laws (MPLs), which typically require cigarette wholesalers and retailers to charge a minimum percentage mark-up for cigarette sales, have been identified as an intervention that can potentially increase cigarette prices. 24 states and the District of Columbia have cigarette MPLs.

METHODS

Using data extracted from SCANTRACK retail scanner data from the Nielsen company, average cigarette prices were calculated for designated market areas in states with and without MPLs in three retail channels: grocery stores, drug stores and convenience stores. Regression models were estimated using the average cigarette pack price in each designated market area and calendar quarter in 2009 as the outcome variable.

RESULTS

The average difference in cigarette pack prices are 46 cents in the grocery channel, 29 cents in the drug channel and 13 cents in the convenience channel, with prices being lower in states with MPLs for all three channels.

CONCLUSIONS

The findings that MPLs do not raise cigarette prices could be the result of a lack of compliance and enforcement by the state or could be attributed to the minimum state mark-up being lower than the free-market mark-up for cigarettes. Rather than require a minimum mark-up, which can be nullified by promotional incentives and discounts, states and countries could strengthen MPLs by setting a simple 'floor price' that is the true minimum price for all cigarettes or could prohibit discounts to consumers and retailers.

Cigarette price-minimization strategies by U.S. smokers

BACKGROUND

Smokers may react to cigarette excise tax increases by engaging in price-minimization strategies (i.e., finding ways to reduce the cost of cigarette smoking) rather than by quitting or reducing their cigarette use, thereby reducing the public health benefits of such tax increases.

PURPOSE

To evaluate the state and national prevalence of five common cigarette price-minimization strategies and the size of price reductions obtained from these strategies.

METHODS

Using data from the 2009-2010 National Adult Tobacco Survey, the prevalence of five common price-minimization strategies by type of strategy and by smoker's cigarette consumption level were estimated. The price reductions associated with these price-minimization strategies also were evaluated. Analyses took place in November 2012.

RESULTS

Approximately 55.4% of U.S. adult smokers used at least one of five price-minimization strategies in the previous year, with an average reduction of $1.27 per pack (22.0%). Results varied widely by state.

CONCLUSIONS

Cigarette price-minimization strategies are practiced widely among current smokers, and resulting price reductions are relatively large. Policies that decrease opportunities to effectively apply cigarette price-minimization strategies would increase the public health gains of cigarette excise tax increases.

Flavored cigar smoking among U.S. adults: findings from the 2009-2010 National Adult Tobacco Survey

INTRODUCTION

Under its authority to regulate tobacco products, the U.S. Food and Drug Administration prohibited certain characterizing flavors in cigarettes in September 2009; however, flavored cigars are still permitted to be manufactured, distributed, and sold. This study assessed the prevalence and correlates of flavored cigar smoking among U.S. adults.

METHODS

Data were obtained from the 2009-2010 National Adult Tobacco Survey, a national landline and cell phone survey of adults aged ≥ 18 years old residing in the 50 U.S. states and the District of Columbia. National and state estimates of flavored cigar use were calculated overall and among current cigar smokers; national estimates were calculated by sex, age, race/ethnicity, educational attainment, annual household income, U.S. Census Region, and sexual orientation.

RESULTS

The national prevalence of flavored cigar smoking was 2.8% (95% confidence interval [CI] = 2.6%-3.1%; state range: 0.6%-5.7%) and was greater among those who were male, younger in age, non-Hispanic Other race, less educated, less wealthy, and lesbian, gay, bisexual, or transgendered (LGBT). Nationally, the prevalence of flavored cigar use among cigar smokers was 42.9% (95% CI = 40.1%-45.7%; state range: 11.1%-71.6%) and was greater among those who were female, younger in age, Hispanic, non-Hispanic Other race, less educated, less wealthy, and LGBT.

