Evaluating US smokers' willingness to pay for different cigarette packaging designs before and after real-world exposure in a randomised trial.

INTRODUCTION: Removal of tobacco industry branding from cigarette packs may reduce their appeal. Adding graphic warning labels (GWLs) should enhance this effect. We investigate whether willingness to pay for various packaging designs changes after 3 months' use of: (1) US branded packs without GWLs (US), (2) non-branded packs without GWLs (Blank), and (3) rotating non-branded packs with GWLs (gangrene; throat cancer; neonatal baby) covering >75% of pack (GWL). METHODS: Californian adult daily smokers not planning to quit (n=287; 56% female; mean age=39.6) completed a discrete choice purchase task before and after 3 months' experience using one of three packaging options. Conjoint analysis and pre-post modelling evaluated the change in importance of pack attributes and willingness to pay for US, Blank or GWL (blindness; teeth; gangrene) pack designs. RESULTS: Price determined ~70% of purchase choices, while pack design determined ~22%. Irrespective of intervention arm, US packaging generated appeal valuations compared with Blank packaging, while GWLs consistently provoked strong aversive valuations at baseline and follow-up. Compared with the US pack arm, using GWL packs for 3 months decreased willingness to pay for US packaging (ß=-$0.38, 95% CI -0.76 to 0.00). Wear-out effects were detected in the discount needed to willingly purchase the gangrene-GWL pack (ß=$0.49, 95% CI 0.16 to 0.82) and Blank pack (ß=$0.42, 95% CI 0.09 to 0.74) but not for GWLs (blindness, teeth) not used in trial. CONCLUSION: Compared with US branded packs, the negative valuation of non-branded GWL packs attenuates with even 3 months' use but does not generalise to non-used GWLs. This suggests that GWLs should be regularly refreshed. The appeal valuation of industry imagery suggests that the US plan to retain such imagery on packs may ameliorate the effect of GWLs.

Menthol versus non-menthol flavouring and switching to e-cigarettes in black and Latinx adult menthol combustible cigarette smokers: secondary analyses from a randomised clinical trial.

BACKGROUND: As the US Food and Drug Administration takes regulatory action on menthol cigarettes, debate continues about how restricting menthol e-liquids might impact adult menthol smokers in switching to e-cigarettes. METHODS: Switching patterns and e-cigarette acceptability were assessed at week 6 among 64 black and Latinx menthol cigarette smokers who used JUUL menthol (n=39) or non-menthol e-cigarettes ((n=25), primarily mint or mango) as part of a randomised switching trial. RESULTS: No clear evidence of effects was found between menthol versus non-menthol e-cigarettes on use or subjective effects/acceptability, effect sizes for all comparisons were small (effect size=0.0-0.2), and Bayes factor ranged from 0.10 to 0.15. Specifically, 82.1% of participants who used menthol-flavoured e-cigarettes fully or partially switched to e-cigarettes compared with 88.0% of participants who used a non-menthol (p=0.75). Further, both groups demonstrated substantial reductions in cigarettes per day (menthol e-cigarettes: -8.5±10.4 vs non-menthol e-cigarettes: -8.8±5.8, p=0.87), comparable grams of e-liquid consumed (menthol e-cigarettes: 9.2±9.8 g vs non-menthol e-cigarettes: 11.0±11.0 g, p=0.47), and positive subjective effects, including 'just right' throat hit (menthol e-cigarettes: 70.7% vs non-menthol e-cigarettes: 66.7%, p=0.93) and flavour liking (menthol e-cigarettes: 75.6% vs non-menthol e-cigarettes: 66.7%, p=0.32). CONCLUSIONS: Both menthol and non-menthol e-cigarettes were associated with high rates of use and acceptability among menthol smokers. Findings require confirmation in a fully powered non-inferiority or equivalence study but provide preliminary evidence to inform regulatory action on menthol e-cigarettes that could slow youth initiation without impacting black and Latinx menthol cigarette smokers interested in switching to e-cigarettes. TRIAL REGISTRATION NUMBER: NCT03511001.

Switching people who smoke to unfiltered cigarettes: perceptions, addiction and behavioural effects in a cross-over randomised controlled trial.

