Association between cigar use, with and without cigarettes, and incident diagnosed COPD: a longitudinal cohort study.

BACKGROUND: While regular cigar smoking is believed to carry similar health risks as regular cigarette smoking, the impact of cigar use, alone or in combination with cigarettes, on obstructive pulmonary disease (COPD) has not been well characterized. The purpose of this study was to examine the prospective association between exclusive and dual cigar and cigarette use and incident self-reported diagnosed COPD. METHODS: This study used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative survey of U.S. adults. Longitudinal data from adults aged 40 to 79 at Wave 1, without a pre-existing COPD diagnosis who participated at follow-up interview were analyzed. A time-varying current tobacco exposure, lagged by one wave and categorized as: (a) never/non-current use; (b) exclusive cigar use; (c) exclusive cigarette use; and (d) dual cigar/cigarette use. Multivariable models adjusted for demographics (age, sex, race or ethnicity, education), clinical risk factors (asthma, obesity), and smoking-related confounders (second-hand smoke exposure, other combustible tobacco product use, e-cigarette use, time since quitting, cigarette pack-years). The incidence of self-reported diagnosed COPD was estimated using discrete-time survival models, using a general linear modeling (GLM) approach with a binomial distribution and a complementary log-log link function. RESULTS: The analytic sample consisted of 9,556 adults with a mean (SD) age of 56 (10.4), who were predominately female (52.8%) and Non-Hispanic White (70.8%). A total of 906 respondents reported a diagnosis of COPD at follow-up. In the fully adjusted model, exclusive cigar use (adjusted hazard ratio (aHR) = 1.57, 95% CI: 0.77, 3.21) was not associated with increased COPD risk compared to non-use, while exclusive cigarette use (aHR = 1.48, 95% CI: 1.13, 1.93) and dual cigar/cigarette use (aHR = 1.88, 95% CI: 1.24, 2.85) were. CONCLUSIONS: Exclusive cigarette use and dual cigar/cigarette use were associated with diagnosed incident COPD. These results suggest that cigars, when used in combination with cigarettes, may be associated with poorer COPD health outcomes. Dual use may promote a higher likelihood of inhaling cigar smoke, and future research would benefit from examining whether inhalation of cigar smoke increases COPD risk.

Cross-sectional patterns and longitudinal transitions of unflavored and flavored cigar use without and with cigarettes among United States adults.

INTRODUCTION: Over half of US adults who smoke cigars use flavored cigars, illustrating their broad appeal; however, their long-term impact on cigar and cigarette use is unknown. METHODS: Using restricted data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, we investigated cross-sectional patterns and longitudinal transition rates of unflavored and flavored cigar use with and without cigarettes among a nationally representative sample of US adults. RESULTS: Proportionally, more adults who used flavored cigars without or with cigarettes were younger and female. More adults with exclusive cigar use were non-Hispanic Black. More adults with dual use had lower educational attainment. The median number of cigars smoked daily and tobacco dependence was highest among adults who used flavored cigars with cigarettes. Only 14.6% of adults with exclusive flavored cigar use at Wave 1 continued their use to Wave 5, with most transitioning to non-current (46.4%) or exclusive cigarette use (22.9%). Likewise, 13.8% of adults with dual flavored cigar and cigarette use at Wave 1 continued their use to Wave 5, with 57.6% transitioning to exclusive cigarette use and 19.7% transitioning to non-current use. Comparatively, 72.9% of adults with exclusive cigarette use continued their use to Wave 5, while 23.6% transitioned to non-current use. CONCLUSION: Adult cigar use was less stable than cigarette use, particularly among those who use flavored cigars. Future research should investigate whether these transition patterns between flavored and unflavored cigar and cigarette use vary across sociodemographic groups and their potential long-term health implications.

Distress about social problems and tobacco and cannabis use outcomes among young adults in Los Angeles County.

