#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans.

BACKGROUND: Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. People took to Twitter to voice their opposition, referencing the phrase "Flavors Save Lives." This study documented the emerging themes pertaining to "Flavors Saves Lives" over a 12-month period. METHODS: The study period was from May 1, 2019, to May 1, 2020. A stratified sampling procedure supplied 2500 tweets for analysis. Posts were classified by one or more of the following themes: (1) Political Referendum; (2) Institutional Distrust; (3) Individual Rights; (4) Misinformation; (5) THC Vaping is the Real Problem; (6) Smoking Cessation; (7) Adult Use; and (8) Not a Bot. The temporal pattern of tweets over the year was examined. RESULTS: Political Referendum (76.5%) and Institutional Distrust (31.3%) were the most prominent themes, followed by Not a Bot (11.0%), Individual Rights (10.4%), Adult Use (8.0%), Smoking Cessation (6.6%), Misinformation (5.9%), and THC Vaping is the Real Problem (3.5%). Total tweet frequencies increased in September 2019 and peaked in November 2019 before returning to relatively low numbers. Political Referendum and Institutional Distrust were consistently the most prevalent themes over time. CONCLUSION: Twitter posts with the phrase "Flavors Save Lives" commonly discussed voting against political incumbents and mentioned distrust of government representatives. Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans. These data may be valuable for designing tobacco control information campaigns in the future. IMPLICATIONS: (a) Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. (b) This study content analyzed Twitter posts with the phrase "Flavors Save Lives" from a 12-month period to understand opposition to flavor restrictions. (c) Twitter posts commonly discussed voting against political incumbents and mentioned distrust of government representatives. (d) Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans, and contribute to a more comprehensive assessment of different sub-population's responses to current and proposed tobacco control information policies.

Sociodemographic differences in young adults' recall of tobacco and cannabis marketing online and in television/film.

Young adults (YA) who report viewing pro-tobacco and cannabis marketing are at increased risk for using tobacco and cannabis. However, there is a growing diversity of tobacco and cannabis products on the market, as well as methods for marketing them. Prevalence of, and sociodemographic differences in, YA's recall of various types of tobacco and cannabis marketing is not well-characterized. Data were from a cohort of YA (mean age: 19.8) from Southern California in 2019. Respondents were asked whether they recalled having seen two types of marketing (online advertisements and portrayals of product use in TV/movies) for 5 tobacco and 3 cannabis products among never-users of tobacco (N = 954) and cannabis (N = 1,046), respectively. Sociodemographic differences in marketing recall were subsequently assessed. Among tobacco-naïve respondents, 31.3% and 49.3% recalled seeing online advertisements and tobacco use in TV/movies, respectively. Among cannabis-naïve respondents, 18.7% and 31.0% recalled seeing online advertisements and cannabis use in TV/movies, respectively. Overall, respondents recalled seeing tobacco and cannabis products on TV/movies at higher rates than seeing online advertisements, with the exception of electronic cigarettes, for which online advertisements were seen at higher rates. Women (vs. men) had higher odds of seeing tobacco (aOR = 1.9) and cannabis use in TV/movies (aOR = 1.4) and cannabis marketing online (aOR = 1.4). LGB (vs. straight) respondents had higher odds of seeing cannabis marketing online (aOR = 1.7). Efforts to regulate exposure to tobacco and cannabis marketing among young women and LGB people merit further consideration.

Cigar-Smoking Patterns by Race/Ethnicity and Cigar Type: A Nationally Representative Survey Among U.S. Adults.

INTRODUCTION: Racial/ethnic minorities have a higher prevalence of past 30-day cigar smoking than White, non-Hispanics. Little is known, however, about racial/ethnic differences in advanced cigar-smoking patterns by cigar types. This research explores whether cigar-smoking patterns differ by race/ethnicity and cigar types. METHODS: This study used a nationally representative sample of adults (aged ≥18 years; N=28,148) from the Wave 3 survey (2015-2016) of the Population Assessment of Tobacco and Health Study for analysis. Cigar-smoking patterns included past 30-day use, daily use, established use, past 12-month blunt use, use within 30 minutes of waking, and the number of cigars used per day. Weighted multivariable regressions were conducted in 2019 to examine the associations between race/ethnicity and cigar-smoking patterns by cigar types (traditional cigars, cigarillos, and filtered cigars), controlling for covariates. RESULTS: Compared with White, non-Hispanics, Black, non-Hispanics were more likely to smoke cigars in the past 30 days (AOR=2.27, 95% CI=2.03, 2.54) and daily (AOR=2.65, 95% CI=1.89, 3.70), have established cigar smoking (AOR=1.95, 95% CI=1.66, 2.29), and smoke blunts in the past 12 months (AOR=2.30, 95% CI=1.84, 2.88). This pattern was generally consistent across cigar types and was especially pronounced for cigarillos. Compared with White, non-Hispanics, Hispanics were more likely to smoke cigars within 30 minutes of waking (AOR=1.50, 95% CI=1.10, 2.06). CONCLUSIONS: This study finds that Black, non-Hispanics and Hispanics have more advanced patterns of cigar smoking than White, non-Hispanics. Interventions and policies for minimizing cigar smoking may differentially benefit these populations and reduce disparities.

