Associations Among Experiences With Racial Discrimination, Religion/Spirituality, and Cigarette Smoking Among African American Adults: The Jackson Heart Study.

BACKGROUND: African American adults exhibit disproportionately high rates of tobacco-related diseases and associated death. Experiences with racial discrimination contribute to health disparities among African Americans, but more research is needed to understand associations between perceived discrimination and tobacco use as well as potential protective factors. PURPOSE: This study examined associations between perceived racial discrimination and cigarette smoking, as well as religion and spirituality as moderators of any associations. METHODS: Cross-sectional data were drawn from the Jackson Heart Study, a study of cardiovascular disease risk factors among African American adults in Jackson, MS. Measures included perceived everyday discrimination and major life events discrimination that was attributed to race. Participants also reported religious attendance, prayer, spirituality, and whether they prayed in response to discriminatory experiences. Logistic regression models tested associations between perceived racial discrimination and cigarette smoking status, and interactions between religiosity/spirituality and discrimination in predicting smoking status. RESULTS: A total of 2,972 participants were included in the analysis (62.7% female, mean age 55.1 years). Thirteen percent reported currently smoking cigarettes. Everyday racial discrimination was associated with a higher likelihood of current smoking (p = .01). The association between lifetime racial discrimination and current smoking status was weaker for those who reported prayer as a reaction compared to those who did not report prayer as a reaction (adjusted odds ratio = 0.32, 95% confidence interval: 0.11 to 0.91) while adjusting for demographics and covariates. CONCLUSIONS: Stressful experiences with racial discrimination may create risks for health behaviors like smoking. However, prayer may act as a coping strategy to help buffer the effects of racial discrimination on smoking behavior.

Examining longitudinal associations between initial perceptions and experiences with electronic nicotine delivery system (ENDS) use and use patterns among adults who smoke and recently initiated ENDS.

INTRODUCTION: Limited data exist on factors associated with concurrent use patterns of electronic nicotine delivery systems (ENDS) and cigarettes. We examined longitudinally perceptions and experiences with ENDS in relationship to concurrent use patterns among established, recent smokers who recently initiated ENDS. METHODS: Participant recruitment took place using paid digital advertisements on social media. Between December 2020 and October 2021, 303 adults aged ≥21 years from across the US who currently or recently smoked and had initiated ENDS use within the past 30 days or reinitiated ENDS use after more than one year of non-use were surveyed. Multinomial logistic regressions were conducted to analyze association between the outcome of current use pattern at follow-up at 1 month [rejectors (discontinued ENDS, continued smoking), primary smokers (concurrent users, mostly smoke), dual user (similar smoking and ENDS use), primary vapers (concurrent users, mostly vape), and switchers (discontinued smoking, continued using ENDS) or quitters (discontinued both smoking and ENDS] and perceptions of and experiences with ENDS predictors at baseline. RESULTS: At follow-up at 1 to 2 months after initiating ENDS, 20% were rejectors, 31% were primary smokers, 13% were dual users, 19% were primary vapers, and 17% were switchers/quitters. Perceiving ENDS as less harmful than smoking or being uncertain and as equally or more enjoyable smoking, experiencing a lot or complete reduction in cravings to smoking and in irritability with ENDS use, liking the taste of ENDS, and being satisfied with vaping were associated with higher odds of quitting smoking compared to rejecting ENDS or mostly smoking at follow-up at 1 month. CONCLUSIONS: Findings highlight the importance of initial ENDS perceptions and experiences when examining tobacco outcomes and potentially for developing policies and interventions targeting smoking cessation. ENDS initiators are differentiating into distinct use patterns based on these factors within a short period of time.

Content analysis of IQOS direct mail and email marketing in the US.