OBJECTIVE: To examine associations of concern, worry, and stress about discrimination, shootings/violence, and police brutality and exclusive and dual tobacco and cannabis use among young adults. METHODS: A prospective, racially/ethnically diverse cohort of young adults (n = 1960) living in Los Angeles, California completed a baseline survey in 2020 (age range: 19-23) and a follow-up survey in 2021. Exploratory factor analysis (EFA) was employed on nine variables assessing levels of concern, worry, and stress about societal discrimination, societal shootings/violence, and community police brutality at baseline. Past 30-day tobacco and cannabis use at follow-up was categorized as current exclusive tobacco, exclusive cannabis, and dual tobacco and cannabis (vs never/former) use based on eleven use variables. Multinomial logistic regressions estimated adjusted associations between each factor score (translated to standard deviation units) with exclusive and dual tobacco and cannabis use. RESULTS: The EFA produced four factor scores representing concern/worry/stress (i.e., distress) about community police brutality (F1), distress about societal shootings/violence (F2), and distress about societal discrimination (F3), as well as generalized stress about police brutality, shootings/violence, and discrimination (F4). F1, F2, and F3 were associated with subsequent exclusive current cannabis use, with F1 having the strongest association (OR: 1.35, 95% CI: 1.18-1.55), while only F1 (OR: 1.51, 95% CI: 1.27-1.78) was associated with dual tobacco and cannabis use. None of the factors were associated with exclusive tobacco use. CONCLUSIONS: Young adult concern, worry, and/or stress about social problems may increase risk of cannabis use with or without concurrent tobacco use 6-12 months later.

A Longitudinal Analysis of Flavored Cigar Use and Cigar Smoking Cessation Among US Adults.

BACKGROUND: Flavorings in cigars increase their appeal, mask the harsh taste of tobacco, and may hinder successful cigar smoking cessation; however, limited evidence has examined whether flavors are associated with short- or long-term cigar smoking cessation. AIMS AND METHODS: Using restricted data from the Population Assessment of Tobacco and Health Study Waves 1-5, we examined whether flavored cigar use was associated with 30-day-plus and 1-year-plus cigar smoking cessation among US adults. Multivariable discrete-time survival models were fit to a nationally representative sample of US adult (18+) respondents who had a current, established cigar use, smoked five or more days in the past 30 days, and did not exclusively smoke traditional premium cigars at baseline. Models adjusted for age, sex, race and ethnicity, income, cigar and cigarette smoking intensity, and blunt use. RESULTS: At baseline, 44.6% of respondents (n = 674) were 18-34 years old, 75.0% were male, 56.7% were non-Hispanic White, 78.9% had household incomes of <$50,000, and 56.2% smoked flavored cigars. In fully adjusted models, flavored cigar use was associated with a lower risk of 30-day-plus (HR = 0.76, 95% CI = 0.60, 0.97) but not 1-year-plus cigar smoking cessation (HR = 0.81, 95% = 0.62, 1.05). CONCLUSIONS: We found that flavored cigar use was associated with a lower risk of short-term but not long-term cigar smoking cessation. More work is needed to understand the dynamics of cigar smoking transitions, including initiation, cessation, and relapse, particularly in larger cohorts and among those who exclusively use cigars or dual-use cigars and cigarettes. IMPLICATIONS: As local and some state jurisdictions continue to adopt partial or complete bans of flavored cigar products and the United States Food and Drug Administration considers a national ban of all characterizing flavors in cigars, there is a need for more longitudinal work examining the associations between flavorings in cigars and short and long-term cigar-smoking behaviors, including but not limited to initiation, cessation, intensity of use, and relapse, particularly in diverse cohorts.

Racial/ethnic differences in the association between transgender-related U.S. state policies and self-rated health of transgender women.

BACKGROUND: Policy protections for transgender adults in the United States are consistently associated with positive health outcomes. However, studies over-represent non-Latinx White transgender people and obscure variation in policies' intended goals. This study examined racial differences in the relationship between transgender-related policies and transgender women's self-rated health. Guided by Critical Race Theory, we hypothesized that policies conferring access to resources (e.g., healthcare) would be associated with better self-rated health among all participants while policies signifying equality (e.g., nondiscrimination laws) would be associated with better self-rated health only for White participants. METHODS: Using cross-sectional data collected between March 2018-December 2020 from 1566 transgender women, we analyzed 7 state-level 'access policies,' 5 'equality policies,' and sum indices of each. Participants represented 29 states, and 54.7% were categorized as people of color. We fit a series of multilevel ordinal regression models predicting self-rated health by each policy. Multivariate models were adjusted for relevant covariates at the individual- and state-level. We then tested moderation by race/ethnicity using interaction terms and generated stratified predicted probability plots. RESULTS: In bivariate models, 4 access policies, 2 equality policies, and both indices were associated with better self-rated health, but associations did not persist in adjusted models. Results from the multivariable models including interaction terms indicated that policies concerning private insurance coverage of gender-affirming care, private insurance nondiscrimination, credit nondiscrimination, and both indices were statistically significantly associated with better self-rated health for White participants and worse self-rated health for participants of color. CONCLUSIONS: The policies included in this analysis do not mitigate racism's effects on access to resources, indicating they may be less impactful for transgender women of color than White transgender women. Future research and policy advocacy efforts promoting transgender women's health must center racial equity as well as transgender people of color's priorities.

