Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

National Trends in Sales and Price for Commercial Tobacco and Nicotine Products, 2018-2022.

This cross-sectional study explores recent trends in sales and price of tobacco and nicotine products in the US.

Cardiovascular disease outcomes among established cigar users 40 years and older: Findings from the population assessment of tobacco and health (PATH) study, waves 1-5 (2013-2019).

This study examined associations between established cigar use and prevalence and incidence of cardiovascular diseases (CVD; congestive heart failure, stroke, or heart attack/needed bypass surgery) among U.S. adults, 40 years or older. Using Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, incidence (Nindividuals (Nind) = 6,692; Nobservations (Nobs) = 23,738) and prevalence (Nind = 7,819; Nobs = 33,952) of CVD outcomes were examined using weighted generalized estimating equations (WGEEs) among adults who were exclusive current/former established cigar smokers (ever cigar smokers who have smoked fairly regularly), exclusive current/former established cigarette smokers (lifetime smokers of 100 or more cigarettes), dual current/former established cigarette and cigar smokers compared with never smokers of cigars or cigarettes, adjusting for covariates. The population-averaged incidence of CVD from one wave to next among exclusive current/former established cigar smokers during a six-year period based on WGEEs was low (overall average rate of 3.0 %; 95 % CI: 1.2, 7.0). Compared with never users, exclusive current/former established cigar smokers (OR = 1.67, 95 % CI: 1.11, 2.51) and exclusive current/former established cigarette smokers (OR = 2.12, 95 % CI: 1.45, 3.09) were more likely to have any CVD outcome in unadjusted analyses. When adjusted for covariates, only exclusive current/former established cigarette use was associated with CVD outcomes (AOR = 1.60, CI: 1.07, 2.40). Results suggest that exclusive established use of cigars or duration of exclusive cigar use was not associated with lifetime CVD prevalence compared with never cigar or cigarette smokers, which is important in understanding health outcomes in cigar users.

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study.

BACKGROUND: In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health. METHODS: Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels. RESULTS: Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05). CONCLUSIONS: Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use.

INTRODUCTION: In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2-5 or minimum prices of $2.50-5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use. METHODS: Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999-2011) to postpolicy (2012-2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race. RESULTS: Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17-0.47) and statewide (AOR: 0.98; 95% CI: 0.98-0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races. CONCLUSIONS: These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.

Patterns of Premium and Nonpremium Cigar Use in the United States: Findings from Wave 6 (2021) of the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Understanding the characteristics of premium cigar use patterns is essential for minimizing public health harms. Typically, premium cigars are handmade, larger, more expensive, and without the characterizing flavors that are present in other cigar types: Nonpremium traditional cigars, cigarillos, and filtered cigars. AIMS AND METHODS: Self-reported brand and price data were used from Wave 6 of the Population Assessment of Tobacco and Health (PATH) Study to define and estimate premium versus nonpremium cigar use among U.S. adults, as well as to explore cigar smoking patterns, purchasing behavior, and reasons for use by cigar type. RESULTS: In 2021, 0.9% (95% CI = 0.7-1.0) of adults were premium cigar users, compared to 0.4% of nonpremium traditional cigar users (95% CI = 0.3-0.5), 1.1% of cigarillo users (95% CI = 1.0-1.2), and 0.6% filtered cigar users (95% CI = 0.5-0.7). Premium cigar users were overwhelmingly male (97.7%), and 35.8% were aged ≥55 years. The average premium cigar price/stick was $8.67, $5.50-7.00 more than other cigar types. Compared to other cigar types, significantly fewer premium cigar users had a regular brand with a flavor other than tobacco (~15% vs. 38%-53%). Though flavors remained the top reason for premium cigar use, they were less likely to endorse flavors as a reason for use than other cigar users (~40% vs. 68-74%). Premium cigar users had a lower prevalence (aRR: 0.37, 95% CI = 0.25-0.55) of dual use of cigars and cigarettes. CONCLUSIONS: Although <1% of U.S. adults use premium cigars, their use and purchasing characteristics continue to differ from other cigar types, highlighting the importance of capturing data specific to premium cigar use. IMPLICATIONS: This manuscript extends previous research from the National Academies of Science, Engineering, and Medicine report, "Premium cigars: Patterns of use, marketing, and health effects" by utilizing the most recent PATH Study data (Wave 6) to examine patterns of cigar use, including purchasing behavior and reasons for use, by cigar type (eg, premium traditional cigars, nonpremium traditional cigars, cigarillos, and filtered cigars). The findings support continued research on patterns of premium cigar use, which differ from use patterns of other cigar types.