Objective: Novel nicotine and tobacco products, including heated tobacco products (HTPs) like IQOS, are growing in global popularity. IQOS was the first HTP authorized for sale by the US Food and Drug Administration, entering the US market in 2019 and being removed in 2021 due to patent-related legal challenges, with the possibility of returning in 2024. Direct marketing is one method tobacco companies use to reach consumers of these products. The purpose of this study was to investigate the content of US IQOS direct mail and email marketing. Methods: Direct marketing items were collected between September 2019 and July 2021 by seven team members in the first US IQOS test market, Atlanta, Georgia. Results: Overall, 101 marketing items were collected, 59 of which were unique. Among the unique items that showed images of persons ("models"), 70 % showed models appearing to be from racial/ethnic minoritized groups, 86.8 % showed at least one female-presenting model, and 37.5 % showed models appearing to be young adults (18-29 years). Items often had an embedded link/URL (91.5 %) and mentioned topics such as online services (54.2 %; for example, online ordering and tutorials), user experience (49.2 %), social media (44.1 %), and purchasing locations (37.3 %). When examined for their main purpose, items focused on subjects such as store experience (37.7 %), product introduction (18.6 %), and product use (15.3 %). Conclusions: Our study highlights the importance of better understanding how novel tobacco products are marketed, which can inform policymakers' regulatory efforts and product authorization decisions.

Reply to Foxon, F.; Shiffman, S. Comment on "Wang et al. Consumption of JUUL vs. Other E-Cigarette Brands among U.S. E-Cigarette Users: Evidence from Wave 5 of the PATH Study. Int. J. Environ. Res. Public Health 2022, 19, 10837".

In this reply, we respond to the comments by Foxon and Shiffman [...].

Cigarette Coupon Receipt and Smoking Relapse by Duration of Smoking Abstinence.

INTRODUCTION: It is unknown whether and to what extent the duration of smoking abstinence may modify the association between receiving cigarette coupons and smoking relapse in the U.S. This study aims to fill this gap. METHODS: Data were from the Population Assessment of Tobacco and Health study Wave 4 (December 2016-January 2018, baseline) and Wave 5 (December 2018-November 2019, follow-up) surveys. Analysis was conducted in May 2022. The study sample was participants who formerly smoked cigarettes at baseline (N=5,186). The exposure was past 12-month receipt of cigarette coupons (yes/no) at baseline, and the outcome was cigarette smoking relapse (yes/no) at follow-up. A potential modifier was the duration of smoking abstinence (within/>1 year) at baseline. Baseline single-wave weights were applied, and a multivariable logistic regression model was used to estimate the adjusted association. Interaction between cigarette coupon receipt and duration of smoking abstinence was examined to explore potential modification effects. RESULTS: Participants who received cigarette coupons at baseline were more likely to relapse at follow-up (AOR=1.63, 95% CI=1.15, 2.32). This association was significantly stronger among participants who quit within 1 year than among participants who quit >1 year at baseline (AOR for the interaction term=2.77, 95% CI=1.22, 6.25). Subgroup analysis shows that receipt of cigarette coupons was significantly associated with smoking relapse among participants who quit within 1 year (AOR=2.10, 95% CI=1.39, 3.17), and this association was not statistically significant among participants who quit >1 year (AOR=0.76, 95% CI=0.36, 1.63). CONCLUSIONS: Policies restricting cigarette coupons may help adults who recently quit sustain abstinence.

Consumption of JUUL vs. Other E-Cigarette Brands among U.S. E-Cigarette Users: Evidence from Wave 5 of the PATH Study.

This study examines the use of JUUL vs. other e-cigarette brands among U.S. youth (12-17 years), young adult (18-24 years), and adult (25 years and above) e-cigarette users. Data were from the Population Assessment of Tobacco and Health (PATH) study Wave 5 survey (2019). The study population was past 30-day e-cigarette users who knew the brand of e-cigarettes they usually/last used (N = 2569). JUUL use was reported by 65.2% of youth, 60.7% of young adult, and 25.6% of adult e-cigarette users in our study sample. The share of JUUL consumed in the past 30 days, measured by the total number of puffs, was 15.4% by youth, 55.5% by young adults, and 29.1% by adults. By contrast, the share of other e-cigarettes consumed was 4.2% by youth, 28.9% by young adults, and 66.9% by adults. Youth JUUL users were more likely to use e-cigarettes within 30 min after waking (aOR = 2.30, 95% CI: 1.12-4.75) than youth users of other brands of e-cigarettes. Additionally, youth e-cigarette users who currently smoked cigarettes were less likely to use JUUL (aOR = 0.55, 95% CI: 0.30-0.99). This study concludes that JUUL consumption was disproportionally higher among youth and young adults in the U.S. in 2019.

