Waterpipe Tobacco Brands and Flavors Sold Online in the USA.

INTRODUCTION: Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies. METHODS: We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder. RESULTS: We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2953 flavors, including 1871 unique flavors. Brands averaged 45 flavors (range: 1-183). Almost three quarters (73.5%, n = 2171) used explicit flavor names and 26.5% (n = 782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%). CONCLUSIONS: WT is available in 1871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Household Food Insecurity Is Associated With Physical Activity in Youth and Young Adults With Diabetes: A Cross-Sectional Study.

BACKGROUND: Physical activity (PA) is essential for optimal diabetes management. Household food insecurity (HFI) may negatively affect diabetes management behaviors. The purpose of this study was to cross-sectionally examine the association between HFI and PA in youth and young adults (YYA) with type 1 (N = 1998) and type 2 (N = 391) diabetes from the SEARCH for Diabetes in Youth Study. METHODS: HFI was measured with the US Household Food Security Survey Module. PA was measured with the International Physical Activity Questionnaire Short Form. Walking, moderate-intensity PA (excluding walking), vigorous-intensity PA, moderate- to vigorous-intensity PA, and total PA were estimated as minutes per week, while time spent sitting was assessed in minutes per day. All were modeled with median regression. Meeting PA guidelines or not was modeled using logistic regression. RESULTS: YYA with type 1 diabetes who experienced HFI spent more time walking than those who were food secure. YYA with type 2 diabetes who experienced HFI spent more time sitting than those who were food secure. CONCLUSIONS: Future research should examine walking for leisure versus other domains of walking in relation to HFI and use objective PA measures to corroborate associations between HFI and PA in YYA with diabetes.

The Development and Testing of a Point-of-Sale E-Cigarette Health Communication Campaign.

Adolescents and young adults continue to use e-cigarettes, and communication campaigns are needed to decrease use among these populations. We developed and tested a point-of-sale communication campaign focused on e-cigarette chemical exposure. We developed messages based on formative research and tested them (versus text-only messages) in a nationally-representative online survey among adolescents and young adults (16-25) (Phase 1). Based on survey findings, we selected a message focused on nicotine and brain development for the point-of-sale trial (Phase 2). We then conducted a cluster-randomized trial at six gas stations with convenience stores, randomly assigned to the intervention (messages displayed) or no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 participants (ages 16-25) per store, at baseline and a four-week follow-up. Phase 1 included 1,636 participants in the online study. Intervention messages were rated as more attention grabbing than plain text messages (p < .05), though were rated similarly on other outcomes. Exposure to intervention messages resulted in larger changes from pre- to posttest for beliefs about addiction and relative harms versus cigarettes (p < .05). Phase 2 included 586 participants in the point-of-sale study. Real-world campaign exposure was low (31.8%), and no differences were found between conditions. E-cigarette prevention messages focused on nicotine's impact on brain development show promise. However, garnering attention for communication campaigns in saturated point-of-sale environments, often dominated by tobacco advertising, is challenging. Future efforts should utilize additional communication channels to directly target adolescents and young adults.

Associations of polygenic risk scores for smoking heaviness and lifetime cannabis use with tobacco and cannabis co-use trajectories among African Americans.

BACKGROUND: We aimed to identify distinct trajectories of tobacco, cannabis, and their co-use among African Americans, and to investigate whether these patterns were associated with polygenic risk scores (PRS) for tobacco and cannabis use. METHOD: Participants (N=428 participants; 50.9% male) were initially recruited for an elementary school-based prevention in a Mid-Atlantic city when they were in first grade. From ages 14-26, participants reported on their frequency of tobacco and cannabis use in the past year during annual assessments. DNA was collected from participants at age 21. PRS for smoking heaviness (i.e., cigarettes per day) and lifetime cannabis use were created based on genome-wide association study results derived from Liu et al. (2019) and Pasman et al. (2018), respectively. RESULTS: We identified five distinct trajectories of tobacco and cannabis co-use, including (1) Low Tobacco and Cannabis Use, (2) Adolescent Limited Tobacco and Cannabis Use, (3) Experimental Cannabis, Young Adult Increasing Tobacco, (4) Experimental Tobacco, Young Adult Increasing Cannabis, and (5) High, Chronic Tobacco and Cannabis Use. Compared to the Low Tobacco and Cannabis Use subgroup, individuals in the High, Chronic Tobacco and Cannabis Use subgroup had greater PRS for smoking heaviness, and individuals in the Experimental Cannabis, Young Adult Increasing Tobacco subgroup had higher PRS for lifetime cannabis use. CONCLUSIONS: Polygenic risk for lifetime cannabis use and smoking heaviness is associated with the developmental progression of tobacco and cannabis co-use among African Americans, furthering knowledge on the etiology of co-use in this population.

