Evaluating Correlations Between Premium Cigar Smoking and Mental Health and Substance Use Dependence Conditions Among U.S. Adults, 2010-2019.

INTRODUCTION: Improved understanding of health conditions associated with premium cigar smoking can inform efforts to reduce cigar use. This paper extends findings commissioned for the National Academies of Science, Engineering, and Medicine report on premium cigars. AIMS AND METHODS: We pooled 2010-2019 National Survey on Drug Use and Health data to evaluate cross-sectional associations between premium cigar smoking and mental health and substance use conditions among U.S. adults. A series of logistic regression models adjusted for age, sex, race and ethnicity, cigarette smoking, and alcohol consumption compared odds of each condition associated with past-month premium cigar smoking relative to past-month nonpremium cigar smoking, never tobacco use, and current established cigarette smoking. RESULTS: Premium cigar smoking was associated with lower adjusted odds of past month serious psychological distress, past year major depressive episode, and cannabis and illicit drug dependence relative to nonpremium cigar and cigarette smoking; however, higher odds of alcohol and cannabis dependence were observed relative to never tobacco use, and lower odds of alcohol dependence were observed relative to current cigarette smoking but not current nonpremium cigar smoking. CONCLUSIONS: We observed considerable variation in both magnitude and direction of associations between premium cigar smoking and mental health and substance use indicators depending on the condition and reference group to which premium cigar smoking was compared. IMPLICATIONS: Premium cigar smoking frequently cooccurs with cigarette smoking and alcohol consumption, thus potential health correlates must be considered in appropriate context. We observed considerable variation in direction and magnitude of association depending on the health condition and reference population, as well as potential for reverse causality and residual confounding in this cross-sectional analysis. As the tobacco landscape continues to evolve, rigorous scientific studies that incorporate clear differentiation of cigar type, measures of cumulative use, and temporal data collection are necessary to fully evaluate the health effects of premium cigar smoking and effectively inform Food and Drug Administration regulation.

Estimating Prevalence of Premium or Traditional Cigar Use and User Characteristics Based on Varying Definitions of Use.

BACKGROUND: Premium cigar use is infrequent compared with the use of other tobacco products, including other cigar types (eg, cigarillos), though current measurement methods for premium cigar use have limitations. Accordingly, prevalence estimates from existing surveillance studies likely underestimate the true prevalence of premium cigar use. AIMS AND METHODS: Using an online convenience sample of adults (ages 18-45 years) surveyed in February 2022, we examined premium or traditional cigar prevalence and characterized users based on four definitions of use: (1) past-year use, (2) past 30-day use, (3) use every day or some days, and (4) use every day, some days, or rarely, using a novel, one-item measure. We examined demographics, cigar use behaviors, and other tobacco product use for each definition and conducted sensitivity analyses using cigar brands. RESULTS: Prevalence estimates ranged from 1.8% using Definition 3 to 11.6% using Definition 1. Regardless of definition, premium or traditional cigar users were largely male, white, and aged 25-45 years. A large proportion of users based on Definition 3 were aged 25-34 years, had a regular premium cigar brand, smoked cigars on more than one day in the past month, used cannabis in the past month, and reported perceiving premium cigars as less harmful compared with cigarettes. DISCUSSION: Prevalence estimates of premium or traditional cigar use varied by more than fivefold based on the definition of use and user characteristics varied by definition. Existing national surveys are likely underestimating the prevalence and patterns of premium cigar use. IMPLICATIONS: Given that the negative health effects of premium cigars vary based on how the cigars are used (eg, frequency or duration), as well as co-use with other tobacco products and substances (eg, alcohol and cannabis), accurate measurement of these products is important for understanding patterns of use and their impact on public health.

Cross-sectional Use Patterns and Characteristics of Premium Versus Non-Premium Cigar Smokers in the United States, 2010-2019.

