Evaluation of the Asian Smokers' Quitline: A Centralized Service for a Dispersed Population.

INTRODUCTION: Asian immigrants to the U.S. smoke at higher rates than U.S.-born Asians. However, few programs exist to help these immigrants quit and little is known about their real-world effectiveness. The Centers for Disease Control and Prevention funded the Asian Smokers' Quitline to serve Chinese, Korean, and Vietnamese immigrants nationwide. This study examines service utilization and outcomes from the first 7 years of the program. METHODS: From August 2012 to July 2019, the Asian Smokers' Quitline enrolled 14,073 Chinese-, Korean-, and Vietnamese-speaking smokers. Service utilization rates and cessation outcomes were compared with those of an earlier trial (conducted 2004-2008) that demonstrated the efficacy of an Asian-language telephone counseling protocol. Data were analyzed in 2019. RESULTS: Asian Smokers' Quitline participants came from all 50 states and the District of Columbia. The main referral sources were Asian-language newspapers (37.2%), family and friends (16.4%), healthcare providers (11.9%), and radio (11.9%). Overall, 37.6% were uninsured, 38.8% had chronic health conditions, and 15.4% had mental health conditions. Compared with participants in the earlier trial, Quitline participants received 1 fewer counseling session (3.8 vs 4.9, p<0.001) but were more likely to use pharmacotherapy (73.6% vs 20.9%, p<0.001). More than 90% were satisfied with the services they received. Six-month prolonged abstinence rates were higher in the Quitline than in the trial (complete case analysis: 28.6% vs 20.0%, p<0.001; intention-to-treat analysis: 20.5% vs 16.4%, p=0.005). CONCLUSIONS: The Asian Smokers' Quitline was utilized by >14,000 Asian-language-speaking smokers across the U.S. in its first 7 years. This quitline could serve as a model for delivering other behavioral services to geographically dispersed linguistic minority populations.

Building Capacity for Logic Models and Evaluation Planning Using Canoe-building Concepts.

Non-communicable diseases (NCDs) are the leading causes of death in the United States Affiliated Pacific Islands (USAPIs); US Centers for Disease Control and Prevention funds programs for prevention and control of diabetes, tobacco use, and related chronic disease conditions. To build USAPI programs' capacity in evaluation and surveillance, we held in-person and virtual trainings on evaluation planning and logic models that were tailored with traditional canoe-building themes to be relatable and memorable. Evaluation results suggest the efforts were effective at translating concepts. Additional tools and technical assistance reinforced concepts and resulted in quality evaluation plans. Culturally tailored evaluation tools can be useful and should be developed with population representatives.

National and state patterns of concept-flavoured cigar sales, USA, 2012-2016.

INTRODUCTION: Cigar sales have increased in the USA in recent years. A growing proportion of cigar sales are of flavoured varieties, many bearing ambiguous or 'concept' flavour descriptions (eg, Jazz). This study assessed US cigar sales by flavour category (ie, concept flavoured, characterising flavoured and tobacco), at national, regional and state levels. METHODS: Sales of cigarillos, large cigars and little cigars from chain, franchise and convenience stores, mass merchandisers, supermarkets, drug, dollar and club stores, and military commissaries during 2012-2016 were acquired from the Nielsen Company. US national-level and state-level sales, including District of Columbia, were analysed by flavour category. Flavour descriptors were classified as 'tobacco', 'characterising' or 'concept', based on Universal Product Code (UPC)-linked characteristics and brand website and consumer review descriptions. RESULTS: Cigar sales increased by 29% during 2012-2016, driven by a 78% increase in cigarillo sales. The proportion of concept-flavoured sales increased from 9% to 15%, while the proportion of sales decreased for tobacco (50% to 49%) and characterising flavours (eg, cherry) (41% to 36%). Cigarillos had the greatest increase in unique concept flavour descriptions (17 to 46 unique UPCs), with most sales occurring among Sweet, Jazz and Green Sweets concept flavours. By US region, total and concept-flavoured cigarillo sales were highest in the South. CONCLUSIONS: Flavoured cigars are increasingly labelled with concept flavours, including in areas with flavoured tobacco sales restrictions. Cigarillos are driving recent increases in US cigar and concept-flavoured cigar sales. It is important to consider concept flavours when addressing flavoured tobacco product sales and use.

