Developing a National Longitudinal Tobacco Cohort of Youth and Young Adults: The Tobacco Epidemic Evaluation Network (TEEN+) Study.

INTRODUCTION: Timely and relevant data are critical to monitoring the rapidly changing youth vaping epidemic and for understanding the prevalence, patterns of use, knowledge, and perceptions of tobacco products. While e-cigarettes have been the most used tobacco product among youth for nearly a decade, new nicotine delivery products continue to be introduced to the US market. Flavored tobacco products, including flavored e-cigarettes, menthol cigarettes, and flavored cigars, drive disparities in use by young people. AIMS AND METHODS: To examine tobacco use among youth and young adults, the Monitoring E-Cigarette Use among Youth project established a longitudinal cohort of youth and young adults (13-24)-the Tobacco Epidemic Evaluation Network (TEEN+) study. TEEN+ focuses on e-cigarette and other tobacco products use and also includes questions about other substance use (eg, marijuana, alcohol), physical health, mental health, and social determinants of health (eg, discrimination, poverty, sexual and gender identity). Geocoding of responses allows for the evaluation of local tobacco control policies. The cohort includes an oversample of California residents to generate reliable and representative state-level estimates. This manuscript provides an overview of methods and baseline demographics from Wave 1. RESULTS: The initial Wave 1 TEEN+ cohort included 10 255 in the national sample and 2761 in the California sample. CONCLUSIONS: TEEN+ study data complement nationally-representative cross-sectional studies and allow for rapid evaluation of local and state policies. This manuscript describes the study's probability-based sample recruitment. Furthermore, we identify this initiative as a resource for evaluating the impact of flavored tobacco restriction policies and informing policy implementation efforts. IMPLICATIONS: This manuscript provides an overview of the methodology and baseline characteristics for a new longitudinal cohort of youth and young adults, the Tobacco Epidemic Evaluation Network (TEEN+) study. The TEEN+ study data can be used to evaluate the impact of flavored tobacco product restriction policies and informing policy implementation efforts.

Chemical Composition of Electronic Vaping Products from School Grounds in California.

INTRODUCTION: The use of electronic vaping products (EVPs) containing nicotine, marijuana, and/or other substances remains prominent among youth; with EVPs containing nicotine being the most commonly used tobacco product among youth since 2014. However, a detailed understanding of the chemical composition of these products is limited. METHODS: During February 25th-March 15th, 2019, a total of 576 EVPs, including 233 e-cigarette devices (with 43 disposable vape pens) and 343 e-liquid cartridges/pods/bottled e-liquids, were found or confiscated from a convenience sample of 16 public high schools in California. Liquids inside 251 vape pens and cartridges/pods/bottled e-liquids were analyzed using a gas chromatography/mass spectrometry (GC/MS). For comparison, new JUUL pods, the most commonly used e-cigarette among youth during 2018-2019, with different flavorings and nicotine content were purchased and analyzed. RESULTS: For e-cigarette cartridges/pods/bottled e-liquids, nicotine was detected in 204 of 208 (98.1%) samples. Propylene glycol (PG) and vegetable glycerin (VG) were dominant solvents in nicotine-containing EVPs. Among 43 disposable vape pen devices, cannabinoids such as tetrahydrocannabinol (THC) or cannabidiol (CBD) were identified in 39 of 43 (90.1%) samples, of which 3 contained both nicotine and THC. Differences in chemical compositions were observed between confiscated or collected JUULs and purchased JUULs. Measured nicotine was inconsistent with labels on some confiscated or collected bottled e-liquids. CONCLUSIONS: EVPs from 16 participating schools were found to widely contain substances with known adverse health effects among youth, including nicotine and cannabinoids. There was inconsistency between labeled and measured nicotine on the products from schools. IMPLICATIONS: This study measured the main chemical compositions of EVPs found at 16 California public high schools. Continued efforts are warranted, including at the school-level, to educate, prevent and reduce youth use of EVPs.

Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021.

