Responses to Real-World and Hypothetical Menthol Flavor Bans Among US Young Adults Who Smoke Menthol Cigarettes.

INTRODUCTION: Menthol cigarette bans have been implemented in some US states and localities, and a federal ban is being proposed by the FDA. This study asks how young adults who use menthol cigarettes respond to changes in menthol cigarette availability. AIMS AND METHODS: An online survey of young adults ages 18-34 who reported smoking menthol cigarettes on ≥7 of 30 days around Thanksgiving 2019 (n = 734), oversampling Massachusetts-the first state with a menthol ban. Participants reported their tobacco use behavior following real-world menthol cigarette bans or predicted their behavior under a hypothetical federal ban. RESULTS: Most respondents who exclusively smoked versus dual used with e-cigarettes continued smoking/using combustible tobacco following real-world bans (95.3% vs. 86.9%), accessing menthol cigarettes from other jurisdictions. Fewer who smoked exclusively responded by using e-cigarettes compared to those who dual used (3.9% vs. 43.7%). Quitting all tobacco use (ie, no smoking, vaping, or any tobacco use) was uncommon for both groups (3.6% vs. 9.0%). Under a hypothetical ban, majorities of those who exclusively smoke and who dual use predicted they would continue smoking (72.2% vs. 71.8%); fewer who smoke exclusively would use e-cigarettes compared to those who dual use (14.7% vs. 41.4%). Those who smoke exclusively were more likely to report quitting all tobacco compared to those who dual use (29.6% vs. 12.4%). CONCLUSIONS: Under real-world and hypothetical menthol cigarette bans, most respondents continued smoking. However, more young adults continued smoking following real-world bans, reflecting the limitations of local/state restrictions when menthol cigarettes are available in other jurisdictions. IMPLICATIONS: This survey asked young adults who use menthol cigarettes how they responded to real-world changes in the availability of menthol cigarettes; 89% reported continuing to smoke. Those who smoked exclusively were far less likely to respond by switching to e-cigarettes compared to people who dual used both products. Under a hypothetical federal menthol cigarette ban, 72% of young adults predicted that they would continue smoking. Quitting all tobacco was less common in the real-world scenario compared to the hypothetical ban. Access to menthol cigarettes in other jurisdictions and flavored cigars likely dampen the public health benefit of menthol cigarette bans.

Modeling cigarette smoking disparities between people with and without serious psychological distress in the US, 1997-2100.

Cigarette smoking rates are significantly higher among people with serious psychological distress (SPD) compared to the general population. US simulation models that project future smoking disparities by SPD status could inform policy interventions, but have not been developed. We calibrated two compartmental models to the National Health Interview Survey 1997-2018 for populations with and without SPD, calculating smoking prevalence, mortality, and life-years lost by SPD status under different scenarios from 2023 to 2100. Under the Status Quo, smoking prevalence among women with SPD falls from 27.0% in 2023 to 10.7% in 2100 (men: 30.1% to 12.2%). For women without SPD, it declines from 9.4% to 3.1% (men: 11.5% to 4.0%). The absolute difference in smoking prevalence between those with and without SPD decreases over time, whereas the relative smoking prevalence ratio increases. From 2023 to 2100, 609,000 premature smoking-attributable deaths would occur in the SPD population, with 8 million life-years lost. Under an ideal tobacco control scenario for people with SPD, in which all smokers quit in 2023 and no new smoking initiation occurs thereafter, up to 386,000 of these premature deaths could be averted with 4.9 million life-years gained. Preventing smoking initiation could avert up to 18% of these deaths, while improving smoking cessation could avert up to 82%. Smoking-related disparities for people with SPD will persist unless a shift in tobacco control substantially improves cessation and prevents initiation in this subpopulation. Smoking disparities by SPD may widen in relative but narrow in absolute terms, so both perspectives should be evaluated.

Responses to real-world and hypothetical e-cigarette flavor bans among US young adults who use flavored e-cigarettes.

