Genetic diversity fuels gene discovery for tobacco and alcohol use.

Tobacco and alcohol use are heritable behaviours associated with 15% and 5.3% of worldwide deaths, respectively, due largely to broad increased risk for disease and injury1-4. These substances are used across the globe, yet genome-wide association studies have focused largely on individuals of European ancestries5. Here we leveraged global genetic diversity across 3.4 million individuals from four major clines of global ancestry (approximately 21% non-European) to power the discovery and fine-mapping of genomic loci associated with tobacco and alcohol use, to inform function of these loci via ancestry-aware transcriptome-wide association studies, and to evaluate the genetic architecture and predictive power of polygenic risk within and across populations. We found that increases in sample size and genetic diversity improved locus identification and fine-mapping resolution, and that a large majority of the 3,823 associated variants (from 2,143 loci) showed consistent effect sizes across ancestry dimensions. However, polygenic risk scores developed in one ancestry performed poorly in others, highlighting the continued need to increase sample sizes of diverse ancestries to realize any potential benefit of polygenic prediction.

Even worse for Black girls: the longitudinal association of racial bullying with the initiation of alcohol and tobacco use.

We used Poisson's linear regression to examine the association between racial bullying (RB) and the initiation of alcohol and tobacco uses after 9 months. Two cluster-randomized controlled trials were conducted in 2019 with children in grades five (girls: 50.0%; 10 years old: 82.0%; White: 36.8%; Black: 58.7%; others: 4.5%) and seven (girls: 49.5%; 12 years old: 78.1%; White: 33.2%; Black: 60.4%; others: 6.4%) from 30 public schools in the municipality of São Paulo, Brazil. We restricted our analyses to 2 subsets of students in each grade: those who reported no lifetime alcohol use at baseline and those who reported no lifetime baseline tobacco use. At baseline, 16.2% of fifth and 10.7% of seventh graders reported suffering from RB in the 30 days before data collection. After 9 months, 14.9% of fifth graders started using alcohol and 2.5%, tobacco. Among seventh graders, the figures were 31.2% and 7.7%, respectively. RB predicted the initiation of use of alcohol (risk ratio [RR] = 1.36; 95% CI, 1.07-1.70) and tobacco (RR = 1.81; 95% CI, 1.14-2.76) among seventh graders, with race-gender differences, particularly in Black girls (alcohol: RR = 1.45; 95% CI, 1.07-1.93; tobacco: RR = 2.34; 95% CI, 1.31-3.99). School-based programs and policies must explicitly address issues related to racism and gender in alcohol and tobacco prevention strategies.

Longitudinal Transitions Between Use of Combustible, Noncombustible, and Multiple Cannabis Products From Adolescence to Young Adulthood and Intersections With Nicotine Use.

Understanding transitions across use of different types of cannabis products and multiple cannabis products and how they intersect with nicotine use in young people can inform etiology and prevention. In this study, we examined transitions across use of combustible and noncombustible forms of cannabis and multiple types of cannabis from adolescence to young adulthood and the role of nicotine use in transitions. In a Southern California longitudinal cohort study (n = 3,298; baseline mean age = 16.1 (standard deviation, 0.4) years) with 9 semiannual survey waves (2015-2021), we used Markov multistate transition modeling to estimate short-term (2-wave) and long-term (9-wave) probabilities of transition across 5 cannabis use states: never use of any product, prior use with no past-6-month (P6M) use of any product, and P6M use of exclusively noncombustible products, exclusively combustible products, and multiple (noncombustible + combustible) products. Sizable transition probabilities from prior and exclusive P6M noncombustible or combustible cannabis use to P6M poly-cannabis-product use were observed in short-term (10.7%-38.9%) and long-term (43.4%-43.8%) analyses. P6M nicotine use increased risk of transitioning from never and prior use to exclusive P6M noncombustible and combustible cannabis use. Cannabis use in any form, even temporary use, during midadolescence may often be followed by poly-cannabis-product use. Nicotine use may amplify the probability of future cannabis use onset or recurrence.

Tobacco use, self-reported professional dental cleaning habits, and lung adenocarcinoma diagnosis are associated with bronchial and lung microbiome alpha diversity.

