Differences in price of flavoured and non-flavoured tobacco products sold in the USA, 2011-2016.

BACKGROUND: Limited data exist on whether there is differential pricing of flavoured and non-flavoured varieties of the same product type. We assessed price of tobacco products by flavour type. METHODS: Retail scanner data from Nielsen were obtained for October 2011 to January 2016. Universal product codes were used to classify tobacco product (cigarettes, roll-your-own cigarettes (RYO), little cigars and moist snuff) flavours as: menthol, flavoured or non-flavoured. Prices were standardised to a cigarette pack (20 cigarette sticks) or cigarette pack equivalent (CPE). Average prices during 2015 were calculated overall and by flavour designation. Joinpoint regression and average monthly percentage change were used to assess trends. RESULTS: During October 2011 to January 2016, price trends increased for menthol (the only flavour allowed in cigarettes) and non-flavoured cigarettes; decreased for menthol, flavoured and non-flavoured RYO; increased for flavoured little cigars, but decreased for non-flavoured and menthol little cigars; and increased for menthol and non-flavoured moist snuff, but decreased for flavoured moist snuff. In 2015, average national prices were US$5.52 and US$5.47 for menthol and non-flavoured cigarettes; US$1.89, US$2.51 and US$4.77 for menthol, non-flavoured and flavoured little cigars; US$1.49, US$1.64 and US$1.78 per CPE for menthol, non-flavoured and flavoured moist snuff; and US$0.93, US$1.03 and $1.64 per CPE flavoured, menthol and non-flavoured RYO, respectively. CONCLUSION: Trends in the price of tobacco products varied across products and flavour types. Menthol little cigars, moist snuff and RYO were less expensive than non-flavoured varieties. Efforts to make flavoured tobacco products less accessible and less affordable could help reduce tobacco product use.

Socioeconomic Differences in Cigarette Smoking Among Sociodemographic Groups.

We examined variations in cigarette smoking by socioeconomic status (education and poverty status) in relation to population sociodemographic characteristics (age, race/ethnicity, region and sex). We analyzed data from a nationally representative sample of US adults by using combined data from the National Survey on Drug Use and Health (2011-2014). Low socioeconomic status was generally associated with increased cigarette smoking prevalence by age, race/ethnicity, and region, irrespective of sex. The only exceptions were for Asian and Hispanic women, where low educational attainment was not associated with a high prevalence of cigarette smoking, and among Hispanic men and Asian women, where there was no association between poverty status and smoking. Efforts to reach smokers of low socioeconomic status by using proven tobacco control strategies could reduce disparities in cigarette smoking and smoking-related disease and death.

Social and Physical Environmental Characteristics Associated With Adult Current Cigarette Smoking.

INTRODUCTION: Our objective was to identify social and physical environmental factors associated with current cigarette smoking among adults by metropolitan county in the United States. METHODS: We linked cigarette smoking data from the 2012 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan Area Risk Trends (SMART) data set to 7 social and physical environmental characteristics: county type (metropolitan designation), primary care physician density, income inequality, percentage of the population that was a racial/ethnic minority, violent crime rate, education, and percentage of county residents with low income and no health insurance, all obtained from several county data sets. Spatial regression and hierarchical logistic regression modeling were performed. RESULTS: Results showed that metropolitan counties with a high proportion of non-Hispanic white adults (P < .001), lower education levels (high school graduate or less) (P < .001), and high violent crime rates (P < .001) had a higher adult cigarette smoking prevalence than other metropolitan counties. Spatial models showed 63.3% of the variability in county cigarette smoking prevalence was explained by these 3 factors as well as county type (based on population size of the of metropolitan area), primary care physician density, and percentage of county residents with low income and no health insurance. At an individual level, results showed that as the density (population) of primary care physicians increased in a county, the odds of being a current smoker decreased (OR, 0.980; P = .02). CONCLUSION: We found a significant association between adult cigarette smoking and county social and physical environmental factors. These place-based factors, especially social environmental characteristics, may reveal tobacco-related disparities to be considered when developing strategies to reduce tobacco use.

Utility of Using Cancer Registry Data to Identify Patients for Tobacco Treatment Trials.

