Nicotine Pouch Awareness and Use Among Youth, National Youth Tobacco Survey, 2021.

INTRODUCTION: This manuscript examines prevalence of awareness and use of nicotine pouches among U.S. middle and high school students by sociodemographic characteristics and other tobacco product use and characterizes nicotine pouch and other tobacco product use behaviors among current nicotine pouch users. AIMS AND METHODS: Data are from the 2021 National Tobacco Youth Survey, a cross-sectional, school-based survey of middle and high school students (N = 20 413; overall response rate: 44.6%), which included questions on nicotine pouches in 2021 for the first time. Prevalence estimates, 95% confidence intervals, and estimated population counts were assessed for nicotine pouch awareness, ever use, and current (past 30 days) use, and for use behaviors related to nicotine pouches (frequency of use, flavor(s) used) and other tobacco products (ever, current, frequency of use) among current nicotine pouch users. RESULTS: Over one-third of students (35.5%) had ever heard of nicotine pouches. An estimated 1.9% (490 000) reported ever using them, while 0.8% (200 000) reported current use. Among current nicotine pouch users, 61.6% reported flavored nicotine pouch use, 64.2% reported current e-cigarette use, and 52.6% used multiple (≥2) tobacco products. Current use of nicotine pouches was common among current smokeless tobacco users (41.3%). CONCLUSIONS: Overall, in 2021, while relatively few students had ever tried nicotine pouches or currently used them, more than one-third had heard of them. Current nicotine pouch users tended to use other tobacco products, particularly e-cigarettes and smokeless tobacco. Given previous rapid increases in youth uptake of e-cigarettes, it is important to continue monitoring nicotine pouch use among young people. IMPLICATIONS: This study's findings provide an important baseline for future monitoring of nicotine pouch awareness and use among middle and high school students. Emerging tobacco products, particularly those that are flavored, widely available, discreet, and inexpensive have the potential to attract youth. Given the potential of these products to appeal to young people, ongoing monitoring of nicotine pouch use behaviors is important to inform public health and regulatory efforts.

#Nicotineaddiction on TikTok: A quantitative content analysis of top-viewed posts.

INTRODUCTION: TikTok, the video-sharing app popular among youth, is a source of user-generated content about nicotine addiction with the potential to endorse or deter nicotine use among young viewers. We systematically analyzed content and themes of TikTok posts tagged #nicotineaddiction. METHODS: We conducted a quantitative content analysis of the visual and textual content of the 149 top-viewed English-language TikTok posts tagged #nicotineaddiction as of 1 March 2021. Posts were double-coded using a shared codebook, noting content creator characteristics, nicotine products featured, references to quitting, and overall themes of #nicotineaddiction expressed. We assessed the prevalence of post characteristics and themes overall and by apparent age of content creators (aged ≥21 years versus <21 years). RESULTS: The 149 posts analyzed received a mean and median of 62433 and 15800 likes, respectively. E-cigarettes were referenced or featured in 75% of posts; 58% featured a specific nicotine product brand, most commonly Puff Bar (23% of total) and JUUL (19%). Overall, 22% of posts mentioned quitting nicotine. The top themes of #nicotineaddiction expressed were physical or psychological consequences (e.g. withdrawal symptoms, 46%), physical or psychological benefits (e.g. tasting good, feeling 'buzzed', 28%), and social benefits (e.g. bonding with fellow users, 28%). Compared to those aged ≥21 years, posts by content creators likely <21 years (26%) less commonly mentioned quitting (p<0.01), had fewer followers (p<0.01), were more commonly from Canada (p<0.01) and less commonly from the US (p<0.01), and more commonly featured JUUL (p<0.05). CONCLUSIONS: While reaching a large and engaged audience, TikTok content creators suggest a range of benefits and consequences of nicotine addiction. Future research is warranted to examine this content's potential to influence young people's intentions to use or quit nicotine products.

ENDS advertising expenditures in English language media in the USA, 2015-2020.