National and State-Specific Unit Sales and Prices for Electronic Cigarettes, United States, 2012-2016.

INTRODUCTION: Few studies have explored patterns of electronic cigarette (e-cigarette) sales and prices by product type over time. We used US retail scanner data to assess national and state-specific trends in e-cigarette unit sales and prices for 4 product types sold from 2012 through 2016. METHODS: Using retail scanner data from the 48 contiguous states and Washington, DC, for convenience stores; supermarkets; mass merchandisers; drug, dollar, and club stores; and military commissaries, we assessed data on monthly unit sales and inflation-adjusted prices by 4 products (rechargeables, disposables, prefilled cartridges, and e-liquids) sold during the 5-year study period. We evaluated national and state trends by using Joinpoint regression (P < .05). RESULTS: From 2012 through 2016, average national monthly unit sales significantly increased for all products, while average monthly prices of rechargeables, disposables, and prefilled cartridges significantly decreased. In 2016, prefilled cartridges had the highest average sales (766 units per 100,000 people) and the lowest average price ($14.36 per unit). By state, average monthly sales significantly increased for at least 1 of 4 e-cigarette products in all 48 states and Washington, DC. However, during the same period, average monthly prices significantly decreased in 39 states for rechargeables, in 31 states for disposables, in 20 states for prefilled cartridges, and in 8 states for e-liquids. CONCLUSION: Overall, US e-cigarette unit sales generally increased as product prices decreased. These findings demonstrate the rapidly evolving landscape of US e-cigarette retail marketplace. Ongoing surveillance of e-cigarette unit sales and price is critical for informing and evaluating evidence-based tobacco control strategies.

Trends in Unit Sales of Flavored and Menthol Electronic Cigarettes in the United States, 2012-2016.

INTRODUCTION: The use of flavored tobacco products, including electronic cigarettes (e-cigarettes), is common in the United States, and flavored products are particularly appealing to young people. The objective of this study was to describe national and state trends in flavored and menthol e-cigarette unit sales. METHODS: We examined data on 4 types of e-cigarette products (rechargeables, disposables, prefilled cartridges, and e-liquid refills). We used Universal Product Code retail scanner data from 2 sources: 1) convenience stores and 2) all other outlets combined, including supermarkets, drug stores, mass merchandisers (including Walmart), dollar stores, club stores, and US Department of Defense commissaries. We aggregated data in 4-week periods for the 48 contiguous states and the District of Columbia for the 5-year period from 2012 through 2016. Data from vape shops and internet sales were not available. We used Joinpoint regression to assess trends. RESULTS: From 2012 through 2016, flavored e-cigarette sales as a percentage of all e-cigarette sales increased nationally (from 2.4% to 19.8%) and in all but 4 states (North Dakota, South Dakota, Utah, and Vermont). Nationally, flavored disposable and prefilled cartridge sales increased. Menthol e-cigarette sales were stable nationally at 35% to 40%, while the percentage of menthol disposable, prefilled cartridge, and e-liquid refill sales decreased. By state, menthol e-cigarette sales increased in 2 states (Idaho and Nebraska) and decreased in 7 states. During 2015-2016, the percentage of flavored sales decreased in one state (Rhode Island) and increased in 29 states. CONCLUSION: These findings demonstrate that sales of flavored e-cigarette products have increased dramatically since 2012, with variations by product type and state. Continued monitoring of sales trends at all retail outlets can inform federal, state, and local efforts to address flavored tobacco product use, including e-cigarettes, in the United States.

Trends in Sales of Flavored and Menthol Tobacco Products in the United States During 2011-2015.

Introduction: Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels. Methods: Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change. Results: Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland). Conclusions: Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption. Implications: Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

Sales Trends in Price-Discounted Cigarettes, Large Cigars, Little Cigars, and Cigarillos-United States, 2011-2016.