The impact of cigar pack size and pricing policies on youth and adult cigar use in the US.

BACKGROUND: Over 250 US localities have adopted cigar pack quantity and price policies. No empirical studies exist on their impact on tobacco use. METHODS: A quasi-experimental design was used to assess the impact of cigar policies on cigar and cigarette use among (1) Minnesota youth (n=569,528, triennially 2007-2019); (2) New York youth (n=111,236, annually 2000-2020), (3) New York adults (n=62,295, annually 2003-2019), and (4) District of Columbia (DC) adults (n=5027, annually 2015-2019). We estimated the county-level policy coverage for 15 local policies in Minnesota. Differences-in-differences approach was used to compare the policy in NYC with the rest of the state (no policy). We examined changes in DC use before and after policy implementation. Analyses adjust for sociodemographic characteristics. RESULTS: In Minnesota, youth in counties with a greater proportion of the population covered by a policy had lower odds of cigar use (AOR: 0.51; 95% CI: 0.38-0.69). Similarly, adult cigar use in DC declined following policy enactment (AOR: 0.65; 95% CI: 0.46-0.93). Cigarette use also decreased in both Minnesota and DC following policy enactment. However, in New York, the NYC policy did not have a significant impact on cigar use among youth (AOR: 0.95; 95% CI: 0.47-1.93) or adults (AOR: 1.98; 95% CI: 0.85-1.37) in NYC compared to the rest of the state. The only significant effect in NYC was reduced odds for adult cigarette use (AOR: 0.79; 95% CI: 0.68-0.92). CONCLUSIONS: Findings suggest regulating cigar packaging could decrease cigar consumption without increasing cigarette consumption, but effects may differ across jurisdictions.

Menthol Cigarette Use Among Adults Who Smoke Cigarettes, 2008-2020: Rapid Growth and Widening Inequities in the United States.

INTRODUCTION: In April 2021, the U.S. Food and Drug Administration announced its intention to issue a product standard banning menthol as a characterizing flavor in cigarettes. Given the potential relevance of national estimates of menthol use to pending legislation, this study estimated the prevalence of menthol use among U.S. adults who smoke cigarettes in 2020 and investigated changes in menthol use from 2008 to 2019 by sociodemographics, mental health, and substance use. AIMS AND METHODS: Nationally representative annual, cross-sectional data from the National Survey on Drug Use and Health, which included participants ages 18 years and older residing in the United States from 2008 to 2019 and the 2020. Data were analyzed using logistic and linear regression models to estimate trends in menthol use among adults who smoke cigarettes by sociodemographic, mental health and substance use variables (total analytic sample 2008-2019 n = 128 327). RESULTS: In 2020, 43.4% of adults who smoked cigarettes in the past month used menthol. Menthol use was most common among black adults (80%) and over 50% of those Hispanic, female, young (ages 18-34 years), lesbian/gay, with serious psychological distress, and with cigar use used menthol. Menthol use increased among adults who used cigarettes from 2008 to 2019, overall, and grew more rapidly among adults ages 26-34 years, Hispanic, light cigarette use (1-5 per day), and those who smoked cigars. CONCLUSIONS: Menthol use has increased among U.S. adults who smoke cigarettes over the past decade. Enacting menthol bans could have a widespread public health impact, especially among younger and minoritized groups. IMPLICATIONS: Menthol cigarette use increased among individuals who smoke cigarettes from 2008 to 2019 in the United States. In 2020, over 40% of smokers used menthol, and menthol use was considerably higher among adult smokers from racial/ethnic minoritized groups, who were younger and who reported mental health problems. The U.S. Food and Drug Administration seeks to ban menthol as a characterizing flavor in cigarettes; our results suggest that such a ban is likely to have a wide-ranging impact on public health.

The Landscape of Cigar Marketing in Print Magazines from 2018-2021: Content, Expenditures, Volume, Placement and Reach.

