Responses to Real-World and Hypothetical Menthol Flavor Bans Among US Young Adults Who Smoke Menthol Cigarettes.

INTRODUCTION: Menthol cigarette bans have been implemented in some US states and localities, and a federal ban is being proposed by the FDA. This study asks how young adults who use menthol cigarettes respond to changes in menthol cigarette availability. AIMS AND METHODS: An online survey of young adults ages 18-34 who reported smoking menthol cigarettes on ≥7 of 30 days around Thanksgiving 2019 (n = 734), oversampling Massachusetts-the first state with a menthol ban. Participants reported their tobacco use behavior following real-world menthol cigarette bans or predicted their behavior under a hypothetical federal ban. RESULTS: Most respondents who exclusively smoked versus dual used with e-cigarettes continued smoking/using combustible tobacco following real-world bans (95.3% vs. 86.9%), accessing menthol cigarettes from other jurisdictions. Fewer who smoked exclusively responded by using e-cigarettes compared to those who dual used (3.9% vs. 43.7%). Quitting all tobacco use (ie, no smoking, vaping, or any tobacco use) was uncommon for both groups (3.6% vs. 9.0%). Under a hypothetical ban, majorities of those who exclusively smoke and who dual use predicted they would continue smoking (72.2% vs. 71.8%); fewer who smoke exclusively would use e-cigarettes compared to those who dual use (14.7% vs. 41.4%). Those who smoke exclusively were more likely to report quitting all tobacco compared to those who dual use (29.6% vs. 12.4%). CONCLUSIONS: Under real-world and hypothetical menthol cigarette bans, most respondents continued smoking. However, more young adults continued smoking following real-world bans, reflecting the limitations of local/state restrictions when menthol cigarettes are available in other jurisdictions. IMPLICATIONS: This survey asked young adults who use menthol cigarettes how they responded to real-world changes in the availability of menthol cigarettes; 89% reported continuing to smoke. Those who smoked exclusively were far less likely to respond by switching to e-cigarettes compared to people who dual used both products. Under a hypothetical federal menthol cigarette ban, 72% of young adults predicted that they would continue smoking. Quitting all tobacco was less common in the real-world scenario compared to the hypothetical ban. Access to menthol cigarettes in other jurisdictions and flavored cigars likely dampen the public health benefit of menthol cigarette bans.

Responses to real-world and hypothetical e-cigarette flavor bans among US young adults who use flavored e-cigarettes.

INTRODUCTION: E-cigarette flavor bans could reduce or exacerbate population health harms. To determine how US e-cigarette flavor restrictions might influence tobacco use behavior, this study assesses responses to real-world and hypothetical flavor bans among young adults who use flavored e-cigarettes. METHODS: An online, national survey of young adults ages 18-34 who use flavored e-cigarettes was conducted in 2021 (n=1,253), oversampling states affected by e-cigarette flavor restrictions. Participants were asked about their responses to real-world changes in the availability of flavored e-cigarettes. Unaffected participants were asked to predict their responses under a hypothetical federal e-cigarette flavor ban. RESULTS: The most common response to real-world changes in flavored e-cigarettes availability was to continue vaping (~80%). Among those who exclusively vaped, 12.5% switched to combustible tobacco. Quitting all forms of tobacco was selected by 5.3% of those exclusively vape vs. 4.2% who dual use. Under a hypothetical federal ban, more than half of respondents stated they would continue vaping; 20.9% and 42.5% of those who exclusively vape vs dual use would use combustible tobacco. Quitting all tobacco products was endorsed by 34.5% and 17.2% of those who exclusively vape vs dual use. CONCLUSIONS: Young adults who vape flavored e-cigarettes have mixed responses to e-cigarette flavor bans. Under both real-world and hypothetical e-cigarette flavor bans, most who use flavored e-cigarettes continue vaping. Under a real-world ban, the second most common response among those who exclusively vape is to switch to smoking; under a hypothetical federal ban, it is to quit all tobacco. IMPLICATIONS: This is the first national survey to directly ask young adults who use flavored e-cigarettes about their responses to real-world changes in flavored e-cigarette availability due to state and local flavor restrictions. The survey also asked individuals to predict their responses under a hypothetical federal e-cigarette flavor ban. Most who use flavored e-cigarettes would continue vaping following e-cig flavor restrictions, but many would switch to or continue using combustible tobacco, highlighting potential negative public health consequences of these policies. Policymakers must consider the impact of e-cigarette flavor bans on both e-cigarette and cigarette use.