Longitudinal associations between age 20 problematic substance use and opioid use disorder incidence at age 30 - findings from an urban cohort.

This study used data from a longitudinal prevention study in an urban cohort to examine associations between nicotine dependence, alcohol, and cannabis use disorder and disorder criteria at age 20, with opioid use disorder (OUD) incidence or criteria onset by age 30. The study sample included 1408 participants (57.5% female, 72.5% African American) drawn from two cohorts of participants in a mid-Atlantic region of the U.S. as part of a series of randomized controlled trials of elementary school-based universal prevention interventions. Lifetime cannabis use disorder (CUD), alcohol use disorder (AUD; both DSM-IV), and current nicotine dependence (Fagerstrom Test for Nicotine Dependence, FTND) assessed at age 20 were used to predict (1) DSM-IV lifetime OUD at age 30, and (2) OUD criteria between ages 20 and 30 in multivariable logistic regression models. Covariates for all analyses included sociodemographics (sex, race, and free/reduced-priced lunch status), community disadvantage, and intervention status. Nicotine dependence (FTND≥3) at age 20 predicted age 30 DSM-IV lifetime OUD (aOR = 2.37; 95% CI 1.02,5.54). The number of CUD criteria (aOR = 1.30; 95% CI 1.09,1.57) and nicotine dependence severity scores (aOR = 1.22; 95% CI = 1.05,1.41) at age 20 predicted any OUD criteria between the ages of 20 and 30. Findings are consistent with previous research on opioid use behavior in young adulthood and suggest that nicotine dependence and CUD criteria among urban young people predict onset of OUD and OUD criteria in young adulthood.

Point-of-Sale Health Communication Campaigns for Cigarillos and Waterpipe Tobacco: Effects and Lessons Learned from Two Cluster Randomized Trials.

Many adolescents and young adults hold erroneous beliefs that cigarillos and waterpipe tobacco (WT) are safer than cigarettes, contributing to use. Communication campaigns can correct misperceptions and increase risk beliefs. We tested point-of-sale (POS) communication campaigns focused on chemical exposure for cigarillos and WT. We conducted two cluster randomized trials at 20 gas stations with convenience stores (10 stores for cigarillos, 10 for WT) in North Carolina between June and November 2017. Within each trial, stores were randomly assigned to either the intervention (campaign messages displayed) or a no message control condition. We conducted intercept surveys with repeated cross-sectional samples of 50 adolescents and young adults (ages 16-25) per store, at baseline and follow-up. There were 978 participants (mean age = 20.9 years) in the cigarillo trial, and 998 participants (mean age = 21.0 years) in the WT trial. Rates of campaign exposure were low (26% for cigarillos; 24.3% for WT). The cigarillo campaign increased knowledge that ammonia is in cigarillo smoke (p < .01). There were also significant increases in knowledge about ammonia and cyanide in cigarillo smoke and arsenic in WT smoke (p < .05) in the sub-sample who reported exposure to the campaign. No differences were found in outcome expectancies, product attitudes, worry about chemical exposure, or behavioral intentions in either campaign. Garnering attention for communication campaigns in saturated POS environments, often dominated by tobacco advertising, is challenging. Our study demonstrates the feasibility of anti-tobacco campaigns at the POS and points to several lessons learned for future POS campaigns.

Responses to pictorial versus text-only cigarillo warnings among a nationally representative sample of US young adults.

