Birthdate-based commercial tobacco sales restrictions: will 'tobacco-free generation' policies advance or delay the endgame?

Endgame thinking means transitioning from merely trying to 'control' the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as 'endgame' policies are so-called 'tobacco-free generation' or 'smoke-free generation' policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

Measuring PM2.5, Ultrafine Particles, Nicotine Air and Wipe Samples Following the Use of Electronic Cigarettes.

BACKGROUND: Few studies have examined the extent of inhalation or dermal contact among bystanders following short-term, secondhand e-cigarette exposure. OBJECTIVE: Measure PM2.5 (particles < 2.5 microns), UF (ultrafine particles < 100 nm), and nicotine in air and deposited on surfaces and clothing pre-/during/post- a short-term (2-hour) e-cigarette exposure. METHODS: E-cigarettes were used ad libitum by three experienced users for 2 hours during two separate sessions (disposable e-cigarettes, then tank-style e-cigarettes, or "tanks") in a 1858 ft3 room. We recorded: uncorrected PM2.5 (using SidePak); UF (using P-Trak); air nicotine concentrations (using air samplers; SKC XAD-4 canisters); ambient air exchange rate (using an air capture hood). Wipe samples were taken by wiping 100 cm2 room surfaces pre- and post- both sessions, and clean cloth wipes were worn during the exposure and collected at the end. RESULTS: Uncorrected PM2.5 and UF were higher (p < .0001) during sessions than before or after. Median PM2.5 during exposure was higher using tanks (0.515 mg/m3) than disposables (0.035 mg/m3) (p < .0001). Median UF during exposure was higher using disposables (31 200 particles/cm3) than tanks (25 200 particles/cm3)(p < .0001). Median air nicotine levels were higher (p < .05) during both sessions (disposables = 0.697 ng/L, tanks = 1.833 ng/L) than before (disposables = 0.004 ng/L, tanks = 0.010 ng/L) or after (disposables = 0.115 ng/L, tanks = 0.147 ng/L). Median accumulation rates of nicotine on surface samples were 2.1 ng/100 cm2/h using disposables and 4.0 ng/100 cm2/h using tanks; for cloth samples, it was 44.4 ng/100 cm2/h using disposables and 69.6 ng/100 cm2/h using tanks (p < .01). Mean room ventilation rate was ~5 air changes per hour during both sessions. CONCLUSIONS: Short-term e-cigarette use can produce: elevated PM2.5; elevated UF; nicotine in the air; and accumulation of nicotine on surfaces and clothing. IMPLICATIONS: Short-term indoor e-cigarette use produced accumulation of nicotine on surfaces and clothing, which could lead to dermal exposure to nicotine. Short-term e-cigarette use produced elevated PM2.5 and ultrafine particles, which could lead to secondhand inhalation of these particles and any chemicals associated with them by bystanders. We measured significant differences in PM2.5 and ultrafine particles between disposable e-cigarettes and tank-style e-cigarettes, suggesting a difference in the exposure profiles of e-cigarette products.

Increasing the dose of television advertising in a national antismoking media campaign: results from a randomised field trial.

BACKGROUND: While antismoking media campaigns have demonstrated effectiveness, less is known about the country-level effects of increased media dosing. The 2012 US Tips From Former Smokers (Tips) campaign generated approximately 1.6 million quit attempts overall; however, the specific dose-response from the campaign was only assessed by self-report. OBJECTIVE: Assess the impact of higher ad exposure during the 2013 Tips campaign on quit-related behaviours and intentions, campaign awareness, communication about campaign, and disease knowledge. METHODS: A 3-month national media buy was supplemented within 67 (of 190) randomly selected local media markets. Higher-dose markets received media buys 3 times that of standard-dose markets. We compared outcomes of interest using data collected via web-based surveys from nationally representative, address-based probability samples of 5733 cigarette smokers and 2843 non-smokers. RESULTS: In higher-dose markets, 87.2% of smokers and 83.9% of non-smokers recalled television campaign exposure versus 75.0% of smokers and 73.9% of non-smokers in standard-dose markets. Among smokers overall, the relative quit attempt rate was 11% higher in higher-dose markets (38.8% vs 34.9%; p<0.04). The higher-dose increase was larger in African-Americans (50.9% vs 31.8%; p<0.01). Smokers in higher-dose markets without a mental health condition, with a chronic health condition, or with only some college education made quit attempts at a higher rate than those in standard-dose markets. Non-smokers in higher-dose markets were more likely to talk with family or friends about smoking dangers (43.1% vs 35.7%; p<0.01) and had greater knowledge of smoking-related diseases. CONCLUSIONS: The US 2013 Tips antismoking media campaign compared standard and higher doses by randomisation of local media markets. Results demonstrate the effectiveness of a higher dose for engaging non-smokers and further increasing quit attempts among smokers, especially African-Americans.