"When I Don't Have a Cigarette It's Helpful, but It Really Don't Satisfy:" Qualitative Study of Electronic Nicotine Delivery Systems (ENDS) Use among Low-Income Smokers.

BACKGROUND: Little is known about the use of electronic nicotine delivery systems (ENDS) among low-income adult cigarette smokers, who experience severe tobacco-related health disparities. METHODS: This study conducted interviews to examine experiences and perceptions associated with ENDS use among predominantly low-income adult smokers (n = 30; mean age 30.2 ± 12.9; 60% male, 46.7% African American, 30% white, 10% more than one race; 76.7% annual household income ≤USD 24,000). Interviews were transcribed verbatim and coded in NVivo 11. RESULTS: Overall, participants reported complementing rather than substituting their smoking with ENDS use (e.g., using ENDS only when smoking is not allowed). Predominant reasons for vaping were convenience, smoking reduction/cessation, stress management, social acceptability, lower long-term costs than smoking, and appealing flavors. Common reasons for not switching to exclusive vaping were that ENDS did not satisfy cigarette cravings and concerns about ENDS health effects. Participants indicated higher likelihood of switching to exclusive ENDS use if the products were more affordable, perceived as substantially less harmful, tasted and felt more like smoking a cigarette, and more effective for reducing cravings. CONCLUSIONS: Continued research is needed to maximize any harm reduction potential of ENDS and ensure that these products do not contribute to worsening health disparities.

What Motivates Smokers to Switch to ENDS? A Qualitative Study of Perceptions and Use.

Switching completely from cigarettes to electronic nicotine delivery systems (ENDS) may reduce health risks for addicted smokers. This paper provides information about perceptions and other factors that may influence smokers' ENDS use and substitution for cigarettes. We conducted 12 online focus groups (N = 61) among smokers who had never tried using ENDS (Never Users, N = 11), currently used both cigarettes and ENDS (Dual Users, N = 21), used but discontinued ENDS (Rejectors, N = 14), and switched completely to ENDS use (Switchers, N = 15). Thematic analysis was used to interpret the transcripts. Participants described initial interest in trying ENDS in hopes of quitting smoking and because of convenience (i.e., due to rules, regulations, or social norms). Risk perceptions and higher prices relative to cigarettes were reported as disadvantages of ENDS that discouraged initiation. Dual Users and Rejectors reported product problems (e.g., products breaking) and dissatisfaction (i.e., inability to satisfy cravings for cigarettes) as factors that lowered their substitutability for cigarettes or led to discontinuing ENDS use. Switchers indicated that satisfaction, lack of product problems, and perceived safety facilitated successfully switching from cigarette smoking to exclusive ENDS use. However, Switchers reported trying many products before they found ones that satisfied their needs. We recommend that policymakers consider the potential impact of tobacco control policies on smokers' motivation and ability to switch completely from cigarettes to ENDS.

Use of and perceptions about electronic nicotine delivery systems (ENDS) among people with mental health conditions or serious psychological distress, 2018.

BACKGROUND: People with mental health conditions (MHC) experience health disparities related to combustible tobacco use, and recent studies suggest disproportionately high use of electronic nicotine delivery systems (ENDS, e.g., e-cigarettes) among adults with MHC. Continued surveillance of ENDS use by MHC status is needed, as well as in-depth examinations of why adults with versus without MHC are using ENDS. METHODS: Using 2018 U.S. nationally representative data (N = 5878), this study examined associations between MHC and serious psychological distress (SPD) with ENDS use. Among current ENDS users (n = 544), associations between MHC and SPD with perceived benefits and reasons for using ENDS were also investigated. RESULTS: Both MHC and SPD were associated with higher likelihood of having ever used ENDS, currently using ENDS, and currently using ENDS daily. There was an interaction between SPD and smoking status in predicting current ENDS use such that the association between SPD and higher current ENDS use was stronger among never smokers. Compared to those without MHC, participants with MHC indicated that using ENDS helped them feel more relaxed and that stress management was a more important reason for ENDS use. CONCLUSIONS: U.S. adults with MHC (and particularly never smokers with SPD) report disproportionately high use of ENDS. Individuals with MHC may be particularly likely to use ENDS for relaxation and stress management.

