Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

Associations of educational and marketing messages with beliefs about nicotine and reduced nicotine cigarettes.

INTRODUCTION: Widespread misperceptions about nicotine may have unintended effects on public health. We examined associations between existing messages about nicotine or tobacco and beliefs about nicotine and reduced nicotine cigarettes (RNC). METHODS: 2962 U.S. 18-45-year-olds were randomized in a May 2022 web-based survey to view one of 26 text-based messages about tobacco or nicotine from three sources: ongoing research (n = 8), messages authorized by FDA for VLN cigarettes (n = 6), and FDA's "From Plant to Product to Puff" campaign (n = 12); six messages from FDA's campaign did not reference nicotine and were treated as the reference source. Analyses examined associations between messages, grouped by source and individually, with beliefs about nicotine and RNC addictiveness and harms. RESULTS: Relative to FDA messages that did not reference nicotine, all message sources were associated with greater odds of a correct belief about nicotine (Odds Ratios [ORs] = 1.40-1.87, p's < 0.01); VLN messages were associated with greater correct beliefs about RNC addictiveness (b = 0.23, p < .05). No campaign produced greater correct beliefs about RNC harms. At the individual level, only five messages were associated with a correct belief about nicotine (ORs = 2.12-2.56, p-values < .01), and one with correct beliefs about RNC harms (b = 1.09, p < .05), vs. the reference message. CONCLUSIONS: Few existing messages improved understanding of the risks of nicotine separately from the risks of combustible products. Communication research is needed to promote greater public understanding of nicotine while minimizing unintended effects on nicotine and tobacco use.

The Impact of New Jersey's 2020 E-Cigarette Flavor Ban on E-Cigarette, Cigarette, and Cigar Sales in NJ.

INTRODUCTION: On April 20, 2020, New Jersey (NJ) implemented a comprehensive ban on the sale of flavored e-cigarettes. This study compares sales of e-cigarettes, cigarettes, and cigars before and after the law. METHODS: Data were biweekly retailer scanner sales in NJ convenience stores for e-cigarettes, cigarettes, and cigars between August 2019 and December 2020. We used Joinpoint regression to assess sales trends for cigarettes (non-menthol, menthol), cigars (unflavored, flavored), and e-cigarettes (unflavored, fruit/sweet/concept flavor, menthol flavor) in the 36 weeks before and 36 weeks after a statewide ban on flavored e-cigarettes. RESULTS: Flavored e-cigarette sales, not including menthol, significantly decreased over the study period while menthol e-cigarette sales significantly increased until the e-cigarette flavor ban took effect, after which these sales rapidly declined through May 2020, then slowed. Unflavored e-cigarette sales declined through September 2019, then grew modestly until the flavored e-cigarette ban, after which sales significantly increased. Flavored cigar sales increased between March and May 2020, then declined; non-flavored cigar sales increased between mid-February and early July 2020, then declined. Cigarette sales were decreasing before the flavored e-cigarette ban but after, significantly increased until June 2020. Overall, there was no significant trend in the average biweekly percent change for cigarette sales. CONCLUSIONS: Flavored e-cigarette sales were declining prior to the ban but the pace of the decline accelerated following federal and state restrictions on flavored e-cigarette sales, then slowed by the second half of 2020, with a brief period of increased cigarette and cigar sales immediately following the ban. IMPLICATIONS: New Jersey's 2020 statewide e-cigarette flavor ban offered the opportunity to observe how sales of e-cigarette, cigarette, and cigar products shifted after the change. The effect of the state law, at least in the short-term, was decreased sales of flavored e-cigarettes and increased sales of unflavored e-cigarettes. Research on long term policy effects is needed.

The impact of exposure to FDA e-cigarette authorization messages on product perceptions and interest - an experiment with adults who smoke and youth.