RATIONALE: The lung microbiome is an inflammatory stimulus whose role in the development of lung malignancies is incompletely understood. We hypothesized that the lung microbiome associates with multiple clinical factors, including the presence of a lung malignancy. OBJECTIVES: To assess associations between the upper and lower airway microbiome and multiple clinical factors including lung malignancy. METHODS: We conducted a prospective cohort study of upper and lower airway microbiome samples from 44 subjects undergoing lung lobectomy for suspected or confirmed lung cancer. Subjects provided oral (2), induced sputum, nasopharyngeal, bronchial, and lung tissue (3) samples. Pathologic diagnosis, age, tobacco use, dental care history, lung function, and inhaled corticosteroid use were associated with upper and lower airway microbiome findings. MEASUREMENTS AND MAIN RESULTS: Older age was associated with greater Simpson diversity in the oral and nasopharyngeal sites (p = 0.022 and p = 0.019, respectively). Current tobacco use was associated with greater lung and bronchus Simpson diversity (p < 0.0001). Self-reported last profession dental cleaning more than 6 months prior (vs. 6 or fewer months prior) was associated with lower lung and bronchus Simpson diversity (p < 0.0001). Diagnosis of a lung adenocarcinoma (vs. other pathologic findings) was associated with lower bronchus and lung Simpson diversity (p = 0.024). Last professional dental cleaning, dichotomized as ≤ 6 months vs. >6 months prior, was associated with clustering among lung samples (p = 0.027, R2 = 0.016). Current tobacco use was associated with greater abundance of pulmonary pathogens Mycoplasmoides and Haemophilus in lower airway samples. Self-reported professional dental cleaning ≤ 6 months prior (vs. >6 months prior) was associated with greater bronchial Actinomyces and lung Streptococcus abundance. Lung adenocarcinoma (vs. no lung adenocarcinoma) was associated with lower Lawsonella abundance in lung samples. Inhaled corticosteroid use was associated with greater abundance of Haemophilus among oral samples and greater Staphylococcus among lung samples. CONCLUSIONS: Current tobacco use, recent dental cleaning, and a diagnosis of adenocarcinoma are associated with lung and bronchial microbiome α-diversity, composition (ß-diversity), and the abundance of several respiratory pathogens. These findings suggest that modifiable habits (tobacco use and dental care) may influence the lower airway microbiome. Larger controlled studies to investigate these potential associations are warranted.

Tobacco 21 Laws and Youth Tobacco Use: The Role of Policy Attributes.

Objectives. To estimate Tobacco-21 policies' relationships to 18- to 20 year-old youth cigarette, cigar, and electronic nicotine delivery system (ENDS) use, and to test for effect modification by policy attributes. Methods. In fall 2022, we used Tobacco 21 Population Coverage Database data to calculate the percentage of state residents covered by state or local Tobacco 21 (T21) laws monthly through June 2020. Matching T21 coverage to Population Assessment of Tobacco and Health and Behavioral Risk Factor Surveillance System data, we used 2-way fixed effect analyses to assess the relationship between T21 laws and 18- to 20-year-old youth cigarette, cigar, and ENDS use, and tested for differences by policy attributes: possession, use, or purchase (PUP) penalties, retailer noncompliance penalties, and compliance check requirements. Results. Increased T21 exposure yielded significant reductions in cigarette and cigar use, as well as in ENDS use, when accounting for policy attributes. These effects were dampened in T21 laws with PUP penalties relative to those without. Conclusions. Tobacco-21 laws yield reductions in 18- to 20-year-old youth cigarette, cigar, and ENDS use, with dampened effects when policies include PUP penalties. Public Health Implications. State policymakers should consider implementing T21 laws without PUP penalties to reduce underage nicotine and tobacco use. (Am J Public Health. 2024;114(1):90-97. https://doi.org/10.2105/AJPH.2023.307447).

Social Ecological Influences on Nicotine/Tobacco Use Among Gender-Varying and Gender-Stable Adolescents and Adults in the USA.