What are the reasons that smokers reject ENDS? A national probability survey of U.S. Adult smokers, 2017-2018.

BACKGROUND: The objective was to examine the reasons smokers have discontinued or chosen not to use electronic nicotine delivery systems (ENDS). METHODS: Data were obtained from a national probability sample of 1843 US adult current smokers who were not current ENDS users pooled from the 2017 and 2018 annual, cross-sectional Tobacco Products and Risk Perceptions Surveys. Participants reported their ENDS use, reasons for discontinuing or not initiating ENDS use, quit smoking intentions, perceptions, and use intentions. Weighted proportions and logistic regression models were estimated. RESULTS: Twenty-three percent of smokers were former ENDS users who reported prior "regular use", and 7.5% were former ENDS users who reported regular use. Three most cited reasons for discontinuing ENDS were: ENDS "didn't feel like smoking" (23%), "only ever tried them to see what they were like" (20%), and "didn't help me deal with cravings for smoking" (14%). Reasons for discontinuing ENDS were associated with the regularity of former ENDS use and ENDS type. Nearly 40% of current smokers had not tried ENDS with the most commonly cited reasons being not wanting to substitute one addiction for another (60%), concerns about their safety (53%), skepticism that ENDS could help them quit smoking (52%), and cost (43%). Reasons were associated with smoking quit intentions, harm perceptions, and age. CONCLUSION: Whereas smokers who had formerly used ENDS cited inadequate craving reduction or incomparability to smoking for their discontinuation, the larger segment of smokers who have never used ENDS cited "safety," "effectiveness," and "costs" as reasons for non-use.

Patterns and trends of dual use of e-cigarettes and cigarettes among U.S. adults, 2015-2018.

INTRODUCTION: If dual use of cigarettes and e-cigarettes is a transition state to tobacco and nicotine use cessation, it may be a tolerable temporary condition. But, if a long-term behavior, dual use may increase tobacco harm to the population as a whole, and efforts should aim to reduce it as much as possible. To develop effective tobacco control policy, the changes in dual use of e-cigarettes and cigarettes need to be better understood. METHODS: National probability samples of U.S. adults in 2015 (n = 6051), 2016 (n = 6014), 2017 (n = 5992), and 2018 (n = 5989) reported their smoking and e-cigarette use status, including frequency of use. Weighted multinomial logistic regression models were used to examine temporal trends and patterns of cigarette and e-cigarette use. RESULTS: Between 2015 and 2018, the prevalence of current e-cigarette use (29.8% in 2015, 22.3% in 2016, 29.1% in 2017, and 27.7% in 2018) did not change significantly among current smokers. This result was consistent among light, moderate, and heavy smokers, and did not change when stratified by sex, age and race. However, the prevalence of cigarette smoking in current e-cigarette users declined from 56.9% in 2015 to 40.8% in 2018 (p < 0.001). Among never (p = .012) and former (ps < 0.001) smokers the prevalence of current e-cigarette use increased significantly. CONCLUSION: The continued high prevalence of dual use and increased prevalence of current e-cigarette use among never smokers highlight the need for better communication about the risks of prolonged dual use for e-cigarette users, and the risks of nicotine initiation and addiction for nonusers.

Sociodemographic Correlates of Electronic Nicotine Delivery Systems (ENDS) Use in the United States, 2016-2017.

Objectives. To investigate use of electronic nicotine delivery systems (ENDS) among priority populations.Methods. Using 2016 through 2017 US nationally representative surveys (n = 11 688), we examined ENDS use by sociodemographic variables (age, education, poverty status, insurance, employment, race/ethnicity, sexual orientation) and combustible tobacco use.Results. Among individuals who currently use noncigarette combustible tobacco, those from certain backgrounds (young adults, those living below the poverty level, those less educated, sexual minorities, Blacks, Hispanics, and those without health insurance) were more likely to use ENDS. Among current cigarette smokers, those who were younger, living at or above poverty (ever use), with higher education (current use), sexual minority, and non-Black were more likely to use ENDS.Conclusions. Associations between sociodemographic variables and ENDS use varied depending on combustible tobacco use status, highlighting the need to consider multiple types of tobacco products to understand ENDS use among priority populations. The impact on tobacco disparities will ultimately depend on whether ENDS are used to transition completely away from combustible tobacco products and how this may differ across priority populations who use diverse tobacco products.

