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

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

Influence of Warning Statements on Understanding of the Negative Health Consequences of Smoking.

INTRODUCTION: Pursuant to the Tobacco Control Act (TCA), the US Food and Drug Administration (FDA) is developing new cigarette health warnings to convey the negative health consequences of cigarette smoking. AIMS AND METHODS: This study assessed which of 15 revised warning statements (10 on topics similar to TCA statements and 5 on other topics) promoted greater understanding of cigarette smoking risks relative to TCA statements. In February 2018, adolescent and adult smokers and adolescents susceptible to smoking (n = 2505) completed an online experiment. Control condition participants viewed TCA statements; treatment condition participants viewed combinations of TCA and revised statements. Analyses compared revised statements to TCA statements on the same health topic or to randomly selected TCA statements if there were no statements on the same topic. RESULTS: Relative to TCA statements, 12 of 15 revised statements were more likely to be considered new information, and 12 resulted in more self-reported learning. Three revised statements made participants think more about health risks than TCA statements; the reverse was true for one revised statement. Participants rated most TCA and revised statements as moderately believable and informative. Seven revised statements were found to be less believable and factual, and one revised statement more believable and factual. Treatment condition participants correctly selected more smoking-related health conditions than control condition participants (13.79 versus 12.42 of 25). CONCLUSIONS: Findings suggest that revised statements can promote greater understanding of cigarette smoking risks. Results informed FDA's selection of warning text that was paired with images for testing in a follow-up study. IMPLICATIONS: The US FDA may adjust the text of the cigarette warning statements provided in the TCA if the revised statements promote greater public understanding of the negative health consequences of cigarette smoking. Most of the revised warning statements tested were more likely to be considered new information and resulted in more self-reported learning compared with paired TCA statements, providing support for using revised statements as part of cigarette health warnings. These results informed the development of pictorial cigarette warnings by FDA that were tested in a follow-up study and included in a proposed rule.

Impact of Pictorial Cigarette Warnings Compared With Surgeon General's Warnings on Understanding of the Negative Health Consequences of Smoking.

INTRODUCTION: The Family Smoking Prevention and Tobacco Control Act requires cigarette packages and advertisements to bear health warnings with "color graphics depicting the negative health consequences of smoking." AIMS AND METHODS: This study assessed whether new US Food and Drug Administration developed pictorial cigarette warnings (PCW) increased understanding of smoking-related risks relative to the current Surgeon General's (SG) warnings. In March-May 2019, adolescent and adult smokers and nonsmokers participated in an online experiment with three sessions completed over approximately 2 weeks. Participants viewed 1 of 16 PCW (treatment conditions) or an SG warning (control) on mock cigarette packages and advertisements. Measures assessed whether warnings provided new information, induced thinking about risks, changed smoking-related health beliefs, and were accurately recalled, among other outcomes. RESULTS: The majority of PCW (≥13 conditions) resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks; they were viewed as more informative, understandable, and attention-drawing compared with the control condition. Most participants believed the warning were factual, although 8 PCW were perceived as less factual than the control. There were changes toward more agreement with health beliefs for 11 PCW between Sessions 1 and 2 and 7 PCW between Sessions 1 and 3. Participants in all treatment conditions were more likely than control condition participants to correctly recall the warning. Across outcomes, PCW related to addiction, death, and quitting did not perform as well as other PCW. CONCLUSIONS: Many of the PCW tested increased understanding of the risks associated with cigarette smoking relative to current SG warnings. IMPLICATIONS: The Tobacco Control Act requires cigarette packages and advertisements to bear PCW depicting the negative health consequences of smoking. This study tested whether any of 16 newly proposed PCW increased understanding of smoking-related risks relative to existing SG warnings. Results suggest that most PCW tested, particularly those related to less widely known health effects, resulted in greater learning of new information, higher self-reported learning, and greater reports of thinking about smoking risks compared with SG warnings. These results, along with other factors, informed the US Food and Drug Administration's selection of proposed PCW.

Item Development and Performance of Tobacco Product and Regulation Perception Items for the Health Information National Trends Survey.