INTRODUCTION: This manuscript examines prevalence of awareness and use of nicotine pouches among U.S. middle and high school students by sociodemographic characteristics and other tobacco product use and characterizes nicotine pouch and other tobacco product use behaviors among current nicotine pouch users. AIMS AND METHODS: Data are from the 2021 National Tobacco Youth Survey, a cross-sectional, school-based survey of middle and high school students (N = 20 413; overall response rate: 44.6%), which included questions on nicotine pouches in 2021 for the first time. Prevalence estimates, 95% confidence intervals, and estimated population counts were assessed for nicotine pouch awareness, ever use, and current (past 30 days) use, and for use behaviors related to nicotine pouches (frequency of use, flavor(s) used) and other tobacco products (ever, current, frequency of use) among current nicotine pouch users. RESULTS: Over one-third of students (35.5%) had ever heard of nicotine pouches. An estimated 1.9% (490 000) reported ever using them, while 0.8% (200 000) reported current use. Among current nicotine pouch users, 61.6% reported flavored nicotine pouch use, 64.2% reported current e-cigarette use, and 52.6% used multiple (≥2) tobacco products. Current use of nicotine pouches was common among current smokeless tobacco users (41.3%). CONCLUSIONS: Overall, in 2021, while relatively few students had ever tried nicotine pouches or currently used them, more than one-third had heard of them. Current nicotine pouch users tended to use other tobacco products, particularly e-cigarettes and smokeless tobacco. Given previous rapid increases in youth uptake of e-cigarettes, it is important to continue monitoring nicotine pouch use among young people. IMPLICATIONS: This study's findings provide an important baseline for future monitoring of nicotine pouch awareness and use among middle and high school students. Emerging tobacco products, particularly those that are flavored, widely available, discreet, and inexpensive have the potential to attract youth. Given the potential of these products to appeal to young people, ongoing monitoring of nicotine pouch use behaviors is important to inform public health and regulatory efforts.

E-cigarette Unit Sales by Product and Flavor Type, and Top-Selling Brands, United States, 2020-2022.

E-cigarette products, related policies, and use patterns change rapidly. In the United States, the prevalence of e-cigarette use is markedly higher among youths and young adults than it is among adults overall. In 2021, 4.5% of all adults aged ≥18 years (an estimated 11.1 million) and 11.0% of young adults aged 18-24 years (an estimated 3.1 million) currently (≥1 day during the previous 30 days) used e-cigarettes; during 2022, 14.1% of high school students (an estimated 2.14 million) currently used e-cigarettes (1,2). E-cigarettes often contain high concentrations of nicotine. Nicotine is highly addictive and can harm the adolescent brain, which continues to develop through approximately age 25 years (3). Since 2020, the availability of e-cigarette products has changed in response to multiple factors, including local and state policies to address flavored e-cigarette sales, actions undertaken by the Food and Drug Administration (FDA), COVID-19-related closures, and global supply chain disruptions. To assess trends in unit sales of e-cigarettes in the United States, by product and flavor, and top-selling brands, the CDC Foundation, Truth Initiative,* and CDC analyzed retail scanner data during January 26, 2020-December 25, 2022, from Information Resources, Inc. (IRI), a U.S. data analytics and market research company. Overall, unit sales increased by 46.6% during the study period. The unit share of menthol-flavored product sales remained relatively stable during this period, whereas nonmenthol flavor unit shares changed. During January 26, 2020-December 25, 2022, unit shares of tobacco-flavored and mint-flavored products decreased (from 28.4% to 20.1% and from 10.1% to 5.9%, respectively), whereas shares of other flavor sales increased (from 29.2% to 41.3%). In addition, during January 2020-December 2022, unit shares of prefilled cartridges decreased from 75.2% to 48.0%, and disposable e-cigarette unit share increased from 24.7% to 51.8% of total unit sales. The five top-selling e-cigarette brands for the 4-week period ending December 25, 2022, were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. Analysis of information on e-cigarette retail sales can guide strategies to prevent youth access to and use of e-cigarettes, including restrictions on flavored tobacco products (4).

Electronic nicotine delivery system advertising in business-to-business publications, United States, 2015-2020.

INTRODUCTION: Tobacco retailers are a key target audience for tobacco product advertising, yet little is known about the messages and channels used to market electronic nicotine delivery systems (ENDS) to retailers. METHODS: We assessed expenditures for business-to-business print advertising for ENDS in the United States, by year and by advertiser, from 2015 to 2020; and the content of advertisements placed in 2020. RESULTS: The total number of ENDS brands placing business-to-business advertisements declined from 45 in 2015 to 6 in 2020; spending declined from $2.6 million in 2015 (for 283 occurrences) to $492,789 in 2020 (69 occurrences). Across years, the top-spending advertisers were Logic ($1.9 million), blu ($1.0 million), JUUL ($625,050), NJOY ($373,126) and Vuse ($322,075). Common messages of advertisements placed in 2020 included that products are not intended for minors; brand market share; health warnings; profitability or revenue potential for retailers; and flavours. DISCUSSION: This study suggests that ENDS companies anticipate that ENDS retailers are interested in stocking products that maximise profits, appeal to consumers and comply with regulatory requirements. Declines in the number of advertisers mirror the overall consolidation of the ENDS industry that occurred during the study period. CONCLUSIONS: Business-to-business print advertising represents an important channel in which ENDS brands communicate a variety of messages about their products directly to potential retailers.

