Community Voices: A Qualitative Study Exploring Perceptions of Menthol Cigarette Sales Restrictions in Los Angeles County Among Black Adults Who Smoke Menthol Cigarettes.

INTRODUCTION: The commercial tobacco industry has long targeted Black communities by making menthol cigarettes not only appealing but affordable through marketing, advertising, and pricing strategies, particularly in the retail environment. Policies that focus on restricting the sale of menthol cigarettes have the potential to significantly reduce the death toll from smoking while also mitigating health inequities and advancing racial equity. However, limited qualitative research exists on the perceptions of menthol cigarette sales restrictions, including local policies, among Black adults who smoke menthol cigarettes. AIMS AND METHODS: In-depth semi-structured interviews were conducted between January and September 2021 with self-identified non-Hispanic Black adults who reported current menthol cigarette use (n = 26). Participants were asked open-ended questions about awareness and perceptions of the Los Angeles County law banning the retail sale of menthol cigarettes in unincorporated communities, including how it influences their smoking and purchasing behaviors. RESULTS: We used three thematic categories to structure the results: (1) Are People Aware of Local Menthol Cigarette Sales Restrictions? Levels of Awareness and Strategies to Increase Awareness, (2) Why Ban Menthol? Concerns About Equity and Fairness, and (3) Will Menthol Cigarette Bans Decrease Smoking? Mixed Perceptions About Potential Impact. Most participants (88.5%) had heard about the menthol ban in their communities. Participants described ambivalence towards the ban and identified several factors that hinder support, participation, and well-being, including uncertainty regarding the rationale for banning menthol cigarettes; perceptions that the ban specifically targets Black communities; and concerns regarding government overreach and constraining individual choice. Participants had differing views on whether the ban would likely help them and others who smoke menthol cigarettes reduce or quit smoking. Participants also described situations in which they would purchase menthol cigarettes in another state, country, online, or in the illicit market. Furthermore, participants often viewed the ban as perpetuating criminalization and over-policing of Black communities-arguments used by the commercial tobacco industry to oppose menthol bans. CONCLUSIONS: Our community-based sample of Black adults who smoke menthol cigarettes face challenges and concerns about local menthol bans. Community-centered interventions, messages, and materials about racial equity in menthol bans, access to free cessation services, and countering commercial tobacco industry interference, in addition to measurable steps toward rectifying injustice from the commercial tobacco industry and repeated exemptions of menthol cigarettes from federal legislation through tangible reparations, would be helpful to this community. IMPLICATIONS: We sought to add to the literature on flavored nicotine and commercial tobacco policies in the United States by centering the voices of Black adults who smoke menthol cigarettes regarding their awareness, perceptions, and opinions of local laws restricting menthol cigarette retail sales and how such polices influence their smoking and purchasing behaviors. Our findings suggest that Black adults who smoke menthol cigarettes are aware of local laws restricting menthol cigarette retail sales and are ambivalent about the rationale. Our findings have implications for the development and delivery of equity-focused strategies and resources to increase awareness of and rationale for the ban; counter commercial tobacco industry interference; and facilitate smoking cessation among Black adults who experience more combustible tobacco-related morbidity and mortality than their racial/ethnic counterparts. By understanding this relevance, we can also recognize how individual awareness and perceptions are moored within and contextualized by broader social structures and systemic inequities that warrant policy considerations.

Commercial Tobacco Retailers Need to Be Included in Research on Policies Restricting the Sale of Menthol Cigarettes.

INTRODUCTION: Menthol cigarettes are disproportionately marketed and advertised in the commercial tobacco retail environment in Black communities across the United States, contributing to menthol cigarette-related disparities and lower likelihood of successful quitting among Black people who smoke. Policies restricting retail sales of menthol cigarettes are aimed at preventing initiation, promoting quitting, and reducing related disparities. METHODS: Structured phone interview surveys were conducted from January to July 2021 with commercial tobacco retailers in Los Angeles County, California, unincorporated communities with a high percentage of Black residents, eight months after a local policy restricting retail sales of menthol cigarettes and other flavored nicotine and commercial tobacco products became effective on May 20, 2020. Interviews examined menthol cigarette sales restrictions-related knowledge, attitudes, and practices. RESULTS: Among 22 retailers interviewed, most (86.4%) reported having knowledge of the local ban on menthol cigarettes, and more than half (54.5%) reported offering price promotions for menthol cigarettes. Additionally, more than half (54.5%) reported believing customers who buy menthol cigarettes would stop smoking altogether following the ban. CONCLUSIONS: Most retailers reported having knowledge of the menthol ban, yet half reported offering price promotions for menthol cigarettes. Findings suggest retail availability of menthol cigarettes in Los Angeles County unincorporated communities with a high percentage of Black residents, post ban. Public health and policy implications are discussed.