INTRODUCTION: Few studies have addressed the use patterns and characteristics of the past 30 days of premium versus non-premium cigar smokers. AIMS AND METHODS: We pooled 10 years of data from the National Survey on Drug Use and Health (NSDUH; 2010-2019) to evaluate use patterns and demographic and tobacco use characteristics of premium and non-premium cigar smokers ages 12 years and older in the U.S. cigar-type was manually coded as premium or non-premium according to the brand used most often. RESULTS: Between 2010 and 2019, 4.7% (95% CI = 4.6-4.8) of individuals aged 12 and older currently smoked cigars (past-30-day use). Smoking premium cigars (0.9% [95% CI = 0.8-0.9]) was less prevalent than smoking non-premium cigars (3.0% [95% CI = 2.9-3.1]). Although current non-premium cigar smoking prevalence steadily declined over the years, current premium cigar smoking prevalence remained stable. Premium cigar smokers were more likely to be older (≥25 years), male, non-Hispanic white, heterosexual, college educated, living in a large metro area, and to have income above 200% of the poverty threshold compared to non-premium users (p < .05). Additionally, past-30-day premium cigar smokers were less likely than non-premium users to initiate cigar smoking before the age of 18 years, smoke cigars frequently or daily, smoke cigarettes, or use marijuana (p < .05). CONCLUSIONS: Overall, premium cigar smoking is less prevalent than non-premium cigar smoking, especially among populations such as youth, racial/ethnic and sexual minorities, and low socioeconomic individuals. Premium cigar smokers tend to smoke infrequently and initiate cigars later in life compared with non-premium smokers. Study results can inform recommendations for regulating premium cigars. IMPLICATIONS: This study found that between 2010 and 2019, there are meaningful differences in the use patterns and characteristics of past-30-day premium versus non-premium cigar smokers in the United States. Premium cigars comprise a small share of the market compared to other cigar types and are less likely to be used by youth and other tobacco control priority groups (eg, racial/ethnic minorities and individuals with low socioeconomic statuses) that bear a disproportionate burden of risk and harm from using tobacco products. Additionally, most premium cigar users smoke them only occasionally. However, it is important to continue to monitor premium cigar use, as these patterns could shift because of factors like changes in marketing practices, consumer awareness, and product prices. Tobacco policy changes may also alter the patterns and trends of premium cigar use over time. A greater, more comprehensive understanding of premium cigars' physical characteristics, patterns of use, user perceptions, tobacco industry marketing strategies, and health effects will together help to inform cigar-related regulations.

Prevalence of Comorbidities and Polypharmacy in a Historically Minoritized Community and Their Impact on Virologic Suppression in Persons with HIV.

Improved life expectancy from advances in antiretroviral therapy (ART) has been followed by a rise in comorbidities and polypharmacy in this aging population. Historically, polypharmacy has been associated with suboptimal virologic outcomes in persons with HIV, although data in the current ART era and among historically marginalized populations in the United States are limited. We measured the prevalence of comorbidities and polypharmacy, evaluating their impact on virologic suppression. This retrospective IRB-approved cross-sectional study reviewed health records of adults with HIV on ART and receiving care (≥2 visits) in 2019 at a single center in a historically minoritized community. Virologic suppression (HIV RNA <200 copies/mL) based on polypharmacy (≥5 non-HIV medications) or multimorbidity (≥2 chronic conditions) was evaluated. Logistic regression analyses were performed to identify factors associated with virologic suppression, with age, race/ethnicity, and CD4 < 200 cells/mm3 as covariates. Of the 963 individuals that met the criteria, 67%, 47%, and 34% had ≥1 comorbidity, multimorbidity, and polypharmacy, respectively. The cohort demographics were: mean of 49 years (range, 18-81), 40% cisgender women, 46% Latinx individuals, 45% Black individuals, 8% White individuals. Virologic suppression rates were 95% among patients with polypharmacy compared with 86% in those with a lower pill burden (p = 0.0001). The odds of virologic success were higher for individuals with polypharmacy [adjusted odds ratio, aOR = 2.3 (95% confidence interval, CI: 1.2-4.4)] and Latinx identity [aOR = 2.4 (95% CI: 1.5-3.8)], but lower if a CD4 count <200 cells/mm3 [aOR = 0.07 (95% CI: 0.04-0.1)]. The comorbidity burden was higher than previously described, which are driving polypharmacy rates. In the current ART era, polypharmacy is not inherently associated with worse virologic outcomes.

Electronic Health Record Prompt to Improve Lung Cancer Screening in Primary Care.

