Exposure to Nicotine and Toxicants Among Dual Users of Tobacco Cigarettes and E-Cigarettes: Population Assessment of Tobacco and Health (PATH) Study, 2013-2014.

INTRODUCTION: Concurrent use of tobacco cigarettes and e-cigarettes ("dual use") is common among tobacco users. Little is known about differences in demographics and toxicant exposure among subsets of dual users. AIMS AND METHODS: We analyzed data from adult dual users (current every/some day users of tobacco cigarettes and e-cigarettes, n = 792) included in the PATH Study Wave 1 (2013-2014) and provided urine samples. Samples were analyzed for biomarkers of exposure to nicotine and selected toxicants (tobacco-specific nitrosamine NNK [NNAL], lead, cadmium, naphthalene [2-naphthol], pyrene [1-hydroxypyrene], acrylonitrile [CYMA], acrolein [CEMA], and acrylamide [AAMA]). Subsets of dual users were compared on demographic, behavioral, and biomarker measures to exclusive cigarette smokers (n = 2411) and exclusive e-cigarette users (n = 247). RESULTS: Most dual users were predominant cigarette smokers (70%), followed by daily dual users (13%), non-daily concurrent dual users (10%), and predominant vapers (7%). Dual users who smoked daily showed significantly higher biomarker concentrations compared with those who did not smoke daily. Patterns of e-cigarette use had little effect on toxicant exposure. Dual users with high toxicant exposure were generally older, female, and smoked more cigarettes per day. Dual users who had low levels of biomarkers of exposure were generally younger, male, and smoked non-daily. CONCLUSIONS: In 2013-2014, most dual users smoked cigarettes daily and used e-cigarettes occasionally. Cigarette smoking appears to be the primary driver of toxicant exposure among dual users, with little-to-no effect of e-cigarette use on biomarker levels. Results reinforce the need for dual users to stop smoking tobacco cigarettes to reduce toxicant exposure. IMPLICATIONS: With considerable dual use of tobacco cigarettes and e-cigarettes in the United States, it is important to understand differences in toxicant exposure among subsets of dual users, and how these differences align with user demographics. Findings suggest most dual users smoke daily and use e-cigarettes intermittently. Low exposure to toxicants was most common among younger users, males, and intermittent smokers; high exposure to toxicants was most common among older users, females, and heavier cigarette smokers. Results underscore the heterogeneity occurring within dual users, and the need to quit smoking cigarettes completely in order to reduce toxicant exposure.

Tobacco-Product Use by Adults and Youths in the United States in 2013 and 2014.

BACKGROUND: Noncigarette tobacco products are evolving rapidly, with increasing popularity in the United States. METHODS: We present prevalence estimates for 12 types of tobacco products, using data from 45,971 adult and youth participants (≥12 years of age) from Wave 1 (September 2013 through December 2014) of the Population Assessment of Tobacco and Health (PATH) Study, a large, nationally representative, longitudinal study of tobacco use and health in the United States. Participants were asked about their use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe tobacco, hookah, snus pouches, other smokeless tobacco, dissolvable tobacco, bidis, and kreteks. Estimates of the prevalence of use for each product were determined according to use category (e.g., current use or use in the previous 30 days) and demographic subgroup, and the prevalence of multiple-product use was explored. RESULTS: More than a quarter (27.6%) of adults were current users of at least one type of tobacco product in 2013 and 2014, although the prevalence varied depending on use category. A total of 8.9% of youths had used a tobacco product in the previous 30 days; 1.6% of youths were daily users. Approximately 40% of tobacco users, adults and youths alike, used multiple tobacco products; cigarettes plus e-cigarettes was the most common combination. Young adults (18 to 24 years of age), male adults and youths, members of racial minorities, and members of sexual minorities generally had higher use of tobacco than their counterparts. CONCLUSIONS: During this study, 28% of U.S. adults were current users of tobacco, and 9% of youths had used tobacco in the previous 30 days. Use of multiple products was common among tobacco users. These findings will serve as baseline data to examine between-person differences and within-person changes over time in the use of tobacco products. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration.).

