Preventive Medicine Reports

IntroductionBeginning in 2019, several U.S. states implemented temporary or permanent bans on the sale of flavored e-cigarettes. This study examined the impact of flavor bans on adult e-cigarette use in Washington, New Jersey, and New York. MethodsAdults who used e-cigarettes at least once a week before the flavor bans were recruited online. Respondents reported their e-cigarette use, primarily used flavor, and ways of obtaining ecigarettes before and after the bans. Descriptive statistics and multinomial logistic regression models were applied. ResultsAfter the ban, 8.1% of respondents (N=1624) quit using e-cigarettes, those primarily used banned menthol or other flavors declined from 74.4% to 50.8, those using tobacco-flavored declined from 20.1% to 15.6%, and those using non-flavored increased from 5.4% to 25.4%. More frequent e-cigarette use and smoking cigarettes were associated with being less likely to quit e-cigarettes and more likely to use banned flavors. Of those primarily using banned flavors, 45.1% obtained e-cigarettes from in-state stores, 31.2% from out-of-state stores, 32% from friends, family, or others, 25.5% from Internet/mail sellers, 5.2% from illegal sellers, 4.2% mixed flavored e-liquids themselves, and 6.9% stocked up on e-cigarettes before the ban. ConclusionsMost respondents continued to use e-cigarettes with banned flavors post-ban. Compliance of local retailers with the ban was not high, and many respondents obtained banned-flavor e-cigarettes through legal channels. However, the significant increase in the use of non-flavored e-cigarettes post-ban suggests that these may serve as a viable alternative among those who used previously used banned or tobacco flavors. ImplicationsThis study examined the impact on adult e-cigarette users from the recent e-cigarette-only flavor bans in Washington State, New Jersey, and New York. We found that most respondents continued to use e-cigarettes with banned flavors post-ban and obtain banned-flavor e-cigarettes through legal channels. Our findings indicate that non-flavored e-cigarettes may serve as an acceptable alternative to both non-tobacco and tobacco-flavored e-cigarettes and state e-cigarette flavor bans are unlikely to prompt a significant number of adult e-cigarette users to replace their e-cigarette use with new or increased smoking. Enforcing compliance of retailers to the policy is crucial to control e-cigarette use.

Sales of deep-discount cigarettes are growing; yet little is known about who is using these products and their potential impact on tobacco use behavior. Using multinomial logistic regression, this cross-sectional analysis of 2021 National Survey on Drug Use and Health data examines associations between sociodemographic characteristics and smoking behaviors and odds of using value and deep-discount cigarettes (versus premium). Use of value and deep-discount cigarettes was significantly more prevalent for older adults and people with lower incomes and significantly less prevalent among non-Hispanic Black individuals. People who received government assistance, smoked daily, smoked more than a pack of cigarettes per day, and who met the criteria for nicotine dependence were significantly more likely to use deep-discount--but not value--brands than premium cigarettes. More research is needed to better understand how deep-discount cigarettes may impact tobacco use behavior (including smoking cessation), particularly among people with low socioeconomic status.

ObjectivesBy raising the legal age of sale from 18 to 21 years old, Tobacco 21 laws (T21) are reshaping the tobacco landscape in the United States. In 2019, Maryland became the 13th state to adopt T21. This study is among the first to examine the perception, awareness, and ease of compliance of T21 among tobacco retailers through a two-wave survey conducted pre-T21 and post-T21. DesignSurveys were conducted among the states more than 6,000 registered retailers prior to the states T21 law going into effect and eight months later after T21 had been enacted. The pre-T21 and post-T21 survey instruments measured retailer awareness, support, and perceived ability to comply with T21, current tobacco practices, revenue from tobacco products, and challenges faced in compliance. 414 retailers completed the pre-T21 survey and 360 completed the post-T21 survey. The final survey data was weighted to reflect the geographic distributions of licensed tobacco retailers in Maryland. ResultsThere was no significant difference in retailer awareness, support and challenges comparing pre and post T21. One notable caveat is lack of consumer knowledge about T21, resulting in retailers being responsible for educating customers. ConclusionsThe evaluation of T21 and impact to retailers is a valuable tool in determining the laws success and barriers to implementation. Results support the idea that T21 laws have had a minor impact on how retailers conduct their business. As a result of the communication and materials provided by the state, retailers largely understand the law and how to adhere to guidelines.