Longitudinal associations between exclusive, dual, and polytobacco use and asthma among US youth.

Little is known about the respiratory health effects of dual (two products) and polytobacco (three or more products) use among youth in the United States. Thus, we followed a longitudinal cohort of youth into adulthood using data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, examining incident asthma at each follow-up (Waves 2-5). We classified past 30-day tobacco use as 1) no products (never/former use), 2) exclusive cigarettes, 3) exclusive electronic nicotine delivery systems (ENDS), 4) exclusive other combustible (OC) tobacco products (cigars, hookah, pipe), 5) dual cigarettes/OC and ENDS, 6) dual cigarettes and OCs, and 7) polytobacco use (cigarettes, OCs, and ENDS). Using discrete time survival models, we analyzed the incidence of asthma across Waves 2-5, predicted by time-varying tobacco use lagged by one wave, and adjusted for potential baseline confounders. Asthma was reported by 574 of the 9141 respondents, with an average annual incidence of 1.44% (range 0.35% to 2.02%, Waves 2-5). In adjusted models, exclusive cigarette use (HR: 1.71, 95% CI: 1.11-2.64) and dual cigarette and OC use (HR: 2.78, 95% CI: 1.65-4.70) were associated with incident asthma compared to never/former use, while exclusive ENDS use (HR: 1.50, 95% CI: 0.92-2.44) and polytobacco use (HR: 1.95, 95% CI: 0.86-4.44) were not. To conclude, youth who use cigarettes with or without OCs had higher risk of incident asthma. Further longitudinal studies on the respiratory health effects of ENDS and dual/polytobacco use are needed as products continue to evolve.

A statewide population-based approach to examining Long COVID symptom prevalence and predictors in Michigan.

OBJECTIVE: The current broad definition of Long COVID, and an overreliance on clinical and convenience samples, is leading to a wide array of Long COVID estimates with limited generalizability. Our objective was to examine Long COVID symptoms using a statewide population-based probability sample. METHODS: Among 8000 sampled adults with polymerase-chain-reaction-confirmed SARS-CoV-2 between June 2020 and July 2021 in the Michigan Disease Surveillance System, 2533 completed our survey (response rate 32.2%). Using modified Poisson regression, we examined sociodemographic, behavioral, and clinical predictors of eight Long COVID symptom clusters, defined as at least one applicable symptom lasting 90 or more days post COVID-19 onset. RESULTS: Neuropsychiatric Long COVID symptoms, including brain fog, were most prevalent (23.7%), followed by systemic symptoms (17.1%), including fatigue, musculoskeletal (11.4%), pulmonary (10.4%), dermatologic (6.7%), cardiovascular (6.1%), gastrointestinal (5.4%), and ear, nose, and throat symptoms (5.3%). In adjusted analyses, female sex, a pre-existing psychological condition, and intensive care unit admission were strong predictors of most Long COVID symptom clusters. Older age was not associated with a higher prevalence of all symptoms - cardiovascular and dermatologic symptoms were most prevalent among middle-aged adults and age was not associated with neuropsychiatric or gastrointestinal symptoms. Additionally, there were fewer associations between pre-existing conditions and cardiovascular, neuropsychiatric, and dermatologic symptoms compared to other symptom clusters. CONCLUSIONS: While many predictors of Long COVID symptom clusters were similar, the relationship with age and pre-existing conditions varied across clusters. Cardiovascular, neuropsychiatric, and dermatologic symptoms require further study as potentially distinct from other Long COVID symptoms.

Social vulnerability and new mobility disability among adults with polymerase chain reaction (PCR)-confirmed SARS-CoV-2: Michigan COVID-19 Recovery Surveillance Study.