BACKGROUND: The US Food and Drug Administration requires six text-only warnings for cigar products, including cigarillos. Research has demonstrated the superiority of pictorial over text-only cigarette warnings, yet the relative effectiveness of pictorial warnings for cigarillos has not been examined. We examined the impact of pictorial cigarillo warnings compared with text-only warnings. METHODS: Data were collected from a nationally representative sample of US young adult (18-29) cigarillo users and susceptible non-users. Participants were randomised to one of three experimental conditions: text-only or one of two pictorial conditions (combined for analyses). For each warning, we assessed negative emotional reactions, cognitive elaboration (ie, thinking about cigarillo risks) and perceived message effectiveness (PME). RESULTS: Participants (N=661) were 46.5% female, 64.7% white and 21.9% Hispanic; 34.1% reported past 30-day cigarillo use; 41.4% were lifetime users (excluding past 30-day use); and 24.4% were susceptible non-users. Pictorial warnings elicited more negative emotional reactions and higher PME than text-only warnings (p values<0.01), with interactions showing the largest effects for past 30-day users (emotional reactions: d=0.99, PME: d=0.63). For cognitive elaboration, there was no main effect of warning type, but an interaction revealed effects for past 30-day users (p<0.05, d=0.46). CONCLUSIONS: Pictorial cigarillo warnings elicited greater negative emotional reactions and PME compared with text-only warnings. These effects and the effects on cognitive elaboration were strongest for past 30-day users. Our findings extend research on cigarette warnings to cigarillos, demonstrating that pictorial warnings are superior to text-only warnings for cigarillos in eliciting beneficial responses.

CBD Retailers in NC Promote CBD Online to Treat Pain Violating FDA Rules About Medical Claims and Offer Low-CBD/High-Price Products.

Introduction: Cannabidiol (CBD) products are available nearly nationwide in the US and can coexist with medical or recreational programs. North Carolina (NC) is an example of a state with a program dedicated to integrating hemp cultivation and medicinal CBD exclusively, containing a multitude of retailers selling it as a primary product. The Food and Drug Administration (FDA) mandates that non-FDA approved CBD products cannot be marketed using medical or health-related claims and has sent warning letters to retailers violating these terms. We aim to characterize the online content of the NC CBD market by analyzing retailers' websites to determine whether hemp/CBD shops comply with FDA regulations in terms of medical claims and analyze the claimed CBD content and price of products offered online. Methods: We randomly selected three CBD retailers from the ten most populated cities of NC. We analyzed their website content: product type, medical claims, other disclaimers, price, and CBD content. Results: We found that edible, oral, inhalable, and topical products are offered in similar proportions. Word analysis of product description revealed that "pain" and "pain relief" were the most common medical claim, followed by inflammation and anxiety. Health claims were mostly related to wellbeing. Other attributes indicate that products are associated with pleasant flavors or sensations (ie, cool, lavender, delicious, honey, menthol), which resembles the strategies used for tobacco advertisement. Most products (61%) claimed to contain less than 1000 mg of CBD. The median price of products ranged from $15-30 per 300 mg. We found a positive correlation between CBD content and price. Discussion: Our data demonstrate that the NC online CBD market does not comply with FDA regulations, primarily targets patients with pain, inflammation, or anxiety, and offers products with low CBD concentration and high prices. New policies should limit the access and online promotion of non-pharmaceutical grade CBD products.

Cigar Harm Beliefs and Associations with Cigar Use among Young Adults.