INTRODUCTION: Emerging tobacco products have become increasingly popular, and the US Food and Drug Administration extended its authority to all products meeting the definition of a tobacco product in 2016. These changes may lead to shifts in public perceptions about tobacco products and regulation, and national surveys are attempting to assess these perceptions at the population level. This article describes the item development and cognitive interviewing of the tobacco product and regulation perception items included in two tobacco-focused cycles of the Health Information National Trends Survey (HINTS-FDA), referred to as HINTS-FDA. METHODS: Cognitive interviewing was used to investigate how respondents comprehended and responded to tobacco product and regulation perception items. Adult participants (n = 20) were selected purposively to oversample current tobacco users and were interviewed in two iterative rounds. Weighted descriptive statistics from the fielded HINTS-FDA surveys (N = 5474) were also calculated. RESULTS: Items were generally interpreted as intended, and participants meaningfully discriminated between tobacco products when assessing addiction perceptions. Response selection issues involved inconsistent reporting among participants with little knowledge or ambivalent opinions about either government regulation or tobacco products and ingredients, which resolved when a "don't know" response option was included in the survey. The fielded survey found that a non-negligible proportion of the population do not have clear perceptions of emerging tobacco products or government regulation. CONCLUSIONS: A "don't know" response option is helpful for items assessing many emerging tobacco products but presents several analytic challenges that should be carefully considered. Multiple items assessing specific tobacco product and regulation perception items are warranted in future surveys. IMPLICATIONS: The findings from this study can serve as a foundation for future surveys that assess constructs related to emerging tobacco products, harm perceptions across multiple tobacco products, and tobacco-related government regulatory activities. The data provide unique insight into item-specific motivation for selecting a "don't know" response option for tobacco survey items.

E-cigarette openness, curiosity, harm perceptions and advertising exposure among U.S. middle and high school students.

Understanding factors associated with youth e-cigarette openness and curiosity are important for assessing probability of future use. We examined how e-cigarette harm perceptions and advertising exposure are associated with openness and curiosity among tobacco naive youth. Findings from the 2015 National Youth Tobacco Survey (NYTS) were analyzed. The 2015 NYTS is a nationally representative survey of 17,711 U.S. middle and high school students. We calculated weighted prevalence estimates of never users of tobacco products (cigarettes, cigars/cigarillos/little cigars, waterpipe/hookah, smokeless tobacco, bidis, pipes, dissolvables, e-cigarettes) who were open to or curious about e-cigarette use, by demographics. Weighted regression models examined how e-cigarette harm perceptions and advertising exposure were associated with openness using e-cigarettes and curiosity about trying e-cigarettes. Among respondents who never used tobacco products, 23.8% were open to using e-cigarettes and 25.4% were curious. Respondents that perceived e-cigarettes cause a lot of harm had lower odds of both openness (OR = 0.10, 95% CI = 0.07, 0.15) and curiosity about e-cigarettes (OR = 0.10, 95% CI = 0.07, 0.13) compared to those with lower harm perception. Respondents who reported high exposure to e-cigarette advertising in stores had greater odds of being open to e-cigarette use (OR = 1.22, 95% CI = 1.03, 1.44) and highly curious (OR = 1.25, 95% CI = 1.01, 1.53) compared to those not highly exposed. These findings demonstrate that youth exposed to e-cigarette advertising are open and curious to e-cigarette use. These findings could help public health practitioners better understand the interplay of advertising exposure and harm perceptions with curiosity and openness to e-cigarette use in a rapidly changing marketplace.

Susceptibility to tobacco product use among youth in wave 1 of the population Assessment of tobacco and health (PATH) study.

The purpose of this study was to investigate susceptibility and ever use of tobacco products among adolescents and young adults in the US. Cross-sectional analysis of Wave 1(2013-2014) adolescent (12-17year-olds; n=13,651) and young adult (18-24year-olds; n=9112) data from the nationally-representative Population Assessment of Tobacco and Health (PATH) Study was conducted. At 12years, 5% were ever tobacco users and 36% were susceptible to use. Seventy percent were susceptible at age 17years, and the same proportion were ever users at age 22years. Susceptibility levels were comparable for cigarettes and e-cigarette (28.6% and 27.4%, respectively), followed by hookah (22.0%), pipes (17.5%), cigars (15.2%), and smokeless tobacco (9.7%). Non-Hispanic (NH) Black (Adjusted Odds Ratio [ORadj]=1.36; 95% Confidence Limit [CL], 1.18-1.56) and Hispanic (ORadj=1.34: 95% CL,1.19-1.49) adolescent never- users were more likely to be susceptible to future use of a tobacco product than NH Whites. Susceptibility was higher with age (15-17yrs. vs 12-14yrs.: ORadj=1.69; 95% CL, 1.55-1.85) and parental education (college graduates vs less than HS education: ORadj=1.22, 95% CL, 1.08-1.39). Compared to exclusive users of hookah, cigars, or smokeless products, larger proportions of exclusive e-cigarette ever users were also susceptible to cigarette use. Among adolescents, lower levels of ever use of tobacco products are often counterbalanced by higher levels of susceptibility for future use, which may suggest delayed initiation in some groups. Ever users of a given tobacco product were more susceptible to use other tobacco products, putting them at risk for future multiple tobacco product use.