INTRODUCTION: Lung cancer is the leading cause of cancer death in the U.S. Combusted tobacco use, the primary risk factor, accounts for 90% of all lung cancers. Early detection of lung cancer improves survival, yet lung cancer screening rates are much lower than those of other cancer screening tests. Electronic health record (EHR) systems are an underutilized tool that could improve screening rates. METHODS: This study was conducted in the Rutgers Robert Wood Johnson Medical Group, a university-affiliated network in New Brunswick, NJ. Two novel EHR workflow prompts were implemented on July 1, 2018. These prompts included fields to determine tobacco use and lung cancer screening eligibility and facilitated low-dose computed tomography ordering for eligible patients. The prompts were designed to improve tobacco use data entry, allowing for better lung cancer screening eligibility identification. Data were analyzed in 2022 retrospectively for the period July 1, 2017 to June 30, 2019. The analyses represented 48,704 total patient visits. RESULTS: The adjusted odds of patient record completeness to determine eligibility for low-dose computed tomography (AOR=1.19, 95% CI=1.15, 1.23), eligibility for low-dose computed tomography (AOR=1.59, 95% CI=1.38, 1.82), and whether low-dose computed tomography was ordered (AOR=1.04, 95% CI=1.01, 1.07) all significantly increased after the electronic medical record prompts were implemented. CONCLUSIONS: These findings show the utility and benefit of EHR prompts in primary care settings to increase identification for lung cancer screening eligibility as well as increased low-dose computed tomography ordering.

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.

US Physicians' Self-reported Discussions About Tobacco-Free Nicotine Pouches During Clinical Encounters With Patients in 2021.

This survey study assesses the extent to which physicians discussed tobacco-free nicotine pouches during clinical encounters with patients.

Perceptions about levels of harmful chemicals in e-cigarettes relative to cigarettes, and associations with relative e-cigarette harm perceptions, e-cigarette use and interest.

BACKGROUND AND AIMS: Exposure to chemicals contributes to harm from nicotine products, and e-cigarette communications often refer to chemicals. However, while e-cigarette studies commonly measure perceived harmfulness of e-cigarettes relative to cigarettes, few have assessed comparative perceptions about chemicals. This study measured perceived levels of harmful chemicals in e-cigarettes compared with cigarettes and associations with e-cigarette/cigarette relative harm perceptions, e-cigarette use and interest. DESIGN, SETTING AND PARTICIPANTS: This was an on-line cross-sectional survey of adults/young adults from a nationally representative research panel in the United States conducted in January 2021. Participants were independent samples of 1018 adults who smoked cigarettes and 1051 young adult non-smokers (aged 18-29 years). MEASUREMENTS: Participants were asked their perceptions of the level of harmful chemicals in e-cigarettes versus cigarettes (fewer/about the same/more/do not know), perceived harmfulness of using e-cigarette versus cigarettes (less/about the same/more/do not know) and their current e-cigarette use and use interest. FINDINGS: Approximately 20% of all participants (18.1% of adult smokers, and 21.0% of young adult non-smokers) believed e-cigarettes contain fewer harmful chemicals than cigarettes, while 35.6% of adult smokers and 24.9% of young adult non-smokers responded 'do not know'. Participants more frequently reported 'do not know' to the chemicals item than the harm item. Approximately half (51.0-55.7%) of those who believed e-cigarettes contain fewer harmful chemicals also believed e-cigarettes are less harmful than cigarettes. Both beliefs were associated with higher odds of interest in using e-cigarettes [less harmful belief, odds ratio (OR) = 5.53, 95% confidence interval (CI = 2.93-10.43); fewer chemicals belief, OR = 2.45, 95% CI = 1.40-4.29] and past 30-day e-cigarette use (less harmful belief, OR = 2.53, 95% CI = 1.17-5.44; fewer chemicals belief, OR = 5.09, 95% CI = 2.31-11.19) for adults who smoke, but not young adult non-smokers. CONCLUSIONS: In the United States, most adults who smoke cigarettes and young adult non-smokers do not appear to think that e-cigarettes have fewer harmful chemicals than cigarettes, and many are uncertain about how these levels compare.

A Pilot Feasibility Study of an Online Youth Tobacco Survey Administration among High School Students.