Introduction: Tobacco manufacturers continue to implement a range of pricing strategies to increase the affordability and consumption of tobacco products. To demonstrate the extent of retail- and brand-level price discounts at the point of sale, this study assessed national sales trends in price-discounted cigarettes, large cigars, little cigars, and cigarillos. Methods: Retail scanner data for tobacco product sales were obtained for convenience stores (C-store) and all-other-outlets-combined (AOC) from September 25, 2011, to January 9, 2016. The proportion of price-discounted sales, average nondiscounted unit price, and average discounted unit price were examined by product category and brand. JoinPoint regression was used to assess average monthly percentage change. Results: Overall, price-discounted sales accounted for 11.3% of cigarette, 3.4% of large cigar, 4.1% of little cigar, and 3.9% of cigarillo sales. The average difference between nondiscounted and discounted prices was 25.5% (C-store) and 36.7% (AOC) for cigarettes; 11.0% (C-store) and 11.2% (AOC) for large cigars; 19.2% (C-store) and 9.6% (AOC) for little cigars; and 5.3% (C-store) and 14.7% (AOC) for cigarillos. Furthermore, price-discounted sales of top-selling tobacco brands comprised up to 36% of cigarette, 7.4% of large cigar, 7.7% of little cigar, and 4.2% of cigarillo unit sales. Conclusions: These findings highlight the use of price discounts by tobacco manufacturers to reduce the cost of cigarettes, large cigars, little cigars, and cigarillos to consumers. These sales patterns underscore the importance of sustained efforts to implement evidence-based strategies to increase prices and reduce availability and consumption of combustible tobacco in the United States. Implications: This study highlights the prevalence and provides a baseline of price-discounted cigarettes, large cigars, little cigars, and cigarillos. Surveillance of tobacco sales data, including state-level trends and additional product types, is critical for informing approaches to reduce tobacco consumption. These approaches include countering tobacco product price-discounting practices and raising and maintaining a high sales price for all tobacco products. The implementation of evidence-based population-level interventions, together with local, state, and federal regulation of tobacco products, could prevent tobacco initiation, increase tobacco cessation, and reduce overall tobacco use among US youth and adults.

State Tobacco Control Program Implementation Strategies for Smoke-Free Multiunit Housing.

Multiunit housing residents are at risk of secondhand smoke exposure from adjoining units and common areas. We developed this case study to document state-level strategies undertaken to address this risk. We explored program documents to identify facilitators, barriers, and outcomes. Three states (Montana, Michigan, and Nebraska) provided detailed information on multiunit housing efforts in the study time frame. We conducted a qualitative analysis using inductive coding to develop themes. Several facilitators relating to existing infrastructure included traditional and nontraditional partnerships, leadership and champions, collecting and using data, efficient use of resources, and strategic plans. We also report external catalysts, barriers, and outcomes. Significant state leadership and effort were required to provide local-level technical assistance to engage traditional and nontraditional partners. Information needs were identified and varied by stakeholder type (i.e., health vs. housing). States recommend starting with public housing authorities, so they can become resources for affordable and subsidized housing. These lessons and resources can be used to inform smoke-free multiunit housing initiatives in other states and localities.

Electronic Nicotine Delivery System Use Among U.S. Adults, 2014.

INTRODUCTION: Electronic nicotine delivery system (ENDS) use has increased rapidly in the U.S. in recent years. The availability and use of ENDS raise new issues for public health practice and tobacco regulation, as it is unknown whether patterns of ENDS use enhance, deter, or have no impact on combustible tobacco product use. This study assessed past-month, lifetime, and frequency of ENDS use among current, former, and never adult cigarette smokers. METHODS: Data were analyzed from the 2014 Styles, a national consumer-based probability-based web panel survey of U.S. adults aged ≥18 years (n=4,269) conducted during June and July. Lifetime ENDS users were defined as those who reported having used ENDS ≥1 day in their lifetime. Past-month ENDS users were defined as those who reported using ENDS in the past 30 days. RESULTS: In 2014, overall lifetime and past-month ENDS use was 14.1% and 4.8%, respectively. By smoking status, 49.5% of current, 14.7% of former, and 4.1% of never cigarette smokers had used ENDS in their lifetime, whereas 20.6% of current, 4.0% of former, and 0.8% of never smokers used ENDS in the past month. Among current and former cigarette smokers who ever used ENDS, 44.1% and 44.7% reported using ENDS >10 days in their lifetime, respectively. CONCLUSIONS: Because the effect ENDS use has on combustible tobacco products use is unknown, and lifetime and past-month ENDS use is more common among current than former or never smokers, continued surveillance of ENDS use among adults is critical to programs and policies.