BACKGROUND AND PURPOSE: Our study examined individual-, interpersonal-, community-, and policy-level associations with nicotine/tobacco use among gender-varying and gender-stable U.S. individuals. METHODS: Data from Waves 2-4 (2014/15-2016/18) of the Population Assessment of Tobacco and Health (n = 33,197 U.S. adolescents and adults aged ≥14 years) and state-level gender minority policy data were used. Using multivariable logistic regression, the odds of past-30-day nicotine/tobacco use at W4 were estimated as a function of gender stability/variability, psychological distress, number of tobacco products used by family/friends, anti-tobacco marketing exposure, and change in gender minority-related policies from 2015 to 2017. RESULTS: Gender-varying individuals had higher odds of nicotine/tobacco use compared with gender-stable individuals (AOR range = 1.7-2.3, p < .01). In the overall sample, positive change in gender minority policy protections (tallied from medium to high) was associated with lower odds of any nicotine/tobacco, other tobacco, and poly-tobacco use (AOR = 0.8, p < .05) compared to states with no change in their negative policies. Anti-tobacco marketing exposure was associated with lower odds of any tobacco, cigarette, e-cigarette, and poly-tobacco use compared with those who had no anti-tobacco marketing exposure (AOR = 0.9, p < .05). Higher psychological distress (AOR range = 1.7-2.4, p < .001) and an increasing number of tobacco products used by family/friends (AOR range = 1.1-1.3, p < .001) were associated with increased odds of nicotine/tobacco use. CONCLUSIONS: Multilevel prevention and intervention strategies are needed to reduce the risk of nicotine/tobacco use among gender-varying and gender-stable individuals.

Prior work has shown that individuals whose gender identity changes over time (i.e., gender-varying) have higher risk for nicotine/tobacco use compared with individuals whose gender identity remains consistent over time (i.e., gender-stable). This study examined individual-, interpersonal-, community-, and policy-level associations with nicotine/tobacco use among gender-varying and gender-stable U.S. adolescents and adults. We analyzed data from Waves 2­4 (2014/15­2016/18) of the Population Assessment of Tobacco and Health study (n = 33,197 U.S. adolescents and adults aged 14 years and above) and state-level gender identity policy data from the Movement Advancement Project. Among the overall sample, we found that a positive change in state-level policy protections was associated with lower odds of any nicotine/tobacco, other tobacco, and poly-tobacco use compared with states that had no change in their negative policies. Exposure to anti-tobacco marketing was associated with lower odds of any tobacco, cigarette, e-cigarette, and poly-tobacco use compared with those who had no exposure to anti-tobacco marketing. Higher psychological distress and an increasing number of tobacco products used by close friends and family were associated with increased odds of nicotine/tobacco use. Multilevel prevention and intervention strategies are needed to reduce the risk of nicotine/tobacco use among gender-varying and gender-stable individuals.

Systems approaches to scaling up: a systematic review and narrative synthesis of evidence for physical activity and other behavioural non-communicable disease risk factors.

BACKGROUND: Non-communicable diseases (NCDs) are the leading causes of death worldwide. Systems approaches have potential for creating sustainable outcomes at scale but have rarely been used to support scale up in physical activity/nutrition promotion or NCD prevention more generally. This review aimed to: (i) synthesise evidence on the use of systems approaches in scaling up interventions targeting four behavioural risk factors for NCDs; and (ii) to explore how systems approaches have been conceptualised and used in intervention implementation and scale up. METHOD: Seven electronic databases were searched for studies published 2016-2021. Eligible studies targeted at least one of four NCD behavioural risk factors (physical inactivity, tobacco use, alcohol consumption, diet), or described evaluation of an intervention planned for or scaled up. Studies were categorised as having a (i) high, (ii) moderate, or (iii) no use of a systems approach. A narrative synthesis of how systems approaches had been operationalised in scale up, following PRISMA guidelines. RESULTS: Twenty-one intervention studies were included. Only 19% (n = 4) of interventions explicitly used systems thinking to inform intervention design, implementation and scale up (targeting all four risk factors n = 2, diet n = 1, tobacco use n = 1). Five studies ('high use') planned and implemented scale up with an explicit focus on relations between system elements and used system changes to drive impact at scale. Seven studies ('moderate use') considered systems elements impacting scale-up processes or outcomes but did not require achieving system-level changes from the outset. Nine studies ('no use') were designed to work at multiple levels among multiple agencies in an intervention setting, but the complexity of the system and relations between system elements was not articulated. We synthesised reported barriers and facilitators to scaling up, and how studies within each group conceptualised and used systems approaches, and methods, frameworks and principles for scaling up. CONCLUSION: In physical activity research, and NCD prevention more broadly, the use of systems approaches in scale up remains in its infancy. For researchers, practitioners and policymakers wishing to adopt systems approaches to intervention implementation at scale, guidance is needed on how to communicate and operationalise systems approaches in research and in practice. TRIAL REGISTRATION: PROSPERO (CRD42021287265).

