Relative efficacy of cigarillo warning statements in text and pictorial formats: An experimental study among a sample of US young adults.

INTRODUCTION: Health warning labels (HWLs) communicate the health risks of cigar use and can decrease use when on cigar packages. This study assessed the relative efficacy of six FDA-proposed individual warning statements in text and pictorial format. METHODS: A sample of young adults (ages 18-29) were randomized to a text or pictorial warning condition on generic cigarillo packages. The warning statements were about lung cancer and heart disease; cancers of the mouth and throat; secondhand smoke; not a safe alternative; nicotine/addiction; and harm to baby. Negative emotional reactions, cognitive elaboration, and perceived message effectiveness (PME) were assessed for each warning using linear mixed models. RESULTS: Of the 661 participants, 47.3% reported ever cigarillo smoking, 32.7% current smoking, and 20% were susceptible. In the pictorial format, cancers of the mouth and throat elicited lower levels of anxiety compared to secondhand smoke, not a safe alternative, nicotine/addiction, and harm to baby (ps<0.001). Pictorial HWLs with human imagery induced high anxiety, sadness, fear, and guilt reactions (p<0.001) and higher PME (p=0.011) compared to pictorial HWLs with diseased body parts. Compared to the text HWL cancers of the mouth and throat, the text HWL harm to baby elicited higher anxiety (p=0.003), sadness (p=0.002) and PME (p<0.001). CONCLUSIONS: Pictorial HWLs depicting people or human imagery, rather than images of diseased organs or body parts, to represent health effects elicited the most negative emotional reactions, such as anxiety and guilt, and higher PME. Including such images and texts highlighting effects on vulnerable populations like babies can better communicate cigarillo health risks, aiming to curb cigarillo use among young people. IMPLICATIONS: The study suggests that pictorial health warning labels (HWLs) with human imagery significantly enhance the communication of cigarillo smoking risks compared to images of diseased organs. These HWLs evoke stronger emotional responses, particularly anxiety and guilt, and higher perceived message effectiveness by depicting a recognizable person. Furthermore, text-only warnings describing the smoking effect on vulnerable populations such as babies might have a higher impact on young adults. This evidence supports a strategic shift in FDA policies to include such impactful images and texts, which could potentially lead to a significant reduction in cigarillo use among young people. Our findings underscore the urgent need for continued research and implementation of these enhanced warning labels to improve public health outcomes.

Poor sleep duration and E-cigarette/Cigarette use among US adults with cardiovascular diseases: findings from the 2022 BRFSS cross-sectional study.

BACKGROUND: Studies have explored the connections between tobacco use, sleep and cardiovascular disease (CVD) risks in adults, but no study has examined the link between tobacco use and sleep among adults with CVDs. This study explores the association between tobacco use (cigarette only, e-cigarette only, and dual use) and poor sleep duration among adults with CVDs. METHODS: A sample of 47,180 US adults with CVDs (myocardial infarction, coronary heart disease, or stroke) was drawn from the 2022 Behavioral Risk Factor Surveillance System (BRFSS) cross-sectional survey. Poor/inadequate sleep (< 7 h/24-hour) was defined based on National Sleep Foundation recommendations. Logistic regression models assessed tobacco use status across seven categories (i.e., non-use [reference], current [past-month use] cigarette only, current e-cigarettes only, current dual use, former cigarette only, former e-cigarette only, and former dual use) with inadequate sleep, adjusting for demographics and health conditions. RESULTS: Overall, 40% of US adults with a history of CVD reported inadequate sleep. Current cigarette, e-cigarette, and dual use were associated with a relatively higher proportion of inadequate sleep duration. Unweighted findings revealed a significant association between current cigarette use (OR = 1.35, 95%CI: 1.26-1.44), e-cigarette use (1.40 [1.19-1.63]) and dual use (1.50 [1.27-1.77]) and increased odds of reporting inadequate sleep among adults with CVDs. Weighted analysis showed only a significant link between current cigarette use and inadequate sleep (1.34 [1.17-1.54]). CONCLUSIONS: Current cigarette use is associated with poor sleep in adults with CVDs. Unweighted findings suggested a similar association for e-cigarettes. Interventions targeting smoking cessation may offer promising avenues for improving sleep health and reducing the burden on adults with CVDs.

Effects of Pictorial Health Warning Labels on Intention to Quit Waterpipe in Lebanon: A Mediation Analysis.