The COVID-19 pandemic restrictions forced many schools to shift to remote or hybrid learning, disrupting surveillance systems such as the New Jersey Youth Tobacco Survey, traditionally administered in schools by paper and pencil. In spring 2021, we conducted a feasibility study among a convenience sample of six public high schools to assess the use of an online survey to allow for remote participation. In each school, 4 to 6 classes were selected randomly, and all students within a sampled class were selected to participate in the survey. A total of 702 students completed surveys. School contacts were asked to provide qualitative feedback about the survey administration. Feedback was generally positive, with a few suggestions for improvement. Approximately 19% of students reported the ever use of e-cigarettes. Among current e-cigarette users, there was a shift in popularity from prefilled or refillable pods or cartridges (23.3%) to disposable e-cigarettes (53.5%). Less than 10% of current e-cigarette users reported using tobacco-flavored e-cigarettes, despite a statewide flavor ban on all other flavors.

Lung Cancer Screening Knowledge and Perceived Barriers Among Physicians in the United States.

Introduction: Lung cancer remains the leading cause of cancer death in the United States and has historically been detected late in its course. Low-dose computed tomography scan (LDCT) reduces lung cancer mortality by 20% and is currently recommended by clinical practice guidelines. However, compared with other cancer screening modalities, LDCT utilization remains low. This study surveyed office-based primary care physicians across the United States to better understand LDCT utilization. Methods: A total of 1500 family and internal medicine physicians selected from the American Medical Association's physician master file were surveyed between April and July 2019 regarding LDCT practices, eligibility, clinical scenarios, and perceived barriers. Results: The American Association for Public Opinion Research response rate 3 was 59% (652 respondents); 599 completed supplemental questions regarding lung cancer screening. A total of 88% of respondents discussed LDCT in the previous year, and 78% had ordered at least one LDCT. Most (59%) knew the tobacco exposure criteria for LDCT and correctly identified appropriate clinical scenarios (49%-86% responded correctly). Less than half of respondents correctly identified the age eligibility criteria (44%-45% responded correctly). In general, male physicians, those who graduated after 1990, and family medicine physicians were more likely to report accurate knowledge regarding LDCT eligibility. The top perceived barriers to LDCT were cost to the patient (48% identified as a major barrier), insurance not covering screening (46% major), and patients being unaware of lung cancer screening (40% major). Conclusion: Knowledge and practices about lung cancer screening are improving, though remain suboptimal. The most common barriers remain cost or insurance-based and suggest the need for a systems-based response to increase awareness and reduce the underutilization of LDCT.

Perceived effectiveness of cancer screening among family medicine and internal medicine physicians in the United States.

Family and internal medicine physicians play an important role in cancer screening, yet there are limited data on their beliefs regarding effectiveness of screening tests, which may affect physicians' likelihood to recommend such tests. The study purpose was to assess current beliefs among family medicine and internal medicine physicians regarding effectiveness of various types of cancer screening. A national sample of 582 physicians from the American Medical Association's Physician Masterfile were surveyed. Participants were asked about their perceived effectiveness of screening for colon, lung, breast, prostate, and cervical cancer among average, healthy individuals. Chi-square tests were conducted to assess relationships between perceiving screening tests to be 'very effective in reducing cancer-related mortality' and demographic characteristics. A substantial majority of physicians perceived colonoscopy (83.8%) and Pap smear (82.9%) to be very effective. Perceiving low-dose computed tomography (LDCT), Pap smear, and prostate-specific antigen (PSA) as 'very effective' differed by gender, with females less likely to endorse LDCT and Pap smear but more likely to endorse PSA. Perceiving PSA as 'very effective' differed by age and graduation year, with younger or more recently graduated physicians being less likely to perceive PSA as 'very effective'. Non-Hispanic Black/African-American physicians were more likely to perceive mammography as 'very effective' than other groups. Physicians' perceived effectiveness about cancer screening tests varies widely and may influence their recommendations or usage of these tests. Understanding physicians' beliefs can help in improving uptake of evidence-based screening tests by providers and patients to promote early detection and successful treatment.

Examining the Survey Setting Effect on Current E-Cigarette Use Estimates among High School Students in the 2021 National Youth Tobacco Survey.

