Use patterns of flavored non-cigarette tobacco products among US adults, 2010-2019.

OBJECTIVE: Flavored non-cigarette tobacco product (NCTP) use is common among US adult tobacco users. To update the estimates of use patterns of flavored NCTPs, this study assessed current NCTP use among adults by flavor use and flavor categories from 2010 to 2019. METHODS: We analyzed data from the 2010-2019 Tobacco Use Supplement to the Current Population Survey to estimate the weighted proportion of adult NCTP users by flavor use across survey waves. Flavor use was defined as past 30-day use of any menthol/mint or fruit/other flavors. We used the 2018-2019 data to examine the differences in demographic characteristics and tobacco use patterns among users of menthol/mint or fruit/other flavors compared to exclusive users of tobacco flavor, by product type. RESULTS: Compared to 2014-2015, electronic nicotine delivery system (ENDS) users were more likely (79.0% vs. 66.6%, p < 0.001) to report flavor use in 2018-2019, whereas cigar (26.9% vs. 31.2%, p = 0.030) and pipe (56.3% vs. 65.5%, p = 0.015) smokers were less likely to report flavor use in 2018-2019. In 2018-2019, the most prevalent flavor categories were exclusive use of tobacco flavor among cigar (73.1%) and smokeless tobacco (48.3%) users, and use of fruit/other flavors among ENDS (64.9%) and pipe (48.4%) users. Flavored users were more likely to be young adults aged 18-24 years (cigars, ENDS, smokeless tobacco) and Non-Hispanic Black or Hispanic persons (cigars, ENDS, pipes) compared to tobacco-flavored users. CONCLUSIONS: Flavored product use increased among adult ENDS users but decreased among cigar and pipe smokers. These findings could inform tobacco regulatory efforts concerning flavored NCTPs.

Characteristics and Patterns of Cigarette Smoking and Vaping By Past-Year Smokers Who Reported Using Electronic Nicotine Delivery System to Help Quit Smoking in the Past Year: Findings From the 2018-2019 Tobacco Use Supplement to the Current Population Survey.

INTRODUCTION: Cigarette smoking has declined, while electronic nicotine delivery system (ENDS) use has increased in the United States. Understanding the role of ENDS in adult smoking quit attempts and cessation is important for estimating their population health impact. AIMS AND METHODS: We used data from 2018 to 2019 tobacco use supplement to the current population survey to examine demographic characteristics and ENDS use patterns among adult ENDS users who reported quitting smoking in the past year by trying to switch to ENDS ("switchers") and smokers who did or did not make a quit attempt in the past year. χ2 tests of proportions and t-tests were used to compare characteristics between groups. RESULTS: In 2018-2019, about three-quarters of switchers reported daily use of ENDS compared to only one-third of dual users with a recent quit attempt by trying to switch to ENDS. Compared to dual users who made a quit attempt by trying to switch to ENDS, switchers were more likely to use menthol/mint-flavored ENDS exclusively (5.6% vs. 13.1%; p = .004) but less likely to use tobacco-flavored ENDS exclusively (21.2% vs. 13.7%; p = .01). CONCLUSIONS: ENDS users who quit smoking in the past year and reported trying to quit by switching to ENDS were more likely to use menthol/mint flavors exclusively and use ENDS daily compared to dual users who made a quit attempt by trying to switch to ENDS. Longer-term prospective data may better clarify the role of ENDS in smoking quit attempts and cessation. IMPLICATIONS: This study provides information on patterns of ENDS use in former smokers and current smokers who tried to quit smoking by switching to ENDS in a national sample of U.S. adults. These results can inform policy actions concerning ENDS products.

The contribution of smoking-attributable mortality to differences in mortality and life expectancy among US African-American and white adults, 2000-2019.