Sources of awareness, perceptions, and use of JUUL e-cigarettes among adult cigarette smokers.

INTRODUCTION: Given JUUL e-cigarettes' potential for smoking cessation and its drastically increased sales in the U.S., more evidence is needed to understand the antecedents of JUUL use among adult cigarette smokers. This study assessed the relationships between awareness sources, perceptions about using JUUL, and JUUL use behavior. METHODS: In an online study with adult smokers who were aware of JUUL e-cigarettes (n = 341), respondents reported their sources for learning about JUUL, perceptions of using JUUL versus Vuse (a competitor brand), and ever and past-30-day (current) JUUL use. Multivariable logistic regressions were used to examine the associations between awareness sources, perceptions, and JUUL use, adjusting for covariates. RESULTS: Learning about JUUL through internet ads was associated with positive perceptions about JUUL compared to Vuse, including JUUL was more fun to use (AOR = 2.04, 95% CI = 1.21, 3.42) and tastier (AOR = 1.96, 95% CI = 1.19, 3.22). Perceiving JUUL as being tastier (AOR = 2.07, 95% CI = 1.23, 3.49), more helpful for quitting smoking (AOR = 2.07, 95% CI = 1.22, 3.53), and cooler (AOR = 2.07, 95% CI = 1.21, 3.56) than Vuse was associated with ever using JUUL. Only perceiving JUUL as being tastier (AOR = 1.98, 95% CI = 1.10, 3.59) than Vuse was associated with current use of JUUL. DISCUSSION: Adult smokers may be more likely to focus on the sensory and social experience of using JUUL rather than JUUL's smoking cessation benefits. These positive perceptions are likely to be influenced by internet ads in general instead of JUUL's official marketing outlets. They are also more likely to sustain JUUL use than JUUL's perceived smoking cessation benefits.

"Isn't there a bunch of side effects?": A focus group study on the beliefs about cessation treatments of non-college educated young adult smokers.

Smoking remains more prevalent among non-college educated and racial/ethnic minority young adults in the U.S. These smokers are less likely than their college educated/non-Hispanic white counterparts to use cessation treatments approved by the U.S. Food and Drug Administration (FDA). Alternative cessation methods (e.g., e-cigarettes) have also grown in popularity among smokers. Therefore, we conducted a focus group study to explore perceptions and beliefs about various cessation treatments among, racially/ethnically diverse, non-college educated young adult smokers. Seventy-five 18-29-year-old current smokers without a 4-year college education were recruited from the U.S. Washington, D.C. metropolitan area and attended one of twelve focus groups to discuss their awareness, beliefs, experiences, and intention for future use of cessation treatments. Focus groups were stratified by race/ethnicity (non-Hispanic white, non-Hispanic black, and Hispanic) and educational attainment (≤ high school vs. some college without obtaining a bachelor's degree). We used a thematic approach to analyze the discussions. We found that few participants were aware of cessation counseling or cessation related programs. Many participants reported previously using nicotine replacement therapies and e-cigarettes to quit smoking. Participants had little intention to use prescription medications due to perceived side effects. Participants' awareness, beliefs, and intentions of using other cessation treatments varied by race/ethnicity and educational attainment. In conclusion, our findings, if confirmed by subsequent quantitative studies, suggest that targeted media campaigns may be needed to explain the contents and benefits of behavioral cessation programs to non-college educated young adult smokers. Targeted media messages aim to overcome negative perceptions related to nicotine replacement therapy and prescription medications among non-college educated young adult smokers, especially those from racial/ethnic minority populations, may promote successful smoking cessation in this population.

Secondhand Smoke Exposure and Subsequent Academic Performance Among U.S. Youth.