Cigar consumption has increased in the U.S. over the past decade, yet gaps remain in research on cigar promotion in print magazines. This study examines ad placement, volume, ad characteristics, and associated expenditures for cigars from 2018-2021, and readership data for magazines containing cigar ads. We merged content analysis data with Kantar Media data on magazine placement and expenditures and used magazine readership data from MRI-Simmons. The only brand in print magazines was Black & Mild (B & M), a top cigar brand in the U.S. There were 30 unique B & M magazine ads and 284 occurrences (i.e., appearances in magazines), translating to $46,504,578 in expenditures. All ads featured the word "enjoy/enjoyment" and a warning label. Filtered cigars were the most featured cigar type (75%) and sweets was the most featured flavor (78%). Nearly half of the publications in which B & M were advertised in have substantial Black/African American readership and were featured in publications with disproportionate young adult and Hispanic/Latino readership. This study identified tactics used in print advertising for a top cigar brand. Future research should examine how these tactics impact consumer perceptions. Findings of cigar ads reaching vulnerable populations may inform the FDA's efforts to reduce health disparities through regulations and public education.

Cigar Warning Noticing and Demographic and Usage Correlates: Analysis from the United States Population Assessment of Tobacco and Health Study, Wave 5.

Although cigars pose health risks similar to cigarettes, their packaging/marketing is not subject to commensurate regulation in the US. In a 2000 agreement with the Federal Trade Commission, seven major manufacturers agreed to use some form of cigar warning. In 2016, the Food and Drug Administration passed a rule requiring larger standardized warnings, but the requirement was successfully challenged in court. Here, we examined U.S. population-level trends in noticing existing cigarillo, traditional and filtered cigar warnings. We analyzed Wave 5 Population Assessment of Tobacco and Health adult data to assess prevalence of past-30 day warning noticing and associations with socio-demographic and tobacco use variables. Noticing was higher among current users of cigarillos (27%), filtered (34%) and traditional cigars (21%), than non-users (8% for each product, p < 0.0001), and among every-day vs. some-day users, established vs. experimental users, and past-30 day users vs. those without past-30 day use. Results varied by product, but generally indicated lower noticing among non-Hispanic Whites and dual cigarette users, but higher noticing among those purchasing cigars by the box/pack (vs. not purchasing for themselves). Low overall noticing but higher prevalence among frequent users underscores a need for a stronger, uniform cigar warning label policy in the US.

Examining the Impact of Question Construction on Reporting of Sexual Identity: Survey Experiment Among Young Adults.

BACKGROUND: Compared with heterosexuals, sexual minorities in the United States experience a higher incidence of negative physical and mental health outcomes. However, a variety of measurement challenges limit researchers' ability to conduct meaningful survey research to understand these disparities. Despite the prevalence of additional identities, many national health surveys only offer respondents 3 substantive options for reporting their sexual identities (straight/heterosexual, gay or lesbian, and bisexual), which could lead to measurement error via misreporting and item nonresponse. OBJECTIVE: This study compared the traditional 3-option approach to measuring sexual identity with an expanded approach that offered respondents 5 additional options. METHODS: An online survey experiment conducted among New Jersey residents between March and June 2021 randomly assigned 1254 young adults (ages 18-21) to answer either the 3-response measure of sexual identity or the expanded item. Response distributions for each measure were compared as were the odds of item nonresponse. RESULTS: The expanded version of the question appeared to result in more accurate reporting among some subgroups and induced less item nonresponse; 12% (77/642) of respondents in the expanded version selected a response that was not available in the shorter version. Females answering the expanded item were less likely to identify as gay or lesbian (2.1% [10/467] vs. 6.6% [30/457]). Females and Non-Hispanic Whites were slightly more likely to skip the shorter version than the longer version (1.1% [5/457 for females and 3/264 for Non-Hispanic Whites] vs. 0% [0/467 for females and 0/277 for Non-Hispanic Whites]). About 5% (32/642) of respondents answering the longer item were unsure of their sexual identity (a similar option was not available in the shorter version). Compared with respondents answering the longer version of the question, those answering the shorter version had substantially greater odds of skipping the question altogether (odds ratio 9.57, 95% CI 1.21-75.74; P=.03). CONCLUSIONS: Results favor the use of a longer, more detailed approach to measuring sexual identity in epidemiological research. Such a measure will likely allow researchers to produce more accurate estimates of health behaviors and outcomes among sexual minorities.