BACKGROUND: The role of smoking in racial disparities in mortality and life expectancy in the United States has been examined previously, but up-to-date estimates are generally unavailable, even though smoking prevalence has declined in recent decades. OBJECTIVE: We estimate the contribution of smoking-attributable mortality to observed differences in mortality and life expectancy for US African-American and white adults from 2000-2019. METHODS: The indirect Preston-Glei-Wilmoth method was used with national vital statistics and population data and nationally representative never-smoker lung cancer death rates to estimate the smoking-attributable fraction (SAF) of deaths in the United States by sex-race group from 2000-2019. Mortality rates without smoking-attributable mortality were used to estimate life expectancy at age 50 (e 50) by group during the period. RESULTS: African-American men had the highest estimated SAF during the period, beginning at 26.4% (95% CI:25.0%-27.8%) in 2000 and ending at 12.1% (95% CI:11.4%-12.8%) in 2019. The proportion of the difference in e 50 for white and African-American men that was due to smoking decreased from 27.7% to 14.8%. For African-American and white women, the estimated differences in e 50 without smoking-attributable mortality were similar to observed differences. CONCLUSIONS: Smoking continues to contribute to racial disparities in mortality and life expectancy among men in the United States. CONTRIBUTION: We present updated estimates of the contribution of smoking to mortality differences in the United States using nationally representative data sources.

Cigarette Smoking Reduction and Health Risks: A Systematic Review and Meta-analysis.

INTRODUCTION: Studies have shown the health benefits of cigarette smoking cessation. However, the literature remains unclear about the relationship between smoking reduction and health risks. This comprehensive review and meta-analysis updates previous reviews with the newest estimates. AIMS AND METHODS: We conducted a systematic review and meta-analysis evaluating the association between smoking reduction and some health risks in observational studies. We defined the following smoking categories: heavy smokers smoked ≥15-20 cigarettes per day (CPD), moderate smokers smoked 10-19 CPD, and light smokers smoked <10 CPD. The relative risks (RRs) and 95% confidence intervals (CIs) were estimated using random-effect models. RESULTS: We identified 19 studies including four case-control and 15 cohort studies. Compared with continuing heavy smokers, we found decreased lung cancer risk for those who reduced CPD by more than 50% (RR = 0.72, 95% CI: 0.52, 0.91), from heavy to moderate (RR = 0.66, 95% CI: 0.46, 0.85), and from heavy to light (RR = 0.60, 95% CI: 0.49, 0.72). We also found lower risk of cardiovascular disease (CVD) for those who reduced from heavy to light smoking (RR = 0.78, 95% CI: 0.67, 0.89) but not those who reduced by more than 50% and reduced smoking from heavy to moderate. We did not find any significant difference in all-cause mortality, all-cancer risks, and smoking-/tobacco-related cancer risk among those who reduced. CONCLUSIONS: Substantial smoking reduction may decrease lung cancer risk but results on CVD (coronary heart disease and stroke combined) risk were mixed. The relationships between smoking reduction and other endpoints examined were not significant. IMPLICATIONS: This meta-analysis helps clarify our understanding of various smoking reduction levels on some health risks. While smoking reduction may decrease risks of lung cancer, the relationships between smoking reduction and other endpoints, including all-cause mortality and cardiovascular disease, remain unclear. Although smoking reduction may decrease lung cancer risks, the magnitude of lung cancer risk remain high. Among smokers, complete cessation remains the most effective approach for cancer and CVD prevention.

Modeling mortality risk effects of cigarettes and smokeless tobacco: results from the National Health Interview Survey Linked Mortality File Data.

BACKGROUND: Cigarettes and smokeless tobacco (SLT) products are among a wide range of tobacco products that are addictive and pose a significant health risk. In this study, we estimated smoking- and SLT use-related mortality hazard ratios (HRs) among U.S. adults by sex, age group, and cause of death, for nine mutually exclusive categories of smoking and/or SLT use. METHODS: We used data from the public-use National Health Interview Survey Linked Mortality with mortality follow-up through 2015. We used Cox proportional hazard models to estimate mortality HRs, adjusted by race/ethnicity, education, poverty level, body mass index, and tobacco-use status. RESULTS: With never users as reference group, HRs for smoking-related diseases for male exclusive current smokers aged 35-64 and 65+ were 2.18 (95% confidence interval [CI]: 1.79-2.65), and 2.45 (95% CI: 2.14-2.79), respectively. Similar significant HR estimates were found for females and for all-cause mortality (ACM) and other-cause mortality (OCM) outcomes. HRs for exclusive current SLT users were only significant for males aged 35-64 for ACM (HR: 2.04, 95% CI: 1.27-3.27) and OCM (HR: 2.80, 95% CI: 1.50-5.25). HRs for users who switched from cigarettes to SLT products were significant for males aged 65+ for smoking-related diseases (HR: 2.06, 95% CI: 1.47-2.88), SLT-related diseases (HR: 1.99, 95% CI: 1.36-2.89), and ACM (HR: 1.63, 95% CI: 1.21-2.19). CONCLUSIONS: Male exclusive current SLT users aged 35-64 had a significant HR for ACM and OCM outcomes, suggesting that deaths not attributed to SLT use could be contributing to the ACM elevated HR for exclusive current SLT users.