INTRODUCTION: In the United States, e-cigarettes have entered a new regulatory era, needing authorizations from FDA to remain on or enter the marketplace. This study explored the impact of e-cigarette authorization messages on product perceptions and interest. METHODS: We conducted an online experiment in June 2022 with nationally-representative samples of adults (21+) who smoke cigarettes (n=866) and youth ages 15-20 (n=859). They were randomized to one of five conditions: viewing an ad for a fictional e-cigarette brand with no reference to FDA (control), an ad with an "authorized for sale by FDA" claim in varying presentation styles (plain text, FDA "approved" stamp, FDA logo), or reading a fictional news excerpt about the product's authorization plus control ad. We compared group differences on product interest, susceptibility, harm perceptions and message perceptions. RESULTS: Among adults who smoke, there were no effects on product interest nor susceptibility, but ratings of the product's harmfulness compared to cigarettes were lower among those in the news versus control condition (ß=-0.25, p=.04). Among youth, odds of susceptibility were higher among ever e-cigarette users who viewed the ad with the FDA logo authorization message relative to the control ad (OR=6.3, 95% CI:1.67-23.9, p<0.01). About 40% of all participants agreed the authorization claim makes them think the product is safe to use, but fewer (14-19%) agreed it makes them more interested in trying it. CONCLUSIONS: FDA e-cigarette authorization messages may impact some beliefs about product harm. More research is needed to track potential impacts on product use. IMPLICATIONS: This study provides new data about the potential impact of messages about FDA authorization of e-cigarette products (presented as ad claims or a news story) on authorized product perceptions, interest and susceptibility among adults who smoke cigarettes and youth. Our results suggest that FDA e-cigarette authorization messages may impact harm-related beliefs among adults who smoke and product susceptibility among youth who have ever used e-cigarettes before, though real-world effects are likely to be impacted by message type and format, and perceived message source and credibility. Authorization messages are likely to be misinterpreted as "FDA approval" by some; therefore, providing clarifications about authorization meaning and standards are relevant where possible.

Examining Demand and Substitutability of Usual Brand Little Cigars/Cigarillos and Cigarettes in Young Adults Who Dual Use.

INTRODUCTION: Cigarette and little cigar/cigarillo (LCC) dual use is popular among young people and poses a substantial health risk. What remains unclear is the abuse liability of LCCs vs. cigarettes, LCCs' substitutability for cigarettes, and the influence of flavors on the abuse liability and substitutability of LCCs. METHODS: Sixty-five young adults (18-34 years) who dual use completed hypothetical purchase tasks to measure consumption of usual brand cigarettes and LCCs in 24h at increasing prices (demand), and LCC consumption at increasing cigarette prices (substitution). Three demand indices were calculated from raw data: breakpoint (price after which consumption reaches 0), Omax (maximum daily expenditure), and Pmax (price at maximum expenditure). Two indices were estimated using nonlinear mixed-effects modeling: intensity (consumption when free), and price-sensitivity (rate of decline in consumption as price increases). Substitution, and associations of flavored use with demand and substitution, were estimated using linear mixed models. RESULTS: Results indicated similar abuse liability for LCCs and cigarettes. Intensity was greater for cigarettes, but price-sensitivity was similar. Flavored LCC use was associated with lower price-sensitivity and greater intensity than unflavored. LCCs were significant substitutes for cigarettes, but the effect was small. Flavored use was not associated with substitution. CONCLUSIONS: Among young adults who dual use, LCCs and cigarettes had similar abuse liability, and those who used flavored had higher demand for their LCCs. A flavored cigar ban, as well as targeted prevention and cessation services for those who smoke flavored LCCs, may be important for reducing dual use in young adults. IMPLICATIONS: Cigarette and little cigar/cigarillo (LCC) dual use remains high among young adults. Using hypothetical purchase tasks with young adults who dual use, LCCs had abuse liability similar to cigarettes, but were only modest substitutes for cigarettes. Participants who used flavored LCCs reported greater abuse liability than those who used unflavored, but not greater substitution for cigarettes. Prevention and cessation services are needed to target LCCs in young people, particularly those smoking flavored products. A flavored cigar ban may help to reduce their demand.

Retailers' Compliance with Federal Age of Cigarette Sales Policies -- Pitt County, North Carolina, January-March 2022.