Motivation to Quit Smoking Among Black Adults Residing in Los Angeles County Communities With Menthol Cigarette Sales Restrictions.

Background: Research is needed to identify the determinants of motivation to quit smoking among non-Hispanic Black (NHB) adults who smoke menthol cigarettes and reside in communities covered by menthol cigarette bans. Objectives: This study examined the associations between motivation to quit smoking and a range of individual-level predictors, including measures of demographics, harm/risk perception of menthol cigarettes, and awareness of a ban on menthol cigarettes in Los Angeles County unincorporated communities. Self-identified NHB adults who currently smoke menthol cigarettes (N=50; M=47.2 years; SD=13.7; 46% female) were recruited in Los Angeles County unincorporated communities. Participants completed an interviewer-administered cross-sectional survey between January to September 2021. Results: Participants (74%) reported an annual household income of less than $25,000. Participants' mean age at cigarette initiation was 15.7 years old (SD=5.68). Most (88%) were aware of the ordinance banning menthol cigarette sales. Employing multivariable linear regression analysis, harm/risk perception of menthol cigarettes (B=14.69, p<0.01) and awareness of the local menthol ban (B=26.18, p<0.05) were found to be independently associated with motivation to quit smoking. Conclusions: Findings from this community-based sample suggest that among NHB adults who smoke menthol cigarettes, motivation to quit smoking is influenced by their perception of menthol cigarettes as harmful and awareness of local policy banning the sale of menthol cigarettes. Findings underscore the need for community-centered and culturally grounded interventions to facilitate quitting among NHB adults who smoke in order for communities covered by menthol bans to achieve health equity in reducing preventable racial inequities due to menthol cigarettes.

Hypothetical e-liquid flavor ban and opinions among vape shop retailers in the Greater Los Angeles Area.

INTRODUCTION: Evaluating anticipated responses to flavor bans in the context of vape shops is needed to inform legislation and enforcement. This cross-sectional study examined vape shop retailers' opinions about the potential impacts of an e-liquid flavor ban on shop sales and customer behavior-change intentions. METHODS: From December 2019 to October 2020 we conducted structured interviews over the phone with 46 brick-and-mortar vape shop retailers in the Greater Los Angeles Area. RESULTS: Most participants were managers (43.5%), followed by owners (26.1%) and clerks (26.1%). More than half (52.2%) reported that sales would drop a lot if flavored e-liquids were banned in all vape shops. Controlling for store position, multivariable linear regression showed that opposition to a hypothetical ban on non-tobacco flavored e-liquids was associated with participants' opinions that customers would likely not purchase tobacco flavored e-liquids (b= -0.44, p<0.01), and would likely use combustible tobacco products (b=0.47, p<0.05). CONCLUSIONS: In this cross-sectional study, vape shop retailers in the Greater Los Angeles Area reported that if a ban on non-tobacco e-liquid flavors occurred, they would oppose strongly, and that a ban would have a negative impact on their shop (e.g. loss in sales) and customer behavior (e.g. would replace vaping with smoking combustible tobacco products). Implications for research and practice are discussed.

Sexual orientation differences among men in a randomized clinical trial of extended-release naltrexone and bupropion for methamphetamine use disorder.

BACKGROUND: Methamphetamine use disorder (MethUD) disproportionately affects men who have sex exclusively with men or with men and women (collectively MSM/W), compared to men who have sex with women (MSW). This study is the first MethUD medication trial to compare treatment effect for these groups, hypothesizing that extended-release injectable naltrexone 380mg every 3 weeks plus oral extended-release bupropion 450mg daily would be less effective for MSM/W than MSW. METHODS: Data come from men (N = 246) in a multi-site, double-blind, randomized, placebo-controlled trial with sequential parallel comparison design. In Stage 1 (6-weeks), participants were randomized to active treatment or placebo. In Stage 2 (6-weeks), Stage 1 placebo non-responders were rerandomized. Treatment response was ≥3 methamphetamine-negative urine samples, out of four obtained at the end of Stages 1 and 2. Treatment effect was the active-versus-placebo between-group difference in the weighted average Stages 1 and 2 responses. RESULTS: MSM/W (n = 151) were more likely than MSW (n = 95) to be Hispanic, college-educated, and living with HIV. Adjusting for demographics, among MSM/W, response rates were 13.95 % (active treatment) and 2.78 % (placebo) in Stage 1; 23.26 % (active treatment) and 4.26 % (placebo) in Stage 2. Among MSW, response rates were 7.69 % (active treatment) and 5.80 % (placebo) in Stage 1; 3.57 % (active treatment) and 0 % (placebo) in Stage 2. Treatment effect was significantly larger for MSM/W (h = 0.1479) than MSW (h = 0.0227) (p = 0.04). CONCLUSIONS: Findings suggest efficacy of extended-release naltrexone plus bupropion for MSM/W, a population heavily burdened by MethUD. While a secondary outcome, this intriguing finding merits testing in prospective trials.