INTRODUCTION: E-cigarette flavor bans could reduce or exacerbate population health harms. To determine how US e-cigarette flavor restrictions might influence tobacco use behavior, this study assesses responses to real-world and hypothetical flavor bans among young adults who use flavored e-cigarettes. METHODS: An online, national survey of young adults ages 18-34 who use flavored e-cigarettes was conducted in 2021 (n=1,253), oversampling states affected by e-cigarette flavor restrictions. Participants were asked about their responses to real-world changes in the availability of flavored e-cigarettes. Unaffected participants were asked to predict their responses under a hypothetical federal e-cigarette flavor ban. RESULTS: The most common response to real-world changes in flavored e-cigarettes availability was to continue vaping (~80%). Among those who exclusively vaped, 12.5% switched to combustible tobacco. Quitting all forms of tobacco was selected by 5.3% of those exclusively vape vs. 4.2% who dual use. Under a hypothetical federal ban, more than half of respondents stated they would continue vaping; 20.9% and 42.5% of those who exclusively vape vs dual use would use combustible tobacco. Quitting all tobacco products was endorsed by 34.5% and 17.2% of those who exclusively vape vs dual use. CONCLUSIONS: Young adults who vape flavored e-cigarettes have mixed responses to e-cigarette flavor bans. Under both real-world and hypothetical e-cigarette flavor bans, most who use flavored e-cigarettes continue vaping. Under a real-world ban, the second most common response among those who exclusively vape is to switch to smoking; under a hypothetical federal ban, it is to quit all tobacco. IMPLICATIONS: This is the first national survey to directly ask young adults who use flavored e-cigarettes about their responses to real-world changes in flavored e-cigarette availability due to state and local flavor restrictions. The survey also asked individuals to predict their responses under a hypothetical federal e-cigarette flavor ban. Most who use flavored e-cigarettes would continue vaping following e-cig flavor restrictions, but many would switch to or continue using combustible tobacco, highlighting potential negative public health consequences of these policies. Policymakers must consider the impact of e-cigarette flavor bans on both e-cigarette and cigarette use.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of youth and adults in the PATH Study in 2015-2017 vs 2017-2019.

INTRODUCTION: It is unknown how recent changes in the tobacco product marketplace have impacted transitions in cigarette and electronic nicotine delivery system (ENDS) use. METHODS: A multistate transition model was applied to 24 242 adults and 12 067 youth in waves 2-4 (2015-2017) and 28 061 adults and 12 538 youth in waves 4 and 5 (2017-2019) of the Population Assessment of Tobacco and Health Study. Transition rates for initiation, cessation and product transitions were estimated in multivariable models, accounting for gender, age group, race/ethnicity and daily versus non-daily product use. RESULTS: Changes in ENDS initiation/relapse rates depended on age, including among adults. Among youth who had never established tobacco use, the 1-year probability of ENDS initiation increased after 2017 from 1.6% (95% CI 1.4% to 1.8%) to 3.8% (95% CI 3.4% to 4.2%). Persistence of ENDS-only use (ie, 1-year probability of continuing to use ENDS only) increased for youth from 40.7% (95% CI 34.4% to 46.9%) to 65.7% (95% CI 60.5% to 71.1%) and for adults from 57.8% (95% CI 54.4% to 61.3%) to 78.2% (95% CI 76.0% to 80.4%). Persistence of dual use similarly increased for youth from 48.3% (95% CI 37.4% to 59.2%) to 60.9% (95% CI 43.0% to 78.8%) and for adults from 40.1% (95% CI 37.0% to 43.2%) to 63.8% (95% CI 59.6% to 67.6%). Youth and young adults who used both products became more likely to transition to ENDS-only use, but middle-aged and older adults did not. CONCLUSIONS: ENDS-only and dual use became more persistent. Middle-aged and older adults who used both products became less likely to transition to cigarette-only use but not more likely to discontinue cigarettes. Youth and young adults became more likely to transition to ENDS-only use.