Cigarette Smoking and the Role of Menthol in Tobacco Use Inequalities for Sexual Minorities.

INTRODUCTION: Cigarette smoking is disproportionately common among sexual minorities. While menthol market share has increased in the past decade, research on menthol cigarette smoking among sexual minorities is scant. For this study, we examined menthol cigarette smoking in the United States, by sex and sexual identity using a nationally representative sample of adults. AIMS AND METHODS: We pooled data from the 2015-2019 National Survey on Drug Use and Health. We used chi-square tests and multivariable logistic regression models to examine (1) past 30-day cigarette use, (2) past 30-day menthol use, and (3) menthol preference among adults who have smoked cigarettes in the past 30 days for the following groups: heterosexual/straight males, heterosexual/straight females, gay males, gay/lesbian females, bisexual males, and bisexual females. Data were analyzed in September 2020. RESULTS: Bivariate analyses revealed that prevalence of cigarette smoking and menthol cigarette smoking were higher among sexual minorities compared with heterosexual respondents, and that preference for menthol was highest among lesbian/gay and bisexual females who smoke. Multivariable models showed that compared with heterosexual females who smoke, odds of menthol preference were lower among heterosexual/straight and bisexual males who smoke, and higher among bisexual females. CONCLUSIONS: Our study found that menthol preference was disproportionately high among sexual minorities who smoke-bisexual and gay/lesbian females who smoke in particular. Research is needed to understand why menthol use is common among sexual minorities who smoke. IMPLICATIONS: Using data from a nationally representative study, this study makes a unique contribution to literature by identifying differences in menthol smoking between sexual minority subgroups. Specifically, we found that menthol smoking was highest among sexual minority females (ie, lesbian/gay and bisexual females) compared with other sexual minorities. These findings highlight the need for targeted interventions to prevent menthol cigarette initiation among sexual minorities, as well as to promote smoking cessation among sexual minorities who smoke menthol cigarettes, with an emphasis on sexual minority females. Future research should examine the impact of a potential menthol ban on these inequalities.

Toward a More Comprehensive Index of Youth Cigarette Smoking: Average Number of Cigarettes Smoked per Day among Students in the United States over Two Decades.

Reliance on 30-day prevalence as the principal means of assessing trends in youth cigarette smoking may understate the magnitude of the decrease in youth smoking, because prevalence does not account for smoking frequency or intensity. We analyzed Youth Risk Behavior Survey (YRBS) data from 1997 through 2017 and estimated cigarette smoking prevalence (any smoking in the previous 30 days), frequency (number of smoking days in the previous 30 days), and intensity (cigarettes per day on smoking days). We calculated average cigarettes smoked per day (ACSD) as the product of frequency and intensity, divided by 30. We estimated ACSD among all high school students and by smoking frequency group (i.e., 1-5, 6-9, 10-19, 20-29, or 30 of the previous 30 days), sex, grade level, and race/ethnicity. Among US high school students, ACSD declined by 86.7% from 1997 to 2017, while prevalence declined by 75.8%. Within smoking frequency groups, smoking intensity remained similar over the two decades. However, changes in ACSD over time varied by race/ethnicity; ACSD increased among Hispanic and non-Hispanic Black daily smokers while it decreased among daily smokers of other race/ethnicity groups. ACSD declined more substantially than smoking prevalence over two decades but remained virtually unchanged within smoking frequency groups, indicating that changes in frequency, rather than intensity, drove this decline. Prevalence estimates alone understate the degree to which youth in the United States have rejected smoking, and racial/ethnic disparities in smoking intensity are hidden when we limit our lens to prevalence-only measures.

Availability of menthol cigarettes in Oakland, California after a partial flavor ban.

