Tobacco 21 Laws and Youth Tobacco Use: The Role of Policy Attributes.

Objectives. To estimate Tobacco-21 policies' relationships to 18- to 20 year-old youth cigarette, cigar, and electronic nicotine delivery system (ENDS) use, and to test for effect modification by policy attributes. Methods. In fall 2022, we used Tobacco 21 Population Coverage Database data to calculate the percentage of state residents covered by state or local Tobacco 21 (T21) laws monthly through June 2020. Matching T21 coverage to Population Assessment of Tobacco and Health and Behavioral Risk Factor Surveillance System data, we used 2-way fixed effect analyses to assess the relationship between T21 laws and 18- to 20-year-old youth cigarette, cigar, and ENDS use, and tested for differences by policy attributes: possession, use, or purchase (PUP) penalties, retailer noncompliance penalties, and compliance check requirements. Results. Increased T21 exposure yielded significant reductions in cigarette and cigar use, as well as in ENDS use, when accounting for policy attributes. These effects were dampened in T21 laws with PUP penalties relative to those without. Conclusions. Tobacco-21 laws yield reductions in 18- to 20-year-old youth cigarette, cigar, and ENDS use, with dampened effects when policies include PUP penalties. Public Health Implications. State policymakers should consider implementing T21 laws without PUP penalties to reduce underage nicotine and tobacco use. (Am J Public Health. 2024;114(1):90-97. https://doi.org/10.2105/AJPH.2023.307447).

How Complete Are Tobacco Sales Data? Assessing The Comprehensiveness Of US Tobacco Product Retail Sales Data Through Comparisons To Excise Tax Collections.

INTRODUCTION: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. METHODS: Using retail sales data from Information Resources Incorporated (IRI) and Nielsen, we conduct tax gap analyses comparing states' cigarette and ENDS tax revenue to tax collection estimates based on retail sales data. For the 23 US states in both retail sales datasets, cigarette tax gap analyses were conducted for each year from 2018-2020. Four (Louisiana, North Carolina, Ohio, and Washington) of those 23 states levied per unit ENDS taxes and provided monthly tax revenue data covering January 2018 - October 2021, where we conducted monthly tax gap analyses for both cigarettes and ENDS. RESULTS: Across states covered by both sales datasets, annual mean cigarette sales in IRI and Nielsen account for 92.3% (95% CI 88.3-96.2%) and 84.0% (95% CI 79.3-88.7%) of state cigarette tax revenue, respectively. Monthly average coverage rates for ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. CONCLUSIONS: IRI and Nielsen sales data capture almost the entire US cigarette market and a substantial but lower portion of the US ENDS market. With proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products. IMPLICATIONS: Policy evaluations and analyses using e-cigarette and cigarette sales data are often criticized because these data do not cover online sales or sales by specialty retailers like tobacconists.Cigarette sales data consistently cover nearly 90% of taxed sales, while e-cigarette sales data cover around 50% of taxed volumes.Retail sales data capture nearly all cigarette sales and a substantial portion of ENDS sales with relatively stable rates of coverage over time, supporting their continued use in tobacco surveillance and policy evaluation work.

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.

Brand Differences in Underage Tobacco Use as Evidence for Targeted Sanctions-Reviving the Lookback.

This survey study uses data from the 2020-2021 National Survey on Drug Use and Health to estimate brand differences in underage cigarette and cigar use in the US.

HOW COMPLETE ARE TOBACCO SALES DATA? ASSESSING THE COMPREHENSIVENESS OF TOBACCO PRODUCT RETAIL SALES DATA THROUGH COMPARISONS TO EXCISE TAX COLLECTIONS.

Introduction: Sales data analyses are increasingly used to guide tobacco regulatory science. However, such data do not cover specialist retailers like vape shops or tobacconists. Understanding the extent of the cigarette and electronic nicotine delivery system (ENDS) markets covered by sales data is critical to establishing such analyses' generalizability and potential biases. Methods: Sales data from Information Resources Incorporated (IRI) and Nielsen Retail Scanner data are used to conduct a tax gap analysis, comparing state tax collections based on cigarette and ENDS sales data to states' annual 2018-2020 cigarette tax collections and monthly ENDS and cigarette tax revenue data for January 2018 to October 2021. Cigarette analyses consider the 23 US states covered by both IRI and Nielsen. ENDS analyses consider the subset of those states with per unit ENDS taxes: Louisiana, North Carolina, Ohio, and Washington. Results: Across states covered by both sales datasets, IRI's mean cigarette sales coverage was 92.3% (95% CI 88.3-96.2%), while Nielsen's was 84.0% (95% CI 79.3-88.7%). Coverage rates for average ENDS sales were lower, ranging from 42.3% to 86.1% for IRI and 43.6% to 88.5% for Nielsen, but remained stable over time. Conclusions: IRI and Nielsen sales data capture almost the entire US cigarette market and, while coverage rates are lower, a substantial portion of the US market for ENDS as well. Coverage rates are relatively stable over time. Thus, with proper care to address shortcomings, sales data analyses can capture changes in the US market for these tobacco products.