IntroductionGiven the rapidly changing media landscape and tobacco marketplace, timely data on media consumption and exposure to pro-tobacco content across media channels among lesbian, gay, and bisexual (LGB) young adults is imperative for developing counter-messaging and public education campaigns for these individuals. MethodsUsing 2023 data from young adults in California, this study examined how social media use differed across media channels for heterosexual and LGB young adults, by gender identity. Exposure to pro-tobacco content across media channels between heterosexual and LGB young adults, by gender identity was also compared. ResultsFindings from a representative sample of young adults in California showed that more LGB young adults reported using Tumblr and fewer reported using Facebook and Snapchat, compared with heterosexual young adults, among both males and females. Additionally, social media use differed by gender identity. For example, use of Reddit was more common among LGB versus heterosexual females, but there were no differences by sexual identity among males. Exposure to tobacco marketing was more common among LGB females compared with heterosexual females, but this was not the case for males. Exposure to user-generated e-cigarette content, and self-reported visits to e-cigarette websites, were more common among LGB females compared to heterosexual females. ConclusionsThese findings highlight the importance of treating LGB individuals as a heterogeneous group. As such, anti-tobacco campaigns designed for LGB individuals that leverage social media will want to consider which social media platforms are most used among their target audience, ensuring maximum campaign reach.

Structured AbstractO_ST_ABSImportanceC_ST_ABSWhile sales and use of cigarettes have declined, it is important to understand how these trends differ across brands and product characteristics, and how the demographic makeup of cigarette smokers has shifted. ObjectiveExamine trends in U.S. market share for leading cigarette brands by brand tier and menthol status and describe the sociodemographic profile of people who use top cigarette brands. DesignCohort study: The Population Assessment of Tobacco and Heath (PATH) Study collects data from a nationally representative sample of U.S. youth (age 12-17) and adults (age 18+) in 1-2-year intervals from 2013-2023 (Waves 1-7). SettingRespondents complete the questionnaire via in-person audio-computer-assisted interviews. Telephone interviews were available in 2020-2023 due to the COVID-19 pandemic. ParticipantsThis study utilized data from 19,722 individuals (youth: N=1,201; adults: N=18,521) who smoked cigarettes in the past 30-days (P30D) ExposuresTime (survey wave). Main Outcome and MeasuresRespondents were asked the cigarette brand that they usually smoke or last smoked, the number of cigarettes smoked per day, and how many days they smoked in the P30D to estimate monthly intake and market share. Cigarette brands were coded into premium and non-premium brand tiers. Demographic characteristics, other tobacco use, alcohol use, marijuana use, and mental health status were also assessed. ResultsPremium brands (overall and menthol) experienced significant market declines. Non-premium brands saw a market share increase. Characteristics of those smoking cigarettes changed: reduced number of cigarettes smoked per day, increased marijuana use, decreased alcohol use, and decreased moderate-to-high-severity mental health symptoms. Conclusions and RelevanceWhile brand loyalty remains strong for the top three cigarette brands, the expanding non-premium market continues to encroach on the premium brand market. Similar patterns were observed in the menthol sector. As the marketplace changes so do the profiles of the people who use them or market potentially reflects the people who are still smoking. Continued timely surveillance of cigarette brand preferences and profiles of the people who use them will inform tobacco control policies that minimize tobacco-related mortality. Key PointsO_ST_ABSObjectiveC_ST_ABSExamine market share trends (2013-2023) for cigarette brands by brand tier and menthol status; describe the sociodemographic profile of people who use top cigarette brands. FindingsPremium brands experienced significant market declines overall and among the menthol category. Non-premium brands saw a market share increase. Characteristics of those smoking cigarettes changed: reduced cigarettes smoked per day, increased marijuana use, decreased alcohol use, and decreased moderate-to-high-severity mental health symptoms. MeaningWhile brand loyalty remains strong for top cigarette brands, the expanding non-premium market is encroaching on the premium brand market. These changes reflect shifts in sociodemographic profiles of people smoking in 2023.