BACKGROUND: Many tobacco dependent cancer survivors continue to smoke after diagnosis and treatment. This study investigated the extent to which hospital-based cancer registries could be used to identify smokers in order to offer them assistance in quitting. The concordance of tobacco use coded in the registry was compared with tobacco use as coded in the accompanying Electronic Health Records (EHRs). METHODS: We gathered data from three hospital-based cancer registries in New York City during June 2014 to December 2016. For each patient identified as a current combustible tobacco user in the cancer registries, we abstracted tobacco use data from their EHR to independently code and corroborate smoking status. We calculated the proportion of current smokers, former smokers, and never smokers as indicated in the EHR for the hospitals, cancer site, cancer stage, and sex. We used a logistic regression model to estimate the log odds of the registry-based smoking status correctly predicting the EHR-based smoking status. RESULTS: Agreement in current smoking status between the registry-based smoking status and the EHR-based smoking status was 65%, 71%, and 90% at the three participating hospitals. Logistic regression results indicated that agreement in smoking status between the registry and the EHRs varied by hospital, cancer type, and stage, but not by age and sex. CONCLUSIONS: The utility of using tobacco use data in cancer registries for population-based tobacco treatment interventions is dependent on multiple factors including accurate entry into EHR systems, updated data, and consistent smoking status definitions and registry coding protocols. Our study found that accuracy varied across the three hospitals and may not be able to inform interventions at these hospitals at this time. Several changes may be needed to improve the coding of tobacco use status in EHRs and registries.

Prevalence and Disparities in Tobacco Product Use Among American Indians/Alaska Natives - United States, 2010-2015.

An overarching goal of Healthy People 2020 is to achieve health equity, eliminate disparities, and improve health among all groups.* Although significant progress has been made in reducing overall commercial tobacco product use,† disparities persist, with American Indians or Alaska Natives (AI/ANs) having one of the highest prevalences of cigarette smoking among all racial/ethnic groups (1,2). Variations in cigarette smoking among AI/ANs have been documented by sex and geographic location (3), but not by other sociodemographic characteristics. Furthermore, few data exist on use of tobacco products other than cigarettes among AI/ANs (4). CDC analyzed self-reported current (past 30-day) use of five tobacco product types among AI/AN adults from the 2010-2015 National Survey on Drug Use and Health (NSDUH); results were compared with six other racial/ethnic groups (Hispanic; non-Hispanic white [white]; non-Hispanic black [black]; non-Hispanic Native Hawaiian or other Pacific Islander [NHOPI]; non-Hispanic Asian [Asian]; and non-Hispanic multirace [multirace]). Prevalence of current tobacco product use was significantly higher among AI/ANs than among non-AI/ANs combined for any tobacco product, cigarettes, roll-your-own tobacco, pipes, and smokeless tobacco. Among AI/ANs, prevalence of current use of any tobacco product was higher among males, persons aged 18-25 years, those with less than a high school diploma, those with annual family income <$20,000, those who lived below the federal poverty level, and those who were never married. Addressing the social determinants of health and providing evidence-based, population-level, and culturally appropriate tobacco control interventions could help reduce tobacco product use and eliminate disparities in tobacco product use among AI/ANs (1).

Disparities in Adult Cigarette Smoking - United States, 2002-2005 and 2010-2013.

Although cigarette smoking has substantially declined since the release of the 1964 Surgeon General's report on smoking and health,* disparities in tobacco use exist among racial/ethnic populations (1). Moreover, because estimates of U.S. adult cigarette smoking and tobacco use are usually limited to aggregate racial or ethnic population categories (i.e., non-Hispanic whites [whites]; non-Hispanic blacks or African Americans [blacks]; American Indians and Alaska Natives [American Indians/Alaska Natives]; Asians; Native Hawaiians or Pacific Islanders [Native Hawaiians/Pacific Islanders]; and Hispanics/Latinos [Hispanics]), these estimates can mask differences in cigarette smoking prevalence among subgroups of these populations. To assess the prevalence of and changes in cigarette smoking among persons aged ≥18 years in six racial/ethnic populations and 10 select subgroups in the United States,(†) CDC analyzed self-reported data collected during 2002-2005 and 2010-2013 from the National Survey on Drug Use and Health (NSDUH) (2) and compared differences between the two periods. During 2010-2013, the overall prevalence of cigarette smoking among the racial/ethnic populations and subgroups ranged from 38.9% for American Indians/Alaska Natives to 7.6% for both Chinese and Asian Indians. During 2010-2013, although cigarette smoking prevalence was relatively low among Asians overall (10.9%) compared with whites (24.9%), wide within-group differences in smoking prevalence existed among Asian subgroups, from 7.6% among both Chinese and Asian Indians to 20.0% among Koreans. Similarly, among Hispanics, the overall prevalence of current cigarette smoking was 19.9%; however, within Hispanic subgroups, prevalences ranged from 15.6% among Central/South Americans to 28.5% among Puerto Ricans. The overall prevalence of cigarette smoking was higher among men than among women during both 2002-2005 (30.0% men versus 23.9% women) and 2010-2013 (26.4% versus 21.1%) (p<0.05). These findings highlight the importance of disaggregating tobacco use estimates within broad racial/ethnic population categories to better understand and address disparities in tobacco use among U.S. adults.

The African American Youth Smoking Experience: An Overview.