The 2021 National Youth Tobacco Survey (NYTS) was completed by youth online during class time, either in school or at home due to the COVID-19 pandemic. Given the role of NYTS data in tobacco regulatory science, it is vital to understand the effect of survey settings (home, school) on tobacco-use estimates. We used a series of multivariable logistic regressions to examine whether survey settings (home vs. school) predicted current e-cigarette use among high school students, controlling for other known predictors of e-cigarette use as well as the pandemic learning model that was dominant in students' counties (e.g., nearly all at-home, majority in school). We observed a significant survey setting effect. Those who completed the survey in school had higher odds of current e-cigarette use than those who completed the same survey at home (AOR = 1.74); this effect was attenuated when we controlled for the pandemic learning model (AOR = 1.38). Moreover, e-cigarette use was independently associated with students' learning model; students whose schools were nearly entirely in-person had the highest odds of e-cigarette use compared to students whose learning model was nearly all at-home (AOR = 1.65). Survey setting is a methodological artifact in the 2021 NYTS. Perceived privacy and peer effects can potentially explain this artifact.

Communication Between US Physicians and Patients Regarding Electronic Cigarette Use.

Importance: Physicians play a primary role in patient smoking cessation, yet their communication regarding e-cigarettes is not well understood. Objective: To assess physician-patient communication regarding e-cigarettes. Design, Setting, and Participants: A national cross-sectional survey in 2018 and 2019 was conducted. Participants were invited by mail; surveys were completed online. Respondents were 2058 board-certified physicians from family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary, and oncology. Data were analyzed from August to September 2021. Exposures: Physician demographic characteristics, tobacco use, medical specialty, and harm-reduction beliefs (ie, not all tobacco products are equally harmful) applied within 2 hypothetical clinical scenarios. Main Outcomes and Measures: Physicians' self-reported e-cigarette communication (being asked about e-cigarettes by patients and recommending e-cigarettes to patients) and hypothetical e-cigarette communication in 2 clinical scenarios. Results: Among 2058 physicians, the mean (SD) age was 51.6 (10.5) years, and 1173 (58.5%) were male. More than 60% of physicians believed all tobacco products to be equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), and 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days). Pulmonologists (adjusted odds ratio [aOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (aOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (aOR, 1.77; 95% CI, 1.12-2.80), had greater odds of recommending e-cigarettes to patients. Physicians who endorsed a harm-reduction perspective (aOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (aOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Physicians who reported being asked about e-cigarettes had greater odds of recommending e-cigarettes (aOR, 16.60; 95% CI, 10.33-26.68). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older heavy smoker with multiple unsuccessful quit attempts (49.3%; 95% CI, 47.1%-51.4%) than a younger light smoker with no prior cessation treatments (15.2%; 95% CI, 13.6%-16.7%) (P < .001). Conclusions and Relevance: In this survey study of physicians, findings suggest that physicians may recommend switching to e-cigarettes for some patients who smoke cigarettes under certain circumstances, presumably for cessation. The belief that all tobacco products are equally harmful was associated with lower rates of recommending e-cigarettes. As the evidence base grows for e-cigarette efficacy for smoking cessation, there is need for physician education regarding e-cigarette efficacy.

The Impact of Varying Incentives on Physician Survey Response Rates: An experiment in the context of COVID-19.

Since 2018, our research team has fielded national, probability surveys of internal medicine physicians. We expected our usually high response rates to fall in the 2021 iteration of the survey due to challenges related to the COVID-19 pandemic and our inability to offer all participants a $50 upfront incentive as we had previously. To understand the independent impacts of the lower incentive and surveying physicians in the context of the pandemic, we fielded an experiment varying the incentive amount physicians were offered. Our results suggest that while higher incentives still lead to higher response rates during COVID-19, the higher incentive did not achieve comparable pre-COVID response rates. We conclude with additional data on the impact of the incentives on survey cost, number of reminders needed, and the mode in which respondents chose to complete the survey.

Examining the Impact of Question Construction on Reporting of Sexual Identity: Survey Experiment Among Young Adults.