OBJECTIVE: Understanding the relationship between social factors and persistent COVID-19 health outcomes, such as onset of a disability after a SARS-CoV-2 (the virus that causes COVID-19) infection, is an increasingly important public health issue. The purpose of this paper is to examine associations between social vulnerability and new onset of a mobility disability post-COVID-19 diagnosis. METHODS: We used data from the Michigan COVID-19 Recovery Surveillance Study, a population-based probability survey of adults with PCR-confirmed SARS-CoV-2 infection in Michigan between January 2020-May 2022 (n = 4295). We used the Minority Health Social Vulnerability Index (MHSVI), with high county-level social vulnerability defined at or above the 75th percentile. Mobility disability was defined as new difficulty walking or climbing stairs. We regressed mobility disability on the overall MHSVI, as well as sub-themes of the index (socioeconomic status, household composition/disability, minority and language, housing type, healthcare access, and medical vulnerability), using multivariable logistic regression, adjusting for age, race, sex, education, employment, and income. RESULTS: Living in a county with high (vs. low) social vulnerability was associated with 1.38 times higher odds (95% confidence interval [CI]:1.18-1.61) of reporting a new mobility disability after a COVID-19 diagnosis after adjustment. Similar results were observed for the socioeconomic status and household composition/disability sub-themes. In contrast, residents of highly racially diverse counties had lower odds (odds ratio 0.74, 95% CI: 0.61, 0.89) of reporting a new mobility disability compared to low diversity counties. CONCLUSIONS: Mitigating the effects of social vulnerabilities requires additional resources and attention to support affected individuals.

Disparities in Cigarette, E-cigarette, Cigar, and Smokeless Tobacco Use at the Intersection of Multiple Social Identities in the US Adult Population. Results From the Tobacco Use Supplement to the Current Population Survey 2018-2019 Survey.

INTRODUCTION: Sociodemographic disparities in tobacco use are prevalent and persistent in the United States. Nevertheless, few studies have examined disparities in tobacco use from an intersectionality perspective. We developed a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of multiple social identities. AIMS AND METHODS: We used the 2018-2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) to estimate the prevalence of tobacco product use at the intersection of age (18-34, 35-54, ≥55 years), sex (male, female), race/ethnicity (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other), and annual household income (<$50 000, $50 000-$99 999, and ≥$100 000). Estimates accounted for the complex survey design. RESULTS: For cigarettes, the most defining characteristic was income, with the highest prevalence among low-income NH White male adults aged 35-54 years (30.7%) and low-income NH White female adults aged 35-54 years (29.7%). For e-cigarettes, the most defining characteristic was age, with adults 18-34 years old having the highest prevalence. High prevalence groups for cigars included young- and middle-aged NH Black and NH White males, while NH White males had the highest prevalence of smokeless tobacco use. CONCLUSIONS: Our intersectionality visualization tool is helpful to uncover complex patterns of tobacco use, facilitating the identification of high-risk groups. IMPLICATIONS: We created a visualization tool to identify disparities in cigarette, e-cigarette, cigar, and smokeless tobacco use at the intersection of age, sex, race/ethnicity, and income. Our visualization tool helps uncover complex patterns of tobacco use, facilitating the identification of high-risk population groups that would otherwise be masked. These results can be used to implement tobacco control policies targeted at factors that promote or sustain tobacco use disparities.

The Longitudinal Association Between Cigarette Coupon Receipt and Short-term Smoking Cessation Among US Adults.

INTRODUCTION: To help offset the increased price of cigarettes and promote brand loyalty, tobacco companies distribute coupons, particularly to price-sensitive consumers. Few studies, however, have examined the longitudinal association between coupon receipt and smoking cessation. AIMS AND METHODS: Using adult data from waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study, we examined the longitudinal association between coupon receipt and short-term smoking cessation. Multivariable discrete-time survival models were fit to an unbalanced person-period dataset for adult respondents (≥18 years) with current established smoking status at baseline (person n = 9472, risk period n = 29 784). Short-term smoking cessation was measured as discontinued cigarette use (no past 30-day cigarette use at follow-up) and self-reported complete quitting. Coupon receipt was measured as a time-varying exposure, measured in the wave preceding the outcome. Tobacco dependence and time-varying cigarette use intensity were controlled as potential confounders. Effect modification by age, sex, race-ethnicity, and education was assessed by examining interaction terms. RESULTS: We found that adults who received a coupon were 19% less likely to quit smoking compared to adults who did not receive a coupon, adjusting for covariates (adjusted hazard rate [aHR]: 0.81, 95% CI: 0.74-0.89). None of the interaction terms were statistically significant, suggesting that the association between coupon receipt and short-term smoking cessation may not differ across the sociodemographic groups that we examined. CONCLUSIONS: Taken together, our results reveal that coupon receipt reduces the likelihood of short-term smoking cessation, and that this association does not differ by age, sex, race-ethnicity, or education. IMPLICATIONS (97/100): Tobacco companies distribute coupons for tobacco products to price-sensitive customers in the United States, and these coupons can be particularly effective in partly offsetting the impact of a tax increases and promoting brand loyalty. This study provides longitudinal evidence that coupon receipt is associated with a decrease in short-term smoking cessation among US adults who smoke cigarettes after adjusting for covariates and tobacco-related confounders. The findings from this study suggest that coupons are an effective tool for tobacco companies to prevent adults who smoke from quitting, and a national ban on coupons may help to facilitate smoking cessation.