Use patterns of flavored non-cigarette tobacco products among US adults, 2010-2019.

OBJECTIVE: Flavored non-cigarette tobacco product (NCTP) use is common among US adult tobacco users. To update the estimates of use patterns of flavored NCTPs, this study assessed current NCTP use among adults by flavor use and flavor categories from 2010 to 2019. METHODS: We analyzed data from the 2010-2019 Tobacco Use Supplement to the Current Population Survey to estimate the weighted proportion of adult NCTP users by flavor use across survey waves. Flavor use was defined as past 30-day use of any menthol/mint or fruit/other flavors. We used the 2018-2019 data to examine the differences in demographic characteristics and tobacco use patterns among users of menthol/mint or fruit/other flavors compared to exclusive users of tobacco flavor, by product type. RESULTS: Compared to 2014-2015, electronic nicotine delivery system (ENDS) users were more likely (79.0% vs. 66.6%, p < 0.001) to report flavor use in 2018-2019, whereas cigar (26.9% vs. 31.2%, p = 0.030) and pipe (56.3% vs. 65.5%, p = 0.015) smokers were less likely to report flavor use in 2018-2019. In 2018-2019, the most prevalent flavor categories were exclusive use of tobacco flavor among cigar (73.1%) and smokeless tobacco (48.3%) users, and use of fruit/other flavors among ENDS (64.9%) and pipe (48.4%) users. Flavored users were more likely to be young adults aged 18-24 years (cigars, ENDS, smokeless tobacco) and Non-Hispanic Black or Hispanic persons (cigars, ENDS, pipes) compared to tobacco-flavored users. CONCLUSIONS: Flavored product use increased among adult ENDS users but decreased among cigar and pipe smokers. These findings could inform tobacco regulatory efforts concerning flavored NCTPs.

Birth-cohort patterns of e-cigarette and other tobacco use among adolescents in the US.

BACKGROUND: E-cigarette use has increased considerably among US adolescents. While many studies have described cross-sectional prevalence trends of youth e-cigarette use, less is known about cohort or generational initiation and use patterns. METHODS: We used data from the US National Youth Tobacco Survey (NYTS) from 2014 to 2022 and age-period-cohort models to analyze age-specific patterns of e-cigarette use initiation and prevalence by cohort and calendar. For comparison, we also examined initiation and prevalence for cigarettes, cigars, and smokeless tobacco, using NYTS data from 1999 to 2022. RESULTS: Age-specific e-cigarette initiation and prevalence varied considerably by calendar year and birth cohort. There was a rapid increase in e-cigarette initiation and prevalence starting with the 1995 birth cohort, peaking with the 2005 birth cohort, and showing signs of decline with more recent cohorts. In contrast, there were substantial continuous reductions in cigarette, cigar, and smokeless use initiation and prevalence by birth cohort. While the reductions in cigarette smoking started with the 1980s birth cohorts, cigar and smokeless initiation and prevalence did not decrease until the 1990-1995 cohorts. CONCLUSIONS: Despite their recent emergence, e-cigarette use has varied considerably across US adolescent cohorts. After early increases, e-cigarette use and initiation peaked with the 2005 birth cohort. These patterns are in contrast with the continuous decreases by cohort in cigarette, cigar, and smokeless use and initiation. As the tobacco product landscape continues to evolve, it will be essential to monitor patterns of use of adolescent and young adult cohorts as they age into adulthood.

Socioecological factors associated with multiple nicotine product use among U.S. youth: Findings from the population assessment of tobacco and health (PATH) study 2013-2018.

OBJECTIVE: This study utilized a socioecological approach to prospectively identify intrapersonal, familial, and environmental factors associated with single nicotine product use (NPU) and multiple NPU among U.S. youth. METHODS: Participants were 10,029 youths (ages 12-17 years) who had completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments and data on past 30-day nicotine product use. Multinomial logistic regression was fit for the 3-level outcome (no use, single NPU, multiple NPU) to estimate adjusted associations between the predictors and the outcome. RESULTS: The current study found that intrapersonal (sex, age, race/ethnicity, internalizing symptoms, sensation seeking, harm perceptions, lifetime history of using two or more tobacco products), familial (parental discussion about not using tobacco and living with someone who uses tobacco products) and environmental factors (exposure to tobacco advertising) commonly associated with tobacco use differentiated between individuals who later reported past 30-day NPU (either multiple or single NPU) from those who did not report past 30-day NPU. One familial factor only differentiated between lifetime users who were single NPUs from those who reported no NPU: non-combustible tobacco product use allowed anywhere in the home. Intrapersonal factors differentiated multiple NPU from single NPU: older age, being male, lifetime history of using nicotine product and less harm perceptions. CONCLUSIONS: This study identified factors that may be studied to prevent any NPU, along with factors that may be studied to promote harm reduction by preventing escalation of single NPU to problematic patterns of multiple NPU.