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany.

BACKGROUND: Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs. METHODS: SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data. RESULTS: Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period. CONCLUSIONS: SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

Public health implications of vaping in the USA: the smoking and vaping simulation model.

BACKGROUND: Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA. METHODS: SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses. RESULTS: The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters. DISCUSSION: Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data. CONCLUSION: The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.

An Expert Elicitation on the Effects of a Ban on Menthol Cigarettes and Cigars in the United States.

INTRODUCTION: The US Food and Drug Administration announced its intention to ban menthol in cigarettes. However, information is needed on how a federal ban would affect population health. AIMS AND METHODS: We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. We developed and pilot tested a questionnaire that focused on tobacco use transitions of current smokers (age 18-24 menthol, age 35-54 menthol, and age 35-54 nonmenthol) and potential menthol smokers (age 12-24). Using a structured expert elicitation, we estimated mean net transitions under a ban from cigarette use to combustible tobacco product, smokeless tobacco, novel nicotine delivery product (NNDPs, such as e-cigarettes) use, or no tobacco use. RESULTS: Eleven experts provided responses. Of those ages 12-24 who would have initiated menthol cigarette use in the absence of a ban, the experts estimated that 41% would still initiate combustible products under a ban, while 18% would initiate with NNDPs and 39% would not initiate regular tobacco use. Combustible use by menthol smokers ages 35-54 was expected to decline by 20% postban relative to preban rates, half switching to NNDPs and half quitting all tobacco use. Menthol smokers ages 18-24 were expected to reduce combustible use by 30%, with 16% switching to NNDPs. Greater reductions in combustible use were estimated for African Americans across the three age groups. Negligible impacts were expected for current adult nonmenthol smokers. CONCLUSIONS: According to expert opinion, a menthol ban is expected to substantially reduce smoking initiation and combustible tobacco product use among current menthol smokers. IMPLICATIONS: The US Food and Drug Administration recently announced its intention to ban menthol in cigarettes, but information on the potential impact on smoking and other nicotine product use is limited. We conducted an expert elicitation to gauge the impact of a menthol cigarette and cigar ban in the United States. A panel of experts estimated that menthol smokers ages 35-54 would reduce combustible tobacco use by 20%, with half switching to e-cigarettes and half quitting all nicotine use. Larger reductions were expected at younger ages, and menthol smoking initiation was reduced by 59% with 18% instead using e-cigarettes. African Americans were expected to have greater reductions in combustible tobacco use than the rest of the population.

Modeling smoking-attributable mortality among adults with major depression in the United States.

Tobacco-related health disparities disproportionately affect smokers with major depression (MD). Although tobacco simulation models have been applied to general populations, to date they have not considered populations with a comorbid mental health condition. We developed and calibrated a simulation model of smoking and MD comorbidity for the US adult population using the 2005-2018 National Surveys on Drug Use and Health. We use this model to evaluate trends in smoking prevalence, smoking-attributable mortality and life-years lost among adults with MD, and changes in smoking prevalence by mental health status from 2018 to 2060. The model integrates known interaction effects between smoking initiation and cessation, and MD onset and recurrence. We show that from 2018 to 2060, smoking prevalence will continue declining among those with current MD. In the absence of intervention, people with MD will be increasingly disproportionately affected by smoking compared to the general population; our model shows that the smoking prevalence ratio between those with current MD and those without a history of MD increases from 1.54 to 2.42 for men and from 1.81 to 2.73 for women during this time period. From 2018 to 2060, approximately 484,000 smoking-attributable deaths will occur among adults with current MD, leading to 11.3 million life-years lost. Ambitious tobacco control efforts could alter this trajectory. With aggressive public health efforts, up to 264,000 of those premature deaths could be avoided, translating into 7.5 million life years gained. This model can compare the relative health gains across different intervention strategies for smokers with MD.

