Noticing Voluntary E-Cigarette Warning Labels and Associations With Harm Perceptions and Use Intentions: A Baseline Cross-Sectional Analysis of Wave 4 of the Population Assessment of Tobacco and Health Study Prior to the Food and Drug Administration Mandate.

PURPOSE: To examine the effect of e-cigarette warning labels (EWLs) prior to the August 2018 FDA-warning label mandate to establish a baseline for future research. DESIGN: Cross-sectional survey. SETTING: United States. PARTICIPANTS: A cohort of adult participants in the Population Assessment of Tobacco and Health (PATH) study (n = 30,004) at Wave 4 (Dec 2016-Jan 2018). MEASURES: Correlates (e.g., sociodemographics, substance use, social influence, cigarette warnings, and mental health) of noticing EWLs in the past 30-days (noticed vs did not notice), perceived harm of e-cigarettes/nicotine (from 1 = not at all harmful to 5 = extremely harmful), relative harm of e-cigarettes (from 1 = less harmful to 3 = more harmful than cigarettes), intention to quit (yes/no) and intention to try e-cigarettes (from 1 = definitely not to 4 = definitely yes). RESULTS: The prevalence of noticing EWLs was 22.1%. Those who currently use electronic nicotine products, established and experimentally, were more likely to notice EWLs relative to never users (aOR = 3.55; 95% CI: 2.96-4.25; P < .001 and aOR = 2.42; 95% CI: 1.88-3.10; P < .001, respectively). Those with past 30-day alcohol and cigarette use were less likely to notice EWLs (aOR = .27; 95% CI: .24-.31 and aOR = .91; 95% CI: .83-.99; respectively). Those who noticed cigarette warnings were more likely to notice EWLs (aOR = 12.00; 95% CI: 10.46-13.77; P < .001). Among those who noticed EWLs, there were higher odds of perceiving e-cigarettes to be equally or more harmful than cigarettes (aOR = 1.15; 95% CI: 1.02-1.30), but no association was found between noticing EWLs and perceived harm of e-cigarettes/nicotine or use intentions. CONCLUSION: Noticing voluntary EWLs was not associated with increased perceived harm of e-cigarettes and nicotine harm, or e-cigarette use intentions. Future research is warranted to examine the effect of the FDA mandated EWLs.

Integrating the "Quit and Stay Quit Monday" Model into Smoking Cessation Services for Smokers with Mental Health Conditions: A Pilot Randomized Controlled Trial.

Introduction: People with mental health conditions (MHCs) are less likely to achieve long-term abstinence than people without MHCs. The Quit and Stay Quit Monday (QSQM) model offers a long-term approach to treating tobacco use by encouraging people to quit, requit, or recommit to quit smoking every Monday. Aim: To evaluate the efficacy, patient satisfaction, and patient engagement with an intervention that integrated the QSQM model into multicomponent smoking cessation services among people with an MHC. Methods: This was a randomized controlled pilot trial. Eligibility criteria were as follows: (1) ≥18 years old, (2) smoked a cigarette in the past 30 days, (3) diagnosis of an ICD-10 MHC, (4) interest in quitting smoking, (5) able to receive services in English, and (5) had an active email and a cell phone. The intervention group (n = 33) received QSQM-focused telephone coaching, a weekly QSQM email newsletter, a SmokefreeTXT anchored around a Monday quit date, and 4 weeks of nicotine replacement therapy (NRT). The control group (n = 36) received information about contacting their state Quitline for usual services. Primary outcomes were self-reported quit attempts, 7-day abstinence, and intervention satisfaction at 3 months. Results: Twenty-four participants (73%) in the intervention group began telephone coaching, 26 (79%) enrolled in the QSQM email newsletter, 19 (58%) enrolled in SmokefreeTXT, and 15 (46%) used NRT. Using a penalized intent-to-treat approach, quit attempts in the intervention and control groups were 63.6% and 38.9% (OR 2.75, 95% CI 1.03-7.30), respectively. Seven-day abstinence in the two groups was 12.1% and 5.6% (OR 2.35, 95% CI 0.40-13.74), respectively. Of the 15 intervention group participants who set a quit date during the intervention, 13 (86.7%) selected a Monday quit day. Qualitative interviews revealed positive participant experiences with picking a Monday quit day. On follow-up surveys, 89.5%, 69.3%, and 64.3% of intervention participants reported that the counseling, QSQM email, and text messaging, respectively, were very or somewhat helpful. Conclusions: The QSQM model was acceptable and potentially efficacious among people with MHCs, but intervention engagement and satisfaction were modest. Future research should adapt or develop new QSQM delivery approaches to improve patient engagement and potential efficacy of the model. This trial is registered with clinicaltrials.gov (NCT04512248).