Examining the Effectiveness of the 2012 Canadian Graphic Warning Label Policy Change by Sex, Income, and Education.

INTRODUCTION: We examined the differential impact of the 2012 Canadian GWL policy changes on key indicators of warning label impact and quit intentions using national cohorts of Canadian and U.S. adults who smoke. AIMS AND METHODS: We used data from all waves of the International Tobacco Control surveys (2002-2020) in Canada and the United States. Our key measures were quit intentions and an index of warning label effectiveness (salience, cognitive and behavioral reactions). We estimated overall policy impact by comparing Canada (treatment group) with the United States (control group) using controlled interrupted time series (CITS) regression models, with interactions to examine whether policy impact varied by sex, education, and income. RESULTS: The CITS model showed a statistically significant increase in the warning label effectiveness in Canada post-policy, compared to the United States (ß = 0.84, 95% CI 0.35,1.33). Similarly, the odds of quit intentions were relatively higher among adults who smoked in Canada compared to the United States (OR = 1.89, 95% CI 1.51,2.36) post-policy. The three-way interaction model showed that these associations were greater among adults from low socioeconomic status (SES) groups than in high SES groups. CONCLUSIONS: The 2012 change in the Canadian GWL policy was associated with stronger cognitive and behavioral responses to GWLs and higher odds of quit intentions among adults who smoked in Canada when compared to the United States, specifically among individuals from low SES groups, suggesting a positive equity impact. Our findings affirm the need for countries to implement or enhance GWLs, in line with the WHO Framework Convention on Tobacco Control (FCTC). IMPLICATIONS: The evidence on the potential health equity benefit of GWL policies is mixed. To further understand the influence of GWL policies on tobacco use disparities, more systematic research using pre/post-policy designs with control groups is needed. Using a CITS model, we aimed to strengthen the available evidence on the causal influence of this tobacco control approach. Our findings show that the 2012 GWL policy change had a greater impact on adults who smoked from low SES groups than it did on adults who smoked from high SES groups, indicating a potentially positive equity impact and confirming the need for countries to implement or maximize the size of GWLs, as recommended by the WHO FCTC.

Cigarette Prices and Disparities in Cessation in the United States.

INTRODUCTION: Achieving cessation in people with established smoking patterns remains a challenge. Increasing cigarette prices has been one of the most effective strategies for lowering smoking rates. It remains unclear how effective it has been in encouraging cessation among adults in recent years and how the effectiveness varies by sociodemographic characteristics. METHODS: Using repeated cross-sectional data collected by the Tobacco Use Supplement of the Current Population Survey, we investigate the relationship between cigarette prices and cessation from 2003 to 2019 in adults 25+. We examine the associations between price and cessation in the population overall and by sex, race/ethnicity, and socioeconomic status. RESULTS: We found mixed support for associations between greater local prices and cessation. Unadjusted models showed that greater local prices were associated with greater odds of cessation, but the associations did not persist after controlling for sociodemographic characteristics. The associations did not significantly differ by respondent characteristics. Sensitivity analysis using alternative specifications and retail state price as the main predictor showed similar results. Sensitivity analysis with controls for e-cigarette use in the 2014-2019 period showed that greater local price was associated with cessation among adults with less than a high school degree. When stratified by year of data collection, results show that greater local prices were associated with cessation after 2009. CONCLUSIONS: Overall, the study adds to the conflicting evidence on the effectiveness of increasing prices on smoking cessation among adults with established smoking patterns. IMPLICATIONS: Higher cigarette prices have been one of the most effective tools for lowering smoking prevalence. It remains unclear how effective they are in encouraging adults with established smoking patterns to quit. Results show that greater local prices were associated with higher odds of cessation, but the association did not persist after sociodemographic adjustment. In a sensitivity analysis, greater local price was associated with cessation among people with less than a high school degree in models controlling for e-cigarette use. We also found evidence that greater local price was associated with cessation after 2009. More comprehensive smoke-free coverage was also associated with greater odds of cessation. The study's results highlight that encouraging cessation among adults with an established smoking pattern remains a challenging policy problem even when cigarette prices rise.

Longitudinal Associations Between Exclusive and Dual Use of Electronic Nicotine Delivery Systems and Cigarettes and Self-Reported Incident Diagnosed Cardiovascular Disease Among Adults.