Smoking and Lung Cancer Mortality in the United States From 2015 to 2065: A Comparative Modeling Approach.

Background: Tobacco control efforts implemented in the United States since the 1960s have led to considerable reductions in smoking and smoking-related diseases, including lung cancer. Objective: To project reductions in tobacco use and lung cancer mortality from 2015 to 2065 due to existing tobacco control efforts. Design: Comparative modeling approach using 4 simulation models of the natural history of lung cancer that explicitly relate temporal smoking patterns to lung cancer rates. Setting: U.S. population, 1964 to 2065. Participants: Adults aged 30 to 84 years. Measurements: Models were developed using U.S. data on smoking (1964 to 2015) and lung cancer mortality (1969 to 2010). Each model projected lung cancer mortality by smoking status under the assumption that current decreases in smoking would continue into the future (status quo trends). Sensitivity analyses examined optimistic and pessimistic scenarios. Results: Under the assumption of continued decreases in smoking, age-adjusted lung cancer mortality was projected to decrease by 79% between 2015 and 2065. Concomitantly, and despite the expected growth, aging, and longer life expectancy of the U.S. population, the annual number of lung cancer deaths was projected to decrease from 135 000 to 50 000 (63% reduction). However, 4.4 million deaths from lung cancer are still projected to occur in the United States from 2015 to 2065, with about 20 million adults aged 30 to 84 years continuing to smoke in 2065. Limitation: Projections assumed no changes to tobacco control efforts in the future and did not explicitly consider the potential effect of lung cancer screening. Conclusion: Tobacco control efforts implemented since the 1960s will continue to reduce lung cancer rates well into the next half-century. Additional prevention and cessation efforts will be required to sustain and expand these gains to further reduce the lung cancer burden in the United States. Primary Funding Source: National Cancer Institute.

The Impact of Implementing Tobacco Control Policies: The 2017 Tobacco Control Policy Scorecard.

The Tobacco Control Scorecard, published in 2004, presented estimates of the effectiveness of different policies on smoking rates. Since its publication, new evidence has emerged. We update the Scorecard to include recent studies of demand-reducing tobacco policies for high-income countries. We include cigarette taxes, smoke-free air laws, media campaigns, comprehensive tobacco control programs, marketing bans, health warnings, and cessation treatment policies. To update the 2004 Scorecard, a narrative review was conducted on reviews and studies published after 2000, with additional focus on 3 policies in which previous evidence was limited: tobacco control programs, graphic health warnings, and marketing bans. We consider evaluation studies that measured the effects of policies on smoking behaviors. Based on these findings, we derive estimates of short-term and long-term policy effect sizes. Cigarette taxes, smoke-free air laws, marketing restrictions, and comprehensive tobacco control programs are each found to play important roles in reducing smoking prevalence. Cessation treatment policies and graphic health warnings also reduce smoking and, when combined with policies that increase quit attempts, can improve quit success. The effect sizes are broadly consistent with those previously reported for the 2004 Scorecard but now reflect the larger evidence base evaluating the impact of health warnings and advertising restrictions.

Has Smoking Cessation Increased? An Examination of the US Adult Smoking Cessation Rate 1990-2014.