ObjectivesMenthol flavoring is a critical public health issue, but prior work has largely represented the voices of White adults who smoke (AWS) menthol cigarettes who comprise a small subset of AWS menthol cigarettes in the US. This study compared perceptions of a hypothetical MC/FC ban among Black and White AWS menthol cigarettes. MethodsParticipants were a convenience sample of 2,113 Black and 1,087 White AWS menthol cigarettes collected through Amazon Mechanical Turk between July 2023 and January 2024. Participants reported opinions about a MC/FC ban, likely public health outcomes, and hypothetical impact of the ban on their smoking behavior. Stepwise logistic regression modeled factors associated with ban opposition/ambivalence. ResultsOver one-third of menthol cigarette users supported a MC/FC ban (Black, 37.2% vs White, 34.5%, p=.13], but Black AWS were more likely to endorse public health benefits of a ban assessed via agreement with 5 statements of FDA rationale [3.0 (SD=1.7) versus 2.4 (SD=1.8), p<.001]. Smoking more cigarettes per day, belief that menthol cigarettes are more addictive/harder to quit, and intent to continue using nicotine under a ban increased odd of opposition/ambivalence. ConclusionsCompared to White AWS, Black AWS were more likely to believe that a MC/FC ban would benefit public health and showed no statistical difference in overall support for a ban. Targeted outreach to those who consume more menthol products and those who do not intend to quit nicotine could increase ban support among menthol users. Summary Box1) What is the current understanding of this subject?Knowledge of the publics perception of a MC/FC ban is largely informed by White menthol cigarette users. Given that Blacks represent the majority of AWS menthol cigarettes in the US, the paucity of data from Black voices engenders a critical gap in research used to inform health policy. 2) What does this report add to the literature?Compared to White AWS, Black AWS were more likely to believe that a MC/FC ban would benefit public health and showed no statistical difference in overall support for a ban. To our knowledge, this study comprises the largest convenience sample of perceptions and perceived impact of a federal MC/FC product standard among Black AWS menthol cigarettes in the US and provides valuable evidence to inform policy action in these areas. 3) What are the implications for public health practice?Findings support ongoing efforts to advance a MC/FC product standard and suggest that targeted outreach to those who consume more menthol products and those who do not intend to quit nicotine could increase ban support among menthol users.

AimsTo report annual 2014-2019 youth estimates of past 30-day e-cigarette use frequency by smoking status in the United States (US). DesignWeighted prevalence estimates of students e-cigarette use using the 2014-2019 National Youth Tobacco Surveys (NYTS). For each year, t-tests for significance were used to compare estimates with those from the preceding year; t-tests were not performed on data for 2019 due to the change in survey format from paper to electronic. SettingThe NYTS is an annual school-based cross-sectional survey of US middle school (MS) and high school (HS) students. Participants117,472 students. MeasurementsSelf-report of past 30 day e-cigarette use based on students smoking status. Smoking status is assessed by asking if students have ever tried smoking, "even one or two puffs", with never smokers responding "no". Former smokers respond "yes" but have not smoked at all in the past 30 days. Current smokers used cigarettes at least once in the past 30 days. Frequent e-cigarette use is defined as use on [&ge;]20 days in the past month. FindingsPast 30-day and frequent e-cigarette use increased among never, former, and current smoker youth from 2014-2019. In 2019, a greater proportion of current smokers used e-cigarettes frequently (HS = 46.1%, 95% CI: 39.1, 53.2; MS = 27.4%, 95% CI: 21.1, 33.6) compared to former smokers (HS = 23.2%, 95% CI: 18.1, 28.2; MS = 10.9%, 95% CI: 6.1, 15.7) and never smokers (HS = 3.7%, 95% CI: 3.0, 4.3; MS = 0.7%, 95% CI: 0.4, 0.9). From 2018 to 2019, the total number of youth using e-cigarettes frequently who were never smokers (2018: 180,000; 2019: 490,000) or former smokers (2018: 260,000; 2019: 640,000) surpassed that of current smokers (2018: 420,000; 2019: 460,000). ConclusionsThe proportion and number of never smoker youth using e-cigarettes frequently increased greatly since 2014.

