Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

INTRODUCTION: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the lung injuries outbreak, flavour bans, Tobacco 21 and the COVID-19 pandemic. METHODS: Using the Population Assessment of Tobacco and Health Study, we applied a multistate transition model to 28 061 adults in waves 4-5 (2017-2019) and 24 584 adults in waves 5-6 (2019-2021), estimating transition rates for initiation, cessation and switching products for each period overall and by age group. RESULTS: Cigarette initiation among adults who never used either product decreased from 2017-2019 to 2019-2021, but ENDS initiation did not significantly change. The persistence of ENDS-only use remained high (75%-80% after 1 year). Cigarette-only use transitions remained similar (88% remaining, 7% to non-current use and 5% to dual or ENDS-only use). In contrast, dual use to ENDS-only transitions increased from 9.5% (95% CI 7.3% to 11.7%) to 20.0% (95% CI 17.4% to 22.6%) per year, decreasing the persistence of dual use. The dual to cigarette-only use transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. CONCLUSIONS: The persistence of ENDS use among adults remained high in 2019-2021, but a larger fraction of dual users transitioned to ENDS-only use compared with 2017-2019. Because the fraction of cigarette-only users switching to dual use remained low, especially among older adults, the public health implications of this change are minimal.

Person explanatory multidimensional item response theory with the instrument package in R.

We present the new R package instrument to perform Bayesian estimation of person explanatory multidimensional item response theory. The package implements an exploratory multidimensional item response theory model and a higher-order multidimensional item response theory model, a type of confirmatory multidimensional item response theory. Explanation of person parameters is accomplished by fixed and random effect linear regression models. Estimation is carried out using Hamiltonian Monte Carlo in Stan. In this article, we provide a detailed description of the models; we use the instrument package to demonstrate fitting explanatory item response models with fixed and random effects (i.e., mixed modeling) of person parameters in R; and, we perform a simulation study to evaluate the performance of our implementation of the models.

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.

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.

Family functioning within the context of families with adolescent children in urban India.

Research on family functioning within given cultural contexts is needed. This study aims to describe salient dimensions of family functioning in two urban contexts in India and to examine differences in family functioning by sociodemographic groups. We measured differences in family functioning using cross-sectional survey questionnaire data collected from 13 to 15-year-old adolescents and one of their parents/primary caregivers in Mumbai (n = 843) and Kolkata (n = 913) during 2019-2020. We drew a multi-stage sample representative of neighborhoods and households in both cities. We assessed a multi-dimensional family functioning latent factor that included parent-reported measures (parent-adolescent communication, family cohesion, and parent monitoring of peers) and adolescent-reported measures (parent support, family cohesion, and parent supervision). Our results support an overall measure of family functioning manifested by multiple dimensions for parent- and adolescent-reported data. Families with male adolescents had worse adolescent-reported family functioning in Mumbai and parent-reported family functioning in Kolkata. Higher socioeconomic status was associated with better parent-reported family functioning in both cities and better adolescent-reported family functioning in Kolkata. Muslim religious identification in Kolkata and the Hindi native language in both cities were associated with better adolescent-reported family functioning. Our findings indicate heterogeneity in family functioning across demographic and social-cultural groups within the two urban contexts of India. This study may inform the development of culturally congruent prevention interventions for families with adolescents in India.

The Impact of Current Tobacco Product Use Definitions on Estimates of Transitions Between Cigarette and ENDS Use.

