Using Exogenous Social Media Exposure Measures to Assess the Effects of Smokeless Tobacco-Related Social Media Content on Smokeless Tobacco Sales in the United States.

INTRODUCTION: Prior research on the effects of social media promotion of tobacco products has predominantly relied on survey-based self-report measures of marketing exposure, which potentially introduce endogeneity, recall, and selection biases. New approaches can enhance measurement and help better understand the effects of exposure to tobacco-related messages in a dynamic social media marketing environment. We used geolocation-specific tweet rate as an exogenous indicator of exposure to smokeless tobacco (ST)-related content and employed this measure to examine the influence of social media marketing on ST sales. AIMS AND METHODS: Autoregressive error models were used to analyze the association between the ST-relevant tweet rate (aggregated by 4-week period from February 12, 2017 to June 26, 2021 and scaled by population density) and logarithmic ST unit sales across time by product type (newer, snus, conventional) in the United States, accounting for autocorrelated errors. Interrupted time series approach was used to control for policy change effects. RESULTS: ST product category-related tweet rates were associated with ST unit sales of newer and conventional products, controlling for price, relevant policy events, and the coronavirus disease 2019 (COVID-19) pandemic. On average, 100-unit increase in the number of newer ST-related tweets was associated with 14% increase in unit sales (RR = 1.14; p = .01); 100-unit increase in conventional ST tweets was associated with ~1% increase in unit sales (p = .04). Average price was negatively associated with the unit sales. CONCLUSIONS: Study findings reveal that ST social media tweet rate was related to increased ST consumption and illustrate the utility of exogenous measures in conceptualizing and assessing effects in the complex media environment. IMPLICATIONS: Tobacco control initiatives should include efforts to monitor the role of social media in promoting tobacco use. Surveillance of social media platforms is critical to monitor emerging tobacco product-related marketing strategies and promotional content reach. Exogenous measures of potential exposure to social media messages can supplement survey data to study media effects on tobacco consumption.

A Patchy Prohibition: Product and flavor substitution after the FDA's prioritized enforcement policy on flavored e-cigarettes.

INTRODUCTION: E-cigarettes have rapidly grown in use among US adolescents; in response, the FDA engaged in an "enforcement policy on banned e-cigarette flavors" ("enforcement action") for pod-based e-cigarettes in January 2020, which accounted for most US e-cigarette sales. No literature has yet examined long-term changes in e-cigarette sales patterns changed in relation to the FDA enforcement action. METHODS: We analyzed US e-cigarette sales using Nielsen retail scanner data between March 2017-December 2021, describing e-cigarette sales trends overall, by device type, and by flavor category. We also performed Joinpoint regression analysis on the sales trends to detect significant changes in the rate of change of sales over time. RESULTS: The FDA enforcement action was associated with a sharp initial decrease in prefilled pod dollar sales, followed by a steady increase from April 2020 through the end of 2021, growing beyond the previous maximum in August 2019. We also observed a dramatic change in the composition of flavors sold: a large decline in mint-flavored pod sales was offset by a similar increase in menthol-flavored sales. Simultaneously, disposable products sales increased nearly ten-fold from July 2019 to July 2020 before stabilizing, dominated by fruit-flavored products. CONCLUSIONS: Our findings suggest rapid product substitution without a long-term decline in e-cigarette sales in association with the enforcement action, along with a growing dominance of youth-friendly flavors, contrasting against FDA policy goals. Our study revealed the weakness of the "patchy" enforcement action, raising a concern of its unintended consequences as consumption simply shifted to other e-cigarette products. IMPLICATIONS: This is the first detailed longitudinal study on e-cigarette sales trends in the US following the FDA flavor enforcement action, with novel findings on flavor trends and their relation to policy events. We report sales overall, by product type, and by flavor category, and highlight several important trends following the action, such as the rise and persistence of disposable e-cigarettes increasingly and overwhelmingly dominated by youth-friendly flavors, and likely substitution of prefilled e-cigarette flavor without any long-term decline in sales. Our results highlight the weaknesses of "patchy" regulation and suggest the need for a more comprehensive approach to flavor regulation.

Associations between partisan media consumption, opioid use disorder stigma, and opioid policy support: An exploration of the media's role in the ongoing opioid epidemic.

