Cigarette smoking decline among US young adults from 2000 to 2019, in relation to state-level cigarette price and tobacco control expenditure.

OBJECTIVE: To investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000-2019 decline in cigarette smoking among US 18-24 year-olds. METHODS: Smoking behaviour was assessed in the 24 most populous US states using the 1992-2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011. RESULTS: Between 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018-2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean. CONCLUSION: National programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

RETRACTED: Changes in Tobacco Dependence and Association With Onset and Progression of Use by Product Type From Wave 1 to Wave 3 of the Population Assessment of Tobacco and Health (PATH) Study.

INTRODUCTION: This study examined trajectories of tobacco dependence (TD) in relation to changes in tobacco product use and explored the effects of product-specific adding, switching, or discontinued use on dependence over time. AIMS AND METHODS: Data were analyzed from the first three waves of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal study of adults and youth in the United States. Data included 9556 Wave 1 (2013/2014) adult current established tobacco users who completed all three interviews and had established use at ≥2 assessments. Groups included cigarettes-only users, e-cigarettes-only users, cigars-only users, hookah-only users, any smokeless-only users, cigarette + e-cigarette dual users, and multiple product users. A validated 16-item scale assessed TD across product users. RESULTS: Wave 1 e-cigarette-only users' who maintained exclusive e-cigarette use increased levels of TD through Wave 3 as did those who added or switched to another product. Wave 1 multiple product users' TD decreased across waves. TD for all other Wave 1 user groups remained about the same. For Wave 1 cigarette-only smokers, switching to another product or moving to a pattern of no established use was associated with lower levels of TD than smokers whose use stayed the same. Movement to no established use of any tobacco product was consistently associated with lower TD for all other product users. CONCLUSIONS: Except for Wave 1 e-cigarette-only users, TD among US tobacco product users was stable over time, with daily users less likely to vary from baseline. IMPLICATIONS: The level of TD among most US tobacco users was stable over the first three waves of the PATH Study and trends in levels of TD were predominantly unrelated to changes in patterns of continued product use. Stable levels of TD suggest a population at persistent risk of health impacts from tobacco. Wave 1 e-cigarette users, including those maintaining exclusive e-cigarette use, experienced increasing levels of TD over time, perhaps because of increases in quantity or frequency of their e-cigarette product use or increasing efficiency of nicotine delivery over time.

Changes in Tobacco Dependence and Association With Onset and Progression of Use by Product Type From Waves 1 to 3 of the Population Assessment of Tobacco and Health (PATH) Study.

INTRODUCTION: This study examined trajectories of tobacco dependence (TD) in relationship to changes in tobacco product use, and explored the effects of product-specific adding, switching, or discontinued use on dependence over time. AIMS AND METHODS: Data were analyzed from the first three waves from the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal study of adults and youth in the United States. Data included 9556 wave 1 (2013-2014) adult current established tobacco users aged 18 or older who completed all three interviews and had established use at ≥2 assessments. Mutually exclusive groups included: users of cigarettes only, e-cigarettes only, cigars only, hookah only, any smokeless only, cigarette + e-cigarette dual users, and other multiple product users. A validated 16-item scale assessed TD across product users. RESULTS: People who used e-cigarettes exclusively at wave 1 had small increases in TD through wave 3. Wave 1 multiple product users' TD decreased across waves. TD for all other wave 1 user groups remained about the same. For wave 1 cigarette only smokers, switching to another product was associated with lower levels of TD than smokers whose use stayed the same. Movement to no established use of any tobacco product was consistently associated with lower TD for all product users. CONCLUSIONS: Except for wave 1 e-cigarette only users (who experienced small increases in TD), TD among U.S. tobacco product users was stable over time, with daily users less likely to vary from baseline. IMPLICATIONS: The level of TD among most U.S. tobacco users was stable over the first three waves of the PATH Study and trends in levels of TD were predominantly unrelated to changes in patterns of continued product use. Stable levels of TD suggest a population at persistent risk of health impacts from tobacco. Wave 1 e-cigarette users experienced small increases in levels of TD over time, perhaps due to increases in quantity or frequency of their e-cigarette use or increasing efficiency of nicotine delivery over time.