Nicotine and Toxicant Exposure Among Concurrent Users (Co-Users) of Tobacco and Cannabis.

BACKGROUND: Smoking cannabis may potentially increase exposure to numerous toxic chemicals that are commonly associated with tobacco use. There is a paucity of data related to toxicant exposures among concurrent users of tobacco and cannabis (co-users). METHODS: Data are from the Population Assessment of Tobacco and Health Study Wave 1 Biomarker Restricted-Use Files. Analyses focused on adults who provided urine samples (N = 5859). Urine samples were analyzed for biomarkers of exposure to nicotine, tobacco-specific nitrosamines, polycyclic aromatic hydrocarbons, and volatile organic compounds. Using weighted linear regression, we compared adjusted geometric mean concentrations of 15 biomarkers between user groups of various tobacco product types according to their self-reported past 30-day cannabis use. RESULTS: Past 30-day cannabis use was similar across various types of tobacco product use subgroups (range: 13%-23%) and significantly more common compared to non-tobacco users (1.0%; p < .001). Across all groups of tobacco users, those who co-used cannabis exhibited significantly higher concentrations of the biomarker of exposure to acrylonitrile (CYMA) compared to non-cannabis users (by 39%-464%). Tobacco-cannabis co-users also showed significantly elevated levels of the biomarker of exposure to acrylamide (AAMA) compared to exclusive tobacco users, and significantly higher exposure to many polycyclic aromatic hydrocarbons (including fluorene and pyrene). CONCLUSIONS: Co-users exhibited higher concentrations for biomarkers of exposure to many combustion byproducts, compared to exclusive tobacco users. More robust measurements of cannabis use can address potential confounding in assessments of exposures to tobacco-related constituents, and potential health effects resulting from co-use. IMPLICATIONS: With disproportionately greater rates of cannabis use occurring among tobacco users, it is critical to consider how concurrent cannabis use may influence health-related outcomes among smokers. Our findings suggest potential additive toxicant exposures among co-users of tobacco and cannabis. Lack of consideration and measurement of cannabis use in assessing tobacco-related exposures may confound estimates thought to be attributable to tobacco, particularly for non-specific biomarkers. Assessing tobacco and cannabis use in tandem will allow for more precise measurement of outcomes related to one or both substances, and can provide additional information on potential health effects related to co-use.

Harm perceptions and tobacco use initiation among youth in Wave 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study.

In the US, youth attribute higher levels of harm and addictiveness to cigarettes relative to other tobacco products. Monitoring harm perceptions across a range of tobacco products is important when forecasting risk for experimentation. This study examined data from US youth (N = 10,081) ages 12-17 from the Population Assessment of Tobacco and Health (PATH) Study who completed both Wave 1 (2013-2014) and Wave 2 (2014-2015) interviews. Analyses assessed: (1) trends in perceived harm and addictiveness of products over time, (2) whether perceived harm and addictiveness of a product at Wave 1 predicted trying that product for the first time by Wave 2, and (3) whether trying a product between Waves 1 and 2 predicted a decrease in one's perceived harm and addictiveness of that product. Levels of perceived harmfulness and addictiveness significantly increased between Wave 1 and Wave 2 for all products (χ2 (range): 7.8-109.2; p's ≤ 0.02). Compared to those with "high" perceived harmfulness of a tobacco product at Wave 1, those with "low" and "medium" perceived harmfulness had a significantly increased probability of use of that product at Wave 2. For all products, Wave 1 youth never tobacco users who tried a product (vs. did not) at Wave 2 had a significantly higher probability of being in the "low" category of perceived harmfulness at Wave 2. Among US youth, there is a bidirectional relationship between harm perceptions and product use. Understanding how changes in perceptions translate to changes in tobacco use could inform efforts to prevent tobacco initiation in youth.

Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina.