We report on a preliminary investigation into the relationship between partisan media consumption (PMC) among U.S. adults and their (1) opioid use disorder (OUD) stigma, (2) national OUD policy support (e.g., Medicaid coverage for OUD treatment), (3) local OUD policy support (e.g., safe injection sites), (4) discriminatory OUD policies (e.g., denying housing), and (5) carceral OUD policies (e.g., jailing people who use opioids). We performed a cross-sectional survey of a nationally-representative sample of U.S. adults (n = 6,515) from October 1-November 19, 2021. We surveyed a sample of U.S. adults ages 18 and older drawn from NORC's AmeriSpeak® Panel. AmeriSpeak is a probability-based ongoing panel of over 40,000 households designed to represent the U.S. household population. Cross-sectional analyses revealed significant relationships between PMC and OUD stigma (b = 0.29, p <.001, CI95 = 0.14,0.43), support for national (b = -0.31, p <.01, CI95 = -0.54,-0.09) and local policy responses (b = -0.38, p <.001, CI95 = -0.59,-0.17), and support for discriminatory opioid use disorder policies (b = 0.27, p <.01, CI95 = 0.07,0.45). After controlling for self-reported political affiliation and other potential covariates, Republican-leaning media consumption was significantly associated with increased OUD stigma, less support for national and local harm reduction or rehabilitative policies, and more support for discriminatory policies against individuals experiencing OUD. The opposite associations were observed for Democratic-leaning media consumption. Markers for racism mediated the relationship between PMC and support for carceral policies (indirect path b = -0.41,p <.001, CI95 = -0.50,-0.31). Our results indicate that public health advocates must collaborate with conservative leaders to find bipartisan common ground for targeted communication campaigns.

A Safety Net Tobacco Use Cessation Resource: Quitline Service Usage, 2019.

INTRODUCTION: Quitlines are free, accessible evidence-based services that may provide an important resource for people facing barriers to clinical treatment for cessation of tobacco use. METHODS: Using 2019 intake data from the National Quitline Data Warehouse, we examined quitline service usage, stratified by sociodemographic characteristics. Only US quitlines reporting service type data were included (n = 40 [of 51]). Callers (aged ≥12 years) who registered with a quitline, reported current use of a tobacco product, and received at least 1 service comprised the analytic data. Chi-square tests examined differences in quitline services received by participant characteristics. RESULTS: In 2019, 182,544 people reporting current use of a tobacco product received at least 1 service from a quitline in 39 states and the District of Columbia. Among them, 80.4% had attained less than a college or university degree and 70.4% were uninsured or enrolled in Medicaid or in Medicare (aged <65 years). By educational attainment (aged ≥25 years), receipt of cessation medications ranged from 59.4% of callers with a college or university degree to 65.0% of callers with a high school diploma (P < .001). The range by insurance coverage was 59.3% of callers with private insurance to 74.7% of callers with Medicare (aged <65 years) (P < .001). CONCLUSION: Quitlines served as a resource for low-SES populations in 2019, providing cessation services to many people who may face barriers to clinical cessation treatment. Strengthening and expanding quitlines may help to increase cessation among populations with a disproportionately high prevalence of tobacco product use and improve the health and well-being of people in the US.

Bans on tobacco display, advertising and vending machines in the Netherlands: impact on visibility of tobacco and compliance of retailers.

INTRODUCTION: Visibility of tobacco products at retail tobacco outlets is associated with smoking initiation. To address this, across 2020-2022 the Netherlands banned tobacco product displays, advertisements and vending machines in the retail environment. Tobacco/vape specialist shops were exempted. This study assessed the impact of these policies on tobacco visibility in the retail environment and retailer compliance. METHODS: We conducted observational audits of all tobacco outlets in four Dutch cities (Amsterdam, Haarlem, Eindhoven and Zwolle) between 2019 and 2022 (before and after policy implementation), assessing visibility of tobacco products and advertisements, compliance and remaining sources of tobacco visibility (after implementation). We described results by location and outlet type. RESULTS: The number of tobacco outlets with any tobacco advertising or product visibility declined from 530 to 267 (-50%). Among outlets not exempt from the ban, the number with visibility declined from 449 to 172 (-62%), with lower postban visibility in petrol stations (12%) and supermarkets (6%) than small shops (47%). Visibility among tobacco/vape shops increased by 17%. Tobacco product displays remained the main source of visibility. 93% of tobacco vending machines were removed. Maps showed that non-compliance is concentrated in Amsterdam's city centre and more evenly distributed in other cities. CONCLUSION: The bans on tobacco display and tobacco advertising halved the visibility of tobacco in the retail environment, and the vending machine ban practically eradicated vending machines. To further reduce tobacco visibility, violations in small shops should be addressed and tobacco visibility should be regulated in currently exempt tobacco specialist shops.

Trends in Nicotine Strength in Electronic Cigarettes Sold in the United States by Flavor, Product Type, and Manufacturer, 2017-2022.