INTRODUCTION: The cardiovascular health effects of electronic nicotine delivery systems (ENDS) use are not well characterized, making it difficult to assess ENDS as a potential harm reduction tool for adults who use cigarettes. AIMS AND METHODS: Using waves 1-5 of the Population Assessment of Tobacco and Health Study (2013-2019), we analyzed the risk of self-reported incident diagnosed myocardial infarction (MI; 280 incident cases) and stroke (186 incident cases) associated with ENDS and/or cigarette use among adults aged 40 + using discrete time survival models. We employed a time-varying exposure lagged by one wave, defined as exclusive or dual established use of ENDS and/or cigarettes every day or some days, and controlled for demographics, clinical factors, and past smoking history. RESULTS: The analytic samples (MI = 11 031; stroke = 11 076) were predominantly female and non-Hispanic White with a mean age of 58 years. At baseline, 14.2% of respondents exclusively smoked cigarettes, 0.6% exclusively used ENDS, and 1.0% used both products. Incident MI and stroke were rare during follow-up (< 1% at each wave). Compared to no cigarette or ENDS use, exclusive cigarette use increased the risk of MI (aHR 1.99, 95% CI = 1.40-2.84) and stroke (aHR 2.26, 95% CI = 1.51-3.39), while exclusive ENDS use (MI: aHR 0.61, 95% CI = 0.12-3.04; stroke: aHR 1.74, 95% CI = 0.55-5.49) and dual use (MI: aHR 1.84, 95% CI = 0.64-5.30; stroke: aHR 1.12, 95% CI = 0.33-3.79) were not significantly associated with the risk of either outcome. CONCLUSIONS: Compared to non-use, exclusive cigarette use was associated with an increased risk of self-reported incident diagnosed cardiovascular disease over a 5-year period, while ENDS use was not associated with a statistically significant increase in the outcomes. IMPLICATIONS: Existing literature on the health effects of ENDS use has important limitations, including potential reverse causation and improper control for cigarette smoking. We accounted for these issues by using a prospective design and adjusting for current and former smoking status and cigarette pack-years. In this context, we did not find that ENDS use was associated with a statistically significant increase in self-reported incident diagnosed myocardial infarction or stroke over a 5-year period. While more studies are needed, this analysis provides an important foundation and key methodological considerations for future research on the health effects of ENDS use.

The longitudinal association between coupon receipt and established cigarette smoking initiation among young adults in USA.

INTRODUCTION: Tobacco companies frequently distribute coupons for their products. This marketing tactic may be particularly effective among young adults, who tend to be especially price-sensitive. Young adulthood is also a stage during which many individuals initiate established cigarette smoking and are especially vulnerable to the effects of tobacco marketing. METHODS: We used five waves of data from the US Population Assessment on Tobacco and Health Study (2013-2019) to assess the longitudinal relationship between cigarette coupon receipt and initiation of established cigarette smoking among young adults (18-24 years) who did not report current smoking and had smoked <100 cigarettes in their lifetime at baseline. Initiation of established cigarette smoking was defined as reporting current cigarette use and having smoked ≥100 cigarettes at follow-up. To test this relationship, we fit four discrete time survival models to an unbalanced person-period data set. The first model included our time-varying coupon receipt variable, which was lagged one wave. Subsequent models added sociodemographic, cigarette smoking exposure and other tobacco use variables. RESULTS: Adopting the model adjusting for sociodemographic variables, respondents who received a coupon were found to be more likely to initiate established cigarette smoking at follow-up (adjusted HR (aHR): 2.31, 95% CI 1.41 to 3.80). This relationship remained significant when controlling for all covariates in the fully adjusted model (aHR: 1.96, 95% CI 1.18 to 3.26). CONCLUSIONS: These findings show that receiving tobacco coupons may increase the likelihood that young adults will initiate established cigarette smoking, underscoring the need to address the effects of this tobacco marketing tactic.

Differential impact of the Canadian point-of-sale tobacco display bans on quit attempts and smoking cessation outcomes by sex, income and education: longitudinal findings from the ITC Canada Survey.