BACKGROUND: Behavioural research is needed to inform a ban on sales of filtered cigarettes that could reduce plastic waste due to discarded filters. This study reports on differences in perceptions, nicotine dependence and behaviour among participants in a cross-over randomised trial of filtered compared with unfiltered cigarettes. METHOD: This proof-of-concept study involved 43 people who smoke filtered cigarettes (41.9% women, mean age 36.7 years). Participants were provided 2 weeks' supply of filtered cigarettes, 2 weeks of the same brand of unfiltered cigarettes and randomly assigned to starting conditions. Measures included the Modified Cigarette Evaluation Questionnaire; single-item cigarette perception questions; Fagerström Test of Nicotine Dependence; 7-day cigarette consumption, urinary cotinine and intention to quit. Analyses included linear and ordinal repeated measures mixed-effects models and paired t-tests. RESULTS: Filtered cigarettes were perceived as better tasting, more satisfying, more enjoyable, less aversive, less harsh, less potent and less negatively reinforcing than unfiltered cigarettes. Filtered cigarettes were smoked at a higher rate during the trial than unfiltered cigarettes (p<0.05). There was no difference in cotinine, dependence or intention to quit between filtered versus unfiltered cigarette conditions (p>0.05). CONCLUSION: People who smoke perceived unfiltered cigarettes as having greater nicotine effects and less desirable sensory effects than filtered cigarettes, and they smoked fewer of these during the trial. Although cotinine, dependence and intention to quit were similar for smoking unfiltered and filtered cigarettes in this small trial, results suggest that banning the sale of filtered cigarettes might make smoking less attractive overall to people who smoke. TRIAL REGISTRATION NUMBER: NCT03749876.

Role of affective reactivity induced by cigarette packaging including graphic warning labels: the CASA Study.

OBJECTIVE: To identify whether three types of cigarette pack designs, including three versions of graphic warning label (GWL) plain packs, one GWL absent and branding absent pack (blank) and the smoker's own GWL absent and branding present pack (US), elicit different valence, type and levels of affect. DESIGN: US daily smokers (n=324) were asked to handle each of the five pack types and 'think aloud' their reactions. To avoid a muted familiarity response, exposure to their own US pack followed exposure to at least one GWL plain pack. Reactions were scored on a reactivity scale (-3 to +3) and the text was coded for speech polarity (-1 to +1) and emotive word frequency. RESULTS: Reactivity scores had excellent inter-rater reliability (agreement ≥86%; intraclass correlation coefficient ≥0.89) and were correlated with speech polarity (r=0.21-0.37, p<0.001). When considering their US pack, approximately two-thirds of smokers had a low (31.5%) to medium (34.6%) positive response (reactivity=1.29; polarity=0.14) with expressed feelings of joy and trust. Blank packaging prompted a largely (65.4%) neutral response (reactivity=0.03; polarity=0.00). The gangrenous foot GWL provoked mostly medium (46.9%) to high (48.1%) negative responses (reactivity=-2.44; polarity=-0.20), followed by neonatal baby (reactivity=-1.85; polarity=-0.10) and throat cancer (reactivity=-1.76; polarity=-0.08) warnings. GWLs varied in their elicitation of disgust, anger, fear and sadness. CONCLUSION: Initial reactions to GWL packs, a blank pack, and smokers' current US pack reflected negative, neutral, and positive affect, respectively. Different versions of the GWL pack elicited different levels and types of immediate negative affect.

Tobacco Tracker: A New Tool to Support College Smoke and Tobacco Free Policies.

INTRODUCTION: University community members are critical to the success of their smoke and tobacco free (STF) policies. The present study evaluates changes in social enforcement-related attitudes and behaviors following introduction of a new online Tobacco Tracker tool in two university settings. METHODS: Campus wide surveys were administered to current students, faculty, and staff at two California public universities with 100% STF policies before (November 2018; N = 5078) and after (December 2019-January 2020; N = 4853) introduction of Tobacco Tracker in February 2019. Prospective surveillance reports over 12 months from Tobacco Tracker, a GIS tool for the campus community to report tobacco use and related litter that displays crowdsourced maps of hotspots, were analyzed. Outcomes included awareness and self-reported use of a tobacco reporting tool, readiness for policy social enforcement, an Intellectual Social Affective (ISA) Engagement scale, and environmental surveillance reports from Tobacco Tracker. RESULTS: In campus surveys, awareness of a tobacco reporting tool doubled (8.0%-16.9%, p < .0001), use of an online reporting tool tripled (1.1%-3.2%, p < .0001), and readiness to enforce the policy increased (p = .0008). ISA engagement did not change (p = .72). In Tobacco Tracker campus reports (N = 1163), active tobacco use was reported more frequently than tobacco-related litter. CONCLUSIONS: Tobacco Tracker is a promising tool for college communities to support STF policy. Introduction of Tobacco Tracker was associated with an increase in campus awareness and utilization of a reporting tool, readiness to enforce policy, and campus tobacco surveillance. Future research should determine how Tobacco Tracker may improve policy compliance. IMPLICATIONS: Tobacco Tracker is a promising tool for college communities to support smoke and tobacco free (STF) policy through active surveillance of smoking, vaping, and related litter on campus. Introduction of Tobacco Tracker was associated with changes in social enforcement-related attitudes and behaviors critical to realizing the preventive potential of STF policies. A crowdsourcing-based tool for monitoring tobacco use on college campuses can address a major barrier to social enforcement: discomfort confronting tobacco users. Further, it provides an alternative to punitive enforcement approaches and promises a sustainable solution to an infrastructure issue faced by many universities lacking resources to collect data on campus tobacco use and related litter.