Rationale, Procedures, and Response Rates for the 2015 Administration of NCI's Health Information National Trends Survey: HINTS-FDA 2015.

The National Cancer Institute (NCI) developed the Health Information National Trends Survey (HINTS) to monitor population trends in cancer communication practices, information preferences, health risk behaviors, attitudes, and cancer knowledge. The U.S. Food and Drug Administration (FDA) recognized HINTS as a unique data resource for informing its health communication endeavors and partnered with NCI to field HINTS-FDA 2015. HINTS-FDA 2015 was a self-administered paper instrument sent by mail May 29 to September 8, 2015, using a random probability-based sample of U.S. postal addresses stratified by county-level smoking rates, with an oversampling of high and medium-high smoking strata to increase the yield of current smokers responding to the survey. The response rate for HINTS-FDA 2015 was 33% (N = 3,738). The yield of current smokers (n = 495) was lower than expected, but the sampling strategy achieved the goal of obtaining more former smokers (n = 1,132). Public-use HINTS-FDA 2015 data and supporting documentation have been available for download and secondary data analyses since June 2016 at http://hints.cancer.gov . NCI and FDA encourage the use of HINTS-FDA for health communication research and practice related to tobacco-related communications, public knowledge, and behaviors as well as beliefs and actions related to medical products and dietary supplements.

Predictive Validity of the Expanded Susceptibility to Smoke Index.

OBJECTIVES: The susceptibility to smoking index can be improved as it only identifies one third of future adult smokers. Adding curiosity to this index may increase the identification of future smokers and improve the identification of effective prevention messages. METHODS: Analyses used data from the California Longitudinal Study of Smoking Transitions in Youth, for whom tobacco use behaviors, attitudes, and beliefs were assessed at 3 time points from age 12 through early adulthood. Logistic regressions were used to evaluate whether baseline curiosity about smoking was predictive of smoking during the 6-year follow-up period and whether curiosity about smoking provided evidence of incremental validity over existing measures of susceptibility to smoking. RESULTS: Compared to those who were classified as definitely not curious about smoking, teens who were classified as probably not curious (OR adj = 1.90, 95% CI = 1.28-2.81) and those classified as definitely curious (OR adj = 2.38, 95% CI= 1.49-3.79) had an increase in the odds of becoming a young adult smoker. Adding curiosity to the original susceptibility to smoking index increased the sensitivity of the enhanced susceptibility index to 78.9% compared to 62.2% identified by the original susceptibility index. However, a loss of specificity meant there was no improvement in the positive predictive value. CONCLUSIONS: The enhanced susceptibility index significantly improves identification of teens at risk for becoming young adult smokers. Thus, this enhanced index is preferred for identifying and testing potentially effective prevention messages.

Judgments, awareness, and the use of snus among adults in the United States.

INTRODUCTION: Alternative tobacco products, such as snus, are emerging in the U.S. market. Understanding correlates of awareness and use, particularly judgments about harm and addictiveness, can inform public health communications about these products. METHODS: Data were collected from a web panel representative of the U.S. population in March 2013 (N = 2,067). The survey assessed awareness and use of snus among adults. Absolute and comparative snus judgments, intentions, smoking status, and sociodemographic variables were measured. Bivariate and multivariable logistic regression analyses were conducted to examine associations between these variables and snus awareness and use. RESULTS: Nearly 36% of the population was aware of snus, and 5.2% reported ever using snus. Current cigarette smokers were about 4 times more likely as nonsmokers to report snus awareness and use. Sociodemographic correlates of snus awareness and use included being male, employed full time, and younger. Compared with respondents who perceived snus to be as harmful and as addictive as cigarettes, those who perceived snus to be less harmful and less addictive than cigarettes were more likely to have used snus. CONCLUSIONS: Current smokers are more likely to be aware of and have used snus. Multiple tobacco product use poses a significant challenge for public health efforts to reduce tobacco-associated morbidity and mortality. Perceptions that snus is less harmful and less addictive compared with cigarettes are associated with snus use. These judgments can inform public health communications about emerging tobacco products and multiple product use.

