Design and methods of the Population Assessment of Tobacco and Health (PATH) Study.

BACKGROUND: This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administration's (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat. METHODS: The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Study's design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use. CONCLUSIONS: The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDA's regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nation's burden of tobacco-related death and disease.

The Language of Cigar Use: Focus Group Findings on Cigar Product Terminology.

INTRODUCTION: The consumption of cigar products has increased since 2000. The multiple product types within this category, combined with the varied language with which consumers refer to them, present challenges for accurately assessing the prevalence of cigar product use. Surveillance is also complicated by the fact that these products can be used to smoke marijuana, as "blunts"-cigars in which the tobacco is removed and replaced with marijuana. Few studies exist regarding the language and terminology used to describe these products. METHODS: Sixteen focus groups were conducted in five cities in the United States between March and May of 2014. Participants (N = 123) included adults who had used cigars, cigarillos, or little cigars in the past 30 days. A semi-structured moderator guide was used to gather data on the terms used to identify cigar product subtypes and the language used to describe the products and their use. RESULTS: Participants used a variety of terms for each product subtype. Brand names were often used, as well as slang terms, including terms describing cigars modified for marijuana use. Some subtypes were less likely than others to be considered "cigars." Participants had mixed opinions about whether users of cigar products are "smokers." CONCLUSIONS: Users of cigar products may classify or label products differently from researchers and policy makers, and many refer to their product by brand name or a slang term. These findings have implications for future research, instrument design, and public health messaging about cigar products. IMPLICATIONS: This study adds to the body of evidence highlighting the challenges for measurement and surveillance of non-cigarette tobacco products, including cigars. Findings illustrate the myriad terms used by consumers to describe their use of cigar product subtypes, as well as the complexity of distinguishing between use of cigar products as intended, versus as a vehicle for smoking marijuana. Future research aimed to enhance specificity of cigar use measures will enable policy-makers and public health practitioners to more fully characterize prevalence and patterns of use by cigar subtype.

Sexual and Gender Minority U.S. Youth Tobacco Use: Population Assessment of Tobacco and Health (PATH) Study Wave 3, 2015-2016.

INTRODUCTION: Tobacco use disparities by sexual identity are well characterized among adults, but relatively less is known about tobacco use disparities in sexual minority youth. Moreover, no national study has reported tobacco use behaviors among gender minority (e.g., transgender) youth. METHODS: Data from Wave 3 (2015-2016) of the Population Assessment of Health Study from youth aged 14-17 years (n=7,772), analyzed in 2018, were stratified by transgender identity, sex, and sexual identity to describe tobacco product use. RESULTS: Transgender youth (n=79) were more likely to report ever use of tobacco products compared with nontransgender youth (electronic nicotine products, 40.2% vs 23.0%; cigarettes, 33.9% vs 14.1%; and smokeless tobacco, 21.5% vs 6.0%, respectively) and more likely to report past 30-day use of these products. Similarly, female sexual minority youth, compared with straight female youth, were more likely to report ever use of electronic nicotine products (37.9% vs 20.1%); cigarettes (28.9% vs 12.0%); cigars (11.3% vs 5.2%); hookah (12.7% vs 7.6%); and past 30-day use of electronic nicotine products, cigarettes, and cigars. Among male youth, sexual minority youth were more likely to report ever use of cigarettes compared with straight youth (25.1% vs 13.5%), but they did not differ in ever or past 30-day use of any other tobacco products. CONCLUSIONS: Sexual minority youth and transgender youth are more likely to use tobacco products compared with their nonminority peers. Similar to patterns among adults, this is especially true for female sexual minority youth. This information is useful for developing communication and education efforts to prevent youth tobacco initiation in these high-risk groups.

Unpacking smokers' beliefs about addiction and nicotine: A qualitative study.

Evidence suggests that consumers correctly identify nicotine as addictive; however, many may also harbor misconceptions about its harmfulness. The majority of this evidence is based on survey data, however, which may be prone to some limitations. In the current study, we employed qualitative methods to examine, in their own words, smokers' beliefs about nicotine and addiction. Twelve 1-hr focus groups were conducted in 3 cities in the United States (Columbus, OH; New Orleans, LA; and Washington, DC) from October to November, 2014. Adult cigarette smokers (N = 108), defined as those who reported smoking cigarettes on every day or some days, were segmented by age group (18-25 years and ≥26 years) and tobacco-use behavior. Thematic, in-depth analysis of focus-group discussion transcripts was conducted. Participant demographic information was recorded. Results showed that smokers identify nicotine as a cause of addiction to cigarettes; however, they also attribute their addiction to other factors. When asked about nicotine's effects on the body, immediate physiological effects of smoking (e.g., stimulation, relaxation) were top of mind. Opinions varied in terms of whether nicotine itself was harmful or harmless; many were unsure and/or had not considered this question. Discussions revealed heterogeneity in smokers' beliefs as well as recognition of their own uncertainty and lack of knowledge. The current findings provide insight that smokers may not be as misinformed regarding the relative harms of nicotine and tobacco, as has been suggested by quantitative evidence. Implications for future research are discussed. (PsycINFO Database Record

Smoke and Vapor: Exploring the Terminology Landscape among Electronic Cigarette Users.

OBJECTIVE: We explored the terminology of adult e-cigarette users in describing e-cigarette products and their use. We report how users discuss and differentiate these products and the language and culture surrounding them. METHODS: Focus groups (N = 12) were held in 5 locations in the United States between March and May, 2014. Participants (N = 99) included young adults or adults who were either exclusive or nonexclusive e-cigarette users. We gathered data on how users identify various types of e-cigarettes and how users understand and describe specific terms. RESULTS: Participants were familiar with the attributes of e-cigarettes in general but confused by the variety of products and unable to describe differences between product types. They were familiar with the term "vaping" even when they used "smoking" more frequently, and were clear that e-cigarettes do not produce traditional cigarette smoke. They had varied opinions about what to call regular users of e-cigarettes. CONCLUSIONS: Findings highlight that conceptual clarity, including using specific and familiar terminology and product descriptions for users and nonusers alike, is challenging and crucial. It is important that surveillance efforts, policy development, messaging, and future research reflect the language understood and used by consumers to enable widespread comprehension.