BACKGROUND: After North Carolina (NC) fire inspectors detected unsafe carbon monoxide (CO) levels inside several waterpipe cafés, the state fire code was amended to include provisions regulating waterpipe cafés, adding a requirement for air ventilation. These regulations apply to new buildings constructed after 1 January 2016, but can be enforced for older buildings where there exists a distinct hazard to life. We measured air quality at a sample of waterpipe cafés before and after the starting date of this regulation and collected information on presence of air ventilation. METHODS: Air quality (CO, fine particulate matter (PM2.5)) monitoring was conducted inside and outside of six waterpipe cafés in NC in September of 2015 (time 1) and September of 2016 (time 2). In addition, questionnaires were administered to managers from each waterpipe café at time 2 to determine the presence of air ventilation systems. RESULTS: Elevated levels of CO and PM2.5 were found inside waterpipe cafés at time 1 (median CO=42 ppm; median PM2.5=379.3 µg/m3) and time 2 (median CO=65 ppm; median PM2.5=484.0 µg/m3), with no significant differences between time periods (p>0.05). Indoor levels were significantly higher than levels outside cafés at both time periods (p<0.05). All waterpipe cafés reported having an air ventilation system that was installed prior to time 1 air monitoring. CONCLUSIONS: Unsafe levels of CO and PM2.5 were observed in waterpipe cafés in NC, despite reported use of air ventilation systems. Prohibiting indoor waterpipe smoking may be necessary to ensure clean air for employees and patrons.

Examining the Association between Body Burdens of Harmful Chemicals and Heaviness of Marijuana Smoking.

Marijuana is seeing increased use both globally and domestically. However, the scientific community has not fully reached a consensus about what negative health effects and to what extent marijuana smoking may cause. In this study, we evaluated the associations between the body burdens of polycyclic aromatic hydrocarbons (PAHs) among marijuana smokers and the smoking heaviness. We observed clear, increasing trends of PAH body burdens as marijuana smoking increased. The findings highlight the importance of capturing the heaviness of marijuana smoking in future studies and support the need for well-designed toxicological and epidemiological studies for understanding the health effects of marijuana use in a changing environment.

Attitudes and experiences with secondhand smoke and smoke-free policies among subsidised and market-rate multiunit housing residents living in six diverse communities in the USA.

BACKGROUND: Given that higher smoking rates persist among lower socioeconomic populations, multiunit housing (MUH) environments may result in higher secondhand smoke (SHS) exposures among subsidised MUH residents. This cross-sectional assessment compares experiences with SHS and smoke-free policies among subsidised and market-rate MUH residents living in six US communities. METHODS: MUH residents (n=1565) were surveyed regarding their smoke-free rules (home and building), SHS exposures and preferences towards smoke-free policies. Binary logistic regression identified predictors of each outcome, focusing on differences by subsidised housing status (subsidised vs market rate). RESULTS: Among residents enforcing smoke-free home rules (76%, overall), 50% reported SHS incursions into their unit. Only 23% reported living in a smoke-free building; 56% of those living in smoking-allowable buildings reported preferences towards smoke-free building policies. Among market-rate housing residents, smoke-free home (OR=4.18) and building (OR=2.26) rules were significantly higher when children were present. Smoke-free building rules reduced the odds of SHS incursions among market-rate housing residents (OR=0.50), but no association was observed among subsidised housing residents. Non-smoking subsidised housing residents exhibited stronger preferences for smoke-free policies compared with those in market-rate housing. DISCUSSION: Smoke-free home rules may not protect MUH residents from SHS exposures, particularly in subsidised MUH. Although strong preferences towards smoke-free policies were present overall, subsidised MUH residents may have fewer alternative smoke-free housing options available. Therefore, all publicly funded housing should be smoke free to protect these vulnerable populations. However, continued efforts to encourage privately owned MUH operators to adopt smoke-free policies are also necessary.

Examining Hookah as an Introduction to Nicotine Products among College Students.