ImportancePhysicians play a primary role in smoking cessation, and their communication regarding e-cigarettes needs to be understood. ObjectiveTo examine physician-patient communication regarding e-cigarettes. DesignA national, repeated cross-sectional survey in 2018 and 2019 was conducted. SettingParticipants were invited by mail; surveys were completed online. ParticipantsResponse rates were 51.8% (2018) and 59.1% (2019), resulting in 2,058 board-certified physicians from family medicine, internal medicine, obstetrics/gynecology, cardiology, pulmonary/critical care, and hematology/oncology. ExposuresPhysician demographics, tobacco use, medical specialty, and harm-reduction beliefs (i.e., not all tobacco products equally harmful); two hypothetical clinical scenarios. Main outcomes and measuresPhysicians self-reported e-cigarette communication behaviors (being asked about e-cigarettes by patients and recommending e-cigarettes to patients), and hypothetical e-cigarette communication in two clinical scenarios. ResultsAmong 2,058 physicians, the mean age was 51.6 years and 41.5% were female. Over 60% of physicians believed all tobacco products are equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), while 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days). Pulmonologists (adjusted odds ratio [AOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (AOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (AOR, 1.77; 95% CI, 1.12-2.80) had greater odds of recommending e-cigarettes to patients. Physicians who endorsed a harm-reduction perspective (AOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (AOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Being asked about e-cigarettes by patients was a strong predictor of physicians recommending (AOR,16.6; 95% CI, 10.3-26.7). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older, heavy smoker with multiple unsuccessful quit attempts than a younger, light smoker with no prior cessation treatments (49.3% vs. 15.2%, p<.001). Conclusions and relevanceFindings suggest physicians may recommend e-cigarettes for cessation under certain circumstances. Given the role of e-cigarettes in FDAs comprehensive nicotine policy, there is need for continued physician education regarding e-cigarette efficacy, particularly correcting misperceptions regarding harm reduction. Key PointsO_ST_ABSQuestionC_ST_ABSHow do physicians communicate with their patients about e-cigarettes? FindingsIn this repeated cross-sectional survey of 2,058 respondents, physicians who were asked about e-cigarettes by their patients, endorsed a harm-reduction perspective, or had ever smoked were significantly more likely to recommend e-cigarettes to patients. Clinical scenarios showed physicians were significantly more likely to recommend e-cigarettes for an older, heavy smoker with prior unsuccessful quit attempts, and use of FDA-approved pharmacotherapy for a younger, light smoker with no prior cessation treatments. MeaningPhysicians may recommend e-cigarettes for cessation under certain circumstances, warranting continued physician education regarding e-cigarette efficacy.

The prevalence of e-cigarette use in adolescents is concerning, particularly because of high rates of vapers transitioning to combustible tobacco. It is unclear why young, never smoker, e-cigarette vapers decide to start smoking cigarettes, but the transition may be influenced by perceptions of health risks and accessibility. We designed a social media questionnaire to assess factors driving switches from vaping to smoking, smoking to vaping, and multi-inhalant use. Among respondents (n=864) who switched from vaping to smoking (n=104), primary reasons included: 1. perception that smoking was healthier (44%); and 2. greater accessibility of cigarettes (40%). For switchers from smoking to vaping (n=178), predominant motivations included: 1. having friends or family who vape (40%); and 2. perception that vaping was healthier (36%). Among multi-inhalant users (n=223), key factors driving this behavior included: 1. increased enjoyment (47%); and 2. greater variety (42%). Our findings imply that there is no single, dominant reason driving switching from vaping to smoking. Further, tobacco users are receiving mixed messaging, leading many to believe that combustible tobacco is the healthier option. Public health interventions are needed to prevent initiation of e-cigarette vaping by youth and education of the public about health effects across tobacco products.

BackgroundAdolescent tobacco and nicotine product (TNP) use remains a public health concern, with emerging gender convergence and rising e-cigarette use among females. We examined gender-specific trends in Georgian adolescents alongside national tobacco control policies and social context. MethodsWe analyzed nationally representative Global Youth Tobacco Survey data from Georgia (2014, 2017, and 2023) for youth aged 11-17 to estimate prevalence and patterns of current TNP use in the context of tobacco-related advertising and promotion, secondhand smoke, and national policy, via a policy review. Adjusted prevalence estimates were derived using post- estimation predictive margins after fitting multinomial logistic regression models. ResultsFrom 2014 to 2023, current TNP use declined among boys but increased among girls, particularly in exclusive e-cigarette use. The percentages reporting no current TNP use increased among boys from 77.4% to 85.6% (p < 0.01), but declined among girls from 92.1% to 88.1% (p = 0.04). By 2023, exclusive e-cigarette use was more prevalent among girls than boys. Across sexes, exposure to pro-tobacco advertising and promotion and secondhand smoke declined. Exposure to anti-tobacco promotion peaked in 2017 and receded by 2023. The policy review documented strengthened measures, alongside gaps in oversight of digital marketing and newer products, including e-cigarettes. ConclusionsGeorgias tobacco control policies have contributed to reduced TNP use among boys and a less permissive social environment. Rising e-cigarette use among girls is concerning. Policies should close regulatory gaps, enhance enforcement, and address evolving product and marketing developments to prevent TNP uptake and protect adolescents from tobacco-related harms. SUMMARY BOXO_ST_ABSWhat is already known on this topicC_ST_ABSAdolescent tobacco use patterns are shifting globally, with narrowing gender gaps and rising use of new products like e-cigarettes, especially among girls. In Georgia, the impact of recent tobacco control reforms targeting youth tobacco and nicotine product use by gender had not been fully assessed. What this study addsBetween 2014 and 2023, TNP use significantly declined among boys in Georgia but rose in exclusive e-cigarette use among girls. Exposure to tobacco advertising and promotion and secondhand smoke decreased, yet gaps in anti-tobacco promotion and regulation of novel products persist. How this study might affect research, practice or policyFindings from this study reinforce WHOs call for gender-responsive tobacco control policies. Regulatory measures must address how product design and marketing tactics exploit gendered social norms and youth vulnerabilities. Comprehensive, gender-responsive strategies that strengthen anti-tobacco promotion and close regulatory gaps are essential to counter these influences and protect all adolescents from targeted industry tactics.

