What Motivates Betel Quid Chewers to Quit? An Analysis of Several Cessation-Relevant Variables.

Introduction: Betel quid (BQ) is globally the fourth most consumed psychoactive substance. It is consumed by an estimated 600 million people worldwide, accounting for nearly 8% of the world's population. There have been very few studies assessing chewers' motivation to quit. Objectives: In the current study, we sought to understand the relationship between several cessation-relevant variables and chewers' motivation to quit. Hypotheses: Based on analogous research on cigarette smoking, we hypothesized that the following cessation-relevant variables would be associated with motivation to quit: health risk perceptions, number of chews per day, cost, degree of BQ dependence, withdrawal symptoms, number of quit attempts, reasons for use, personal health improvement, and type of BQ chewed. Methods: A total of 351 adult BQ chewers from Guam participated in the survey and served as the sample for the analyses. Results: Majority of chewers want to quit and intend to quit. Chewers relatively high in motivation to quit evinced greater health risk perceptions of BQ chewing, greater perceived health benefits to quitting, and a greater number of past quit attempts, compared to those relatively low in motivation to quit. Conclusions: Understanding which factors are associated with chewers' motivation to quit can be helpful for designing BQ cessation programs. The results suggest that BQ cessation programs could be improved by an increased emphasis on information about the negative health effects of BQ chewing and relapse-prevention.

Resistance to peer influence, smoking friends, cigarette and betel nut use, and gender among Pacific Islander youth.

The present study examined the relationships between resistance to peer influence and cigarette and betel nut use, as well as the potential mediating role of friends who use cigarettes and betel nut, among boys and girls in Guam. This study included 673 ethnically diverse students (49% female; M age = 12.7, SD = 0.89) from eight public middle schools. The mediation analysis demonstrated that higher resistance to peer influence for both cigarette and betel nut use was associated with lower cigarette and betel nut use directly and that this association was mediated by friends who used cigarette and betel nut products. That is, low resistance to peer influence for both cigarette and betel nut use was associated with a greater number of friends who smoke and use betel nut, which was linked with more cigarette and betel nut use. The moderated mediation analysis revealed no gender difference in the indirect effect (i.e., the mediation of friends who used cigarettes and betel nut). These findings can be used to inform the design and implementation of intervention and prevention programs for at-risk youth, regardless of gender, who are vulnerable to substance use in the Pacific.

Ethnicity, Coronavirus Disease-Related Stress, and E-cigarette Use and Cigarette Smoking Among Young Adults: A Longitudinal Study.

INTRODUCTION: Research has rarely examined ethnic differences in exposure to coronavirus disease (COVID)-related stress in relation to smoking and e-cigarette use. AIMS AND METHODS: Using pre- and post-COVID data from a sample of predominantly Asian American (AA) and Native Hawaiian and Pacific Islander (NHPI) young adults, this study aimed to test the effects of ethnicity on cigarette smoking and e-cigarette use through exposure to COVID-related stress. Young adults from Hawaii who provided pre-COVID data in or before January 2020 were followed up with in March-May 2021. N = 1907 (mean age = 24.9 [SD = 2.9], 56% women) provided complete data relevant to the current analysis at both waves of data collection. Structural equation modeling was used to test the effects of ethnicity (white, Asian [eg, Japanese, Chinese], Filipino, NHPI, and other) on pre- to post-COVID changes in cigarette and e-cigarette use via effects on COVID-related stress. RESULTS: Relative to Asian young adults, members of all other ethnic groups (NHPI, Filipino, white, and other) indicated greater exposure to COVID-related stress. Higher levels of COVID-related stress were associated with increased dual-use status and increased current e-cigarette and cigarette use frequencies. Higher COVID-related stress mediated the effects of NHPI, Filipino, and other ethnicity on increased dual-use status. CONCLUSIONS: The current data indicate that young adults of vulnerable ethnic groups who experience higher COVID-related stress are at increased risk for dual use of cigarettes and e-cigarettes. IMPLICATIONS: The findings imply that tobacco use prevention and treatment efforts may need to pay increased attention to racial or ethnic groups that have experienced greater adverse impact of the COVID-19 pandemic.

Exploring the ChatGPT platform with scenario-specific prompts for vaping cessation.

