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.

Association between free tobacco product sample receipt and tobacco use in youth and adults in the PATH Study, 2014-2016.

Tobacco companies have distributed free samples of tobacco products in the past. While prior studies have found a relationship between various marketing strategies and tobacco use, no study has assessed the prevalence of free sample receipt or the relationship between receipt and subsequent tobacco use. We analyze three waves of Population Assessment of Tobacco and Health (PATH) Study data to provide the first nationally representative prevalence estimates of free tobacco product receipt among US youth and adults in 2014 to 2016. This analysis also examines the relationship between free tobacco product receipt and ever, past 30-day, and new tobacco use one year later. The prevalence of free sample receipt in the US population in 2014-2016 was 0.8% for any tobacco product but 1.6% for ENDS/e-liquid in adults, and 0.5% for any tobacco product but 1.05% for ENDS/e-liquid in youth. Free sample receipt was higher among vulnerable subgroups. Receipt of free tobacco product samples was associated with tobacco use status using cross-sectional data in youth and adults, as well as one year later in youth. Receipt of a free ENDS or e-liquid sample was associated with any tobacco and ENDS use status using cross-sectional data in youth and adults. After these data were collected, the US Food and Drug Administration broadened the ban on distributing free samples to include all tobacco products except smokeless tobacco in adult-only facilities. Our findings support limiting free samples to further prevent youth access to tobacco products.

Adult Use of and Transitions From Nicotine and Non-nicotine-Containing E-cigarettes: Data From the Population Assessment of Tobacco and Health (PATH) Study, 2013-2016.

INTRODUCTION: Studies largely focus on nicotine-containing e-cigarettes (NiCE) though non-nicotine-containing e-cigarettes (NoCE) exist; NoCE prevalence and patterns of use are largely unknown. This study examines self-reported prevalence and patterns of NiCE/NoCE use. METHODS: We analyzed adult (18+ years) data from the Population Assessment of Tobacco and Health (PATH) study from Wave 1 (2013-2014, n = 32,320), Wave 2 (2014-2015, n = 28,632), and Wave 3 (2015-2016, n = 28,148). We test associations between Wave 1 self-reported current NoCE/NiCE use status and demographic characteristics and assess the proportion of self-reported current NoCE/NiCE users at Wave 1 or Wave 2 who continue to use NoCE or NiCE, switch to NiCE or NoCE, discontinue e-cigarette use, switch to use other nicotine products (ONP), or add ONP use 1 year later (i.e., at Wave 2 or 3). RESULTS: Maintaining the same self-reported NiCE/NoCE and ONP use status 1 year later was the most common use pattern between waves. However, 15.65% of exclusive NoCE users in Wave 2 transitioned to NoCE plus nicotine product use in Wave 3. Also, some exclusive NoCE users transitioned to exclusive NiCE use (17.77% Waves 1-2; 11.55% Waves 2-3). DISCUSSION: Some exclusive NoCE users transitioned to NiCE or added nicotine product use, suggesting there may be other factors (e.g., familiarity with using an aerosolizing device) in addition to the presence of nicotine in influencing initiation or sustained use of nicotine products. IMPLICATIONS: Studies largely focus on nicotine-containing e-cigarettes (NiCE) though non-nicotine-containing e-cigarettes (NoCE) exist; this study adds to the literature by describing demographic characteristics and tobacco use of adult self-reported NoCE users. In addition, the study examines transitions in self-reported NoCE/NiCE use, revealing that some exclusive NoCE users transition to other nicotine product use 1 year later.

Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015.

INTRODUCTION: Changes to the U.S. smokeless tobacco landscape in recent years include a change to health warnings on packages, the implementation of bans in some stadiums, and the launch of a federal youth prevention campaign. It is unclear whether such changes have impacted consumer beliefs about smokeless tobacco. This study examines relative harm perceptions of smokeless tobacco compared to cigarettes among adults and assesses changes in smokeless tobacco harm perceptions over time. METHODS: We analyzed data from three cycles (2012, 2014, 2015) of the Health Information National Trends Survey (HINTS). Using 2015 data, we assessed bivariate associations between smokeless tobacco harm perceptions and tobacco use, beliefs, information seeking, and demographics. Using 2012, 2014, and 2015 data, we assessed whether smokeless tobacco harm perceptions changed over time within demographic groups using chi-square tests. We then used a weighted multinomial logistic regression to assess the association between smokeless tobacco perceptions and survey year, adjusting for covariates. RESULTS: When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of respondents across cycles said "no." The percent of respondents who selected this response option decreased over time. Findings showed significant differences in relative harm perceptions of smokeless tobacco versus cigarettes for specific demographic subgroups. Among subgroups, these shifts did not occur with a discernible pattern. CONCLUSIONS: Understanding factors associated with perceptions of smokeless tobacco can inform tobacco control efforts. Additional monitoring of these trends may provide researchers with a deeper understanding of how and why smokeless tobacco harm perceptions change.