Tobacco Product Use Among Sexual Minority Adults: Findings From the 2012-2013 National Adult Tobacco Survey.

INTRODUCTION: A growing body of evidence reveals higher rates of tobacco use among sexual minority populations relative to non-minority ("straight") populations. This study seeks to more fully characterize this disparity by examining tobacco use by distinct sexual identities and gender to better understand patterns of: (1) cigarette smoking and smoking history; and (2) use of other tobacco products including cigars, pipes, hookah, e-cigarettes, and smokeless tobacco. METHODS: Data from the 2012-2013 National Adult Tobacco Survey, a random-digit dialed landline and cellular telephone survey of U.S. adults aged ≥18 years, were analyzed in 2014. A sexual minority category was created by combining gay, lesbian, and bisexual responses, along with those who selected an option for other non-heterosexual identities. RESULTS: Smoking prevalence was higher among sexual minority adults (27.4%) than straight adults (17.3%). Cigarette smoking was particularly high among bisexual women (36.0%). Sexual minority women started smoking and transitioned to daily smoking earlier than their straight peers. Use of other tobacco products was higher among sexual minority women: prevalence of e-cigarette (12.4%), hookah (10.3%), and cigar use (7.2%) was more than triple that of their straight female peers (3.4%, 2.5%, and 1.3%, respectively). Likewise, prevalence of sexual minority men's e-cigarette (7.9%) and hookah (12.8%) use exceeded that of straight men (4.7% and 4.5%, respectively). CONCLUSIONS: Tobacco use is significantly higher among sexual minority than straight adults, particularly among sexual minority women. These findings underscore the importance of tobacco control efforts designed to reach sexual minorities and highlight the heterogeneity of tobacco use within this population.

"It's not smoke. It's not tar. It's not 4000 chemicals. Case closed": Exploring attitudes, beliefs, and perceived social norms of e-cigarette use among adult users.

BACKGROUND: Electronic cigarette (e-cigarette) use is rapidly increasing among adults in the U.S. The purpose of this qualitative study was to explore consumer perceptions about e-cigarettes, including knowledge, attitudes, beliefs and perceived social norms. METHODS: A total of 14 focus groups (N=116) were conducted with current adult e-cigarette users in five U.S. cities from March through May, 2014. Focus groups were segmented by age (young adults aged 18-29 and older adults aged 30 and older) as well as by e-cigarette use status (exclusive e-cigarette users and non-exclusive e-cigarette users). Focus group discussions lasted approximately 60-min and were audio-recorded and transcribed; data were analyzed using a phenomenological approach. RESULTS: Participants expressed many positive attitudes towards e-cigarettes and simultaneously reported a lack of information and knowledge about the products. Focus group participants overwhelmingly felt as though the ingredients of e-cigarettes were likely less harmful than conventional cigarettes. Additionally, many described positive reactions from family and friends, especially when e-cigarettes were used in place of conventional cigarettes. CONCLUSIONS: Findings from this qualitative study provide insight into consumer knowledge, attitudes and beliefs about e-cigarettes increasing our understanding of why and how they are being used. Such information will help provide insight into the potential public health impact of these emerging products.

Exposure to tobacco coupons among U.S. middle and high school students.

BACKGROUND: Tobacco marketing contributes to increased tobacco use susceptibility and sustained use. There are limited data on youth exposure to tobacco coupons, a type of pro-tobacco promotion. PURPOSE: To explore channels through which youth report exposure to coupons and characteristics associated with this exposure. This may help inform efforts aimed at decreasing youth exposure to advertising and promotion. METHODS: Data from the 2012 National Youth Tobacco Survey were analyzed in 2013 to estimate the self-reported prevalence of U.S. middle and high school student exposure to coupons through various channels. Associations among exposure to coupons and demographics, tobacco use, living with a tobacco user, and receptivity to tobacco marketing were examined using multivariate logistic regression models. RESULTS: Approximately 13% of students reported exposure to tobacco coupons in the past 30 days through mail, digital communications, or tobacco packages. Prevalence was greatest among current tobacco users (34.0%) and those receptive to tobacco marketing (23.4%) compared to non-tobacco users (9.3%) and those not receptive to tobacco marketing (8.2%), respectively. Coupon exposure varied by sex, grade, and race/ethnicity. In adjusted models, current tobacco use (AOR=3.4, 95% CI=3.0, 3.9); living with a tobacco user (AOR=2.1, 95% CI=1.9, 2.4); and receptivity to tobacco marketing (AOR=2.3, 95% CI=2.0, 2.7) were independently associated with coupon exposure. CONCLUSIONS: Findings from this study indicate that despite restrictions on marketing to youth, youth are still being exposed to tobacco promotions such as coupons. Efforts to limit youth exposure may be valuable in reducing curiosity, susceptibility, and initiation.

The marketing of dissolvable tobacco: social science and public policy research needs.

The latest generation of smokeless tobacco products encompasses a wide range of offerings, including what is commonly referred to as dissolvable tobacco. Designed to deliver nicotine upon dissolving or disintegrating in a user's mouth, dissolvable tobacco products currently appear in various United States markets as strips, orbs, sticks, and lozenges. The emergence of these new products poses distinct opportunities and challenges for social and behavioral science and public health research and raises important public policy questions.