INTRODUCTION: Definitions of current tobacco and nicotine delivery product use vary and depend on frequency of use, established-use criteria, and the product type. Previous research has not considered how transition rates between current use of different products depend on the current use definition. AIMS AND METHODS: We applied a multistate transition model to data on U.S. adults from waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health (PATH) study. We estimated transition rates between never, non-current, cigarette, electronic nicotine delivery systems (ENDS), and dual use states with and without established-use criteria (has smoked 100+ cigarettes in their lifetime; ever fairly regularly used ENDS) and different frequency thresholds (1+, 10+, 20+, and 30 days of the past 30 days). We considered use below a frequency threshold as either non-current use or a distinct, infrequent use category. RESULTS: When treating use below a frequency threshold as non-current use, transition probability estimates were largely robust to the choice of use frequency threshold, although sole ENDS users were more likely to transition to non-current use or dual use as the current use threshold increased. Removing the established-use criterion for ENDS reduced the estimates of sole ENDS and dual users staying in their use state. When treating infrequent use as a separate category, transition probability estimates were dependent on the use frequency threshold, particularly transitions among the dual use states. CONCLUSIONS: Product use definitions have important implications for assessing product use transitions and thus the public health implications of cigarette and ENDS control strategies. IMPLICATIONS: How we define "current use" of tobacco and nicotine delivery products changes our estimates of how individuals transition to, between, and from different patterns of use. We show that the robustness of transition estimates to whether or not non-established users are included as current users and to different frequency-of-use threshold depends in part on whether low-frequency users are categorized as non-current users or as a distinct category. Our results emphasize the importance of intentional definitions of product use that reflect the larger goals of public health and tobacco control.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation.

INTRODUCTION: Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation. AIMS AND METHODS: We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias. RESULTS: Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies. CONCLUSIONS: Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point. IMPLICATIONS: A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

Neighbourhood tobacco retail access and tobacco use susceptibility in young adolescents in urban India.

BACKGROUND: Neighbourhood tobacco retail access may influence adolescent tobacco use. In India, we examined the association between neighbourhood tobacco retail access and cognitive risks for tobacco use during early adolescence. METHODS: In 2019-2020, a population-based sample (n=1759) of adolescents aged 13-15 years was surveyed from 52 neighbourhoods in Mumbai and Kolkata. Neighbourhood tobacco retail access was measured as the frequency of visits to tobacco retailers, mapped tobacco retailer density and perceived tobacco retailer density. We estimated associations between neighbourhood tobacco retail access and cognitive risks for tobacco use (perceived ease of access to tobacco, perceived peer tobacco use and intention to use tobacco). RESULTS: There was high neighbourhood tobacco retail access. Tobacco retailer density was higher in lower income neighbourhoods (p<0.001). Adolescent frequency of tobacco retailer visits was positively associated with cognitive tobacco use risks. Mapped tobacco retailer density was associated with perceived ease of access in Kolkata but not in Mumbai, and it was not associated with perceived peer tobacco use nor intention. Perceived tobacco retailer density was associated with perceived ease of access and perceived peer use, but not with intention. In Kolkata, higher perceived retailer density and frequency of tobacco retailer visits were negatively associated with perceived ease of access. CONCLUSIONS: Efforts to reduce neighbourhood tobacco retail access in India may reduce cognitive tobacco use risk factors in young adolescents. The frequency of tobacco retailer visits and perceived tobacco retailer density increased cognitive risks, though there were some exceptions in Kolkata that further research may explain.

A mixed-methods study on the dietary practices of early postpartum women during the summer rainy season in Belgaum, Karnataka, India.

The current mixed-method study uses Food Frequency Questionnaires and 24-hour dietary recalls (n = 41) to assess the food/nutrient intake; and qualitative interviews to identify local perceptions of food among 41 early postpartum women in Belgaum, India. The results show that total energy, protein, and most micronutrient intake were significantly lower than the Recommended Dietary Allowance of India (p < .05 individually); ninety percent of mothers restricted the consumption of some specific fruits, vegetables, and other foods during postpartum due to their perceptions of foods, folk medicines, and health beliefs. Culturally sensitive programs relevant to postpartum diet practices for women should be implemented.

Latent class analysis of use frequencies for multiple tobacco products in US adults.