OBJECTIVE: To evaluate and start a discussion on the potential usefulness of applying Artificial Intelligence (AI)-driven natural language processing technology such as the ChatGPT in tobacco control efforts, specifically vaping cessation. METHOD: Ten real-world questions about vaping cessation were selected from a Reddit forum and used as ChatGPT prompts or queries. Content analysis was performed on the ChatGPT responses to identify the thematic aspects of vaping cessation support represented in the responses. Next, the responses were empirically evaluated by five experts in tobacco control on accuracy, quality, clarity, and empathy. RESULT: The following themes related to vaping cessation support were identified: understanding nicotine withdrawal symptoms, self-regulation, peer support, motivational support, and Nicotine Replacement Therapy (NRT). The experts judged the ChatGPT responses to be 'satisfactory' to 'excellent' in areas of accuracy, quality, clarity, and empathy. CONCLUSION: If managed by a group of experts, including clinicians, and behavioral and computer scientists, a platform such as the ChatGPT may be leveraged to design tailored interventions for tobacco use cessation, including vaping cessation.

Methodological Challenges in Web-Based Qualitative Research With Medically Underserved Populations.

Internet- or web-based research is rapidly increasing, offering multiple benefits for researchers. However, various challenges in web-based data collection have been illustrated in prior research, particularly since the onset of the COVID-19 pandemic. To add to the literature on best practices for web-based qualitative data collection, we present 4 case studies in which each research team experienced challenges unique to web-based qualitative research and had to modify their research approaches to preserve data quality or integrity. The first 2 case examples describe issues with using social media to recruit hard-to-reach populations, the third example demonstrates the challenge in engaging adolescents in sensitive conversations on the web, and the final example discusses both the issues in recruitment and the use of different modalities in collecting data to accommodate the medical needs of study participants. Based on these experiences, we provide guidance and future directions for journals and researchers in collecting qualitative data on the web.

Guam Adolescents' Use of Strategies to Resist Cigarette, e-Cigarette, and Betel Nut Offers: Findings from a Focus Group Study.

Background: This study examined resistance strategies used by predominantly Pacific Islander young adolescents in response to offers of tobacco, e-cigarettes, and betel [areca] nuts. This study was intended to inform the development of a prevention curriculum focused on training young adolescents from the U.S.-Affiliated Pacific Islands (USAPI) on culturally appropriate strategies to resist substance use offers. Currently, very little is understood in terms of how Pacific Islander youths deal with tobacco and other substance use offers, although the use of tobacco products among Pacific Islander youths is high. Specifically, given the collectivist sociocultural orientation of the Pacific Islander communities, it is unclear whether the direct (overt) confrontational style of resistance is a viable mode of resistance for youths to practice when faced with a substance use offer. Methods: We conducted 10 focus groups with public middle school students (N = 34) from Guam, which is part of the USAPI. Results: Results suggested that, as with other communities in the U.S., the resistance strategies fall into two categories-overt/confrontational and non-confrontational resistance strategies. Overt/confrontational strategies included (a) saying "no" and (b) verbally confronting the offeror. Non-confrontational strategies included (a) avoiding or leaving the situation and (b) telling an adult. Conclusions: Our findings have implications for the development of culturally grounded interventions aimed at preventing youth tobacco and other substance use in Guam, the USAPI, and the Pacific region.

Tobacco use among native Hawaiian and Pacific Islander youth in the U.S. and USAPI: a systematic review of the literature.

With rates of tobacco use among youth in the United States on the rise, further analysis of disproportionately impacted populations, like Native Hawaiian and other Pacific Islanders (NHPIs), is needed. NHPIs face a unique set of challenges compared to other ethnic minorities that contribute to their health disparities from tobacco use. This systematic literature review investigated empirical studies published between 2010-2020 on tobacco use among NHPI youth and young adults. Using comprehensive literature search engines and focused author searches of tobacco researchers in NHPI communities, 7,208 article abstracts were extracted for potential inclusion. Explicit inclusionary and exclusionary criteria were used to identify peer-reviewed articles related to tobacco use correlates and interventions for NHPI youth populations. A total of 17 articles met our criteria for inclusion in this study. Community influences, peer pressure, social status, variety of flavors, craving, and stimulation were correlates found in smoking and vaping for NHPI youth. There were also few published tobacco use prevention and intervention studies focused specifically on NHPI youth. Our study addresses the needs of an under-researched population that is heavily affected by the adverse consequences of short-term and long-term use of cigarettes and e-cigarettes. Additional research should focus on developing effective and culturally relevant interventions to reduce NHPI health disparities.