BACKGROUND: Tobacco use remains a leading cause of preventable morbidity and premature mortality. In December 2019, the federal age of sale for tobacco products increased from 18 to 21 years of age. This study aimed to evaluate the implementation of federal tobacco 21 policies in Pitt County, North Carolina (NC), by conducting multiple purchase attempts for cigarettes. METHOD: Stores in Pitt County that sold cigarettes were randomly sampled and visited by up to six different underage (18-20) buyers who attempted to buy cigarettes from January-March 2022. Buyers made a total of 217 cigarette purchase attempts from 49 Pitt County retailers. Analyses were conducted using SPSS Complex Samples (v.28/Macintosh) and estimate retailer prevalence of requesting identification (ID) and selling to underage buyers across multiple purchase attempts. RESULTS: On average, retailers failed to request ID in 15.4% of purchase attempts (95% CI: 9.4%-21.3%) and sold to an underage buyer 34.2% of the time (95% CI: 27.0-41.4%). Additionally, 75.5% (95% CI: 63.4%-84.6%) of retailers sold to an underage buyer at least once. LIMITATIONS: This study is limited to a single county in NC and to underage buyers aged 18 to 20. CONCLUSION: There is widespread non-compliance with federal age of sale policies for tobacco products in Pitt County, NC. State enforcement is warranted, and NC's youth access law should be amended to match the federal age of sale. Changes to the law should allow research involving underage purchases.

Evaluating Correlations Between Premium Cigar Smoking and Mental Health and Substance Use Dependence Conditions Among U.S. Adults, 2010-2019.

INTRODUCTION: Improved understanding of health conditions associated with premium cigar smoking can inform efforts to reduce cigar use. This paper extends findings commissioned for the National Academies of Science, Engineering, and Medicine report on premium cigars. AIMS AND METHODS: We pooled 2010-2019 National Survey on Drug Use and Health data to evaluate cross-sectional associations between premium cigar smoking and mental health and substance use conditions among U.S. adults. A series of logistic regression models adjusted for age, sex, race and ethnicity, cigarette smoking, and alcohol consumption compared odds of each condition associated with past-month premium cigar smoking relative to past-month nonpremium cigar smoking, never tobacco use, and current established cigarette smoking. RESULTS: Premium cigar smoking was associated with lower adjusted odds of past month serious psychological distress, past year major depressive episode, and cannabis and illicit drug dependence relative to nonpremium cigar and cigarette smoking; however, higher odds of alcohol and cannabis dependence were observed relative to never tobacco use, and lower odds of alcohol dependence were observed relative to current cigarette smoking but not current nonpremium cigar smoking. CONCLUSIONS: We observed considerable variation in both magnitude and direction of associations between premium cigar smoking and mental health and substance use indicators depending on the condition and reference group to which premium cigar smoking was compared. IMPLICATIONS: Premium cigar smoking frequently cooccurs with cigarette smoking and alcohol consumption, thus potential health correlates must be considered in appropriate context. We observed considerable variation in direction and magnitude of association depending on the health condition and reference population, as well as potential for reverse causality and residual confounding in this cross-sectional analysis. As the tobacco landscape continues to evolve, rigorous scientific studies that incorporate clear differentiation of cigar type, measures of cumulative use, and temporal data collection are necessary to fully evaluate the health effects of premium cigar smoking and effectively inform Food and Drug Administration regulation.

Estimating Prevalence of Premium or Traditional Cigar Use and User Characteristics Based on Varying Definitions of Use.

BACKGROUND: Premium cigar use is infrequent compared with the use of other tobacco products, including other cigar types (eg, cigarillos), though current measurement methods for premium cigar use have limitations. Accordingly, prevalence estimates from existing surveillance studies likely underestimate the true prevalence of premium cigar use. AIMS AND METHODS: Using an online convenience sample of adults (ages 18-45 years) surveyed in February 2022, we examined premium or traditional cigar prevalence and characterized users based on four definitions of use: (1) past-year use, (2) past 30-day use, (3) use every day or some days, and (4) use every day, some days, or rarely, using a novel, one-item measure. We examined demographics, cigar use behaviors, and other tobacco product use for each definition and conducted sensitivity analyses using cigar brands. RESULTS: Prevalence estimates ranged from 1.8% using Definition 3 to 11.6% using Definition 1. Regardless of definition, premium or traditional cigar users were largely male, white, and aged 25-45 years. A large proportion of users based on Definition 3 were aged 25-34 years, had a regular premium cigar brand, smoked cigars on more than one day in the past month, used cannabis in the past month, and reported perceiving premium cigars as less harmful compared with cigarettes. DISCUSSION: Prevalence estimates of premium or traditional cigar use varied by more than fivefold based on the definition of use and user characteristics varied by definition. Existing national surveys are likely underestimating the prevalence and patterns of premium cigar use. IMPLICATIONS: Given that the negative health effects of premium cigars vary based on how the cigars are used (eg, frequency or duration), as well as co-use with other tobacco products and substances (eg, alcohol and cannabis), accurate measurement of these products is important for understanding patterns of use and their impact on public health.