Adolescent and Young Adult Response to Hypothetical E-Liquid Flavor Restrictions.

OBJECTIVE: Rates of e-cigarette use among adolescents and young adults (AYAs) remain high despite several federal policy changes intended to limit their availability and appeal. The current study examined how restricting flavors would affect current AYA users' intentions to discontinue vaping, as a function of their current flavor preference. METHOD: In a national cross-sectional survey, AYA e-cigarette users (N = 1,414) completed measures of e-cigarette use, device type, e-liquid flavor (tobacco, menthol, cool mint, fruit ice, fruit/sweet), and intent to discontinue e-cigarette use in response to hypothetical federal product standards (i.e., tobacco and menthol or tobacco-only e-liquid). Logistic regression was used to model the association of preferred flavor with odds of discontinuing e-cigarette use (vs. continuing), for menthol and tobacco hypothetical product standards. RESULTS: Overall, 38.8% of the sample reported intent to discontinue using their e-cigarette if tobacco and menthol-flavored e-liquid were the only options available, whereas 70.8% would discontinue under a tobacco-only product standard. AYAs preferring fruit/sweet flavor were most sensitive to either restricted scenario, with odds of discontinuing use ranging from adjusted odds ratio (aOR) = 2.22 to aOR = 2.38 under a tobacco and menthol product standard and aOR = 1.33 to aOR = 2.59 under a tobacco-only product standard, compared with other flavor preferences. In addition, AYAs using cooling flavors (e.g., fruit ice) reported higher odds of discontinuing use under a tobacco-only product standard, compared with menthol flavor users, indicating an important distinction between these groups. CONCLUSIONS: Results indicate potential for flavor restrictions to reduce use of e-cigarettes among AYAs and suggest that a tobacco flavor product standard may result in the greatest discontinuation of use.

Advancing racial equity and social justice for Black communities in US tobacco control policy.

The US Food and Drug Administration (FDA) applies the Population Health Standard in tobacco product review processes by weighing anticipated health benefits against risks associated with a given commercial tobacco product at the population level. However, systemic racism (ie, discriminatory policies and practices) contributes to an inequitable distribution of tobacco-related health benefits and risks between white and Black/African Americans at the population level. Therefore, Black-centered, antiracist data standards for tobacco product review processes are needed to achieve racial equity and social justice in US tobacco control policy. Regardless of whether FDA implements such data standards, non-industry tobacco scientists should prioritise producing and disseminating Black-centred data relevant to FDA's regulatory authority. We describe how systemic racism contributes to disparities in tobacco-related outcomes and why these disparities are relevant for population-level risk assessments, then discuss four possible options for Black-centred data standards relevant to tobacco product review processes.

A content analysis of website marketing for cooling flavored e-liquids in a sample of brick-and-mortar vape shops in the Greater Los Angeles area.

INTRODUCTION: Menthol is a characterizing flavor in combustible cigarettes and electronic nicotine delivery systems (ENDS). E-liquids are recognized as an important reason for ENDS use. Yet, compared to menthol cigarettes, menthol flavored e-liquids and other cooling flavors, including mint and 'ice' for ENDS, are an understudied area of investigation. The present study examined cooling flavored e-liquid website marketing among brick-and-mortar vape shops in Greater Los Angeles Area. METHODS: A total of 104 brick-and-mortar vape shops were identified, and 38 had active websites. Over a 30-day period (28 September - 28 October 2020), we collected marketing for all flavored refillable e-liquids (photos/images) from each website. Data were collected for 1330 products. Only refillable e-liquid bottles were selected for this study, excluding prefilled pod vapes and disposable vapes. Each e-liquid per website was coded (e.g. menthol or not) and grouped into categories (e.g. type of menthol). The three flavor descriptor categories that the e-liquids were grouped into were menthol, mint, or ice. An 'other' category was also created for identified e-liquids with flavor descriptors that did not mention menthol, mint, or ice. RESULTS: A total of 1330 e-liquid flavors were identified from 38 active websites. Among them, 219 were coded as menthol/mint/ice flavor e-liquids. Frequencies included ice/iced/icy (n=123; 56%), menthol (n=32; 15%), mint (n=23; 11%), and other (n=41; 19%). Of the 123 ice-flavor e-liquids, 70.3% (n=83) were in combination with fruit (e.g. 'Apple Ice', 'Grape Iced', 'Icy Mango'). Of the 32 menthol-flavored e-liquids, 63.3% (n=19) were in combination with fruit (e.g. 'Dragon Fruit Menthol', 'Blue Raspberry Menthol', 'Fresh Peach Menthol'). Flavors in the other category were ice-related flavor descriptors (e.g. 'Arctic Air', 'Brain Freeze', 'Frozen Hulk Tears'). CONCLUSIONS: Brick-and-mortar vape shops in the Greater Los Angeles Area market a variety of cooling flavor e-liquids on their websites. Such marketing focused largely on ice fruit flavor combinations. Future research is needed to understand how exposure to and appeal of cooling flavored e-liquid marketing differs among diverse consumer groups, including adult menthol cigarette smokers and non-smoking youth.