BACKGROUND: Electronic nicotine delivery system (ENDS) advertising is associated with ENDS purchase and use. This study assessed trends in ENDS advertisement (ad) expenditures in the USA from 2015 to 2020 overall, by media channel and by advertiser. METHODS: Data came from Numerator, which conducts surveillance of ads and estimates expenditures. The estimates are dollars spent (adjusted to 2020) by the advertiser for each ad occurrence for print, radio, television and digital (online, mobile) media channels. ENDS ad expenditures were assessed by quarter, media channel and the top five advertisers based on ad occurrences. RESULTS: Overall ENDS ad expenditures increased from $38 million in 2015 to $217 million in 2019 before decreasing to a low of $22 million in 2020. By media channel, print expenditures led the channels with more than twice as much spent as television, four times more than radio and 10 times more than digital. By advertiser, JUUL led in ENDS ad expenditures from 2015 to 2020 with almost $189 million spent, followed by British American Tobacco (BAT, $105 million) and Imperial Tobacco ($62 million). CONCLUSIONS: Overall ad expenditures were relatively stable from 2015 to mid-2018 when large expenditures by JUUL and subsequent expenditures by BAT and Imperial Tobacco led to expenditure highs in 2019. E-cigarette and vaping-associated lung injury (EVALI), the JUUL self-imposed ad suspension and COVID-19 likely all played a role in advertising lows in 2020. The absence of popular Puff Bar brand ads from the traditional media channels studied highlights the importance of monitoring direct and indirect advertising on newer media channels like social media.

Association of e-cigarette advertising with e-cigarette and cigarette use among US adults.

AIMS: To estimate the association of e-cigarette advertisement exposure with e-cigarette and cigarette use behavior among US adults. DESIGN: Data from the 2013-14 National Adult Tobacco Survey (NATS) were linked to Kantar Media and National Consumer Study data to construct measures of e-cigarette advertisements on TV and in magazines. The relationship between advertisement measures and outcomes was estimated using logistic and Poisson regressions, controlling for socio-demographics, state cigarette taxes and state and year fixed-effects. SETTING: United States. PARTICIPANTS/CASES: A total of 98 746 adults aged ≥ 18 years who responded to the 2013-14 NATS. MEASUREMENTS: The independent variables of interest were the number of e-cigarette advertisements in magazines to which an adult was exposed in the past 6 months and the number of e-cigarette advertisements on TV to which an adult was exposed in the past 6 months. Outcomes were awareness of e-cigarettes, ever e-cigarette use, current e-cigarette use, current cigarette use and number of cigarettes smoked per month. FINDINGS: Exposure to one additional e-cigarette advertisement on TV was associated with a 0.18, 0.13 and 0.03 percentage point increase, respectively, in awareness, ever use and current use of e-cigarettes among all adults (P < 0.05). This exposure also was associated with a 0.11 percentage point increase in current cigarette use among all adults and an increase in cigarette consumption of 2.24 cigarettes per month among adults aged ≥ 45 (P < 0.05). CONCLUSIONS: Exposure to e-cigarette advertising appears to be positively associated with the use of e-cigarettes and cigarettes among adults of all ages, and with increased cigarette consumption among older adults.

E-cigarette advertising expenditures in the USA, 2014-2018.

BACKGROUND: Tobacco product advertising has been shown to reach youth and promote initiation. This study assessed trends in e-cigarette advertising expenditures in the USA during 2014-2018, overall and by manufacturer and media type. METHODS: Data came from Kantar Media, which provides information on US advertising expenditures, including for e-cigarettes. Advertising expenditures were estimated as the dollar amount spent by e-cigarette companies to purchase advertising space in print, television, Internet, radio and outdoors. Dollar amounts were adjusted to 2017 dollars. Trends in e-cigarette advertising expenditures during 2014-2018 were analysed using Joinpoint regression overall, by media type, and by manufacturers based on 2017-2018 national sales. RESULTS: Total e-cigarette advertising expenditures in print, radio, television, Internet and outdoors decreased substantially from US$133 million in 2014 to US$48 million in 2017, followed by an increase to US$110 million in 2018. By media type, expenditures were highest for print advertising, irrespective of year. By manufacturer, Altria had the highest e-cigarette advertising expenditures, totalling over US$134 million during 2014-2018. Imperial Tobacco had the second highest, totalling over US$85 million during 2014-2018, while JUUL Labs had the highest single-year expenditures, spending over US$73 million in 2018 alone. CONCLUSIONS: E-cigarette advertising expenditures have been volatile in the USA, with declines in traditional advertising venues during 2014-2017 that may reflect a shift towards social media. However, an increase occurred in 2018 that is likely reflective of advertising by newer manufacturers. Continued monitoring of e-cigarette advertising is important to inform tobacco control strategies.