Effects of Marijuana Use on Smokers Switching to E-Cigarettes in a Randomized Clinical Trial.

INTRODUCTION: Co-use of tobacco and marijuana is common, and research suggests that marijuana use may be a barrier to smoking cessation. Research to date has not evaluated how marijuana use affects e-cigarette switching behaviors and related outcomes in a harm reduction trial. AIMS AND METHODS: This secondary analysis includes African American (48%) and Latinx (52%) adult smokers randomized to the e-cigarette group (N = 114) of a harm reduction clinical trial from 2018 to 2019. Participants were provided JUUL e-cigarettes and encouraged to make an exclusive switch for 6 weeks. Our primary outcome was cigarettes smoked per week. Secondary health outcomes were e-cigarette substitution (calculated by measuring e-cigarette pod use), expired carbon monoxide (CO), and respiratory symptoms. Marijuana products were recorded at three timepoints and coded for combustion. RESULTS: Marijuana use during the study (n = 52, 46%) was not associated with week 6 cigarettes smoked or e-cigarette substitution, and combustible marijuana use was not associated with week 6 respiratory symptoms (ps > .05). After controlling for cigarettes smoked at week 6, combustible marijuana use was significantly associated with a 4.4 ppm increase in CO compared with no use of marijuana (p = .001). CONCLUSIONS: Marijuana use was not a barrier to switching to e-cigarettes in this 6-week trial. Marijuana use contributed to elevated CO, reflecting greater exposure to toxic combustion products, beyond the effects of cigarette smoking. Marijuana co-use may increase risk of adverse health outcomes and may be a confounding factor when using CO as an endpoint to bioverify exclusive e-cigarette use. IMPLICATIONS: This is the first known study to examine the effects of marijuana use on smokers switching to e-cigarettes. Marijuana use was not a barrier to cigarette reduction in a 6-week randomized clinical trial. Marijuana use uniquely contributed to higher carbon monoxide among cigarette smokers, indicating greater exposure to toxic combustion products, which could increase risk of adverse health outcomes. Furthermore, combustible marijuana use may be a confounding factor when CO is used as an endpoint to bioverify exclusive e-cigarette use.

Harm Reduction Associated with Dual Use of Cigarettes and e-Cigarettes in Black and Latino Smokers: Secondary Analyses from a Randomized Controlled e-Cigarette Switching Trial.

INTRODUCTION: Most adult cigarette smokers who use e-cigarettes are dual cigarette and e-cigarette (CC-EC) users, yet little is known about relative consumption of cigarettes to e-cigarettes and any associated harm reduction. METHODS: Rate of substitution from cigarettes to e-cigarettes at week 6 and change in biomarkers of exposure and potential harm were examined among dual dual cigarette and e-cigarette users [64/114 (56%); 35 Black, 29 Latino] in an e-cigarette switching randomized trial. RESULTS: Dual users averaged 79% substitution of cigarettes for e-cigarettes at week 6, resulting in a reduction from baseline of 70.0 ± 54.1 cigarettes per week (p < .001). Total nicotine consumption remained stable (baseline: 1160.5 ± 1042.1 pg/mL of cotinine, week 6: 1312.5 ± 1725.9 pg/mL of cotinine, p = .47), while significant reductions were seen in the potent lung carcinogen 4-(methylnitrosamino)-1-(3-pyridul)-1-butanol (NNAL) (-55.9 ± 88.6 ng/ml, p < .001), carbon monoxide (-6.3 ± 8.6 ppm, p < .001), and self-reported respiratory symptoms (-3.3 ± 8.0, p = .002). No significant changes were found in blood pressure or spirometry. Greater substitution from cigarettes to e-cigarettes was associated with larger reductions in NNAL (r = -.29, p = .02). CONCLUSIONS: The predominant dual-use pattern was characterized by regular e-cigarette and intermittent cigarette use. Findings demonstrate the short-term harm reduction potential of this dual-use pattern in Black and Latino smokers and suggest that the greatest benefit, aside from cessation of both products, is achieved by higher substitution of e-cigarettes for cigarettes. Findings need confirmation in a larger sample with longer follow-up in dual users with greater variability in the rate of substitution. CLINICALTRIALS.GOV IDENTIFIER: NCT03511001. IMPLICATIONS: Findings suggest short-term harm reduction potential of dual cigarette-e-cigarette use for Black and Latino smokers. Results also demonstrate the heterogeneity of dual-use, with the greatest harm reduction seen in dual users with higher rates of substitution from cigarettes to e-cigarettes. Study results should be confirmed in a full clinical trial with long-term follow-up to evaluate maintenance of dual-use patterns and associated harm reduction potential over time.