Characteristics of Hookah Tobacco Smoking Sessions and Correlates of Use Frequency Among US Adults: Findings From Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study.

Introduction: Hookah tobacco smoking has increased in the United States. However, information on hookah use frequency and other characteristics of hookah use is limited. Methods: Investigators analyzed data from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of US youth and adults. Our analysis draws on baseline data from adult (ages ≥18 years) ever (N = 10 624) and past year (n = 3947) hookah users. Bivariate and regression analyses were conducted to identify associations between demographics, use characteristics, and hookah use frequency. Results: Overall, 16.4% of adults reported ever smoking tobacco from a hookah. Of those, 31.9% reported smoking hookah within the past year. Among 3947 past-year hookah tobacco smokers, 10.7% were daily/weekly users, 13.7% were monthly users, 42.1% smoked every couple of months, and 33.5% smoked about once a year. Among daily/weekly hookah users, 66% were young adults (ages 18-24 years). When comparing daily/weekly hookah users to those who smoked every couple of months, more frequent hookah use was associated with younger age, male gender, a greater number of times the hookah is refilled during a session, fewer people sharing, and hookah ownership. Conclusion: Although there were few demographic differences between daily/weekly users and less frequent hookah tobacco smokers, some notable differences in use behaviors exist among use frequency groups. Unlike other tobacco products, hookah is often smoked communally, over an extended time period. A detailed understanding of hookah user characteristics and experiences could inform hookah-specific measures, messaging, and regulations. Implications: To our knowledge, this is one of the first studies to characterize hookah use frequency, session length, and other hookah use experiences using a nationally representative sample of US adult hookah smokers. Understanding characteristics of hookah tobacco smokers, their use experiences, and patterns of hookah use frequency would be useful in assessing risks for hookah tobacco dependence at the population level. Additionally, identifying variation in use behaviors of hookah tobacco smokers could be used to inform the development of strategies to reduce and prevent hookah tobacco use, such as tobacco regulations or public education efforts, particularly among young adults.

News Media Framing of New York City's Sugar-Sweetened Beverage Portion-Size Cap.

OBJECTIVES: We assessed news media framing of New York City's proposed regulation to prohibit the sale of sugar-sweetened beverages greater than 16 ounces. METHODS: We conducted a quantitative content analysis of print and television news from within and outside New York City media markets. We examined support for and opposition to the portion-size cap in the news coverage from its May 31, 2012, proposal through the appellate court ruling on July 31, 2013. RESULTS: News coverage corresponded to key events in the policy's evolution. Although most stories mentioned obesity as a problem, a larger proportion used opposing frames (84%) than pro-policy frames (36%). Mention of pro-policy frames shifted toward the policy's effect on special populations. The debate's most prominent frame was the opposing frame that the policy was beyond the government's role (69%). CONCLUSIONS: News coverage within and outside the New York City media market was more likely to mention arguments in opposition to than in support of the portion-size cap. Understanding how the news media framed this issue provides important insights for advocates interested in advancing similar measures in other jurisdictions.

Patterns and predictors of state adult obesity prevention legislation enactment in US states: 2010-2013.

OBJECTIVE: This study examined bill- and state-level factors associated with enactment of adult obesity prevention legislation in US states. METHODS: A review of bills in the Rudd Center for Food Policy and Obesity's legislative database identified 487 adult obesity prevention bills, or proposed legislation, introduced between 2010 and 2013. Multilevel models were constructed to examine bill- and state-level characteristics associated with enactment. RESULTS: From 2010 to 2013, 81 (17%) of obesity prevention bills introduced were enacted across 35 states and the District of Columbia. Bills introduced in 2010 were more likely to be enacted than in 2013 (OR=9.49; 95% CI: 2.61-34.5). Bills focused on access to healthy food, physical activity, general and educational programs, as well as modifying rules and procedures (e.g., preemption) had greater odds of enactment relative to food and beverage taxes (OR=8.18; 95% CI: 2.85-23.4 healthy food; OR=17.3; 95% CI: 4.55-65.7 physical activity; OR=15.2; 95% CI: 4.80-47.9 general; OR=13.7; 95% CI: 3.07-61.5 rules). CONCLUSION: The year of bill introduction and overall bill enactment rate were related to adult obesity prevention legislation enactment in states. This study highlights the importance of a bill's topic area for enactment and provides insights for advocates and policymakers trying to address enactment barriers.