A persistent challenge is characterizing patterns of tobacco use in terms of product combinations and frequency. Using Wave 4 (2016-17) Population Assessment of Tobacco and Health Study adult data, we conducted latent class analyses (LCA) of past 30-day frequency of use for 9 tobacco products. One-step LCA with joint multinomial logistic regression models compared sociodemographic factors between users (n = 13,716) and non-users (n = 17,457), and between latent classes of users. We accounted for survey design and weights. Our analyses identified 6 classes: in addition to non-users (C0: 75.7%), we found 5 distinct latent classes of users: daily exclusive cigarette users (C1: 15.5%); occasional cigarette and polytobacco users (C2: 3.8%); frequent e-product and occasional cigarette users (C3: 2.2%); daily smokeless tobacco (SLT) and infrequent cigarette users (C4: 2.0%); and occasional cigar users (C5: 0.8%). Compared to C1: C2 and C3 had higher odds of being male (versus female), younger (especially 18-24 versus 55 years), and having higher education; C2 had higher, while C3 and C4 had lower, odds of being a racial/ethnic minority (versus Non-Hispanic White); C4 and C5 had much higher odds of being male (versus female) and heterosexual (versus sexual minority) and having higher income; and C5 had higher odds of college or more education. We identified three classes of daily or frequent users of a primary product (cigarettes, SLT or e-products) and two classes of occasional users (cigarettes, cigars and polytobacco). Sociodemographic differences in class membership may influence tobacco-related health disparities associated with specific patterns of use.

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.

A comparison of tobacco product prevalence by different frequency of use thresholds across three US surveys.

BACKGROUND: With the increasing changes in tobacco use patterns, "current use" definition and the survey used may have important implications for monitoring population use trends. METHODS: Using three US surveys (2014/15 TUS-CPS, NHIS and PATH), we compared the adult (age 18+) prevalence of four product groups (cigarettes, other combustibles, smokeless tobacco, and e-cigarettes) based on three past 30-day frequency of use thresholds: 1+, 10+, and 25+ days. We also examined mutually exclusive single, dual, and polytobacco users as a percentage of total users for each product group. RESULTS: Regardless of threshold or product, the prevalence was higher in PATH followed by NHIS and TUS-CPS, in some cases by large percentages. The differences in cigarette and smokeless tobacco use prevalence in going from the 1+ to 10+ days and to the 25+ days threshold were minimal. Applying different frequency thresholds had the largest impact on other combustibles prevalence, with a 60% reduction with the 10+ days threshold and a 80% reduction with the 25+ days threshold, compared to the 1+ days threshold, followed by e-cigarettes with 40 and 60% reductions, respectively. The proportion of dual and polytobacco users decreased considerably when using the 10+ vs. the 1+ days threshold and polytobacco use was almost non-existent with the 25+ days threshold. CONCLUSION: The estimated prevalence of each tobacco product use depends largely on the survey and frequency of use threshold adopted. The choice of survey and frequency threshold merits serious consideration when monitoring patterns of tobacco use.

Transitions between cigarette, ENDS and dual use in adults in the PATH study (waves 1-4): multistate transition modelling accounting for complex survey design.

INTRODUCTION: Even prior to 2018, electronic nicotine delivery systems (ENDS) began to dramatically change the landscape of tobacco products and product use patterns in the USA. METHODS: Using a Markov multistate transition model accounting for complex survey design, transition rates between never, non-current, cigarette, ENDS and dual use states were estimated for 23 253 adult participants in waves 1-4 (approximately 2013-2017) of the Population Assessment of Tobacco and Health study. We made short-term transition projections and estimated HRs for age, sex, race/ethnicity, education and income. RESULTS: Cigarette use was persistent among adults, with 89.7% (95% CI 89.1% to 90.3%) of exclusive cigarette users and 86.1% (95% CI 84.4% to 87.9%) of dual users remaining cigarette users (either exclusive or dual) after one wave. In contrast, ENDS use was less persistent, with 72.1% (95% CI 69.6% to 74.6%) of exclusive ENDS users and 50.5% (95% CI 47.8% to 53.3%) of dual users remaining ENDS users (with or without cigarettes) after one wave. Exclusive ENDS users were more likely to start cigarette use after one wave than either never users (HR 25.2; 95% CI 20.9 to 30.5) or non-current users (HR 5.0; 95% CI 4.3 to 5.8). Dual users of ENDS and cigarettes were more likely to stop using cigarettes than exclusive cigarette users (HR 1.9; 95% CI 1.6 to 2.3). Transition rates varied among sociodemographic groups. CONCLUSIONS: Multistate transition models are an effective tool for uncovering and characterising longitudinal patterns and determinants of tobacco use from complex survey data. ENDS use among US adults was less persistent than cigarette use prior to 2018.