Changes in Cigarettes per Day and Biomarkers of Exposure Among US Adult Smokers in the Population Assessment of Tobacco and Health Study Waves 1 and 2 (2013-2015).

INTRODUCTION: Some studies have found some reduction in tobacco exposure and tobacco-related disease risk with decreased numbers of cigarettes smoked per day (CPD), but biomarker of exposure estimates by change in CPD are generally unavailable for the US population. METHODS: We analyzed biomarker of exposure data by smoking status from over 1100 adult exclusive daily cigarette smokers in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study who were either exclusive daily smokers or had quit tobacco use entirely at Wave 2. Wave 1 smoking categories consisted of "very light" (1-4 CPD), "light" (5-9 CPD), "moderate" (10-19 CPD), and "heavy" (20+ CPD), and Wave 2 categories were "quitters" (stopped smoking entirely), exclusive cigarette "reducers" (CPD decreased ≥ 50%), "maintainers" (CPD within 50%-150% of Wave 1 value), and "increasers" (CPD increased ≥ 50%). RESULTS: Complete quitters had significantly lower levels of TNE-2, NNAL, NNN, 2-Fluorene, HPMA, CYMA, and MHB3 at Wave 2 for all Wave 1 CPD categories, and decreases were often large. Moderate "reducers" had lower levels of NNAL and 1-Hydroxypyrene at Wave 2, and heavy "reducers" had lower levels of NNAL, 2-Fluorene, and MHB3. Light "increasers" had higher levels of TNE-2, NNAL, 2-Fluorene, CYMA, and cadmium at Wave 2, and heavy "increasers" had higher levels of NNAL and HPMA. CONCLUSIONS: Smoking "reducers" and "increasers" had changes in some biomarker of tobacco exposure levels, but reductions were much greater and more consistent for complete quitters. IMPLICATIONS: PATH longitudinal cohort study data show that some exclusive daily cigarette smokers increase or decrease CPD over time. These differences may result in moderate changes in the levels of some biomarkers such as NNAL. Even so, however, reductions in biomarker levels are much greater with complete smoking cessation.

US Adult Cigar Smoking Patterns, Purchasing Behaviors, and Reasons for Use According to Cigar Type: Findings From the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014.

Introduction: The US cigar market is diverse, yet until recently most research studies and tobacco surveillance systems have not reported behavioral and related outcomes by cigar type. Methods: The 2013-2014 Population Assessment of Tobacco and Health Study collected data separately for filtered cigars (FCs), cigarillos, and traditional cigars, which were further distinguished as premium or nonpremium. Descriptive statistics for adult established current smokers of each cigar type and cigarettes were calculated for demographic characteristics, tobacco use patterns, purchasing behaviors and reasons for use. Adjusted prevalence ratios (APRs) using a marginal predictions approach with logistic regression assessed correlates of dual cigar and cigarette smoking. Results: Age, sex, race/ethnicity, education level, and poverty status of smokers varied according to cigar type. Daily cigar smoking prevalence and number of cigars smoked per day were higher for FCs (37.3%; median: 1.6 cigars/day, respectively), than all other cigar types (6.7%-25.3%, all p < .01; 0.1-0.4 cigars/day, all p < .01, respectively); daily smoking and cigars per day were similar for nonpremium cigars and cigarillos (p = .11; p = .33, respectively). Cigarette smoking was twice as common among smokers of nonpremium cigars, cigarillos, and FCs (58.0%-66.0%) than among premium cigars (29.9%). Among current cigar smokers, FC smokers (APR = 1.23, 95% confidence interval [CI] = 1.09-1.39), other tobacco product users (APR = 1.27, 95% CI = 1.15-1.41), and those with a GED/high school diploma or less (APR = 1.20, 95% CI = 1.09-1.33) were more likely to also smoke cigarettes. Conclusion: User characteristics, cigar smoking patterns, and dual smoking with cigarettes varied by cigar type highlighting the importance of adequately describing the cigar type studied and, where appropriate, differentiating results by cigar type. Implications: Despite the diversity of the cigar market place, historically many research studies and tobacco surveillance systems have treated cigars as a single product type. This study describes similarities and differences in the user characteristics, tobacco use patterns, and purchasing behaviors of premium, nonpremium, cigarillo, and filtered cigar smokers. To enhance tobacco regulatory science, sufficient descriptions of the cigar type(s) studied and, where appropriate, differentiation of the particular cigar type(s) studied should be undertaken to improve the interpretation of study findings, understanding of cigar use patterns and related behaviors and future approaches to reducing cigar-attributable morbidity and mortality.