Industry marketing of tobacco products on social media: case study of Philip Morris International's IQOS.

SIGNIFICANCE: Newer tobacco products might be particularly likely to use social media as they emerge in the global market. Little is known about the official use of social media in marketing heated tobacco products (HTPs). This study examined Philip Morris International's (PMI) social media marketing globally of its leading HTP, IQOS. METHODS: PMI IQOS country-specific official websites were accessed (N=59) in May to September 2022 and social media accounts listed were recorded. Accounts were then coded for their number of posts in the past month and year and for their number of subscribers. Posts on online accounts with at least one past-month post were categorised to describe the post's function: instructional, general advertising, price promotions or event promotions. RESULTS: Of the 59 country websites, 45 (76.3%) listed at least one social media account; of these, an average of 2.5 accounts (SD=0.8) were listed. Across websites, 111 accounts were identified: 42 Facebook, 23 YouTube, 21 Twitter, 19 Instagram, 2 Telegram, 1 LinkedIn, 1 KakaoTalk, 1 VK and 1 LINE. Across YouTube, Twitter and Instagram, accounts made 2550 past-year posts and had ~490 961 subscribers. Of the 165 past-month posts, 101 (60.1%) functioned as general advertising, 30 (17.9%) instructional, 29 (17.3%) event promotions and 8 (4.8%) price promotions. CONCLUSION: Social media posts were used to engage consumers with advertising, event promotions, product use instructions and price promotions. The study provides evidence of the company-sponsored official marketing of an HTP via social media globally, underscoring the need for monitoring and tobacco control regulatory efforts in the digital arena.

IQOS marketing strategies in the USA before and after US FDA modified risk tobacco product authorisation.

INTRODUCTION: Given that the US Food and Drug Administration (FDA) authorised reduced exposure messaging to be used in IQOS marketing, we examined: (1) IQOS ad content; (2) advertising media channels and (3) changes in advertising efforts over time. METHODS: We conducted a mixed-methods study regarding IQOS ad content (headlines, themes, images), ad occurrence characteristics (including content, media channels and adspend) in the USA from August 2019 to April 2021 using Numerator advertising/marketing data. RESULTS: Across 24 unique ads and 591 occurrences (84.6% online, 8.0% print, 7.4% mobile), there was $4 902 110 total adspend (98.9% allocated to print). Across unique ads, occurrences and adspend, prominent themes included 'real tobacco' (45.8%, 47.4%, 30.1%, respectively), less odour/ash (29.2%, 21.0%, 29.9%) and switching from cigarettes (25.0%, 19.5%, 69.4%), and images mainly featured the product alone (58.2%, 61.4%, 99.5%) or with women (25.0%, 19.1%, 0.3%). Per occurrences and adspend, the most prominent media channel themes (eg, magazine/website topics) were technology (19.3%, 10.6%), women's fashion (18.1%, 26.2%), weather/news (9.0%, 15.3%) and entertainment/pop culture/gaming (8.5%, 23.1%). Ad themes appearing only post-FDA authorisation included switching from traditional cigarettes, same-day/home-delivery, convenience (eg, use indoors), reduced exposure to some dangerous substances, science/research and distinction from e-cigarettes. Overall adspend per occurrence increased postauthorisation (p=0.016); the highest adspend per unique ad (69.3% of total) focused on ads featuring reduced exposure. CONCLUSIONS: Regulatory efforts must be informed by ongoing surveillance of IQOS marketing efforts and its impacts, particularly how specific consumer subgroups (eg, tobacco non-users, women, young people) are impacted by marketing exposure.

Cannabidiol Knowledge, Perceptions, and Use Among Young Adults in 6 U.S. Metropolitan Areas.