INTRODUCTION: Pictorial health warning labels on waterpipe tobacco packages represent a better strategy for communicating the health risks associated with waterpipe use and promoting quit intention than text-only. However, the mechanism by which these warnings lead to higher intentions to quit remains unknown. This study explores how pictorial warnings vs. text-only induce higher quit intention among a sample of young adult waterpipe smokers in Lebanon. METHODS: An online randomized cross-over experimental study was conducted in August 2021 among 276 young adult waterpipe smokers who were exposed to two conditions: pictorial health warning label and text-only warning on waterpipe tobacco packages in random order. After each image, participants completed post-exposure assessments of health communication outcomes (e.g., attention and negative affect). Using serial and parallel mediation analysis, we examined the role of attention, negative affect, cognitive elaboration, and perceived harm in mediating the relationship between exposure to HWLs and intention to quit. RESULTS: Using serial mediation, exposure to pictorial warnings vs. text-only was found to affect intention to quit through the following pathways: attention and negative affect, which accounted for 17.28% of the total effect, and through negative affect and cognitive elaboration, which accounted for 21.53% of the total effect. Results of parallel mediation showed that the indirect effect pathways via negative affect [ß= 0.063; (95% bootstrap CI=0.004, 0.149)] and cognitive elaboration [0.047; (0.001, 0.114)] were statistically significant. CONCLUSIONS: The findings call on designing and implementing attention-grabbing, emotionally evocative, and cognitively persuasive pictorial warnings in Lebanon and other countries to curb waterpipe tobacco smoking. IMPLICATIONS: This is among the first experimental studies looking at multiple mediators underlying the effect of exposure to pictorial health warning labels on intention to quit in a sample of current waterpipe smokers in Lebanon. The findings showed that using attention-grabbing, emotionally evocative, and persuasive pictures with a clear textual warning is crucial to maximizing the impact of implementing waterpipe health warning labels regulations in Lebanon and other countries to curb waterpipe tobacco smoking.

Impact of pictorial health warning labels on smoking beliefs and perceptions among waterpipe smokers: an online randomised cross-over experimental study.

PURPOSE: Waterpipe tobacco smoking (WTS) has substantially increased among young people in Lebanon, who perceive WTS as safer than cigarettes. Health warning labels (HWLs) can inform the adverse effects associated with smoking. Thus, their application to waterpipe offers a favourable policy to limit WTS epidemic. This study assessed the effectiveness of pictorial HWLs and their placements on waterpipe parts (device, tobacco and charcoal package) on several communication outcomes. METHODS: We conducted a randomised cross-over experimental study among 276 waterpipe smokers (aged 18-34) between 13 and 26 August 2021. Participants observed three conditions: pictorial HWLs on tobacco packages, pictorial HWLs on three parts of the waterpipe (device, tobacco and charcoal package) and text only on tobacco package in random order. Participants completed baseline and postexposure assessments evaluating HWL effectiveness on attention, reaction, attitudes and beliefs, perceived effectiveness of HWLs and intention to quit WTS. Planned comparisons using Friedman test followed by pairwise Wilcoxon signed-rank test for multiple comparisons were conducted. RESULTS: Compared with text only, pictorial HWLs elicited greater attention (p=0.011), higher cognitive elaboration (p=0.021), perceived message effectiveness (p=0.007), negative affect reactions (p<0.01) and greater psychological reactance (p=0.01). No significant differences were found for most communication outcomes between pictorial HWLs on three parts of the waterpipe compared with tobacco package only. CONCLUSIONS: Pictorial HWLs on tobacco package were superior to text only for several communication outcomes. These findings provide strong evidence for potential implementation of pictorial HWLs on waterpipe tobacco packages to increase smokers' awareness of the health effects of WTS and correct false safety perceptions.

The Effects of Pictorial Health Warning Label on Waterpipe (Low- and High-Frequency) Smokers' Experiences, Toxicant Exposures, and Puffing Behavior.