Patterns of Use of Smokeless Tobacco in US Adults, 2013-2014.

OBJECTIVES: To examine patterns of smokeless tobacco (SLT) use, by type, in wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study in the United States. METHODS: We analyzed data from 32 320 adults (aged ≥ 18 years) to assess the use of pouched snus and other SLT products (loose snus, moist snuff, dip, spit, and chewing tobacco). RESULTS: Overall, SLT use was most common among men, younger adults, non-Hispanic Whites, and nonurban respondents. Pouched snus users were more likely to report nondaily and polytobacco use than users of other SLT products. Respondents who used SLT some days were more likely to be current established cigarette smokers than those who used SLT every day (57.9% vs 20.2%). Furthermore, current established smokers who used SLT some days were more likely to smoke every day and had a higher median number of cigarettes smoked per day than smokers who used SLT every day. CONCLUSIONS: Polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily snus use and polytobacco use than users of other SLT products.

Dependence symptoms and cessation intentions among US adult daily cigarette, cigar, and e-cigarette users, 2012-2013.

BACKGROUND: Cigar and e-cigarette use is becoming increasingly common among US tobacco users and the Food and Drug Administration recently asserted regulatory jurisdiction over these products, among others, in May 2016. Research on tobacco dependence among users of these products is limited, however. We therefore examined several symptoms of dependence and cessation intentions among adult cigarette, cigar, and/or e-cigarette users in a nationally representative sample. METHODS: We used nationally representative data from more than 60,000 participants in the US National Adult Tobacco Survey (NATS) from 2012 to 2013 to analyze dependence symptoms and cessation intentions for users of cigarettes, cigars, and/or e-cigarettes but not other tobacco products. RESULTS: Among daily tobacco users, dual cigarette and cigar users on average smoked more cigarettes per day (17.3, 95 % CI = 16.1, 18.6 vs. 15.8, 95 % CI = 15.4, 16.2), had shorter times to first tobacco use after waking (21.4 min, 95 % CI = 16.6, 24.9 vs. 25.9 min, 95 % CI = 25.3, 26.5), and were more likely to report withdrawal and craving symptoms than exclusive cigarette smokers. Dual cigarette and e-cigarette users were more likely than exclusive cigarette smokers to report withdrawal and craving symptoms and cessation intentions. Exclusive cigar and e-cigarette users were less likely to report withdrawal and craving symptoms than users of other products, but even so, more than a third of exclusive cigar (38.8 %, 95 % CI = 27.4 %, 51.6 %) and e-cigarette (46.1 %, 95 % CI = 35.1 %, 57.4 %) users reported experiencing a strong craving for a tobacco product in the past 30 days. CONCLUSIONS: Dual cigarette and cigar users show evidence of greater dependence symptoms and dual cigarette and e-cigarette users show evidence of greater dependence symptoms and cessation intentions compared with exclusive cigarette smokers. A sizeable number of users of all of the tobacco products report dependence symptoms such as craving for tobacco.

