Associations Between Noticing E-Cigarette Advertising Features and E-Cigarette Appeal and Switching Interest Among Young Adult Dual Users.

BACKGROUND: E-cigarette advertising, which often includes various features, may prompt e-cigarette use and product switching. This study examined the associations between noticing e-cigarette ad features and perceived product appeal and interest in completely switching from cigarettes to advertised e-cigarettes among young adult dual users of both products. METHODS: We analyzed data from an online heatmap experiment among young adult dual users defined as established cigarette smokers who currently used e-cigarettes (ages 18-34 years; n = 1,821). Participants viewed 12 e-cigarette ads, clicked on ad features (e.g., fruit flavors, nicotine warnings, price promotions, smoker-targeted claims) that attracted their attention (defined as "noticing"), and answered questions about e-cigarette product appeal and interest in completely switching from cigarettes to the e-cigarettes shown. We examined within-person associations between noticing specific ad features and outcomes, controlling for demographic and tobacco use-related characteristics. RESULTS: Noticing fruit flavors (AOR = 1.67 and 1.28) and fruit images (AOR = 1.53 and 1.21) was positively associated with having any e-cigarette product appeal and switching interest. Noticing price promotions (AOR = 1.23) was positively associated with product appeal. In contrast, noticing nicotine warnings (AOR = 0.74 and 0.86), smoker-targeted claims (AOR = 0.78 and 0.89), and tobacco flavors (AOR = 0.92 and 0.90) was negatively associated with product appeal and switching interest. CONCLUSIONS: Noticing certain e-cigarette ad features (e.g., fruit flavors and nicotine warnings) may be associated with product appeal and/or switching interest among young adult dual users. More research is needed to assess the influence of e-cigarette ad features that promote product switching interests among cigarette smokers while discourage interests among tobacco-naïve individuals.

A Randomized Clinical Trial of a Quitline Vaping Cessation Intervention: Baseline Characteristics of Young Adult Exclusive E-Cigarette Users Seeking Treatment.

Despite interest in quitting vaping among young adults (YAs), little is known about characteristics of e-cigarette (EC) users seeking treatment. In this study, YAs aged 18-24 living in the United States interested in vaping cessation treatment were recruited to complete an online survey regarding demographics and EC use. Primary eligibility criteria were EC use on at least 20 days per month (no other tobacco use), and interest in quitting in the next month. We report descriptive statistics for those who did and did not complete a mandatory coaching call (n = 981). In this sample, most EC users reported high nicotine dependence, a history of unsuccessful quit attempts (including 29.4% with previous NRT use), along with stress, anxiety, and depression. There were few meaningful differences in demographics, EC use behaviors, or behavioral health factors between those who engaged with a phone coaching call (fully enrolled in study; n = 508), and those who did not (n = 473). YAs demonstrated interest in vaping cessation support, but there were no clear characteristics for the half who did not complete a coaching call. Vaping cessation program designers should consider tailoring for the self-reported behavioral health concerns present in this population.

Nicotine information disclosed online by e-cigarette brands popular with young people.

INTRODUCTION: E-cigarette use is most prevalent among adolescents and young adults - and there are often misperceptions about product risk. The purpose of this study was to determine what nicotine information is provided on e-cigarette brand websites. METHODS: Based on national and local surveys, we identified 44 e-cigarette brands commonly used in the US by adolescents and young adults. For each of these brands, their associated websites were analyzed for disclosed nicotine information. Specifically, for each brand's website, we coded whether there was information on nicotine concentration (recorded if a numerical value was provided such as '5% nicotine'), nicotine form (free-base, nicotine salts, or not stated), and nicotine type (tobacco-derived, synthetically derived, or not stated). Coding allowed for both lay (e.g. 'nic salts') as well as scientific (e.g. 'isomers') terms. RESULTS: Of the 44 brands examined, all provided basic information on nicotine concentration (e.g. '5% nicotine'). However, 23% of brands did not disclose information on nicotine form (i.e. nicotine salt vs free-base), and 66% of brands did not disclose information on nicotine type (i.e. synthetic vs tobacco-derived). CONCLUSIONS: Overall, these results suggest that the e-cigarette industry is not fully informing its consumers about the nicotine in their products. Given that nicotine form and type have implications for e-cigarette addiction potential, these findings highlight a public health concern. There is a need for more comprehensive national regulations for mandating product constituents and emissions disclosures.