IntroductionIn England, non-cigarette tobacco products (e.g., cigarillos, cigars, waterpipes, bidis, smokeless tobacco, heated tobacco) are subject to fewer regulatory restrictions than cigarettes/rolling tobacco. This study assessed trends in youth use of these products in England, Canada, and the US, focussing on evaluating the impact of Englands May 2020 ban on menthol in cigarettes but not non-cigarette tobacco. MethodsData were from the ITC Youth Tobacco and Vaping Survey (16-19-year-olds; N=129,575) across ten waves (2017-2024). Segmented regressions assessed changes in trends of non-cigarette tobacco products before vs. after May 2020, adjusting for race/ethnicity/sex/age. ResultsIn England, non-cigarette tobacco use increased similarly before (aOR=1.16,1.02-1.31) and after (1.13,1.07-1.20) the ban (change in trend: 0.98,0.91-1.06), from 7.4% in 2017 and reaching in 11.6% in 2024. In contrast, non-cigarette tobacco use decreased similarly before and after the ban in both the US (pre-ban: 0.82, 0.73-0.93; post-ban: 0.84,0.80-0.89; change in trend: 1.02,0.94-1.11; from 10.2% reaching 7.1%), and Canada (pre-ban: 0.84,0.76-0.93; post-ban: 0.90,0.86-0.94; from 9.2% reaching 7.9%), although the decline in Canada after the ban was slightly slower (1.07,1.001-1.15). Cigarillo, cigar, and smokeless tobacco use specifically increased to a greater extent in England than Canada and the US. ConclusionsBetween 2017 and 2024, youth non-cigarette tobacco product use increased in England and surpassed declining use in Canada and the US. There was little evidence that Englands menthol cigarette ban accelerated increases, although increases highlight the need for comprehensive regulations encompassing all tobacco products in England. IMPLICATIONSYouth use of non-cigarette tobacco products has been increasing in England but declining in Canada and the US. Englands menthol cigarette ban did not appear to alter trends in use of non-cigarette tobacco, but findings highlight a need for more comprehensive regulation encompassing all tobacco products to mitigate youth uptake.

IntroductionTo identify intervention priorities for reducing tobacco use among youth in Heilongjiang, this study examined provincial epidemiological patterns of cigarette and e-cigarette adoption from 2014 to 2023, providing evidence-based foundations for timely provincial school tobacco control strategies. MethodsSchool-based cross-sectional surveys were conducted in 2014, 2019, 2021 and 2023. A randomized multistage stratified cluster sampling design was employed to obtain representative samples of middle school students (MSs) and high school students (HSs). ResultsIn 2019, 2021 and 2023, the current cigarette and e-cigarette use rates among MSs and HSs were 6.79%, 5.45%, and 4.70%, and 3.61%, 5.46%, and 2.07%, respectively. The current dual-use rates for cigarettes and e-cigarettes were 1.74%, 2.83%, and 1.03%, respectively. The current rates for either cigarette or e-cigarette use were 8.70%, 8.10%, and 5.76%, respectively. Among current cigarette users of MSs and HSs, the rates of e-cigarette use first were 15.59%, 12.75%, and 21.80%, respectively. Among cigarette and e-cigarette dual-users of MSs and HSs, the rates of e-cigarette use first were 17.46%, 14.99%, and 28.41%, respectively. ConclusionsFrom 2014 to 2023, based on results from four province-wide surveys, cigarette use rates among MSs and HSs in Heilongjiang declined, while e-cigarette use rates showed a peak in 2021 before decreasing. Policies such as "smoke-free schools" and e-cigarette regulation were beginning to show results. Joint efforts between families and schools, as well as collaboration among multiple departments were essential to ensure effective implementation of tobacco control measures and would be the focus of future tobacco control work.

