Examining the relationship of flavored tobacco product policy restrictions and flavored tobacco product use, among adolescents and young adults in the U.S.

OBJECTIVE: This work examines the relationship between local flavor policy exposure and any tobacco product use and flavored tobacco product use among U.S. youth and young adults, as well as the equity potential of these policies by race/ethnicity. METHODS: Participants were aged 15-36 (n = 10,893) surveyed from September-December 2019 using national, address- and probability-based sampling. Local flavor policies enacted before survey completion were linked to participant home address. Weighted cross-sectional multivariable logistic regression examined individual coverage by flavor policy vs. no flavor policy, with current any tobacco or flavored tobacco use, controlling for individual and county-level demographics, psychosocial variables, and other tobacco control policies. Interactions between race/ethnicity and any tobacco use and flavored tobacco use were assessed. RESULTS: Those covered by a flavor policy vs. no policy had lower odds of any tobacco use (aOR = 0.74, 95% CI = 0.55-1.00) and current flavored tobacco use (aOR = 0.67, 95% CI = 0.48-0.93). Compared with Non-Hispanic (NH)-White individuals, NH-Black individuals (aOR = 1.08, CI = 1.04-1.12) had higher odds of any tobacco use, and non-Hispanic Asian individuals had lower odds of any tobacco use (aOR = 0.67, CI = 0.53-0.85). Hispanic individuals exposed to policy had lower odds of flavored tobacco use compared to NH-White peers. CONCLUSIONS: Exposure to flavor restriction policies is associated with lower odds of any tobacco and flavored use among youth and young adults. Flavor restrictions may be beneficial in reducing tobacco use in youth from diverse racial/ethnic backgrounds. However, passing policies covering NH-Black individuals is needed to mitigate disparities in tobacco use by flavor policy coverage over time.

Neighborhood Inequities in Tobacco Product Descriptors, Washington, DC, 2018-2019.

BACKGROUND: The tobacco industry uses product descriptors to communicate reduced harm and increase appeal. This cross-sectional study assessed store-level racial, ethnic, and socioeconomic inequities in the distribution of retail tobacco product descriptors in a convenience sample of retailers in Washington, DC. METHODS: Young adults (n = 146) who did not currently use tobacco reported real-time store visits over 14 days. Trained data collectors took high-resolution photographs of all tobacco (including e-cigarette) marketing in each store (n = 96) participants visited. We coded text descriptors on tobacco product advertisements and displays into descriptor categories (eg, fruit, sweet, concept). We fit multilevel models to examine relationships between store neighborhood census tract-level racial, ethnic, and socioeconomic characteristics and tobacco product descriptors in stores. As a supplementary analysis, we used geospatial methods to model predicted patterns of descriptors at the census tract level. RESULTS: Stores located in census tracts with the highest versus lowest percentage of Black residents had a greater count of fruit, sweet or dessert, alcohol, and concept descriptors (p < .05), similar to findings from the geospatial approach. Adjusted models also indicated some inequities in stores in census tracts with higher percentages of Hispanic or Latino residents for fruit, alcohol, and concept descriptors; however, tract-level models showed opposite results for concept flavors. CONCLUSIONS: In this convenience sample, fruit, alcohol, sweet/dessert, and concept FTP descriptors were prevalent in stores in neighborhoods with more Black residents demonstrated through two analytic approaches. Surveillance using representative samples of tobacco retailers could improve the ability to track the extent of this inequity. IMPLICATIONS: We document inequities in the amount of fruit, sweet or dessert, alcohol, and concept flavor descriptors in stores across neighborhoods in Washington, DC. Federal, state, and local regulatory action is needed to reduce inequities in flavored tobacco product availability and marketing, including for concept flavors.

Using Exogenous Social Media Exposure Measures to Assess the Effects of Smokeless Tobacco-Related Social Media Content on Smokeless Tobacco Sales in the United States.