Tests for confounding with cigarette smoking in the association of E-cigarette use with respiratory disorder: 2020 National-Sample Data.

Associations of e-cigarette use with respiratory disorder have been demonstrated but it has been unclear whether these are confounded by current or previous cigarette smoking. We address this question through studying different time frames for e-cigarette use and respiratory disorders in 2020 BRFSS data (N = 214,945). E-cigarette use and combustible cigarette smoking were classified into four categories: Participant never used either (Nonuse); used e-cigarettes/cigarettes but not in the past 30 days (Former Use), used in past 30 days on some days (Nondaily Use), or used past 30 days on all days (Daily Use). Contrasts for e-cigarette status and cigarette status (with nonuse as reference group) were entered with covariates in logistic regression with asthma or COPD as criterion. Stratified analyses of e-cigarette use were also performed for smokers and nonsmokers. In the total sample, results showed independent positive associations with both lifetime and current asthma for Former, Nondaily, and Daily e-cigarette use (mostly p < .0001) and the three cigarette indices. Significant positive associations with COPD were found for the three e-cigarette indices (p < .0001) and all the cigarette indices. Stratified analyses showed significant associations of e-cigarette use with respiratory disorder among nonsmokers as well as among smokers. We conclude that independent associations for former e-cigarette use (controlling for current/former smoking) and significant associations of e-cigarette use with respiratory disorder among nonsmokers indicate these associations are not confounded with cigarette smoking and suggest reverse causation is implausible. Findings for former use are discussed with reference to possible mechanisms including sensitization effects.

Tobacco product use and cultural connectedness among Native Hawaiian/Pacific Islander, Asian American, and Filipino American young adults in Hawai'i.

Tobacco product use rates among Native Hawaiian/Pacific Islander (NHPI), Asian American, and Filipino American young adults in Hawai'i have risen rapidly in recent years following the introduction of electronic nicotine delivery systems. Though some research has examined tobacco use correlates for these demographics of young adults, research examining protective factors, such as cultural connectedness, is lacking. Additionally, research that disaggregates Asian Americans from Pacific Islanders is scarce, despite the differing risk and protective factors that have been determined for each group. This study separately examined cultural connectedness among NHPIs, Asian Americans, and Filipino Americans to help fill the gaps in the current tobacco product literature. The findings indicated that Asian Americans and Filipino Americans who identify more with their own cultures are less likely to use e-cigarettes; however, this relationship was not supported for NHPIs. No significant evidence was found to indicate a relationship between cultural connectedness and combustible cigarette use among any of the sampled groups. The lack of relationship between cultural connectedness and e-cigarette use among Native Hawaiians may be explained by measurement limitations in the study, and suggest the need for more culturally competent scales (e.g., an enculturation scale) that account for Indigenous status.

Body esteem, weight-control outcome expectancies, and e-cigarette use among young adults.

INTRODUCTION: Evidence is still scarce regarding the use of e-cigarettes by young people for weight-control reasons. This study aimed to test a model in which the prospective association between negative body esteem and e-cigarette use is mediated by weight-control outcome expectancies for e-cigarette use. The model was tested across genders. METHODS: Data were collected at three time points, 6 months apart, from 2327 young adults (mean age = 21.2; SD = 2.2; 54% women). Self-reported data were collected on demographics, body mass index, body esteem, weight-control outcome expectancies for e-cigarette use, and current e-cigarette use and cigarette smoking. RESULTS: Among women, we found a significant indirect effect of lower body esteem on higher likelihood of current e-cigarette use 1 year later, mediated by higher weight-control outcome expectancies at 6-month follow-up, adjusting for demographics, body mass index, and baseline e-cigarette use and cigarette smoking. Among men, body esteem was not found to have significant effect on either weight-control expectancies or e-cigarette use. CONCLUSIONS: Based on the current findings, young adult women who have higher negative body esteem are at increased risk for using e-cigarettes for weight-control motives. IMPLICATIONS: The current findings are some of the first to show prospective associations among weight-control motives and e-cigarette use among young adults. These findings suggest that a group of vulnerable young women may be using e-cigarettes to lose or control weight. More research is needed to understand their choice of flavors, nicotine concentration, and device type. In addition, research is needed to understand whether e-cigarettes are being marketed, directly or indirectly, as being useful for weight loss or control. There may be a need for health promotion strategies that provide healthier alternatives to young women struggling with low body esteem who use e-cigarettes for weight loss or control.