BACKGROUND: Limited data exist on what young adults report as their first-ever nicotine product; some evidence suggests that they report hookah as their first product smoked. OBJECTIVES: This study reports on the first nicotine product used among undergraduates who had ever tried tobacco, and explores correlates of hookah as that first product. METHODS: Participants included a convenience sample of undergraduate students (n = 1538) at four universities in upstate New York during fall 2013. Descriptive statistics assessed first nicotine product used and prevalence of current use. Logistic regression was used to examine correlates of hookah as the first nicotine product used. RESULTS: Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. Among students who ever smoked cigarettes, most reported cigarettes as their introductory product. Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. Among ever nicotine users, current hookah smoking was common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. Never users of cigarettes, females, and non-Hispanic African Americans, had higher adjusted odds of reporting hookah as their introductory product. CONCLUSIONS: The results of this study have implications for the identification of risk factors for tobacco initiation, the assessment of tobacco use patterns and behaviors, and the tailoring of tobacco prevention initiatives among youth. Our findings suggest that broadening prevention efforts beyond a focus on combustible cigarettes may be warranted.

Patterns of Use of Smokeless Tobacco in US Adults, 2013-2014.

OBJECTIVES: To examine patterns of smokeless tobacco (SLT) use, by type, in wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study in the United States. METHODS: We analyzed data from 32 320 adults (aged ≥ 18 years) to assess the use of pouched snus and other SLT products (loose snus, moist snuff, dip, spit, and chewing tobacco). RESULTS: Overall, SLT use was most common among men, younger adults, non-Hispanic Whites, and nonurban respondents. Pouched snus users were more likely to report nondaily and polytobacco use than users of other SLT products. Respondents who used SLT some days were more likely to be current established cigarette smokers than those who used SLT every day (57.9% vs 20.2%). Furthermore, current established smokers who used SLT some days were more likely to smoke every day and had a higher median number of cigarettes smoked per day than smokers who used SLT every day. CONCLUSIONS: Polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily snus use and polytobacco use than users of other SLT products.

Tobacco Smoke Pollution in Hospitality Venues Before and After Passage of Statewide Smoke-Free Legislation.

OBJECTIVE: In 2012, North Dakota enacted a comprehensive statewide law prohibiting smoking in enclosed public places. Disparities in tobacco control exist in rural areas. This study's objective was to determine the extent to which the passage of a comprehensive, statewide, smoke-free law in a predominantly rural state influenced tobacco smoke pollution in rural and nonrural venues. DESIGN AND SAMPLE: A longitudinal cohort design study comparing the levels of tobacco smoke pollution before and after passage of the statewide smoke-free law was conducted in 64 restaurants and bars statewide in North Dakota. MEASURES: Particulate matter with a median aerodynamic diameter of <2.5 µm (a valid atmospheric marker of tobacco smoke pollution) was assessed. RESULTS: A significant 83% reduction in tobacco smoke pollution levels occurred after passage of the law. Significant reductions in tobacco smoke pollution levels occurred in each of the rural categories; however, no difference by rurality was noted in the analysis after passage of the law, in contrast to the study before passage. CONCLUSIONS: To our knowledge, this was the largest, single, rural postlaw study globally. A comprehensive statewide smoke-free law implemented in North Dakota dramatically decreased the level of tobacco smoke pollution in bars and restaurants.

Design Characteristics and Tobacco Metal Concentrations in Filtered Cigars.

INTRODUCTION: While U.S. cigarette consumption has declined, cigar use has steadily increased, for reasons including price compared to cigarettes and the availability of filtered varieties resembling cigarettes, and flavors that have been banned in cigarettes (excluding menthol). Little published data exists on the design characteristics of such cigars. METHODS: A variety of filtered cigar brands were tested for design characteristics such as whole cigar weight, ventilation, and per-cigar tobacco weight. Cigar sticks were then sent to the University of St. Andrews for metal concentration testing of As, Pb, Cr, Ni, and Cd. RESULTS: Large and small cigars were statistically different between cigar weight (p ≤ .001), per-cigar tobacco weight (p = .001), rod diameter (p = .006), and filter diameter (p = .012). The differences in mean ventilation (overall mean = 19.6%, min. = 0.84%, max. = 57.6%) across filtered cigar brands were found to be statistically significant (p = .031), and can be compared to the ventilation of the average of 2013 U.S. Marlboro Red, Gold, and Silver packs at 29% ventilation. There were no significant differences for metal concentrations between cigar types (p = .650), with Pb and As levels being similar to U.S. 2009 cigarette concentrations, Cd cigar levels being slightly higher, and Cr and Ni levels much lower than cigarette levels. CONCLUSIONS: With cigar use rising, and filtered cigars displaying substantial similarities to filtered cigarettes, more research on product characteristics is warranted. Future plans include testing tobacco alkaloid and more observation of cigar weight for tax bracket purposes.