Reduced fatalism and increased prevention behavior after two high-profile lung cancer events.

The positive impact of media coverage of high-profile cancer events on cancer prevention behaviors is well-established. However, less work has focused on potential adverse psychological reactions to such events, such as fatalism. Conducting 3 studies, the authors explored how the lung cancer death of Peter Jennings and diagnosis of Dana Reeve in 2005 related to fatalism. Analysis of a national media sample in Study 1 found that media coverage of these events often focused on reiterating the typical profile of those diagnosed with lung cancer; 38% of the media mentioned at least 1 known risk factor for lung cancer, most often smoking. Data from a nationally representative survey in Study 2 found that respondents reported lower lung cancer fatalism, after, compared with before, the events (OR = 0.16, 95% CI [0.03, 0.93]). A sustained increase in call volume to the national tobacco Quitline after these events was found in Study 3. These results suggest that there is a temporal association between high-profile cancer events, the subsequent media coverage, psychological outcomes, and cancer prevention behaviors. These results suggest that high-profile cancer events could be leveraged as an opportunity for large-scale public heath communication campaigns through the dissemination of cancer prevention messages and services.

Physicians' attitudes about communicating and managing scientific uncertainty differ by perceived ambiguity aversion of their patients.

BACKGROUND: Medical interventions are often characterized by substantial scientific uncertainty regarding their benefits and harms. Physicians must communicate to their patients as part of the process of shared decision making, yet they may not always communicate scientific uncertainty for several reasons. One suggested by past research is individual differences in physicians' tolerance of uncertainty. Relatedly, an unexplored explanation is physicians' beliefs about their patients' tolerance of uncertainty. DESIGN: To test this possibility, we surveyed a sample of primary care physicians (N = 1500) and examined the association between their attitudes about communicating and managing scientific uncertainty and their perceptions of negative reactions to uncertainty by their patients. Physician perceptions were measured by their propensity towards pessimistic appraisals of risk information and avoidance of decision making when risk information is ambiguous--of uncertain reliability, credibility or adequacy, known as 'ambiguity aversion'. RESULTS: Confirming past studies, physician demographics (e.g. medical specialty) predicted attitudes toward communicating scientific uncertainty. Additionally, physicians' beliefs about their patients' ambiguity aversion significantly predicted these preferences. Physicians who thought that more of their patients would have negative reactions to ambiguous information were more likely to think that they should decide what is best for their patients (ß = 0.065, P = 0.013), and to withhold an intervention that had uncertainty associated with it (ß = 0.170, P < 0.001). DISCUSSION: When faced with the task of communicating scientific uncertainty about medical tests and treatments, physicians' perceptions of their patients' ambiguity aversion may be related to their attitudes towards communicating uncertainty.

Worry and risk perceptions as independent and interacting predictors of health protective behaviors.

Worry and risk perceptions are generally found to be independently associated with health-promoting behaviors, although it is unknown whether they interact in ways that potentially dampen the effect of either construct on behavior. In this hypothesis-generating study, cancer-related worry and risk perception, and their interaction, were used to predict odds of meeting 5-a-day fruit and vegetable consumption guidelines and engaging in any exercise using data from a nationally representative sample (N = 10,230). Risk perception was not associated with either behavior; worry was associated only with exercise (OR = 1.77, 95% CI: 1.16, 2.70, p < .01). More important, their interaction was associated with these behaviors in a counterintuitive manner; among those higher in worry, higher levels of risk perception were associated with lower vegetable consumption (OR = 0.79, 95% CI: 0.62, 1.00, p < .05) and exercise (OR = 0.77, 95% CI: 0.63, 0.95, p = .01). These results suggest the hypothesis that, among people high in worry, attempts to increase risk perception could be counterproductive. These and related findings suggest the importance of distinguishing worry from risk perception, and future research is necessary to determine the causal nature of these associations.