Serious psychological distress and higher associations with tobacco and cannabis use among college students in the United States.

OBJECTIVE: To examine associations between serious psychological distress (SPD) and tobacco and cannabis use among college students in the United States. METHODS: This cross-sectional study included 257,626 college students from the 2019-2022 National College Health Assessment survey. SPD was defined as having symptoms in the past month. Current tobacco (i.e., cigarettes, e-cigarettes) and cannabis use was defined as past month use. Multiple product use was categorized for single, dual, or triple products. Adjusted logistic regression models were used to examine associations between SPD, tobacco, cannabis, and multiple product use. RESULTS: SPD increased over time (18.4% to 23.8%) among students and nearly 30% of tobacco or cannabis users reported SPD. Cigarette, e-cigarette, or cannabis use was associated with about a 50-60% increased likelihood of reporting SPD than non-current use of each product, with the highest associations in Fall 2020. Triple product users had double the likelihood of reporting SPD, followed by dual users at 70% and single users at 47%, relative to non-current users. Daily users also had nearly twice the likelihood of reporting SPD, followed by non-daily users at 13-35%, relative to non-current users. CONCLUSIONS: College students have an increasing burden of SPD which is significantly associated with tobacco and cannabis use. There is a dose-response relationship between the number of tobacco and cannabis products used, as well as the frequency of use, and SPD among U.S. college students. Colleges addressing student mental health should prioritize the implementation of screening and treatment support for tobacco, cannabis, and multiple product use.

Parenting practices, mental health, and electronic cigarette use among U.S. young adolescents: A longitudinal panel analysis, 2013-2018.

PURPOSE: This study examined prospective association of parenting practices related to tobacco use with adolescent e-cigarette use and the moderating role of mental health among U.S. young adolescents. METHODS: We study used multi-wave longitudinal data (2013-2018) drawn from the Population Assessment of Tobacco and Health Study. A total of 5114 young adolescents (12-14 years) who were not lost to follow-ups across four waves (Wave 1-4) comprised the study sample. Weighted logistic regression models along with generalized linear mixed modeling assessed the within-subject associations of parenting practices related to tobacco use (tobacco availability at parent/guardian's home, past-year parent talk about tobacco use, and rules about non-combustible tobacco use at home) with adolescent current e-cigarette use. RESULTS: Prevalence of having home rules about non-combustible tobacco use increased (74.5%-80.2%) and that of parent talk about tobacco use decreased (52.0%-33.9%) over time while tobacco availability at home did not show a specific trend. Tobacco availability at home was associated with increased odds of adolescent e-cigarette use (adjusted odd ratio[OR] = 2.25, 95% confidence interval[CI] = 1.72-2.95), and having home rules about non-combustible tobacco use was linked to decreased likelihood of e-cigarette use (adjusted OR = 0.72, 95% CI = 0.55-0.92). The magnitude of negative association between having rules about non-combustible tobacco and adolescent e-cigarette use was stronger among adolescents with internalizing problems but weaker among those with externalizing problems. CONCLUSIONS: Our findings highlight the important role of home-based interventions in discouraging young adolescents from e-cigarette use. Parents/guardians should consider adolescents' mental health to provide more efficient home- and/or clinical-based e-cigarette use prevention.

Distress about social problems and tobacco and cannabis use outcomes among young adults in Los Angeles County.