INTRODUCTION: Beginning in the late 1970s, a very sharp decline in cigarette smoking prevalence was observed among African American (AA) high school seniors compared with a more modest decline among whites. This historic decline resulted in a lower prevalence of cigarette smoking among AA youth that has persisted for several decades. METHODS: We synthesized information contained in the research literature and tobacco industry documents to provide an account of past influences on cigarette smoking behavior among AA youth to help understand the reasons for these historically lower rates of cigarette smoking. RESULTS: While a number of protective factors including cigarette price increases, religiosity, parental opposition, sports participation, body image, and negative attitudes towards cigarette smoking may have all played a role in maintaining lower rates of cigarette smoking among AA youth as compared to white youth, the efforts of the tobacco industry seem to have prevented the effectiveness of these factors from carrying over into adulthood. CONCLUSION: Continuing public health efforts that prevent cigarette smoking initiation and maintain lower cigarette smoking rates among AA youth throughout adulthood have the potential to help reduce the negative health consequences of smoking in this population. IMPLICATIONS: While AA youth continue to have a lower prevalence of cigarette smoking than white youth, they are still at risk of increasing their smoking behavior due to aggressive targeted marketing by the tobacco industry. Because AAs suffer disproportionately from tobacco-related disease, and have higher incidence and mortality rates from lung cancer, efforts to prevent smoking initiation and maintain lower cigarette smoking rates among AA youth have the potential to significantly lower lung cancer death rates among AA adults.

Disparities in Smoking-Related Mortality Among American Indians/Alaska Natives.

INTRODUCTION: Smoking-related disparities continue to be a public health problem among American Indian/Alaska Native (AI/AN) population groups and data documenting the health burden of smoking in this population are sparse. The purpose of this study was to assess mortality attributable to cigarette smoking among AI/AN adults relative to non-Hispanic white adults (whites) by calculating and comparing smoking-attributable fractions and mortality. METHODS: Smoking-attributable fractions and mortality among AI/ANs (n=1.63 million AI/ANs) and whites were calculated for people living in 637 Indian Health Service Contract Health Service Delivery Area counties in the U.S., from mortality data collected during 2001-2009. Differences in smoking-attributable mortality between AI/ANs and whites for five major causes of smoking-related deaths were examined. All data analyses were carried out in 2013-2014. RESULTS: Overall, from 2001 to 2009, age-adjusted death rates, smoking-attributable fractions, and smoking-attributable mortality for all-cause mortality were higher among AI/ANs than among whites for adult men and women aged ≥35 years. Smoking caused 21% of ischemic heart disease, 15% of other heart disease, and 17% of stroke deaths in AI/AN men, compared with 15%, 10%, and 9%, respectively, for white men. Among AI/AN women, smoking caused 18% of ischemic heart disease deaths, 13% of other heart diseases deaths, and 20% of stroke deaths, compared with 9%, 7%, and 10%, respectively, among white women. CONCLUSIONS: These findings underscore the need for comprehensive tobacco control and prevention efforts that can effectively reach and impact the AI/AN population to prevent and reduce smoking.

Vital signs: disparities in nonsmokers' exposure to secondhand smoke--United States, 1999-2012.

Exposure to secondhand smoke (SHS) from burning tobacco products causes sudden infant death syndrome (SIDS), respiratory infections, ear infections, and asthma attacks in infants and children, and coronary heart disease, stroke, and lung cancer in adult nonsmokers. No risk-free level of SHS exposure exists. SHS exposure causes more than 41,000 deaths among nonsmoking adults and 400 deaths in infants each year, and approximately $5.6 billion annually in lost productivity. Although population exposure to SHS has declined over the past 2 decades, many nonsmokers remain exposed to SHS in workplaces, public places, homes, and vehicles.

Addressing the Social Determinants of Health to Reduce Tobacco-Related Disparities.

INTRODUCTION: Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smokings (e.g., those with lower education and incomes). METHODS: Education and income are the 2 main social determinants of health that negatively impact health. However, there are other social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This article will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control. RESULTS: Tobacco control policy interventions can be effective in addressing the social determinants of health in tobacco prevention and control to achieve equity and eliminate tobacco-related disparities when they are implemented consistently and equitably across all population groups. CONCLUSIONS: Taking a social determinants of health approach in tobacco prevention and control will be necessary to achieve equity and eliminate tobacco-related disparities.

Cigarette smoking - United States, 2006-2008 and 2009-2010.