BACKGROUND: Pictorial health warning label (PHWL) is an effective risk communication measure among cigarette smokers. However, there is a lack of knowledge regarding the effect of PHWL on low- and high-frequency waterpipe (WP) smokers. This study examined the effects of PHWL on puffing behavior, subjective experiences, and toxicant exposures among low- and high-frequency WP smokers in the United States (US). METHODS: Sixty current (past-month) WP smokers (low-frequency; n = 30 and high-frequency; n = 30) completed two 45-min ad libitum WP smoking sessions in a cross-over design study (WP with no-PHWL vs. WP with PHWL). We compared the mean differences of puff topography, expired carbon monoxide (eCO), plasma nicotine concentration, and subjective experiences between the two smoking groups. RESULTS: Mean age of low-frequency smokers was 21.5 years and high-frequency smokers was 21.3 years. Compared to high-frequency, low-frequency smokers had significant reduction in average total smoking time [mean difference (SD) = -7.6 (10.2) min vs. -2.6 (6.7) min, p = 0.03] and number of puffs [mean difference (SD) = -33.37 (70.7) vs. -0.70 (29.2), p = 0.02] following exposure to PHWL compared to no-PHWL condition. Post-session subjective experiences were lower among high-frequency smokers compared to low-frequency smokers following smoking WP with PHWL compared to the no-PHWL session (puff liking -1.2 vs. -0.5; puff satisfaction -1.0 vs. -0.3; craving reduction -0.5 vs. 1.2) (p < 0.05 for all). CONCLUSION: Our findings indicate that placing PHWL on the WP device may be a promising strategy with differential effectiveness among WP smokers: low-frequency (reduce puffing behaviors) and high-frequency (reduce smoking experience).

High on Hookah: Smoking Marijuana from a Hookah among Adults in the United States, Population Assessment of Tobacco and Health Study, 2015-2019.

Background: This study aimed to examine the trend and factors associated with smoking marijuana from a hookah device among US adults. Methods: Data were drawn from the Population Assessment of Tobacco and Health (PATH) Study, an ongoing nationally representative, longitudinal cohort study of the US population. Adult respondents who self-reported ever smoking marijuana from a hookah at Wave 5 (2018-19, N = 34,279 US adults) were included in the multivariable analysis. Trend analysis also was conducted using National Cancer Institute JoinPoint software from 2015 to 2019. Results: In 2018-19, an estimated 23.6 million (9.7%) US adults reported ever smoking marijuana from a hookah. Trend analysis showed the increasing prevalence of using marijuana from a hookah device from Wave 3 (8.9%) to Wave 5 (9.7%; time trend p = .007). Adults aged 25-44 years old (vs. 18-24; 13%, vs. 9%), whites (vs. Black; 11% vs. 9%), and lesbian, gay, or bisexual (LGB vs. straight; 17% vs. 9%) were more likely to report ever smoking marijuana from a hookah (ps < .05). Former and current users (vs. never users) of e-cigarettes (19% and 25% vs. 5%), cigarettes (11% and 21% vs. 2%), cigars (17% and 27% vs. 3%), and pipes (21% and 33% vs. 7%) and past 30-day blunt users (vs. non-users; 39% vs. 9%) were more likely to ever smoke marijuana from a hookah (ps < .05). Pregnant women (vs. non-pregnant; 12.8% vs. 8.6%; p = 0.03) were more likely to smoke marijuana from a hookah. Conclusions: Smoking marijuana from a hookah device is prevalent among young adults in the US, especially among vulnerable populations, and has increased significantly from 2015-2019.

Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies.

OBJECTIVES: This umbrella review aims to summarise the evidence about electronic nicotine delivery systems' (ENDS) risk and safety health profile to inform ENDS health communication strategies. DATA SOURCES AND STUDY SELECTION: Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4. DATA EXTRACTION: Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine's Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive. DATA SYNTHESIS: We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes. CONCLUSIONS: As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided. PROSPERO REGISTRATION NUMBER: CRD42021241630.

Nighttime sleep duration, daytime napping, and metabolic syndrome: findings from the China Health and Retirement Longitudinal Study.

PURPOSE: This study aimed to assess the association between nighttime sleep, daytime napping, and metabolic syndrome (MetS) in an elderly Chinese population. METHODS: A cross-sectional study was conducted using data from the 2011 China Health and Retirement Longitudinal Study (CHARLS) to examine the association between nighttime sleep, daytime napping, and MetS (defined according to the Chinese Diabetes Society criteria). Sleep duration was assessed by a self-reported questionnaire. Binary logistic regression models were used to estimate odds ratios and 95% confidence intervals of the associations adjusting for covariates. RESULTS: Among 4785 elderly Chinese aged over 65 years old, there was no association between short-time sleep duration (< 7 h/day) and MetS. However, long-time sleep duration (> 8 h/day) decreased the odds of MetS by 53% (aOR= 0.47; 95% CI 0.23-0.96) compared to normal sleep duration (7-8 h/day). Compared to no daytime napping, short-time napping (≤ 30 min/day) was associated with increased odds of MetS (aOR = 1.55, 95% CI 1.02-2.36) and long-time napping (> 30 min/day) was associated with even higher odds of MetS (aOR = 1.77, 95%CI 1.24-2.53). Individuals who were over 75 years old, with elementary school education, and good health status had lower odds of MetS, while women, individuals living in rural areas, and those who reported poor health status had higher odds of MetS. CONCLUSION: Long-time sleep duration decreased and daytime napping increased the risk of MetS among the elderly Chinese population. We speculate that increasing nighttime sleep duration and decreasing daytime napping may help reduce the risk of MetS.