Perceiving interpersonally-mediated risk in virtual environments.

Using virtual reality (VR) to examine risky behavior that is mediated by interpersonal contact, such as agreeing to have sex, drink, or smoke with someone, offers particular promise and challenges. Social contextual stimuli that might trigger impulsive responses can be carefully controlled in virtual environments (VE), and yet manipulations of risk might be implausible to participants if they do not feel sufficiently immersed in the environment. The current study examined whether individuals can display adequate evidence of presence in a VE that involved potential interpersonally-induced risk: meeting a potential dating partner. Results offered some evidence for the potential of VR for the study of such interpersonal risk situations. Participants' reaction to the scenario and risk-associated responses to the situation suggested that the embodied nature of virtual reality override the reality of the risk's impossibility, allowing participants to experience adequate situational embedding, or presence.

Youth perception of harm and addictiveness of tobacco products: Findings from the Population Assessment of Tobacco and Health Study (Wave 1).

PURPOSE: We provide a US national assessment of youth perceptions of the harm and addictiveness of six separate tobacco products, identifying a continuum of perceived harm associated with a range of products in relation to patterns of current use, former use, and susceptibility to use tobacco products. METHODS: We evaluated youth respondents (N = 13,651) ages 12-17 from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Analyses (2015-2016) focused on refining measures of perceived harm for each product and delineating youth characteristics (demographic, tobacco use status) associated with beliefs about the harmfulness and addictiveness of tobacco products. RESULTS: Cigars, hookah and e-cigarettes were each perceived as having significantly lower harm (p's < 0.05) than smokeless products, with the lowest ratings of harmfulness and addictiveness observed for hookah and e-cigarettes (p's < 0.001). Incrementally lower levels of harm and addictiveness perceptions were observed among youth at increasing risk for tobacco use (p's < 0.05). CONCLUSIONS: Among U.S. youth, lower perceptions of harm and addictiveness of tobacco products were associated with susceptibility to use tobacco and patterns of tobacco product use. Future longitudinal assessments from the PATH Study can provide key information on youth development of perceptions of harm and addictiveness and influences on patterns of tobacco use.

Tobacco Product Use and Associated Factors Among Middle and High School Students - United States, 2019.

PROBLEM/CONDITION: Tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various smoked, smokeless, and electronic products. PERIOD COVERED: 2019. DESCRIPTION OF SYSTEM: The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6-8) and high school (grades 9-12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS is designed to provide national data on tobacco product use and has been conducted periodically during 1999-2009 and annually since 2011. Data from NYTS are used to support the design, implementation, and evaluation of comprehensive tobacco use prevention and control programs and to inform tobacco regulatory activities. Since its inception in 1999 through 2018, NYTS had been conducted via paper and pencil questionnaires. In 2019, NYTS for the first time was administered in schools using electronic data collection methods. CDC's Office on Smoking and Health, in collaboration with the U.S. Food and Drug Administration's (FDA's) Center for Tobacco Products, analyzed data from the 2019 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 19,018 questionnaires were completed and weighted to represent approximately 27.0 million students. On the basis of self-reported grade level, this included 8,837 middle school questionnaires (11.9 million students) and 10,097 high school questionnaires (15.0 million students); 84 questionnaires with missing information on grade level were excluded from school-level analyses. RESULTS: In 2019, an estimated 53.3% of high school students (8.0 million) and 24.3% of middle school students (2.9 million) reported having ever tried a tobacco product. Current (past 30-day) use of a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, and bidis [small brown cigarettes wrapped in a leaf]) was reported by 31.2% of high school students (4.7 million) and 12.5% of middle school students (1.5 million). E-cigarettes were the most commonly cited tobacco product currently used by 27.5% of high school students (4.1 million) and 10.5% of middle school students (1.2 million), followed in order by cigars, cigarettes, smokeless tobacco, hookahs, and pipe tobacco. Tobacco product use also varied by sex and race/ethnicity. Among current users of each tobacco product, the prevalence of frequent tobacco product use (on ≥20 days of the preceding 30 days) ranged from 16.8% of cigar smokers to 34.1% of smokeless tobacco product users. Among current users of each individual tobacco product, e-cigarettes were the most commonly used flavored tobacco product (68.8% of current e-cigarette users). Among students who reported ever having tried e-cigarettes, the three most commonly selected reasons for use were "I was curious about them" (55.3%), "friend or family member used them" (30.8%), and "they are available in flavors, such as mint, candy, fruit, or chocolate" (22.4%). Among never users of each individual tobacco product, curiosity and susceptibility (a construct that can help to identify future tobacco product experimentation or use) was highest for e-cigarettes (39.1% and 45.0%, respectively) and cigarettes (37.0% and 45.9%, respectively). Overall, 86.3% of students who reported contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines) reported exposure to marketing for any tobacco product; 69.3% reported exposure to e-cigarette marketing and 81.7% reported exposure to marketing for cigarettes or other tobacco products. Among all students, perceiving no harm or little harm from intermittent tobacco product use (use on some days but not every day) was 28.2% for e-cigarettes, 16.4% for hookahs, 11.5% for smokeless tobacco products, and 9.5% for cigarettes. Among current users of any tobacco product, 24.7% reported experiencing cravings to use tobacco products during the past 30 days and 13.7% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 57.8% of current tobacco product users reported they were seriously thinking about quitting the use of all tobacco products and 57.5% reported they had stopped using all tobacco products for ≥1 day because they were trying to quit. INTERPRETATION: In 2019, approximately one in four youths (23.0%) had used a tobacco product during the past 30 days. By school level, this represented approximately three in 10 high school students (31.2%) and approximately one in eight middle school students (12.5%). Since 2014, e-cigarettes have been the most commonly used tobacco product among youths. Importantly, more than half of current youth tobacco product users reported seriously thinking about quitting all tobacco products in 2019. However, established factors of use and initiation, including the availability of flavors, exposure to tobacco product marketing, curiosity and susceptibility, and misperceptions about harm from tobacco product use, remained prevalent in 2019 and continue to promote tobacco product use among youths. PUBLIC HEALTH ACTION: The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and community levels. Everyone, including public health professionals, health care providers, policymakers, educators, parents, and others who influence youths, can help protect youths from the harms of all tobacco products. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA's regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