Changing Perceptions of Harm of e-Cigarette vs Cigarette Use Among Adults in 2 US National Surveys From 2012 to 2017.

Importance: Debate is ongoing about whether the scientific evidence of the health risks of electronic cigarettes (e-cigarettes) compared with combustible cigarettes (hereinafter referred to as cigarettes) has been accurately communicated to the public. Large representative surveys are needed to examine how the public perceives the health risk of e-cigarettes and how their perceptions change over time. Objective: To examine how US adults perceived the harm of e-cigarettes relative to cigarettes and how their perception has changed from 2012 to 2017. Design, Setting, and Participants: Survey study using data from 2 multiyear cross-sectional nationally representative surveys-the Tobacco Products and Risk Perceptions Surveys (TPRPS) and the Health Information National Trends Surveys (HINTS)-to assess perceived harm of e-cigarettes relative to cigarettes among US adults in 2012, 2014, 2015, 2016, and 2017. Respondents were selected via address-based sampling or random-digit dialing and consisted of adults 18 years or older. Analyses were conducted from February through April 2018. Main Outcomes and Measures: Self-reported perceived harm of e-cigarettes relative to cigarettes. Results: The analytical samples of TPRPS consisted of 2800 adults in 2012 (cumulative response rate, 7.3%), 5668 in 2014 (cumulative response rate, 6.6%), 5372 in 2015 (cumulative response rate, 6.8%), 5245 in 2016 (cumulative response rate, 6.4%), and 5357 in 2017 (cumulative response rate, 5.8%). The analytical samples of HINTS consisted of 2609 adults in 2012 (response rate, 39.9%), 3301 in 2014 (response rate, 34.4%), 2224 in 2015 (response rate, 33.0%), and 2683 in 2017 (response rate, 32.4%). The proportion of adults who perceived e-cigarettes as less harmful than cigarettes decreased from 39.4% (95% CI, 36.9%-41.9%) in 2012 to 33.9% (95% CI, 32.7%-35.2%) in 2017 in TPRPS and decreased from 50.7% (95% CI, 48.8%-52.7%) in 2012 to 34.5% (95% CI, 32.7%-36.3%) in 2017 in HINTS. During the same period, the proportion of adults who perceived e-cigarettes to be as harmful as cigarettes increased from 11.5% (95% CI, 10.0%-13.2%) in 2012 to 36.4% (95% CI, 35.1%-37.7%) in 2017 (TPRPS) and from 46.4% (95% CI, 44.5%-48.3%) in 2012 to 55.6% (95% CI, 53.7%-57.5%) in 2017 (HINTS). Those who perceived e-cigarettes to be more harmful than cigarettes increased from 1.3% (95% CI, 0.8%-2.2%) in 2012 to 4.3% (95% CI, 3.8%-4.9%) in 2017 (TPRPS) and from 2.8% (95% CI, 2.2%-3.5%) in 2012 to 9.9% (95% CI, 8.8%-11.1%) in 2017 (HINTS). Conclusions and Relevance: In this study, the proportion of US adults who perceived e-cigarettes to be as harmful as or more harmful than cigarettes increased substantially from 2012 to 2017. The findings of this study underscore the urgent need to accurately communicate the risks of e-cigarettes to the public, which should clearly differentiate the absolute from the relative harms of e-cigarettes.

Use of other combustible tobacco products among priority populations of smokers: Implications for U.S. tobacco regulatory policy.