21st-century hazards of smoking and benefits of cessation in the United States.

BACKGROUND: Extrapolation from studies in the 1980s suggests that smoking causes 25% of deaths among women and men 35 to 69 years of age in the United States. Nationally representative measurements of the current risks of smoking and the benefits of cessation at various ages are unavailable. METHODS: We obtained smoking and smoking-cessation histories from 113,752 women and 88,496 men 25 years of age or older who were interviewed between 1997 and 2004 in the U.S. National Health Interview Survey and related these data to the causes of deaths that occurred by December 31, 2006 (8236 deaths in women and 7479 in men). Hazard ratios for death among current smokers, as compared with those who had never smoked, were adjusted for age, educational level, adiposity, and alcohol consumption. RESULTS: For participants who were 25 to 79 years of age, the rate of death from any cause among current smokers was about three times that among those who had never smoked (hazard ratio for women, 3.0; 99% confidence interval [CI], 2.7 to 3.3; hazard ratio for men, 2.8; 99% CI, 2.4 to 3.1). Most of the excess mortality among smokers was due to neoplastic, vascular, respiratory, and other diseases that can be caused by smoking. The probability of surviving from 25 to 79 years of age was about twice as great in those who had never smoked as in current smokers (70% vs. 38% among women and 61% vs. 26% among men). Life expectancy was shortened by more than 10 years among the current smokers, as compared with those who had never smoked. Adults who had quit smoking at 25 to 34, 35 to 44, or 45 to 54 years of age gained about 10, 9, and 6 years of life, respectively, as compared with those who continued to smoke. CONCLUSIONS: Smokers lose at least one decade of life expectancy, as compared with those who have never smoked. Cessation before the age of 40 years reduces the risk of death associated with continued smoking by about 90%.

Warning about the harms of tobacco use in 22 countries: findings from a cross-sectional household survey.

BACKGROUND: Knowledge about the harms of tobacco use deters initiation and is associated with cessation. Most studies on this knowledge in the general population have been in high-income countries, but the tobacco use burden is increasing in low-income and middle-income countries. We sought to estimate levels of knowledge about tobacco-related diseases in 22 countries and determine the factors associated with differences in knowledge. METHODS: We used data from the Global Adult Tobacco Survey (GATS), a nationally representative survey of persons aged ≥15 years. GATSs were conducted from 2008 to 2013 in 22 low-income and middle-income countries. Information was gathered on tobacco-related knowledge and noticing of antismoking mass media messages and health warning labels on cigarette packages. We constructed a four-point knowledge scale and performed multivariate regression analyses. RESULTS: Median country values for the proportion of adults who believed smoking causes a specific illness were 95.9% for lung cancer, 82.5% for heart attack and 74.0% for stroke. Knowledge scores ranged from 2.1 to 3.8. In multivariate regressions, adults scored significantly higher on the knowledge scale if they noticed antismoking media messages (22 countries) or health warning labels (17 countries). Significantly higher knowledge scores occurred in all 9 countries with pictorial health warning labels compared with only 8 out of 13 countries with text-only warning labels. CONCLUSIONS: Antismoking media messages appear effective for warning the public about the harms from tobacco use in all 22 countries, while warning labels are effective in the majority of these countries. Our findings suggest opportunities to motivate smoking cessation globally.