BACKGROUND: Cigar use, including little cigars and cigarillos (LCCs) and large traditional cigars, continues to harm young adults. Research on harm beliefs about cigars, particularly large cigars, is sparse. The current study examined cigar harm beliefs and associations with cigar use. Methods: Data are from a 2019 survey of a young adult cohort study recruited in fall 2010. Participants were asked questions about their beliefs about the harm of LCC and large cigar use. Those reporting ever use of cigars were asked how frequently they inhale the smoke into their lungs. Results: Participants (N = 1910) were 51.9% female with a mean age of 26.7 (SD = 0.6). Ever cigar use was 44.2% for large cigars and 43% for LCCs. Compared to those who have never used large cigars or LCCs, those reporting ever use of large cigars or LCCs reported lower harm beliefs about inhaling harmful chemicals and becoming addicted (ps <.0001). Those who reported higher harm beliefs also reported inhaling the smoke into their lungs more frequently for large cigars and LCCs (ps<.05). Conclusions: Cigar use harm beliefs were lower among participants reporting ever use of cigars compared to those reporting never use. Contrary to predictions, those reporting greater harm beliefs were more likely to report inhaling smoke more frequently than those with lower harm beliefs.

Longitudinal latent class analysis of tobacco use and correlates among young adults over a 10-year period.

INTRODUCTION: We assessed patterns and correlates, including demographic characteristics, psychological factors, and social role transitions, of young adults' tobacco use over time. METHODS: In the fall of 2010, we recruited a cohort of 3146 students from 11 colleges in North Carolina and Virginia. Participants completed baseline and at least two survey waves between 2010 and 2019. RESULTS: The sample was 49.8% female, 15.7% non-white, and 6.6% Hispanic. Longitudinal latent class analysis revealed a five-class model with distinct patterns and correlates of tobacco use. Limited Use (52.6% of sample) had minimal use. College-Limited Combustible Tobacco Users (18.6%) had moderate probability of cigarette, cigar, and waterpipe smoking, which decreased to no use post-college. Intermittent Sustained Polytobacco Users (10.9%) had low probability of use that continued post-college. College Polytobacco with Continued Cigarette and E-Cigarette Users (14.5%) had high probability of use of cigarette smoking and increasing probability of e-cigarette, both of which continued post-college. Sustained Polytobacco Users (5.7%) had moderate probability of use of tobacco products across all waves. CONCLUSIONS: Patterns of tobacco use varied considerably. In most classes, tobacco use was highest during freshman year and in three classes, use continued post-college. Prevention activities should focus on first-year students and target those at risk for post-college tobacco use.

Exposure to e-cigarette health claims and association with e-cigarette use and risk perceptions: A cohort study of young adults.

INTRODUCTION: E-cigarettes have been marketed illicitly as smoking cessation aids and reduced risk tobacco products in the United States. Our study assessed consumers' exposure to such claims and evaluated their impact on relative risk perceptions and e-cigarette use. METHODS: Data are from the Assessment of the post-College Experience study, which followed a cohort of young adults since 2010 when they were college freshmen. We used data from survey waves 10 (fall 2017) through 14 (fall 2019) to assess past 6 month exposure to e-cigarette marketing that made smoking cessation or modified risk tobacco product (MRTP) claims. Logistic regression models examined if exposure to claims at waves 11 through 14 were predictors of e-cigarette use and relative risk perceptions at wave 14. RESULTS: Exposure to MRTP (28.4% to 40.1%) and cessation claims (29.1% to 46.6%) increased, with participants reporting more exposure to cessation than MRTP claims at each wave. Multiple exposures were associated with perceptions that e-cigarettes are less harmful compared to cigarettes (Cessation: AOR = 1.12, CI: 1.01-1.23; p = 0.025; MRTP: AOR = 1.16; CI: 1.05-1.29; p = 0.003). Neither claim type was associated with past 30-day e-cigarette use. Claim exposure did not increase e-cigarette initiation among never e-cigarette users. However, current cigarette smokers who had never used e-cigarettes at wave 10 had 2.5 higher odds of initiating e-cigarette use by wave 14 for each exposure to a cessation claim (AOR = 2.53; CI: 1.43-4.45; p = 0.001). CONCLUSIONS: Young adults reported increasing exposure to unauthorized e-cigarette health claims. Exposure was associated with reduced relative risk perceptions, but was not associated with past 30-day e-cigarette use. Cessation claims may motivate current cigarette smokers to try e-cigarettes.

Decreases in smoking and vaping during COVID-19 stay-at-home orders among a cohort of young adults in the United States.