Examining Cigar Pack Quantity Purchases by Cigar Type in the United States Between 2014 and 2017.

INTRODUCTION: We examined whether the proportion of cigar pack quantity usually purchased differed between 2014 and 2017 in the United States. METHODS: Data are from waves 1 and 4 of the Population Assessment of Tobacco and Health Study. The proportions of pack quantity purchases between waves for premium cigars, large cigars, cigarillos, and filtered cigars for 10-pack quantities (singles, 2-packs, 3-packs, 4-packs, 5-packs, 6-9-packs, 10-packs, 11--19-packs, 20-packs, ≥21 packs) were compared using Z-tests. We used multivariable linear regressions to examine factors associated with pack quantity. RESULTS: For premium cigars, most adults purchased singles, with 84.4% in 2014 and 88.7% in 2017. For large cigars, single purchases increased from 46.2% to 62.7% (p < .00001). Two-packs also increased, 3.1% to 10.2% (p < .00001), while 5-packs, 6-9 packs, 10-19-packs, and 20-packs decreased. For cigarillos, singles purchases increased from 51.9% to 57.5% (p = .0002). Two-packs also increased, 8.8% to 19.6% (p < .00001), while 3-packs, 4-packs, 5-packs, and 20-packs decreased. For filtered cigars, the most prevalent pack quantity shifted from 20-packs in 2014 (62.6%) to singles in 2017 (36.7%). Singles, 2-packs, 3-4-packs, and 5-packs increased while 11-19-packs, 20-packs, and ≥21 packs decreased. Days used were positively associated with pack quantity purchase for all cigar types in 2017, while the price was positively associated with premium cigar purchase. CONCLUSIONS: Between 2014 and 2017, the proportion of consumers who purchased singles remained at over 80% for premium cigars and increased for other cigars. Continued monitoring of use behaviors, including pack quantities by cigar type, is needed as the market and policy landscapes continue shifting. IMPLICATIONS: Single cigar purchases are prominent across cigar types. Five-packs and 20-packs were the second most common pack quantities across cigar types, with relatively low proportions for other pack quantities. These findings suggest adults consuming premium cigars consistently prefer singles, a pattern that was found across cigar types. However, when considering purchases made online, premium cigars are widely purchased in larger pack quantities. Age and race were associated with purchase for some cigar types at some years, days used were associated with the purchase quantity in 2017 for all cigar types, and price was positively associated across time periods for only premium cigar purchases. Thus, the factors associated with cigar pack quantity purchase remain unclear. As the cigar policy landscape shifts, continued monitoring of the purchase behaviors by cigar type will be important to better inform future cigar policies.

Menthol Cigarette Use Among Adults Who Smoke Cigarettes, 2008-2020: Rapid Growth and Widening Inequities in the United States.