Cigarette, Cigar, and Marijuana Use Among High School Students - United States, 1997-2013.

What is already known on this topic? Since 2010, the proportion of U.S. 12th grade students who reported using marijuana during the preceding 30 days (21.4%) has surpassed the proportion reporting use of cigarettes during the preceding 30 days (19.2%).What is added by this report? During 1997­2013, the proportion of white, black, and Hispanic high school students overall who were exclusive cigarette or cigar users decreased 64%, from 20.5% to 7.4%. The proportion of white, black, and Hispanic students who were exclusive marijuana users more than doubled from 4.2% to 10.2%, and among cigarette or cigar users, marijuana use increased, with considerable increases identified among black and Hispanic students toward the end of the study period.What are the implications for public health practice? Despite significant declines since 1997, approximately 30% of white, black, and Hispanic U.S. high school students were current users of cigarettes, cigars, or marijuana in 2013. Policy and programmatic efforts might benefit from integrated approaches that focus on reducing the use of tobacco and marijuana among youths.

Tobacco use among middle and high school students - United States, 2011-2014.

Tobacco use and addiction most often begin during youth and young adulthood. Youth use of tobacco in any form is unsafe. To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6-8) and high school (grades 9-12) students, CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development, causes addiction, and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States.

Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities.

INTRODUCTION: Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes). METHODS: Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control. RESULTS: Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups. CONCLUSIONS: Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Effect of the first federally funded US antismoking national media campaign.

BACKGROUND: Every year, smoking kills more than 5 million people globally, including 440,000 people in the USA, where the long-term decline in smoking prevalence has slowed. The US Centers for Disease Control and Prevention (CDC) delivered a national, 3-month antismoking campaign called Tips From Former Smokers (Tips) that started in March, 2012, in which hard-hitting, emotionally evocative television advertising was featured, depicting smoking-related suffering in real people. We aimed to assess the effects of the Tips campaign. METHODS: We undertook baseline and follow-up surveys of nationally representative cohorts of adult smokers and non-smokers. The national effect of the Tips campaign was estimated by applying rates of change in the cohort before and after the campaign to US census data. FINDINGS: 3051 smokers and 2220 non-smokers completed baseline and follow-up assessments. 2395 (78%) smokers and 1632 (74%) non-smokers recalled seeing at least one Tips advertisement on television during the 3-month campaign. Quit attempts among smokers rose from 31.1% (95% CI 30.3-31.9) at baseline to 34.8% (34.0-35.7) at follow-up, a 12% relative increase. The prevalence of abstinence at follow-up among smokers who made a quit attempt was 13.4% (95% CI 9.7-17.2). Nationally, an estimated 1.64 million additional smokers made a quit attempt, and 220,000 (95% CI 159,000-282,000) remained abstinent at follow-up. Recommendations by non-smokers to quit grew from 2.6% at baseline to 5.1% at follow-up, and the prevalence of people talking with friends and family about the dangers of smoking rose from 31.9% (95% CI 31.3-32.5) to 35.2% (34.6-35.9), resulting in an estimated 4.7 million additional non-smokers recommending cessation services and more than 6 million talking about the dangers of smoking. INTERPRETATION: The high-exposure Tips media campaign was effective at increasing population-level quit attempts. The growth in smokers who quit and became sustained quitters could have added from a third to almost half a million quality-adjusted life-years to the US population. Expanded implementation of similar campaigns globally could accelerate progress on the WHO Framework Convention on Tobacco Control and reduce smoking prevalence globally. FUNDING: CDC, US Department of Health and Human Services.

Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012.