BackgroundOral nicotine pouches (ONPs) have become the second most commonly used nicotine product among U.S. youth. However, little is known about how ONP use is distributed across population subgroups and how strongly it is patterned by use of other tobacco or nicotine products. MethodData were drawn from the 2021-2023 waves of the National Youth Tobacco Survey (NYTS), a nationally representative survey of U.S. middle and high school students (N = 66,349). We estimated the annual survey-weighted prevalence of current ONP use ([&ge;]1 day in the past 30). Using 2023 data (N = 20,174), we estimated prevalence by demographics and other tobacco/nicotine product use, and fitted survey-weighted Poisson regression models to estimate associations of current ONP use with demographics and other nicotine/tobacco product use. ResultsIn 2023, 1.6% reported current ONP use (95% confidence interval [CI] 1.0-2.1), up from 0.8% in 2021 (95% CI 0.5-1.0). Prevalence in 2023 was higher among males (2.3%, 95% CI 1.5-3.1) than females (0.8%, 95% CI 0.4-1.3), and among students who used any other tobacco or nicotine product (13.4%, 95% CI 10.3-16.5) than those who did not (0.4%, 95% CI 0.1-0.8). In fully adjusted models, use of nicotine products other than cigarettes or e-cigarettes showed the strongest association with ONP use (APR 21.1, 95% CI 13.0-34.0), followed by cigarette smoking (APR 2.0, 95% CI 1.1-3.7) and e-cigarette use (APR 1.9, 95% CI 0.8-4.5). Most current ONP users also used other tobacco/nicotine products (75.0%), though 16.6% reported no lifetime use of other products. ConclusionsOverall ONP prevalence among U.S. youth remains low but is increasing. While ONP use is largely concentrated in youth who use other nicotine/tobacco products, it is also increasing among adolescents who are otherwise nicotine-naive. These findings highlight the need for continued monitoring and targeted regulations that balance harm reduction for people who smoke against the risk of expanding nicotine dependence among youth. Key Points QuestionWhat are the prevalence, demographic patterns, and tobacco/nicotine co-use profiles of oral nicotine pouch users among US middle and high school students? FindingsIn this cross-sectional study of 66,349 students from the 2021-2023 National Youth Tobacco Survey, current oral nicotine pouch use doubled from 0.8% in 2021 to 1.6% in 2023. Most users also used other tobacco or nicotine products, but the proportion of current users with no lifetime use of other products increased from 7.4% to 16.6%. MeaningAlthough oral nicotine pouch use among US youth remains low, increasing uptake among adolescents without prior tobacco or nicotine exposure suggests a need for targeted prevention efforts alongside continued surveillance.

BackgroundCOVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a global pandemic in March 2020. Electronic cigarette use (vaping) rapidly gained popularity in the US in recent years. Whether electronic cigarette users (vapers) are more susceptible to COVID-19 infection is unknown. MethodsUsing integrated data in each US state from the 2018 Behavioral Risk Factor Surveillance System (BRFSS), United States Census Bureau and the 1Point3Acres.com website, generalized estimating equation (GEE) models with negative binomial distribution assumption and log link functions were used to examine the association of weighted proportions of vapers with number of COVID-19 infections and deaths in the US. ResultsThe weighted proportion of vapers who used e-cigarettes every day or some days ranged from 2.86% to 6.42% for US states. Statistically significant associations were observed between the weighted proportion of vapers and number of COVID-19 infected cases as well as COVID-19 deaths in the US after adjusting for the weighted proportion of smokers and other significant covariates in the GEE models. With every one percent increase in weighted proportion of vapers in each state, the number of COVID-19 infected cases increase by 0.3139 (95% CI: 0.0554 -0.5723) and the number of COVID-19 deaths increase by 0.3705 (95% CI: 0.0623 - 0.6786) in log scale in each US state. ConclusionsThe positive associations between the proportion of vapers and the number of COVID-19 infected cases and deaths in each US state suggest an increased susceptibility of vapers to COVID-19 infections and deaths.