Public support for a sugar-sweetened beverage tax and pro-tax messages in a Mid-Atlantic US state.

OBJECTIVE: To examine the characteristics of supporters and opponents of a sugar-sweetened beverage (SSB) tax and to identify pro-tax messages that resonate with the public. DESIGN: A survey was administered by telephone in February 2013 to assess public opinion about a penny-per-ounce tax on SSB. Support was also examined for SSB consumption reduction and pro-tax messages. Individual characteristics including sociodemographics, political affiliation, SSB consumption behaviours and beliefs were explored as predictors of support using logistic regression. SETTING: A representative sample of voters was recruited from a Mid-Atlantic US state. SUBJECTS: The sample included 1000 registered voters. RESULTS: Findings indicate considerable support (50 %) for an SSB tax. Support was stronger among Democrats, those who believe SSB are a major cause of childhood obesity and those who believe childhood obesity warrants a societal intervention. Belief that a tax would be effective in lowering obesity rates was associated with support for the tax and pro-tax messages. Respondents reporting that a health-care provider had recommended they lose weight were less convinced by pro-tax messages. Women, Independents and those concerned about childhood obesity were more convinced by the SSB reduction messages. Overall, the most popular messages focused on the importance of reducing consumption among children without mentioning the tax. CONCLUSIONS: Understanding who supports and opposes SSB tax measures can assist advocates in developing strategies to maximize support for this type of intervention. Messages that focus on the effect of consumption on children may be useful in framing the discussion around SSB tax proposals.

Patient navigation for breast and colorectal cancer in 3 community hospital settings: an economic evaluation.

BACKGROUND: The Ralph Lauren Cancer Center implemented patient navigation programs in sites across the United States building on the model pioneered by Harold P. Freeman, MD. Patient navigation targets medically underserved with the objective of reducing the time interval between an abnormal cancer finding, diagnostic resolution, and treatment initiation. In this study, the authors assessed the incremental cost effectiveness of adding patient navigation to standard cancer care in 3 community hospitals in the United States. METHODS: A decision-analytic model was used to assess the cost effectiveness of a colorectal and breast cancer patient navigation program over the period of 1 year compared with standard care. Data sources included published estimates in the literature and primary costs, aggregate patient demographics, and outcome data from 3 patient navigation programs. RESULTS: After 1 year, compared with standard care alone, it was estimated that offering patient navigation with standard care would allow an additional 78 of 959 individuals with an abnormal breast cancer screening and an additional 21 of 411 individuals with abnormal colonoscopies to reach timely diagnostic resolution. Without including medical treatment costs saved, the cost-effectiveness ratio ranged from $511 to $2080 per breast cancer diagnostic resolution achieved and from $1192 to $9708 per colorectal cancer diagnostic resolution achieved. CONCLUSIONS: The current results indicated that implementing breast or colorectal cancer patient navigation in community hospital settings in which low-income populations are served may be a cost-effective addition to standard cancer care in the United States.

A cost-effectiveness analysis of India's 2008 prohibition of smoking in public places in Gujarat.

Tobacco smoking and exposure to secondhand tobacco smoke are associated with disability and premature mortality in low and middle-income countries. The aim of this study was to assess the cost-effectiveness of implementing India's Prohibition of Smoking in Public Places Rules in the state of Gujarat, compared to implementation of a complete smoking ban. Using standard cost-effectiveness analysis methods, the cost of implementing the alternatives was evaluated against the years of life saved and cases of acute myocardial infarction averted by reductions in smoking prevalence and secondhand smoke exposure. After one year, it is estimated that a complete smoking ban in Gujarat would avert 17,000 additional heart attacks and gain 438,000 life years (LY). A complete ban is highly cost-effective when key variables including legislation effectiveness were varied in the sensitivity analyses. Without including medical treatment costs averted, the cost-effectiveness ratio ranges from $2 to $112 per LY gained and $37 to $386 per acute myocardial infarction averted. Implementing a complete smoking ban would be a cost saving alternative to the current partial legislation in terms of reducing tobacco-attributable disease in Gujarat.