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany.

BACKGROUND: Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs. METHODS: SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data. RESULTS: Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period. CONCLUSIONS: SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

Introduction: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019. Methods: Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group. Results: Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. Conclusions: Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S.

INTRODUCTION: Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics. METHODS: Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021. RESULTS: Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group. CONCLUSIONS: Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Summary and Concluding Remarks: Patterns of Birth Cohort‒Specific Smoking Histories.

The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group age-period-cohort methodology to study smoking patterns can be applied to tackle important issues in tobacco control and public health. This paper summarizes the analyses of smoking patterns in the U.S. by race/ethnicity, educational attainment, and family income and for each of the 50 U.S. states using the CISNET Lung Working Group age-period-cohort approach. We describe how decision makers, policy advocates, and researchers can use the sociodemographic analyses in this supplement to project state smoking trends and develop effective state-level tobacco control strategies. The all-cause mortality RR estimates associated with smoking for U.S. race/ethnicity and education groups are also discussed in the context of research that measures and evaluates health disparities. Finally, the application of the CISNET Lung Working Group age-period-cohort methodology to Brazil is reviewed with a view to how the same types of analyses can be applied to other low- and middle-income countries.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of youth and adults in the PATH Study in 2015-2017 vs 2017-2019.

INTRODUCTION: It is unknown how recent changes in the tobacco product marketplace have impacted transitions in cigarette and electronic nicotine delivery system (ENDS) use. METHODS: A multistate transition model was applied to 24 242 adults and 12 067 youth in waves 2-4 (2015-2017) and 28 061 adults and 12 538 youth in waves 4 and 5 (2017-2019) of the Population Assessment of Tobacco and Health Study. Transition rates for initiation, cessation and product transitions were estimated in multivariable models, accounting for gender, age group, race/ethnicity and daily versus non-daily product use. RESULTS: Changes in ENDS initiation/relapse rates depended on age, including among adults. Among youth who had never established tobacco use, the 1-year probability of ENDS initiation increased after 2017 from 1.6% (95% CI 1.4% to 1.8%) to 3.8% (95% CI 3.4% to 4.2%). Persistence of ENDS-only use (ie, 1-year probability of continuing to use ENDS only) increased for youth from 40.7% (95% CI 34.4% to 46.9%) to 65.7% (95% CI 60.5% to 71.1%) and for adults from 57.8% (95% CI 54.4% to 61.3%) to 78.2% (95% CI 76.0% to 80.4%). Persistence of dual use similarly increased for youth from 48.3% (95% CI 37.4% to 59.2%) to 60.9% (95% CI 43.0% to 78.8%) and for adults from 40.1% (95% CI 37.0% to 43.2%) to 63.8% (95% CI 59.6% to 67.6%). Youth and young adults who used both products became more likely to transition to ENDS-only use, but middle-aged and older adults did not. CONCLUSIONS: ENDS-only and dual use became more persistent. Middle-aged and older adults who used both products became less likely to transition to cigarette-only use but not more likely to discontinue cigarettes. Youth and young adults became more likely to transition to ENDS-only use.

Mortality Relative Risks by Smoking, Race/Ethnicity, and Education.

INTRODUCTION: The impact of cigarette smoking on mortality is well studied, with estimates of the relative mortality risks for the overall population widely available. However, age-specific mortality estimates for different sociodemographic groups in the U.S. are lacking. METHODS: Using the 1987-2018 National Health Interview Survey Linked Mortality Files through 2019, all-cause mortality relative risks (RRs) were estimated for current smokers or recent quitters and long-term quitters compared with those for never smokers. Stratified Cox proportional hazards regression models were used to estimate RRs by age, gender, race/ethnicity, and educational attainment. RRs were also assessed for current smokers or recent quitters by smoking intensity and for long-term quitters by years since quitting. The analysis was conducted in 2021-2022. RESULTS: All-cause mortality RRs among current smokers or recent quitters were generally highest for non-Hispanic White individuals than for never smokers, followed by non-Hispanic Black individuals, and were lowest for Hispanic individuals. RRs varied greatly by educational attainment; generally, higher-education groups had greater RRs associated with smoking than lower-education groups. Conversely, the RRs by years since quitting among long-term quitters did not show clear differences across race/ethnicity and education groups. Age-specific RR patterns varied greatly across racial/ethnic and education groups as well as by gender. CONCLUSIONS: Age-specific all-cause mortality rates associated with smoking vary considerably by sociodemographic factors. Among high-education groups, lower underlying mortality rates for never smokers result in correspondingly high RR estimates for current smoking. These estimates can be incorporated in modeling analyses to assess tobacco control interventions' impact on smoking-related health disparities between different sociodemographic groups.