Indicators of Tobacco Dependence Among Youth: Findings From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study.

BACKGROUND: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth. METHODS: One thousand one hundred and forty-eight youth aged 12-17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. FINDINGS: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = -1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = -0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults. CONCLUSION: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group. IMPLICATIONS: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco.

Effects of menthol use and transitions in use on short-term and long-term cessation from cigarettes among US smokers.

OBJECTIVES: To estimate the effect of menthol use and transitions in use (switching to or from menthol) on short-term and long-term cessation from cigarette smoking and whether this differed across demographic groups (age, sex, race). METHODS: We compared the probability of 30+ day and 12-month abstinence from cigarette smoking by menthol use status using two cohorts of US adult cigarette smokers who attempted to quit smoking in the Population Assessment of Tobacco and Health (wave 1 to wave 3 and wave 2 to wave 4; n=5759), inverse probability of treatment weighting and adjusted risk ratios (aRRs). RESULTS: Using menthol (vs non-menthol) prior to a quit attempt decreased the probability of 30+ day abstinence by 28% (aRR=0.78; 95% CI 0.67 to 0.91) and the probability of 12-month abstinence by 53% (aRR=0.65; 95% CI 0.47 to 0.88). Additionally, switching from menthol (vs maintaining menthol use) increased the probability of 30+ day abstinence by 58% (aRR=1.58; 95% CI 1.00 to 2.50) and the probability of 12-month abstinence by 97% (aRR=1.86; 95% CI 0.92 to 3.74). Switching to menthol (vs maintaining non-menthol use) was associated with a lower probability of 30+ day (aRR=0.70; 95% CI 0.42 to 1.16) and 12-month abstinence (aRR=0.64; 95% CI 0.30 to 1.36), but these associations were imprecise. The effects of menthol use on impaired quitting were slightly larger for non-Hispanic Black smokers, but not different for other demographic groups. CONCLUSION: These results demonstrate that menthol impaired menthol smokers' attempts to quit smoking but switching from menthol improved success. This suggests that removing menthol may improve menthol smokers' success during quit attempts.

Evaluating US smokers' willingness to pay for different cigarette packaging designs before and after real-world exposure in a randomised trial.

INTRODUCTION: Removal of tobacco industry branding from cigarette packs may reduce their appeal. Adding graphic warning labels (GWLs) should enhance this effect. We investigate whether willingness to pay for various packaging designs changes after 3 months' use of: (1) US branded packs without GWLs (US), (2) non-branded packs without GWLs (Blank), and (3) rotating non-branded packs with GWLs (gangrene; throat cancer; neonatal baby) covering >75% of pack (GWL). METHODS: Californian adult daily smokers not planning to quit (n=287; 56% female; mean age=39.6) completed a discrete choice purchase task before and after 3 months' experience using one of three packaging options. Conjoint analysis and pre-post modelling evaluated the change in importance of pack attributes and willingness to pay for US, Blank or GWL (blindness; teeth; gangrene) pack designs. RESULTS: Price determined ~70% of purchase choices, while pack design determined ~22%. Irrespective of intervention arm, US packaging generated appeal valuations compared with Blank packaging, while GWLs consistently provoked strong aversive valuations at baseline and follow-up. Compared with the US pack arm, using GWL packs for 3 months decreased willingness to pay for US packaging (ß=-$0.38, 95% CI -0.76 to 0.00). Wear-out effects were detected in the discount needed to willingly purchase the gangrene-GWL pack (ß=$0.49, 95% CI 0.16 to 0.82) and Blank pack (ß=$0.42, 95% CI 0.09 to 0.74) but not for GWLs (blindness, teeth) not used in trial. CONCLUSION: Compared with US branded packs, the negative valuation of non-branded GWL packs attenuates with even 3 months' use but does not generalise to non-used GWLs. This suggests that GWLs should be regularly refreshed. The appeal valuation of industry imagery suggests that the US plan to retain such imagery on packs may ameliorate the effect of GWLs.

Declines in cigarette smoking among US adolescents and young adults: indications of independence from e-cigarette vaping surge.