INTRODUCTION: Most e-cigarettes contain highly addictive nicotine. This study assessed trends in nicotine strength in e-cigarettes sold in the United States during January 2017-March 2022. AIMS AND METHODS: We obtained January 2017-March 2022 national retail e-cigarette sales data from NielsenIQ. We assessed monthly average nicotine strength overall, by e-cigarette product and flavor type, and manufacturer. A Joinpoint regression model assessed the magnitude and significance of changes in nicotine strength. RESULTS: During January 2017-March 2022, monthly average nicotine strength of e-cigarette products increased from 2.5% to 4.4%, an average of 0.8% per month (p < .001). Monthly average nicotine strength of disposable e-cigarettes increased the most (average monthly percentage change [AMPC] = 1.26%, p < .001) as compared to prefilled pods (AMPC = 0.6%, p < .001) and e-liquids (AMPC = 0.5%, p = .218). Monthly average nicotine strength for all flavors of e-cigarette products increased except for mint-flavored products. Increases were greatest for beverage-flavored products (AMPC = 2.1%, p < .001), followed by menthol-flavored products (AMPC = 1.2%, p < .001). Among the top 10 e-cigarette manufacturers assessed, monthly average nicotine strength decreased for Juul Labs products from 5% to 4.7% (AMPC = -0.1%, p < .001) but increased significantly for five manufacturers' products and remained unchanged at 5%-6% for four manufacturers' products. CONCLUSIONS: Monthly average nicotine strength of e-cigarette products increased overall, for most product and flavor types, and for some manufacturers in the United States during the study period. Imposing maximum limits on nicotine strength of e-cigarettes together with other evidence-based tobacco control strategies can help reduce the use of e-cigarettes among youth and increase tobacco product cessation among adults. IMPLICATIONS: From January 2017 to March 2022, the monthly average nicotine strength of disposable e-cigarettes increased substantially and exceeded prefilled pods since May 2020. E-cigarettes with menthol flavor and youth-appealing flavors, like fruit, also had sharp increases in monthly average nicotine strength. Among the top 10 e-cigarette manufacturers, monthly average nicotine strength increased or remained unchanged at a high nicotine level for all manufacturers' products, except Juul Lab's products. Comprehensive strategies including restricting sales of all flavored e-cigarettes, restricting youth tobacco product access, and imposing maximum limits on nicotine strength may help reduce youth e-cigarette use and increase tobacco cessation.

Changes in Sales of E-Cigarettes, Cigarettes, and Nicotine Replacement Therapy Products Before, During, and After the EVALI Outbreak.

INTRODUCTION: In 2019, an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in the US. We used Nielsen retail sales data to assess trends in sales of e-cigarettes, cigarettes, and nicotine replacement therapy (NRT) products before, during, and after the EVALI outbreak. METHODS: Monthly unit sales of e-cigarettes, cigarettes, and NRT products overall and by product type were assessed during January 2019 through June 2020 by using an interrupted time series model. Two time points were specified at the period ending July 13, 2019, and the period ending February 22, 2020, to partition before, during, and after the outbreak period. Sales trends by aggregated state-level EVALI case prevalence (low, medium, and high) were assessed to investigate interstate variations in changes of sales coinciding with the EVALI outbreak. RESULTS: Monthly e-cigarette sales increased 3.5% (P < .001) before the outbreak and decreased 3.1% (P < .001) during the outbreak, with no significant changes after the outbreak. Monthly cigarette sales increased 1.6% (P < .001) before the outbreak, decreased 1.8% (P < .001) during the outbreak, and increased 2.7% (P < .001) after the outbreak. NRT sales did not change significantly before or during the outbreak but decreased (2.8%, P = .01) after the outbreak. Sales trends by state-level EVALI case prevalence were similar to national-level sales trends. CONCLUSION: Cigarette and e-cigarette sales decreased during the EVALI outbreak, but no changes in overall NRT sales were observed until after the outbreak. Continued monitoring of tobacco sales data can provide insight into potential changes in use patterns and inform tobacco prevention and control efforts.

Promoting corporate image or preventing underage use? Analysis of the advertising strategy and expenditures of the JUUL parent education for youth vaping prevention campaign.