Systematic review of cigar smoking and all cause and smoking related mortality.

BACKGROUND: Cigars are a growing public health concern, given the changes in cigar use patterns in the US and elsewhere since the 1960s. We conducted a systematic review of published studies on current cigar smoking and all-cause and cause-specific mortality risks to inform potential regulatory approaches and future research that would strengthen the body of evidence. METHODS: Using 3 different databases and handsearching, we identified epidemiological studies published prior to June 2014 that examined the association between cigar smoking and all-cause mortality and smoking-related mortality. Detailed study characteristics as well as association-level characteristics, including effect estimates and 95% confidence intervals, were abstracted or calculated from each selected study. RESULTS: A total of 22 studies from 16 different prospective cohorts were identified. Primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, esophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease (CHD), and aortic aneurysm. Strong dose trends by cigars per day and inhalation level for primary cigar smoking were observed for oral, esophageal, laryngeal, and lung cancers. Among primary cigar smokers reporting no inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers. CONCLUSIONS: In summary, cigar smoking carries many of the same health risks as cigarette smoking. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level and can be as high as or exceed those of cigarette smoking. The body of evidence would be strengthened by future studies that focus on the health effects of primary cigar smoking and incorporate more contemporary and diverse study populations to better reflect the current patterns of cigar use in the US. Ideally, these studies would also collect detailed information on cigar type, exposure level, and biomarkers of exposure and potential harm.

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

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

Assessing the relationship between biomarkers of exposure and biomarkers of potential harm: PATH Study Wave 1 (2013-2014).

BACKGROUND: The adequacy of biomarkers of potential harm (BOPH) for assessing tobacco products was explored based on their ability to distinguish tobacco use from non-use, change with cessation, and to show biological gradient. METHODS: The sample included individuals with biomarker data in Wave 1 of the Population Assessment of Tobacco Health (PATH) Study who never used tobacco, currently smoke cigarettes exclusively, used to smoke cigarettes exclusively (quit in past 12 months), currently use smokeless tobacco exclusively, and currently use e-cigarettes exclusively. We compared BOPH levels between groups and assessed the relationships between log-transformed biomarkers of exposure (BOE) [Total Nicotine Equivalents including seven nicotine metabolites (TNE-7), 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanonol (NNAL), N-acetyl-S-(2-cyanoethyl)-L-cysteine (CYMA), 1-Hydroxypyrene (1-OHP), cadmium, and serum cotinine (SCOT)], and BOPH [high-sensitivity C-reactive protein (hs-CRP), interleukin-6 (IL-6), fibrinogen, soluble intercellular adhesion molecule-1 (sICAM-1) and 8-isoprostane]. RESULTS: Among people who smoke, both sICAM-1 and 8-isoprostane distinguished smoking from non-use and were associated with all six BOE. Among people who use smokeless tobacco, 8-isoprostane was associated with TNE-7 and NNAL whereas hs-CRP was associated with SCOT. Among people who use e-cigarettes, no associations between BOPH and BOE were observed. CONCLUSIONS: Both sICAM-1 and 8-isoprostane may be useful for assessing the use or changes in use of some tobacco products. Studies examining their predictive validity could further strengthen our understanding of these two biomarkers. IMPACT: We found that two BOPH, sICAM-1 and 8-isoprostane, may have utility in studies assessing the potential harm of tobacco use in absence of long-term epidemiological studies.

Validating Wave 1 (2014) Urinary Cotinine and TNE-2 Cut-points for Differentiating Wave 4 (2017) Cigarette Use from Non-use in the United States Using Data from the PATH Study.