OBJECTIVE: To compare trends in cigarette smoking and nicotine vaping among US population aged 17-18 years and 18-24 years. METHODS: Regression analyses identified trends in ever and current use of cigarettes and e-cigarettes, using three US representative surveys from 1992 to 2022. RESULTS: From 1997 to 2020, cigarette smoking prevalence among those aged 18-24 years decreased from 29.1% (95% CI 27.4% to 30.7%) to 5.4% (95% CI 3.9% to 6.9%). The decline was highly correlated with a decline in past 30-day smoking among those aged 17-18 years (1997: 36.8% (95% CI 35.6% to 37.9%; 2022: 3.0% (95% CI 1.8% to 4.1%). From 2017 to 2019, both ever-vaping and past 30-day nicotine vaping (11.0% to 25.5%) surged among those 17-18 years, however there was no increase among those aged 18-24 years. Regression models demonstrated that the surge in vaping was independent of the decline in cigarette smoking. In the 24 most populous US states, exclusive vaping did increase among those aged 18-24 years, from 1.7% to 4.0% to equivalent to 40% of the decline in cigarette smoking between 2014-15 and 2018-19. Across these US states, the correlation between the changes in vaping and smoking prevalence was low (r=0.11). In the two US states with >US$1/fluid mL tax on e-cigarettes in 2017, cigarette smoking declined faster than the US average. CONCLUSIONS: Since 1997, a large decline in cigarette smoking occurred in the US population under age 24 years, that was independent of the 2017-19 adolescent surge in past 30-day e-cigarette vaping. Further research is needed to assess whether the 2014-15 to 2018-19 increase in exclusive vaping in those aged 18-24 years is a cohort effect from earlier dependence on e-cigarette vaping as adolescents.

Role of affective reactivity induced by cigarette packaging including graphic warning labels: the CASA Study.

OBJECTIVE: To identify whether three types of cigarette pack designs, including three versions of graphic warning label (GWL) plain packs, one GWL absent and branding absent pack (blank) and the smoker's own GWL absent and branding present pack (US), elicit different valence, type and levels of affect. DESIGN: US daily smokers (n=324) were asked to handle each of the five pack types and 'think aloud' their reactions. To avoid a muted familiarity response, exposure to their own US pack followed exposure to at least one GWL plain pack. Reactions were scored on a reactivity scale (-3 to +3) and the text was coded for speech polarity (-1 to +1) and emotive word frequency. RESULTS: Reactivity scores had excellent inter-rater reliability (agreement ≥86%; intraclass correlation coefficient ≥0.89) and were correlated with speech polarity (r=0.21-0.37, p<0.001). When considering their US pack, approximately two-thirds of smokers had a low (31.5%) to medium (34.6%) positive response (reactivity=1.29; polarity=0.14) with expressed feelings of joy and trust. Blank packaging prompted a largely (65.4%) neutral response (reactivity=0.03; polarity=0.00). The gangrenous foot GWL provoked mostly medium (46.9%) to high (48.1%) negative responses (reactivity=-2.44; polarity=-0.20), followed by neonatal baby (reactivity=-1.85; polarity=-0.10) and throat cancer (reactivity=-1.76; polarity=-0.08) warnings. GWLs varied in their elicitation of disgust, anger, fear and sadness. CONCLUSION: Initial reactions to GWL packs, a blank pack, and smokers' current US pack reflected negative, neutral, and positive affect, respectively. Different versions of the GWL pack elicited different levels and types of immediate negative affect.

Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017-2019.