A daily process investigation of alcohol-involved sexual risk behavior among economically disadvantaged problem drinkers living with HIV/AIDS.

Alcohol use is believed to increase sexual risk behavior among people living with HIV/AIDS (PLWHA). As drinking and sexual risk acts often occur in the same social contexts, this association is difficult to confirm. In this study, electronic daily diaries were completed by 116 PLWHA over 5 weeks. This yielded a total of 1,464 records consisting of data pertaining to discrete occasions of anal and vaginal sex. Simultaneous within- and between-person multilevel analyses were conducted, including situational variables (partner type, partner serostatus, partner drinking) and individual difference variables (gender, level of alcohol dependence). The resulting model explains 27.5% of the variance and reveals that interactions among these situational and individual difference variables predict changes in the estimated rate of unprotected sex (US). Also, in defined contexts, the amount of alcohol consumed prior to sex significantly affects the rate of US among members of the sample. Implications are discussed.

Association Between Receptivity to Tobacco Advertising and Progression to Tobacco Use in Youth and Young Adults in the PATH Study.

Importance: Cigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults. Objective: To investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking. Design, Setting, and Participants: The Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted. Exposures: Advertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1. Main Outcomes and Measures: Progression to susceptibility or ever tobacco use at 1-year follow-up in wave 2. Results: Of the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95% confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95% CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95% CL, 1.41-1.85; cigars: AOR, 2.01; 95% CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95% CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95% CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95% CL, 1.19-1.75; cigars: AOR, 2.07; 95% CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95% CL, 1.08-2.38). Conclusions and Relevance: Receptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

Engagement With Online Tobacco Marketing and Associations With Tobacco Product Use Among U.S. Youth.