Characterization of Electronic Cigarette Warning Statements Portrayed in YouTube Videos.

INTRODUCTION: In 2018, the United States Food and Drug Administration (FDA) required that electronic cigarette (e-cigarette) manufacturers, packagers, importers, distributors, and retailers display an addictive or alternate warning statement on e-cigarette visual advertisements. Few studies have investigated the FDA-mandated and other warnings on social media. This study examined the prevalence and content of warning statements in e-cigarette-related YouTube videos. METHODS: In 2019, The Virginia Commonwealth University Center for the Study of Tobacco Products conducted bi-monthly (February-June) YouTube searches by relevance and view count to identify e-cigarette-related videos. Overall, 178 videos met the inclusion criteria. Staff coded each video for the presence of a visual/verbal warning statement, warning statement type (eg, FDA-mandated, addiction/tobacco, safety/toxic exposure, health effects), sponsorship, and tobacco product characteristics. A data extraction tool collected the video URL, title, upload date, and number of views, likes/dislikes, and comments. RESULTS: Only 5.1% of videos contained FDA-mandated and 21.9% contained non-mandated warnings. All videos with FDA-mandated and 46.2% of non-mandated warnings were represented visually. Only 13.1% of industry-sponsored videos uploaded after the mandate effective date had an FDA-mandated warning statement and videos with FDA-mandated and non-mandated (v. no) warnings had significantly fewer views, likes, dislikes, and comments. Among all non-mandated warnings, 31.3% featured an addiction/tobacco, 18.8% a safety/toxic exposure, and 37.5% a health effects warning. CONCLUSIONS: The prevalence of FDA-mandated warning statements in e-cigarette related YouTube videos was low. FDA enforcement of the warning statement mandate on YouTube could increase the public's understanding of the addictive nature of nicotine in e-cigarettes. IMPLICATIONS: The FDA has the authority to regulate the advertisement and promotion of e-cigarettes on the Internet. These data can inform future FDA requirements related to the language content and visual representation of addiction/tobacco, safety/exposure, and health effects warning statements that appear in YouTube videos and other visual social media popular among young people. Such data would help consumers make informed decisions about purchasing e-cigarette products, using e-cigarettes, and avoiding unintentional harm related to e-cigarettes. In addition, these data may help social media platforms make decisions on whether they will prohibit advertisements that promote or facilitate the sale of tobacco products.

Peer Crowd Identification of Young and Early Middle Adulthood Customers at Vape Shops.

Vape shops specialize in the sales of e-cigarettes and other vaping products. In recent studies, young adults who use e-cigarettes have tended to identify with at-risk peer crowds. This is the first study to examine vape shop customers' clientele. Composed primarily of young adults and persons in early middle adulthood, we speculated that a relatively high prevalence of those who appeared to bystanders as radical/extreme (at-risk) customers would be identified as such at these shops. We recruited vape shops throughout Southern California (N = 44 shops), and trained teams of data collectors visited each of the consented vape shops, making note of 451 customers' appearance, including features such as manner of dress, presence of tattoos, and hairstyles. Customers were then coded as either belonging to a conventional, progressive, or radical/extreme crowd based on outward appearance. Of the customers observed, 223 (49%) were rated as appearing to be in the conventional crowd; 169 (38%) were rated as appearing to be in the progressive crowd, and only 59 (13%) were rated as appearing to be in the radical/extreme crowd. The conventional crowd tended to appear older. Clientele may reflect that more conventional young and early middle age adults are tempted to visit vape shops due to perceptions of greater acceptability or safety of e-cigarettes. E-cigarette mass media campaigns aimed at protecting potential vape shop customers from harm may need to depict more conservative-looking characters.