Adolescence exposure to China's great famine period and the association of metabolic syndrome in adulthood: a retrospective study.

BACKGROUND: Exposure to famine during early life is related to several adverse health outcomes in adulthood, but the effect of famine exposure during adolescence is unclear. This study aims to examine whether exposure to famine in adolescence is associated with metabolic syndrome (MetS) in adulthood. METHODS: This study included 4130 Chinese adults (2059 males and 2071 females) aged 59-71 from the 2011 China Health and Retirement Longitudinal Study (CHARLS). All the selected participants were exposed to the three-year time period (1959-1961) of China's Great Famine. Participants were categorized into an adolescent-exposed group (born 01/01/1944-12/31/1948) and a non-adolescent-exposed group (born 01/01/1940-12/31/1941 and 01/01/1951-12/31/1952). Sex-stratified multiple logistic regression models were used to estimate the association between exposure to famine in adolescence and MetS. RESULTS: Participants exposed to famine during adolescence were more likely to report MetS (aOR = 1.35; 95%CI 1.01-1.78) compared to the non-adolescent-exposed group. Further, males were 45% less likely to report MetS than females (aOR = 0.55; 95%CI 0.36-0.83). After stratification by sex, the effects of famine exposure during adolescence on MetS were detected among males only (aOR = 1.97; 95%CI 1.20-3.24). Additionally, males with a history of drinking were more likely to report MetS compared to those with no history of drinking (aOR = 2.63; 95%CI 1.41-4.90). CONCLUSIONS: Our findings reveal that exposure to famine during adolescence is associated with higher odds of MetS in adulthood overall, and this association is only pronounced among males. This study emphasizes that undernutrition in early life, including adolescence, may have a long-term effect and be associated with adverse health events in middle-to-late life. Targeting those elderly people who suffered famine during adolescence may help prevent the development of MetS in later life.

A Group-Based Modeling Approach to Identify Developmental Trajectories of Nicotine Dependence Among Lebanese Adolescents Waterpipe Smokers.

INTRODUCTION: Adolescence represents a critical period in which nicotine dependence (ND) symptoms are developing. Little is known about waterpipe (WP) smoking and developmental trajectories of ND criteria across adolescence. AIMS AND METHODS: Here, we aimed to identify ND trajectories from early- to late-adolescence in current (past 30 days) WP smokers and examine baseline correlates of each identified trajectory, using the International Classification of Diseases, 10th Revision (ICD-10). The analytical sample consisted of 278 current WP smokers from eight waves of an ongoing longitudinal cohort of eighth to ninth graders in Lebanon. Group-based trajectory modeling was estimated to identify trajectory classes for ICD-10-ND criteria over ages 11-18. RESULTS: A group-based modeling approach yielded a four-class solution that best fit the data and reflected differences in the timing of ND onset during adolescence: no-onset of ND (43.9%), early-onset (16.2%), mid-onset (26.6%), and late-onset (13.3%) of ND criteria. Having a less-educated mother (adjusted odds ratio [aOR] = 4.08, 95% confidence interval [95% CI] = 1.01% to 16.53%) and siblings who smoke WP (aOR = 3.95, 95% CI = 1.08% to 14.42%), exposure to favorite WP-specific advertisements (aOR = 3.33, 95% CI = 1.03% to 10.85%), and being a novelty seeker (aOR = 1.12, 95% CI = 1.02% to 1.23%) were associated with early-onset of ND. Daily (aOR = 3.48, 95% CI = 1.08% to 11.23%) or weekly (aOR = 2.20, 95% CI = 1.05% to 4.62%) WP smokers (vs. monthly) and having higher stress level (aOR = 1.07, 95% CI = 1.00% to 1.14%) were associated with mid-onset trajectory. Believing that WP smoking is not harmful to health (aOR = 0.11, 95% CI = 0.02% to 0.82%) and spending less than 60 minutes on a WP smoking session (aOR = 5.62, 95% CI = 1.20% to 26.44%) were associated with late-onset ND trajectory class. CONCLUSIONS: Monitoring the development of ND trajectories among WP smokers may identify an individual as belonging to one of these four groups with distinct individual and socioenvironmental factors and allow the individual and health care providers opportunities to inform initiate on-time WP-specific tailored prevention and cessation interventions. IMPLICATIONS: The results from this study showed a four-class trajectory of ICD-10-ND criteria and suggested that every ND trajectory class during adolescence could have distinctive characteristics and therefore provides new insights into the process of ND in terms of when and what specific interventions are needed to curb the development of ND and long-term WP smoking among youth.