SIGNIFICANCE: This study examines the differential effects of Canadian point-of-sale (POS) tobacco display bans across provinces on quit attempts and smoking cessation, by sex, education and income. METHODS: We analysed survey data from five waves (waves 4-8) of the International Tobacco Control Canada Survey, a population-based, longitudinal survey, where provinces implemented display bans between 2004 and 2010. Primary outcomes were quit attempts and successful cessation. We used generalised estimating equation Poisson regression models to estimate associations between living in a province with or without a POS ban (with a 24-month threshold) and smoking outcomes. We tested whether these associations varied by sex, education and income by including interaction terms. RESULTS: Across survey waves, the percentage of participants in provinces with POS bans established for more than 24 months increased from 5.0% to 95.8%. There was no association between POS bans and quit attempts for provinces with bans in place for 0-24 months or more than 24 months, respectively (adjusted relative risk (aRR)=0.99, 95% CI: 0.89 to 1.10; 1.03, 95% CI: 0.88 to 1.20). However, we found a differential impact of POS bans on quit attempts by sex, whereby bans were more effective for women than men for bans of 0-24 months. Participants living in a province with a POS ban for at least 24 months had a higher chance of successful cessation (aRR=1.49; 95% CI: 1.08 to 2.05) compared with those in a province without a ban. We found no differences in the association between POS bans and quit attempts or cessation by education or income, and no differences by sex for cessation. CONCLUSION: POS bans are associated with increased smoking cessation overall and more quit attempts among women than men.

Patterns of poly tobacco use among adults in the Population Assessment of Tobacco and Health (PATH) study, 2013-2017: a multistate Markov transition analysis.

BACKGROUND: A better understanding of sociodemographic transition patterns between single, dual and poly tobacco product use may help improve tobacco control policy interventions. METHODS: HRs of transition between never, non-current (no past 30-day use), cigarette, e-cigarette, other combustible, smokeless tobacco (SLT), dual and poly tobacco use states in adults were estimated for age, sex, race/ethnicity, education and income using a multistate model for waves 1-4 of the Population Assessment of Tobacco and Health study (2013-2017), a US-based cohort study, accounting for complex survey design. RESULTS: Sole cigarette and SLT use were persistent, with 77% and 78% of adults continuing use after one wave. Other use states were more transient, with 29%-48% of adults reporting the same pattern after one wave. If single-product users transitioned, it was most likely to non-current use while dual or poly cigarette users were most likely to transition to exclusive cigarette use. Males were more likely than females to initiate combustible product use after a history of no use, and after a period of tobacco use cessation. Hispanic and non-Hispanic black participants initiated cigarette use at higher rates than non-Hispanic white participants, and had higher rates of experimentation with tobacco products between study waves. Lower socioeconomic status was associated with higher rates of transition into combustible tobacco use. CONCLUSIONS: Dual and poly tobacco use is largely transient, while single-use patterns are more stable over time. Transitions differ by age, sex, race/ethnicity, education and income, which may influence the impact of current and future tobacco control efforts.

Public health impact of a US ban on menthol in cigarettes and cigars: a simulation study.

INTRODUCTION: The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs). METHODS: After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060. RESULTS: As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications. CONCLUSIONS AND RELEVANCE: Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.

Prevalence and predictors of perceived COVID-19 stigma within a population-based sample of adults with COVID-19.

BACKGROUND: Growing evidence suggests that individuals with COVID-19 face stigmatization, which is associated with poor health outcomes and behaviors. However, very few population-based studies have examined risk factors for experiencing COVID-19 stigma. This study examined prevalence and predictors of perceived COVID-19 stigma using a population-based probability sample of adults with COVID-19. METHODS: We included adults with polymerase chain reaction-confirmed SARS-CoV-2 in Michigan between January 1, 2020 and July 31, 2021. Perceived COVID-19 stigma was considered present if a respondent answered affirmatively to any of the following items due to people thinking they might have COVID-19: "you were treated badly," "people acted as if they were scared of you," and "you were threatened or harassed." We conducted modified Poisson regression with robust standard errors to estimate associations between perceived COVID-19 stigma and potential predictors, including sex, age, race and ethnicity, household income, education, employment, smoking status, body mass index, preexisting diagnosed physical or mental comorbidities, and COVID-19 illness severity. RESULTS: Perceived COVID-19 stigma was commonly reported among our respondents (38.8%, n = 2,759). Compared to those over 65 years, respondents who were 18 - 34 (adjusted prevalence ratio (aPR): 1.41, 95% confidence intervals (CI): 1.12 - 1.77) and 35 - 44 years old (aPR: 1.66, 95% CI: 1.31 - 2.09) reported higher perceived stigma. Female respondents had 1.23 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.10 - 1.37) than male respondents and non-Hispanic Black respondents had 1.22 times higher prevalence of perceived COVID-19 stigma (95% CI: 1.04 - 1.44) than non-Hispanic White respondents. Moreover, respondents with pre-existing diagnosed psychological or psychiatric comorbidities were more likely to report perceived COVID-19 stigma (aPR: 1.29, 95% CI: 1.13 - 1.48) compared to those without diagnosed comorbidities. Respondents with very severe COVID-19 symptoms were also more likely to report perceived COVID-19 stigma (aPR: 1.47, 95% CI: 1.23 - 1.75) than those with asymptomatic or mild symptoms. CONCLUSIONS: We found that populations who are marginalized in United States, such as females, non-Hispanic Black adults, or individuals with chronic conditions, are more likely to report perceived COVID-19 stigma. Continuing to monitor COVID-19 stigma, especially in vulnerable populations, may provide useful insights for anti-stigma campaigns and future pandemics.