INTRODUCTION: We examine the trajectory of adult smoking prevalence in the United States over the period 1990-2014 to investigate whether the smoking cessation rate has changed during this period. METHODS: We employ a dynamic model of smoking prevalence, and data from the National Health Interview Survey (NHIS) and the National Survey on Drug Use and Health (NSDUH), to estimate the adult cessation rate in 6-year intervals. We use weighted nonlinear least squares to perform the estimation. We then employ a meta-regression model to test whether the cessation rate has increased. RESULTS: The annual cessation rate has increased from 2.4% in 1990 to 4.5% in 2014 according to the NHIS data, and from 3.2% in 2002 to 4.2% in 2014 according to the NSDUH data. The increasing trend is statistically significant (p value = 1.57×10-6) and the two independent surveys produced nearly identical results, which makes it unlikely that our findings are a product of chance. CONCLUSIONS: Our analysis finds that the smoking cessation rate in the United States has almost doubled since 1990. This increase is responsible for at least 2 million fewer smokers in 2014. If current conditions persist, by the year 2020 the increase in cessation rates will be responsible for 3.5 million fewer smokers. Our findings can assist in predicting the future path of the smoking epidemic and determining the correct allocation of resources to eradicate it. IMPLICATIONS: We show that the adult smoking cessation rate has greatly increased since 1990. We demonstrate this by studying prevalence trajectories from two independent population surveys, which yielded nearly identical results. Different from other studies, we focus on permanent quit rates (net of relapses) which we estimate from a dynamic model of prevalence. Our results do not stem from self-reported quitting behavior, but from the analysis of observed prevalence and its inherent variability. Our findings can contribute to predicting the future path of the smoking epidemic and to determining the optimal allocation of resources to eradicate it.

The Effect of Tobacco Control Policies on US Smokeless Tobacco Use: A Structured Review.

INTRODUCTION: Tobacco use has shifted increasingly from cigarettes to other products. While the focus has been mostly on cigarette-oriented policies, it is important to gauge the effects of policies targeting other products. We review and critique the literature on how policies affect smokeless tobacco (ST). METHODS: We conducted a search of the literature on tobacco control policies as they relate to ST use, focusing on tobacco taxes, smoke-free air laws, media campaigns, advertising restrictions, health warnings, cessation treatment policies, and youth access policies. Findings from 78 total studies are summarized. RESULTS: ST taxes, media campaigns, health warnings, and cessation treatment policies were found to be effective tools in reducing ST use. Evidence on the effects of current youth access policies is less strong. Studies have not yet been conducted on marketing or product content restrictions, but the literature indicates that product marketing, through advertising, packaging, flavorings, and extension of cigarette brands, plays an important role in ST use. CONCLUSIONS: Although the evidence base is less established for ST policies than for cigarette policies, the existing literature indicates ST use responds to tobacco control policies. Policies should be structured in a way that aims to reduce all tobacco use while at the same time increasing the likelihood that continuing tobacco users use the least risky products. IMPLICATIONS: Studies find that policies targeting smoking and policies targeting smokeless products affect smokeless use, but studies are needed to examine the effect of policies on the transitions between cigarette and smokeless use.

Modeling the Effects of E-cigarettes on Smoking Behavior: Implications for Future Adult Smoking Prevalence.

BACKGROUND: Electronic cigarette (e-cigarette) use has increased rapidly in recent years. Given the unknown effects of e-cigarette use on cigarette smoking behaviors, e-cigarette regulation has become the subject of considerable controversy. In the absence of longitudinal data documenting the long-term effects of e-cigarette use on smoking behavior and population smoking outcomes, computational models can guide future empirical research and provide insights into the possible effects of e-cigarette use on smoking prevalence over time. METHODS: Agent-based model examining hypothetical scenarios of e-cigarette use by smoking status and e-cigarette effects on smoking initiation and smoking cessation. RESULTS: If e-cigarettes increase individual-level smoking cessation probabilities by 20%, the model estimates a 6% reduction in smoking prevalence by 2060 compared with baseline model (no effects) outcomes. In contrast, e-cigarette use prevalence among never smokers would have to rise dramatically from current estimates, with e-cigarettes increasing smoking initiation by more than 200% relative to baseline model estimates to achieve a corresponding 6% increase in smoking prevalence by 2060. CONCLUSIONS: Based on current knowledge of the patterns of e-cigarette use by smoking status and the heavy concentration of e-cigarette use among current smokers, the simulated effects of e-cigarettes on smoking cessation generate substantially larger changes to smoking prevalence compared with their effects on smoking initiation.

A systematic review of transitions between cigarette and smokeless tobacco product use in the United States.