Demographic and Behavioral Differences Between Adolescents and Young Adults Who Use E-Cigarettes at Low and High Frequency.

BACKGROUND: Among adolescents and young adults (AYAs), "current use" of electronic cigarettes (e-cigarettes) is commonly defined as any use in the past 30 days. However, few studies have examined differences among those within this broad category. This study examined characteristics of AYAs who used e-cigarettes at a low frequency (within the last 3 months but <6 days out of the past 30 days) and those who used e-cigarettes at a high frequency (6+ days out of the past 30 days). METHODS: We conducted cross-sectional analyses among 551 Ohio AYAs (15- to 24-year-olds) who reported using an e-cigarette to vape nicotine in the past 3 months. We used descriptive statistics and logistic regression to characterize those using e-cigarettes at a low frequency and a high frequency. RESULTS: Among our sample of AYAs who reported past 3-month e-cigarette use, about half (50.8%) reported using an e-cigarette 6 or more days out of the past 30 days (ie, high frequency). In the multivariable analysis, reported nicotine dependence (Odds Ratio [OR]: 7.0, 95% CI: 4.8, 10.3) and current other tobacco product use (OR: 1.8, 95% CI: 1.1, 2.9) were associated with high-frequency e-cigarette use. CONCLUSION: Our results suggest that frequency of use is an important characteristic in understanding AYA e-cigarette use. Any use in the past 30 days may not be sensitive enough to understand dependence and tobacco-use behaviors. Further characterizing "current" e-cigarette use by frequency of use may provide meaningful information for public health professionals to better target intervention and cessation efforts to AYAs.

What do young people know about the nicotine in their e-cigarettes?

INTRODUCTION: In recent years, the nicotine in e-cigarettes has been available in either a 'free-base' (unprotonated) or 'nicotine salt' (protonated) form. Additionally, e-cigarette nicotine can be either 'synthetic' or 'tobacco-derived'. These dimensions of nicotine have implications for nicotine absorption, bioavailability and sensory experiences. However, it is unclear if the young people using e-cigarettes are aware of these nicotine dimensions. METHODS: Data came from a cohort of Ohio youth (aged 15-24) who reported using an e-cigarette in the past 4 months (N=271). Participants were enrolled and provided background information in 2021; their 12-month follow-up survey asked about the presence, form and type of nicotine in their usual e-cigarette. Individuals who reported that they could distinguish between tobacco-derived and synthetic nicotine were additionally asked to describe the difference. RESULTS: Of the 247 youth who reported that there was nicotine in their usual e-cigarette, 71.7% did not know whether it was free-base or nicotine salt and 75.7% did not know whether it was synthetic or tobacco-derived. Awareness was higher among youth who were using e-cigarettes at a greater frequency and quantity. The majority reported that they could not detect a difference between the experience of using synthetic vs tobacco-derived nicotine. CONCLUSIONS: These findings indicate the generally limited awareness about nicotine among youth who used e-cigarettes. Improvements in health communications and requirements for e-cigarette industry disclosures are necessary to ensure that consumers are better informed about the dimensions-and the risks-of the nicotine they are consuming.

The Role of Cigarillo Flavor in the Co-Use of Cigarillos and Cannabis among Young Adults.