An Instagram-Based Study to Understand Betel Nut Use Culture in Micronesia: Exploratory Content Analysis.

BACKGROUND: A 2012 World Health Organization report recognizes betel nut use as an urgent public health threat faced by the Western Pacific region. However, compared with other addictive substances, little is known about how betel nuts are depicted on social media platforms. In particular, image-based social media platforms can be powerful tools for health communication. Studying the content of substance use on visual social media may provide valuable insights into public health interventions. OBJECTIVE: This study aimed to explore and document the ways that betel nut is portrayed on the photo-sharing site Instagram. The analysis focuses on the hashtag #pugua, which refers to the local term for betel nut in Guam and other parts of Micronesia. METHODS: An exploratory content analysis of 242 Instagram posts tagged #pugua was conducted based on previous research on substance use and Instagram and betel nut practices in Micronesia. In addition, the study examined the social engagement of betel nut content on the image-based platform. RESULTS: The study findings revealed content themes referencing the betel nut or betel nut tree, betel nut preparation practices, and the unique social and cultural context surrounding betel nut activity in Guam and Micronesia. In addition, certain practices and cultural themes encouraged social engagement on Instagram. CONCLUSIONS: The findings from this study emphasize the cultural relevance of betel nut use in Micronesia. These findings provide a basis for empirically testing hypotheses related to the etiological roles of cultural identity and pride in shaping betel nut use behavior among Micronesians, particularly youths and young adults. Such research is likely to inform the development of culturally relevant betel nut prevention and cessation programs.

E-cigarette Advertising Exposure, Explicit and Implicit Harm Perceptions, and E-cigarette Use Susceptibility Among Nonsmoking Young Adults.

Introduction: This study tested whether exposure to e-cigarette advertising increases e-cigarette use susceptibility among nonsmoking young adults by promoting explicit and implicit attitudes toward e-cigarettes as a safer and healthier alternative to combustible cigarettes. Methods: Young adult current nonsmokers who had never used an e-cigarette (n = 393; mean age = 22.1, standard deviation = 3.9; 66% women) were randomly assigned to one of the three conditions that involved viewing real-world, print e-cigarette ads. Two of the three conditions were experimental conditions where ads with different predominant themes (harm reduction ["Health"] versus social enhancement ["Social"] focused) were interspersed among ads of everyday objects. The third condition was the Control condition involving ads of everyday objects only. Participants provided data on explicit (ie, self-reported harm perceptions) and implicit (ie, Implicit Association Test) attitudes toward e-cigarette use and e-cigarette use intentions. Hypotheses were tested using structural equation modeling. Results: Relative to Control participants, participants in Health and Social conditions were more likely to show higher implicit attitudes toward e-cigarettes as a safer alternative to cigarettes. Only the Social condition, relative to Control, had a significant effect on lower explicit harm perceptions of e-cigarette versus cigarette use. The Social condition had a significant indirect effect on e-cigarette use susceptibility, mediated by explicit harm perceptions. Conclusions: Social enhancement-themed ads may communicate the reduced harm messages more strongly among young adults so as to affect both explicit and implicit attitudes and, through these, e-cigarette use susceptibility. Regulatory bodies may need to scrutinize reduced harm claims communicated through social enhancement-themed ads. Implications: The findings imply that implicit and explicit health benefit or reduced harm claims in e-cigarette marketing may be propagated via ads that use social enhancement gimmicks to attract youth and young adults. As the US Food and Drug Administration develops regulations on e-cigarette marketing, informed decisions need to be made that address harm reduction needs of current smokers as well as e-cigarette use onset among nonsmokers. In regard to the latter, e-cigarette marketing may need to be studied closely to monitor implicit and explicit health benefit claims that are coupled with the use of visual and textual gimmicks in ads that intend to make e-cigarettes more appealing to youth and young adults.

Adolescent betel nut use in Guam: beliefs, attitudes and social norms.