This study measures the availability of menthol cigarettes in Oakland, California where such products were banned from the majority of tobacco retailers, except for those who sold a significant amount of tobacco (e.g., 60% gross income). Out of a total of 385 retailers in Oakland, only forty-eight retailers were exempt from this ban at the time of data collection. In February 2019, seven months after the ban went into effect, we selected a stratified random sample of 15 census tracts, based on race/ethnicity. In pairs, data collectors walked on opposite sides of the street and collected all discarded cigarette packs (n = 641) from the streets and sidewalks on weekdays. Overall, we found almost half (46.0%; 95% CI = 32.6%-59.3%) of the packs collected were menthol, with Newport as the dominant brand. We found at least one pack of menthol cigarettes in 14 of the 15 sampled census tracts. In predominantly black/African American census tracts, the proportion of menthol cigarettes collected was significantly higher (70.1%; 95% CI = 62.6%-77.7%) when compared to mixed race/ethnicity (55.9%; 95% CI = 41.0-70.9%) and white tracts (35.1%; 95% CI = 13.2%-57.1%). Finally, there was a moderate and negative correlation between distance to exempt tobacco retailer and menthol availability (r = -0.66, p < .05). The proportion of menthol cigarette packs decreased the further away census tracts were from exempt tobacco retailers. Results from this study lend support that partial bans provide disproportionate availability of menthol cigarettes in black/African American census tracts. Complete bans may help eliminate disparities associated with menthol cigarette use across communities.

Changes in Tobacco Product Advertising at Point of Sale: 2015-2018.

OBJECTIVES: Tobacco point-of-sale advertising, particularly in retailers surrounding schools, is associated with youth tobacco use and must be monitored. This study examines how the point-of-sale environment surrounding youth changed over time with regard to diverse tobacco products. METHODS: Each spring from 2015 to 2018, research staff visited the same tobacco retailers (n = 141) within a half-mile of New Jersey high schools. For cigarettes, cigars, electronic cigarettes, and smokeless tobacco, advertisement presence, volume, and share of advertising voice (SAV) were measured for both the exterior and interior of the store. Analyses examined changes over time by product, controlling for store type and poverty. RESULTS: Over time, exterior cigarette advertisements declined in presence (61% to 49%) and SAV (50% to 40%), whereas interior advertisements maintained stable presence, volume, and SAV. In contrast, cigar advertisements increased in presence (exterior 11% to 23%; interior 19% to 30%) and volume (exterior mean 0.2 to 0.5; interior 0.3 to 0.8). For electronic cigarettes, exterior and interior advertising presence, volume, and SAV decreased from 2015 to 2017 but increased in 2018. Smokeless tobacco advertising was infrequent and stayed consistent except in volume in the interior of stores (mean 0.2 to 0.3). When there were any differences by store type, chain convenience stores had the most exterior and interior advertising for all products. CONCLUSIONS: The longitudinal changes observed for each product's advertising reflect national youth use rates of the corresponding products. The point-of-sale environment around schools may be influencing youth tobacco use and must be monitored and regulated.

Prevalence of Electronic Cigarette Use Among Adolescents in New Jersey and Association With Social Factors.

Importance: Use of electronic cigarettes (e-cigarettes) is high among adolescents, but the extent to which the JUUL e-cigarette brand accounts for the high prevalence has not been explored using population-based surveys. Objective: To examine e-cigarette and JUUL use among adolescents in New Jersey. Design, Setting, and Participants: Survey study using data from the 2018 New Jersey Youth Tobacco Survey, a cross-sectional statewide representative survey of tobacco use. The survey was school based and sampled New Jersey students in grades 9 to 12. Exposures: Use of tobacco products; JUUL as first tobacco product tried; exposure to JUUL at school; number of friends perceived as JUUL users; liking or following a tobacco brand on social media; and buying or receiving tobacco-branded merchandise. Main Outcomes and Measures: Prevalence ratio (PR) for current and frequent e-cigarette use, inclusive of JUUL. Results: In this sample of 4183 adolescents, respondents were 49.6% female and 49.6% non-Hispanic white. Students were evenly distributed across grades 9 through 12. Overall, the estimate for current use of e-cigarettes inclusive of JUUL was higher (24.2%; 95% CI, 22.5%-25.9%) compared with current use assessed by use of e-cigarettes only (17.8%; 95% CI, 16.4%-19.4%) or JUUL use only (21.3%; 95% CI, 19.7%-23.0%). Divergence in e-cigarette use estimates was higher for certain subgroups, including female respondents and non-Hispanic black respondents. Also, 88.8% (95% CI, 86.6%-91.1%) of current e-cigarette users reported JUUL as a brand they used. Hispanic students (PR, 0.78; 95% CI, 0.69-0.89) and non-Hispanic students of other races (PR, 0.64; 95% CI, 0.51-0.81) were significantly less likely than non-Hispanic white students to be current e-cigarette users, and students in 12th grade were more likely than those in 9th grade to be current users (PR, 1.29; 95% CI, 1.11-1.48). Current e-cigarette use was positively associated with current use of other tobacco products (PR, 2.57; 95% CI, 2.24-2.95), endorsing a tobacco brand on social media (PR, 1.43; 95% CI, 1.19-1.72), having tobacco-branded merchandise (PR, 1.70; 95% CI, 1.46-1.97), having close friends who used JUUL (PR, 3.81; 95% CI, 3.17-4.58), and seeing JUUL used on school grounds (PR, 1.43; 95% CI, 1.24-1.65). Estimates of prevalence were greater when modeling frequent use. Conclusions and Relevance: This study found that prevalence of current and frequent e-cigarette use among adolescents was higher when inclusive of JUUL use, and JUUL was by far the most common e-cigarette brand used, providing support for inclusion of brand-specific questions when assessing e-cigarette use. The results also identify characteristics of adolescents who may be more likely to use e-cigarettes.