Background: Cannabidiol (CBD) has gained popularity in the United States, particularly among certain populations, including young adults. Thus, we examined (1) CBD product knowledge, perceptions, use, and use intentions among young adults and (2) correlates of use and use intentions. Methods: We analyzed data from a Fall 2020 survey regarding tobacco and other substance use among 2464 young adults in 6 U.S. cities (Mage=24.67; 57.4% female; 28.7% racial/ethnic minority). We used multinomial regression to identify correlates of use status (i.e., former [ever but no past 6 months] use vs. current [past 6 months] and never use, respectively), and linear regression to examine use intentions among never users. Results: Around 51.4% reported ever use, and 32.0% reported current use. On average, participants perceived CBD as safe and effective for addressing pain, anxiety, and sleep (also prominent use motives: ∼40% to 60%, respectively). Use intentions were relatively high, particularly for edibles and topicals (also the most common use modes). Roughly one-fourth mistakenly believed that CBD products were required to be approved by U.S. Food and Drug Administration (24.9%), tested/proven safe (28.8%), and proven effective to be marketed for pain, anxiety, sleep, and so on. (27.2%). Compared to former users, never users perceived greater CBD-related risk (p<0.001), less social acceptability (p<0.001), and greater difficulty accessing CBD (p=0.004); current users perceived more health benefits (p<0.001). Among never users, greater use intentions were associated with greater perceived social acceptability (p<0.001), health benefits (p<0.001), and difficulty accessing CBD (p=0.005). Conclusions: Given misperceptions about CBD, surveillance of young adults' knowledge, perceptions, and use of CBD is critical as its market expands.

IQOS and cigarette advertising across regulatory periods and population groups in Israel: a longitudinal analysis.

BACKGROUND: Tobacco regulation recently changed in Israel, including a partial advertisement ban. We assessed the impact of regulatory changes on Philip Morris International's (PMI) IQOS and cigarette advertisements. METHODS: Weekly number of ads and weekly adspend of PMI's IQOS and cigarettes were analysed descriptively and using Quasi-Poisson regressions over time, across regulatory periods and in relation to subpopulations (general public, Arab, Russian and Ultra-Orthodox), from 25 December 2016 to 4 August 2020. Exponentiated coefficients (a value >1 indicates an increase) and 95% CIs are reported. RESULTS: The average weekly number of ads and the average weekly adspend of IQOS were higher than cigarettes (42.22 vs 26.76 ads/week and 59 409 vs 45 613 new Israeli shekels/week; p<0.001 for both) during the study period, with exclusive IQOS advertisements during market penetration (December 2016 to May 2017). Variation in both outcomes was observed with regard to regulatory decisions. After the advertisement ban, there was a significant decrease in the weekly number of ads (IQOS: ß=0.04, 95% CI 0.002 to 0.20; cigarettes: ß=0.05, 95% CI 0.01 to 0.15) and weekly adspend (IQOS: ß=0.15, 95% CI 0.07 to 0.29; cigarettes: ß=0.31, 95% CI 0.17 to 0.53) for both products. The Ultra-Orthodox had significantly higher average weekly ads compared with the Arab population (IQOS: 0.67 vs 0.07; cigarettes: 2.74 vs 0.13; p=0.02 for both) but lower adspend. CONCLUSIONS: IQOS and cigarette advertisements varied over time and appeared to have been impacted by regulatory changes. PMI invested more in IQOS advertisements than in cigarettes, with a partial advertisement ban decreasing both products' advertisements. PMI might be targeting the Ultra-Orthodox Jewish population which has a low smoking rate. Further research and surveillance are needed to better understand targeting strategies in order to inform tobacco control policy.

Young adults' knowledge, perceptions and use of cannabidiol products: a mixed-methods study.