BACKGROUND: Compared with heterosexuals, sexual minorities in the United States experience a higher incidence of negative physical and mental health outcomes. However, a variety of measurement challenges limit researchers' ability to conduct meaningful survey research to understand these disparities. Despite the prevalence of additional identities, many national health surveys only offer respondents 3 substantive options for reporting their sexual identities (straight/heterosexual, gay or lesbian, and bisexual), which could lead to measurement error via misreporting and item nonresponse. OBJECTIVE: This study compared the traditional 3-option approach to measuring sexual identity with an expanded approach that offered respondents 5 additional options. METHODS: An online survey experiment conducted among New Jersey residents between March and June 2021 randomly assigned 1254 young adults (ages 18-21) to answer either the 3-response measure of sexual identity or the expanded item. Response distributions for each measure were compared as were the odds of item nonresponse. RESULTS: The expanded version of the question appeared to result in more accurate reporting among some subgroups and induced less item nonresponse; 12% (77/642) of respondents in the expanded version selected a response that was not available in the shorter version. Females answering the expanded item were less likely to identify as gay or lesbian (2.1% [10/467] vs. 6.6% [30/457]). Females and Non-Hispanic Whites were slightly more likely to skip the shorter version than the longer version (1.1% [5/457 for females and 3/264 for Non-Hispanic Whites] vs. 0% [0/467 for females and 0/277 for Non-Hispanic Whites]). About 5% (32/642) of respondents answering the longer item were unsure of their sexual identity (a similar option was not available in the shorter version). Compared with respondents answering the longer version of the question, those answering the shorter version had substantially greater odds of skipping the question altogether (odds ratio 9.57, 95% CI 1.21-75.74; P=.03). CONCLUSIONS: Results favor the use of a longer, more detailed approach to measuring sexual identity in epidemiological research. Such a measure will likely allow researchers to produce more accurate estimates of health behaviors and outcomes among sexual minorities.

Persistent Misperceptions about Nicotine among US Physicians: Results from a Randomized Survey Experiment.

We conducted a survey experiment among US physicians to evaluate whether question wording impacted perceptions about the health effects of nicotine. 926 physicians were randomized to receive one of two versions of a question matrix that asked about the "extent to which they agree or disagree that 'nicotine' (Version 1) or 'nicotine, on its own,' (Version 2) directly contributes to" birth defects, cardiovascular disease (CVD), cancer, depression, and chronic obstructive pulmonary disease (COPD). We evaluated whether question condition predicted strong agreement and/or agreement with each statement, and assessed demographic correlates of each outcome while adjusting for question version. Physicians who received Version 2 were less likely to "strongly agree" that nicotine directly caused birth defects (Prevalence Ratio (PR) 0.84, 95% CI 0.72-0.98), CVD (PR 0.89, 95% CI 0.84-0.95), cancer (PR 0.81, 95% CI 0.75-0.87), and COPD (PR 0.78, 95% CI 0.72-0.84). Females were more likely to "strongly agree" that nicotine directly contributes to birth defects and cancer, and family physicians were most likely to "strongly agree" that nicotine directly contributes to CVD, cancer, and COPD. Question wording is important when measuring physicians' beliefs about nicotine; however, even after accounting for question version, misperceptions about the direct health effects of nicotine were common and varied by sex and specialty.

Toward a More Comprehensive Index of Youth Cigarette Smoking: Average Number of Cigarettes Smoked per Day among Students in the United States over Two Decades.

Reliance on 30-day prevalence as the principal means of assessing trends in youth cigarette smoking may understate the magnitude of the decrease in youth smoking, because prevalence does not account for smoking frequency or intensity. We analyzed Youth Risk Behavior Survey (YRBS) data from 1997 through 2017 and estimated cigarette smoking prevalence (any smoking in the previous 30 days), frequency (number of smoking days in the previous 30 days), and intensity (cigarettes per day on smoking days). We calculated average cigarettes smoked per day (ACSD) as the product of frequency and intensity, divided by 30. We estimated ACSD among all high school students and by smoking frequency group (i.e., 1-5, 6-9, 10-19, 20-29, or 30 of the previous 30 days), sex, grade level, and race/ethnicity. Among US high school students, ACSD declined by 86.7% from 1997 to 2017, while prevalence declined by 75.8%. Within smoking frequency groups, smoking intensity remained similar over the two decades. However, changes in ACSD over time varied by race/ethnicity; ACSD increased among Hispanic and non-Hispanic Black daily smokers while it decreased among daily smokers of other race/ethnicity groups. ACSD declined more substantially than smoking prevalence over two decades but remained virtually unchanged within smoking frequency groups, indicating that changes in frequency, rather than intensity, drove this decline. Prevalence estimates alone understate the degree to which youth in the United States have rejected smoking, and racial/ethnic disparities in smoking intensity are hidden when we limit our lens to prevalence-only measures.