Test-to-Stay Implementation in 4 Pre-K-12 School Districts.

OBJECTIVES: Globally, coronavirus disease 2019 (COVID-19) has affected how children learn. We evaluated the impact of Test to Stay (TTS) on secondary and tertiary transmission of severe acute respiratory syndrome coronavirus 2 and potential impact on in-person learning in 4 school districts in the United States from September 13 to November 19, 2021. METHODS: Implementation of TTS varied across school districts. Data on index cases, school-based close contacts, TTS participation, and testing results were obtained from 4 school districts in diverse geographic regions. Descriptive statistics, secondary and tertiary attack risk, and a theoretical estimate of impact on in-person learning were calculated. RESULTS: Fifty-one schools in 4 school districts reported 374 coronavirus disease COVID-19 index cases and 2520 school-based close contacts eligible for TTS. The proportion participating in TTS ranged from 22% to 79%. By district, the secondary attack risk and tertiary attack risk among TTS participants ranged between 2.2% to 11.1% and 0% to 17.6%, respectively. Nine clusters were identified among secondary cases and 2 among tertiary cases. The theoretical maximum number of days of in-person learning saved by using TTS was 976 to 4650 days across jurisdictions. CONCLUSIONS: TTS preserves in-person learning. Decisions to participate in TTS may have been influenced by ease of access to testing, communication between schools and families, testing logistics, and school resources. Tertiary attack risk determination became more complicated when numbers of close contacts increased. Minimizing exposure through continued layered prevention strategies is imperative. To ensure adequate resources for TTS, community transmission levels should be considered.

#Nicotineaddiction on TikTok: A quantitative content analysis of top-viewed posts.

INTRODUCTION: TikTok, the video-sharing app popular among youth, is a source of user-generated content about nicotine addiction with the potential to endorse or deter nicotine use among young viewers. We systematically analyzed content and themes of TikTok posts tagged #nicotineaddiction. METHODS: We conducted a quantitative content analysis of the visual and textual content of the 149 top-viewed English-language TikTok posts tagged #nicotineaddiction as of 1 March 2021. Posts were double-coded using a shared codebook, noting content creator characteristics, nicotine products featured, references to quitting, and overall themes of #nicotineaddiction expressed. We assessed the prevalence of post characteristics and themes overall and by apparent age of content creators (aged ≥21 years versus <21 years). RESULTS: The 149 posts analyzed received a mean and median of 62433 and 15800 likes, respectively. E-cigarettes were referenced or featured in 75% of posts; 58% featured a specific nicotine product brand, most commonly Puff Bar (23% of total) and JUUL (19%). Overall, 22% of posts mentioned quitting nicotine. The top themes of #nicotineaddiction expressed were physical or psychological consequences (e.g. withdrawal symptoms, 46%), physical or psychological benefits (e.g. tasting good, feeling 'buzzed', 28%), and social benefits (e.g. bonding with fellow users, 28%). Compared to those aged ≥21 years, posts by content creators likely <21 years (26%) less commonly mentioned quitting (p<0.01), had fewer followers (p<0.01), were more commonly from Canada (p<0.01) and less commonly from the US (p<0.01), and more commonly featured JUUL (p<0.05). CONCLUSIONS: While reaching a large and engaged audience, TikTok content creators suggest a range of benefits and consequences of nicotine addiction. Future research is warranted to examine this content's potential to influence young people's intentions to use or quit nicotine products.

ENDS advertising expenditures in English language media in the USA, 2015-2020.