Vape Shop Owners/Managers' Opinions About FDA Regulation of E-Cigarettes.

INTRODUCTION: In the United States, prominent sources of vaping products are specialty vape shops, which are subject to Food and Drug Administration (FDA) regulation. This study interviewed vape shop owners/managers to assess: (1) reasons for entering into or engaging in vape shop retail; (2) personnel training, particularly with regard to FDA and state regulations; and (3) how existing regulations are perceived and the anticipated impact of future regulation. AIMS AND METHODS: The current study involved phone-based semi-structured interviews of 45 vape shop owners/managers in six metropolitan statistical areas (Atlanta, Boston, Minneapolis, Oklahoma City, San Diego, and Seattle) during Summer 2018 as FDA regulations regarding minimum age verification, bans on product sampling, and health warnings (among others) were first being implemented. RESULTS: Vape shop owners/managers reported: (1) entering the industry with positive intentions for their customers, (2) training their personnel to adhere to regulations and provide good customer service, and (3) significant concerns about the impact of FDA regulations. With regard to the latter, participants reported mistrust of the intentions of the FDA regulations, financial implications of the regulations (particularly for small businesses), difficulty understanding and interpreting the regulations, insufficient evidence to support the regulations, negative impact on customer service, negative impact on product offerings and product innovation/advancement, and negative implications of flavor bans and/or restrictions on sale of flavors. CONCLUSIONS: These findings indicate the complexities in implementing tobacco regulations, particularly from the perspective of the vape shop industry. Current findings should inform future regulatory actions and efforts to assess compliance with regulations. IMPLICATIONS: Current and impending FDA regulation of vaping products present a critical period for examining regulatory impact on the vape shop industry. Current results indicated that many vape shop owners/managers reporting positive intentions for engaging in the vaping product industry and in training vape shop personnel to adhere to regulations. However, the majority reported concerns about FDA regulation and other state/local regulations that could have negative implications for their industry. Particular concerns include difficulty understanding the regulations due to complexity, vagueness, and changes in language and/or interpretation over time. These issues have implications for compliance that must be addressed.

Young Adults' Vaping, Readiness to Quit, and Recent Quit Attempts: The Role of Co-use With Cigarettes and Marijuana.

INTRODUCTION: E-cigarette cessation intervention research is limited. Young adult e-cigarette use and cessation is particularly nuanced, given various user profiles (ie, polytobacco use, co-use with marijuana) warranting different intervention approaches. METHODS: The current study is an analysis of baseline survey data (collected September-December 2018) among 1133 young adult (aged 18-34) e-cigarette users in a 2-year longitudinal study. We examined (1) e-cigarette user profiles (ie, e-cigarette only; e-cigarette/other tobacco; e-cigarette/marijuana; e-cigarette/other tobacco/marijuana) and (2) correlates of readiness to quit e-cigarette use in the next 6 months and past-year e-cigarette quit attempts. RESULTS: In this sample (Mage = 23.91, 47.3% male, 35.5% sexual minority, 75.2% White, 13.7% Hispanic), e-cigarette user profiles were as follows: 16.8% e-cigarettes-only, 23.4% e-cigarette/other tobacco, 18.0% e-cigarette/marijuana, and 41.8% e-cigarette/other tobacco/marijuana. Multinomial logistic regression (referent: e-cigarette-only use) indicated that all polyuse groups were more likely to use high-nicotine e-liquids (containing ≥9 mg of nicotine). Other predictors included e-cigarettes/other tobacco users being older and male; e-cigarettes/marijuana users using closed systems; and e-cigarettes/other tobacco/marijuana users being sexual minority (p's < .01). Readiness to quit e-cigarettes and past-year quit attempts were reported by 20.8% and 32.3%, respectively. Per multilevel regression, readiness to quit and quit attempts correlated with using fewer days, high-nicotine e-liquids, and closed systems, but not marijuana, as well as being heterosexual and Black (vs White); readiness to quit also correlated with being single; past-year quit attempts correlated with other tobacco use and being Hispanic. CONCLUSIONS: Young adult e-cigarette users demonstrate distinct user profiles and cessation-related experiences that should be considered in developing cessation interventions. IMPLICATIONS: The vast majority of young adult e-cigarette users use other tobacco products and marijuana. Unfortunately, few reported readiness to quit or attempting quit. Moreover, certain subgroups (eg, sexual/racial/ethnic minorities) are more likely to be ready or attempt to quit, but may not be successful. Vaping cessation interventions must attend to these nuances.