OBJECTIVE: To assess the effectiveness of e-cigarettes in smoking cessation in the USA from 2017 to 2019, given the 2017 increase in high nicotine e-cigarette sales. METHODS: In 2017, the PATH Cohort Study included data on 3578 previous year smokers with a recent quit attempt and 1323 recent former smokers. Respondents reported e-cigarettes or other products used to quit cigarettes and many covariates associated with e-cigarette use. Study outcomes were 12+ months of cigarette abstinence and tobacco abstinence in 2019. We report weighted unadjusted estimates and use propensity score matched analyses with 1500 bootstrap samples to estimate adjusted risk differences (aRD). RESULTS: In 2017, 12.6% (95% CI 11.3% to 13.9%) of recent quit attempters used e-cigarettes to help with their quit attempt, a decline from previous years. Cigarette abstinence for e-cigarette users (9.9%, 95% CI 6.6% to 13.2%) was lower than for no product use (18.6%, 95% CI 16.0% to 21.2%), and the aRD for e-cigarettes versus pharmaceutical aids was -7.3% (95% CI -14.4 to -0.4) and for e-cigarettes versus any other method was -7.7% (95% CI -12.2 to -3.2). Only 2.2% (95% CI 0.0% to 4.4%) of recent former smokers switched to a high nicotine e-cigarette. Subjects who switched to e-cigarettes appeared to have a higher relapse rate than those who did not switch to e-cigarettes or other tobacco, although the difference was not statistically significant. CONCLUSIONS: Sales increases in high nicotine e-cigarettes in 2017 did not translate to more smokers using these e-cigarettes to quit smoking. On average, using e-cigarettes for cessation in 2017 did not improve successful quitting or prevent relapse.

Tobacco Use and Respiratory Symptoms Among Adults: Findings From the Longitudinal Population Assessment of Tobacco and Health (PATH) Study 2014-2016.

INTRODUCTION: We examined the relationship between current tobacco use and functionally important respiratory symptoms. METHODS: Longitudinal cohort study of 16 295 US adults without COPD in Waves 2-3 (W2-3, 2014-2016) of the Population Assessment of Tobacco and Health Study. Exposure-Ten mutually exclusive categories of tobacco use including single product, multiple product, former, and never use (reference). Outcome-Seven questions assessing wheezing/cough were summed to create a respiratory symptom index; cutoffs of ≥2 and ≥3 were associated with functional limitations and poorer health. Multivariable regressions examined both cutoffs cross-sectionally and change over approximately 12 months, adjusting for confounders. RESULTS: All tobacco use categories featuring cigarettes (>2/3's of users) were associated with higher risk (vs. never users) for functionally important respiratory symptoms at W2, for example, at symptom severity ≥ 3, risk ratio for exclusive cigarette use was 2.34 [95% CI, 1.92, 2.85] and for worsening symptoms at W3 was 2.80 [2.08, 3.76]. There was largely no increased symptom risk for exclusive use of cigars, smokeless tobacco, hookah, or e-cigarettes (adjustment for pack-years and marijuana attenuated the cross-sectional e-cigarette association from 1.53(95% CI 0.98, 2.40) to 1.05 (0.67, 1.63); RRs for these products were also significantly lower compared to exclusive use of cigarettes. The longitudinal e-cigarette-respiratory symptom association was sensitive to the respiratory index cutoff level; exclusive e-cigarette use was associated with worsening symptoms at an index cutoff ≥ 2 (RR = 1.63 [1.02, 2.59]) and with symptom improvement at an index cutoff of ≥ 3 (RR = 1.64 [1.04, 2.58]). CONCLUSIONS: Past and current cigarette smoking drove functionally important respiratory symptoms, while exclusive use of other tobacco products was largely not associated. However, the relationship between e-cigarette use and symptoms was sensitive to adjustment for pack-years and symptom severity. IMPLICATIONS: How noncigarette tobacco products affect respiratory symptoms is not clear; some studies implicate e-cigarettes. We examined functionally important respiratory symptoms (wheezing/nighttime cough) among US adults without COPD. The majority of adult tobacco users smoke cigarettes and have higher risk of respiratory symptoms and worsening of symptoms, regardless of other products used with them. Exclusive use of other tobacco products (e-cigarettes, cigars, smokeless, hookah) was largely not associated with functionally important respiratory symptoms and risks associated with their use was significantly lower than for cigarettes. The association for e-cigarettes was greatly attenuated by adjustment for cigarette pack-years and sensitive to how symptoms were defined.

Racial/Ethnic Disparities Across Indicators of Cigarette Smoking in the Era of Increased Tobacco Control, 1992-2019.