INTRODUCTION: Prior research on the effects of social media promotion of tobacco products has predominantly relied on survey-based self-report measures of marketing exposure, which potentially introduce endogeneity, recall, and selection biases. New approaches can enhance measurement and help better understand the effects of exposure to tobacco-related messages in a dynamic social media marketing environment. We used geolocation-specific tweet rate as an exogenous indicator of exposure to smokeless tobacco (ST)-related content and employed this measure to examine the influence of social media marketing on ST sales. AIMS AND METHODS: Autoregressive error models were used to analyze the association between the ST-relevant tweet rate (aggregated by 4-week period from February 12, 2017 to June 26, 2021 and scaled by population density) and logarithmic ST unit sales across time by product type (newer, snus, conventional) in the United States, accounting for autocorrelated errors. Interrupted time series approach was used to control for policy change effects. RESULTS: ST product category-related tweet rates were associated with ST unit sales of newer and conventional products, controlling for price, relevant policy events, and the coronavirus disease 2019 (COVID-19) pandemic. On average, 100-unit increase in the number of newer ST-related tweets was associated with 14% increase in unit sales (RR = 1.14; p = .01); 100-unit increase in conventional ST tweets was associated with ~1% increase in unit sales (p = .04). Average price was negatively associated with the unit sales. CONCLUSIONS: Study findings reveal that ST social media tweet rate was related to increased ST consumption and illustrate the utility of exogenous measures in conceptualizing and assessing effects in the complex media environment. IMPLICATIONS: Tobacco control initiatives should include efforts to monitor the role of social media in promoting tobacco use. Surveillance of social media platforms is critical to monitor emerging tobacco product-related marketing strategies and promotional content reach. Exogenous measures of potential exposure to social media messages can supplement survey data to study media effects on tobacco consumption.

Retailers' Compliance with Federal Age of Cigarette Sales Policies -- Pitt County, North Carolina, January-March 2022.

BACKGROUND: Tobacco use remains a leading cause of preventable morbidity and premature mortality. In December 2019, the federal age of sale for tobacco products increased from 18 to 21 years of age. This study aimed to evaluate the implementation of federal tobacco 21 policies in Pitt County, North Carolina (NC), by conducting multiple purchase attempts for cigarettes. METHOD: Stores in Pitt County that sold cigarettes were randomly sampled and visited by up to six different underage (18-20) buyers who attempted to buy cigarettes from January-March 2022. Buyers made a total of 217 cigarette purchase attempts from 49 Pitt County retailers. Analyses were conducted using SPSS Complex Samples (v.28/Macintosh) and estimate retailer prevalence of requesting identification (ID) and selling to underage buyers across multiple purchase attempts. RESULTS: On average, retailers failed to request ID in 15.4% of purchase attempts (95% CI: 9.4%-21.3%) and sold to an underage buyer 34.2% of the time (95% CI: 27.0-41.4%). Additionally, 75.5% (95% CI: 63.4%-84.6%) of retailers sold to an underage buyer at least once. LIMITATIONS: This study is limited to a single county in NC and to underage buyers aged 18 to 20. CONCLUSION: There is widespread non-compliance with federal age of sale policies for tobacco products in Pitt County, NC. State enforcement is warranted, and NC's youth access law should be amended to match the federal age of sale. Changes to the law should allow research involving underage purchases.

Association of Non-Cigarette Tobacco Advertisements and Racial Discrimination With Non-Cigarette Tobacco Product Use Among Black Adults.

INTRODUCTION: Black communities are targeted by more cigarette advertisements than White communities and racial discrimination among Black people is related to cigarette use. However, little is known about these factors with non-cigarette tobacco product use among Black adults. Therefore, this study assessed the association of non-cigarette advertisement exposure and racial discrimination with use of non-cigarette tobacco products among Black adults. AIMS AND METHODS: Black adults (n = 533) from The Family and Community Health Study in 2016 were asked if they had seen advertisements for e-cigarettes, snus pouches, filtered cigars, large cigars, cigarillos, dissolvable tobacco, smokeless tobacco, hookah, and tobacco pipe and if they used these in the past month. For products with the highest past month use and significant correlations with advertisement exposure, separate logistic regression models were performed that evaluated the association between advertisement exposure, racial discrimination, and non-cigarette tobacco product use while controlling for cigarette use, sex, socioeconomic status, and age. RESULTS: Use of cigarillos, large cigars, and hookah were higher than other non-cigarette tobacco products assessed. Logistic regressions revealed that more advertisement exposure in the past month was associated with higher odds of using cigarillos, large cigars, and hookah (p < .01). More experiences of racial discrimination were associated with past month cigarillo use, but not hookah or large cigars (p < .01). CONCLUSIONS: Non-cigarette tobacco advertisement exposure was associated with the use of non-cigarette tobacco products. Experiences of racial discrimination were associated with the most used non-cigarette tobacco product among Black adults, cigarillos. IMPLICATIONS: This is the first time that a specific type of cigar (ie cigarillos) has been associated with experiences of racial discrimination among Black adults. Efforts to reduce non-cigarette tobacco marketing and eradicate exposure to racial discrimination among Black adults may aid in eliminating tobacco-related health disparities.