Exploring the Point-of-Sale Among Vape Shops Across the United States: Audits Integrating a Mystery Shopper Approach.

INTRODUCTION: Vape shops represent prominent, unique retailers, subject to Food and Drug Administration (FDA) regulation in the United States. AIMS AND METHODS: This study assessed compliance of US vape shop retail marketing strategies with new regulations (eg, required age verification, prohibited free samples) and pre-implementation conditions for other regulations (eg, health warning labels on all nicotine products, required disclosures of e-liquid contents). RESULTS: 95.0% of shops displayed minimum-age signage; however, mystery shoppers were asked for age verification at 35.6% upon entry and at 23.4% upon purchase. Although 85.5% of shops had some evidence of implementing FDA health warnings, 29.1% had signage indicating prohibited health claims, 16.3% offered free e-liquid samples, 27.4% had signage with cartoon imagery, and 33.3% were within two blocks of schools. All shops sold open-system devices, 64.8% sold closed-system devices, 68.2% sold their own brand of e-liquids, 42.5% sold e-liquids containing cannabidiol, 83.2% offered price promotions of some kind, and 89.9% had signage for product and price promotions. CONCLUSIONS: Results indicated that most shops complied with some implementation of FDA health warnings and with free sampling bans and minimum-age signage. Other findings indicated concerns related to underage access, health claims, promotional strategies, and cannabidiol product offerings, which call for further FDA and state regulatory/enforcement efforts.

Tool to assess appeal-aversion response to graphic warning labels on cigarette packs among US smokers.

INTRODUCTION: Graphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal-aversion assessment tool to help regulators choose among graphic packaging options. METHODS: After familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal-aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017-2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated. RESULTS: Among purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=-US$2.53, 95% CI: -US$2.76 to -US$2.31; teeth damage=-US$2.90, 95% CI: -US$3.17 to -US$2.63; and gangrenous foot=-US$3.70, 95% CI: -US$4.01 to -US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal-aversion valuations were moderated by sex, income and nicotine dependence (p<0.05). CONCLUSIONS: Smokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal-aversion tool could be useful for regulators to differentiate between graphic warning labels.

The Development of a Web-Based Tobacco Tracker Tool to Crowdsource Campus Environmental Reports for Smoke and Tobacco-Free College Policies: Mixed Methods Study.

BACKGROUND: College campuses in the United States have begun implementing smoke and tobacco-free policies to discourage the use of tobacco. Smoke and tobacco-free policies, however, are contingent upon effective policy enforcement. OBJECTIVE: This study aimed to develop an empirically derived web-based tracking tool (Tracker) for crowdsourcing campus environmental reports of tobacco use and waste to support smoke and tobacco-free college policies. METHODS: An exploratory sequential mixed methods approach was utilized to inform the development and evaluation of Tracker. In October 2018, three focus groups across 2 California universities were conducted and themes were analyzed, guiding Tracker development. After 1 year of implementation, users were asked in April 2020 to complete a survey about their experience. RESULTS: In the focus groups, two major themes emerged: barriers and facilitators to tool utilization. Further Tracker development was guided by focus group input to address these barriers (eg, information, policing, and logistical concerns) and facilitators (eg, environmental motivators and positive reinforcement). Amongst 1163 Tracker reports, those who completed the user survey (n=316) reported that the top motivations for using the tool had been having a cleaner environment (212/316, 79%) and health concerns (185/316, 69%). CONCLUSIONS: Environmental concerns, a motivator that emerged in focus groups, shaped Tracker's development and was cited by the majority of users surveyed as a top motivator for utilization.