Certain sub-populations (e.g., those living in poverty, racial/ethnic minorities, sexual minorities, and people with mental health conditions) experience profound tobacco-related health disparities. Ongoing surveillance of use of various combustible tobacco products by priority populations of cigarette smokers is needed, particularly in the changing U.S. tobacco regulatory landscape. In 2018 the FDA announced their consideration of a tobacco product standard that would limit the level of nicotine in combustible cigarettes, and such regulations should consider potential effects on tobacco-related disparities. If certain subgroups of cigarette smokers are also using other combustible products, they may be particularly likely to continue dual use or switch to exclusive use of those products if a nicotine reduction standard only applies to cigarettes. Accordingly, this study provided recent U.S. nationally representative data on use of other combustible tobacco products among current cigarette smokers by sociodemographic characteristics. Data were drawn from current cigarette smokers (n = 2559) in 2016 and 2017 U.S. nationally representative surveys. Associations between sociodemographic variables (poverty status, education, race/ethnicity, sexual orientation, and mental health status) with use of little cigars and cigarillos (LCCs), traditional cigars, and hookah were examined. Among current cigarette smokers, those living in poverty, racial/ethnic minorities, and those with mental health conditions were particularly likely to use LCCs. Racial/ethnic minority smokers were more likely to smoke traditional cigars. Non-heterosexual smokers, Hispanic smokers, and smokers with mental health conditions were particularly likely to use hookah. These findings have important implications for tobacco regulatory policy and other efforts to combat tobacco-related disparities.

Electronic nicotine delivery system (ENDS) use in relation to mental health conditions, past-month serious psychological distress and cigarette smoking status, 2017.

BACKGROUND AND AIMS: Adults with mental health conditions (MHC) exhibit disproportionately high smoking prevalence and experience profound tobacco-related disparities. US nationally representative surveys from 2012 to 2015 found relatively high usage of electronic nicotine delivery systems (ENDS; e.g. e-cigarettes) among adults with MHC. However, research has not examined these associations specifically among never smokers. Aims were to examine associations among MHC diagnosis, serious psychological distress (SPD) and ENDS use and to test whether associations varied by cigarette smoking status. DESIGN: Cross-sectional US nationally representative survey. SETTING: United States, 2017. PARTICIPANTS: A total of 5762 adults (52.0% female; 64.8% non-Hispanic white, 11.4% non-Hispanic black, 15.9% Hispanic, 7.9% non-Hispanic other). MEASUREMENTS: Outcomes were lifetime, current and current daily ENDS use. Predictors were lifetime MHC, past-month SPD and cigarette smoking status, and covariates were gender, age, race/ethnicity, education and annual household income. FINDINGS: lifetime MHC and past-month SPD were each associated with higher likelihood of having ever used ENDS (P ≤ 0.001), currently using ENDS (P ≤ 0.001) and currently using ENDS daily (P < 0.05). There were interactions between MHC and smoking status in predicting ENDS use, such that MHC status predicted higher lifetime and current ENDS use specifically among never and current smokers. Never smokers with MHC had 2.62 higher odds [95% confidence interval, (CI) = 1.54, 4.45] of current ENDS use than those without MHC. Among never smokers, those with MHC indicated higher expectations that ENDS would improve relaxation and concentration (P < 0.05). CONCLUSIONS: In 2017, US adults with versus without mental health conditions (MHC) were more likely to use electronic nicotine delivery systems (ENDS). In particular, both never and current smokers with MHC reported disproportionately high rates of current ENDS use.

A National Comparison of Dual Users of Smokeless Tobacco and Cigarettes and Exclusive Cigarette Smokers, 2015-2016.