BACKGROUND: Electronic nicotine delivery system (ENDS) advertising is associated with ENDS purchase and use. This study assessed trends in ENDS advertisement (ad) expenditures in the USA from 2015 to 2020 overall, by media channel and by advertiser. METHODS: Data came from Numerator, which conducts surveillance of ads and estimates expenditures. The estimates are dollars spent (adjusted to 2020) by the advertiser for each ad occurrence for print, radio, television and digital (online, mobile) media channels. ENDS ad expenditures were assessed by quarter, media channel and the top five advertisers based on ad occurrences. RESULTS: Overall ENDS ad expenditures increased from $38 million in 2015 to $217 million in 2019 before decreasing to a low of $22 million in 2020. By media channel, print expenditures led the channels with more than twice as much spent as television, four times more than radio and 10 times more than digital. By advertiser, JUUL led in ENDS ad expenditures from 2015 to 2020 with almost $189 million spent, followed by British American Tobacco (BAT, $105 million) and Imperial Tobacco ($62 million). CONCLUSIONS: Overall ad expenditures were relatively stable from 2015 to mid-2018 when large expenditures by JUUL and subsequent expenditures by BAT and Imperial Tobacco led to expenditure highs in 2019. E-cigarette and vaping-associated lung injury (EVALI), the JUUL self-imposed ad suspension and COVID-19 likely all played a role in advertising lows in 2020. The absence of popular Puff Bar brand ads from the traditional media channels studied highlights the importance of monitoring direct and indirect advertising on newer media channels like social media.

Presence of Nicotine Warning Statement on US Electronic Nicotine Delivery Systems (ENDS) Advertisements 6 Months Before and After the August 10, 2018 Effective Date.

INTRODUCTION: Effective in August 10, 2018, FDA requires advertisements for electronic nicotine delivery systems (ENDS) that meet the definition of a "covered tobacco product" to feature a standard nicotine warning statement. To date, limited data exist on the presence of warning statements in ENDS advertising. METHODS: We acquired ENDS ads (n = 459) that first ran six months before (February 10, 2018-August 9, 2018) and after (August 10, 2018-February 9, 2019) the effective date. The sample included online, print, and outdoor static ads (ie, without video or animated graphics) (n = 166 before, n = 198 after), online and television video ads (n = 16 before, n = 49 after), and radio ads (n = 9 before, n = 21 after). We coded ads for the presence of the verbatim FDA warning. Ads with verbatim warnings were coded for required formatting and additional features. RESULTS: Overall, 28% of static (n = 46/166), 62% of video (n = 10/16), and 67% of radio (n = 6/9) ads that ran before the effective date contained the verbatim warning versus 84% (n = 167/198, p < .001), 96% (n = 47/49, p = .002), and 86% (n = 18/21, p =.329) of ads that ran after, respectively. Following the effective date, nearly all static ads placed the warning as required at the top of the ad (76% [n = 35/46] before, 97% [n = 162/167] after, p < .001), and many video ads featured the warning statement for the entire ad duration (0% [n = 0/10] before, 60% [n = 28/47] after, p < .001). Half (n = 9/18) of radio warnings running after the effective date were read faster than the other promotional content. CONCLUSIONS: The presence of the nicotine warning statement on paid promotional static, video, and radio ENDS ads in this sample increased after August 10, 2018, but a notable number still lacked the warning. IMPLICATIONS: Results from this study provide initial insights into the extent to which required nicotine warning statements appear in ENDS ads in the study sample across traditional (eg, magazines, television, radio) and digital (eg, online/mobile ads) advertising mediums. Following the August 10, 2018, effective date, we observed a substantial increase in the presence of the required FDA warning statement on the ENDS ads in this sample. However, a notable number of ads in the study lacked the required warning and warnings did not always include the required formatting displays.

Characterization of Total and Unprotonated (Free) Nicotine Content of Nicotine Pouch Products.

INTRODUCTION: Nicotine pouch products, oral smokeless products that contain nicotine but no tobacco leaf material, have recently entered the US marketplace. Available data indicate sales of these products in the United States have increased since 2018; however, the extent of use among US youth and adults is uncertain. METHODS: To assay the chemistry of these emerging tobacco products, we analyzed 37 nicotine pouch brands from six total manufacturers. Almost all of the products had flavor descriptors (36 of 37), such as mint, licorice, coffee, cinnamon, and fruit. The amount of free nicotine, the form most easily absorbed, was calculated for each product using total nicotine, product pH, the appropriate pKa, and the Henderson-Hasselbalch equation. RESULTS: Nicotine pouch products varied in pouch content mass, moisture content (1.12%‒47.2%), alkalinity (pH 6.86‒10.1), and % free nicotine (7.7%‒99.2%). Total nicotine content ranged from 1.29 to 6.11 mg/pouch, whereas free nicotine ranged from 0.166 to 6.07 mg/pouch. These findings indicate that nicotine and pH levels found in some of these nicotine pouches are similar to conventional tobacco products, such as moist snuff and snus, and that most of these pouch products are flavored. CONCLUSIONS: Although these products likely lack many tobacco-related chemicals, each product analyzed contained nicotine, which is both addictive and can harm human health. Given that nicotine pouches may appeal to a spectrum of users, from novice to experienced users, it is important to include these emerging tobacco products in tobacco control research, policy, and practice. IMPLICATIONS: These "tobacco-free" nicotine pouches have similar pH and nicotine content to conventional tobacco products, such as moist snuff and snus. Although they lack many tobacco-related chemicals, most are highly flavored which could increase experimentation from new users. Given that nicotine pouches may appeal to a spectrum of users, from novice to experienced users, in terms of their flavors and nicotine content, it is important to examine and include these emerging tobacco products as they relate to tobacco control research, policy, and practice.