Patterns of Birth Cohort‒Specific Smoking Histories in Brazil.

INTRODUCTION: Smoking prevalence has decreased considerably in Brazil from 34.8% in 1989 to 12.6% in 2019 owing to the implementation of strong tobacco control policies. However, recent data show that the downward trend may be stagnating. Detailed analyses of historical smoking patterns by birth cohort could guide tobacco control decision making in Brazil. METHODS: Using the 2008 Global Adult Tobacco Survey and the 2013 and 2019 National Health Surveys, historical smoking patterns in Brazil were estimated, supplemented with data from the 2006‒2019 Surveillance System of Risk Factors for Chronic Diseases by Telephone Interviews. Age‒period‒cohort models with constrained natural splines were applied to estimate the annual probabilities of smoking initiation and cessation, current smoker prevalence, and mean cigarettes smoked per day by age, gender, and birth cohort. Analysis was conducted in 2021‒2022. RESULTS: Current smoker prevalence has declined considerably since the 1950 and 1955 birth cohorts for males and females, respectively, reflecting decreased smoking initiation and increased smoking-cessation probabilities over time. Among female cohorts born on or after 2000, smoking initiation may be increasing even as their smoking cessation has increased considerably. Mean cigarettes smoked per day has remained relatively constant across period and cohorts, showing only a minor decrease among males. CONCLUSIONS: These detailed cohort-specific smoking parameters can be used to inform models that evaluate the impact of tobacco use and policies on long-term health outcomes and guide public health decision making in Brazil. Stagnant mean cigarettes smoked per day, increasing female smoking initiation, and limited improvement in male cessation among recent cohorts present challenges to tobacco control.

Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S.

INTRODUCTION: In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking. METHODS: Using the National Health Interview Survey 1983-2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900-2000) for 5 income groups: <100%, 100%-199%, 200%-299%, 300%-399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020-2021. RESULTS: Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts. CONCLUSIONS: Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S.

INTRODUCTION: U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity. METHODS: Adult smoking data were obtained from the 1978-2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020-2021. RESULTS: Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages. CONCLUSIONS: There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.

Smoking Histories by State in the U.S.

INTRODUCTION: Smoking rates across U.S. states have declined at different rates over time because some states have progressive tobacco control policies, whereas others have yet to adopt them. Therefore, each state has its own unique historical experience of smoking initiation, cessation, and prevalence. This study characterizes smoking histories for each U.S. state by birth cohort. METHODS: Using 1965-2018 National Health Interview Survey and 1992-2019 Tobacco Use Supplement to the Current Population Survey data, statistical methods applied an age‒period‒cohort modeling framework to reconstruct population-level smoking histories for each state. Smoking initiation, cessation, and intensity by age, gender, and cohort were estimated for each state. These were used to construct state-specific trends in the prevalence of current, former, and never smoking as well as the mean smoking duration and pack years. Analysis was conducted from 2017 to 2022. RESULTS: California and Kentucky, respectively, are exemplar states of more and less aggressive tobacco control. Initiation probabilities were consistently lower in California than in Kentucky, and cessation probabilities were higher. Hence, the smoking prevalence derived from these parameters is higher in Kentucky. The intensity of cigarette smoking was higher in Kentucky than in California, yielding considerably higher estimated pack years when used with the other parameters. Summaries of smoking trends are given for all states. CONCLUSIONS: Smoking initiation, cessation, and intensity trends vary substantially across states, resulting in major differences in estimated smoking prevalence, duration, and pack years. Some states show improvements in smoking metrics over time with more recent birth cohorts, but others have shown very little.