"It is the One Thing that has Worked": facilitators and barriers to switching to nicotine salt pod system e-cigarettes among African American and Latinx people who smoke: a content analysis.

BACKGROUND: Electronic cigarettes are a harm reduction strategy for individuals who smoke cigarettes who cannot or do not want to quit using FDA-approved cessation methods. Identifying perceived facilitators and barriers to switching among people who smoke cigarettes is critical to optimizing health impact. This is particularly important for the most dominant e-cigarette device, nicotine salt pod electronic cigarettes. We investigate the experience using pod electronic cigarettes among African American and Latinx individuals who smoke, the two largest racial/ethnic minority groups who experience significant health disparities. METHODS: From July 2018 to May 2019, adults who smoked cigarettes, age 21 + (N = 114; M age = 44.6, 59.6% male, 52.6% African American from Kansas City, 47.4% Latinx from San Diego) received JUUL-brand electronic cigarettes (referred to hereafter as JUUL) for 6 weeks and answered interview questions at week six. We inquired what they liked and disliked about using JUUL, what helped with switching and made switching difficult, future intentions for continued JUUL use, and how JUUL compared to past smoking reduction methods. Responses were coded into themes by independent raters. Theme frequencies were analyzed separately by race/ethnicity and week 6 use trajectory (exclusive JUUL use, dual JUUL and cigarette use, exclusive cigarette use). RESULTS: Clean/smell was the aspect of using JUUL most commonly liked (23%), followed by convenience (19%). Coughing/harshness was a more common barrier to switching for African American (44%) than Latinx (9%), and for continuing cigarette use (56%) than for those who exclusively switched or dually used JUUL and combustible cigarettes (15-21%). Most (78% African American; 90% Latinx) reported that the benefits of using JUUL outweighed barriers, and this varied by JUUL use trajectory: 94% exclusive switch, 86% dual use, and 42% continued cigarette use. The majority said they would continue using JUUL to replace cigarettes (83% African American; 94% Latinx) and that JUUL worked better than other methods to reduce cigarettes (72%). CONCLUSION: African American and Latinx individuals who smoked experience using pod electronic cigarettes was generally positive. Understanding facilitators and impediments to switching to electronic cigarettes among racial/ethnic minority people who smoke can inform harm reduction interventions and reduce tobacco-related health disparities. Trial Registration ClinicalTrials.gov Identifier: NCT03511001 posted April 27, 2018.

Tobacco Consumption and Toxicant Exposure of Cigarette Smokers Using Electronic Cigarettes.

Background: There is considerable debate about the benefits and risks of electronic cigarettes (ECs). To better understand the risk-benefit ratio of ECs, more information is needed about net nicotine consumption and toxicant exposure of cigarette smokers switching to ECs. Methods: Forty cigarette smokers (≥1 year of smoking) interested in switching to ECs but not necessarily quitting smoking were enrolled in a 4-week observational study and provided an e-Go C non-variable battery and refillable atomizers and choice of eight flavors in 12 or 24 mg nicotine dosage. Measurement of urinary cotinine (metabolite of nicotine), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL; a pulmonary carcinogen), and eight volatile organic compounds (VOCs) that are toxic tobacco smoke constituents was conducted at baseline and week 4. Results: All participants with follow-up data (92.5%) reported using the study EC. Of the 40 smokers, 16 reported no cigarettes at week 2 (40%) and six continued to report no cigarettes at week 4 (15%). Change in nicotine intake over the 4 weeks was non-significant (p = .90). Carbon monoxide (p < .001), NNAL (p < .01) and metabolites of benzene (p < .01) and acrylonitrile (p = .001) were significantly decreased in the study sample. Smokers switching exclusively to ECs for at least half of the study period demonstrated significant reductions in metabolites of ethylene oxide (p = .03) and acrylamide (p < .01). Conclusion: Smokers using ECs over 4 weeks maintained cotinine levels and experienced significant reductions in carbon monoxide, NNAL, and two out of eight measured VOC metabolites. Those who switched exclusively to ECs for at least half of the study period significantly reduced two additional VOCs. Implications: This study extends current literature by measuring change in smoking dependence and disease-associated biomarkers, NNAL and a panel of eight common VOCs that are toxic tobacco smoke constituents in smokers who switch to ECs. The findings support the idea of harm reduction, however some levels of toxicant exposure are still of clinical concern, particularly for dual users. Extrapolation of these results must be careful to separate the different toxic exposure results for exclusive switchers versus dual cigarette + EC users, and not to equate harm reduction with the idea that using ECs is harmless.