CONCLUSIONS

More than two fifths of current cigar smokers report using flavored cigars. Disparities in flavored cigar use also exist across states and subpopulations. Efforts to curb flavored cigar smoking have the potential to reduce the prevalence of overall cigar smoking among U.S. adults, particularly among subpopulations with the greatest burden.

Attitudes toward smoke-free workplaces, restaurants, and bars, casinos, and clubs among u.s. Adults: findings from the 2009-2010 national adult tobacco survey

INTRODUCTION

An increasing number of U.S. states and communities have implemented smoke-free policies prohibiting smoking in all indoor workplaces and public areas. Public attitudes toward smoke-free environments are an evidenced-based, key indicator for the successful implementation and enforcement of smoke-free policies.

METHODS

Data were obtained from the 2009-2010 National Adult Tobacco Survey, a landline and cell phone survey of adults aged ≥18 years old residing in the 50U.S. states and the District of Columbia. The overall proportion of respondents who reported that smoking should "never be allowed" in workplaces, restaurants, and bars/casinos/clubs was calculated, both nationally and by state. National estimates were also calculated by sex, age, race/ethnicity, education, annual household income, sexual orientation, and smoking status.

RESULTS

Nationally, 81.6% of U.S. adults think workplaces should be smoke-free (state range: 68.6% [Kentucky] to 89.1% [California]); 74.9% think restaurants should be smoke-free (state range: 59.5% [Missouri] to 84.6% [California]); 50.0% think bars/casinos/clubs should be smoke-free (state range: 32.3% [Nevada] to 61.3% [Maine]); and 47.5% think workplaces, restaurants, and bars/casinos/clubs should be smoke-free (state range: 30.3% [Nevada] to 58.8% [Maine]). Regardless of venue type, women, older individuals, non-Hispanic Asians, individuals with higher education and income, and nonsmokers were the most likely to think these environments should be smoke-free.

CONCLUSIONS

A majority of U.S. adults think workplaces and restaurants should be smoke-free, while half think bars, casinos, and clubs should be smoke-free. Continued efforts are needed to educate the public about the dangers of secondhand smoke and the benefits of smoke-free indoor environments.

National and state estimates of secondhand smoke infiltration among U.S. multiunit housing residents

INTRODUCTION

Multiunit housing (MUH) residents are susceptible to secondhand smoke (SHS), which can infiltrate smoke-free living units from nearby units and shared areas where smoking is permitted. This study assessed the prevalence and characteristics of MUH residency in the United States, and the extent of SHS infiltration in this environment at both the national and state levels.

METHODS

National and state estimates of MUH residency were obtained from the 2009 American Community Survey. Assessed MUH residency characteristics included sex, age, race/ethnicity, and poverty status. Estimates of smoke-free home rule prevalence were obtained from the 2006-2007 Tobacco Use Supplement to the Current Population Survey. The number of MUH residents who have experienced SHS infiltration was determined by multiplying the estimated number of MUH residents with smoke-free homes by the range of self-reported SHS infiltration (44%-46.2%) from peer-reviewed studies of MUH residents.

RESULTS

One-quarter of U.S. residents (25.8%, 79.2 million) live in MUH (state range: 10.1% in West Virginia to 51.7% in New York). Nationally, 47.6% of MUH residents are male, 53.3% are aged 25-64 years, 48.0% are non-Hispanic White, and 24.4% live below the poverty level. Among MUH residents with smoke-free home rules (62.7 million), an estimated 27.6-28.9 million have experienced SHS infiltration (state range: 26,000-27,000 in Wyoming to 4.6-4.9 million in California).

CONCLUSIONS

A considerable number of Americans reside in MUH and many of these individuals experience SHS infiltration in their homes. Prohibiting smoking in MUH would help protect MUH residents from involuntary SHS exposure.

Current tobacco use among adults in the United States: findings from the National Adult Tobacco Survey

OBJECTIVES

We assessed the prevalence and sociodemographic correlates of tobacco use among US adults.