The actual and anticipated effects of a menthol cigarette ban: a scoping review.

BACKGROUND: The United States (US) Food and Drug Administration (FDA), under the 2009 Family Smoking Prevention and Tobacco Control Act, banned characterizing flavors in cigarettes; however, mentholated tobacco products were exempt. Since 2009, over 20 US jurisdictions and numerous countries around the world have extended this restriction to menthol. Currently, the FDA is reconsidering its position on a nation-wide menthol cigarette ban. However, the effects of such a ban remain unclear. We conducted a scoping review to explore the impact of a menthol cigarette ban on individual behaviors (initiation, cessation, and product switching), sales, and compliance. METHODS: We conducted a search of the international literature using PubMed, EBSCO, and Web of Science (to November 25, 2019). We retrieved articles relevant to the impacts of an implemented or hypothetical menthol ban. We also included studies of flavored tobacco product bans due to their potential relevance in gauging compliance and product substitutability. RESULTS: The search identified 493 articles, of which 24 were included. Studies examined the effects of implemented menthol bans (n = 6), hypothetical menthol bans (n = 12) and implemented flavor bans that exclude menthol (n = 6). Menthol bans were found to reduce sales and increase smoking cessation with only partial substitution for non-menthol cigarettes. US smokers' reactions to a hypothetical ban indicate that about 25-64% would attempt to quit smoking and 11-46% would consider switching to other tobacco products, including 15-30% to e-cigarettes. Flavor ban studies indicate reductions in initiation of 6%. Ban compliance was high, but studies indicate that the tobacco industry and retailers have attempted to circumvent their impact via packaging changes and online sales. CONCLUSION: Our review finds that extending the US cigarette flavor ban to menthol products would promote smoking cessation and reduce initiation. This evidence supports further action by the FDA towards mentholated tobacco products. However, few studies have been conducted in the vaping era.

Compliance with point-of-sale tobacco control policies and student tobacco use in Mumbai, India.

BACKGROUND: We measured how student tobacco use and psychological risk factors (intention to use and perceived ease of access to tobacco products) were associated with tobacco vendor compliance with India's Cigarettes and Other Tobacco Products Act provisions regulating the point-of-sale (POS) environment. METHODS: We conducted a population-based cross-sectional survey of high school students (n=1373) and tobacco vendors (n=436) in school-adjacent communities (n=26) in Mumbai, India. We used in-class self-administered questionnaires of high school students, face-to-face interviews with tobacco vendors and compliance checks of tobacco POS environments. Logistic regression models with adjustments for clustering were used to measure associations between student tobacco use, psychological risk factors and tobacco POS compliance. RESULTS: Compliance with POS laws was low overall and was associated with lower risk of student current tobacco use (OR 0.48, 95% CI 0.26 to 0.91) and current smokeless tobacco use (OR 0.40, 95% CI 0.21 to 0.77), when controlling for student-level and community-level tobacco use risk factors. Compliance was not associated with student intention to use tobacco (OR 0.50; 95% CI 0.21 to 1.18) and perceived ease of access to tobacco (OR 0.73; 95% CI 0.53 to 1.00). CONCLUSIONS: Improving vendor compliance with tobacco POS laws may reduce student tobacco use. Future studies should test strategies to improve compliance with tobacco POS laws, particularly in low-income and middle-income country settings like urban India.