OBJECTIVE: In April 2018, JUUL Labs announced a $30 million investment in efforts to combat underage use of its products through 'independent research, youth and parent education and community engagement'. Prior evidence demonstrates that tobacco industry-funded prevention programmes are ineffective and may work against tobacco control efforts; they do not discourage novices and youth from tobacco use but often improve the tobacco industry's public image. We describe the nature, timing of and expenditures related to the JUUL underage use prevention advertisements across media channels. METHODS: Expenditures for newspaper, magazine, television, and radio marketing and promotional efforts were collected through Kantar Media's 'Stradegy' dashboard, an online platform which provides counts of advertisement occurrences and expenditures on various media channels. JUUL public relations and corporate social responsibility ads were identified in the Kantar Database. All ad expenditures were extracted and aggregated by date. Analysis of the expenditure data was triangulated with newspaper and industry advertisement archives. RESULTS: Advertisements aired nationally and in over half of all US-designated market areas (n=130) across media platforms including newspapers, magazines, radio, and online in mobile web and internet displays. In 2018, JUUL Labs spent $30 million, predominantly for print advertising. The 'What Parents Need to Know about JUUL' ads primarily advertised JUUL's smoking reduction 'mission' and promoted the product. By 2019, advertising increased to $36.2 million. JUUL's message strategy transitioned to 'Cracking Down on Underage Sales in Retail Stores' and featured adult smoker testimonies, linking JUUL to smoking cessation. DISCUSSION: Marketing expenditures promoting JUUL's corporate social responsibility mission exceeded their $30 million investment in the underage use prevention efforts. The expenditures were focused on the media market areas where health organisation and legislative officials were launching investigations into JUUL social media and other promotional strategies.

Daily Reports of Aggressive Behaviors in Interpersonal Conflicts.

Interpersonal conflicts are inevitable, but the probability that conflicts involve aggressive behavior varies. Prior research that has tended to focus on victimization in intimate partnerships reported through retrospective designs. Addressing these limitations, the current study examines daily reports of behaving aggressively in any conflict across relationships in a sample of 512 young adults drawn from the nationally representative iCOR cohort. Respondent attitudes and affective measures were collected at the end of the daily data collection period. Regression methods were applied to examine the probability and frequency of aggression, investigating early and recent exposure to adversities, attitudes, self-control, affect and emotional states, and alcohol use behavior. Recent adversities and the propensity to endorse a defensive honor code attitude, consistent with theory and retrospective studies of aggression, predicted both prevalence and frequency of aggressive behavior. The associations of childhood maltreatment and self-control with the prevalence of behaving aggressively were as expected, but these constructs were significantly associated with the frequency of aggression with unexpected, inverse directionality. Moreover, respondents' affect and other emotional states were only associated with the frequency, not the prevalence, of aggressive behavior. Overall, this daily data collection constructively distinguished risk and protective factors for behaving aggressively more often. Further research is needed to disentangle the extent to which affective states drive or is a consequence of frequent aggressive behavior.

Trends in Cigar Sales and Prices, by Product and Flavor Type-the United States, 2016-2020.

INTRODUCTION: Cigar smoking has increased in recent decades as the cigar product landscape has diversified. This study assessed trends in US cigar sales during 2016-2020. AIMS AND METHODS: Unit sales and average unit price for cigars were assessed during January 3, 2016-June 13, 2020, overall and by product and flavor type, for the 48 contiguous US states and D.C. Assessed cigar types were large cigars, little cigars, and cigarillos; assessed flavor types were tobacco/unflavored, candy/sweets, fruit, menthol, alcohol, coffee, other flavors, and no flavor stated. A joinpoint regression model was used to assess the magnitude and significance of sales trends. RESULTS: During January 3, 2016-June 13, 2020, unit sales of cigarillos increased (average monthly percentage change [AMPC] = 0.7%, p < .001), while unit sales of large cigars (AMPC = -0.8%, p < .001) and little cigars decreased (AMPC = -0.2%, p < .001). The average price of cigarillos gradually decreased since mid-August 2017 (AMPC = -0.1%, p < .001), and the average price of little cigars decreased from mid-June 2016 to mid-June 2019 (AMPC = -0.3%, p < .001). In contrast, the average price of large cigars increased during the entire study period (AMPC = 0.6%, p < .001). Irrespective of cigar type, tobacco-flavored/unflavored products were the most commonly sold cigars during the assessed period; however, sales of other flavors varied by cigar type. CONCLUSIONS: Cigar sales and price vary by type over time in the United States, including sales of cigarillos (94.2% of unit sales) increasing as their prices have decreased in recent years. Public health strategies are warranted to address the full scope of cigar types being used in the United States. IMPLICATIONS: Surveillance of cigar sales data, including product characteristics, can provide a timely complement to self-reported survey data of cigar use. This study assessed trends in US cigar sales during 2016-2020, including by product and flavor type. The findings indicate that sales of cigarillos, which comprise most cigar sales in the United States during the assessed period, increased as their prices decreased. Sales of certain flavors, such as candy/sweet cigarillos and coffee large cigars, increased significantly. These findings reinforce the importance of evidence-based strategies, including increasing price and restricting flavors, to reduce the affordability and consumption of cigars in the United States.