OBJECTIVE: To examine associations of concern, worry, and stress about discrimination, shootings/violence, and police brutality and exclusive and dual tobacco and cannabis use among young adults. METHODS: A prospective, racially/ethnically diverse cohort of young adults (n = 1960) living in Los Angeles, California completed a baseline survey in 2020 (age range: 19-23) and a follow-up survey in 2021. Exploratory factor analysis (EFA) was employed on nine variables assessing levels of concern, worry, and stress about societal discrimination, societal shootings/violence, and community police brutality at baseline. Past 30-day tobacco and cannabis use at follow-up was categorized as current exclusive tobacco, exclusive cannabis, and dual tobacco and cannabis (vs never/former) use based on eleven use variables. Multinomial logistic regressions estimated adjusted associations between each factor score (translated to standard deviation units) with exclusive and dual tobacco and cannabis use. RESULTS: The EFA produced four factor scores representing concern/worry/stress (i.e., distress) about community police brutality (F1), distress about societal shootings/violence (F2), and distress about societal discrimination (F3), as well as generalized stress about police brutality, shootings/violence, and discrimination (F4). F1, F2, and F3 were associated with subsequent exclusive current cannabis use, with F1 having the strongest association (OR: 1.35, 95% CI: 1.18-1.55), while only F1 (OR: 1.51, 95% CI: 1.27-1.78) was associated with dual tobacco and cannabis use. None of the factors were associated with exclusive tobacco use. CONCLUSIONS: Young adult concern, worry, and/or stress about social problems may increase risk of cannabis use with or without concurrent tobacco use 6-12 months later.

Time to first report of signs of nicotine dependence among youth who use e-cigarettes and cigarettes in the United States: A nationally representative cohort study, findings from the Population Assessment of Tobacco and Health, 2013-2019.

OBJECTIVE: To determine the time to first report of signs of nicotine dependence among youth exclusive e-cigarette users and compare this time to that for exclusive cigarette users. METHODS: Secondary analysis of data (Waves 1-5; 2013-2019) from the Population Assessment of Tobacco and Health was conducted. Youth never tobacco users in the United States who reported exclusive past-30-day (P30D) e-cigarette or cigarette use (n = 2940, N = 5,391,642) in at least one wave were included in the current analysis. Survival analysis was used to estimate the time to the first report of three nicotine dependence indicators (i.e., "use within 30 minutes of waking"; "cravings" and "really needing to use") following the first report of P30D use. Multivariable Cox proportional hazard models were used to estimate adjusted hazard ratios (aHR). RESULTS: There were no significant differences in the time to first report of "use within 30 minutes of waking" (aHR = 1.1, 95% CI = 0.87-1.40) and "cravings" (aHR = 1.09, 95% CI = 0.81-1.47) between exclusive P30D e-cigarette use and exclusive P30D cigarette use. However, compared to exclusive P30D e-cigarette use, the hazard of first reporting "really needing to use" tobacco was 39% (aHR 1.39; 95% CI: 1.05-1.84) times higher for those who reported exclusive P30D cigarette use after controlling for covariates. CONCLUSION: Compared to exclusive P30D cigarette use, no differences in the time to first report of signs of nicotine dependence ("use within 30 minutes" and "cravings") were observed among exclusive P30D e-cigarette users. Policymakers and regulatory agencies should consider this evidence when assessing the abuse liability of e-cigarette products.

Sex differences in tobacco use, attempts to quit smoking, and cessation among dual users of cigarettes and e-cigarettes: Longitudinal findings from the US Population Assessment of Tobacco and Health Study.

SIGNIFICANCE: A growing number of adults use more than one tobacco product, with dual use of cigarettes and e-cigarettes being the most common combination. Monitoring sex disparities in tobacco use is a public health priority. However, little is known regarding whether dual users differ by sex. METHODS: Data came from Waves 4-6 (12/2016-11/2021) of the Population Assessment of Tobacco and Health Study, a US nationally-representative longitudinal survey. This analysis included current adult dual users of cigarettes and e-cigarettes. We used weighted generalized estimating equations to assess the association between sex and (1) making a cigarette quit attempt (n = 1882 observations from n = 1526 individuals) and (2) smoking cessation (n = 2081 observations from n = 1688 individuals) across two wave pairs, adjusting for age, education, ethnicity, time-to-first cigarette after waking, and e-cigarette use frequency. RESULTS: Among US dual users, 14.1% (95% Confidence Intervals [Cl] = 11.9-16.4) of females and 23.4% (20.0-26.9) of males were young adults (aged 18-24), 11.7% (9.2-14.2) of females and 14.4% (11.6-17.2) of males had

"I Thought Cancer was a Tobacco Issue": Perspectives of Veterans with and without HIV on Cancer and Other Health Risks Associated with Alcohol and Tobacco/Nicotine Use.