INTRODUCTION: This study compared tobacco use and cessation for African Americans (AA), Asians/Pacific Islanders (API), Hispanics/Latinos (H/L), American Indian/Alaskan Natives (AI/AN), and non-Hispanic Whites (NHW) in the United States to California (CA), the state with the longest continually funded tobacco control program. The purpose of this study was to identify tobacco use disparities across racial/ethnic groups across time. METHODS: Cigarette use prevalence (uptake and current use), consumption (mean number of cigarettes smoked per day [CPD]), and quit ratios were calculated across survey years, and trends were examined within each race/ethnic group and comparing between CA and the United States, utilizing the 1992-2019 Tobacco Use Supplements to the Current Population Survey. RESULTS: Prevalence decreased for all race/ethnic groups. Current use among CA NHW showed significant decline compared with US counterparts, whereas US H/L showed greater decline than CA counterparts. CPD decreased by approximately 30% across race/ethnic groups, with CA groups having lower numbers. The greatest decrease occurred among AA in CA (average 10.3 CPD [95% confidence interval (CI): 10.3, 12.6] in 1992/1993 to 3 CPD [95% CI: 2.4, 3.7] in 2018/2019). Quit ratios increased from 1992/1993 to 2018/2019 for CA H/L 52.4% (95% CI: 49.8, 53.0) to 59.3 (95% CI: 55.8, 62.5) and CA NHWs 61.5% (95% CI: 60.7, 61.9) to 63.8% (95% CI: 63.9, 66.9). CONCLUSIONS: Although overall prevalence decreased over time for each racial/ethnic group, declines in CA outpaced the United States only for NHWs. Reductions in CPD were encouraging but the quit ratio points to the need to increase tobacco control efforts toward cessation. IMPLICATIONS: The successes in reduced cigarette use uptake and prevalence across time for both California and the rest of the United States were observed largely among non-Hispanic White populations. Although reductions in the number of cigarettes smoked per day are a notable success, particularly among the Californian African Americans, efforts to support quitting across racial/ethnic groups, especially marginalized groups, need to be prioritized.

Tool to assess appeal-aversion response to graphic warning labels on cigarette packs among US smokers.

INTRODUCTION: Graphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal-aversion assessment tool to help regulators choose among graphic packaging options. METHODS: After familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal-aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017-2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated. RESULTS: Among purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=-US$2.53, 95% CI: -US$2.76 to -US$2.31; teeth damage=-US$2.90, 95% CI: -US$3.17 to -US$2.63; and gangrenous foot=-US$3.70, 95% CI: -US$4.01 to -US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal-aversion valuations were moderated by sex, income and nicotine dependence (p<0.05). CONCLUSIONS: Smokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal-aversion tool could be useful for regulators to differentiate between graphic warning labels.

Use of Electronic Cigarettes to Aid Long-Term Smoking Cessation in the United States: Prospective Evidence From the PATH Cohort Study.

Electronic cigarettes (e-cigarettes) are the preferred smoking-cessation aid in the United States; however, there is little evidence regarding long-term effectiveness among those who use them. We used the Population Assessment of Tobacco and Health Study to compare long-term abstinence between matched US smokers who tried to quit with and without use of e-cigarettes as a cessation aid. We identified a nationally representative cohort of 2,535 adult US smokers in 2014-2015 (baseline assessment), who, in 2015-2016 (exposure assessment), reported a past-year attempt to quit and the cessation aids used, and reported smoking status in 2016-2017 (outcome assessment; self-reported ≥12 months continuous abstinence). We used propensity-score methods to match each e-cigarette user with similar nonusers. Among US smokers who used e-cigarettes to help quit, 12.9% (95% confidence interval (CI): 9.1%, 16.7%) successfully attained long-term abstinence. However, there was no difference compared with matched non-e-cigarette users (cigarette abstinence difference: 2%; 95% CI: -3%, 7%). Furthermore, fewer e-cigarette users were abstinent from nicotine products in the long term (nicotine abstinence difference: -4%; 95% CI: -7%, -1%); approximately two-thirds of e-cigarette users who successfully quit smoking continued to use e-cigarettes. These results suggest e-cigarettes may not be an effective cessation aid for adult smokers and, instead, may contribute to continuing nicotine dependence.

Research-based PAM50 signature and long-term breast cancer survival.