Cigarette smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 443,000 deaths and $193 billion in direct health-care expenditures and productivity losses each year. Declines in smoking prevalence would significantly impact the health-care and economic costs of smoking. Efforts to accelerate the decline in cigarette smoking include reducing cigarette smoking disparities among specific population groups. Findings from the previous report on cigarette use in the first CDC Health Disparities and Inequalities Report (CHDIR) indicated that progress has been achieved in reducing disparities in cigarette smoking among certain racial/ethnic groups. However, little progress has been made in reducing disparities in cigarette smoking among persons of low socioeconomic status (SES) and low educational attainment.

The role of menthol in cigarettes as a reinforcer of smoking behavior.

INTRODUCTION: The World Health Organization has identified several additives such as menthol in the manufacturing of cigarettes to specifically reduce smoke harshness. These additives may have important implications for reinforcing smoking behavior and motivation to quit smoking. The purpose of this paper is to synthesize research related to the role of menthol's sensory characteristics in strengthening the reinforcing effects of nicotine in cigarettes and the impact on nicotine addiction and smoking behavior. METHODS: Research reports from 2002 to 2010 on the addictive potential of menthol cigarettes were reviewed that included qualitative focus groups, self-reports and biomarkers of nicotine dependence, human laboratory, and epidemiological studies. RESULTS: Positive sensory effects of menthol cigarette use were identified via reports of early smoking experiences and as a potential starter product for smoking uptake in youth. Menthol cigarettes may serve as a conditioned stimulus that reinforces the rewarding effects of smoking. Nicotine dependence measured by shorter time-to-first cigarette upon waking was increased with menthol cigarette use in most of the studies reviewed. Smoking quit rates provide additional indicators of nicotine dependence, and the majority of the studies reviewed provided evidence of lower quit rates or higher relapse rates among menthol cigarette smokers. CONCLUSIONS: The effects of menthol cigarette use in increasing the reinforcing effects of nicotine on smoking behavior were evidenced in both qualitative and quantitative empirical studies. These findings have implications for enhanced prevention and cessation efforts in menthol smokers.

Perceptions of menthol cigarette use among U.S. adults and adult smokers: findings from the 2009 HealthStyles survey.

INTRODUCTION: Perceptions of menthol cigarette use may have implications for smoking initiation and cessation. This study explores harm and health perceptions of menthol cigarette use among a national sample of U.S. adults and current smokers. METHODS: We examined data from the 2009 HealthStyles survey (n = 4,556), an annual mail survey of adults ≥18 years of age that collects information on attitudes and behaviors, including smoking. Frequencies and weighted percentages were calculated by sex, race/ethnicity, age, education level, household income, and smoking status. Unadjusted odds ratios (OR) were used to compare perceptions of menthol cigarette use between demographic groups. RESULTS: Close to half of adults (45.8%) believed that menthol cigarettes are just as harmful as nonmenthol cigarettes, and 40.9% of adults did not know whether menthol cigarettes are more or less harmful than nonmenthol cigarettes. Few adults (0.6%), including smokers, perceived menthol cigarettes to be less harmful than nonmenthol cigarettes. Blacks (OR = 3.22, 95% CI = 1.80-5.76) were more likely to believe that menthol cigarettes have health benefits when compared with Whites. Almost half of current smokers believed menthol cigarettes are equally addictive as nonmenthol cigarettes and 74.9% believed menthol and nonmenthol cigarettes are equally hard to quit. CONCLUSIONS: Findings suggest directions for targeted public health messages for menthol cigarette use. Future research is needed among a nationally representative sample to capture more subtle differences in perceptions among menthol and nonmenthol smokers.

Menthol pharmacology and its potential impact on cigarette smoking behavior.

Menthol is the only tobacco additive promoted and advertised by the tobacco industry. Although a considerable body of research has examined the effects of menthol when it is administered alone and unburned, the effects of menthol when burned in cigarette smoke are more complex because it is administered in a matrix of more than 4,000 substances. Therefore, it is difficult to isolate potential pharmacological and toxic effects of menthol when it is administered in a smoke mixture. Menthol properties include cooling and local anesthesia, as well as effects on drug absorption and metabolism, bronchodilation and respiration changes, and electrophysiology. Subjective effects of smoothness and less harshness have been identified as reasons for menthol cigarette smoking, but findings have been inconclusive regarding the effect of menthol on carbon monoxide exposure and smoking topography parameters. Gaps in the research literature and future research areas include the following: (a) What is the role of menthol in tobacco reinforcement and addiction? (b) In the absence of nicotine, is menthol reinforcing? (c) Are the pharmacological and physiological effects of menthol mediated by a menthol-specific receptor or some other central nervous system-mediated action? (d) What are the influences of menthol and menthol metabolism on the metabolic activation and detoxification of carcinogens in tobacco smoke? and (e) Do differences exist in cigarette smoking topography in relation to the interaction of ethnicity, gender, and menthol cigarette preference? Answers to these questions will help to elucidate the function of menthol in cigarettes and its impact on smoking behavior.