BACKGROUND: Smokeless tobacco use is becoming an increasingly important public health issue in the US and may influence cigarette smoking behavior. Systematic information on transitions between smokeless tobacco and cigarette use in the US is limited. METHODS: We conducted a systematic review of published literature on transitions between smokeless tobacco and cigarette use in the US. We searched PubMed, Web of Science and EbscoHost databases for all published articles from January 2000 to March 2014 that presented estimates of transitions in US youth and adult study populations over time between at least one of the following tobacco use states: exclusive cigarette smoking, exclusive smokeless tobacco use, dual use of both products, and use of neither product. We excluded non-English language studies, studies published before 2000, clinical trials, controlled cessation programs, and clinical studies or evaluations of smokeless tobacco cessation programs. RESULTS: The review identified six studies on US populations published since 2000 with longitudinal data on some or all of the transitions that users can undergo between smokeless tobacco and cigarette use. There was considerable heterogeneity across studies in design and tobacco use definitions. Despite these differences, the existing data indicate that switching behaviors from exclusive smoking to exclusive smokeless tobacco use are limited (adults: 0%-1.4%, adolescents: 0.8%-3.8%) but may be more common from exclusive smokeless tobacco use to exclusive smoking (adults: 0.9%-26.6%, adolescents: 16.6%-25.5%). Among adults, exclusive cigarette smoking was generally stable and consistent (79.7% to 87.6%) over follow-up across studies but less stable in adolescents (46.8%-78.7%). Exclusive smokeless tobacco use was less stable than exclusive cigarette smoking over time (adults: 59.4%-76.6%, adolescents: 26.2%-44.8%). CONCLUSION: This review provides published estimates of the proportions of adults and adolescents transitioning between tobacco use categories from the most recently available studies on longitudinal transitions between smokeless tobacco and cigarettes in the US. These data can be used to track tobacco use behaviors and evaluate their effect on public health; however, the data for these studies were generally collected more than a decade ago. Additional research including nationally representative longitudinal estimates using consistent definitions and designs, would improve understanding of current tobacco transition behaviors.

Impact of changing U.S. demographics on the decline in smoking prevalence, 1980-2010.

INTRODUCTION: U.S. smoking prevalence has been declining over the last several decades. During this time, the population has also experienced changes in its demographic composition, as Americans are living longer and becoming increasingly racially and ethnically diverse. Since smoking rates vary across age and race/ethnicity groups, demographics alone could contribute to changes in smoking prevalence among the general population. We examined the effect of changing age and race/ethnicity distributions on total smoking prevalence from 1980 to 2010. METHODS: Using the National Health Interview Survey weighting scheme, we applied the distribution of smokers across age and race/ethnicity categories for the years 1980 and 2010 to the distribution of adults in those categories for both years. The total number of smokers was summed to determine resulting smoking prevalence. RESULTS: The combined effect of aging and the changing racial/ethnic composition of the U.S. population has contributed 2.1% points to the decline in smoking prevalence. If the age and racial/ethnic demographic composition had not changed since 1980, smoking prevalence would have been 21.3% in 2010 (with rounding)--statistically significantly higher than the reported 19.3%. Of the 3 demographic factors we considered (age, race, and ethnicity), ethnicity--specifically the rising share of Hispanics in the population--is the most important contributor to declines in smoking. CONCLUSIONS: Our changing demographics have had an impact on smoking prevalence over the last 3 decades. Future declines in smoking may be driven even more by the aging of the population and increasing racial and ethnic diversity.

Tobacco control in Namibia: the importance of government capacity, media coverage and industry interference.