Impact of the 5As brief counseling on smoking cessation among pregnant clients of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics in Ohio.

OBJECTIVES: We assessed whether smoking cessation improved among pregnant smokers who attended Women, Infants and Children (WIC) Supplemental Nutrition Program clinics trained to implement a brief smoking cessation counseling intervention, the 5As: ask, advise, assess, assist, arrange. METHODS: In Ohio, staff in 38 WIC clinics were trained to deliver the 5As from 2006 through 2010. Using 2005-2011 Pregnancy Nutrition Surveillance System data, we performed conditional logistic regression, stratified on clinic, to estimate the relationship between women's exposure to the 5As and the odds of self-reported quitting during pregnancy. Reporting bias for quitting was assessed by examining whether differences in infants' birth weight by quit status differed by clinic training status. RESULTS: Of 71,526 pregnant smokers at WIC enrollment, 23% quit. Odds of quitting were higher among women who attended a clinic after versus before clinic staff was trained (adjusted odds ratio, 1.16; 95% confidence interval, 1.04-1.29). The adjusted mean infant birth weight was, on average, 96 g higher among women who reported quitting (P<0.0001), regardless of clinic training status. CONCLUSIONS: Training all Ohio WIC clinics to deliver the 5As may promote quitting among pregnant smokers, and thus is an important strategy to improve maternal and child health outcomes.

Strategies to Support Tobacco Cessation and Tobacco-Free Environments in Mental Health and Substance Abuse Facilities.

We identified and described strategies for promoting smoking cessation and smoke-free environments that were implemented in Oregon and Utah in treatment centers for mental illness and substance abuse. We reviewed final evaluation reports submitted by state tobacco control programs (TCPs) to the Centers for Disease Control and Prevention and transcripts from a call study evaluation. The TCPs described factors that assisted in implementing strategies: being ready for opportunity, having a sound infrastructure, and having a branded initiative. These strategies could be used by other programs serving high-need populations for whom evidence-based interventions are still being developed.

Protobacco Media Exposure and Youth Susceptibility to Smoking Cigarettes, Cigarette Experimentation, and Current Tobacco Use among US Youth.

PURPOSE: Youth are exposed to many types of protobacco influences, including smoking in movies, which has been shown to cause initiation. This study investigates associations between different channels of protobacco media and susceptibility to smoking cigarettes, cigarette experimentation, and current tobacco use among US middle and high school students. METHODS: By using data from the 2012 National Youth Tobacco Survey, structural equation modeling was performed in 2013. The analyses examined exposure to tobacco use in different channels of protobacco media on smoking susceptibility, experimentation, and current tobacco use, accounting for perceived peer tobacco use. RESULTS: In 2012, 27.9% of respondents were never-smokers who reported being susceptible to trying cigarette smoking. Cigarette experimentation increased from 6.3% in 6th grade to 37.1% in 12th grade. Likewise, current tobacco use increased from 5.2% in 6th grade to 33.2% in 12th grade. Structural equation modeling supported a model in which current tobacco use is associated with exposure to static advertising through perception of peer use, and by exposure to tobacco use depicted on TV and in movies, both directly and through perception of peer use. Exposure to static advertising appears to directly increase smoking susceptibility but indirectly (through increased perceptions of peer use) to increase cigarette experimentation. Models that explicitly incorporate peer use as a mediator can better discern the direct and indirect effects of exposure to static advertising on youth tobacco use initiation. CONCLUSIONS: These findings underscore the importance of reducing youth exposure to smoking in TV, movies, and static advertising.