Daily and Nondaily Smoking Varies by Acculturation among English-Speaking, US Latino Men and Women.

Background: Higher smoking prevalence and quantity (cigarettes per day) has been linked to acculturation in the United States among Latinas, but not Latino men. Our study examines variation between a different and increasingly important target behavior, smoking level (nondaily vs daily) and acculturation by sex. Methods: An online English-language survey was administered to 786 Latino smokers during July through August 2012. The Brief Acculturation Rating Scale for Mexican Americans-II (ARSMA-II) and other acculturation markers were used. Multinomial logistic regression models were implemented to assess the association between smoking levels (nondaily, light daily, and moderate/heavy daily) with acculturation markers. Results: Greater ARMSA-II scores (relative risk ratio, RRR=.81, 95% CI: .72-.91) and being born inside the United States (RRR=.42, 95% CI: .24-.74) were associated with lower relative risk of nondaily smoking. Greater Latino orientation (RRR=1.29, 95% CI: 1.11-1.48) and preference for Spanish language (RRR=1.06, 95% CI: 1.02-1.10) and media (RRR=1.12, 95% CI: 1.05-1.20) were associated with higher relative risk of nondaily smoking. The relationship between acculturation and smoking level did not differ by sex. Conclusion: This study found that among both male and female, English-speaking Latino smokers, nondaily smoking was associated with lower acculturation, while daily smoking was linked with higher acculturation.

Acculturative stress, mental health symptoms, and the role of salivary inflammatory markers among a Latino sample.

OBJECTIVES: Exposure to psychosocial stressors is associated with increases in adverse mental health outcomes and inflammatory markers. Limited research has investigated if acculturative stress, related to cultural adaptation in Latinos, one of the fastest growing minority groups in the United States, follows a similar pattern. This study hypothesized that acculturative stress would be associated with increased mental health symptoms as well as increases in salivary inflammatory markers. In addition, it was hypothesized that higher levels of salivary inflammatory markers would mediate the pathways between acculturative stress and mental health symptoms. The ability of salivary inflammatory markers to moderate the relationship between acculturative stress and mental health symptoms was also tested. METHOD: One hundred and fifty-four Latino participants were recruited from a local university. Participants completed measures of acculturative stress, perceived stress, state/trait anxiety, and depressive symptoms. Saliva samples measured C-reactive protein (CRP) and interleukin (IL)-1ß. RESULTS: Acculturative stress was significantly associated with increases in perceived stress, state/trait anxiety and depressive symptoms. Salivary inflammatory markers did not mediate the relationship between acculturative stress and mental health symptoms. Alternatively, CRP, but not IL-1ß, moderated the relationship between acculturative stress and state anxiety, such that when salivary CRP levels were low, there was a positive association between acculturative stress and state anxiety symptoms. DISCUSSION: Results suggests that the interplay between acculturative stress and salivary inflammation might indicate risk for anxiety in vulnerable populations. (PsycINFO Database Record

Tobacco use disparities by racial/ethnic groups: California compared to the United States.

Racial/ethnic disparities in cigarette use and cessation persist. This study compared cigarette consumption and former smoking trends in California (CA) with the rest of the United States (US) by racial/ethnic categories of non-Hispanic White, Black, Hispanic/Latino, and Asian/Pacific Islander groups. Data were analyzed from the 1992 to 2011 Tobacco Use Supplement to the Current Population Survey. Consumption levels across decades were examined and adjusted logistic regression models were fit to compare across CA and US. Results indicated steady declines in ever smoking prevalence for all groups with much lower magnitudes of change among US Blacks and Whites compared to their CA counterparts. After controlling for age, gender, and education, CA had significantly fewer heavy smokers (OR=0.45, 95% CI:0.38-0.54), more light and intermittent smokers (LITS; OR=1.68, 95%CI: 1.45-1.93), and a greater proportion of former smokers (OR=1.35, 95%CI: 1.24-1.48) than the rest of US. Data were stratified by race/ethnicity and the patterns shown were mostly consistent with CA performing statistically better than their US counterparts with the exception of Black LITS and Asian/Pacific Islander former smokers. California's success in reducing tobacco use disparities may serve as a prime example of tobacco control policy for the country. CA and the US will need to continue to address tobacco use and cessation in the context of the growing diversity of the population.