Cannabidiol (CBD) product regulatory efforts must be informed by research regarding consumer perceptions. This mixed-methods study examined CBD product information sources, knowledge, perceptions, use and use intentions among young adults. This study analyzed (i) Fall 2020 survey data from 2464 US young adults (Mage = 24.67, 51.4% ever users, 32.0% past 6-month users) and (ii) Spring 2021 qualitative interviews among 40 survey participants (27.5% past-month users). Overall, 97.9% of survey participants reported having heard of CBD, 51.4% ever/lifetime use and 32.0% past 6-month use. Survey participants learned about CBD from friends/family (58.9%), products/ads at retailers (36.4%), online content/ads (34.8%), CBD stores (27.5%) and social media (26.7%). One-fourth believed that CBD products were required to be US Food and Drug Administration-approved (24.9%), tested for safety (28.8%) and proven effective to be marketed for pain, anxiety, sleep, etc. (27.2%). Survey and interview participants perceived CBD as safe, socially acceptable and effective for addressing pain, anxiety and sleep. Interview findings expanded on prominent sources of marketing and product exposure, including online and specialty retailers (e.g. vape shops), and on participants' concerns regarding limited regulation and/or evidence regarding CBD's effectiveness/risks. Given young adults' misperceptions about CBD, surveillance of CBD knowledge, perceptions and use is critical as the CBD market expands.

'It's like if a vape pen and a cigarette had a baby': a mixed methods study of perceptions and use of IQOS among US young adults.

Young adults' perceptions and use of heated tobacco products (HTPs) are understudied. This mixed methods study analyzed (i) Fall 2020 survey data from 2470 US young adults (meanage = 24.67; 19.5% and 25.2% past-month cigarette and e-cigarette use; 4.1% ever HTP use) assessing HTP use intentions and perceptions (1 = not at all to 7 = extremely) and (ii) Spring 2021 interview data regarding IQOS (most widely available HTP) in a subset of 40 e-cigarette users. Among survey participants, HTPs versus cigarettes and e-cigarettes showed lower use intentions (mean = 1.27 vs. mean = 1.73, mean = 2.16) but were perceived as less addictive (mean = 5.11 vs. mean = 6.28, mean = 5.82) and harmful (mean = 5.37 vs. mean = 6.65, mean = 5.62). HTPs were perceived more socially acceptable than cigarettes but less than e-cigarettes (mean = 3.39 vs. mean = 3.13, mean = 4.37). Among interviewees, most reported limited HTP knowledge. A few perceived IQOS as a hybrid of traditional cigarettes and e-cigarettes. Most perceived IQOS as harmful but less harmful than cigarettes and were uncertain in relation to e-cigarettes. Over half reported minimal interest in trying IQOS; common reasons included IQOS containing tobacco, limited flavors and use complexity. The varied perceptions of IQOS versus cigarettes and e-cigarettes underscore the need for continued surveillance of perceptions, use and marketing of IQOS to inform regulatory oversight and potential interventions.

The reciprocal relationships of social norms and risk perceptions to cigarette, e-cigarette, and cannabis use: Cross-lagged panel analyses among US young adults in a longitudinal study.

INTRODUCTION: Given the distinct and evolving social norms, research on health implications, and regulations regarding cigarettes, e-cigarettes, and cannabis, it is important to understand the interplay between social norms, risk perceptions, and use of these products. METHODS: We analyzed 3 waves of longitudinal data (Fall 2018, 2019, 2020) from 3006 young adults (Mage=24.56, 54.8% female, 31.6% sexual minority, 39.6% racial/ethnic minority) from 6 US metropolitan statistical areas. Cross-lagged panel models (CLPMs) examined reciprocal relationships of (a) perceived social norms (i.e., peer use, social acceptability) and risk perceptions (i.e., harm, addictiveness) to (b) number of days of cigarette, e-cigarette, and cannabis use in the past 30 days, respectively. RESULTS: At baseline, lifetime and past 30-day use prevalence was: 61.8% and 26.9% for cigarettes, 57.7% and 37.7% for e-cigarettes, and 70.7% and 39.2% for cannabis. Perceived social norms and use of cigarettes and e-cigarettes decreased over time, and risk perceptions increased (except cigarettes showed stable perceived harm). Regarding cannabis, perceived social norms and use increased, yet perceived harm and addictiveness also increased. CLPM indicated that greater perceived social norms predicted greater cigarette, e-cigarette, and cannabis use over time, and vice versa. While greater perceived risk predicted less e-cigarette and cannabis use and vice versa, this did not hold true for cigarettes: use predicted lower perceived risk, but risk perceptions did not predict later use. CONCLUSIONS: Tobacco and cannabis intervention and regulatory efforts should address health risks of use, particularly of e-cigarettes and cannabis, as well as denormalizing use.