Incorporating Intersectionality as a Framework for Equity-Minded Tobacco Control Research: A Call for Collective Action Toward a Paradigm Shift.

INTRODUCTION: To eliminate tobacco-related disparities, tobacco control research would benefit from a paradigm shift. Intersectionality, a framework pioneered by Kimberlé Crenshaw in late 1980s, has the potential to improve our understanding of why and how certain social groups are disproportionately harmed by commercial tobacco use, and improve our ability to address persistent tobacco-related health disparities. AIMS AND METHODS: In this commentary, we outline the rationale and recommendations for incorporating intersectionality into equity-minded tobacco control research. These recommendations arose from intersectionality webinars organized by the Health Disparities (now Health Equity) Network of the Society for Research on Nicotine & Tobacco (SRNT) in 2019 and 2020. RESULTS: Specifically, we propose that eliminating tobacco-related disparities through intersectionality-informed research requires a multilevel, multipronged approach. We summarize priority actions for the tobacco control research field to achieve health equity through the intersectionality framework including acknowledging that structural factors, racism and power dynamics shape lived experiences, integrating critical theoretical frameworks and intersectionality scholarship into research questions, and embracing collaborative community-based approaches at every level of the research process. CONCLUSIONS: Through these actions, our field can take concrete steps to fundamentally improve our approach to conducting research to achieve health equity. IMPLICATIONS: Intersectionality is a valuable tool to align our field with our pursuit of health equity. The recommendations aim to improve methods of equity-focused tobacco control, prompt ongoing dialogue on the utility of this tool, and shift paradigms in how the research process is conducted at every level among stakeholders, including researchers, journal editors and reviewers, funders, practitioners, and policy makers.

Characterising advertising strategies and expenditures for conventional and newer smokeless tobacco products.

OBJECTIVE: Nicotine pouch products are an emerging and rapidly growing smokeless tobacco (ST) category in the USA. Little is known about the promotional strategies and media channels used to advertise this ST category or the extent to which the marketing strategies differ from strategies used to promote 'conventional' smokeless products (eg, snuff). We describe the nature, timing of and expenditures related to conventional, snus and newer ST product advertising on print, broadcast and internet media. METHODS: Advertising expenditures were collected using Kantar Media's 'Stradegy' tool, which provides advertising data including dollars spent promoting specific products across various media channels, including print magazines and newspapers, broadcast television and radio, outdoor posters and billboards, and internet. We identified 306 smokeless products within Kantar database and collected ad expenditures retrospectively for January 2018-April 2020. Promotional expenditures were aggregated by product category, by month and by designated market area (DMA). RESULTS: Kantar data analysis returned 28 conventional ST, 22 oral nicotine and 3 snus products (53 total) advertised during the period of observation, with over $71 million spent collectively on ST promotion. Across categories, more advertising dollars were spent on conventional ST products (63%) than newer oral nicotine products (25%) or snus (12%). However, during the later 9-month period from August 2019 to April 2020, oral nicotine products accounted for the majority of monthly ad spending. Most ad spending was placed in the national market ($66.5 million), with Atlanta ($1.1 million), Houston ($1 million) and Las Vegas ($0.8 million) as the top three local DMAs for expenditures. DISCUSSION: Advertising expenditures for nicotine pouches have recently exceeded conventional ST product advertising and nicotine pouches are being promoted nationally. Marketing surveillance as well as understanding consumer appeal, perceptions and consumption are critical next steps in tracking potential uptake of these new products.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults.