INTRODUCTION: In April 2021, the U.S. Food and Drug Administration announced its intention to issue a product standard banning menthol as a characterizing flavor in cigarettes. Given the potential relevance of national estimates of menthol use to pending legislation, this study estimated the prevalence of menthol use among U.S. adults who smoke cigarettes in 2020 and investigated changes in menthol use from 2008 to 2019 by sociodemographics, mental health, and substance use. AIMS AND METHODS: Nationally representative annual, cross-sectional data from the National Survey on Drug Use and Health, which included participants ages 18 years and older residing in the United States from 2008 to 2019 and the 2020. Data were analyzed using logistic and linear regression models to estimate trends in menthol use among adults who smoke cigarettes by sociodemographic, mental health and substance use variables (total analytic sample 2008-2019 n = 128 327). RESULTS: In 2020, 43.4% of adults who smoked cigarettes in the past month used menthol. Menthol use was most common among black adults (80%) and over 50% of those Hispanic, female, young (ages 18-34 years), lesbian/gay, with serious psychological distress, and with cigar use used menthol. Menthol use increased among adults who used cigarettes from 2008 to 2019, overall, and grew more rapidly among adults ages 26-34 years, Hispanic, light cigarette use (1-5 per day), and those who smoked cigars. CONCLUSIONS: Menthol use has increased among U.S. adults who smoke cigarettes over the past decade. Enacting menthol bans could have a widespread public health impact, especially among younger and minoritized groups. IMPLICATIONS: Menthol cigarette use increased among individuals who smoke cigarettes from 2008 to 2019 in the United States. In 2020, over 40% of smokers used menthol, and menthol use was considerably higher among adult smokers from racial/ethnic minoritized groups, who were younger and who reported mental health problems. The U.S. Food and Drug Administration seeks to ban menthol as a characterizing flavor in cigarettes; our results suggest that such a ban is likely to have a wide-ranging impact on public health.

Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019.

INTRODUCTION: Few studies have addressed the use patterns and characteristics of the past 30 days of premium versus non-premium cigar smokers. AIMS AND METHODS: We pooled 10 years of data from the National Survey on Drug Use and Health (NSDUH; 2010-2019) to evaluate use patterns and demographic and tobacco use characteristics of premium and non-premium cigar smokers ages 12 years and older in the U.S. cigar-type was manually coded as premium or non-premium according to the brand used most often. RESULTS: Between 2010 and 2019, 4.7% (95% CI = 4.6-4.8) of individuals aged 12 and older currently smoked cigars (past-30-day use). Smoking premium cigars (0.9% [95% CI = 0.8-0.9]) was less prevalent than smoking non-premium cigars (3.0% [95% CI = 2.9-3.1]). Although current non-premium cigar smoking prevalence steadily declined over the years, current premium cigar smoking prevalence remained stable. Premium cigar smokers were more likely to be older (≥25 years), male, non-Hispanic white, heterosexual, college educated, living in a large metro area, and to have income above 200% of the poverty threshold compared to non-premium users (p < .05). Additionally, past-30-day premium cigar smokers were less likely than non-premium users to initiate cigar smoking before the age of 18 years, smoke cigars frequently or daily, smoke cigarettes, or use marijuana (p < .05). CONCLUSIONS: Overall, premium cigar smoking is less prevalent than non-premium cigar smoking, especially among populations such as youth, racial/ethnic and sexual minorities, and low socioeconomic individuals. Premium cigar smokers tend to smoke infrequently and initiate cigars later in life compared with non-premium smokers. Study results can inform recommendations for regulating premium cigars. IMPLICATIONS: This study found that between 2010 and 2019, there are meaningful differences in the use patterns and characteristics of past-30-day premium versus non-premium cigar smokers in the United States. Premium cigars comprise a small share of the market compared to other cigar types and are less likely to be used by youth and other tobacco control priority groups (eg, racial/ethnic minorities and individuals with low socioeconomic statuses) that bear a disproportionate burden of risk and harm from using tobacco products. Additionally, most premium cigar users smoke them only occasionally. However, it is important to continue to monitor premium cigar use, as these patterns could shift because of factors like changes in marketing practices, consumer awareness, and product prices. Tobacco policy changes may also alter the patterns and trends of premium cigar use over time. A greater, more comprehensive understanding of premium cigars' physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will together help to inform cigar-related regulations.

Prioritizing common terminology and measures to advance research on oral nicotine product use.

This commentary calls for consistent measurement of oral nicotine product use by the scientific community, recommends specific measures where possible, and emphasizes areas in need of further research. We hope to expedite the use of consistent measures of oral nicotine product use so that this area of tobacco research can advance quickly.