Quitting smoking substantially reduces smokers' risk for smoking-related morbidity and mortality and can increase life expectancy by up to a decade. Most smokers want to quit and make at least one medical provider visit annually. Health care providers can play an important role in helping smokers quit by documenting patients' tobacco use, advising smokers to quit, and providing evidence-based cessation treatments or referrals for treatment, but many providers and practices do not regularly take these actions. Systems to increase provider screening and delivery of cessation interventions are available; in particular, electronic health records (EHRs) can be powerful tools to facilitate increased cessation interventions. This analysis reports on an EHR-based pay-for-improvement initiative in 19 community health centers (CHCs) in New York City (NYC) that sought to increase smoking status documentation and cessation interventions. At the end of the initiative, the mean proportion of patients who were documented as smokers in CHCs had increased from 24% to 27%, whereas the mean proportion of documented smokers who received a cessation intervention had increased from 23% to 54%. Public health programs and health systems should consider implementing strategies to equip and train clinical providers to use information technology to increase delivery of cessation interventions.

Adherence to varenicline in the COMPASS smoking cessation intervention trial.

INTRODUCTION: Patient adherence to smoking cessation medications can impact their effectiveness. It is important to understand the extent to which prescribed medications are actually taken by smokers, how this influences smoking cessation outcomes, and what factors may influence adherence. METHODS: Smokers recruited from a large health plan were randomized to receive different modes of cessation counseling in combination with varenicline (Swan, G. E., McClure, J. B., Jack, L. M., Zbikowski, S. M., Javitz, H. S., Catz, S. L., et al. 2010.Behavioral counseling and varenicline treatment for smoking cessation. American Journal of Preventive Medicine, 38, 482-490). One thousand one hundred and sixty-one participants were mailed a 28-day varenicline supply when they set a quit date and were able to request up to two refills from the health plan pharmacy at no cost. Pharmacy fill records were obtained and telephone surveys completed at baseline, 21 days, 12 weeks, and 6 months post target quit date. RESULTS: Good adherence to varenicline (≥80% of days taken) was associated with a twofold increase in 6-month quit rates compared with poor adherence (52% vs. 25%). Smokers were more likely than nonsmokers to stop varenicline early. Purposeful nonadherence was associated with smoking at 12 weeks and was predicted in multivariate analyses by age, gender, adherence self-efficacy, and initial medication side effect severity. CONCLUSIONS: Innovative methods for increasing adherence to smoking cessation medications are needed, particularly early in the quit process. Simple metrics of adherence such as number of days cessation medication is taken can and should be routinely incorporated in effectiveness trials and reported to advance future attempts to understand and reduce nonadherence.

Differences in Quitline Registrants' Characteristics During National Radio Versus Television Antismoking Campaigns.

INTRODUCTION: The Centers for Disease Control and Prevention's Tips From Former Smokers® campaign encourages smokers to get help with quitting smoking by promoting 1-800-QUIT-NOW. Campaign advertisements featuring an offer of help with obtaining free cessation medication aired nationally on radio for 2 weeks in 2016. Similar advertisements aired nationally on TV for 3 weeks in 2017. The comparison period of 2016 radio campaign and 2017 TV campaign was used to examine the characteristics of quitline registrants by a media referral source (TV or radio). METHODS: Data on the number and demographics of quitline registrants in 2016 and 2017 were obtained from the Centers for Disease Control and Prevention's National Quitline Data Warehouse. The investigators conducted t-tests to assess the demographic differences between registrants who heard about the quitline through the radio advertisements and those who heard about it through the TV advertisements during the comparison period. This analysis was conducted in 2019. RESULTS: The registrants who heard about the quitline from radio advertisements were more likely to be male, younger, and have more years of education. However, the registrants who heard about the quitline from TV advertisements were more likely to be Black, non-Hispanic, and have fewer years of education. CONCLUSIONS: The findings suggest that the demographic profiles of quitline registrants vary significantly based on how registrants hear about the quitline (via radio or TV). These differences in the characteristics of registrants can help inform the tobacco control mass media purchasing strategies and may enable media efforts to target the specific subgroups of smokers in a better way.

Mood, side-effects and smoking outcomes among persons with and without probable lifetime depression taking varenicline.