Background: Research suggests flavor facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis ("co-use"), which is common among young adult smokers. This study's aim was to determine the role of the cigarillo flavor in co-use among young adults. Methods: Data were collected (2020-2021) in a cross-sectional online survey administered to young adults who smoked ≥2 cigarillos/week (N = 361), recruited from 15 urban areas in the United States. A structural equation model was used to assess the relationship between flavored cigarillo use and past 30-day cannabis use (flavored cigarillo perceived appeal and harm as parallel mediators), including several social-contextual covariates (e.g., flavor and cannabis policies). Results: Most participants reported usually using flavored cigarillos (81.8%) and cannabis use in the past 30 days ("co-use") (64.1%). Flavored cigarillo use was not directly associated with co-use (p = 0.90). Perceived cigarillo harm (ß = 0.18, 95% CI = 0.06, 0.29), number of tobacco users in the household (ß = 0.22, 95% CI = 0.10, 0.33), and past 30-day use of other tobacco products (ß = 0.23, 95% CI = 0.15, 0.32) were significantly positively associated with co-use. Living in an area with a ban on flavored cigarillos was significantly negatively associated with co-use (ß = -0.12, 95% CI = -0.21, -0.02). Conclusions: Use of flavored cigarillos was not associated with co-use; however, exposure to a flavored cigarillo ban was negatively associated with co-use. Cigar product flavor bans may reduce co-use among young adults or have a neutral impact. Further research is needed to explore the interaction between tobacco and cannabis policy and use of these products.

Flavour loyalty may predict cessation or substitution following a cigarillo flavour ban among young adults in the USA.

SIGNIFICANCE: The purpose of this research was to measure flavour loyalty and identify how current cigarillo users may respond to a hypothetical flavour ban in the USA. METHODS: Cigarillo users aged 21-28 (n=531) were recruited between October 2020 and April 2021 to participate in an online survey. Respondents categorised their preferred, usual and current cigarillo flavours. Individuals who preferred tobacco flavours were compared with individuals who preferred any other flavours. Strength of preferences, or flavour loyalty, was defined when an individual's preferred flavour matched what they use both usually and currently creating a spectrum of individuals with a strong tobacco preference (n=34), weak tobacco preference (n=20), weak flavour preference (n=162) and strong flavour preference (n=315). Those preferring tobacco were aggregated into any tobacco preference (n=54). RESULTS: Individuals who preferred any flavour scored higher on a scale of nicotine dependence. There was a dose-response relationship in those who said they would discontinue cigarillos if flavoured options were not available: 11.4% of individuals with any tobacco flavour preference, 27.8% of those with a weak flavour preference and 38.1% of those with a strong flavour preference. A similar trend was noted among those who would switch to another product: 19.2% of those with tobacco flavour preference, 34.3% of those with a weak flavour preference and 43.2% of those with a strong flavour preference. CONCLUSION: Individuals who display strong flavour preferences were more likely to say they would discontinue use or seek out alternative flavoured products following a ban on flavoured cigarillos.

Geographic Differences in JUUL Use and Risk Perceptions.

PURPOSE: The aim of this study was to compare prevalence of JUUL use and JUUL risk perceptions between adolescents living in an urban area versus Appalachian areas of the U.S. METHODS: Data were drawn from a prospective cohort study of adolescent males (the Buckeye Teen Health Study, or BTHS); our cross-sectional analysis used data from one timepoint, collected between January and December 2019 (N = 873). Chi-square tests and multivariable logistic regression compared JUUL use prevalence and risk perceptions between participants in an urban Ohio county and nine predominantly rural Appalachian Ohio counties. RESULTS: Over a quarter of the sample (29.2%) had ever used JUUL. In the unadjusted model, prevalence of JUUL use was similar between regions but Appalachian participants perceived JUUL as more harmful (p < .001) and more addictive (p = .04) than urban participants. In the adjusted model, region was not significantly related to current JUUL use (OR: 1.20, 95% CI: 0.77, 1.87) or ever JUUL use (OR: 1.15, 95% CI: 0.83, 1.60). CONCLUSIONS: JUUL use was similar between urban and Appalachian participants despite regional differences in risk perceptions. Interventions that only target risk perceptions may not be sufficient to prevent adolescent e-cigarette use, particularly in rural communities.