Nationally representative surveys on cannabis use lack product details relevant to public health.

Objectives: Many annual, nationally representative US surveys that assess cannabis use do not collect information on product characteristics despite varying health risks and benefits. Capitalizing on a rich dataset of primarily medical users, the purpose of this study was to describe the degree of potential misclassification in clinically relevant cannabis use measures when primary mode of use is recorded but not product type. Methods: Analyses consider user-level data from the Releaf App™ database on product types, consumption modes, and potencies in a non-nationally representative sample of 26,322 cannabis administration sessions occurring in 2018, across 3,258 users. Proportions, means, and 95% confidence intervals were calculated and compared across products and modes. Results: Primary consumption modes were smoking (47.1%), vaping (36.5%), and eating/drinking (10.4%), with 22.7% of users reporting multiple modes of use. Moreover, mode of use did not signify a single product type: users reported vaping both flower (41.3%) and concentrates (68.7%). Of those who smoked cannabis, 8.1% reported smoking concentrates. Concentrates averaged 3.4 times higher tetrahydrocannabinol (THC) potency and 3.1 times higher cannabidiol (CBD) potency than flower. Conclusions: Cannabis consumers employ multiple consumption modes, and product type cannot be inferred from mode of use. With THC potencies markedly higher in concentrates, these findings underscore the importance of including information on cannabis product types and mode of use in surveillance surveys. Clinicians and policymakers need these data to inform treatment decisions and assess cannabis policies' implications for population health.

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.

Intended and unintended effects of e-cigarette taxes on youth tobacco use.

Over the past decade, rising youth use of e-cigarettes and other electronic nicotine delivery systems (ENDS) has contributed to aggressive regulation by state and local governments. Between 2010 and mid-2019, ten states and two large counties adopted ENDS taxes. We use two large national surveys (Monitoring the Future and the Youth Risk Behavior Surveillance System) to estimate the impact of ENDS taxes on youth tobacco use. We find that ENDS taxes reduce youth ENDS consumption, with estimated ENDS tax elasticities of -0.06 to -0.21. However, we estimate sizable positive cigarette cross-tax effects, suggesting economic substitution between cigarettes and ENDS for youth. These substitution effects are particularly large for frequent cigarette smoking. We conclude that the unintended effects of ENDS taxation may considerably undercut or even outweigh any public health gains.

Differences in Cancer Screening Responses to State Medicaid Expansions by Race and Ethnicity, 2011‒2019.

Objectives. To estimate whether state Medicaid expansions' relationships to breast, cervical, and colorectal cancer screening differ by race/ethnicity. Methods. Analyses conducted in 2021 used 2011-2016 and 2018-2019 Behavioral Risk Factor Surveillance System data on adults aged 40 to 64 years with household incomes below 400% of the federal poverty guideline (FPG; n = 537 250). Triple-difference analyses compared cancer screening in Medicaid expansion versus nonexpansion states, before versus after expansion, among people with incomes above versus below the eligibility cutoff (138% FPG). Race/ethnicity and ethnicity-by-language interaction terms tested for effect modification. Results. Associations between Medicaid expansions and cancer screening were significant for past-2-year mammograms and past-5-year colorectal screening. Effect modification analyses showed elevated mammography among non-Hispanic Asian women (+9.0 percentage points; 95% confidence interval [CI] = 3.2, 14.8) and Hispanic women (+6.0 percentage points; 95% CI = 2.0, 10.1), and Papanicolaou tests among Hispanic women (+4.2 percentage points; 95% CI = 0.1, 8.2). Findings were not limited to English- or Spanish-speaking respondents and were robust to insurance status controls. Conclusions. Medicaid expansions yielded statistically significant increases in income-eligible Asian and Hispanic women's mammography and Hispanic women's Pap testing relative to non-Hispanic White women. Neither language proficiency nor insurance status explained these findings. (Am J Public Health. 2022;112(11):1630-1639. https://doi.org/10.2105/AJPH.2022.307027).

Young adult responses to taxes on cigarettes and electronic nicotine delivery systems.