BACKGROUND: Varenicline may be associated with greater mood disturbance and side-effects among smokers with psychiatric history, but empirical evidence is limited. Differential treatment effectiveness by psychiatric history may also exist. OBJECTIVE: To compare mood, prevalence and intensity of treatment side-effects, and abstinence among people with a probable history of major depression (DH+) or not (DH-) who took varenicline and received behavioral smoking cessation treatment. DESIGN: Smokers participated in a randomized behavioral intervention effectiveness trial. Treatment side-effects and outcomes were compared between DH+ and DH- participants (n = 1,117) at 21 [corrected] days and 3 months after the target quit date. PARTICIPANTS: Smokers recruited from a large regional health plan. MEASUREMENTS: Change in stress and depression scores, prevalence and intensity of treatment side-effects, and abstinence rates. RESULTS: All side-effects averaged moderate intensity or less and were similar across DH groups, except DH+'s endorsed slightly worse confusion, nausea (adjusted P = 0.04) and trouble sleeping (adjusted P = 0.008) at 21 days. Depression and stress scores declined in both DH groups and an equal proportion of each evidenced new/worsening depressive symptoms. Despite few differences in symptom intensity, more DH+ participants reported recent tension/agitation, irritability/anger, confusion, and depression at 21 days (adjusted P < 0.05), and depression and anxiety (adjusted P < 0.01) at three months. Nonsmoking rates did not differ by DH group at follow-up. CONCLUSION: While some group differences were noted, DH+ smokers did not report qualitatively worse neuropsychiatric symptoms, more new/worsening mood disturbance, or differential abstinence rates compared to DH- smokers.

Using free patches to improve reach of the Oregon Quit Line.

For 2 1/2 months, the Oregon Tobacco Quit Line (ORQL) offered a free 2-week starter kit of nicotine patches to all callers. The promotional plan, utilizing Roger's Diffusion of Innovation theory, targeted health plans, local policy makers, media sources, and referral sources, such as healthcare providers. Word-of-mouth advertising was also encouraged using a free patch card, which could be handed out to tobacco users. Six weeks prior to the public launch, information about the initiative was disseminated by e-mailing and sending letters to public and private sector partners. Call volume to the ORQL was monitored 6 months prior to the Free Patch Initiative and immediately following the launch. Demographic characteristics of callers pre- and postinitiative were compared using ORQL data. A media firm tracked earned media generated by the initiative. The Initiative generated free "earned" media attention, increased calls to the ORQL by 12-fold, and reached 1.3% of the smoking population within a 3-month period. Offering a short course of free NRT is an effective way to promote the use of quitlines.

Predictors of 12-month outcome in smokers who received bupropion sustained-release for smoking cessation.

AIM: To examine heterogeneity in outcome at 12 months following 8 weeks of treatment for smoking cessation with bupropion sustained-release (SR) 150 or 300 mg/day combined with behavioural counselling. DESIGN, SETTING, PARTICIPANTS: Smokers were recruited from a large healthcare system and then randomized to receive either bupropion SR 150 mg/day (n = 763) or 300 mg/day (n = 761) taken for 8 weeks in combination with either proactive telephone counselling or a tailored mail approach. MEASUREMENTS AND FINDINGS: A comprehensive set of relevant individual pretreatment and treatment characteristics was included in the analysis. Smoking outcome at 12 months was defined as point-prevalence of any regular self-reported smoking within the 7 days prior to follow-up contact. Classification and regression tree analysis identified subgroups that varied with respect to likelihood of being nonsmokers at 12 months. Seven subgroups were identified among those receiving bupropion SR 150 mg/day (proportion of nonsmokers at 12 months ranged from 13.7% to 43.5%) and eight subgroups among those receiving bupropion SR 300 mg/day (proportion of nonsmokers at 12 months ranged from 9.6% to 51.7%). In the 150-mg/day group, those with the lowest rate reported no previous quit attempt of 1 month or more in duration while those with the highest rate all reported previous quit attempts of 1 month or longer. In the 300 mg/day group, those with the lowest rate had very high levels of dependence while those with the highest rate were more highly educated and smoked at a lower level. Across all subgroups, cost per 12-month quitter ranged from a low of USD302 to a high of USD2,502. CONCLUSIONS: These results indicate the presence of a substantial amount of variation in outcome following treatment with both dosages of bupropion SR, with substantial cost consequences. Variation in outcome could be reduced by providing treatments tailored to subgroups of individuals who are at exceptionally high risk for smoking following a quit attempt.