Cigarettes and e-cigarettes use among US adults with multimorbidity.

Background: Tobacco use leads to multiple illnesses. Yet, the effects of different categories of tobacco use on multimorbidity remain understudied. We investigated the associations between tobacco use categories and multimorbidity and the potential moderating effects of age, sex, or race/ethnicity among adults in the United States. Methods: We conducted a cross-sectional analysis using pooled data from the Behavioral Risk Factor Surveillance System for the years 2020-2022. Multimorbidity was ascertained through self-reported ≥2 chronic health conditions. We categorized tobacco use into nine derived from nonuse (did not use e-cigarettes or cigarettes), former cigarette or e-cigarette use, current (used on some days/everyday) cigarette use or e-cigarette use, or both (dual use). We used multinomial logistic regression to investigate the associations while accounting for potential confounding factors. Results: Within the sample (N=1,080,257), 28.2% reported multimorbidity. For the categories examined (former exclusive e-cigarette, exclusive e-cigarette, former exclusive cigarette, former dual, former cigarette/current e-cigarette, exclusive cigarette, current cigarette/former e-cigarette and dual use), all reported higher odds of having multimorbidity compared to those who reported nonuse of both e-cigarettes and cigarettes. We found significant interactions for age, sex and race/ethnicity with the tobacco use categories for multimorbidity (p<0.01), where stronger associations were observed among younger adults, females and non-Hispanic Multiracial for current dual use (p<0.05). Conclusions: The use of cigarettes, e-cigarettes, or both was associated with multimorbidity among adults, which was more pronounced among younger adults, females and non-Hispanic Multiracial. These findings underscore the importance of implementing targeted public health interventions to mitigate the health risks associated with using both products, particularly among specific demographics, to reduce the prevalence of multimorbidity.

Partial Nicotine Reduction and E-Cigarette Users' Puffing Behaviors Among Adults Aged 21 to 35 Years: A Randomized Crossover Clinical Trial.

Importance: The advent of salt-based, high-nicotine electronic nicotine delivery systems [e-cigarettes] has contributed to their epidemic use among young people in the US, necessitating the need for policies to address the addictiveness of these products. Objective: To evaluate the effect of partial nicotine reduction on new-generation e-cigarette users' puffing behaviors. Design, Setting, and Participants: This randomized crossover clinical trial was conducted at the Clinical Research Lab for Tobacco Smoking at Florida International University in Miami between April 15, 2022, and October 17, 2023. Using a volunteering sampling method by distributing flyers and advertisements, current e-cigarette users (who preferred 5% nicotine concentration), aged 21 to 35 years, were included. Intervention: In a crossover design, participants completed 2 sessions of the same product (JUUL or NJOY) that differed by nicotine concentration (3% [JUUL] or 2.4% [NJOY] and 5% [JUUL or NJOY]) in random order. In each session, participants vaped up to 60 minutes ad libitum, preceded by 12 hours of nicotine abstinence. Main Outcomes and Measures: The primary outcomes were puffing topography parameters (eg, total session time, puffing time, total puffing number, interpuff interval, total inhaled volume, average puff volume, duration, and flow rate) measured during each session and plasma nicotine measured before and after each session. Results: Among 735 participants who were approached for eligibility, 675 were excluded, and 10 did not complete session 2. Of the 50 remaining current e-cigarette users (mean [SD] age, 23 [3] years; 56% men), 23 (46%) were low nicotine dependent. The median topography parameters were significantly higher during the e-cigarette use sessions with 3% or 2.4% nicotine concentration compared with 5% nicotine concentration for 3 outcomes: puffing time (1.3 minutes [IQR, 0.3-9.4 minutes] vs 1.2 minutes [IQR, 0.2-5.6 minutes]; P = .02), puff duration (2.6 seconds [IQR, 0.8-6.9 seconds] vs 2.4 seconds [IQR, 0.4-6.6 seconds]; P = .02), and total inhaled volume (1990.0 mL [IQR, 279.0-24 400.0 mL] vs 1490.0 mL [IQR, 148.0-14 300.0 mL]; P = .05). The median plasma nicotine boost observed in the 5% nicotine concentration condition (0.0060 mg/L [IQR, 0.0001-0.0249 mg/L]) was significantly higher than that in the 3% or 2.4% session (0.0043 mg/L [IQR, 0.0008-0.0225 mg/L]) (P = .001). Additionally, deeper puffing (increased average puff duration and average puff volume) was observed in participants with higher nicotine dependence (1.42 seconds [95% CI, 1.12-1.80 seconds]; P = .03) and male users (1.38 mL [95% CI, 1.09-1.75 mL]; P = .04) in response to nicotine reduction. Conclusions and Relevance: This randomized crossover clinical trial provides direct evidence that partial nicotine reduction in salt-based e-cigarettes was associated with acute compensatory puffing and the potential for increased exposure to toxicants. However, given the reduced nicotine delivery associated with nicotine reduction, the acute compensatory response observed in this study may not preclude a population benefit due to the marketing of less addictive products. These results suggest that at least for current e-cigarette users, partial nicotine reduction can lead to enhanced exposure to some toxicants in the short term. Trial Registration: ClinicalTrials.gov Identifier: NCT05205382.