Marketing claims on websites of brick-and-mortar vape shops in the Greater Los Angeles area.

INTRODUCTION: Brick-and-mortar vape shops have increased in recent years, but there is limited research on the types of marketing claims consumers are exposed to on their websites - a dominant channel for marketing electronic nicotine delivery systems (ENDS). We investigated the websites of vape shop retailers in the Greater Los Angeles Area to describe their ENDS marketing claims. METHODS: Data collection occurred between 25 March and 20 June 2020. Of the 104 brick-and-mortar vape shops identified, 37 were found to have active websites. Rules were established to analyze website content. ENDS Marketing Claims were coded as the presence or absence of: 1) a direct claim of ENDS as a quitting aid; 2) a disclaimer that ENDS are not approved as smoking cessation devices (i.e. ENDS products are not FDA-approved for smoking cessation); 3) a direct claim of ENDS as healthier/safer than combustible cigarettes; and 4) direct claims regarding social benefits, including that ENDS are less expensive, can be used in more places, are cleaner or less messy/smelly, and are more socially accepted than combustible cigarettes. RESULTS: Smoking cessation-related benefits were claimed most frequently (43%), followed by health-related claims (30%), and disclaimers that ENDS are not approved as smoking cessation devices (24%). More than half (56.4%) of websites had an age restriction, requiring the user to click on a box to state that they were aged ≥21 years to view the site. None required proof or outside verification of age. CONCLUSIONS: Brick-and-mortar vape shops in the Greater Los Angeles Area are marketing ENDS on their websites as a healthier alternative to smoking cigarettes. Although half of the websites had an age gate popup that consumers see when they enter the website, action is needed to better enforce age restriction on access to vape shop websites. Utility for smoking cessation was claimed most frequently, followed by the claims of healthier alternatives to smoking cigarettes, and disclaimers that ENDS are not approved as smoking cessation devices. We discuss implications for tobacco regulatory policy.

Trajectories of Nicotine Use Leading to Dual and Cyclical Tobacco Product Use in Young Adults.

INTRODUCTION: Young adult never-smokers who vape are at elevated risk of initiating cigarettes, while young adults who smoke often begin vaping to substitute or reduce cigarette use. Reasons underlying different use patterns of tobacco products are not well-understood. AIMS AND METHODS: We conducted 1-on-1 qualitative interviews with young adults (N = 62) who vape in Los Angeles, California from June 2018 to June 2019. Participants were 18-25 years old (79% male; racially/ethnically diverse) and self-reported vaping ≥1x/week. We used a semi-structured interview guide and applied thematic analysis method to analyze data. RESULTS: Young adults initiated vaping due to peer socialization and e-liquid flavor novelty. They often reported vaping (after first smoking) due to a belief that e-cigarettes are healthier, social pressure to quit smoking, and convenience of use. Participants reported smoking (after first vaping) when traveling outside of the United States where vaping products were less accessible, and cigarettes were normative. Many of the personal narratives described patterns of dual and cyclical use, which was often attributed to nicotine dependence and cost, or described as dependent upon the current environment (eg, at a party). CONCLUSIONS: The current study characterizes nicotine use trajectories and reasons why young adults vape, and smoke cigarettes. Dual and cyclical use of both e-cigarettes and cigarettes was common; this pattern of use should be considered in policy and prevention work to address nicotine dependence among young people. IMPLICATIONS: We display findings from the current study in a model depicting common trajectories of nicotine use, along with reasons for initiation, transitions between products, and dual/cyclical e-cigarette and combustible cigarette use.

Instagram Posts Related to Backwoods Cigarillo Blunts: Content Analysis.