BACKGROUND AND AIMS: Although over half of United States states have passed taxes on electronic nicotine delivery systems (ENDS), recent evidence links ENDS tax rates to increases in smoking, suggesting potentially substantive health costs. Overall health implications will depend on how these taxes affect transitions from experimentation to regular smoking and vaping. Current analyses have not assessed ENDS tax rates' effects in young adulthood (ages 18-25). This study measures the relationship between ENDS and cigarette tax rates and ENDS use and smoking in young adulthood, a key period for initiation of regular tobacco use. DESIGN: Observational study of data from the Current Population Survey's 2010-2019 Tobacco Use Supplements. SETTING: The United States. PARTICIPANTS/CASES: A total of 38 906 18 to 25 year-olds MEASUREMENTS: Multivariable linear regressions estimated two-way fixed effects analyses to assess ENDS and cigarette tax rates' relationships to recent and daily smoking and vaping, adjusting for an array of potential sociodemographic and policy confounders along with state and year fixed effects. FINDINGS: A $1 increase in ENDS taxes yielded significant reductions in young adults' daily vaping ( ß Ì‚ = -0.025; 95% CI, -0.037, -0.014) alongside increases in recent smoking ( ß Ì‚ = 0.037; 95% CI, 0.013, 0.061), primarily reflecting greater dual use ( ß Ì‚ =2.078; 95% CI, 0.890, 4.852; P = 0.09). A $1 cigarette tax increase yielded 2.1 and 2.5 percentage point increases in recent and daily vaping, with 95% CIs of (0.004, 0.038) and (0.018, 0.032) respectively. CONCLUSIONS: In the United States, higher ENDS tax rates are associated with decreased ENDS use but increased cigarette smoking among 18- to 25-year-olds, with associations reversed for cigarette taxes.

State marijuana policies and vaping associated lung injuries in the US.

BACKGROUND: The United States' 2019 outbreak of e-cigarette or vaping-associated lung injuries (EVALI) was linked to an additive most common in informally-sourced vaporizable marijuana concentrates. This study estimates how states' recreational and medical marijuana policies related to their 2019 EVALI incidence and residents' likelihood of vaping as their primary mode of marijuana use. METHODS: Multivariable negative binomial regressions estimated associations between states' total 2019 EVALI cases and marijuana policies: recreational legalization, medical legalization only, and whether medical-only policies allowed home cultivation, prohibited combustible use, or had operational dispensaries. Logistic regressions used survey data from the Behavioral Risk Factor Surveillance System's 2016-2019 marijuana supplements to assess how these policies related to past-30-day marijuana users' selection of vaping as their primary mode of use. RESULTS: EVALI incidence was 42% lower in recreational marijuana states (95%CI=0.339,0.993), versus a positive but statistically insignificant association with medical legalization alone. Adjusting for policy attributes revealed heterogeneity: among medical-marijuana-only states, EVALI incidences were > 60% lower where laws allowed home cultivation (aIRR=0.374; 95%CI=0.196, 0.715). Similarly, among past-30-day marijuana users, odds of vaping as one's primary mode of use were > 40% lower in medical-only states where home cultivation was allowed versus prohibited (aOR=0.588; 95%CI=0.365,0.946). CONCLUSIONS: Marijuana policy attributes linked to lower EVALI incidences were also associated with reduced likelihoods of vaping as one's primary mode of use. As additives in informally-sourced vaping concentrates could drive future EVALI cases, marijuana policy design should account for effects on mode of use in licit and illicit markets, to limit the scope of future outbreaks.

Adding vaping restrictions to smoke-free air laws: associations with conventional and electronic cigarette use.

BACKGROUND AND AIMS: In the United States, some states and localities have added vaping restrictions to established smoke-free indoor air laws in order to reduce electronic cigarette use. Yet, if smokers use e-cigarettes to quit, such restrictions could have the unintended effect of attenuating the original smoke-free air policy's effects on smoking. This study estimated changes in current smoking, past-year smoking cessation, and recent vaping following the introduction of smoke- and vape-free air laws. DESIGN: Observational study of nationally representative data from the 2014-2018 National Health Interview Survey. SETTING: United States. PARTICIPANTS/CASES: 87 334 participants, 18-54 years of age. MEASUREMENTS: Multivariable linear regressions estimated the association between increased exposure to smoke- and vape-free worksite and restaurant laws and self-reported current smoking and recent vaping among emerging adults (ages 18-25), as well as past-12-month smoking cessation among prime age adults (ages 26-54). All regressions adjusted for respondent sociodemographic and other tobacco control policies, along with state and year fixed effects. FINDINGS: Smoke-free worksite laws were associated with significant reductions in the likelihood of current smoking ( ß̂  = - 0.050, 95% CI: -0.098, -0.002, P = 0.038) and recent vaping ( ß̂  = - 0.040, 95% CI: -0.072, -0.007, P = 0.013), as well as increases in the likelihood of smoking cessation ( ß̂  = 0.026, 95% CI: 0.000, 0.052, P = 0.046). Adding vaping restrictions to smoke-free worksite laws did not yield further reductions in recent vaping ( ß̂  = 0.008, 95% CI: -0.021, 0.036, P = 0.568) and counteracted over half of the estimated association with current smoking relative to smoke-free policies alone ( ß̂  = 0.030, 95% CI: -0.028, 0.088, P = 0.301). CONCLUSIONS: From 2014 to 2018, increased adoption of smoke-free worksite laws in the United States was associated with reductions in both current smoking and recent vaping, as well as increases in smoking cessation. Adding vaping restrictions to smoke-free worksite laws, however, was not associated with a reduction in recent vaping among emerging adults and may have attenuated the smoke-free policy's impact on current smoking in this age group.