Modeling cigarette smoking disparities between people with and without serious psychological distress in the US, 1997-2100.

Cigarette smoking rates are significantly higher among people with serious psychological distress (SPD) compared to the general population. US simulation models that project future smoking disparities by SPD status could inform policy interventions, but have not been developed. We calibrated two compartmental models to the National Health Interview Survey 1997-2018 for populations with and without SPD, calculating smoking prevalence, mortality, and life-years lost by SPD status under different scenarios from 2023 to 2100. Under the Status Quo, smoking prevalence among women with SPD falls from 27.0% in 2023 to 10.7% in 2100 (men: 30.1% to 12.2%). For women without SPD, it declines from 9.4% to 3.1% (men: 11.5% to 4.0%). The absolute difference in smoking prevalence between those with and without SPD decreases over time, whereas the relative smoking prevalence ratio increases. From 2023 to 2100, 609,000 premature smoking-attributable deaths would occur in the SPD population, with 8 million life-years lost. Under an ideal tobacco control scenario for people with SPD, in which all smokers quit in 2023 and no new smoking initiation occurs thereafter, up to 386,000 of these premature deaths could be averted with 4.9 million life-years gained. Preventing smoking initiation could avert up to 18% of these deaths, while improving smoking cessation could avert up to 82%. Smoking-related disparities for people with SPD will persist unless a shift in tobacco control substantially improves cessation and prevents initiation in this subpopulation. Smoking disparities by SPD may widen in relative but narrow in absolute terms, so both perspectives should be evaluated.

The Potential Impact of Widespread Cessation Treatment for Smokers With Depression.

INTRODUCTION: Experts recommend integrating smoking-cessation treatments within U.S. mental health settings, but the population health benefits of doing so have not been estimated. This study simulates the impact of widespread cessation treatment for patients with depression under best-case treatment and maximum potential cessation scenarios. METHODS: Cessation interventions were simulated for U.S. adult smokers seeing a health professional for depression from 2020 to 2100. Interventions included (1) Any Treatment (behavioral counseling, pharmacological, combination) and (2) Pharmacological Treatment (including counseling), combined with increased mental health service utilization each. These were compared with a maximum potential cessation scenario where all patients with major depression quit smoking. Analyses were conducted in 2016-2020. RESULTS: Widespread uptake of Any Treatment among patients with depression would avert 32,000 deaths and result in 138,000 life-years gained by 2100; Any Treatment combined with 100% mental health service utilization would result in 53,000 and 231,000, respectively. Pharmacological Treatment would avert 125,000 deaths, with 540,000 life-years gained. Pharmacological Treatment combined with 100% mental health service utilization would result in 203,000 deaths averted and 887,000 life-years gained. Health gains under best-case treatment scenarios represent modest fractions of those projected under maximum potential cessation scenarios at current mental health service utilization levels (835,000 deaths averted, 3.73 million life-years gained) and at 100% utilization (1.11 million deaths averted, 5.07 million life years gained). CONCLUSIONS: Providing smoking-cessation treatment to patients with depression and increasing mental health service utilization would reduce the toll of tobacco on this population. These gains would be considerably larger if cessation treatments were more effective.

US Nicotine Vaping Product SimSmoke Simulation Model: The Effect of Vaping and Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths.

The public health impact of nicotine vaping products (NVPs) is subject to a complex set of uncertain transitions between NVP and cigarette use. Instead, we apply an indirect method to gauge the impact of NVP use on smoking prevalence and smoking-attributable deaths (SADs) using the well-established SimSmoke tobacco control policy simulation model. Upon validating the model before NVPs were more widely used, we project a No-NVP (i.e., in the absence of NVPs) while controlling for the impact of cigarette-oriented policies. The net impact of NVPs on smoking prevalence is inferred by comparing the projected No-NVP smoking trends to corresponding trends from two US national surveys. Using the TUS-CPS estimates for the period 2012-2018, we estimate that adult smoking prevalence declined in relative terms by 9.7% (95% CI: 7.5-11.7%) for males and 10.7% (95% CI: 9.1-13.0%) for females. Compared to NHIS, smoking prevalence declined by 10.7% (95% CI: 6.8-14.6%) for males and 11.3% (95% CI: 7.4-15.6%) for females. These impacts were confined mainly to ages 18-44. Vaping-related reductions in smoking prevalence were projected to avert nearly 0.4 million SADs between 2012 and 2052. Our analysis indicates that NVP use is associated with substantial reductions in US smoking prevalence among younger adults.