PURPOSE: Youth who engage with online tobacco marketing may be more susceptible to tobacco use than unengaged youth. This study examines online engagement with tobacco marketing and its association with tobacco use patterns. METHODS: Cross-sectional analysis of youths aged 12-17 years who participated in wave 1 of the Population Assessment of Tobacco and Health Study (N = 13,651). Engagement with tobacco marketing was based on 10 survey items including signing up for email alerts about tobacco products in the past 6 months. Logistic regression was used to examine the association of online engagement with tobacco marketing and susceptibility to use any tobacco product among never-tobacco users, ever having tried tobacco, and past 30-day tobacco use. RESULTS: An estimated 2.94 million U.S. youth (12%) engaged with ≥ one forms of online tobacco marketing. Compared with no engagement, the odds of susceptibility to the use of any tobacco product among never-tobacco users was independently associated with the level of online engagement: adjusted odds ratio (AOR) = 1.48 (95% confidence interval [CI], 1.24-1.76) for one form of engagement and AOR = 2.37 (95% CI, 1.53-3.68) for ≥ two forms of engagement. The odds of ever having tried tobacco were also independently associated with the level of online engagement: AOR = 1.33 (95% CI: 1.11-1.60) for one form of engagement and AOR = 1.54 (95% CI, 1.16-2.03) for ≥ two forms of engagement. The level of online engagement was not independently associated with past 30-day tobacco use. CONCLUSIONS: Online engagement with tobacco marketing may represent an important risk factor for the onset of tobacco use in youth.

Receptivity to Tobacco Advertising and Susceptibility to Tobacco Products.

BACKGROUND AND OBJECTIVES: Non-cigarette tobacco marketing is less regulated and may promote cigarette smoking among adolescents. We quantified receptivity to advertising for multiple tobacco products and hypothesized associations with susceptibility to cigarette smoking. METHODS: Wave 1 of the nationally representative PATH (Population Assessment of Tobacco and Health) study interviewed 10 751 adolescents who had never used tobacco. A stratified random selection of 5 advertisements for each of cigarettes, e-cigarettes, smokeless products, and cigars were shown from 959 recent tobacco advertisements. Aided recall was classified as low receptivity, and image-liking or favorite ad as higher receptivity. The main dependent variable was susceptibility to cigarette smoking. RESULTS: Among US youth, 41% of 12 to 13 year olds and half of older adolescents were receptive to at least 1 tobacco advertisement. Across each age group, receptivity to advertising was highest for e-cigarettes (28%-33%) followed by cigarettes (22%-25%), smokeless tobacco (15%-21%), and cigars (8%-13%). E-cigarette ads shown on television had the highest recall. Among cigarette-susceptible adolescents, receptivity to e-cigarette advertising (39.7%; 95% confidence interval [CI]: 37.9%-41.6%) was higher than for cigarette advertising (31.7%; 95% CI: 29.9%-33.6%). Receptivity to advertising for each tobacco product was associated with increased susceptibility to cigarette smoking, with no significant difference across products (similar odds for both cigarette and e-cigarette advertising; adjusted odds ratio = 1.22; 95% CI: 1.09-1.37). CONCLUSIONS: A large proportion of US adolescent never tobacco users are receptive to tobacco advertising, with television advertising for e-cigarettes having the highest recall. Receptivity to advertising for each non-cigarette tobacco product was associated with susceptibility to smoke cigarettes.

Openness to Using Non-cigarette Tobacco Products Among U.S. Young Adults.

INTRODUCTION: National data indicate that the prevalence of non-cigarette tobacco product use is highest among young adults; however, little is known about their openness to use these products in the future and associated risk factors. This study sought to characterize openness to using non-cigarette tobacco products and associated factors among U.S. young adults. METHODS: In 2014, National Adult Tobacco Survey data (2012-2013) were analyzed to characterize openness to using the following tobacco products among all young adults aged 18-29 years (N=5,985): cigars; electronic cigarettes ("e-cigarettes"); hookah; pipe tobacco; chew, snuff, or dip; snus; and dissolvables. Among those who were not current users of each product, multivariable logistic regression was used to examine associations between demographics, cigarette smoking status, lifetime use of other non-cigarette products, perceived harm and addictiveness of smoking, and receipt of tobacco industry promotions and openness to using each product. RESULTS: Among all young adults, openness to using non-cigarette tobacco products was greatest for hookah (28.2%); e-cigarettes (25.5%); and cigars (19.1%). In multivariable analyses, which included non-current users of each product, non-current ever, current, and former smokers were more likely than never smokers to be open to using most examined products, as were men and adults aged 18-24 years. Receipt of tobacco industry promotions was associated with openness to using e-cigarettes; chew, snuff, or dip; and snus. CONCLUSIONS: There is substantial openness to trying non-cigarette tobacco products among U.S. young adults. Young adults are an important population to consider for interventions targeting non-cigarette tobacco product use.