Phone and web-based tobacco cessation treatment: real-world utilization patterns and outcomes for 11,000 tobacco users.

BACKGROUND: Phone-based tobacco cessation programs have been proven effective and widely adopted. Web-based solutions exist; however, the evidence base is not yet well established. Many cessation treatments are commercially available, but few integrate the phone and Web for delivery and no published studies exist for integrated programs. OBJECTIVE: This paper describes a comprehensive integrated phone/Web tobacco cessation program and the characteristics, experience, and outcomes of smokers enrolled in this program from a real-world evaluation. METHODS: We tracked program utilization (calls completed, Web log-ins), quit status, satisfaction, and demographics of 11,143 participants who enrolled in the Free & Clear Quit For Life Program between May 2006 and October 2007. All participants received up to five proactive phone counseling sessions with Quit Coaches, unlimited access to an interactive website, up to 20 tailored emails, printed Quit Guides, and cessation medication information. The program was designed to encourage use of all program components rather than asking participants to choose which components they wanted to use while quitting. RESULTS: We found that participants tended to use phone services more than Web services. On average, participants completed 2-2.5 counseling calls and logged in to the online program 1-2 times. Women were more adherent to the overall program; women utilized Web and phone services significantly (P = .003) more than men. Older smokers (> 26 years) and moderate smokers (15-20 cigarettes/day) utilized services more (P < .001) than younger (< 26 years) and light or heavy smokers. Satisfaction with services was high (92% to 95%) and varied somewhat with Web utilization. Thirty-day quit rates at the 6-month follow-up were 41% using responder analysis and 21% using intent-to-treat analysis. Web utilization was significantly associated with increased call completion and tobacco abstinence rates at the 6-month follow-up evaluation. CONCLUSIONS: This paper expands our understanding of a real-world treatment program combining two mediums, phone and Web. Greater adherence to the program, as defined by using both the phone and Web components, is associated with higher quit rates. This study has implications for reaching and treating tobacco users with an integrated phone/Web program and offers evidence regarding the effectiveness of integrated cessation programs.

Systemic absorption of nicotine following acute secondhand exposure to electronic cigarette aerosol in a realistic social setting.

Evidence suggests exposure of nicotine-containing e-cigarette aerosol to nonusers leads to systemic absorption of nicotine. However, no studies have examined acute secondhand exposures that occur in public settings. Here, we measured the serum, saliva and urine of nonusers pre- and post-exposure to nicotine via e-cigarette aerosol. Secondarily, we recorded factors affecting the exposure. Six nonusers of nicotine-containing products were exposed to secondhand aerosol from ad libitum e-cigarette use by three e-cigarette users for 2 h during two separate sessions (disposables, tank-style). Pre-exposure (baseline) and post-exposure peak levels (Cmax) of cotinine were measured in nonusers' serum, saliva, and urine over a 6-hour follow-up, plus a saliva sample the following morning. We also measured solution consumption, nicotine concentration, and pH, along with use behavior. Baseline cotinine levels were higher than typical for the US population (median serum session one = 0.089 ng/ml; session two = 0.052 ng/ml). Systemic absorption of nicotine occurred in nonusers with baselines indicative of no/low tobacco exposure, but not in nonusers with elevated baselines. Median changes in cotinine for disposable exposure were 0.007 ng/ml serum, 0.033 ng/ml saliva, and 0.316 ng/mg creatinine in urine. For tank-style exposure they were 0.041 ng/ml serum, 0.060 ng/ml saliva, and 0.948 ng/mg creatinine in urine. Finally, we measured substantial differences in solution nicotine concentrations, pH, use behavior and consumption. Our data show that although exposures may vary considerably, nonusers can systemically absorb nicotine following acute exposure to secondhand e-cigarette aerosol. This can particularly affect sensitive subpopulations, such as children and women of reproductive age.