Air quality in New York City hookah bars.

BACKGROUND: Hookahs are increasingly being used in the USA and elsewhere. Despite the popularity of hookah bars, there is a paucity of research assessing the health effects of hookah smoke, and although New York City (NYC) bans indoor tobacco smoking, hookah lounges claim that they only use herbal products without tobacco. This study investigated levels of multiple indices of indoor air pollution in hookah bars in NYC. METHODS: Air samples were collected in 8 hookah bars in NYC. Along with venue characteristics, real-time measurements of fine particulate matter (PM2.5), black carbon (BC), and carbon monoxide (CO), and total gravimetric PM, elemental carbon (EC), organic carbon (OC), and nicotine were collected in 1-2 hour sessions. RESULTS: Overall, levels of indoor air pollution increased with increasing numbers of active hookahs smoked. The mean (SD) real time PM2.5 level was 1179.9 (939.4) µg/m(3), whereas the filter-based total PM mean was 691.3 (592.6) µg/m(3). The mean real time BC level was 4.1 (2.3) µg/m(3), OC was 237.9 (112.3) µg/m(3), and CO was 32 (16) ppm. Airborne nicotine was present in all studied hookah bars (4.2 (1.5) µg/m(3)). CONCLUSIONS: These results demonstrate that despite the ban on smoking tobacco products, at the very least, some NYC hookah bars are serving tobacco-based hookahs, and have elevated concentrations of indoor air pollutants that may present a health threat to visitors and employees. Therefore, there is an urgent need for better air quality monitoring in such establishments and policies to combat this emerging public health threat.

Tobacco smoke exposure and impact of smoking legislation on rural and non-rural hospitality venues in North Dakota.

The purpose of this cross-sectional study in a stratified random sample of 135 bars and restaurants in North Dakota was to describe factors that influenced tobacco smoke pollution levels in the venues; to compare the quantity of tobacco smoke pollution by rurality and by presence of local ordinances; and to assess compliance with state and local laws. In data collection in 2012, we measured the indoor air quality indicator of particulate matter (2.5 microns aerodynamic diameter or smaller), calculated average smoking density and occupant density, and determined compliance with state and local smoking ordinances using observational methods. As rurality increased, tobacco smoke pollution in bars increased. A significant association was found between stringency of local laws and level of tobacco smoke pollution, but the strength of the association varied by venue type. Compliance was significantly lower in venues in communities without local ordinances. Controlling for venue type, 69.2% of smoke-free policy's impact on tobacco smoke pollution levels was mediated by observed smoking. This study advances scientific knowledge on the factors influencing tobacco smoke pollution and informs public health advocates and decision makers on policy needs, especially in rural areas.