Patterns of Premium and Nonpremium Cigar Use in the United States: Findings from Wave 6 (2021) of the Population Assessment of Tobacco and Health Study.

INTRODUCTION: Understanding the characteristics of premium cigar use patterns is essential for minimizing public health harms. Typically, premium cigars are handmade, larger, more expensive, and without the characterizing flavors that are present in other cigar types: Nonpremium traditional cigars, cigarillos, and filtered cigars. AIMS AND METHODS: Self-reported brand and price data were used from Wave 6 of the Population Assessment of Tobacco and Health (PATH) Study to define and estimate premium versus nonpremium cigar use among U.S. adults, as well as to explore cigar smoking patterns, purchasing behavior, and reasons for use by cigar type. RESULTS: In 2021, 0.9% (95% CI = 0.7-1.0) of adults were premium cigar users, compared to 0.4% of nonpremium traditional cigar users (95% CI = 0.3-0.5), 1.1% of cigarillo users (95% CI = 1.0-1.2), and 0.6% filtered cigar users (95% CI = 0.5-0.7). Premium cigar users were overwhelmingly male (97.7%), and 35.8% were aged ≥55 years. The average premium cigar price/stick was $8.67, $5.50-7.00 more than other cigar types. Compared to other cigar types, significantly fewer premium cigar users had a regular brand with a flavor other than tobacco (~15% vs. 38%-53%). Though flavors remained the top reason for premium cigar use, they were less likely to endorse flavors as a reason for use than other cigar users (~40% vs. 68-74%). Premium cigar users had a lower prevalence (aRR: 0.37, 95% CI = 0.25-0.55) of dual use of cigars and cigarettes. CONCLUSIONS: Although <1% of U.S. adults use premium cigars, their use and purchasing characteristics continue to differ from other cigar types, highlighting the importance of capturing data specific to premium cigar use. IMPLICATIONS: This manuscript extends previous research from the National Academies of Science, Engineering, and Medicine report, "Premium cigars: Patterns of use, marketing, and health effects" by utilizing the most recent PATH Study data (Wave 6) to examine patterns of cigar use, including purchasing behavior and reasons for use, by cigar type (eg, premium traditional cigars, nonpremium traditional cigars, cigarillos, and filtered cigars). The findings support continued research on patterns of premium cigar use, which differ from use patterns of other cigar types.

Nicotine pouch product awareness, interest and ever use among US adults who smoke, 2021.

BACKGROUND: Tobacco-free nicotine pouches are one of the fastest growing tobacco product categories in the US market. However, data on awareness, appeal or ever use of these products in the USA are limited. METHODS: We surveyed a population-based sample of US adults who smoked (n=1018) between January and February 2021 about awareness, ever use of or interest in nicotine pouches. Multivariable logistic regression models explored the relationship between nicotine pouch variables and demographic and tobacco use characteristics. RESULTS: In early 2021, 29.2% of adults who smoked had ever seen or heard of nicotine pouches, 5.6% had ever tried pouches and 16.8% reported interest in using pouches in the next 6 months. Adults who smoked aged 18-44 years and those who had ever used smokeless tobacco (SLT) were more likely to be aware of nicotine pouches. Interest in using nicotine pouches was more prevalent among adult smokers who planned to quit within 6 months, attempted to quit before using counselling or another tobacco product and had ever used pouches. Among adults who smoked, those with more education had lower odds of ever using nicotine pouches while those who had attempted to quit before using traditional methods or ever used SLT had higher odds of ever use. CONCLUSION: Levels of awareness, appeal and trial of nicotine pouches among US adults who smoke were modest, with variation by age, education, quit plans and quit attempt methods. Continued surveillance is warranted, including among naïve users and users of other tobacco and nicotine products.

Influence of cigarillo packaging characteristics on young adults' perceptions and intentions: findings from three online experiments.