BACKGROUND: Sex and racial/ethnic identity-specific cut-points for validating tobacco use using Wave 1 (W1) of the Population Assessment of Tobacco and Health (PATH) Study were published in 2020. The current study establishes predictive validity of the W1 (2014) urinary cotinine and total nicotine equivalents-2 (TNE-2) cut-points on estimating Wave 4 (W4; 2017) tobacco use. METHODS: For exclusive and polytobacco cigarette use, weighted prevalence estimates based on W4 self-report alone and with exceeding the W1 cut-point were calculated to identify the percentage missed without biochemical verification. Sensitivity and specificity of W1 cut-points on W4 self-reported tobacco use status were examined. ROC curves were used to determine the optimal W4 cut-points to distinguish past 30-day users from non-users, and evaluate whether the cut-points significantly differed from W1. RESULTS: Agreement between W4 self-reported use and exceeding the W1 cut-points was high overall and when stratified by demographic subgroups (0.7%-4.4% of use was missed if relying on self-report alone). The predictive validity of using the W1 cut-points to classify exclusive cigarette and polytobacco cigarette use at W4 was high (>90% sensitivity and specificity, except among polytobacco Hispanic smokers). Cut-points derived using W4 data did not significantly differ from the W1-derived cut-points [e.g., W1 exclusive = 40.5 ng/mL cotinine (95% confidence interval, CI: 26.1-62.8), W4 exclusive = 29.9 ng/mL cotinine (95% CI: 13.5-66.4)], among most demographic subgroups. CONCLUSIONS: The W1 cut-points remain valid for biochemical verification of self-reported tobacco use in W4. IMPACT: Findings from can be used in clinical and epidemiologic studies to reduce misclassification of cigarette smoking status.

Characteristics of Past 30-Day Cigar Smoking, U.S. Adolescents, 2020.

INTRODUCTION: Data from the 2019 National Youth Tobacco Survey indicated that cigars were the most commonly used combustible tobacco product in the past 30 days among youth. This study uses 2020 National Youth Tobacco Survey data to report the prevalence estimates and characteristics of current cigar use, overall and by cigar type, among middle- and high-school students in the U.S. METHODS: Weighted prevalence estimates and 95% CIs were calculated in 2020 for overall cigar use and by cigar type. RESULTS: In 2020, current cigar smoking was reported by 3.5% of students (1.5% middle school and 5.0% high school). Cigarillos (44.1%) were the most reported cigar type smoked, followed by regular (33.1%) and little (22.6%) cigars; 21.8% did not know the cigar type. Most cigar smokers were in high school (81.2%) and were male (52.4%), and 42.3% were non-Hispanic White. More than half of cigar smokers reported smoking flavored cigars (58.3%), with fruit (61.5%), candy/desserts/other sweets (34.0%), and mint (30.4%) as the most frequently reported flavor categories. Approximately 1 in 5 current cigar smokers (18.4%) smoked on ≥20 days in the past 30 days, and 78.8% reported multiple tobacco product use. CONCLUSIONS: Cigar smoking was highest among non-Hispanic Black and Hispanic youth. More than half of youth cigar smokers reported using flavored cigars, and most were also currently using other tobacco products. Cigarillos were the most reported cigar type used by youth, followed by regular cigars. These findings highlight the continued importance of youth tobacco use reduction strategies and can inform policy development.

Changes in Biomarkers of Tobacco Exposure among Cigarette Smokers Transitioning to ENDS Use: The Population Assessment of Tobacco and Health Study, 2013-2015.

Limited data are available for how biomarkers of tobacco exposure (BOE) change when cigarette smokers transition to using electronic nicotine delivery systems (ENDS). Using biomarker data from Waves 1 (2013-2014) and 2 (2014-2015) of the PATH Study, we examined how mean BOE concentrations, including metabolites of nicotine, tobacco-specific nitrosamines (TSNA), polycyclic aromatic hydrocarbons (PAH), and volatile organic compounds (VOC) and metals, changed when 2475 adult smokers transitioned to using ENDS or quit tobacco products. Exclusive smokers who transitioned to dual use had a significant decrease in NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol), but not nicotine metabolites, most PAHs, metals, or VOCs. Exclusive smokers who became dual users had significant reductions in total nicotine equivalents, NNAL, and 2CyEMA (acrylonitrile metabolite), but only in those who reduced cigarettes per day (CPD) by >=50%. Smokers who transitioned to exclusive ENDS use had significant reductions in most TSNAs, PAHs, and VOCs; however, nicotine metabolites did not decrease in dual users who became exclusive ENDS users. Smokers who quit tobacco use had significant decreases in nicotine metabolites, all TSNAs, most PAHs, and most VOCs. Cigarette smokers who became dual users did not experience significant reductions in most BOEs. Reductions were impacted by changes in CPD. However, transitioning from smoking to no tobacco or exclusive ENDS use was associated with reduced exposure to most BOEs measured. Future analyses could incorporate additional waves of PATH data and examine changes in biomarker exposure by ENDS device type and CPD.