Secondhand exposure to vapors from electronic cigarettes.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are designed to generate inhalable nicotine aerosol (vapor). When an e-cigarette user takes a puff, the nicotine solution is heated and the vapor is taken into lungs. Although no sidestream vapor is generated between puffs, some of the mainstream vapor is exhaled by e-cigarette user. The aim of this study was to evaluate the secondhand exposure to nicotine and other tobacco-related toxicants from e-cigarettes. MATERIALS AND METHODS: We measured selected airborne markers of secondhand exposure: nicotine, aerosol particles (PM(2.5)), carbon monoxide, and volatile organic compounds (VOCs) in an exposure chamber. We generated e-cigarette vapor from 3 various brands of e-cigarette using a smoking machine and controlled exposure conditions. We also compared secondhand exposure with e-cigarette vapor and tobacco smoke generated by 5 dual users. RESULTS: The study showed that e-cigarettes are a source of secondhand exposure to nicotine but not to combustion toxicants. The air concentrations of nicotine emitted by various brands of e-cigarettes ranged from 0.82 to 6.23 µg/m(3). The average concentration of nicotine resulting from smoking tobacco cigarettes was 10 times higher than from e-cigarettes (31.60±6.91 vs. 3.32±2.49 µg/m(3), respectively; p = .0081). CONCLUSIONS: Using an e-cigarette in indoor environments may involuntarily expose nonusers to nicotine but not to toxic tobacco-specific combustion products. More research is needed to evaluate health consequences of secondhand exposure to nicotine, especially among vulnerable populations, including children, pregnant women, and people with cardiovascular conditions.

Secondhand smoke exposure levels in outdoor hospitality venues: a qualitative and quantitative review of the research literature.

OBJECTIVE: This paper considers the evidence on whether outdoor secondhand smoke (SHS) is present in hospitality venues at high levels enough to potentially pose health risks, particularly among employees. DATA SOURCES: Searches in PubMed and Web of Science included combinations of environmental tobacco smoke, secondhand smoke, or passive smoke AND outdoor, yielding 217 and 5,199 results, respectively through June, 2012. STUDY SELECTION: Sixteen studies were selected that reported measuring any outdoor SHS exposures (particulate matter (PM) or other SHS indicators). DATA EXTRACTION: The SHS measurement methods were assessed for inclusion of extraneous variables that may affect levels or the corroboration of measurements with known standards. DATA SYNTHESIS: The magnitude of SHS exposure (PM2.5) depends on the number of smokers present, measurement proximity, outdoor enclosures, and wind. Annual excess PM2.5 exposure of full-time waitstaff at outdoor smoking environments could average 4.0 to 12.2 µg/m3 under variable smoking conditions. CONCLUSIONS: Although highly transitory, outdoor SHS exposures could occasionally exceed annual ambient air quality exposure guidelines. Personal monitoring studies of waitstaff are warranted to corroborate these modeled estimates.

Indoor air quality in Virginia waterpipe cafes.

INTRODUCTION: A revised indoor air quality law has been implemented in Virginia to protect the public from the harmful effects of secondhand smoke exposure. This legislation contains exemptions that include allowances for smoking in a room that is structurally separated and separately ventilated. The objective of the current study was to examine the impact of this law on air quality in waterpipe cafés, as well as to compare the air quality in these cafés to restaurants that allow cigarette smoking and those where no smoking is permitted. METHODS: Indoor air quality in 28 venues (17 waterpipe cafés, five cigarette smoking-permitted restaurants and six smoke-free restaurants (five with valid data)) in Virginia was assessed during 4 March to 27 May 2011. Real-time measurements of particulate matter (PM) with 2.5 µm aerodynamic diameter or smaller (PM2.5) were obtained and occupant behaviour/venue characteristics were assessed. RESULTS: The highest mean PM2.5 concentration was observed for waterpipe café smoking rooms (374 µg/m(3), n=17) followed by waterpipe café non-smoking rooms (123 µg/m(3), n=11), cigarette smoking-permitted restaurant smoking rooms (119 µg/m(3), n=5), cigarette smoking-permitted restaurant non-smoking rooms (26 µg/m(3), n=5) and smoke-free restaurants (9 µg/m(3), n=5). Smoking density was positively correlated with PM2.5 across smoking rooms and the smoke-free restaurants. In addition, PM2.5 was positively correlated between smoking and non-smoking rooms of venues. CONCLUSIONS: The PM2.5 concentrations observed among the waterpipe cafés sampled here indicated air quality in the waterpipe café smoking rooms was worse than restaurant rooms in which cigarette smoking was permitted, and state-required non-smoking rooms in waterpipe cafés may expose patrons and employees to PM2.5 concentrations above national and international air quality standards. Reducing the health risks of secondhand smoke may require smoke-free establishments in which tobacco smoking sources such as water pipes are, like cigarettes, prohibited.