An Expert Elicitation on the Effects of a Ban on Menthol Cigarettes and Cigars in the United States.

INTRODUCTION: The US Food and Drug Administration announced its intention to ban menthol in cigarettes. However, information is needed on how a federal ban would affect population health. AIMS AND METHODS: We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. We developed and pilot tested a questionnaire that focused on tobacco use transitions of current smokers (age 18-24 menthol, age 35-54 menthol, and age 35-54 nonmenthol) and potential menthol smokers (age 12-24). Using a structured expert elicitation, we estimated mean net transitions under a ban from cigarette use to combustible tobacco product, smokeless tobacco, novel nicotine delivery product (NNDPs, such as e-cigarettes) use, or no tobacco use. RESULTS: Eleven experts provided responses. Of those ages 12-24 who would have initiated menthol cigarette use in the absence of a ban, the experts estimated that 41% would still initiate combustible products under a ban, while 18% would initiate with NNDPs and 39% would not initiate regular tobacco use. Combustible use by menthol smokers ages 35-54 was expected to decline by 20% postban relative to preban rates, half switching to NNDPs and half quitting all tobacco use. Menthol smokers ages 18-24 were expected to reduce combustible use by 30%, with 16% switching to NNDPs. Greater reductions in combustible use were estimated for African Americans across the three age groups. Negligible impacts were expected for current adult nonmenthol smokers. CONCLUSIONS: According to expert opinion, a menthol ban is expected to substantially reduce smoking initiation and combustible tobacco product use among current menthol smokers. IMPLICATIONS: The US Food and Drug Administration recently announced its intention to ban menthol in cigarettes, but information on the potential impact on smoking and other nicotine product use is limited. We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. A panel of experts estimated that menthol smokers ages 35-54 would reduce combustible tobacco use by 20%, with half switching to e-cigarettes and half quitting all nicotine use. Larger reductions were expected at younger ages, and menthol smoking initiation was reduced by 59% with 18% instead using e-cigarettes. African Americans were expected to have greater reductions in combustible tobacco use than the rest of the population.

Biomarkers of Potential Harm among Adult Cigarette and Smokeless Tobacco Users in the PATH Study Wave 1 (2013-2014): A Cross-sectional Analysis.

BACKGROUND: While smokeless tobacco (ST) causes oral cancer and is associated with cardiovascular diseases, less is known about how its effects differ from other tobacco use. Biomarkers of potential harm (BOPH) can measure short-term health effects such as inflammation and oxidative stress. METHODS: We compared BOPH concentrations [IL6, high-sensitivity C-reactive protein, fibrinogen, soluble intercellular adhesion molecule-1 (sICAM-1), and F2-isoprostane] across 3,460 adults in wave 1 of the Population Assessment of Tobacco and Health study (2013-2014) by tobacco use groups: primary ST users (current exclusive ST use among never smokers), secondary ST users (current exclusive ST use among former smokers), exclusive cigarette smokers, dual users of ST and cigarettes, former smokers, and never tobacco users. We estimated geometric mean ratios using never tobacco users, cigarette smokers, and former smokers as referents, adjusting for demographic and health conditions, creatinine (for F2-isoprostane), and pack-years in smoker referent models. RESULTS: BOPH levels among primary ST users were similar to both never tobacco users and former smokers. Most BOPH levels were lower among ST users compared with current smokers. Compared with never tobacco users, dual users had significantly higher sICAM-1, IL6, and F2-isoprostane. However, compared with smokers, dual users had similar biomarker levels. Former smokers and secondary ST users had similar levels of all five biomarkers. CONCLUSIONS: ST users have lower levels of inflammatory and oxidative stress biomarkers than smokers. IMPACT: ST use alone and in combination with smoking may result in different levels of inflammatory and oxidative stress levels.

Public health implications of vaping in the USA: the smoking and vaping simulation model.

BACKGROUND: Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA. METHODS: SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses. RESULTS: The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters. DISCUSSION: Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data. CONCLUSION: The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.