Biomarkers of Inflammation and Oxidative Stress among Adult Former Smoker, Current E-Cigarette Users-Results from Wave 1 PATH Study.

BACKGROUND: Former smokers who currently use e-cigarettes have lower concentrations of biomarkers of tobacco toxicant exposure than current smokers. It is unclear whether tobacco toxicant exposure reductions may lead to health risk reductions. METHODS: We compared inflammatory biomarkers (high-sensitivity C-reactive protein, IL6, fibrinogen, soluble intercellular adhesion molecule-1) and an oxidative stress marker (F2-isoprostane) among 3,712 adult participants in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study by tobacco user groups: dual users of cigarettes and e-cigarettes; former smokers who currently use e-cigarettes-only; current cigarette-only smokers; former smokers who do not currently use any tobacco; and never tobacco users. We calculated geometric means (GM) and estimated adjusted GM ratios (GMR). RESULTS: Dual users experienced greater concentration of F2-isoprostane than current cigarette-only smokers [GMR 1.09 (95% confidence interval, CI, 1.03-1.15)]. Biomarkers were similar between former smokers who currently use e-cigarettes and both former smokers who do not use any tobacco and never tobacco users, but among these groups most biomarkers were lower than those of current cigarette-only smokers. The concentration of F2-isoprostane decreased by time since smoking cessation among both exclusive e-cigarette users (P trend = 0.03) and former smokers who do not currently use any tobacco (P trend = 0.0001). CONCLUSIONS: Dual users have greater concentration of F2-isoprostane than smokers. Exclusive e-cigarette users have biomarker concentrations that are similar to those of former smokers who do not currently use tobacco, and lower than those of exclusive cigarette smokers. IMPACT: This study contributes to an understanding of the health effects of e-cigarettes.

Urinary Cotinine and Cotinine + Trans-3'-Hydroxycotinine (TNE-2) Cut-points for Distinguishing Tobacco Use from Nonuse in the United States: PATH Study (2013-2014).

BACKGROUND: Determine the overall, sex-, and racially/ethnically-appropriate population-level cotinine and total nicotine equivalents (TNE-2, the molar sum of the two major nicotine metabolites) cut-points to distinguish tobacco users from nonusers across multiple definitions of use (e.g., exclusive vs. polytobacco, and daily vs. non-daily). METHODS: Using Wave 1 (2013-2014) of the U.S. Population Assessment of Tobacco and Health (PATH) Study, we conducted weighted Receiver Operating Characteristic (ROC) analysis to determine the optimal urinary cotinine and TNE-2 cut-points, stratified by sex and race/ethnicity. RESULTS: For past 30-day exclusive cigarette users, the cotinine cut-point that distinguished them from nonusers was 40.5 ng/mL, with considerable variation by sex (male: 22.2 ng/mL; female: 43.1 ng/mL) and between racial/ethnic groups (non-Hispanic other: 5.2 ng/mL; non-Hispanic black: 297.0 ng/mL). A similar, but attenuated, pattern emerged when assessing polytobacco cigarette users (overall cut-point = 39.1 ng/mL, range = 5.5 ng/mL-80.4 ng/mL) and any tobacco users (overall cut-point = 39.1 ng/mL, range = 4.8 ng/mL-40.0 ng/mL). Using TNE-2, which is less impacted by racial differences in nicotine metabolism, produced a comparable pattern of results although reduced the range magnitude. CONCLUSIONS: Because of similar frequency of cigarette use among polytobacco users, overall cut-points for exclusive cigarette use were not substantially different from cut-points that included polytobacco cigarette use or any tobacco use. Results revealed important differences in sex and race/ethnicity appropriate cut-points when evaluating tobacco use status and established novel urinary TNE-2 cut-points. IMPACT: These cut-points may be used for biochemical verification of self-reported tobacco use in epidemiologic studies and clinical trials.