BACKGROUND: Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs). PURPOSE: This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA). METHODS: This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context. RESULTS: Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined. CONCLUSIONS: Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers.

To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.

Individual Health Determinants That Predict Low Risk of Transitioning to Tobacco Use During Young Adulthood: An In-Depth Examination of Race and Ethnicity.

INTRODUCTION: The present study examines the contributions of individual-level health determinants on young adult tobacco use initiation to improve understanding of racial and ethnic distinctions and to inform effective tobacco prevention strategies. METHODS: Using time-to-event analyses, the 10-wave (2011-2016) Truth Initiative Young Adult Cohort, a probability-based, nationally representative sample of the US young adults aged 18-34 years (N = 7 665), provides data to examine differences in variables that influence tobacco uptake, by race and ethnicity. RESULTS: Among Non-Hispanic White young adults, having fewer peers who smoke cigarettes is protective against any tobacco initiation, whereas hazard of tobacco initiation increases for males, having low confidence to resist smoking, and having higher proclivity for sensation seeking. Depressive and anxiety symptoms increase uptake hazard most in the Non-Hispanic All Other Races group and least among Non-Hispanic Black individuals. Among Hispanic young adults, being female and perceiving tobacco as harmful are notably protective while being male is a notable uptake hazard. Unlike other groups, higher income levels do not lower hazards among Hispanic individuals. Cannabis use and overestimating the smoking rate among peers increase hazard least among Hispanic individuals. In the Non-Hispanic All Other Races group, aging is least protective; hazard increases notably if individuals engage in regular alcohol or cannabis use. CONCLUSIONS: Tobacco prevention efforts are critical during young adulthood. Specific tobacco uptake hazard and protective factors exist by race and ethnicity and should be considered when developing selective young adult prevention, particularly among groups with the highest risk for tobacco initiation during this life stage. IMPLICATIONS: Rising rates of tobacco initiation among the US young adults necessitate expanded efforts to prevent tobacco use initiation and progression beyond youth. Results highlight nuanced and differential tobacco uptake hazards by race and ethnicity for late initiation and sustained non-tobacco use among young adults. The study confirms existing evidence on tobacco use patterns and contributes to new knowledge on risk and protective factors. Tobacco prevention and control interventions, including policies, tailored in more meaningful ways could reduce tobacco use disparities among those most disproportionately affected.

Inequitable Distribution of FTP Marketing by Neighborhood Characteristics: Further Evidence for Targeted Marketing.

INTRODUCTION: Flavored tobacco products (FTPs) are disproportionately used among young people and racial/ethnic minority populations. However, few studies have examined the retail distribution of such product marketing beyond menthol cigarettes. This study created geographic-based predictions about marketing of FTPs (overall, cigarettes, cigars, e-cigarettes, and smokeless) in stores across Washington, DC neighborhoods. We examined neighborhood-level demographic correlates of the amount of FTP and non-FTP marketing. METHODS: We conducted photographic audits of interior and exterior tobacco marketing in 96 Washington, DC tobacco retailers visited by 149 young adult respondents between 2018-2019. We created a geographic predictive surface of overall and product-specific tobacco marketing and then estimated the average predicted amount of marketing at the census-tract level using zonal statistics. Using linear regression, we examined neighborhood demographic correlates (race/ethnicity, family poverty, and youth population under 18) of FTP and non-FTP marketing. RESULTS: The predicted amount of non-FTP ads/displays were evenly distributed with no neighborhood variability (Range 8.46-8.46). FTP marketing overall was geographically concentrated with greater range across neighborhoods (Range 6.27-16.77). Greater FTP marketing overall and flavored cigar marketing was available in neighborhoods with higher percentages of Black residents. Flavored cigar marketing was less available in neighborhoods with more Hispanic residents, but there was greater flavored smokeless tobacco marketing. Nonflavored marketing overall and by product did not vary across neighborhoods. CONCLUSIONS: This study provides evidence of disproportionate distribution of FTP marketing in Black neighborhoods, especially for flavored cigars, at the point-of-sale. Policies that restrict the sale of FTPs may enhance health equity. IMPLICATIONS: Tobacco marketing has frequently been shown to be more prevalent in neighborhoods with lower household income and more Black residents. Using geographic-based predictions, we find that greater flavored tobacco marketing in these neighborhoods, not decreased marketing for nonflavored tobacco, is driving this disparity. Targeting Black neighborhoods with increased marketing of flavored tobacco products, which has been found to be more appealing, easier to use, and harder to quit is a social justice issue.