Bidirectional associations between depressive symptoms and cigarette, e-cigarette, cannabis, and alcohol use: Cross-lagged panel analyses among young adults before and during COVID-19.

BACKGROUND: The literature regarding bidirectional relationships of depressive symptoms to cigarette and alcohol use is mixed, and limited regarding e-cigarette and cannabis use. Moreover, COVID-19 has significantly impacted mental health and substance use, especially among young adults. Thus, this is a critical period for focused research on these relationships among young adults. METHODS: We analyzed longitudinal data (assessments in Fall 2018, 2019, and 2020) from 3,006 young adults (Mage = 24.56 [SD = 4.72], 54.8% female, 31.6% sexual minority, 71.6% White, 5.3% Black, 12.2% Asian, 11.4% Hispanic) from 6 US metropolitan statistical areas. Cross-lagged panel models were conducted to examine bidirectional associations between depressive symptoms and past 30-day use of cigarettes, e-cigarettes, cannabis, and alcohol (respectively), controlling for sociodemographics. RESULTS: During the study period, depressive symptoms decreased before the pandemic but increased during, cigarette and e-cigarette use decreased in both periods, alcohol use showed no change before but increases during the pandemic, and cannabis use increased in both periods. Additionally, each outcome demonstrated greater stability before versus during COVID-19. Finally, greater antecedent depressive symptoms correlated with more days of subsequent cigarette (ß = 0.03, SE = 0.01, p =.011) and e-cigarette use (ß = 0.03, SE = 0.01, p =.021), but fewer days of alcohol use (ß = -0.02, SE = 0.01, p =.035). W2 cannabis use and alcohol use, respectively, were related to W3 depressive symptoms (cannabis: ß = 0.09, SE = 0.02, p <.001; alcohol: ß = 0.06, SE = 0.02, p =.002). No other cross-lagged associations were significant. CONCLUSIONS: Intervention efforts targeting depression and substance use should explicitly address the potential for onset and escalation of substance use and depressive symptoms, respectively, especially during societal stressors.

Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020.

INTRODUCTION: Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults. AIMS AND METHODS: Using 2020 cross-sectional data from 2,470 young adults (ages 18-34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively. RESULTS: 19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (ß = 0.26, 95%CI = 0.21, 0.30; ß = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (ß = -0.06, 95%CI = -0.10, -0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users. CONCLUSIONS: Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims. IMPLICATIONS: Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.

Latent Heterogeneity in the Impact of Financial Coaching on Delay Discounting among Low-Income Smokers: A Secondary Analysis of a Randomized Controlled Trial.

Low-income adults are significantly more likely to smoke, and face more difficulty in quitting, than people with high income. High rates of delay discounting (DD) may be an important factor contributing to the high rates of tobacco use among low-income adults. Future-oriented financial coaching may offer a novel approach in the treatment of smoking cessation among low-income adults. This secondary analysis (N = 251) of data from a randomized controlled trial examined the integration of future-oriented financial coaching into smoking cessation treatment for low-income smokers. Linear regression and finite mixture models (FMM) estimated the overall and the latent heterogeneity of the impact of the intervention versus usual care control on DD rates 6 months after randomization. Though standard linear regression found no overall difference in DD between intervention and control (ß = -0.23, p = 0.338), the FMM identified two latent subgroups with different responses to the intervention. Subgroup 1 (79% of the sample) showed no difference in DD between intervention and control (ß = 0.25, p = 0.08). Subgroup 2 (21% of the sample) showed significantly lower DD (ß = -2.06, p = 0.003) among intervention group participants versus control at 6 months. Participants were more likely to be a member of subgroup 2 if they had lower baseline DD rates, were living at or below 100% of federal poverty, or were married/living with a partner. This study identified a group of low-income adults seeking to quit smoking who responded to financial coaching with decreased DD rates. These results can be used to inform future targeting of the intervention to individuals who may benefit most, as well as inform future treatment adaptations to support the subgroup of low-income smokers, who did not benefit.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial.