Antenatal Tobacco Use and Secondhand Smoke Exposure in the Home in India.

Introduction: Antenatal tobacco use and secondhand smoke (SHS) exposure can have grave health consequences. We estimated the prevalence of tobacco use and SHS exposure in the home among pregnant and reproductive age women in India, and identified sociodemographic risk factors. Methods: Data were from the National Family Health Survey-3 (2005-2006), a population-based cross-sectional survey. We measured current tobacco use and SHS exposure in the home, and used logistic regression analysis to identify sociodemographic risk factors. Results: Nationally, antenatal tobacco use and SHS exposure in the home were reported by 9% and 25% of women, respectively. Tobacco use rates were slightly higher in reproductive age women (11%) than in pregnant women (9%). Common risk factors for tobacco use in pregnant and reproductive age women included older age, lower education, lower socioeconomic status, Scheduled Tribe status, Muslim religion, and rural residence. Being married lowered the risk of tobacco use among pregnant women, but increased the risk among reproductive age women. Antenatal SHS exposure decreased with older age and higher socioeconomic status. Conclusions: Antenatal tobacco use and SHS exposure in the home is a significant public health problem in India. Programs should target low socioeconomic status pregnant women, including single pregnant mothers. Implications: Antenatal tobacco use and SHS exposure in the home are significant public health problems in India. Intervention strategies should target younger women, single and socioeconomically disadvantaged pregnant women.

Longitudinal study of adolescent tobacco use and tobacco control policies in India.

BACKGROUND: This project will use a multilevel longitudinal cohort study design to assess whether changes in Community Tobacco Environmental (CTE) factors, measured as community compliance with tobacco control policies and community density of tobacco vendors and tobacco advertisements, are associated with adolescent tobacco use in urban India. India's tobacco control policies regulate secondhand smoke exposure, access to tobacco products and exposure to tobacco marketing. Research data about the association between community level compliance with tobacco control policies and youth tobacco use are largely unavailable, and are needed to inform policy enforcement, implementation and development. METHODS: The geographic scope will include Mumbai and Kolkata, India. The study protocol calls for an annual comprehensive longitudinal population-based tobacco use risk and protective factors survey in a cohort of 1820 adolescents ages 12-14 years (and their parent) from baseline (Wave 1) to 36-month follow-up (Wave 4). Geographic Information Systems data collection will be used to map tobacco vendors, tobacco advertisements, availability of e-cigarettes, COTPA defined public places, and compliance with tobacco sale, point-of-sale and smoke-free laws. Finally, we will estimate the longitudinal associations between CTE factors and adolescent tobacco use, and assess whether the associations are moderated by family level factors, and mediated by individual level factors. DISCUSSION: India experiences a high burden of disease and mortality from tobacco use. To address this burden, significant long-term prevention and control activities need to include the joint impact of policy, community and family factors on adolescent tobacco use onset. The findings from this study can be used to guide the development and implementation of future tobacco control policy designed to minimize adolescent tobacco use.

Contextual Factors Related to Conventional and Traditional Tobacco Use Among California Asian Indian Immigrants.

California's tobacco control program contracted for tobacco use surveillance of Asian Indian Americans to address the paucity of information about tobacco use in this community, given their growing proportion of California's population. This study examined correlates of conventional (CTU) and Asian Indian traditional tobacco use (TTU) in a population-based sample of predominantly immigrant Asian Indian adults residing in California (N = 3228). The analytic sample (n = 2140) was limited to self-identified immigrants from India. Descriptive statistics, bivariate analyses, and multivariate logistic regressions were conducted to examine correlates of tobacco use among Asian Indian immigrants related to their acculturation and religious affiliation. While 65% of the sample had ever used traditional tobacco products (paan masala, gutka, bidis), only 25% had ever used conventional tobacco (cigarettes, cigar, pipe, chewing tobacco, snuff). Less than 5% reported tobacco use in the past 30 days. Rates of ever TTU and CTU were higher among men than women. Ethnic enclave residence was not associated with tobacco use. Impaired mental health was associated with CTU, and number of years spent in the U.S. was positively associated with both CTU and TTU. Individuals affiliated with Sikhism were less likely to use tobacco than individuals affiliated with Hinduism. Few population-based studies in the U.S. address both CTU and TTU use among Asian Indian immigrants. Tobacco use in Asian Indian immigrants may be seriously underestimated if surveillance is limited to conventional tobacco products. Interventions to reduce tobacco use should address mental health issues and consider religious affiliation.