BACKGROUND: Instagram, one of the most popular social media platforms among youth, offers a unique opportunity to examine blunts-partially or fully hollowed-out large cigars, little cigars, and cigarillos that are filled with marijuana. Cigarillo brands like Backwoods (Imperial Tobacco Group Brands LLC) have product features that facilitate blunt making, including a variety of brand-specific flavors that enhance the smoking experience (eg, honey, dark stout). Backwoods has an active online presence with a user-friendly website. OBJECTIVE: This study examined the extent to which Backwoods cigarillo-related posts on Instagram showed blunt making. Instagram offers a unique opportunity to examine blunt making as Instagram accounts will contain images reflective of behavior occurring without the prime of a researcher. METHODS: Data consisted of publicly available Instagram posts with the hashtag #backwoods collected from August 30 to September 12, 2018. Inclusion criteria for this study included an Instagram post with the hashtag "#backwoods". Rules were established to content analyze posts. Categories included Type of post (ie, photo, video, or both); Blunt-related hashtags (ie, the corresponding post caption contained one or more hashtags like #blunts, #cannabis, and #weed that were identified in previous social media research); Rolling blunts (ie, the post contained an image of one or more individuals rolling a Backwoods cigarillo visibly containing marijuana); and Smoking blunts (ie, the post contained an image of one or more individuals blowing smoke or holding a lit blunt). We coded images for Product flavor reference, where a code of 1 showed a Backwoods cigarillo pack with a brand-specific flavor (eg, honey, dark stout, Russian crème) visible in the blunt-related image, and a code of 0 indicated that it was not visible anywhere in the image. RESULTS: Among all posts (N=1206), 871 (72.2%) were coded as Blunt-related hashtags. A total of 125 (10.4%) images were coded as Smoking blunts, and 25 (2.1%) were coded as Rolling blunts (ie, Backwoods cigarillo explicitly used to roll blunts). Among blunt images, 434 of 836 (51.9%) were coded as Product flavor (ie, a Backwoods pack with a brand-specific flavor was visible). CONCLUSIONS: Most Backwoods cigarillo-related Instagram images were blunt-related, and these blunt-related images showed Backwoods packages indicating flavor preference. Continued monitoring and surveillance of blunt-related posts on Instagram is needed to inform policies and interventions that reduce the risk that youth may experiment with blunts. Specific policies could include restrictions on product features (eg, flavors, perforated lines, attractive resealable foil pouches, sale as singles) that facilitate blunt making.

Retail Marketing of Menthol Cigarettes in Los Angeles, California: a Challenge to Health Equity.

INTRODUCTION: Sales of menthol cigarettes continue to increase, accounting for a third of the US cigarette market. Retail marketing of menthol cigarettes is a contributing factor to tobacco-related health disparities. To inform regulation to address associated disparities, we examined retail marketing strategies for menthol cigarettes and their features and characteristics in relation to neighborhood racial/ethnic composition. METHODS: We used multilevel regression models to examine associations of neighborhood racial/ethnic composition and store type with menthol cigarette sales outcomes, including availability, exterior advertising, price promotions, and price in a sample of tobacco retailers (N = 673) in Los Angeles County neighborhoods with a median or below-median household income. We also recorded the prices of Newport cigarettes (the highest selling menthol cigarette brand in the United States) and blu disposable menthol e-cigarettes. RESULTS: Overall, 94.5% of retailers sold menthol cigarettes, 31.2% displayed menthol cigarette price promotions, and 30.2% displayed at least one menthol cigarette advertisement on their exterior. Adjusting for racial/ethnic zip code cluster and store type, stores located in predominantly African American neighborhoods showed significantly higher odds in the availability of Newport cigarettes than stores in Hispanic neighborhoods (OR = 0.21; 95% CI, 0.09-0.53; P = .001) or non-Hispanic White (OR = 0.12; 95% CI, 0.05-0.31; P < .001) neighborhoods. Stores located in predominantly African American neighborhoods displayed significantly higher odds of having price promotions for menthol cigarettes and storefront advertisements than those in Hispanic neighborhoods (OR = 0.51; 95% CI, 0.30-0.88; P = .02 and OR = 0.25; 95% CI, 0.13-0.48; P < .001, respectively). CONCLUSION: In 2016 and 2017, menthol cigarettes were widely available in Los Angeles County across racial/ethnic neighborhoods. We found a disproportionate number of storefront advertisements and price promotions for menthol cigarettes in stores located in predominantly African American neighborhoods along with the lowest advertised pack price. This evidence supports tobacco control policies that restrict menthol cigarette sales in the retail environment.