OBJECTIVES: Packaging is an important component of tobacco marketing that influences product perceptions and use intentions. However, little research exists on cigar packaging. We leveraged variability in existing Swisher Sweets cigarillo packaging to extend the evidence base. METHODS: Between 2017 and 2019, we conducted three online experiments with 774 young adult past-year cigar smokers recruited via Amazon Mechanical Turk. After viewing Swisher package images that differed by flavour descriptor and/or colour, participants rated them on perceptions and purchase intentions. In study 1, participants viewed one of four cigarillos ('Wild Rush Encore', 'Wild Rush Limited', 'Twisted Berry' and 'Strawberry'). In study 2, participants viewed two different watermelon rum-flavoured cigarillos ('Boozy Watermelon' and 'Island Madness'). In study 3, participants viewed two of three 'Wild Rush' cigarillo versions ('Encore' with or without an explicit flavour descriptor or 'Limited'). RESULTS: In study 1, more participants perceived 'Twisted Berry' and 'Wild Rush Limited' as tasting good and less harsh tasting compared with 'Wild Rush Encore'. In study 2, compared with 'Island Madness', more participants perceived 'Boozy Watermelon' as tasting good, less harsh tasting and used by younger users but less by masculine users; female participants were more likely to purchase 'Boozy Watermelon'. In study 3, participants perceived 'Wild Rush Encore' with the explicit flavour descriptor as tasting better than packages without and being used by younger users but less by masculine users. CONCLUSIONS: Variations in cigarillo packaging, even among cigarillos with the same flavour, may have differential consumer appeal, suggesting packaging features should be considered in cigar product regulation.

Over 1 year later: smokers' EVALI awareness, knowledge and perceived impact on e-cigarette interest.

OBJECTIVES: The e-cigarette or vaping product use-associated lung injury (EVALI) outbreak caused serious lung injuries in over 2800 people in the USA in 2019. By February 2020, most cases were determined as linked with vaping tetrahydrocannabinol (THC), including black market products using vitamin E acetate. This study examined smokers' EVALI awareness, knowledge and perceived impact on their e-cigarette interest approximately 16 months after its peak. DESIGN: Between January and February 2021, we surveyed 1018 adult current smokers from a nationally representative US research panel. Participants were asked if they had heard about EVALI prior to COVID-19, knew its main cause, and if EVALI had impacted their interest in future e-cigarette use. RESULTS: Approximately 54% of smokers had heard of EVALI. Among those who had heard of EVALI (n=542), 37.3% believed its main cause was e-cigarettes used to vape nicotine, like JUUL. Fewer (16.6%) thought the main cause was products for vaping marijuana/THC, and 20.2% did not know. About 29% had heard vitamin E acetate was associated with EVALI, and 50.9% indicated EVALI made them less interested in using e-cigarettes in the future. EVALI awareness was significantly associated with e-cigarette risk perceptions (ie, that e-cigarettes are as harmful as smoking). CONCLUSIONS: Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.

IQOS print magazine advertising characteristics and reach before and after FDA authorisation as a modified risk tobacco product.

INTRODUCTION: IQOS is a heated tobacco product that was authorised as a modified risk tobacco product (MRTP) in July 2020. While it was removed from the US market in 2021 for legal reasons, as the first tobacco product to receive an 'exposure modification' MRTP order, surveillance of IQOS marketing is needed to inform regulation and policy for future MRTPs. The purpose of this study is to expand the current research on IQOS advertising in the USA by examining content and readership characteristics of IQOS ads in print magazines before and after US Food and Drug Administration MRTP authorisation. METHODS: We merged content analysis data with Kantar Media data on magazine placement and expenditures. Magazine readership data were obtained from MRI-Simmons. We compared data from pre-MRTP authorisation with data post-MRTP authorisation. This study was conducted in 2021. RESULTS: There was one unique ad and there were 13 observations pre-MRTP, and eight unique ads and 132 observations post-MRTP. Compared with pre-MRTP ads, more post-MRTP ads featured Marlboro HeatSticks, including Amber HeatSticks, and featured people. All ads contained a warning label-most warning labels were cigarette specific. IQOS ads were featured in magazines that are especially popular among women. CONCLUSIONS: After receiving MRTP authorisation, IQOS increased ad expenditures in print magazines with a readership comprised of primarily women. If IQOS returns to the US market, it will be important for tobacco control to monitor their advertisement content, placement, and expenditures.