BACKGROUND: Namibia is typical of low-income and middle-income countries with growing tobacco use, but with limited capacity to impose comprehensive tobacco control legislation. Despite initiating dialogue on national tobacco control policy in 1991, the country took nearly 20 years to pass the Tobacco Products Control Act. OBJECTIVE: To use Namibia as a case study to illustrate challenges faced by low-income countries working to forward tobacco control legislation. METHOD: Face-to-face and telephonic interviews were conducted with 13 bureaucrats and advocates currently or previously engaged in tobacco-related work in Namibia. Tobacco-related news articles from national newspapers were examined. RESULTS: The constitutional obligation of the government to promote public health laid the foundation for Namibia's tobacco control policy. Staff capacity constraints greatly delayed the passing of tobacco control legislation. It is unclear what influence the tobacco industry's involvement as a stakeholder had on policy; however, in at least one instance, the tobacco industry actively misled government. Namibia's ratification of the Framework Convention on Tobacco Control was instrumental in passing legislation that meets most provisions of the international treaty. The media have generally played a supportive role in pushing the government to pass tobacco control legislation. CONCLUSIONS: The fact that Namibia was able to pass fairly comprehensive tobacco control legislation with such meagre resources is commendable. The government must now implement the regulations that make the legislation effective. Tobacco control progress in low-income and middle-income nations can be encouraged through use of the media and improved staff and legal capacity within health ministries.

Growth in Tobacco Control publications by authors from low- and middle-income countries.

BACKGROUND: Research has contributed significantly to tobacco control in high-income nations, but has not yet played a comparable role in low- and middle-income countries (LMIC). In recent years, efforts have been devoted to building research capacity in LMICs. Using publication in Tobacco Control as a proxy for all tobacco control research, we examine whether research articles authored by scholars from LMICs and about LMIC issues have increased over the Journal's history. METHODS: We examined every issue of Tobacco Control from 1992 to 2011, coding contributions as to their authorship (LMIC, high-income country, or both), and whether they covered tobacco control issues in LMICs. We included all the following journal categories: Original/Research articles, Brief reports, Reviews, Letters to the editor, Special communications, Commentaries, and Editorials. RESULTS: We divided the Journal's first 20 years into four 5-year periods. There was no statistically significant change in LMIC authorship or LMIC issue coverage during the first three periods. From those three periods combined (1992-2006), to the most recent 5-year period (2007-2011), articles including any LMIC authors increased from 7.2% to 22.7% (p<0.05) of all original research articles; lead authorship by LMIC scholars increased from 4.0% to 13.7% (p<0.05); and coverage of LMIC issues rose from 10.1% to 30.9% (p<0.05). Similar findings resulted when combining all the journal categories. CONCLUSIONS: Efforts to expand research by LMIC authors and about LMIC issues have begun to bear fruit, with a recent substantial increase. Still, the centrality of LMICs in the global tobacco pandemic implies that this progress only begins to address the enormous need.

Cultivating the next generation of tobacco endgame advocates.

Long-term success for any tobacco endgame is contingent not only on acquiring political will, but also on sustaining it over a long period of time, perhaps even for decades. Future cohorts of public health professionals with knowledge of tobacco issues are therefore needed to carry on with the endgame strategy (should early attempts fail) and to keep tobacco control salient after an endgame strategy has initially been implemented. The endgame itself offers a unique pedagogical opportunity that could revive interest in tobacco control at schools of public health--an important first step in cultivating the future advocacy base for a tobacco endgame.

Summary and Concluding Remarks: Patterns of Birth Cohort‒Specific Smoking Histories.

The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group age-period-cohort methodology to study smoking patterns can be applied to tackle important issues in tobacco control and public health. This paper summarizes the analyses of smoking patterns in the U.S. by race/ethnicity, educational attainment, and family income and for each of the 50 U.S. states using the CISNET Lung Working Group age-period-cohort approach. We describe how decision makers, policy advocates, and researchers can use the sociodemographic analyses in this supplement to project state smoking trends and develop effective state-level tobacco control strategies. The all-cause mortality RR estimates associated with smoking for U.S. race/ethnicity and education groups are also discussed in the context of research that measures and evaluates health disparities. Finally, the application of the CISNET Lung Working Group age-period-cohort methodology to Brazil is reviewed with a view to how the same types of analyses can be applied to other low- and middle-income countries.