In Spring 2020, most US states and territories implemented stay-at-home orders to slow transmission of the novel coronavirus SARS-CoV2, the cause of COVID-19. Little is known about the impact of stay-at-home orders on tobacco and nicotine use including among young adults. The current study examined participants (N = 1727) completing three recent survey waves from a longitudinal cohort of young adults recruited in 2010 from North Carolina and Virginia, USA: Wave 13 (Spring 2019), Wave 14 (Fall 2019), and Wave 15 (Spring 2020) to assess changes in cigarette and e-cigarette use. We conducted logistic regression analyses to compare the odds that participants reported smoking or vaping in Wave 14 relative to Wave 13 to establish if there was a trend of use pre-pandemic. Then, we conducted logistic regression analyses to compare the odds that participants reported smoking or vaping in Wave 15 relative to Wave 14 to determine the impact of COVID-19 stay-at-home orders. When comparing the odds of reporting tobacco use at Wave 14 to Wave 13, no differences emerged (p > 0.05). However, when comparing tobacco use at Wave 15 to Wave 14, participants had 40% lower odds of reporting past 30-day cigarette use (p = 0.02) and 50% lower odds of reporting past 30-day e-cigarette use (p < 0.01). The current study provides initial evidence that young adults may have reduced their tobacco and nicotine use during the stay-at-home orders. However, more work is needed to determine the long-term impact of the COVID-19 pandemic on tobacco use and cessation in this population.

Tobacco and marijuana co-use in a cohort of young adults: Patterns, correlates and reasons for co-use.

BACKGROUND: As marijuana is legalized in more states, modes of administration that facilitate co-use with tobacco are growing in popularity among young adults. This study examines the prevalence, patterns, correlates, and reasons for co-use so that targeted interventions can be developed to prevent negative consequences associated with tobacco use and co-use. METHODS: In Fall 2019, 1887 young adults, originally recruited in 2010 from 11 colleges in North Carolina and Virginia to participate in a cohort study, completed an online survey. Co-use was defined as self-reported use of marijuana and tobacco in the past month. Tobacco-only, marijuana-only and co-users were compared using regression modeling. RESULTS: Overall, 9.3% of the sample were co-users, 7.1% tobacco-only, and 15.8% marijuana-only users. Tobacco use was associated with an increased likelihood of marijuana use and vice-versa. Co-users were more likely to use e-cigarettes and blunts to administer marijuana and less likely to use smokeless tobacco products. They were more likely to use cocaine, have less anxiety, and be heavier marijuana users than marijuana-only users. Co-users of e-cigarettes and marijuana were less likely to be daily e-cigarette users and make quit attempts than e-cigarette users that did not use marijuana. Experimentation was the primary reason for co-use of tobacco and marijuana. CONCLUSIONS: Co-users were more likely to use modes of administration that facilitate use of both substances and have patterns of use that may impact cessation efforts. These findings highlight the importance of surveillance of co-use and the development of interventions targeting experimentation with these substances by young adults.

Waterpipe Tobacco Warnings: An Experimental Study Among a Nationally Representative Sample of US Young Adults.

BACKGROUND: Waterpipe tobacco (WT) smoking by young adults remains high and misperceptions are common. Product warnings can increase knowledge of harms and reduce use. The goal of this study was to test warning statements, including the FDA-required nicotine warning (prior to implementation), on young adults' thinking about harms of and discouragement from WT smoking. METHODS: We conducted a between-subjects experiment in a nationally representative telephone survey of 1152 young adults aged 18-29. Participants were randomly assigned to hear one of five warning statements and reported how much, on a 4-point scale, the warning made them think about the harms and discouraged them from WT smoking. RESULTS: The sample was 36.8% female, 57.8% white, 20.2% Black, 24.1% Hispanic, with a mean age of 23.2 (SE = 0.25). Under half (43.5%) had ever smoked WT. There were significant differences among the statements on both thinking about harms (p < .0001) and discouragement (p < .0001). The FDA-required "nicotine" warning led to the lowest thinking about harms (M = 2.85, SE = 0.08) and was the least discouraging (M = 2.86, SE = 0.08), while the "100 cigarettes" warning resulted in the greatest thinking about harms (M = 3.62, SE = 0.05) and was the most discouraging (M = 3.56, SE = 0.06). CONCLUSIONS: The nicotine warning resulted in the lowest levels of thinking about harms and discouragement from WT smoking, suggesting limited impact. However, a warning focused on comparing smoke inhalation from WT smoking to cigarettes seems promising. Warnings should cover a broad range of WT health effects, and possibly comparisons to cigarettes. Findings also have implications for the content of international waterpipe warnings. IMPLICATIONS: This study indicates that the nicotine warning is the least effective at making young adults think about the harms of and discouraging WT smoking. The FDA and other countries should consider requiring warnings to cover a broader range of health harms, misperceptions, and possibly comparisons to cigarettes.