Chemical Composition of JUUL Pods Collected From Students in California High Schools.

PURPOSE: To examine the chemical composition of JUUL pods collected from a convenience sample of 16 high schools in California to identify possible consumer modification or counterfeit use. METHODS: Using Gas Chromatography-Mass Spectrometry, we quantitatively analyzed the nicotine, propylene glycol (PG), and vegetable glycerin (VG) in JUUL pods (n = 26) collected from California high schools and compared results to commercial 3% (n = 15) and 5% (n = 24) JUUL pods purchased online. RESULTS: Most of the collected JUUL pods (24/26 pods) had a nicotine concentration (43.3 mg/ml, 95% PI: 21.5-65.1) outside the prediction intervals (PI) of the 3% (33.5 mg/ml, 95% PI: 31.8-35.2) and 5% (55.0 mg/ml, 95% PI: 51.5-58.3) commercial JUUL pods. Most (73%) collected JUUL pods had VG concentrations (583.5 mg/ml, PI: 428.9-738.1) lower than the 3% (722.2 mg/ml, PI: 643.0-801.4) and 5% (710.5 mg/ml, PI: 653.1-767.8) commercial JUUL pods. CONCLUSIONS: Used JUUL products collected from high school students or found on school grounds were not chemically consistent with the manufacturer's stated formulations.

Association of e-cigarette advertising with e-cigarette and cigarette use among US adults.

AIMS: To estimate the association of e-cigarette advertisement exposure with e-cigarette and cigarette use behavior among US adults. DESIGN: Data from the 2013-14 National Adult Tobacco Survey (NATS) were linked to Kantar Media and National Consumer Study data to construct measures of e-cigarette advertisements on TV and in magazines. The relationship between advertisement measures and outcomes was estimated using logistic and Poisson regressions, controlling for socio-demographics, state cigarette taxes and state and year fixed-effects. SETTING: United States. PARTICIPANTS/CASES: A total of 98 746 adults aged ≥ 18 years who responded to the 2013-14 NATS. MEASUREMENTS: The independent variables of interest were the number of e-cigarette advertisements in magazines to which an adult was exposed in the past 6 months and the number of e-cigarette advertisements on TV to which an adult was exposed in the past 6 months. Outcomes were awareness of e-cigarettes, ever e-cigarette use, current e-cigarette use, current cigarette use and number of cigarettes smoked per month. FINDINGS: Exposure to one additional e-cigarette advertisement on TV was associated with a 0.18, 0.13 and 0.03 percentage point increase, respectively, in awareness, ever use and current use of e-cigarettes among all adults (P < 0.05). This exposure also was associated with a 0.11 percentage point increase in current cigarette use among all adults and an increase in cigarette consumption of 2.24 cigarettes per month among adults aged ≥ 45 (P < 0.05). CONCLUSIONS: Exposure to e-cigarette advertising appears to be positively associated with the use of e-cigarettes and cigarettes among adults of all ages, and with increased cigarette consumption among older adults.

Delay or Avoidance of Medical Care Because of COVID-19-Related Concerns - United States, June 2020.

Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19 (2). To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24-30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18-24 years versus adults aged 25-44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay (3).

E-cigarette advertising expenditures in the USA, 2014-2018.