Association of vaping-related lung injuries with rates of e-cigarette and cannabis use across US states.

BACKGROUND AND AIMS: Responses to the 2019 US outbreak of 'e-cigarette or vaping product use-associated lung injury' (EVALI) ranged from temporary restrictions on nicotine e-cigarette sales to critiques of state cannabis policies. However, if either mass-marketed nicotine e-cigarettes or cannabis use per se drove this outbreak, as opposed to an additive in regionally available black-market e-liquids, states' rates of vaping and/or cannabis use should predict their EVALI prevalence. This study tests that relationship. DESIGN: Observational study of EVALI data from US states' health departments SETTING: United States. PARTICIPANTS: All US states (n = 50). MEASUREMENTS: The outcome of interest was each state's total EVALI cases per 12-64-year-old resident-an age group covering most EVALI patients-as reported in the second week of January 2020. Predictors are 2017-18 rates of adult e-cigarette use and past-month cannabis use by state. FINDINGS: The average state EVALI prevalence was 1.4 cases per 100 000 12-64-year-olds. Maps suggest a high-prevalence cluster comprising seven contiguous states in the northern Midwest. EVALI cases per capita were negatively associated with rates of vaping and past-month cannabis use, with the preferred specification's coefficients at -0.239 [95% confidence interval (CI) = -0.441, -0.037; P = 0.02] and -0.086 (95% CI = -0.141, -0.031; P = 0.003), respectively. Robustness checks supported this finding. CONCLUSIONS: In the United States, states with higher rates of e-cigarette and cannabis use prior to the 2019 'e-cigarette or vaping product use-associated lung injury' (EVALI) outbreak had lower EVALI prevalence. These results suggest that EVALI cases did not arise from e-cigarette or cannabis use per se, but rather from locally distributed e-liquids or additives most prevalent in the affected areas.

Marijuana Vaping in U.S. Adults: Evidence From the Behavioral Risk Factor Surveillance System.

INTRODUCTION: As of February 18, 2020, states have reported 2,807 cases of e-cigarette, or vaping, product use-associated lung injury to the Centers for Disease Control and Prevention. Most cases involved cannabinoids. This study identifies current risk factors for adult marijuana vaping by analyzing 2017 and 2018 Behavioral Risk Factor Surveillance System data. METHODS: Data on 8,255 people who recently used marijuana were analyzed in September 2019. Sample-weighted multivariate logistic regressions considered a binary indicator for vaping as the primary method of marijuana use. Adjusting for demographic controls, regressions assessed the association between marijuana vaping and marijuana use for medical purposes (versus nonmedical only), current conventional cigarette use, current nicotine e-cigarette use, and 2 mental health variables. Demographic controls were binary indicators for female sex, Hispanic ethnicity, race, and having completed ≥1 year of college. RESULTS: Odds of marijuana vaping were higher among those who reported using for medical purposes (AORage18-24years=3.8, 95% CI=1.91, 7.67; AORage25-54years=1.8, 95% CI=1.02, 3.08; AORage55-64years=2.3, 95% CI=0.75, 7.07) and lower among people who smoked combustible cigarettes (AORage18-24years=0.2, 95% CI=0.06, 0.65; AORage25-54years=0.2, 95% CI=0.10, 0.26; AORage55-64years=0.1, 95% CI=0.05, 0.34). Vaping nicotine e-cigarettes was associated with greater odds of vaping marijuana for adults aged 25-54 years (AOR=4.6, 95% CI=2.70, 7.78) but not those aged 18-24 years (AOR=0.9, 95% CI=0.33, 2.26). CONCLUSIONS: Among people who use marijuana, adults reporting medical marijuana use were more likely to vape as their primary mode of consumption, whereas conventional cigarette smokers were less likely to do so. Use of nicotine e-cigarettes was associated with a greater likelihood of vaping marijuana for adults aged 25-54 years.