INTRODUCTION: Previous research shows the associations between secondhand smoke exposure and health consequences among youth, but less is known about its effect on academic performance. This study examines a dose-response relationship between secondhand smoke exposure and subsequent academic performance among U.S. youth. METHODS: Data were from a nationally representative sample of youth non-tobacco users (aged 12-16 years) in Wave 2 (2014-2015) who completed Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study (n=9,020). Past-7-day number of hours exposed to secondhand smoke at Wave 2 and academic performance at Wave 3 (1=Mostly As to 9=Mostly Fs) were assessed. Weighted multivariable linear regression models were used to examine the association between hours of self-reported secondhand smoke exposure at Wave 2 and academic performance at Wave 3 (1=Mostly Fs, 9=Mostly As), adjusting for covariates including sociodemographics, prior academic performance, internalizing and externalizing problems, and substance use problems. Analyses were conducted in 2019. RESULTS: More than 30% of U.S. youth non-tobacco users were exposed to secondhand smoke in the past 7 days. Compared with unexposed youth at Wave 2, those who were exposed for 1-9 hours had poorer academic performance at Wave 3 (adjusted regression coefficient= -0.11, 95% CI= -0.18, -0.04), and those who were exposed for ≥10 hours at Wave 2 had even poorer academic performance (adjusted regression coefficient = -0.31, 95% CI= -0.45, -0.18). CONCLUSIONS: A dose-response relationship was observed between secondhand smoke exposure and academic performance among U.S. youth. Reducing youth secondhand smoke exposure may promote academic performance and subsequent educational attainment.

Characteristics and Reach Equity of Policies Restricting Flavored Tobacco Product Sales in the United States.

In 2009, flavored cigarettes (except menthol) were banned in the United States, but other flavored tobacco products (FTPs) were allowed. Women, populations of color, youth, sexual minority, and low-socioeconomic status populations disproportionately use FTPs. Localities have passed sales restrictions on FTPs that may reduce disparities if vulnerable populations are reached. This study assessed the extent to which FTP restrictions reached these subgroups ("reach equity"). We identified 189 U.S. jurisdictions with FTP policies as of December 31, 2018. We linked jurisdictions with demographics of race/ethnicity, gender, age, partnered same-sex households and household poverty, and stratified by policy strength. We calculated Reach Ratios (ReRas) to assess reach equity among subgroups covered by FTP policies relative to their U.S. population representation. Flavor policies covered 6.3% of the U.S. population (20 million individuals) across seven states; 0.9% were covered by strong policies (12.7% of policies). ReRas indicated favorable reach equity to young adults, women, Hispanics, African Americans, Asians, partnered same-sex households, and those living below poverty. Youth, American Indians/Alaska Natives (AIAN) and Native Hawaiians/Pacific Islanders (NHPI) were underrepresented. Strong policies had favorable reach equity to young adults, those living below poverty, Asians, NHPIs, individuals of 2+ races, and partnered same-sex households, but unfavorable reach equity to women, youth, Hispanic, AIAN, and African American populations. U.S. flavor policies have greater reach to many, but not all, subgroups at risk of FTP use. Increased enactment of strong policies to populations not covered by flavor policies is warranted to ensure at-risk subgroups sufficiently benefit.

"Hey, I Got to Smoke Some Weed": Favorable Perceptions of Marijuana Use Among Non-College-Educated Young Adult Cigarette Smokers.

Introduction: As marijuana legalization progresses in the U.S., this study investigated the perceptions of marijuana use among non-college-educated young adult smokers. Methods: Twelve focus groups were conducted to explore themes related to marijuana and marijuana use among a racially and ethnically diverse sample of 75 young adult smokers (ages 18-29 years) with <4-year college education and <$90,000 annual household income living in the Washington, D.C. metropolitan area. Thematic content analysis was employed to analyze the transcripts. Data collection and analysis took place in 2017 and 2018, respectively. Results: Many participants reported smoking cigarettes to boost and maintain the psychoactive effect ("high") of smoking marijuana; some smoked marijuana to substitute frequent cigarette smoking. Participants generally stated that they believed marijuana smoking was healthier and less addictive than cigarette smoking; many preferred smoking marijuana over cigarettes. Participants also mentioned that cigarette smoking was stigmatized and not socially acceptable but marijuana smoking was "trendy" and "cool." Some reported that they smoked marijuana to cut down on cigarettes, although most were unsuccessful. Racial and ethnic differences in marijuana use were also identified. Discussion: Non-college-educated young adult smokers expressed largely favorable views towards smoking marijuana. Such positive views may lead to prolonged and escalated use of cigarettes and marijuana, resulting in exacerbated adverse health consequence of smoking both products as well as worsened outcomes of cigarette smoking cessation. Evidence-based messages are greatly needed to communicate the harm and risks of marijuana use and marijuana and tobacco co-use among this group.

Will Electronic Nicotine Delivery System (ENDS) use reduce smoking disparities? Prevalence of daily ENDS use among cigarette smokers.