Knowledge and beliefs about blunts among youth in the United States.

Background: Blunts (i.e., cannabis rolled in cigar paper with or without tobacco) are a popular way of consuming cannabis. Little survey research has examined knowledge and beliefs about blunts, especially among youth who use cigars or are susceptible to cigar use. Methods: Participants were a convenience sample of N = 506 youth (ages 15-20) from the United States (US) recruited April-June 2023 who reported ever using little cigars or cigarillos (LCCs), past 30-day use of LCCs, or susceptibility to using LCCs. We used adjusted logistic and ordinal regression models to examine correlates of knowledge that blunts contain nicotine and, separately, relative addiction/harm perceptions for blunts vs. unmodified cigars containing only tobacco. Results: One-third of youth (32.1 %) thought that blunts do not contain nicotine. Around half of youth thought that blunts were "much less" or "slightly less" addictive (45.0 %) and "much less" or "slightly less" harmful (51.5 %) than unmodified cigars. Youth who identified as Black/African American (vs. white) had lower odds of knowledge that blunts contain nicotine (aOR = 0.51, 95 % CI: 0.30, 0.87). Youth who frequently used blunts were less likely to report that blunts were more addictive (aOR = 0.39; 95 % CI: 0.24, 0.63) and harmful (aOR = 0.31; 95 % CI: 0.19, 0.50 (vs. unmodified cigars) compared with youth who never used blunts. Conclusions: Our study with a sample of US youth-who have used or are susceptible to using LCCs-found that about 1 in 3 participants thought that blunts do not contain nicotine, and many believed blunts were less harmful and addictive than unmodified cigars.

Associations between ENDS and cigarette use, and compromised immunity in US adults: Findings from the 2021-2022 NHIS.

BACKGROUND: Tobacco use presents increased risks for individuals with weakened immune systems (WIS). We investigated the association between cigarette and electronic nicotine delivery systems (ENDS or e-cigarettes) use and WIS in US adults using data from the 2021-2022 National Health Interview Survey. METHODS: Data from 57,133 adults were analyzed, focusing on WIS prevalence due to health conditions, prescriptions, or both. Cigarette and ENDS use were categorized as never, former, or current. Weighted multivariable regression models adjusted for demographics and other health conditions to assess associations between tobacco use and WIS. RESULTS: Among US adults, 4.3% had prescription-related WIS, 4.6% had health condition-related WIS, and 7% had WIS due to either reason. Adjusted results from multivariable regression models indicated that adults with WIS due to health conditions were more likely to be current (AOR = 1.21, 95%CI: 1.05-1.40) and former (AOR = 1.25, 95%CI: 1.11-1.39) cigarette smokers compared to counterparts without WIS. Adults with WIS due to prescriptions were more likely to be former cigarette smokers (AOR = 1.19, 95%CI: 1.06-1.34). Those with WIS for any reason were more likely to be current (AOR = 1.19, 95%CI: 1.05-1.35) and former (AOR = 1.24, 95%CI: 1.13-1.36) cigarette smokers. Adults with WIS due to health conditions (AOR = 1.23, 95%CI: 1.06-1.41) or any reasons (AOR = 1.19, 95%CI:1.05-1.34) were more likely to be former ENDS users compared to those without WIS. CONCLUSIONS: In this nationally representative study, we found a notable link between cigarette and ENDS use with WIS, particularly among those with health condition-related or prescription-related WIS, underscoring the importance of addressing tobacco use in this vulnerable population.