Introduction: While smoking rates have declined, use of smokeless tobacco (ST) has remained constant. ST is heavily marketed to cigarette smokers, and many ST users smoke cigarettes. This study provides updated comparisons of the characteristics, smoking behaviors, and perceptions of US adult dual ST and cigarette users and exclusive cigarette smokers in 2015-2016. Methods: Data were from nationally representative, cross-sectional surveys from 2015 and 2016. Adult smokers reported past 30-day use of ST, current cigarette smoking, risk perceptions, smoking, and quitting behaviors. We estimated Rao-Scott χ2 and adjusted odds ratios (AORs) to compare dual users and exclusive smokers. Results: Dual users were more likely to be younger, reside in nonmetropolitan statistical areas (MSA) and outside the Northeast United States. Adjusting for covariates, dual users did not differ significantly from exclusive smokers on most smoker characteristics, including number of past year quit attempts. Dual users were more likely to report past 30-day use of novel tobacco products (AORs 2.90 [little cigars and cigarillos] to 11.02 [hookah]). Dual users who reported at least 1 past year cigarette quit attempt were more likely than exclusive smokers to report using ST, traditional cigars, hookah, or heat-not-burn as a past year quit method (AOR: 9.54 [95% CI: 3.22 to 28.23]). Conclusions: Smokers who use ST are more likely than exclusive smokers to attempt to quit smoking cigarettes using other tobacco products. These findings may be attributed to increasing use prevalence of novel products. We recommend further monitoring to assess polytobacco use and differences among these populations. Implications: Many current ST users smoke cigarettes and ST promotions often target cigarette smokers. As the FDA considers ST regulations and implements a nicotine centered regulatory framework, it is imperative to evaluate how these policies and promotion of ST as potentially reduced risk products impact dual and polytobacco use. Our study found that many dual users engage in novel tobacco use in general and as a cessation method. Consideration of ST and polytobacco use among smokers may be helpful in the development of forthcoming FDA regulations, messaging, and interventions.

Awareness and use of heated tobacco products among US adults, 2016-2017.

INTRODUCTION: Although heated tobacco products (HTP) have been on and off the commercial market for the past three decades (eg, Premier, Eclipse and Accord), they have not received widespread consumer acceptance as an alternative to combustible cigarettes. This may change with recent product innovations, shifts in consumer preferences and the tobacco market landscape and a US regulatory environment that may permit an internationally available HTP to be sold in the USA, possibly with a reduced exposure or risk statement. This study examined the extent of awareness and use of HTP in the USA and assessed the characteristics of those aware of and using these products. METHODS: Data came from the 2016 and 2017 Tobacco Products and Risk Perceptions Surveys of national probability samples of US adults, conducted online during September-October 2016 (n=6014) and August-September 2017 (n=5992). Weighted χ2 tests and regression analyses examined changes in awareness and use of HTP between 2016 and 2017 and characteristics associated with awareness and use. RESULTS: From 2016 to 2017, awareness of HTP among US adults increased from 9.3% to 12.4% (p<0.001), ever use increased from 1.4% to 2.2% (p=0.005) and current use increased two fold, from 0.5% to 1.1% (p=0.004). Men and adults under age 45 years had higher rates of awareness than women and those 45 and older, respectively. Non-white adults, cigarette smokers and both current and former users of electronic nicotine delivery systems were more likely to be using HTP. CONCLUSIONS: Awareness and use of HTP in the USA are increasing. These products are more familiar to men and younger adults and may be being used disproportionately by racial/ethnic minorities. With increases in HTP availability and the potential for reduced-risk claims ahead, surveillance of patterns and consequences of use by both smokers and non-smokers is needed.

Adults' Perceptions of Nicotine Harm to Children.

BACKGROUND: Given the changing landscape of tobacco products in recent years, the array of products through which children could be exposed to nicotine has grown substantially. Thus, it is particularly important to understand adults' perceptions of the harms of nicotine to children and to identify any sociodemographic factors related to inaccurate risk perceptions. METHODS: Data were drawn from 2015 to 2016 US nationally representative surveys (n = 11 959). Using multinomial logistic regression analyses, we examined whether race, sex, education, tobacco product use, and having a minor child in the home are associated with the level of perceived harmfulness of nicotine to children. RESULTS: Although the majority of respondents characterized nicotine as "definitely harmful" to children, there were notable subgroup differences. Compared with women, men had significantly lower odds of characterizing nicotine as "definitely harmful" to children. Tobacco product users had significantly lower odds of endorsing "definitely harmful" or "don't know" than nonusers. African American non-Hispanic individuals, Hispanic individuals, and "other" non-Hispanic individuals had significantly lower odds of endorsing "definitely harmful" or "maybe harmful" than white individuals. CONCLUSIONS: Although most adults perceive nicotine exposure as harmful for children, there are important differences based on sex, racial and/or ethnic background, and tobacco use status. The results reveal the need for public health efforts to better understand and target inaccurate risk perceptions among specific subgroups.