Impact of Canada's menthol cigarette ban on quitting among menthol smokers: pooled analysis of pre-post evaluation from the ITC Project and the Ontario Menthol Ban Study and projections of impact in the USA.

INTRODUCTION: Between 2015 and 2018, Canada banned menthol cigarettes. This study pooled data from two pre-post cohort studies (the Ontario Menthol Ban Study, and the International Tobacco Control Policy Evaluation (ITC) Canada Survey, conducted in seven provinces) to derive more precise estimates of the impact of Canada's menthol ban on quitting and to apply these estimates to project the impact of a menthol ban in the USA. METHODS: Weighted multivariable logistic analyses compared post-ban quit success of menthol smokers with non-menthol smokers (for daily smokers and for all (daily + non-daily) smokers), controlling for sex, age, ethnicity, education, baseline smoking status, baseline cigarettes per day and study regions. Projections to the USA were created by multiplying the effect size of the Canadian menthol ban on quitting (percentage of increased quitting among menthol smokers) by the number of menthol smokers overall and among African Americans, from the 2019 National Survey on Drug Use and Health. RESULTS: After the menthol cigarette ban, menthol smokers were more likely than non-menthol smokers to have quit smoking among daily smokers (difference=8.0%; 95% CI: 2.4% to 13.7%,p=0.005) and all (daily+non-daily) smokers (difference=7.3%; 95% CI: 2.1% to 12.5%,p=0.006). The projected number of smokers who would quit after a US menthol ban would be 789 724 daily smokers (including 199 732 African Americans) and 1 337 988 daily+non-daily smokers (including 381 272 African Americans). CONCLUSIONS: This pooled analysis of Canada's menthol cigarette ban provides the foundation for estimating the impact of menthol bans in the USA and other countries. Projections suggest that a US menthol cigarette ban would have a substantial impact on increasing quitting.

Longitudinal analysis of cigar use patterns among US youth and adults, 2013-2019.

BACKGROUND: Cigars are available in a range of pack quantities, which contrasts regulations requiring cigarettes to be sold in packs of 20 or greater. Smaller packages may be associated with increases in initiation while larger packs may lead consumers to smoke more. The purpose of this study was to inform pack quantity regulations by examining whether usual cigar pack quantity purchased was associated with use, initiation, and discontinuation among youth and adults for four cigar types: premium cigars, large cigars, cigarillos, and filtered cigars. METHODS: We analyzed waves 1-5 (2013-2019) of the adult and waves 2-5 (2014-2019) of the youth Population Assessment of Tobacco and Health (PATH) Study. Samples included those responding to the item on pack quantity and providing data at all waves (adults: premium cigars [N = 536], large cigars [N = 1,272], cigarillos [N = 3,504], filtered cigars [N = 1,281]; youth: premium cigars [N = 55], large cigars [N = 217], cigarillos [N = 1514], filtered cigars [N = 266]). Generalized estimating equation models examined the population-averaged effects of pack quantity on cigar use, initiation, and discontinuation. RESULTS: Adult pack quantity was positively associated with the days used per month for premium cigars (b: 0.23, 95% CI: 0.11, 0.34), large cigars (b: 0.17, 95% CI: 0.08, 0.25), cigarillos (b: 0.12, 95% CI: 0.003, 0.24), and filtered cigars (b: 0.07, 95% CI: 0.04, 0.10), and positively associated with amount smoked per day for all cigar types. Youth pack quantity was positively associated with days used per month for premium cigars (b: 0.88, 95% CI: 0.33, 1.43), large cigars (b: 0.79, 95% CI: 0.43, 1.15), and cigarillos (b: 0.17, 95% CI: 0.01, 0.34). Adult initiation was associated with pack quantity for filtered cigars (b: -2.22, 95% CI: -4.29, -0.13), as those who initiated purchased smaller pack quantities compared to those who did not initiate that wave. Pack quantity was not associated with discontinuation for adults or youth. CONCLUSIONS: Cigar use increased as usual pack quantity purchased increased across cigar types for youth and adults. Small increases in pack quantity (e.g., one additional cigar) are likely to result in consuming less than one additional day per month, though larger increases (e.g., 10 additional cigars per pack) may result in greater use.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults.

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.