Age of tobacco use initiation and association with current use and nicotine dependence among US middle and high school students, 2014-2016.

INTRODUCTION: Tobacco use mostly begins in adolescence and young adulthood. Earlier age of initiation of cigarette smoking is associated with greater nicotine dependence and sustained tobacco use. However, data are limited on the age of initiation of non-cigarette tobacco products, and the association between using these products and nicotine dependence and progression to established use. METHODS: Combined 2014-2016 National Youth Tobacco Survey data, a nationally representative cross-sectional survey of US students in grades 6-12 yielded 19 580 respondents who reported ever using any of five tobacco products: electronic cigarettes, cigarettes, cigars, smokeless tobacco and hookah. Analyses assessed age of reported first use of each product among ever-users, overall and by sex and race/ethnicity. Current daily use, past 30-day use, feelings of craving tobacco and time to first tobacco use after waking were assessed by age of first use. RESULTS: Among ever-users, weighted median age for first use was 12.6 years for cigarettes, 13.8 years for cigars, 13.4 years for smokeless tobacco, 14.1 years for hookah and 14.1 years for e-cigarettes. First trying these tobacco products at age ≤13 years was associated with greater current use of the respective product and nicotine dependence compared with initiating use at age >13 years. CONCLUSIONS: First tobacco use at age ≤13 years is associated with current daily and past 30-day use of non-cigarette tobacco products, and with the development of nicotine dependence among youth ever-users. Proven tobacco prevention interventions that reach early adolescents are important to reduce overall youth tobacco use.

Substances used in electronic vapor products among adults in the United States, 2017.

INTRODUCTION: Electronic vapor products (EVPs), including e-cigarettes, can be used to aerosolize many substances. Examination of substances used in EVPs by US adults has been limited; we assessed past-year use of EVPs to deliver various substances. METHODS: Data came from the 2017 SummerStyles Survey, a web-based survey of US adults (N = 4107). Ever EVP users were asked if they had used nicotine, marijuana, flavors or "something else" in an EVP during the past year. Weighted estimates for any, exclusive, and combined EVP substance use were calculated among ever (n = 586) and current (past 30-day; n = 121) EVP users. RESULTS: Past-year use of nicotine, flavors, and marijuana in EVPs was 30.7%, 23.6%, and 12.5% among ever EVP users, respectively; and 72.3%, 54.6%, and 17.8% among current EVP users. Among ever EVP users, the most commonly used substances were nicotine only (29.6%), nicotine plus flavors (27.2%), flavors only (16.4%), and marijuana only (14.9%). Among current EVP users, the most common substances used were nicotine plus flavors (39.1%), nicotine only (29.6%), and flavors only (11.2%). Among ever users, males and 18-29 year olds were more likely to report use of flavors than females and respondents ≥30 years. CONCLUSIONS: Approximately 7 in 10 current EVP users reported nicotine use, about 1 in 2 used flavors, and nearly 1 in 6 used marijuana. These findings suggest that EVPs are used to consume a variety of substances and could guide efforts to address tobacco and non-tobacco substance use.

Severe Pulmonary Disease Associated with Electronic-Cigarette-Product Use - Interim Guidance.

On September 6, 2019, this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr). As of August 27, 2019, 215 possible cases of severe pulmonary disease associated with the use of electronic cigarette (e-cigarette) products (e.g., devices, liquids, refill pods, and cartridges) had been reported to CDC by 25 state health departments. E-cigarettes are devices that produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, including any additives, into their lungs. Aerosols produced by e-cigarettes can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, cancer-causing chemicals, or other agents such as chemicals used for cleaning the device (1). E-cigarettes also can be used to deliver tetrahydrocannabinol (THC), the principal psychoactive component of cannabis, or other drugs; for example, "dabbing" involves superheating substances that contain high concentrations of THC and other plant compounds (e.g., cannabidiol) with the intent of inhaling the aerosol. E-cigarette users could potentially add other substances to the devices. This report summarizes available information and provides interim case definitions and guidance for reporting possible cases of severe pulmonary disease. The guidance in this report reflects data available as of September 6, 2019; guidance will be updated as additional information becomes available.

Use and reasons for use of electronic vapour products shaped like USB flash drives among a national sample of adults.