Many smokers reported using Electronic Nicotine Delivery System (ENDS, e.g., electronic cigarettes or e-cigarettes) to quit cigarette smoking. Previous studies suggested that daily ENDS use may promote cigarette smoking cessation. We assessed variations in the prevalence of daily ENDS use among adult smokers by demographics and implications for cigarette smoking disparities. Data were from a nationally representative sample of US adults who participated in the 2014-2015 Tobacco Use Supplement to the Current Population Survey (n = 163,920). Participants reported socio-demographics, current cigarette smoking, current ENDS use, and past-year cigarette smoking cessation attempts. We estimated the prevalence of current cigarette smoking in the full sample by socio-demographics. We also estimated the prevalence of daily ENDS use among current smokers (n = 23,232) and those who attempted to quit smoking in the past year (n = 9,341) by socio-demographics. Multivariable logistic regression models were used to assess associations between daily ENDS use and socio-demographics. Prevalence of daily ENDS use was low: 1-6% among current smokers and 2-9% among those who made a past-year quit attempt, across socio-demographics. Hispanic (Adjusted odds ratio [AOR] = 0.45, 95% confidence interval [CI] = 0.29-0.69) and non-Hispanic black smokers (AOR = 0.38, 95% CI = 0.23-0.61) were less likely than non-Hispanic white smokers to use ENDS daily. Similar associations were observed among current smokers who made a past-year quit attempt (p < 0.05). Low prevalence of daily ENDS use suggests that ENDS may only promote smoking cessation in a small fraction of smokers. Lower prevalence of daily ENDS use among non-Hispanic black smokers may worsen race-related cigarette smoking disparities.

E-cigarette Marketing Exposure and Subsequent Experimentation Among Youth and Young Adults.

OBJECTIVES: Electronic cigarette (e-cigarette) use has become increasingly prevalent among US youth and young adults in recent years. Exposure to e-cigarette marketing may stimulate e-cigarette use. In this study, we estimated the longitudinal association between e-cigarette marketing exposure and e-cigarette experimentation among US youth and young adult never tobacco users. METHODS: The analysis included nationally representative samples of youth (ages 12-17; n = 8121) and young adult (ages 18-24; n = 1683) never tobacco users from wave 2 (2014-2015) and wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study. In the study, researchers measured past-month exposure to e-cigarette marketing through various places (eg, Web sites and events) at wave 2 and e-cigarette experimentation at wave 3. Statistical analysis included multivariable regressions to examine the associations between wave 2 e-cigarette marketing exposure and wave 3 e-cigarette experimentation. RESULTS: At wave 2, 70.7% of youth and 73.9% of young adult never tobacco users reported past-month exposure to e-cigarette marketing; at wave 3, 4.9% and 4.5% of youth and young adults experimented with e-cigarettes, respectively. Youth and young adults exposed to e-cigarette marketing at wave 2 were more likely (adjusted odds ratio = 1.53, 95% confidence interval = 1.07-2.17; and adjusted odds ratio = 2.73, 95% confidence interval = 1.16-6.42, respectively) to have experimented with e-cigarettes at wave 3 than those not exposed. Marketing exposure through each place at wave 2 was associated with e-cigarette experimentation at wave 3. CONCLUSIONS: E-cigarette marketing exposure predicted subsequent e-cigarette experimentation among youth and young adult never tobacco users. Increased restrictions on marketing through various channels may help minimize their exposure to e-cigarette marketing messages.

Flavored cigar smoking among African American young adult dual users: An ecological momentary assessment.

BACKGROUND: Flavored cigar sales have increased in recent years in the U.S. African American young adults (AAYAs) have high prevalence of smoking flavored cigars and dual use with cigarettes, but the predictors of use are unclear. We examined the predictors of flavored cigar smoking among AAYA dual users. METHODS: We analyzed data from an Ecological Momentary Assessment (EMA) study that captured near real-time affect, smoking cues, and tobacco smoking from eight text-messaging surveys per day over two weeks. Sixty-three AAYA (ages 18-29) dual users of cigarettes and cigars recorded 1205 cigar smoking moments. Multivariable Generalized Estimating Equations were used to assess the predictors of smoking cigars with flavors and specific flavor types. RESULTS: Half of the participants were women (49.2%) and aged between 18-24 (46.7%). Over the two-weeks, almost all (98.4%) participants smoked flavored cigars, and 64.2% of the cigars smoked were flavored. Alcohol (34.4%) was the most frequently smoked flavor type followed by sweet (23.4%) and mint (5.7%). Feeling stressed (AOR = 1.07) and bored (AOR = 1.10) predicted smoking alcohol flavors. Blunt smoking positively predicted smoking sweet flavors (AOR = 4.79), but negatively predicted smoking alcohol flavors (AOR = 0.40). CONCLUSIONS: Smoking flavored cigars, especially alcohol-flavored cigars, was prevalent among AAYA dual users in this study. This group might use specific flavors for different purposes including smoking blunts and boosting mood. Efforts to reduce cigar use need to tackle these risk factors and the increased marketing and low-cost pricing of cigars. A federal ban of cigar flavors might reduce the appeal of cigar products.