PURPOSE: Multi-gene signatures provide biological insight and risk stratification in breast cancer. Intrinsic molecular subtypes defined by mRNA expression of 50 genes (PAM50) are prognostic in hormone-receptor positive postmenopausal breast cancer. Yet, for 25-40% in the PAM50 intermediate risk group, long-term risk remains uncertain. Our study aimed to (i) test the long-term prognostic value of the PAM50 signature in pre- and post-menopausal breast cancer; (ii) investigate if the PAM50 model could be improved by addition of other mRNAs implicated in oncogenesis. METHODS: We used archived FFPE samples from 1723 breast cancer survivors; high quality reads were obtained on 1253 samples. Transcript expression was quantified using a custom codeset with probes for > 100 targets. Cox models assessed gene signatures for breast cancer relapse and survival. RESULTS: Over 15 + years of follow-up, PAM50 subtypes were (P < 0.01) associated with breast cancer outcomes after accounting for tumor stage, grade and age at diagnosis. Results did not differ by menopausal status at diagnosis. Women with Luminal B (versus Luminal A) subtype had a > 60% higher hazard. Addition of a 13-gene hypoxia signature improved prognostication with > 40% higher hazard in the highest vs lowest hypoxia tertiles. CONCLUSIONS: PAM50 intrinsic subtypes were independently prognostic for long-term breast cancer survival, irrespective of menopausal status. Addition of hypoxia signatures improved risk prediction. If replicated, incorporating the 13-gene hypoxia signature into the existing PAM50 risk assessment tool, may refine risk stratification and further clarify treatment for breast cancer.

The effect of college attendance on young adult cigarette, e-cigarette, cigarillo, hookah and smokeless tobacco use and its potential for addressing tobacco-related health disparities.

The goal of this study was to assess the effect of college attendance on tobacco use among young adults and across subpopulations with disparities in tobacco use. Using a cohort of US youth (<18 years) who aged into young adulthood (18-24 years) in the Population Assessment of Tobacco and Health (2013-14, 2015-16, n = 3619) and propensity score matching we estimated the effect of college attendance on past 30-day use of cigarettes, e-cigarettes, cigarillos, hookah and smokeless tobacco. In unmatched analysis, college attenders (vs. nonattenders) had lower risk of using any form of tobacco (Risk Difference (RD): -10.0; 95% CI: -13.2, -7.0), cigarettes (RD: -13.0; 95% CI: -15.4, -10.5), e-cigarettes (RD: -4.1; 95% CI: -6.8, -1.7), cigarillos (RD: -5.7; 95% CI: -7.6, -3.8), and smokeless tobacco (RD: -2.0; 95% CI: -3.4, -0.6), but not hookah (RD: -0.2; 95% CI: -2.1, 1.6). In matched analysis, these associations were all near-null, with the exception of cigarettes (matched RD: -7.1; 95% CI: -10.3, -3.9). The effect of college attendance on cigarette smoking was stable for all subpopulations we assessed including among those identifying as non-Hispanic Black or Lesbian, Gay or Bisexual as well as among those living in the South, Midwest or whose parents did not attend college. The results suggest that college attendance may reduce young adults' risk of cigarette smoking but may not reduce the risk of using other tobacco products.

Widening disparities in cigarette smoking by race/ethnicity across education level in the United States.

Reducing tobacco use is an important public health objective. It is the largest preventable cause of death and disease, yet inequalities remain. This study examines combined educational and racial/ethnic disparities in the United States related to cigarette smoking for the three largest racial/ethnic groups (African Americans, Hispanics/Latinos, and non-Hispanic Whites). Data included nine Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) conducted in the United States from 1992/1993-2018 for four smoking metrics: ever smoking rates, current smoking rates, consumption (cigarettes per day), and quit ratios. Across all TUS-CPS samples, there were 9.5% African Americans, 8.8% Hispanics/Latinos, and 81.8% non-Hispanic Whites who completed surveys. Findings revealed that lower educational attainment was associated with increased ever and current smoking prevalence over time across all racial/ethnic groups, and education-level disparities within each race/ethnicity widened over time. Disparities in ever and current smoking rates between the lowest and highest categories of educational attainment (less than a high school education vs. completion of college) were larger for African Americans and non-Hispanic Whites than Hispanics/Latinos. Non-Hispanic Whites had the highest cigarette consumption across all education levels over time. College graduates had the highest quit ratios for all racial/ethnic groups from 1992 to 2018, with quit ratios significantly increasing for Hispanics/Latinos and non-Hispanic Whites, but not African Americans. In conclusion, educational disparities in smoking have worsened over time, especially among African Americans and Hispanics/Latinos. Targeted tobacco control efforts could help reduce these disparities to meet public health objectives, although racial/ethnic disparities may persist regardless of educational attainment.