Trends and Disparities in Waterpipe Tobacco Smoking Among US Adolescents and Adults: PATH Study 2013-2021.

Background: Waterpipe tobacco smoking (WTS) is a popular mode of nicotine delivery among young people. We examined the trends and disparities in WTS from 2013 to 2021 among US adolescents and adults. Methods: Data were from Wave 1 (initially conducted among 32 320 adults and 13 651 adolescents) to Wave 6 (2013-2021) of the Population Assessment of Tobacco and Health Study. We assessed the weighted prevalence of ever and current (past 30-day) WTS for adults and adolescents across waves stratified by demographics. Results: From 2013-2021 among adolescents, the prevalence of ever and current WTS decreased by 86.5% (7.4% to 1.00%; p = 0.0364) and 97.1% (1.65% to 0.05%; p = 0.0012), respectively. Despite the decreasing trends among adolescents across all waves, females had a higher prevalence of ever and current WTS compared to males (p 's < 0.001 for all trends). Hispanics had the highest prevalence of ever WTS compared to other races/ethnicities (p 's < 0.001). Adolescents aged 15-17 had a higher (except Wave 6) prevalence of ever and current WTS than 12-14 years old (p 's < 0.001). For adults, the prevalence of ever WTS increased by 27.4% (16.39% to 20.92%; p = 0.0006), and current WTS decreased by 45.5% (2.19% to 1.24%; p = 0.0012). Young adults aged 18-24 experienced increasing trends in WTS and had the highest prevalence of ever and current WTS compared to other age groups (p 's < 0.001) across all waves. Conclusions: Our study indicates a notable decrease in adolescent WTS prevalence from 2013 to 2021 but an increase of ever WTS among adults. Demographic differences underscore disparities in WTS, calling for tailored interventions.

Temporal Trends in Tobacco Product Use Among US Middle and High School Students: National Youth Tobacco Survey, 2011-2020.

OBJECTIVES: Despite significant declines in cigarette smoking during the past decade, other tobacco products gained popularity among middle and high school students. This study examined temporal trends in exclusive and concurrent use of tobacco products among middle and high school students in the United States from 2011 through 2020. METHODS: We used multiple annual datasets from the National Youth Tobacco Survey from 2011 through 2020 (N = 193 350) to examine trends of current (past 30 days) exclusive, dual, and poly use of tobacco products (ie, cigarettes, electronic cigarettes [e-cigarettes], cigars, hookahs, and smokeless tobacco). We used joinpoint regression models to calculate log-linear trends in annual percentage change (APC). RESULTS: During 2011-2020, exclusive use of any tobacco product decreased significantly, except for e-cigarettes, which increased significantly at an APC of 226.8% during 2011-2014 and 14.6% during 2014-2020. This increase was more pronounced among high school students (APC = 336.6% [2011-2014] and 15.7% [2014-2020]) than among middle school students (APC = 10.4% [2014-2020]) and among male students (APC = 252.8% [2011-2014] and 14.8% [2014-2020]) than among female students (APC = 13.6% [2014-2020]). During 2011-2020, we also found upward trends in dual use of e-cigarettes and cigarettes (APC = 17.3%). Poly use of e-cigarettes, cigarettes, and any other tobacco products increased significantly at an APC of 57.1% during 2011-2014. CONCLUSIONS: The emergence of new tobacco products such as e-cigarettes in the US market has shifted the landscape of tobacco use among adolescents in the last decade toward poly product use, in which e-cigarettes are a prominent component. Our findings underscore the increasing complexity of tobacco use among adolescents in the United States and the need for strong policies and regulations adapted to evolving trends in cigarette and noncigarette tobacco products.

COVID-19 and tobacco products use among US adults, 2021 National Health Interview Survey.