[Change of secondhand smoke levels in a public hospital in Budapest after implementation of anti-smoking policy in 2011]. / Dohányfüst-koncentráció változása egy budapesti közkórházban a nemdohányzók védelmét célzó 2011-es törvényt követoen.

INTRODUCTION: Our previous 2009 study demonstrated high secondhand smoke levels throughout a public hospital in Budapest. AIM: To compare changes in indoor air pollution level between 2009 and 2012, before and after the Hungarian anti-smoking policy legislation adopted in 2011. METHODS: TSI SidePak AM510 Personal Aerosol Monitor was used. RESULTS: In-patient care department PM2.5 levels declined by 92% from 87.7 µg/m3 to 6.9 µg/m3. Non-patient care area PM2.5 level increased by 67% from 64.8 µg/m3 to 108.0 µg/m3. The increase was driven entirely by a large increase in the level in public toilets. Excluding these, there was a 83% drop in PM2.5 in non-patient care areas from 64.8 µg/m3 to 11.1 µg/m3. CONCLUSIONS: PM2.5 decreased significantly due to the 2011 law. However, smoking still occurred in the hospital, albeit in less frequently visited areas. A stricter enforcement of this beneficial law is needed to reach a comprehensive smoke-free hospital environment.

Attitudes, experiences, and acceptance of smoke-free policies among US multiunit housing residents.

We assessed factors related to smoke-free policies among a cross-sectional, nationally representative, random-digit-dial sample (landline and cell phone) of US multiunit housing residents (n = 418). Overall, 29% reported living in smoke-free buildings, while 79% reported voluntary smoke-free home rules. Among those with smoke-free home rules, 44% reported secondhand smoke incursions in their unit. Among all respondents, 56% supported smoke-free building policy implementation. These findings suggest that smoke-free building policies are needed to protect multiunit housing residents from secondhand smoke in their homes.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study.

INTRODUCTION: Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time. METHODS: This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves. RESULTS: Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age. CONCLUSIONS: Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Secondhand tobacco smoke exposure in selected public places (PM2.5 and air nicotine) and non-smoking employees (hair nicotine) in Ghana.

BACKGROUND: Secondhand tobacco smoke (SHS) exposure is a global public health problem. Ghana currently has no legislation to prevent smoking in public places. To provide data on SHS levels in hospitality venues in Ghana the authors measured (1) airborne particulate matter <2.5 µm (PM(2.5)) and nicotine concentrations and (2) hair nicotine concentrations in non-smoking employees. Quantifying SHS exposure will provide evidence needed to develop tobacco control legislation. METHOD: PM(2.5) was measured for 30 min in 75 smoking and 13 non-smoking venues. Air nicotine concentrations were measured for 7 days in 8 smoking and 2 non-smoking venues. Additionally, 63 non-smoking employees provided hair samples for nicotine analysis. RESULT: Compared to non-smoking venues, smoking venues had markedly elevated PM(2.5) (median 553 [IQR 259-1038] vs 16.0 [14.0-17.0]µg/m(3)) and air nicotine (1.83 [0.91-4.25] vs 0.03 [0.02-0.04]µg/m(3)) concentrations. Hair nicotine concentrations were also higher in non-smoking employees working in smoking venues (median 2.49 [0.46-6.84] ng/mg) compared to those working in non-smoking venues (median 0.16 [0.08-0.79]ng/mg). Hair nicotine concentrations correlated with self-reported hours of SHS exposure (r=0.35), indoor air PM(2.5) concentrations (r=0.47) and air nicotine concentrations (r=0.63). CONCLUSION: SHS levels were unacceptably high in public places in Ghana where smoking is allowed, despite a relatively low-smoking prevalence in the country. This is one of the first studies to ascertain SHS and hair nicotine in Africa. Levels were comparable to those measured in American, Asian and European countries without or before smoking bans. Implementing a comprehensive smoke-free legislation that protects workers and customers from exposure to secondhand smoke is urgently needed in Ghana.