Flavour types used by youth and adult tobacco users in wave 2 of the Population Assessment of Tobacco and Health (PATH) Study 2014-2015.

BACKGROUND: Most youth and young adult (YA) tobacco users use flavoured products; however, little is known about specific flavours used. METHODS: We report flavour types among US tobacco users from the Population Assessment of Tobacco and Health Study, wave 2, 2014-2015. At wave 2, we examined (1) flavour use and type at past 30-day use; (2) new flavoured tobacco product use and type; (3) product-specific flavour patterns across youth (ages 12-17) (n=920), YA (18-24) (n=3726) and adult (25+) (n=10 346) past 30-day and new tobacco users and (4) concordance between self-coded and expert-coded brand flavour type among all adults (18+). RESULTS: Prevalence of flavoured tobacco product use was highest among youth, followed by YA and adult 25+ any tobacco users. Within each age group, flavoured use was greatest among hookah, e-cigarette and snus users. Overall, menthol/mint, fruit and candy/sweet were the most prevalent flavour types at first and past 30-day use across age groups. For past 30-day use, all flavour types except menthol/mint exhibited an inverse age gradient, with more prevalent use among youth and YAs, followed by adults 25+. Prevalence of menthol/mint use was high (over 50% youth, YAs; 76% adults 25+) and exhibited a positive age gradient overall, though the reverse for cigarettes. Brand-categorised and self-reported flavour use measures among adults 18+ were moderately to substantially concordant across most products. CONCLUSIONS: Common flavours like menthol/mint, fruit and candy/sweet enhance appeal to young tobacco users. Information on flavour types used by product and age can inform tobacco flavour regulations to addess flavour appeal especially among youth.

A discarded cigar package survey in New York City: indicators of non-compliance with local flavoured tobacco restrictions.

INTRODUCTION: In 2009, New York City (NYC) restricted the sale of flavoured tobacco products. We assessed product availability as a proxy for potential non-compliance by analysing discarded cigar, cigarillo and blunt wrap packages in New York City. METHODS: A discarded cigar package survey was conducted in 2016, in a stratified random sample of 94 block groups in NYC resulting in the collection of 886 discarded cigar packages. Each package was coded for brand name, flavour description (explicit and implicit) and size. FINDINGS: Overall, 19.2% of the cigar packages were explicitly flavoured. An additional 9.4% of the packages reflected implicit flavours. Explicit flavoured cigar packages were at increased odds of being found in Staten Island (adjusted OR (AOR)=3.96, 95% CI=1.66 to 9.46), in packaging size of two or three (AOR=8.49, 95% CI=4.24 to 17.02) or four or more (AOR=4.26, 95% CI=1.95 to 9.30). CONCLUSION: Nearly one out of three cigar packages were flavoured products suggesting a problematic level of non-compliance and continued availability. Potential non-compliance is likely fueled by licensed wholesalers and retailers who continue to sell restricted flavoured products. Some retailers may be unaware that implicitly named cigars are typically flavoured and are, therefore, illegal. This lack of awareness of implicit flavoured cigars may be exacerbated by NYC's lack of education or enforcement specific to implicitly flavoured tobacco products.