Betel (areca) nut is an addictive substance chewed with or without tobacco widely in Asia and the Pacific, including the U.S.-affiliated Pacific Islands (USPI). Betel nut use has been found to cause oral cancer. Research suggests that most betel nut use initiation occurs in adolescence. However, very little is currently known about the etiology of adolescent betel nut use. The present study reports findings of a formative, qualitative research conducted to understand the attitudinal and social factors associated with adolescent betel nut use in USAPI. The objective was to develop a theoretical framework of adolescent betel nut etiology that would guide the development of a prevention program. Semi-structured interviews were conducted with 20 adolescent betel nut users (M age = 14.5; SD = 2.2) from Guam. Findings suggested a framework of adolescent betel nut etiology in which intrapersonal, social, and environmental factors influence betel nut use behavior. The framework is consistent with ecological frameworks of adolescent substance use in which proximal personal and social influences on adolescent substance use occur within the context of a wider socio-cultural context conducive to adolescent substance use. Specifically, we found that beliefs such as betel nut tastes good and induces relaxation represent some of the betel nut use motives; parental permissiveness and peer and sibling use encourage betel nut use; and cultural acceptance and easy accessibility to betel nuts provide an environmental context conducive to betel nut use. Findings are discussed in the context of developing an adolescent betel nut use prevention program.

Sugar and Aldehyde Content in Flavored Electronic Cigarette Liquids.

Introduction: Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66). Methods: Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fisher's exact test, and Pearson's correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations. Results: Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose. Conclusions: Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity. Implications: The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDA's interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.

Warning Statements and Safety Practices Among Manufacturers and Distributors of Electronic Cigarette Liquids in the United States.

Introduction: Prior to the US Food and Drug Administration's (FDA) regulation of electronic cigarettes and warning statements related to nicotine addiction, there was no critical examination of manufacturer/distributor voluntary practices that could potentially inform FDA actions aimed to protect consumers. This study examined the content of warning statements and safety characteristics of electronic cigarette liquid bottles using a national sample. Methods: Research staff randomly selected four electronic cigarette liquid manufacturers/distributors from four US geographic regions. Staff documented the characteristics of product packaging and content of warning statements on 147 electronic cigarette liquids (0-30 mg/ml of nicotine) purchased online from 16 manufacturers/distributors in April of 2016. Results: Data showed that 97.9% of the electronic cigarette liquid bottles included a warning statement, most of which focused on nicotine exposure rather than health. Only 22.4% of bottles used a warning statement that indicated the product "contained nicotine." Of bottles that advertised a nicotine-based concentration of 12 mg/ml, 26% had a warning statements stated that the product "contains nicotine." None of the statements that indicated that the product "contained nicotine" stated that nicotine was "addictive." All bottles had a safety cap and 12% were in plastic shrink-wrap. Fifty-six percent of the websites had a minimum age requirement barrier that prevented under-aged persons from entering. Conclusions: Most manufacturers/distributors printed a warning statement on electronic cigarette liquid bottles, but avoided warning consumers about the presence and the addictiveness of nicotine. Studies are needed to examine manufacturer/distributor modifications to product packaging and how packaging affects consumer behaviors. Implications: These data can inform future FDA requirements related to the packaging and advertising of e-cigarette liquids; regulation related to the content of warning statements, including exposure warning statements, which are not currently mandated; and requirements on websites or language on packaging to help manufacturers adhere to the minimum age of purchase regulation. The data can also be used to help FDA develop additional guidance on the framing of statements on packaging that helps consumers make informed decisions about purchasing the product or protecting young people from use or unintentional exposure to the product.

Individualism-Collectivism, Social Self-Control and Adolescent Substance Use and Risky Sexual Behavior.

Individualism and collectivism are cultural syndromes that have been associated with adolescent problem behavior in studies conducted in the U.S. and Southeast Asia. However, research investigating the mechanisms of how cultural orientation impacts health risk behaviors has been limited. This study tested a new model explaining the relationship between cultural orientation (i.e., individualism, collectivism) and adolescent problem behavior (i.e., substance use and risky sex) in terms of interpersonal self-regulation (i.e., social self-control). As such, the study is rooted in theories of the role of culture in developing self-regulation. Participants were high school students (N = 716) from the Bashkirtostan Republic of the Russian Federation. Adolescents from the Russian Federation tend to show high prevalence of cigarette smoking and binge drinking. People of the Russian Federation in general are traditionally collectivist in orientation, although increased globalization and post-Soviet capitalism may indicate high individualist values in younger generation Russians. Using path analysis we found that in addition to having direct effects, higher individualism indirectly affected substance use and risky sexual behavior through social self-control and negative life events. Higher collectivism was found to have a direct protective effect on risky sexual behavior and a direct effect on social self-control. However, collectivism was not found to have indirect effects on substance use or risky sexual behavior. Higher individualism appears to function as a risk factor for adolescent problem behavior and this relationship may be mediated by lower social self-control. Culturally-tailored prevention programs utilizing the individualism-collectivism framework may benefit from addressing social self-control.