Sources of Awareness of JUUL E-cigarettes in 2 Surveys of Adults in the United States.

Objectives: Since their introduction in 2015, JUUL e-cigarettes have gained >60% of the United States (US) 2018 retail market share among branded e-cigarette companies. The sources through which consumers learn about JUUL e-cigarettes is not known. Methods: We assessed the sources of awareness about JUUL through 2 cross-sectional surveys of US adults (Survey 1: 502 18-24 year-olds; Survey 2: 803 smokers age 18+). Primary measures were awareness of JUUL and sources through which participants learned about JUUL. Results: Awareness of JUUL was greater among smokers and younger adults (age <30). Common sources of awareness were advertisements, news, and word-of-mouth. Conclusions: This study is the first to identify sources through which never, non-current ever, and current smokers learned about JUUL e-cigarettes. Regulatory efforts and educational interventions may opt to focus on these channels.

Perceived ease of flavored e-cigarette use and e-cigarette use progression among youth never tobacco users.

BACKGROUND: There is an increased need to understand how e-cigarette flavors may contribute to e-cigarette uptake and use among youth. We examined the relationship between perceived ease of flavored e-cigarette use and e-cigarette use susceptibility and progression among a nationally representative sample of U.S. youth never tobacco users. METHODS: The wave 1 (2013-2014) and wave 2 (2014-2015) surveys of PATH Study were used. Youth never tobacco users (ages 12-17) who reported whether flavored e-cigarettes were easier to use than unflavored e-cigarettes at wave 1 (n = 6,983) were included in the study. Multivariable logistic regressions were used to examine the associations between perceived ease of using flavored e-cigarettes (wave 1) and e-cigarette use outcomes including e-cigarette use susceptibility (wave 1) and e-cigarette initiation and past-30-day use (wave 2). RESULTS: Overall, 21.2% of the sample perceived flavored e-cigarettes easier to use than unflavored e-cigarettes; and 28.9% of the sample were susceptible to using e-cigarettes at wave 1, and 7.5% and 2.0% initiated e-cigarettes and used e-cigarettes in the past 30 days at wave 2, respectively. Among those who perceived flavored e-cigarettes easier to use, 41.0% were susceptible to using e-cigarettes at wave 1, and 10.6% and 3.4% initiated and used e-cigarettes in the past 30 days at wave 2, respectively. Perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes at wave 1 was positively associated with e-cigarette use susceptibility at wave 1 (AOR = 1.43, CI = 1.21, 1.69), and e-cigarette initiation (AOR = 1.32, CI = 1.12, 1.67) and past-30-day use (AOR = 1.25, CI = 1.10, 2.47) at wave 2. CONCLUSIONS: Perceiving flavored e-cigarettes as easier to use than unflavored e-cigarettes may lead to e-cigarette use progression among youth never tobacco users. Determining the factors (including e-cigarette marketing and specific e-cigarette flavors) that lead to perceived ease of using flavored e-cigarettes would inform efforts to prevent and curb youth e-cigarette use.

Association between marital status and cigarette smoking: Variation by race and ethnicity.

It is unclear whether health risk behaviors differ by nuanced marital statuses and race/ethnicity. We examined the association between detailed marital status and current cigarette smoking among U.S. adults by race/ethnicity. Data were from four Health Information National Trends (HINTS) study cycles collected in 2011-2017 with a nationally representative sample of adults 30 years and older (n = 11,889). Current cigarette smoking prevalence was compared across detailed marital statuses (married, cohabiting, divorced, widowed, separated, single/never married) by race/ethnicity. Adults who had the highest prevalence of cigarette smoking were non-Hispanic Black cohabitors (36.2%), separated non-Hispanic White adults (35.3%), and single/never married Hispanic adults (28.2%). It is noteworthy that widowed adults had lower cigarette smoking prevalence than those who were divorced or separated across races/ethnicities. Taken together, this study demonstrates how cigarette smoking prevalence varies by intersection of marital status and race/ethnicity. Ensuring the equitable implementation of a comprehensive best-practice tobacco prevention and control program that includes prevention and treatment is important to reduce the burden of cigarette smoking in these populations.