Substitution of flavored cigarillos with menthol cigarettes among young adults in the U.S.

BACKGROUND: Young adult cigarillo users often cite flavor as a primary reason for initiating and sustaining product use and are more likely to concurrently use other tobacco products such as menthol cigarettes. This study examines substitution with menthol cigarettes among cigarillo users facing a hypothetical ban on flavored cigarillos. METHODS: Current young adult (21-28 years) cigarillo users were recruited from October 2020 to April 2021 for an online survey about cigarillo and other tobacco use behaviors. Participants (n = 500) self-reported past or current menthol cigarette experience, and if they would switch to menthol cigarettes if they could not get flavored cigarillos. Logistic regression was used to test differences in switching behaviors by level of experience with menthol cigarettes. RESULTS: Most young adult cigarillo users (76.8 %) had ever used a menthol cigarette and 46.6 % reported current use of menthol cigarettes. No participant who had never used menthol cigarettes reported they would switch to menthol cigarettes. Current users were 4.2 times as likely to say they would switch after controlling for demographic characteristics and nicotine dependence. CONCLUSION: Most young adult cigarillo users reported they would not switch to menthol cigarettes if flavored cigarillos became unavailable. However, participants who currently use or have used menthol cigarettes were more likely to report their intention to switch products than those who had never used menthol cigarettes. There may be a subsequent increase in menthol cigarette use among past menthol cigarette users if policies restricting flavored tobacco products exclude menthol cigarettes, diluting these policies' intended population health impact.

Dissonance in Young Adult Cigarillo Users' Categorization of Concept Flavored and Unflavored Products.

This study asks young adult cigarillo users to categorize their preferred flavor in order to examine user consensus and potential methodological and regulatory implications of flavor name-based categorization systems. Young adult (21-28 years) cigarillo users (n = 426) named and categorized their favorite cigarillo flavor into one of seven categories: Fruit, Sweet and Candy, Mint, Alcohol, Menthol, Tobacco, and Other. Flavor responses were coded as characterizing (ex: Grape, Wine) or concept (ex: Jazz, Diamond) flavors. Variation within and between categories was assessed, including the presence of concept flavors and the placement of flavors in multiple categories. Of the 66 unique flavor names provided, participants placed 20 (30.1%) in more than one flavor category. Most of the Tobacco (76.9%) and Other (69.2%) flavor names appeared in multiple categories. The majority of flavor names in the Tobacco (69.2%) and Other (61.5%) categories were concept flavors. Concept flavors were placed in multiple categories (45.0%) twice as often as characterizing flavors (23.9%). This study has identified dissonance among cigarillo users' flavor categorizations, particularly for concept flavored and unflavored products. Flavor names may obscure how and whether a product is flavored. Research on and regulation of flavored tobacco products should classify products by flavor additives rather than by name alone.

Cigarillo Flavor and Motivation to Quit among Co-Users of Cigarillos and Cannabis: A Structural Equation Modeling Approach.

Flavored cigar restrictions have the potential to benefit public health. Flavor availability facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis, an increasingly prevalent behavior among young adults. Data were collected (2020-2021) in a cross-sectional online survey administered to a convenience sample of young adults who smoked cigarillos from 15 areas with high cigar use prevalence. We assessed the relationship between flavored cigarillo use and motivation to quit cannabis and cigarillo use among past 30-day co-users (N = 218), as well as several covariates (e.g., cigarillo price and flavor/cannabis policy). Flavored cigarillo perceived appeal and harm were hypothesized parallel mediators. Most co-users reported usually using flavored cigarillos (79.5%), which was not significantly associated with motivation to quit cigarillos or cannabis. Perceived cigarillo harm (ß = 0.17, 95% CI = 0.00, 0.33), advertising exposure (ß = 0.12, 95% CI = 0.00, 0.24), and income (among racial/ethnic minorities; ß = -0.13, 95% CI = -0.25, -0.02) were significant predictors of motivation to quit cigarillos. There were no significant predictors of motivation to quit cannabis. Cigarillo flavor was not associated with motivation to quit, so findings could suggest that banning flavors in cigars may have a neutral impact on co-use with cannabis among young adults.