Effect of a Behavioral Intervention to Increase Vegetable Consumption on Cancer Progression Among Men With Early-Stage Prostate Cancer: The MEAL Randomized Clinical Trial.

Importance: Guidelines endorsing vegetable-enriched diets to improve outcomes for prostate cancer survivors are based on expert opinion, preclinical studies, and observational data. Objective: To determine the effect of a behavioral intervention that increased vegetable intake on cancer progression in men with early-stage prostate cancer. Design, Setting, and Participants: The Men's Eating and Living (MEAL) Study (CALGB 70807 [Alliance]) was a randomized clinical trial conducted at 91 US urology and medical oncology clinics that enrolled 478 men aged 50 to 80 years with biopsy-proven prostate adenocarcinoma (International Society of Urological Pathology grade group = 1 in those <70 years and ≤2 in those ≥70 years), stage cT2a or less, and serum prostate-specific antigen (PSA) level less than 10 ng/mL. Enrollment occurred from January 2011 to August 2015; 24-month follow-up occurred from January 2013 to August 2017. Interventions: Patients were randomized to a counseling behavioral intervention by telephone promoting consumption of 7 or more daily vegetable servings (MEAL intervention; n = 237) or a control group, which received written information about diet and prostate cancer (n = 241). Main Outcomes and Measures: The primary outcome was time to progression; progression was defined as PSA level of 10 ng/mL or greater, PSA doubling time of less than 3 years, or upgrading (defined as increase in tumor volume or grade) on follow-up prostate biopsy. Results: Among 478 patients randomized (mean [SD] age, 64 [7] years; mean [SD] PSA level, 4.9 [2.1] ng/mL), 443 eligible patients (93%) were included in the primary analysis. There were 245 progression events (intervention: 124; control: 121). There were no significant differences in time to progression (unadjusted hazards ratio, 0.96 [95% CI, 0.75 to 1.24]; adjusted hazard ratio, 0.97 [95% CI, 0.76 to 1.25]). The 24-month Kaplan-Meier progression-free percentages were 43.5% [95% CI, 36.5% to 50.6%] and 41.4% [95% CI, 34.3% to 48.7%] for the intervention and control groups, respectively (difference, 2.1% [95% CI, -8.1% to 12.2%]). Conclusions and Relevance: Among men with early-stage prostate cancer managed with active surveillance, a behavioral intervention that increased vegetable consumption did not significantly reduce the risk of prostate cancer progression. The findings do not support use of this intervention to decrease prostate cancer progression in this population, although the study may have been underpowered to identify a clinically important difference. Trial Registration: ClinicalTrials.gov Identifier: NCT01238172.

Efficacy of a web-based women's health survivorship care plan for young breast cancer survivors: a randomized controlled trial.