BACKGROUND: Tobacco product advertising has been shown to reach youth and promote initiation. This study assessed trends in e-cigarette advertising expenditures in the USA during 2014-2018, overall and by manufacturer and media type. METHODS: Data came from Kantar Media, which provides information on US advertising expenditures, including for e-cigarettes. Advertising expenditures were estimated as the dollar amount spent by e-cigarette companies to purchase advertising space in print, television, Internet, radio and outdoors. Dollar amounts were adjusted to 2017 dollars. Trends in e-cigarette advertising expenditures during 2014-2018 were analysed using Joinpoint regression overall, by media type, and by manufacturers based on 2017-2018 national sales. RESULTS: Total e-cigarette advertising expenditures in print, radio, television, Internet and outdoors decreased substantially from US$133 million in 2014 to US$48 million in 2017, followed by an increase to US$110 million in 2018. By media type, expenditures were highest for print advertising, irrespective of year. By manufacturer, Altria had the highest e-cigarette advertising expenditures, totalling over US$134 million during 2014-2018. Imperial Tobacco had the second highest, totalling over US$85 million during 2014-2018, while JUUL Labs had the highest single-year expenditures, spending over US$73 million in 2018 alone. CONCLUSIONS: E-cigarette advertising expenditures have been volatile in the USA, with declines in traditional advertising venues during 2014-2017 that may reflect a shift towards social media. However, an increase occurred in 2018 that is likely reflective of advertising by newer manufacturers. Continued monitoring of e-cigarette advertising is important to inform tobacco control strategies.

State and Territorial Laws Prohibiting Sales of Tobacco Products to Persons Aged <21 Years - United States, December 20, 2019.

Raising the minimum legal sales age (MLSA) for tobacco products to 21 years (T21) is a strategy to help prevent and delay the initiation of tobacco product use (1). On December 20, 2019, Congress raised the federal MLSA for tobacco products from 18 to 21 years. Before enactment of the federal T21 law, localities, states, and territories were increasingly adopting their own T21 laws as part of a comprehensive approach to prevent youth initiation of tobacco products, particularly in response to recent increases in use of e-cigarettes among youths (2). Nearly all tobacco product use begins during adolescence, and minors have cited social sources such as older peers and siblings as a common source of access to tobacco products (1,3). State and territorial T21 laws vary widely and can include provisions that might not benefit the public's health, including penalties to youths for purchase, use, or possession of tobacco products; exemptions for military populations; phase-in periods; and preemption of local laws. To understand the landscape of U.S. state and territorial T21 laws before enactment of the federal law, CDC assessed state and territorial laws prohibiting sales of all tobacco products to persons aged <21 years. As of December 20, 2019, 19 states, the District of Columbia (DC), Guam, and Palau had enacted T21 laws, including 13 enacted in 2019. Compared with T21 laws enacted during 2013-2018, more laws enacted in 2019 have purchase, use, or possession penalties; military exemptions; phase-in periods of 1 year or more; and preemption of local laws related to tobacco product sales. T21 laws could help prevent and reduce youth tobacco product use when implemented as part of a comprehensive approach that includes evidence-based, population-based tobacco control strategies such as smoke-free laws and pricing strategies (1,4).

Self-reported exposure to, perceptions about, and attitudes about public marijuana smoking among US adults, 2018.

BACKGROUND AND AIMS: Eleven US states and the District of Columbia have legalized the non-medical use of marijuana. Public marijuana smoking is generally prohibited, although some states have considered exemptions. This study assessed attitudes about public marijuana smoking, perceptions of harm from marijuana second-hand smoke (SHS) and self-reported marijuana SHS exposure. DESIGN: Internet panel survey fielded in June-July 2018. SETTING: United States. PARTICIPANTS: US adults aged ≥ 18 years (n = 4088). MEASUREMENTS: Current (past-30 day) tobacco product use, current marijuana use, opinions about public indoor marijuana smoking, perceptions of harm from marijuana SHS and self-reported past-7 day exposure to marijuana SHS in public indoor or outdoor areas were assessed. Weighted prevalence estimates were computed and correlates were assessed using logistic and multinomial regression. FINDINGS: Overall, 27.4% [95% confidence interval (CI) = 25.7, 29.1] of adults reported past-week marijuana SHS exposure in indoor and/or outdoor public areas; younger adults, blacks, Hispanics, those in the Northeast or West, and current marijuana and/or tobacco users were more commonly exposed (Ps < 0.0001). More than half of adults (52.4%; 95% CI = 50.7, 54.2) regarded marijuana SHS as harmful, and most (81.0%; 95% CI = 79.5, 82.4) opposed public marijuana smoking. Correlates of favoring public marijuana smoking included being male, younger (Ps < 0.01), black or Hispanic, past-month tobacco and/or marijuana users and perceiving no/low harm from marijuana SHS (Ps < 0.0001). CONCLUSION: While one in four US adults report recent marijuana second-hand smoke exposure, a majority believe marijuana second-hand smoke is harmful and most oppose public marijuana smoking.