Distress tolerance is linked to unhealthy eating through pain catastrophizing.

Low distress tolerance, an important component of emotion regulation, is a risk factor for unhealthy eating. Identifying factors which explain the link between distress tolerance and unhealthy eating can advance the understanding of problematic eating and inform prevention and treatment of obesity and eating disorders. The present study examines pain catastrophizing as a mediator between distress tolerance and unhealthy eating in a nonclinical population, which has received little attention despite being a risk factor for unhealthy eating behaviors. The Distress Tolerance Scale (DTS), Pain Catastrophizing Scale (PCS), and the Dutch Eating Behavior Questionnaire (DEBQ), were administered to 171 college students (62.6% female, 38.6% White, 28.1% Hispanic). There was no evidence of a significant direct effect of distress tolerance on unhealthy eating. However, as hypothesized, there was a significant indirect or mediated effect of pain catastrophizing on the relationship between distress tolerance and unhealthy eating. Individuals low in distress tolerance reported higher pain catastrophizing, and a result, these individuals also reported higher levels of unhealthy eating. These findings introduce pain catastrophizing as an influential variable in the link between distress tolerance and unhealthy eating. Findings suggest that reducing catastrophic thinking about pain may be a worthy target of intervention in reducing unhealthy eating.

Light and intermittent smoking among California Black, Hispanic/Latino, and non-Hispanic White men and women.

INTRODUCTION: The prevalence of light and intermittent smoking (LITS) is increasing as the prevalence of heavier smoking continues to fall. The purpose of this study was to examine changes in LITS over time among Blacks, Hispanic/Latinos (Latinos) and non-Hispanic Whites (Whites). METHODS: Data from the California Tobacco Surveys from 1990, 1992, and 1996 (Time 1 [T1]) were combined and compared to combined data from 1999, 2002, 2005, and 2008 (Time 2 [T2]). T1 participants (N = 50,424) included Blacks (n = 3,029), Latinos (n = 7,910), and Whites (n = 39,485). T2 participants (N = 53,005) included Blacks (n = 5,460), Latinos (n = 14,273), and Whites (n = 33,246). RESULTS: LITS increased by a factor of 12.9% to a rate of 79.6% (76.0-83.2) among Latinos, by 19.4% to a rate of 74.4% (70.9-77.9) among Blacks, and by 51.7% to a rate of 48.9% (47.5-50.3) among Whites. In unadjusted analyses at T1, females were more likely to be LITS than males across ethnic groups. At T2, this sex difference was maintained among Whites, but not Blacks and Latinos. Females were significantly more likely to be LITS than males when controlling for demographic variables. CONCLUSIONS: The present study found that LITS rates increased over time for male and female Black, Latino and White adults. There is a need for increased tobacco control attention to LITS across all ethnic groups, but with additional focus on Blacks, Latinos, and women who have the highest rates of LITS.

Tobacco Use, Quitting Behavior, and Health Characteristics Among Current Electronic Cigarette Users in a National Tri-Ethnic Adult Stable Smoker Sample.

INTRODUCTION: The present study characterizes the tobacco use, quitting behaviors, and health characteristics of cigarette smokers who did not change their smoking pattern over the past 6 months and have used electronic cigarettes (ECs) in the past 30 days. This is an important subpopulation to characterize if EC dual use with cigarettes continues to grow. METHODS: Participants (N = 2,376) from a research survey panel completed an online cross-sectional survey between June and August 2012. Sampling was stratified to recruit equal numbers of cigarette smoking participants by race/ethnicity (Black, Hispanic, and Caucasian) and smoking frequency (nondaily and daily). All displayed a stable rate of smoking for the past 6 months and were not currently in treatment. Bivariate and multivariate analyses were used to examine correlates of current EC use (any use within the past 30 days). RESULTS: Current EC use was reported by 9.2% (n = 219) of the total sample. Of current EC users, 44% reported having used ECs as a quit method. Bivariate and multivariate analyses showed that current EC use was significantly associated with greater nicotine dependence, concurrent poly-tobacco use, more past-year quit attempts, past use of multiple cessation methods, and more depressive symptoms. No demographic variables were significantly associated with current EC use. CONCLUSIONS: This study suggests that stable smokers who currently use ECs possess characteristics that are associated with difficulty in achieving smoking cessation. These characteristics should be considered when examining the effectiveness of ECs on cessation and in designing future cessation trials using ECs.