Health Claims About Cannabidiol Products: A Retrospective Analysis of U.S. Food and Drug Administration Warning Letters from 2015 to 2019.

Background: Cannabidiol (CBD) products are increasingly available to consumers in the United States and are subject to regulation by the U.S. Food and Drug Administration (FDA). CBD products cannot be marketed as unapproved new drugs with claims of therapeutic benefit. In addition, because CBD is the active ingredient in a FDA-approved CBD product, Epidiolex, CBD cannot be marketed as, or in, food products or dietary supplements. The FDA has issued Warning Letters to promote voluntary regulatory compliance. These letters provide insights as to the types of violations for CBD products detected in the U.S. market. Objective: The goal of this retrospective study was to content analyze Warning Letters issued by the FDA to identify illicit marketing of CBD products. Design: Warning Letters issued by the FDA between 2015 and 2019 were content analyzed using a deductive approach. We extracted year of issuance, issuing office, and claim types that are currently prohibited by the FDA, including (i) unapproved new drug, (ii) misbranded drug, (iii) false and/or misleading, (iv) FDA-approved/endorsed, (v) dietary supplement, and (vi) adulterated food product. In addition, we documented the disease or conditions the product claimed to affect, pharmacological effects, and location of violation. Results: Of the 39 Warning Letters issued, 97% were for violations made on company websites and 56% were for social media accounts. Almost all letters (97%) cited violations of marketing CBD as an unapproved new drug. These illicit therapeutic claims were made for >125 unique health problems, including cancer (87.2%), diabetes (71.8%), inflammation (66.7%), pain (66.7%), and arthritis (66.7%). The majority of letters (79.5%) also cited illicit marketing of CBD as a dietary supplement or food product. CBD was promoted as having 16 unique pharmacological effects, including anti-inflammatory (53.8%), anticancer (43.6%), and antipsychotic (30.8%). Conclusions: CBD products have been unlawfully advertised online as unauthorized drugs with health claims that promote therapeutic benefits and as dietary supplements. Efforts are needed to regulate and monitor illicit advertising so consumers are not misled about the risks and benefits of CBD use.

Alcohol trajectories and subsequent risk for opioid misuse in a cohort of urban adolescents.

Background: The opioid epidemic is a public health emergency in the US. Alcohol is the most widely used addictive substance among all age groups; however, the contribution of different alcohol use trajectories throughout adolescence and young adulthood to the development of opioid misuse in young adulthood among urban minority youth has not been investigated. Methods: Data are from a study of 580 youth (85% African American, 67% low SES) residing in Baltimore City followed from ages 6-26. Alcohol trajectories were identified between ages 14 and 26 using group-based trajectory modeling. Opioid misuse was defined as using opioid painkillers without a prescription or using heroin between ages 19 and 26. Opioid misuse outcomes were also investigated separately. Logistic regression examined associations of alcohol trajectories with opioid misuse in young adulthood adjusting for socio-demographics, early use of tobacco and cannabis, neighborhood, and peer factors. Results: Six alcohol use trajectories were identified: Young adult increasing (21.4%), adult increasing (19.1%), abstaining (19.1%), experimenting (15.3%), adolescent increasing (14.8%), and adolescent limited (10.2%). In models fully adjusted for covariates, relative to the abstaining trajectory, the adolescent increasing trajectory was associated with an elevated risk of opioid misuse (aOR = 3.3, 95%CI = 1.4, 7.8) and prescription opioid misuse (aOR = 3.9, 95%CI = 1.4, 10.8) in young adulthood. Conclusions: Escalating alcohol use in adolescence and young adulthood is associated with an elevated risk of opioid misuse in young adulthood in a cohort of predominantly African American and socio-economically disadvantaged young people. Tailored interventions should target high levels of alcohol use during these developmental periods to reduce risk for opioid misuse among disadvantaged youth.