Antenatal tobacco use and iron deficiency anemia: integrating tobacco control into antenatal care in urban India.

BACKGROUND: In India, tobacco use during pregnancy is not routinely addressed during antenatal care. We measured the association between tobacco use and anemia in low-income pregnant women, and identified ways to integrate tobacco cessation into existing antenatal care at primary health centers. METHODS: We conducted an observational study using structured interviews with antenatal care clinic patients (n = 100) about tobacco use, anemia, and risk factors such as consumption of iron rich foods and food insecurity. We performed blood tests for serum cotinine, hemoglobin and ferritin. We conducted in-depth interviews with physicians (n = 5) and auxiliary nurse midwives (n = 5), and focus groups with community health workers (n = 65) to better understand tobacco and anemia control services offered during antenatal care. RESULTS: We found that 16% of patients used tobacco, 72% were anemic, 41% had iron deficiency anemia (IDA) and 29% were food insecure. Regression analysis showed that tobacco use (OR = 14.3; 95%CI = 2.6, 77.9) and consumption of green leafy vegetables (OR = 0.6; 95%CI = 0.4, 0.9) were independently associated with IDA, and tobacco use was not associated with consumption of iron-rich foods or household food insecurity. Clinics had a system for screening, treatment and follow-up care for anemic and iron-deficient antenatal patients, but not for tobacco use. Clinicians and community health workers were interested in integrating tobacco screening and cessation services with current maternal care services such as anemia control. Tobacco users wanted help to quit. CONCLUSION: It would be worthwhile to assess the feasibility of integrating antenatal tobacco screening and cessation services with antenatal care services for anemia control, such as screening and guidance during clinic visits and cessation support during home visits.

Banning tobacco sales and advertisements near educational institutions may reduce students' tobacco use risk: evidence from Mumbai, India.

BACKGROUND: India's Cigarettes and Other Tobacco Products Act bans tobacco sales and advertisements within 100 yards of educational institutions. In school-adjacent neighbourhoods in Mumbai, we assessed adherence to these policies and whether tobacco vendor and advertisement densities were associated with students' tobacco use. METHODS: High school students' tobacco use was measured using a multistage cluster sampling survey (n=1533). Field geographic information systems data were obtained for all tobacco vendors and advertisements within 500 m of schools (n=26). Random-effects multilevel logistic regression was used to estimate associations of tobacco vendor and advertisement densities with ever tobacco use, current smokeless tobacco use and current tobacco use. RESULTS: There were 1741 tobacco vendors and 424 advertisements within 500 m of schools, with 221 vendors (13%) and 42 advertisements (10%) located within 100 m. School-adjacent tobacco vendor density within 100 m was not associated with the tobacco use outcomes, but tobacco advertisement density within 100 m was associated with all outcomes when comparing highest to lowest density tertiles: ever use (OR: 2.01; 95% CI 1.00 to 4.07), current use (2.23; 1.16, 4.28) and current smokeless tobacco use (2.01; 1.02, 3.98). Tobacco vendor density within 200, 300, 400 and 500 m of schools was associated with current tobacco use and current smokeless tobacco use, but not ever use. CONCLUSIONS: The tobacco sales ban near educational institutions could be expanded beyond 100 m. Greater enforcement is needed regarding the current bans, particularly because advertisement density within 100 m of schools was associated with all students' tobacco use outcomes.