Oral nicotine marketing claims in direct-mail advertising.

BACKGROUND: Little is known regarding how oral nicotine products (eg, nicotine pouches, lozenges) are marketed to consumers, including whether potential implicit reduced harm claims are used. In the current study, we explored the marketing claims present in a sample of direct-mail oral nicotine advertisements sent to US consumers (March 2018-August 2020). METHODS: Direct-mail ads (n=50) were acquired from Mintel and dual-coded for the following claims: alternative to other tobacco products, ability to use anywhere, spit-free, smoke-free and product does not contain tobacco leaf. We merged the coded data with Mintel's volume estimate (number of mail pieces sent to consumers) and calculated the proportion of oral nicotine advertisements containing claims by category. RESULTS: Of the 38 million pieces of oral nicotine direct-mail sent to US consumers, most featured claims that the product could be used anywhere (84%, 31.8 million pieces); was an alternative to other tobacco products (69%, 26.1 million pieces); and did not contain tobacco leaf (eg, 'tobacco leaf-free', 'simple' approach of extracting nicotine from tobacco; 55%, 20.7 million pieces). A slightly smaller proportion contained claims that oral nicotine was 'spit-free' (52%, 19.8 million pieces) or 'smoke-free' (31%, 11.7 million pieces). CONCLUSION: Our results provide an early indication of marketing claims used to promote oral nicotine. The strategies documented, particularly the use of language to highlight oral nicotine is tobacco-free, may covey these products as lower-risk to consumers despite the lack of evidence or proper federal authorisation that oral nicotine products are a modified-risk tobacco product. Future research is needed to examine consumer perceptions of such claims.

Going Smokeless: Promotional Features and Reach of US Smokeless Tobacco Direct-Mail Advertising (July 2017-August 2018).

INTRODUCTION: Although cigarette use in the United States has declined over time, smokeless tobacco (SLT) use has remained steady. Direct-mail advertising and coupon redemption have been linked to increased tobacco use, and efforts to promote SLT through direct-mail advertising may contribute to sustained SLT use. We examined reach of SLT direct-mail advertisements by recipient demographics and promotional features, including coupons. METHODS: Direct-mail data (n = 418) were acquired from Comperemedia (Mintel) and coded for product type (traditional [eg, chewing tobacco], pouched [eg, moist snuff, snus], or both [traditional SLT and any pouched SLT products]); promotions (eg, coupons); flavors; and themes (eg, masculinity). Using Mintel's volume estimates for number of pieces sent, we calculated the proportion of mail volume sent by recipient demographics (age, income, region) and advertising features across product type. RESULTS: Between July 2017 and August 2018, tobacco companies sent an estimated 249 million pieces of SLT direct-mail to US households; approximately half (49.6%) featured pouched SLT products. Across product types, over 75% of mail volume was sent to 31- to 60-year-old adults and 30-40% was sent to low-income households. The majority (>70%) of pouched SLT product mail contained coupons and flavor promotions. Outdoor and blue-collar-lifestyle themes were prominent in advertisements for all product types, along with less common adventure- and fun-related appeals. CONCLUSIONS: Coupons, flavors, and a combination of blue-collar and fun/adventure message themes were used to promote traditional and pouched SLT products through direct-mail, particularly to low-income households. Results support limits on direct-mail coupon distribution and continued surveillance of marketing appeals. IMPLICATIONS: There is a long history of research into tobacco advertising practices, largely focusing on cigarettes. This study highlights specific direct-mail marketing tactics used by the tobacco industry, including coupons to promote SLT products across the United States. Given the limited success in reducing SLT use and the association between direct-mail promotions and tobacco use, these study results provide support for policies to restrict use of coupons in direct-to-consumer tobacco marketing and indicate the need for continued surveillance of direct-mail advertisements as the SLT market continues to evolve.

Image Processing for Public Health Surveillance of Tobacco Point-of-Sale Advertising: Machine Learning-Based Methodology.