METHODS

We used data from the 2009-2010 National Adult Tobacco Survey, a national landline and cell phone survey of adults aged 18 years and older, to estimate current use of any tobacco; cigarettes; cigars, cigarillos, or small cigars; chewing tobacco, snuff, or dip; water pipes; snus; and pipes. We stratified estimates by gender, age, race/ethnicity, education, income, sexual orientation, and US state.

RESULTS

National prevalence of current use was 25.2% for any tobacco; 19.5% for cigarettes; 6.6% for cigars, cigarillos, or small cigars; 3.4% for chewing tobacco, snuff, or dip; 1.5% for water pipes; 1.4% for snus; and 1.1% for pipes. Tobacco use was greatest among respondents who were male, younger, of non-Hispanic "other" race/ethnicity, less educated, less wealthy, and lesbian, gay, bisexual, or transgender. Prevalence ranged from 14.1% (Utah) to 37.4% (Kentucky).

CONCLUSIONS

Tobacco use varies by geography and sociodemographic factors, but remains prevalent among US adults. Evidence-based prevention strategies are needed to decrease tobacco use and the health and economic burden of tobacco-related diseases.

Fiscal and policy implications of selling pipe tobacco for roll-your-own cigarettes in the United States

BACKGROUND

The Federal excise tax was increased for tobacco products on April 1, 2009. While excise tax rates prior to the increase were the same for roll-your-own (RYO) and pipe tobacco, the tax on pipe tobacco was $21.95 per pound less than the tax on RYO tobacco after the increase. Subsequently, tobacco manufacturers began labeling loose tobacco as pipe tobacco and marketing these products to RYO consumers at a lower price. Retailers refer to these products as "dual purpose" or "dual use" pipe tobacco.

METHODS

Data on tobacco tax collections comes from the Alcohol and Tobacco Tax and Trade Bureau. Joinpoint software was used to identify changes in sales trends. Estimates were generated for the amount of pipe tobacco sold for RYO use and for Federal and state tax revenue lost through August 2011.

RESULTS

Approximately 45 million pounds of pipe tobacco has been sold for RYO use from April 2009 to August 2011, lowering state and Federal revenue by over $1.3 billion.

CONCLUSIONS

Marketing pipe tobacco as "dual purpose" and selling it for RYO use provides an opportunity to avoid paying higher cigarette prices. This blunts the public health impact excise tax increases would otherwise have on reducing tobacco use through higher prices. Selling pipe tobacco for RYO use decreases state and Federal revenue and also avoids regulations on flavored tobacco, banned descriptors, prohibitions on shipping, and reporting requirements.

Secondhand smoke exposure in cars among middle and high school students--United States, 2000-2009

OBJECTIVES

Exposure to secondhand smoke (SHS) from cigarettes poses a significant health risk to nonsmokers. Among youth, the home is the primary source of SHS. However, little is known about youth exposure to SHS in other nonpublic areas, particularly motor vehicles.

METHODS

Data were obtained from the 2000, 2002, 2004, 2006, and 2009 waves of the National Youth Tobacco Survey, a nationally representative survey of US students in grades 6 to 12. Trends in SHS exposure in a car were assessed across survey years by school level, gender, and race/ethnicity by using binary logistic regression.

RESULTS

From 2000 to 2009, the prevalence of SHS exposure in cars declined significantly among both nonsmokers (39.0%-22.8%; trend P < .001) and smokers (82.3%-75.3%; trend P < .001). Among nonsmokers, this decline occurred across all school level, gender, and race/ethnicity subgroups.

CONCLUSIONS

SHS exposure in cars decreased significantly among US middle and high school students from 2000 to 2009. Nevertheless, in 2009, over one-fifth of nonsmoking students were exposed to SHS in cars. Jurisdictions should expand comprehensive smoke-free policies that prohibit smoking in worksites and public places to also prohibit smoking in motor vehicles occupied by youth.