U.S. Veterans and people living with HIV (PWH) experience higher rates of unhealthy alcohol and tobacco/nicotine use than non-Veterans and people without HIV (PWoH). Both groups are susceptible to adverse health outcomes associated with alcohol and tobacco/nicotine use. We explored awareness of alcohol- and tobacco/nicotine-related cancer and immune health risks among Veterans Health Administration (VA) patients with and without HIV. Among a sample of 41 (46% PWH; 73% male; 39% Black) purposively-selected VA patients receiving care 2020-2021 we conducted semi-structured interviews via telephone; interviews were recorded, transcribed and analyzed using a Rapid Assessment Process. Purposive selection was based on HIV status, alcohol and/or tobacco/nicotine use, and demographics. Among participants, 66% reported current smoking, and most screened positive for unhealthy alcohol use. Participants had high awareness of cancer and other health risks related to smoking but low awareness of synergistic risks and cancer risks associated with alcohol use despite awareness of a range of other alcohol-related risks. Awareness of alcohol and/or tobacco/nicotine's impacts on the immune system was variable. Findings did not distinctly differ between PWH and PWoH. Low awareness of alcohol-related cancer risk, risks of co-occurring use, and varying awareness of the impacts of alcohol and tobacco/nicotine on the immune system suggest a need for improved messaging regarding substance use-related cancer and immune risk. This may be especially important among PWH, for whom the prevalence and adverse effects of alcohol and tobacco use, and immune dysfunction are higher.

Examining Tobacco-Related Social Media Research in Government Policy Documents: Systematic Review.

BACKGROUND: Social media data have been used to describe tobacco industry marketing practices, user experiences with tobacco, and youth-oriented protobacco content. OBJECTIVE: Examine the extent to which tobacco-related social media research is cited in government policy documents. SEARCH METHODS: Peer-reviewed tobacco-related social media studies were searched for on Web of Science, PubMed, and other databases from 2004 to 2022. The DOI number for each identified article was then used to search the Overton database to find policy documents citing such research. A secondary, manual search of national and international governmental agency websites was also conducted. SELECTION CRITERIA: Documents were included in this study if they were tobacco-related, written in English, cited social media research in the document text and reference section, and were published by a governmental office or agency. DATA COLLECTION AND ANALYSIS: The analytic sample consisted of (n = 38) government policy documents, and were coded for content themes, agency type, document type, and subsequent citations. MAIN RESULTS: When this research was utilized, it was often in the context of highlighting tobacco industry marketing practices, bringing attention to an issue (eg, youth e-cigarette use), and/or describing how social media platforms can be used as a data source to understand tobacco-related attitudes and behaviors. Agencies that often cited this research were the WHO, FDA, and CDC. The document types included research reports, policy recommendations, industry guidance, legal complaints, and practice-based recommendations. CONCLUSIONS: Tobacco-related social media research has been utilized by government agencies in the last decade to guide the policy process. IMPLICATIONS: Tobacco-related social media research has been used in government policy documents to detail tobacco industry marketing and bring attention to youth exposure to protobacco content online. Continued surveillance of social media may be necessary to track the changing tobacco landscape.

Exploring the Influence of E-cigarette Ad Features on Perceived Product Appeal and Use Interest Among Young Adults of Varying Tobacco-Use Behaviors.

INTRODUCTION: Exposure to certain features in commercial e-cigarette ads may influence e-cigarette use perceptions. This study explored the reactions toward common features in e-cigarette ads among young adults of various tobacco-use behaviors. AIMS AND METHODS: We used data from in-depth interviews with U.S. young adults (ages 18-29) who do not use tobacco (n = 26) and who currently smoke cigarettes (n = 26). Participants viewed 30 print e-cigarette ads that included multiple features (eg, fruit flavors, price promotions, smoker-targeted messages) before discussing their perceived influence of memorable ad features. We used reflective thematic analysis to analyze interview data. RESULTS: Participants from both groups generally noticed fruit and multiple flavors displayed in the ads, which were seen as appealing and were reported to generate product-use interest because of bright colors, sensory appeal, and a variety of flavor options. Participants who smoke perceived price promotions and positive experience testimonials to be appealing, and some reported this generated use interest. Participants from both groups perceived smoker-targeted messages to be unconvincing, and reported this dampened ad and product appeal and use interest. Participants who do not use tobacco perceived nicotine warnings to be unappealing, resulting in reduced perceived appeal of other attractive features (eg, fruit flavors) appearing in the same ads. CONCLUSIONS: Marketing features appearing in e-cigarette ads may be perceived by young adults of various tobacco-use behaviors in both similar and different ways. Communication and policy strategies that account for these differential perceptions towards various marketing features are needed to reduce the negative impact of e-cigarette marketing. IMPLICATIONS: This study revealed evidence related to young adults' reactions to and perceived influence of commonly used marketing features (eg, fruit flavors, nicotine warnings, price promotions, smoker-targeted messages) in commercial e-cigarette ads. The results highlight the similar and differential perceived appeal and use interest of e-cigarette products promoted with various marketing features among young adults of different tobacco-use behaviors. The results have implications for informing the design of communication strategies and policies related to e-cigarette marketing aimed at promoting complete product switching among young adults who smoke while simultaneously deterring e-cigarette use interest among those who do not use tobacco.