Dual Use of E-cigarettes and Cannabis among Young People in America: A New Public Health Hurdle?

In this commentary, we discuss the concerning prevalence of cannabis use among young people who use e-cigarettes. National data in the U.S., as well as our own local data, indicate that dual use (i.e., nicotine e-cigarette use and cannabis use) is more common than e-cigarette use alone. Our commentary discusses why this dual use is a major concern for public health. We argue that continuing to examine e-cigarettes in isolation is not only impractical but also problematic, as it misses out on opportunities to understand additive and multiplicative health impacts, to share cross-knowledge, and to inform prevention and treatment. This commentary calls for more attention to dual use and concerted, equity-enhancing efforts from funders and researchers.

Visual attention to blu's parody warnings and the FDA's warning on e-cigarette advertisements.

OBJECTIVES: In 2017, the e-cigarette brand, blu, released advertisements featuring large, boxed, positively-framed messages. These messages mimicked the format of FDA-mandated warnings that would appear on e-cigarette advertisements in the United States in 2018. We compared attention to blu's parody warnings and FDA-mandated warning appearing on blu advertisements. METHODS: N = 73 young adults who had used tobacco participated in an eye-tracking study. Participants viewed three blu e-cigarette advertisements in random order: one with a parody warning and two with the FDA-mandated warning (one with a model's face and one without). Areas of interest (AOIs) were the parody or FDA-mandated warning. We compared dwell time on AOIs between the three advertisements. RESULTS: Participants viewed parody warnings longer than each FDA-mandated warning on average (254 and 608 ms longer; p's < 0.02). Comparing the advertisements with FDA-mandated warnings revealed that participants spent less time looking at the warning in the advertisement with a model's face (354 fewer milliseconds; p = 0.001). CONCLUSIONS: Parody warnings attracted more visual attention than FDA-mandated warnings, and the presence of a face in the advertisement drew attention away from the FDA-mandated warning. Results underscore the need for advertisement regulations that support increased attention to health warnings.

Testing potential disclosures for e-cigarette sponsorship on social media.

OBJECTIVES: Few e-cigarette social media posts are authentic posts to friends; most come from commercially sponsored influencers. Potential disclosure strategies need to be tested to confirm whether users recognize such posts as commercially sponsored. METHODS: Between July - August 2019, young adult (ages 16-24; n = 200) participants were recruited to view their native Instagram feed on a laboratory mobile device. Posts from e-cigarette influencers were manipulated to add either #ad or #sponsored while eye tracking software measured visual attention. Participants self-reported their interpretation of the hashtags in open-ended responses. Logistic regression analyses compared recognition of commercial content by condition, and qualitative content analyses summarized the key themes related to the hashtags. RESULTS: The #ad condition had nearly twice the odds of commercial recognition compared to #sponsored (OR = 1.98, CI: 1.14-3.38). Every second of attention paid to the hashtag significantly increased the odds of commercial recognition by 22% (OR: 1.22, CI: 1.00-1.33). CONCLUSION: The #ad disclosure attracted visual attention and significantly increased recognition of commercial sponsorship from young social media users. Labeling commercially sponsored content on social media is a promising strategy to better inform users about paid social media influence.

Real-Time Reflectance Confocal Microscopy of Cutaneous Graft-versus-Host Disease Correlates with Histopathology.