Why We Must Continue to Investigate Menthol's Role in the African American Smoking Paradox.

BACKGROUND: The disproportionate burden of tobacco use among African Americans is largely unexplained. The unexplained disparities, referred to as the African American smoking paradox, includes several phenomena. Despite their social disadvantage, African American youth have lower smoking prevalence rates, initiate smoking at older ages, and during adulthood, smoking rates are comparable to whites. Smoking frequency and intensity among African American youth and adults are lower compared to whites and American Indian and Alaska Natives, but tobacco-caused morbidity and mortality rates are disproportionately higher. Disease prediction models have not explained disease causal pathways in African Americans. It has been hypothesized that menthol cigarette smoking, which is disproportionately high among African Americans, may help to explain several components of the African American smoking paradox. PURPOSE: This article provides an overview of the potential role that menthol plays in the African American smoking paradox. We also discuss the research needed to better understand this unresolved puzzle. METHODS: We examined prior synthesis reports and reviewed the literature in PubMed on the menthol compound and menthol cigarette smoking in African Americans. RESULTS: The pharmacological and physiological effects of menthol and their interaction with biological and genetic factors may indirectly contribute to the disproportionate burden of cigarette use and diseases among African Americans. CONCLUSIONS: Future studies that examine taste sensitivity, the menthol compound, and their effects on smoking and chronic disease would provide valuable information on how to reduce the tobacco burden among African Americans. IMPLICATIONS: Our study highlights four counterintuitive observations related to the smoking risk profiles and chronic disease outcomes among African Americans. The extant literature provides strong evidence of their existence and shows that long-standing paradoxes have been largely unaffected by changes in the social environment. African Americans smoke menthols disproportionately, and menthol's role in the African American smoking paradox has not been thoroughly explored. We propose discrete hypotheses that will help to explain the phenomena and encourage researchers to empirically test menthol's role in smoking initiation, transitions to regular smoking and chronic disease outcomes in African Americans.

Nicotine Metabolism in Young Adult Daily Menthol and Nonmenthol Smokers.

INTRODUCTION: Menthol cigarette smoking may increase the risk for tobacco smoke exposure and inhibit nicotine metabolism in the liver. Nicotine metabolism is primarily mediated by the enzyme CYP2A6 and the nicotine metabolite ratio (NMR = trans 3' hydroxycotinine/cotinine) is a phenotypic proxy for CYP2A6 activity. No studies have examined differences in this biomarker among young adult daily menthol and nonmenthol smokers. This study compares biomarkers of tobacco smoke exposure among young adult daily menthol and nonmenthol smokers. METHODS: Saliva cotinine and carbon monoxide were measured in a multiethnic sample of daily smokers aged 18-35 (n = 186). Nicotine, cotinine, the cotinine/cigarette per day ratio, trans 3' hydroxycotinine, the NMR, and expired carbon monoxide were compared. RESULTS: The geometric means for nicotine, cotinine, and the cotinine/cigarette per day ratio did not significantly differ between menthol and nonmenthol smokers. The NMR was significantly lower among menthol compared with nonmenthol smokers after adjusting for race/ethnicity, gender, body mass index, and cigarette smoked per day (0.19 vs. 0.24, P = .03). White menthol smokers had significantly higher cotinine/cigarettes per day ratio than white nonmenthol smokers in the adjusted model. White menthol smokers had a lower NMR in the unadjusted model (0.24 vs. 0.31, P = .05) and the differences remained marginally significant in the adjusted model (0.28 vs. 0.34, P = .06). We did not observe these differences in Native Hawaiians and Filipinos. CONCLUSIONS: Young adult daily menthol smokers have slower rates of nicotine metabolism than nonmenthol smokers. Studies are needed to determine the utility of this biomarker for smoking cessation treatment assignments.