PURPOSE: Breast cancer survivorship care plans (SCP) have limited content addressing women's health issues. This trial tested if young breast cancer survivors who receive a web-based, women's health SCP were more likely to improve on at least one of the four targeted issues (hot flashes, fertility-related concerns, contraception, and vaginal symptoms) compared to attention controls. METHODS: A randomized controlled trial recruited female survivors ages 18-45 at diagnosis, 18-50 at enrollment, completed primary cancer treatment, and had a significant women's health issue: moderate or higher fertility-related concerns; ≥ 4 hot flashes/day with ≥ 1 of moderate severity; ≥ 1 moderate vaginal atrophy symptoms; or not contracepting/using less effective methods. Survivors underwent stratified, block randomization with equal allocation to intervention and control groups. The intervention group accessed the online SCP; controls accessed curated resource lists. In intention-to-treat analysis, the primary outcome of improvement in at least one issue by 24 weeks was compared by group. RESULTS: 182 participants (86 intervention, 96 control), mean age 40.0 ± 5.9 and 4.4 ± 3.2 years since diagnosis, were randomized. 61 intervention group participants (70.9%) improved, compared to 55 controls (57.3%) (OR 1.82, 95% CI 0.99-3.4, p = 0.057). The following issue-specific improvements were observed in the intervention versus control arms: fertility-related concerns (27.9% vs. 14.6%, OR 2.3, 95% CI 1.1-4.8); hot flashes (58.5% vs. 55.8%, OR 1.1, 95% CI 0.57-2.2); vaginal symptoms (42.5% vs. 40.7%, OR 1.1, 95% CI 0.6-2.0); contraception (50% vs. 42.6%, OR 1.4, 95% CI 0.74-2.5). CONCLUSIONS: In young breast cancer survivors, a novel, web-based SCP did not result in more change in the primary outcome of improvement in at least one of the four targeted women's health issues, than the attention control condition. The intervention was associated with improved infertility concerns, supporting efficacy of disseminating accessible, evidence-based women's health information to this population.

Harm perceptions and tobacco use initiation among youth in Wave 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study.

In the US, youth attribute higher levels of harm and addictiveness to cigarettes relative to other tobacco products. Monitoring harm perceptions across a range of tobacco products is important when forecasting risk for experimentation. This study examined data from US youth (N = 10,081) ages 12-17 from the Population Assessment of Tobacco and Health (PATH) Study who completed both Wave 1 (2013-2014) and Wave 2 (2014-2015) interviews. Analyses assessed: (1) trends in perceived harm and addictiveness of products over time, (2) whether perceived harm and addictiveness of a product at Wave 1 predicted trying that product for the first time by Wave 2, and (3) whether trying a product between Waves 1 and 2 predicted a decrease in one's perceived harm and addictiveness of that product. Levels of perceived harmfulness and addictiveness significantly increased between Wave 1 and Wave 2 for all products (χ2 (range): 7.8-109.2; p's ≤ 0.02). Compared to those with "high" perceived harmfulness of a tobacco product at Wave 1, those with "low" and "medium" perceived harmfulness had a significantly increased probability of use of that product at Wave 2. For all products, Wave 1 youth never tobacco users who tried a product (vs. did not) at Wave 2 had a significantly higher probability of being in the "low" category of perceived harmfulness at Wave 2. Among US youth, there is a bidirectional relationship between harm perceptions and product use. Understanding how changes in perceptions translate to changes in tobacco use could inform efforts to prevent tobacco initiation in youth.

Ethnic and Socioeconomic Disparities in Recalled Exposure to and Self-Reported Impact of Tobacco Marketing and Promotions.

The role of tobacco marketing in tobacco use, particularly among the vulnerable ethnic and socioeconomic sub-populations is a regulatory priority of the U.S. Food and Drug Administration. There currently exist both ethnic and socioeconomic disparities in the use of tobacco products. Monitoring such inequalities in exposure to tobacco marketing is essential to inform tobacco regulatory policy that may reduce known tobacco-related health disparities. We use data from the Population Assessment of Tobacco and Health (PATH) Wave 1 youth survey to examine (1) recalled exposure to and liking of tobacco marketing for cigarettes, non-large cigars, and e-cigarettes, (2) self-reported exposure to specific tobacco marketing tactics, namely coupons, sweepstakes, and free samples, and (3) self-reported impact of tobacco marketing and promotions on product use. Findings indicate that African Americans and those of lower SES were more likely to recall having seen cigarette and non-large cigar ads. Reported exposure to coupons, sweepstakes and free samples also varied ethnically and socioeconomically. African Americans and those of lower SES were more likely than other respondents to report that marketing and promotions as played a role in their tobacco product use. Better understanding of communication inequalities and their influence on product use is needed to inform tobacco regulatory action that may reduce tobacco company efforts to target vulnerable groups. Tobacco education communication campaigns focusing on disproportionately affected groups could help counter the effects of targeted industry marketing.