Reflectance confocal microscopy (RCM) allows noninvasive, real-time evaluation of the skin at a resolution akin to histopathology (HP), but its application in cutaneous graft-versus-host disease (GVHD) has not been extensively assessed. We describe RCM features of cutaneous GVHD including acute (aGVHD), late acute, chronic (cGVHD; sclerotic and nonsclerotic subtypes), and inactive GVHD and correlate RCM with same-site HP for a subset of patients. Thirty-two adult and pediatric allogeneic hematopoietic cell transplantation (allo-HCT) recipients with cutaneous GVHD received RCM imaging of ≥1 lesions (n = 44), 13 of which necessitated skin biopsy. RCM images were deidentified and assessed by 2 RCM experts blinded to clinical and HP findings to reach a consensus on the features and patterns of the inflammatory dermatoses. Major RCM features (present in ≥65% of lesional sites) and patterns were reported. To determine the correlation between RCM and HP, detection of cellular features and patterns of inflammatory dermatoses were compared using percent agreement and prevalence-adjusted, bias-adjusted kappa estimates. Seven patients with early or late aGVHD (7 lesions) had irregular honeycombing, spongiosis, dermoepidermal junction (DEJ) and dermal inflammation, and melanophages; those with early aGVHD also had hyperkeratosis, dilated vessels, and coarse connective tissue. Both groups had an interface dermatitis pattern. Eighteen patients with nonsclerotic cGVHD (24 lesions) had irregular honeycombing, spongiosis, DEJ and dermal inflammation, dilated vessels, coarse connective tissue, and interface and spongiotic dermatitis patterns. Three sclerotic patients with cGVHD (7 lesions) had irregular honeycombing, DEJ and dermal inflammation with an interface dermatitis pattern. Four patients with inactive GVHD (6 lesions) showed minimal inflammation. RCM and HP had similar detection rates for 6 of 13 features and overall patterns important for diagnosis in 2 patients with late aGVHD (2 lesions; 15%) and 10 with nonsclerotic cGVHD (11 lesions; 85%) necessitating skin biopsy. RCM can detect features commonly reported in cutaneous GVHD and is comparable to HP. Additional characterization of cutaneous GVHD by RCM may enable future use in diagnosing, monitoring, or predicting disease in real time.

A Year of Child Injury Prevention on Instagram.

Injury is the leading cause of death for children but little is known about what types of injury prevention messages are communicated on Instagram. Conducted in the United States, the aim of this study was to better understand child injury prevention messages on Instagram to develop recommendations for the future. Informed by Social Cognitive Theory, a quantitative content analysis was conducted on all Instagram posts from selected organizations from May 2018 through April 2019. Of the 818 injury prevention posts, almost all included an image (575, 70%) or video (211, 26%). Of the 575 images, 245 (42.46%) had in image that did not match the topic of the post. Regarding injury prevention recommendations, 579 posts (71%) provided a clear action that parents should take. For these posts, 115 (20%) had an image that communicated the desired safety recommendation, but many more (285, 50%) did not; in 23 cases it was not clear if there was a match or not. There are missed opportunities for child health and injury organizations to reach parents and caregivers through Instagram. Posts made during the study period often lacked specificity about action-oriented measures and failed to utilize images that demonstrated the recommended practices. Organizations posting on Instagram and other social media platforms should provide clear action tips and utilize images that depict child injury prevention recommendations.

Beyond Strong Enforcement: Understanding the Factors Related to Retailer Compliance With Tobacco 21.