BACKGROUND: With a rapidly evolving tobacco retail environment, it is increasingly necessary to understand the point-of-sale (POS) advertising environment as part of tobacco surveillance and control. Advances in machine learning and image processing suggest the ability for more efficient and nuanced data capture than previously available. OBJECTIVE: The study aims to use machine learning algorithms to discover the presence of tobacco advertising in photographs of tobacco POS advertising and their location in the photograph. METHODS: We first collected images of the interiors of tobacco retailers in West Virginia and the District of Columbia during 2016 and 2018. The clearest photographs were selected and used to create a training and test data set. We then used a pretrained image classification network model, Inception V3, to discover the presence of tobacco logos and a unified object detection system, You Only Look Once V3, to identify logo locations. RESULTS: Our model was successful in identifying the presence of advertising within images, with a classification accuracy of over 75% for 8 of the 42 brands. Discovering the location of logos within a given photograph was more challenging because of the relatively small training data set, resulting in a mean average precision score of 0.72 and an intersection over union score of 0.62. CONCLUSIONS: Our research provides preliminary evidence for a novel methodological approach that tobacco researchers and other public health practitioners can apply in the collection and processing of data for tobacco or other POS surveillance efforts. The resulting surveillance information can inform policy adoption, implementation, and enforcement. Limitations notwithstanding, our analysis shows the promise of using machine learning as part of a suite of tools to understand the tobacco retail environment, make policy recommendations, and design public health interventions at the municipal or other jurisdictional scale.

Exposure to Multimedia Tobacco Marketing and Product Use Among Youth: A Longitudinal Analysis.

INTRODUCTION: Tobacco companies continue to reach youth through direct-to-consumer marketing, which has been associated with overall tobacco use. We examine how exposure to these marketing activities influences product-specific use behaviors. METHODS: We analyzed data from 10 081 youth (aged 12-18 years) who participated in Waves 1 and 2 (2013-2015) of the Population Assessment of Tobacco and Health (PATH) Study. Participants reported past 6-month tobacco coupon receipt and online tobacco marketing engagement, and susceptibility to ever and current use of cigarette, e-cigarettes, cigars, smokeless tobacco, and hookah. Weighted multivariable logistic regression examined Wave 1 predictors of coupon receipt at Wave 2, and associations between coupon receipt, online engagement, and past 30-day use of different tobacco products. RESULTS: Youth received tobacco coupons at one (9.7%) or both waves (1.2%) and 11.1% engaged with online tobacco marketing. Coupon receipt and online marketing engagement at Wave 1 predicted Wave 2 coupon receipt among susceptible-never, ever-but-not-current, and current tobacco users (p < .05). Coupon receipt and online engagement at Wave 1 was positively associated with past 30-day use of cigarettes, e-cigarettes, cigars, smokeless tobacco, and hookah at Wave 2 (p < .05). The relationships were stronger for those who received coupons at both waves or engaged with more sources of online marketing. CONCLUSIONS: Tobacco direct-to-consumer marketing is reaching youth. Repeated exposure to these marketing activities within and across media is associated with use of different tobacco products. New policies and strong enforcement of existing regulations prohibiting these illegal marketing tactics are critical to protect youth from future tobacco use. IMPLICATIONS: Tobacco companies utilize coupons and online engagement activities to increase brand awareness, knowledge, and sales of their products. These kinds of marketing activities can be influential among youth at a time when they may develop tobacco use behaviors. Our findings suggest that tobacco companies may be targeting at-risk youth through cross-media marketing activities. The findings also indicate that exposure to these marketing activities predicts subsequent use of different tobacco products, with suggestive dose-response relationships. Increased regulations are needed to protect youth from these marketing activities.

Flavour types used by youth and adult tobacco users in wave 2 of the Population Assessment of Tobacco and Health (PATH) Study 2014-2015.