BACKGROUND: Financial distress is a barrier to cessation among low-income smokers. OBJECTIVE: To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers. DESIGN: Randomized waitlist control trial conducted from 2017 to 2019. PARTICIPANTS: Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community. INTERVENTION: The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period. MAIN MEASURES: Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months. KEY RESULTS: At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (ß, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (ß, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (ß, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (ß, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (ß, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (ß, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05). CONCLUSIONS: Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03187730.

IQOS Marketing in the US: The Need to Study the Impact of FDA Modified Exposure Authorization, Marketing Distribution Channels, and Potential Targeting of Consumers.

IQOS, the leading heated tobacco product globally, recently received 'reduced exposure' authorization from the US Food and Drug Administration. Independent research focusing on IQOS marketing and potential impact on consumers' perceptions and behavior, and ultimately public health, is critical. The literature to date has underscored several concerns. First, Philip Morris's (PM's) marketing distribution requires scrutiny, particularly given its innovative promotional strategies. For example, IQOS is distributed via unique points-of-sale (POS; e.g., specialty and pop-up stores, "corners" in convenience stores) and uses various other opportunities (e.g., social media, sponsored events, direct-to-consumer). Second, although PM claims that IQOS' target market is current combustible tobacco users and not young people, the literature indicates that in some populations, IQOS use is equally prominent among smokers and nonsmokers, and that specific subgroups (e.g., young adults, women) are targeted. Third, the impact of IQOS' use of ad content promoting IQOS health benefits must be studied (e.g., how consumers interpret modified exposure messages). In conclusion, surveillance of IQOS marketing, particularly following reduced exposure authorization, is critical for obtaining valuable data to estimate population impact, particularly among population subgroups (e.g., young adults), and inform future tobacco regulation. These considerations have implications beyond IQOS-to other products and companies.

Heated Tobacco Product Awareness, Use, and Perceptions in a Sample of Young Adults in the United States.

INTRODUCTION: The emergence of heated tobacco products (HTPs) in the US marks a critical time for identifying those most likely to use, particularly among young adults. AIMS AND METHODS: We analyzed Fall 2019 data from a longitudinal study of young adults (ages 18-34; n = 2375, Mage=24.66±4.68) in 6 US cities, 24.1% of whom used cigarettes and 32.7% e-cigarettes. We assessed HTP awareness, use, and sources, as well as perceived risk, social acceptability, and the likelihood of future use. RESULTS: In this sample, 9.7% (n = 230) heard of HTPs, 3.5% (n = 84) ever used them, and 2.4% (n = 56) reported past-year purchases (tobacco shops, 66.1%; traditional retailers, 60.7%; online, 39.3%; IQOS specialty stores, 35.7%). In multivariable analyses, having heard of HTPs correlated with being an older, male, and current cigarette and e-cigarette users; among those ever hearing of them, using HTPs correlated with being non-Hispanic and current cigarette and e-cigarette users. Greater likelihood of future use correlated with being older, male, sexual minority, non-Hispanic, and current cigarette and e-cigarette users. Among past-month users (n = 78), the average number of days used was 5.48 (SD = 5.54). Past-month cigarette and e-cigarette users, respectively, who tried HTPs were more likely to report consistent or more frequent use of their respective products than a year ago (p < .001). HTPs were perceived as less addictive than cigarettes, smokeless tobacco, and e-cigarettes, and less harmful and more socially acceptable than other tobacco products except for e-cigarettes and hookah. CONCLUSIONS: The relatively positive perceptions of HTPs and access via various channels underscores the potential penetration of HTPs among US young adults. IMPLICATIONS: In Fall 2019, as IQOS was launching in the US, there were relatively low rates of awareness, use, and use intentions in this sample of young adults with high proportions of other tobacco use. However, this sample reported relatively positive perceptions of HTPs with regard to potential addiction and harm, as well as social acceptability. They also reported accessing HTPs via various channels, underscoring how pervasive the availability to HTPs already has become and may increasingly become. Moreover, certain subgroups (ie, other tobacco users, men) are particularly likely to use HTPs.

Psychosocial Factors, Smoke-Free Restrictions, and Media Exposure in Relation to Smoking-Related Attitudes and Behaviors among Adults in Armenia and Georgia.