IntroductionHistorically, tobacco use among women and girls in sub-Saharan Africa has been significantly lower than among men. However, recent trends show a concerning rise in smoking rates within this demographic. This shift necessitates a deeper examination of the role tobacco industry marketing plays in driving these changes. Focusing on five key countries--Nigeria, South Africa, Rwanda, Kenya, and Senegal--this research provides a comprehensive analysis of industry marketing tactics targeting women and girls in the region. Aims and MethodsThis study aims to investigate the evolving strategies used by the tobacco industry to market products to African women and girls. A mixed-methods approach was employed, combining a literature review, quantitative surveys, and qualitative semi-structured interviews. In addition, a historical analysis of tobacco industry documents and an evaluation of tobacco control laws and regulations in the five surveyed countries were conducted to gain deeper insights into industry practices. ResultsFindings from TIDs suggest that the tobacco industry has systematically targeted women for several decades, with a particular focus on young women aged 18-24. None of the surveyed countries currently have comprehensive laws addressing new and emerging products like e-cigarettes. Tobacco marketing was most commonly encountered in nightclubs, bars, lounges, and parties, with 32.8% of participants reporting exposure in these settings. Social media exposure varied across countries, while television shows and movies consistently showed high exposure rates (77.2%) across all five nations. Key informant interviews highlighted dominant themes such as brands targeting females, cultural perceptions of female tobacco use, femininity, autonomy, influencer marketing, digital strategies, harm reduction narratives, proximity marketing, peer and parental influences, and the perceived benefits of tobacco, particularly in terms of flavor, taste, and smell. Conclusion and ImplicationsThe tobacco industry uses sophisticated marketing strategies to enhance product appeal, particularly targeting women through emerging products, flavor manipulation, and harm reduction messaging. Proximity marketing in social settings has proven effective in increasing young womens access to tobacco products. Critical regulatory gaps remain, particularly concerning e-cigarettes and other novel tobacco products. The adequacy and enforcement of existing TAPS regulations, especially those concerning digital media and cross-border advertising, need urgent attention. Countries should adopt proactive regulations that anticipate industry adaptations and reduce the need for frequent updates. TAPS bans must be extended to encompass emerging tobacco and nicotine products across both traditional and digital platforms. Additionally, regulations need to target proximity and harm-reduction marketing to safeguard young women and prevent the normalization of tobacco use among these vulnerable demographics.

BackgroundThe estimates of economic burden due to smoking attributed illnesses provide an opportunity to assess its overall impact on the economy and generate evidence for public health policy interventions for tobacco control. In this study, we estimated out of pocket expenditures on tobacco attributed illnesses and smoking attributable burden in Pakistan. MethodsWe used a prevalence-based disease-specific cost approach by including three major tobacco attributed illnesses i.e. lung cancer, chronic obstructive pulmonary disease, and cardiovascular diseases. Our analysis included out of pocket healthcare expenditures including direct and indirect costs which were estimated by interviewing the patients of selected illnesses. The smoking-attributable expenditure was calculated by the WHO tool kit. ResultsIn 2018, the economic burden attributed to smoking related illnesses was Rs 192 billion (USD 1.3 billion). Smoking-attributable expenditure on cardiovascular disease was Rs 123 billion (USD 0.9 billion) which was 69% of the total economic cost of tobacco attributed illnesses in Pakistan. The economic cost in males was nearly three times higher than females. ConclusionsOur study showed a significant economic burden due to tobacco attributed illnesses in Pakistan which can be prevented by implementing tobacco control policies effectively.

IntroductionsAn increasing number of countries are adopting the tobacco endgame goal. High levels of public support can accelerate momentum towards implementing tobacco endgame policies. We aimed to conduct a systematic review on the level of public support for tobacco endgame policies and to examine the geographical distribution of studies, support among key populations (adolescents and young adults, people who smoke), and the association between survey design and support. MethodsWe searched Embase, PubMed, Scopus, Web of Science, and Google Scholar for studies published from 2013 onwards. Google was used to search the grey literature. The reference lists of included articles were hand-searched. Studies were included if they reported the proportions of people supporting one or more endgame policies. Risk of bias was assessed using the JBI checklist for prevalence studies. ResultsForty-seven articles were included. New Zealand and the United States were the countries with the most studies (n=11, respectively). Three-level meta-analyses showed the highest support for mandating a very low nicotine content in tobacco products (76%, 95% CI 61-87%). Meta-regressions were performed to assess the associations of population subgroup and survey design with support levels. The level of support was lower among people who smoke compared to the general population ({beta} range: -1.59 to -0.51). Support for some policies was lower when neutral or dont know response options were included. ConclusionsPublic support for most tobacco endgame policies was high. ImplicationsAssessing public support can assist with progressing tobacco endgame policies. Policies that are widely supported by the public may be more politically feasible to implement. Qualitative studies and trial studies can further inform communication and implementation strategies for tobacco endgame policies.