OBJECTIVES: Assess use and reasons for use of electronic vapour products (EVPs) shaped like universal serial bus (USB) flash drives among adults in the USA. METHODS: Data came from SummerStyles, an internet survey of US adults aged ≥18 (N=4088) fielded in June to July 2018. Respondents were shown product images and asked about ever use, current (past 30 days) use and reasons for use. Weighted point estimates and adjusted ORs were assessed. RESULTS: In 2018, 7.9% of participants had ever used flash drive-shaped EVPs, including 25.7% of current cigarette smokers and 45.9% of current EVP users. Moreover, 2.0% reported current use, including 6.8% of cigarette smokers and 34.3% of EVP users. Leading reasons for ever use were 'to deliver nicotine' (30.7%) and 'friend or family member used them' (30.2%). CONCLUSIONS: About one in 13 US adults have ever used flash drive-shaped EVPs, with use being highest among current EVP users. Nicotine content and friend/family use are drivers of ever use. PUBLIC HEALTH IMPLICATIONS: Understanding use of emerging EVP types can inform strategies to maximise any potential benefits for adult cessation and minimise risks of youth initiation.

Exposure to Secondhand Smoke and Secondhand E-Cigarette Aerosol Among Middle and High School Students.

INTRODUCTION: Youth exposure to secondhand smoke (SHS) and secondhand aerosol from e-cigarettes (SHA) may contribute to the renormalization of tobacco product use behaviors. Our study assessed self-reported SHS or SHA exposures in indoor or outdoor public places among US students. METHODS: Data came from the 2015 and 2017 National Youth Tobacco Survey, a school-based survey of US students in grades 6 through 12. Past 30-day exposure to SHS and SHA in indoor and outdoor public places was assessed. The prevalence of exposure was assessed overall and by covariates for each year. We used adjusted prevalence ratios (aPRs) to assess determinants of exposure. RESULTS: We observed no significant change from 2015 through 2017 in exposure to SHS (52.6% to 50.5%), SHA (25.2% to 25.6%), or either SHS or SHA (56.7% to 55.1%). Following multivariable adjustment, in 2017, exposure to either SHS or SHA in public was higher among female students versus male students (aPR = 1.29), high school students versus middle school students (aPR = 1.15), current e-cigarette users versus nonusers (aPR = 2.89), and current users of other tobacco product versus nonusers (aPR = 1.21). Exposure was higher for students who reported that a household member used tobacco products. CONCLUSION: In 2017, more than half (55.1%, 14.3 million) of US middle and high school students reported exposure to secondhand tobacco product emissions in indoor or outdoor public places. E-cigarette use may complicate the enforcement of existing smoke-free policies and contribute to the renormalization of tobacco use behaviors. Continued efforts are warranted to reduce the social acceptability of tobacco product use and protect bystanders from all tobacco product emissions.

E-Cigarettes and Young People: Communicating an Emerging Public Health Risk.

E-cigarettes are the most commonly used tobacco product among US youth. Most e-cigarettes contain nicotine, which can cause addiction and can harm the developing adolescent brain. In coordination with the release of a Surgeon General's Report on e-cigarette use among young people, the Centers for Disease Control and Prevention collaborated with the Office of the Surgeon General to launch a campaign to educate parents, youth influencers, and young people about the risks of e-cigarettes. This article describes the development of communication products, including innovative media, about this public health risk, and shares lessons learned to inform public health practice.

Attitudes Toward Smoke-Free Casino Policies Among US Adults, 2017.

Research shows that there is no risk-free level of exposure to secondhand smoke (SHS) and that eliminating smoking indoors fully protects nonsmokers from indoor SHS exposure. Casinos often allow smoking indoors and can be a source of involuntary SHS exposure for employees and visitors. We examined attitudes toward smoke-free casino policies among US adults. During June and July 2017, we used a web-based survey to ask a nationally representative sample of 4107 adults aged ≥18 about their attitudes toward smoke-free casinos. Among 4048 respondents aged ≥18, a weighted 75.0% favored smoke-free casino policies, including respondents who visited casinos about once per year (74.1%), several times per year (75.3%), and at least once per month (74.2%). Although the sociodemographic characteristics of respondents who favored smoke-free casino policies varied, the majority in each group, except current smokers (45.4%), supported smoke-free policies. Allowing smoking inside casinos involuntarily exposes casino employees and visitors to SHS, a known and preventable health risk. Further assessment of public knowledge and attitudes toward smoke-free casinos at state and local levels may help inform tobacco control policy, planning, and practice.