A Mixed-Methods Assessment of a Brief Smoking Cessation Intervention Implemented in Ohio Public Health Clinics, 2013.

OBJECTIVES: In 2006, the state of Ohio initiated the implementation of a brief smoking cessation intervention (5As: Ask, Advise, Assess, Assist, and Arrange) in select public health clinics that serve low-income pregnant and post-partum women. Funds later became available to expand the program statewide by 2015. However, close to half of the clinics initially trained stopped implementation of the 5As. To help guide the proposed statewide expansion plan for implementation of the 5As, this study assessed barriers and facilitators related to 5As implementation among clinics that had ever received training. METHODS: A mixed-methods approach was used, comprising semi-structured interviews with clinic program directors (n = 21) and a survey of clinic staff members (n = 120), to assess implementation-related barriers, facilitators, training needs, and staff confidence in delivering the 5As. RESULTS: Semi-structured interviews of program directors elucidated implementation barriers including time constraints, low self-efficacy in engaging resistant clients, and paperwork-related documentation challenges. Facilitators included availability of community referral resources, and integration of cessation interventions into the clinic workflow. Program directors believed they would benefit from more hands-on training in delivering the 5As. The survey results showed that a majority of staff felt confident advising (61%) or referring clients for tobacco dependence treatment (74%), but fewer felt confident about discussing treatment options with clients (29%) or providing support to clients who had relapsed (30%). CONCLUSIONS: Time constraints and documentation issues were major barriers to implementing the 5As. Simplified documentation processes and training enhancements, coupled with systems change, may enhance delivery of evidence-based smoking cessation interventions.

Patterns of current use of tobacco products among U.S. high school students for 2000-2012--findings from the National Youth Tobacco Survey.

PURPOSE: The purpose of this study was to assess patterns and trends of tobacco use among high school students to better understand which products are used individually or concurrently. METHODS: Data from the National Youth Tobacco Survey from 2000 through 2012 were used to assess patterns and trends of current tobacco use (cigarettes, cigars, smokeless tobacco, and other tobacco products) among U.S. high school students. We assessed use of products individually and concurrently. RESULTS: During 2000-2012, overall linear declines were observed in current use of any tobacco product from 33.6% to 20.4% (p < .05), current use of only 1 tobacco product, from 18.8% to 10.5% (p < .05), and current poly tobacco use, from 14.7% to 9.9% (p < .05), among high school students. Overall current use of only cigarettes had both a linear decline, from 14.0% to 4.7%, as well as a quadratic trend. CONCLUSIONS: During 2000-2012, the most significant overall decline observed was for students who reported smoking only cigarettes. The results suggest that more data on the use of multiple tobacco products, not just cigarettes, is needed to guide tobacco prevention and control policies and programs.

Newspaper coverage of implementation of the Michigan smoke-free law: lessons learned.

OBJECTIVE: To examine whether newspaper coverage of the Michigan smoke-free law was favorable or hostile, contained positive messages that had been disseminated by public health groups, contained negative messages, and differed across regions. METHOD: Articles about the smoke-free law in print or online editions of Michigan newspapers the month immediately before and after the law took effect were identified and were coded for tone, positive messages contained in media outreach materials, and negative messages commonly disseminated by smoke-free law opponents. RESULTS: A total of 303 print and online articles were identified; the majority were coded as "both positive and negative" (34%) or "mainly positive" in tone (32%). Of 303 articles, 75% contained at least one pro-law message and 56% contained at least one anti-law message. The most common pro-law messages were information about enforcement of the law (52%) and the benefits of smoke-free air (48%); the most common anti-law messages were about potential negative economic impact (36%), government intrusion/overreach (31%), and difficulties with enforcement (28%). CONCLUSIONS: Public health departments and partners play an important role in implementation of smoke-free laws by providing the public, businesses, and other stakeholders with clear and accurate rationale, provisions, and impacts of these policies.