Differential care-seeking behaviors during the beginning of the COVID-19 pandemic in Michigan: a population-based cross-sectional study.

BACKGROUND: At the beginning of the COVID-19 pandemic in the United States in the spring of 2020, many Americans avoided the healthcare system, while those with COVID-19 symptoms were faced with decisions about seeking healthcare services for this novel virus. METHODS: Using a probability sample (n = 1088) from the Michigan adult population of PCR-confirmed COVID-19 cases who were diagnosed prior to July 31, 2020, we used logistic regression to examine sociodemographic and symptom severity predictors of care-seeking behaviors. The analyses examined three different outcomes: (1) whether respondents sought care and, among those who sought care, whether they sought care from (2) a primary care provider or (3) an emergency room. Final models were adjusted for sex, age, race and ethnicity, income, education, marital status, living arrangement, health insurance, and self-reported symptom severity. RESULTS: We found that participants ages 65 and older had 4.00 times higher odds of seeking care than 18-34-year-olds (95% CI: 2.21, 7.24), while adults reporting very severe symptoms had roughly 15 times higher odds of seeking care than those with mild symptoms (95% CI: 7.73, 27.01). Adults who were non-Hispanic Black or were uninsured had lower odds of seeking care from a primary care physician versus seeking care from other locations in comparison to adults who were non-Hispanic White or were privately insured, respectively (non-Hispanic Black: aOR = 0.27, 95% CI: 0.16, 0.44; Uninsured: aOR = 0.19, 95% CI: 0.09, 0.42). Conversely, adults who were older or reported more severe symptoms had higher odds of seeking care from an emergency room versus other locations in comparison to adults who were younger or reported less severe symptoms (Age 65+: aOR = 2.96, 95% CI: 1.40, 6.28; Very Severe Symptoms: aOR = 6.63, 95% CI: 3.33, 13.20). CONCLUSIONS: Our results suggest differential utilization of healthcare services early in the COVID-19 pandemic. Further analyses are needed to examine the reasons for these differences.

Patterns and predictors of depressive and anxiety symptoms within a population-based sample of adults diagnosed with COVID-19 in Michigan.

PURPOSE: The COVID-19 pandemic has had wide-ranging impacts on mental health, however, less is known about predictors of mental health outcomes among adults who have experienced a COVID-19 diagnosis. We examined the intersection of demographic, economic, and illness-related predictors of depressive and anxiety symptoms within a population-based sample of adults diagnosed with COVID-19 in the U.S. state of Michigan early in the pandemic. METHODS: Data were from a population-based survey of Michigan adults who experienced a COVID-19 diagnosis prior to August 1, 2020 (N = 1087). We used weighted prevalence estimates and multinomial logistic regression to examine associations between mental health outcomes (depressive symptoms, anxiety symptoms, and comorbid depressive/anxiety symptoms) and demographic characteristics, pandemic-associated changes in accessing basic needs (accessing food/clean water and paying important bills), self-reported COVID-19 symptom severity, and symptom duration. RESULTS: Relative risks for experiencing poor mental health outcomes varied by sex, age, race/ethnicity, and income. In adjusted models, experiencing a change in accessing basic needs associated with the pandemic was associated with higher relative risks for anxiety and comorbid anxiety/depressive symptoms. Worse COVID-19 symptom severity was associated with a higher burden of comorbid depressive/anxiety symptoms. "Long COVID" (symptom duration greater than 60 days) was associated with all outcomes. CONCLUSION: Adults diagnosed with COVID-19 may face overlapping risk factors for poor mental health outcomes, including pandemic-associated disruptions to household and economic wellbeing, as well as factors related to COVID-19 symptom severity and duration. An integrated approach to treating depressive/anxiety symptoms among COVID-19 survivors is warranted.