INTRODUCTION: Tobacco 21 (T21), which sets the minimum legal sales age for tobacco to age 21, is now a national law in the United States. Although T21 is expected to help curb youth tobacco use, its impact may be dampened due to poor retailer compliance. Even within environments where enforcement is strong (ie, compliance checks are conducted with tough sanctions for violations), compliance might vary due to other factors. AIMS AND METHODS: Three studies were conducted in Columbus, OH, where T21 became strongly enforced in 2018. These studies examined how retailer compliance related to features of the neighborhood in which a retailer was located (Study 1), features of the retailer (Study 2), and features of the retail cashier (Study 3). RESULTS: Study 1 found that, after controlling for race- and age-based factors, retailers located in high (vs. low)-poverty neighborhoods had a lower likelihood of conducting identification (ID) checks. Study 2 found that ID checks were related to whether retailers displayed signage about T21, as required by the city law. Study 3 found that, among cashiers, T21 awareness (which was high) and perceptions about T21 (which were moderate) were not generally related to their retailer's compliance; having (vs. not having) scanners for ID checks was related to a higher likelihood of compliance. CONCLUSIONS: These studies emphasize the many, multilevel factors influencing T21 outcomes. Findings also indicate the potential for T21 to widen disparities in tobacco use, indicating the need for strategies to equitably improve T21 compliance. IMPLICATIONS: T21, which sets the minimum legal sales age for all tobacco products to age 21, is now a national law in the United States. Despite optimistic projections about what T21 could achieve, the ultimate impact may be dampened when it is applied in real-world settings. Our project revealed the many, multilevel factors influencing T21 compliance. Findings also indicate the potential for T21 to widen disparities in tobacco use if gaps in compliance persist. Strategies for equitably improving T21 compliance are discussed. This article is of relevance to areas interested in implementing or improving their local T21 enforcement.

Pulling Your Mask down to Smoke: Qualitative Themes from Young Adults on Nicotine Use during a Pandemic.

Introduction: The COVID-19 pandemic may have resulted in a change in life routines for tobacco users, but little is known about the rationale underlying these changes. Methods: A convenience sample of young adults ages 21-28 (n = 29) were recruited online May-July 2020 to participate in semi-structured interviews about nicotine use behaviors specific to cigarillos and e-cigarettes. Audio-recorded interviews were 60-90 min long and were conducted remotely. Participants were asked opinions and behavioral effects of the COVID-19 pandemic on tobacco use. Verbatim transcripts and field notes from each interview were coded by a trained researcher using a codebook developed using inductive and deductive approaches. Thematic analysis was used to examine product access, use frequency, stress and use triggers. Results: Most current users reported tobacco use stayed the same or increased since the pandemic and attributed this to being home more with greater time/boredom. COVID-19 impacted purchasing behaviors such as purchasing products in greater quantities, through the Internet, or at a different store due to perceived cleanliness. Few reported using tobacco products less frequently and not smoking in public due to the perception of risks associated with smoking and COVID-19, plus having to take off their mask to smoke. Lack of social use modified shared product use, flavors selected, and setting of use. Financial impacts included increased product costs and job loss. Few mentioned wanting to quit due to the pandemic. Discussion: Current tobacco users have experienced major changes in their tobacco use routines during the COVID-19 pandemic.

Waterpipe Warning Placement and Risk Perceptions: An Eye Tracking Study.

Objectives: The purpose of this study was to select a health warning message location on a waterpipe (WP) that both attracted visual attention and conveyed the risks associated with WP smoking. Methods: During June through November 2019, we conducted a within-subjects randomized experiment (N = 74) using eye tracking equipment to examine visual attention to 3 placements of a health warning on the WP (stem, water bowl, hose). We asked young adult ever WP users 3 questions about WP harm perceptions. We used generalized linear mixed models to examine the amount of fixation time spent on the placement locations; we used repeated measures ANOVA to model changes in harm perceptions. Results: There were statistically significant differences across all 3 placement locations; regardless of place, all HWLs attracted a comparable amount of visual attention. Absolute WP harm perceptions significantly increased following the experiment and remained significantly higher at the one-week follow-up, compared to baseline. Conclusions: Warnings on WPs attracted visual attention and increased harm perceptions, and those harm perceptions remained high one week after the experiment. Findings indicate the value of including a warning on the WP device, and underscore the necessity and effectiveness of those health warnings to combat WP harm misperceptions.