Adolescent cannabis and tobacco use are associated with opioid use in young adulthood-12-year longitudinal study in an urban cohort.

BACKGROUND AND AIMS: Cannabis, tobacco and alcohol use are prevalent among youth in the United States and may be risk factors for opioid use. The current study aimed at investigating associations between developmental trajectories of cannabis, tobacco and alcohol use in adolescence and opioid use in young adulthood in an urban cohort over the span of 12 years. DESIGN: Cohort study of adolescents originally recruited for a randomized prevention trial with yearly assessments into young adulthood. SETTING: Nine urban elementary schools in Baltimore, MD in the United States. PARTICIPANTS: Participants (n = 583, 86.8% African American, 54.7% male) were originally recruited as first grade students. MEASUREMENTS: Cannabis, tobacco and alcohol use were assessed annually from ages 14-18 years and opioid use from ages 19-26. Socio-demographics were assessed at age 6. Intervention status was also randomly assigned at age 6. Gender, race, free/reduced-priced lunch and intervention status were included as covariates in individual and sequential growth models. FINDINGS: There were significant positive associations between the cannabis use intercept at age 14 and the opioid use intercept at age 19 (beta = 1.43; P = 0.028), the tobacco use intercept at age 14 and the opioid use intercept at age 19 (beta = 0.82; P = 0.042). Specifically, more frequent use of cannabis or tobacco at age 14 was associated with more frequent use of opioids at age 19. CONCLUSIONS: Cannabis and tobacco use in early adolescence may be risk factors for opioid use in young adulthood among African Americans living in urban areas.

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults.

OBJECTIVE: E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults. METHODS: In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018. RESULTS: Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03). CONCLUSIONS: Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Developing Pictorial Cigarillo Warnings: Insights From Focus Groups.

INTRODUCTION: The Food and Drug Administration (FDA) selected six text-only warnings for cigarillos to be implemented on packaging and advertising. Pictorial warnings are more effective at discouraging cigarette use than text-only warnings, yet no research exists for cigarillos. We sought to understand what types of images might be most effectively paired with the cigarillo text warnings to inform broad principles for developing pictorial warnings, with a focus on young adults, who have the highest rate of cigarillo use. METHODS: We conducted five focus groups with a total of N = 30 young adult cigarillo users and susceptible nonusers (53% female, 50% White, and 33% Black). Participants were shown four to eight unique images for each of the six text statements and were asked about visual-verbal congruency, emotional and cognitive reactions, and perceived effectiveness of each image. Sessions were recorded and transcribed; two investigators independently coded transcripts for emergent themes. RESULTS: Participants reported images that were graphic or "gross" would best grab attention and discourage use of cigarillos. Participants preferred images that were a direct illustration of the information in the warning text, rather than abstract images that required more cognitive effort to understand. Participants also highlighted that including people in the images, especially youth and young adults making eye contact, helped them relate to the warnings, garner their attention, and positively influence their reactions. CONCLUSIONS: We identified several principles to inform the selection of images to pair with the FDA-required cigarillo text statements. These insights may also apply to pictorial warnings for other tobacco products. IMPLICATIONS: This focus group study identified principles for selecting images to develop pictorial warnings for the six FDA text-only cigarillo warnings. We found that young adult cigarillo users and susceptible nonusers preferred images that were graphic and gross, believable, congruent to the warning text, and included people. Images that match young adults' visual expectations of a disease and are emotion-provoking may be most effective in pictorial warnings and highlight challenges for developing pictorial warnings for health effects that do not have a visible health consequence.