Background: Smoking and vaping are linked to lung inflammation and lowered immune response. Objective: Examine the prevalence of coronavirus disease 2019 (COVID-19) cases, testing, symptoms, and vaccine uptake, and associations with tobacco product use. Methods: Data came from the 2021 National Health Interview Survey. The 2021 Sample Adult component included 29,482 participants with a response rate of 50.9%. We investigated COVID-19-related outcomes by tobacco product use status and reported national estimates. Multivariable regression models were performed accounting for demographics (e.g., age, sex, poverty level), serious psychological distress, disability, and chronic health conditions. Results: In our regression analyses, odds of self-reported COVID-19 infection were significantly lower for combustible tobacco product users (vs. nonusers; adjusted odds ratio [AOR = 0.73; 95% confidence interval [CI] = 0.62-0.85]). Combustible tobacco users also were less likely to report ever testing for COVID-19 (AOR = 0.88; 95% CI = 0.79-0.98), ever testing positive for COVID-19 (AOR = 0.66; 95% CI = 0.56-0.77), and ever receiving COVID-19 vaccine (AOR = 0.58; 95% CI = 0.51-0.66) compared with their nonuser peers. Compared to nonusers, users of any type of tobacco who contracted COVID-19 had higher odds of losing smell (AOR = 1.36; 95%CI = 1.04-1.77), which was more pronounced among exclusive e-cigarette users. The odds of receiving vaccine were lower for all current exclusive tobacco product users compared to nonusers (AORs = 0.40 to 0.70). Conclusions: Continued monitoring of tobacco product use and its association with respiratory diseases such as COVID-19 is crucial to inform public health policies and programs. In addition, efforts to promote vaccination, especially among tobacco product users, are warranted.

A Systematic Review and Meta-analysis to Estimate the Time from HIV Infection to Diagnosis for People with HIV.

Timely HIV diagnosis is critical to minimizing transmission events. We sought to estimate the meantime from HIV infection to diagnosis and its temporal trend among people with HIV. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a search of MEDLINE, Embase, and Google Scholar, supplemented by a hand search of bibliographies of articles, was conducted. Study information and outcome measures of time from HIV infection to diagnosis were synthesized. Random-effects metaanalyses were performed. The search identified 12 articles from 4541 unduplicated citations. Studies were conducted in the UK (k = 3), US (k = 3), France (k = 2), Australia (k = 1), Switzerland (k = 1), Netherlands (k = 1), and China (k = 1). The pooled meantime from HIV infection to diagnosis was 3.00 years (95% confidence interval: 2.16-3.84). From 1996 to 2002, meantime reduced from 4.68 to 2.66 years. Subsequently, it increased to 3.20 years in 2003 and remained relatively stable until 2015. In sub-group meta-analyses, men who have sex with men (MSM) had a meantime of 2.62 years (1.91-3.34), while for heterosexuals and people who inject drugs, it was 5.00 (4.15-5.86) and 4.98 (3.97-5.98) years, respectively. In the high- and upper-middle-income countries included in this study, persons live with undiagnosed HIV for about 3 year before being diagnosed. This period is shorter for MSM relative to people with infections attributable to other risk factors.

State-specific Prevalence and Factors Associated With Current Marijuana, ENDS, and Cigarette use Among US Adults With Asthma.

Background: The use of marijuana (MJ), combustible cigarettes (hereafter cigarettes), and electronic nicotine delivery systems (ENDS) is widespread among United States (US) adults and linked to worsening respiratory symptoms, especially among adults with asthma. This study examined state-specific prevalence and factors associated with MJ, ENDS, and cigarette use among US adults with asthma. Methods: We analyzed data of 41 974 adults aged ≥18 years having self-reported current asthma from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). We reported weighted prevalence to account for complex survey design and performed multivariable logistic regression models to examine factors associated with current use of MJ, ENDS, and cigarettes. Results: Overall prevalence of current MJ, ENDS, and cigarette use among adults with asthma was 14.5%, 6.6%, and 27.2%, respectively. Our results showed the US states and territories with highest and lowest use prevalence for MJ (California: 23.6% vs Guam: 3.2%), ENDS (Indiana: 12.8% vs North Dakota: 4.0%), and cigarettes (West Virginia: 42.1% vs Guam: 12.3%). Both MJ and ENDS users were more likely to be male, younger, and live in an urban area, but MJ users were more likely and ENDS users less likely to be Non-Hispanic (NH) American Indian/Alaskan Native. Cigarette users were more likely to be older, have at least 1 health condition, and were less likely to be NH Black or Hispanic and college-educated. Conclusion: Many US adults with asthma use MJ, ENDS, and cigarettes. Our findings provide insights for clinicians about the urgent need for effective interventions to reduce tobacco and MJ use among adults with asthma.