BACKGROUND: Perceived harm, social influences, smoke-free policies, and media exposure have been understudied in relation to tobacco-related attitudes/behaviors in aggregate or in low and middle-income countries; thus, this study examined these factors collectively in relation to smoking-related outcomes among Armenian and Georgian adults. METHODS: Using 2018 cross-sectional survey data (n = 1456), multivariable regression analyses examined these factors in relation to smoking status, perceived harm among nonsmokers, and readiness to quit and past-year quit attempts among smokers. RESULTS: Significant predictors (p < 0.05) of current smoking (27.3%) included lower perceived harm, more smoking friends, and fewer home and vehicle restrictions. Among nonsmokers, more home and restaurant/bar restrictions, fewer vehicle restrictions, greater anti-tobacco media exposure, and less pro-tobacco media exposure predicted greater perceived harm. Among smokers, greater perceived social acceptability of smoking, less anti-tobacco media exposure, and greater pro-tobacco media exposure predicted readiness to quit (12.7% of smokers). More smoking friends, more home restrictions, less anti-tobacco media exposure, and greater pro-tobacco media exposure predicted past-year quit attempts (19.2%). CONCLUSIONS: Findings support the importance of smoke-free policies but were counterintuitive regarding the roles of social and media influences, underscoring the need to better understand how to address these influences, particularly in countries with high smoking rates.

Sociodemographic Correlates of Food Insecurity Among New York City Tobacco Users.

PURPOSE: To identify rates and sociodemographic correlates of food insecurity among low-income smokers. DESIGN: Cross-sectional analysis of baseline survey data from a randomized controlled trial (N = 403) testing a smoking cessation intervention for low-income smokers. SETTING: Two safety-net hospitals in New York City. SAMPLE: Current smokers with annual household income <200% of the federal poverty level. MEASURES: Food insecurity was measured using the United States Department of Agriculture 6-item food security module. Participant sociodemographics were assessed by self-reported survey responses. ANALYSIS: We used frequencies to calculate the proportion of smokers experiencing food insecurity and multivariable logistic regression to identify factors associated with being food insecure. RESULTS: Fifty-eight percent of participants were food insecure, with 29% reporting very high food insecurity. Compared to married participants, separated, widowed, or divorced participants were more likely to be food insecure (adjusted odds ratio [AOR] = 2.33, 95% confidence interval [CI]: 1.25-4.33), as were never married participants (AOR = 2.81, 95% CI: 1.54-5.14). CONCLUSIONS: Health promotion approaches that target multiple health risks (eg, smoking and food access) may be needed for low-income populations. Interventions which seek to alleviate food insecurity may benefit from targeting socially isolated smokers.

Tobacco Screening and Treatment of Patients With a Psychiatric Diagnosis, 2012-2015.

INTRODUCTION: Smoking disproportionately affects individuals with psychiatric diagnoses. Providers can play a role in reducing tobacco-related morbidity among people with a psychiatric diagnosis by routinely screening and treating all patients for tobacco use. This study seeks to identify rates of tobacco screening, counseling, and medication orders during outpatient visits with adults who have a psychiatric diagnosis. METHODS: Data from the 2012-2015 National Ambulatory Medical Care Survey were examined to calculate the proportion of visits with people who have a psychiatric diagnosis that included tobacco screening, counseling, or smoking-cessation medications. Logistic regression was used to identify patient and visit factors associated with tobacco screening and treatment. All analyses were conducted in 2018. RESULTS: Seventy-two percent of visits included tobacco screening, 23% of visits with tobacco users included cessation counseling, and 4% of visits with tobacco users included a cessation medication order. Visits were more likely to include tobacco screening if they were for a nonpsychiatric condition, were >30 minutes, or were with a primary care physician (p<0.05). Visits were less likely to include tobacco screening if they were with a black, non-Hispanic patient or patient with Medicaid (p<0.05). Visits were more likely to include cessation counseling if they were for a nonpsychiatric condition (p<0.05), and were less likely to include counseling if they were with a Hispanic or self-pay patient (p<0.05). CONCLUSIONS: There is still room for improvement in providing equitable treatment for people with psychiatric conditions for smoking, particularly in nonprimary settings.