BACKGROUND: Most youth and young adult (YA) tobacco users use flavoured products; however, little is known about specific flavours used. METHODS: We report flavour types among US tobacco users from the Population Assessment of Tobacco and Health Study, wave 2, 2014-2015. At wave 2, we examined (1) flavour use and type at past 30-day use; (2) new flavoured tobacco product use and type; (3) product-specific flavour patterns across youth (ages 12-17) (n=920), YA (18-24) (n=3726) and adult (25+) (n=10 346) past 30-day and new tobacco users and (4) concordance between self-coded and expert-coded brand flavour type among all adults (18+). RESULTS: Prevalence of flavoured tobacco product use was highest among youth, followed by YA and adult 25+ any tobacco users. Within each age group, flavoured use was greatest among hookah, e-cigarette and snus users. Overall, menthol/mint, fruit and candy/sweet were the most prevalent flavour types at first and past 30-day use across age groups. For past 30-day use, all flavour types except menthol/mint exhibited an inverse age gradient, with more prevalent use among youth and YAs, followed by adults 25+. Prevalence of menthol/mint use was high (over 50% youth, YAs; 76% adults 25+) and exhibited a positive age gradient overall, though the reverse for cigarettes. Brand-categorised and self-reported flavour use measures among adults 18+ were moderately to substantially concordant across most products. CONCLUSIONS: Common flavours like menthol/mint, fruit and candy/sweet enhance appeal to young tobacco users. Information on flavour types used by product and age can inform tobacco flavour regulations to addess flavour appeal especially among youth.

Tobacco Industry Marketing Exposure and Commercial Tobacco Product Use Disparities among American Indians and Alaska Natives.

Background: Non-Hispanic American Indians and Alaska Natives (NH AI/AN) have the highest commercial tobacco use (CTU) among U.S. racial/ethnic groups. Tobacco marketing is a risk factor, however few studies examine it among NH AI/AN. Objective: We identified prevalence of tobacco industry marketing exposure and correlates of CTU among NH AI/AN compared to other racial/ethnic groups. Methods: Data were from wave 1 (2013-2014; N = 32,320) of the Population Assessment of Tobacco and Health Study, analyzing self-reported exposure to tobacco ads from stores, tobacco package displays, direct mail and email marketing. Correlates of CTU were identified and interactions between racial/ethnic groups and tobacco marketing were assessed. Results: NH AI/AN (n = 955) had a higher prevalence of exposure to retail tobacco ads (64.5% vs 59.3%; p < 0.05), mail (20.2% vs.14.3%; p < 0.001) and email (17.0% vs.10.6%; p < 0.001) marketing than NH Whites (n = 19,297). Adjusting for tobacco use and related risk factors, exposure to email marketing remained higher among NH AI/AN than NH Whites. Interactions between racial/ethnic groups and marketing exposures on CTU were nonsignificant. CTU was higher among NH AI/AN than NH Whites and among adults who reported exposure to tobacco ads, mail, and email marketing. Conclusions/importance: There is higher tobacco marketing exposure in stores and via mail for NH AI/AN. Email marketing exposure was higher, even after controlling for tobacco-related risk factors. The tobacco industry may be targeting NH AI/AN through emails, which include coupons and other marketing promotions. Culturally relevant strategies that counter-act tobacco industry direct marketing tactics are needed to reduce disparities in this population.

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.

Longitudinal Response to Restrictions on Menthol Cigarettes Among Young Adult US Menthol Smokers, 2011-2016.

Objectives. To examine responses to hypothetical restrictions on menthol cigarettes among young adult menthol smokers in the United States.Methods. We surveyed Truth Initiative Young Adult Cohort respondents 18 to 34 years of age every 6 months from December 2011 through October 2016. Menthol cigarette smokers (n = 806, n = 1963 observations) indicated their response if menthol cigarettes were unavailable. Weighted analyses accounting for repeated measures were used to estimate the prevalence and correlates of responses and trends over time.Results. Overall, 23.5% of young adult menthol smokers said they would quit if menthol cigarettes were unavailable, with this response largely unchanged between 2011 and 2016. There was a significant increase in the switch to another tobacco product response (from 7.4% to 13.2%; P = .01) associated with current noncigarette use. In adjusted analyses, African Americans, women, those with less than a high school education, and those with any quit intention were more likely to say they would quit smoking.Conclusions. Increased intentions to switch products suggest the acceptability and availability of alternatives to menthol cigarette smokers. Menthol cigarette restrictions benefit vulnerable groups and those interested in quitting, but the availability of menthol in noncigarette products could limit benefits.