American Indian Perspectives on Culturally Aligning a Digital Smoking Cessation Resource.

INTRODUCTION: Innovative smoking cessation approaches that overcome barriers such as traveling to program site or that require the staff and infrastructure for sustaining are likely needed to improve smoking quit rates among American Indian (AI) peoples in the United States. In this study, qualitative methods identified recommendations from AI peoples to guide alignment of an evidence-based smoking cessation smartphone app (i.e., QuitGuide) to the culture and needs of AI persons. METHODS: Semi-structured interviews were conducted with AI adults who smoke (n = 40) and with public health professionals (n = 6). Questions included: "The app asks if something triggered you to slip and lists several options. What options were you expecting to see on this list?" as well as how to make the app more engaging such as "What would make the app more helpful for AI peoples, like you, who want to quit smoking?." Constant comparative techniques were used to develop codes and themes. RESULTS: Loss, grief, and not accessing traditional tobacco were put forward as smoking triggers to be addressed in the app. Features that help users connect with and learn about AI cultures and promote healing, such as encouraging traditional tobacco use, being in community, embracing Native spirituality, and participating in cultural crafting were recommended. Some noted the need to motivate AI peoples to think about legacy and ability to care for younger generations and Indigenizing the app with Native imagery. CONCLUSIONS: Themes pointed towards promotion of strengths-based factors, such as healing, cultural connectedness and traditional tobacco use, in the app. IMPLICATIONS: Results will be used to culturally align a smartphone app for smoking cessation among AI peoples and may be insightful for other tribal, federal, and state public health efforts aimed at advancing health equity for AI peoples.

Tobacco Imagery in the 50 Most Popular Malaysian Movies Released During 2015-2019.

INTRODUCTION: Exposure to tobacco imagery creates a positive impression about smoking and is associated with youth smoking uptake. METHODS: From the list of movies released during 2015-2019, we selected the top 10 movies per year rated by the Malaysian Film Development Corporation. Two researchers coded tobacco imagery in each movie considering 5-minute time intervals as a unit. The 5-minute interval coding was adopted from previous research for comparability. Frequencies and the average occurrence of tobacco imagery were compared by movie language, genre, and age categorization. RESULTS: In 50 movies analyzed, there were a total of 1037 five-minute intervals of which 26 (52%) movies and 277 (26.7%) of intervals tobacco imagery were present. Brand appearances were absent and health warnings about tobacco use were present in just one movie. The proportions of intervals containing actual use, paraphernalia, and implied use were 63.5%, 22.0%, and 14.5%. Tobacco imagery of actual use, paraphernalia, and implied use was present in 25, 20, and 10 movies, respectively. In those movies with tobacco imagery, the average number of occurrences of actual use, paraphernalia, and implied use was 3 (interquartile range [IQR] 2-11.5), 2.5 (IQR 1.3-4.0), and 1 (IQR 1-4), respectively. Movies classified as "p13" (median 6, IQR 6-13) and "18" (median 5, IQR 0-15) had higher average occurrences of tobacco imagery than "U" movies (median 0, IQR 0-2; p = .028). CONCLUSIONS: The lack of health warnings despite the presence of tobacco imagery in Malaysian movies calls for measures to regulate tobacco-related content and reclassify such movies as "for adults-only." IMPLICATIONS: Tobacco imagery was prevalent in Malaysian movies that are allowed viewing by individuals aged 13 years and above. A review of the age categorization of Malaysian movies and the placement of health warnings in movies is needed. A comprehensive implementation of the ban on tobacco advertisements, promotion, and sponsorship should also include a ban on tobacco imagery in movies.