BackgroundRegulating features of tobacco products can reduce the appeal and addictiveness of smoking. We examined predicted behavioural responses to bans on i) filter ventilation (FV), ii) regular nicotine content (RNC), and iii) menthol and flavour crushballs (MFC), as well as perceived rationales for these bans. MethodsAustralian adults who smoked at least weekly were recruited from an online research panel to participate in a cross-sectional survey and were allocated to either the FV (n=301), RNC (n=335), or MFC (n=298) study arm, depending on current product use. Respondents viewed a basic description of each ban before completing measures of predicted behavioural responses and perceived rationale. ResultsThe proportion of respondents who reported being likely to try to quit smoking in response to the product regulations was 25.9% in the FV arm, 18.5% in the RNC arm, and 13.4% in the MFC arm. However, in each study arm, respondents more commonly predicted that they would switch to tobacco products that would remain available after the ban (FV: 33.6%; RNC: 37.0%; MFC: 51.3%), and some reported being likely to switch to e-cigarettes (FV: 14.6%; RNC: 11.6%; MFC: 23.2%). The majority of respondents reported either misperceptions or uncertainty about the rationale for the bans (FV: 69.8%; RNC: 81.5%; MFC: 62.4%). ConclusionA higher proportion of people who smoke anticipate that they would respond to tobacco product bans by switching to a different product, rather than using the ban as an opportunity to quit. Future studies should experimentally investigate whether public health messaging about these product regulation measures can be used to encourage greater rates of quitting by minimising switching to available products, including e-cigarettes, and to minimise misperceptions by increasing awareness of the rationale for each product regulation measure.

IntroductionElectronic cigarette (e-cig) use in previously tobacco-naive individuals may increase the risk of nicotine addiction and adverse health outcomes, including lung injury and cardiovascular disease. This study identifies a subgroup of heavy exclusive e-cig vapers, characterizes their demographics, and establishes an optimal serum cotinine threshold to differentiate them from tobacco-naive individuals. MethodsWe analyzed data from the National Health and Nutrition Examination Survey (2013- 2020) to characterize serum cotinine levels by e-cig use frequency. The optimal cotinine cutoff for identifying heavy exclusive vapers was 2.2 ng/mL (sensitivity 98%, specificity 96%). We used receiver operating characteristic curve analysis to identify the cotinine threshold for discriminating heavy exclusive e-cig vapers from tobacco-naive individuals and logistic regression to explore sociodemographic factors. ResultsExclusive heavy e-cig vapers--defined as those who vaped on four or more of the past five days--had mean cotinine levels (220 {+/-} 38 ng/mL) comparable to cigarette smokers (212 {+/-} 6 ng/mL). These vapers were more likely to be 12-18 (AOR 7.96; 95% CI: [3.38 - 18.7]) or 19-25 [AOR 7.36 [2.84 - 19]) years old and less likely to be female (AOR 0.3 [0.16-0.57]). ConclusionHeavy exclusive e-cig vapers had serum cotinine levels similar to cigarette smokers and were predominantly young males. Public health interventions should target this high-risk subgroup to reduce potential long-term health consequences.

ObjectivesLittle is known of socioeconomic and gender disparities in tobacco use in the Caribbean. We evaluated education and occupation disparities in tobacco smoking prevalence in Jamaica. MethodsData on tobacco smoking, education attainment and usual occupation in adults 25-74 years in a national survey collected between 2007 and 2008 was analyzed. Using post stratification survey weights, Poisson regression models estimated sex-specific, age-adjusted prevalence estimates, prevalence differences and prevalence ratios. ResultsAnalyses included 2299 participants (696 men, 1603 women), mean age 43 years. Current smoking prevalence was 26% in men and 8% in women (p<0.001). Among men, age adjusted prevalence of current smoking was highest in primary education (36.5%) and lowest in the post-secondary education groups (10.2%), (p= 0.003). Among women, prevalence was highest in junior secondary education (10.2%) and lowest in primary education groups (4.7%), (p = 0.014). Among men, for education, age-adjusted prevalence ratios for current smoking ranged from 2.6 to 3.6 using post-secondary education as the reference category (p<0.05). For occupation, age-adjusted prevalence ratios ranged from 1.7 to 4.1 using professionals and managers as the reference category. Among women, using the same reference categories age-adjusted prevalence ratios for education ranged from 1.4 to 2.2 and for occupation 0.6 to 2.2, neither were statistically significant. ConclusionIn Jamaica, there are socioeconomic disparities in current tobacco smoking among men, where it is inversely associated with education attainment and occupation but in women is less clear. These findings suggest interventions to reduce smoking should consider these disparities.