National and state patterns of concept-flavoured cigar sales, USA, 2012-2016.

INTRODUCTION: Cigar sales have increased in the USA in recent years. A growing proportion of cigar sales are of flavoured varieties, many bearing ambiguous or 'concept' flavour descriptions (eg, Jazz). This study assessed US cigar sales by flavour category (ie, concept flavoured, characterising flavoured and tobacco), at national, regional and state levels. METHODS: Sales of cigarillos, large cigars and little cigars from chain, franchise and convenience stores, mass merchandisers, supermarkets, drug, dollar and club stores, and military commissaries during 2012-2016 were acquired from the Nielsen Company. US national-level and state-level sales, including District of Columbia, were analysed by flavour category. Flavour descriptors were classified as 'tobacco', 'characterising' or 'concept', based on Universal Product Code (UPC)-linked characteristics and brand website and consumer review descriptions. RESULTS: Cigar sales increased by 29% during 2012-2016, driven by a 78% increase in cigarillo sales. The proportion of concept-flavoured sales increased from 9% to 15%, while the proportion of sales decreased for tobacco (50% to 49%) and characterising flavours (eg, cherry) (41% to 36%). Cigarillos had the greatest increase in unique concept flavour descriptions (17 to 46 unique UPCs), with most sales occurring among Sweet, Jazz and Green Sweets concept flavours. By US region, total and concept-flavoured cigarillo sales were highest in the South. CONCLUSIONS: Flavoured cigars are increasingly labelled with concept flavours, including in areas with flavoured tobacco sales restrictions. Cigarillos are driving recent increases in US cigar and concept-flavoured cigar sales. It is important to consider concept flavours when addressing flavoured tobacco product sales and use.

Awareness and Ever Use of "Heat-Not-Burn" Tobacco Products Among U.S. Adults, 2017.

INTRODUCTION: Heated tobacco products, sometimes marketed as "heat-not-burn" technology, represent a diverse class of products that heat leaf tobacco to produce an inhaled aerosol. Global sales of heated tobacco products are increasing; however, the extent of current heated tobacco product awareness and use in the U.S. is unknown. This study assessed awareness and ever use of heated tobacco products among U.S. adults. METHODS: Data were obtained from the 2017 SummerStyles, an Internet survey of U.S. adults aged ≥18 years (N=4,107). Respondents were given a description of heated tobacco products, then asked about awareness and ever use. In 2017, descriptive statistics were calculated overall and by sex, age, race/ethnicity, and cigarette smoking status. Logistic regression was used to calculate AORs. RESULTS: In 2017, a total of 5.2% of U.S. adults were aware of heated tobacco products, including 9.9% of current cigarette smokers. Overall, 0.7% of U.S. adults, including 2.7% of current smokers, reported ever use of heated tobacco products. Odds of ever use were higher among current smokers (AOR=6.18) than never smokers, and higher among adults aged <30 years (AOR=3.35) than those aged ≥30 years. CONCLUSIONS: As of July 2017, few U.S. adults had ever used heated tobacco products; however, about one in 20 were aware of the products, including one in ten cigarette smokers. The uncertain impact of heated tobacco products on individual- and population-level health warrants timely and accurate public health surveillance. These first estimates among U.S. adults can serve as a key baseline measure.

Harm Perceptions of Intermittent Tobacco Product Use Among U.S. Youth, 2016.

PURPOSE: We aimed to describe U.S. youth harm perceptions of intermittent tobacco use. METHODS: Using data from the 2016 National Youth Tobacco Survey of U.S. students (grades 6-12; N = 20,675), we examined prevalence and correlates of all respondents' perceived harm of using four different tobacco products on "some days but not every day." Associations between current (past 30-day) use and harm perceptions were assessed using multivariable regression. RESULTS: Perceiving that intermittent use causes "no" or "little" harm was 9.7% for cigarettes, 12.0% for smokeless tobacco, 18.7% for hookah, and 37.5% for e-cigarettes. Compared with those who reported "a lot" of harm, youth with lower harm perceptions were more likely to report current use. CONCLUSIONS: One in ten youth perceived intermittent cigarette smoking as causing "little" or "no" harm; this perception was higher among current users. Efforts to educate youth about the risks of even intermittent tobacco product use could reduce misperceptions of harm.

National and State Trends in Sales of Cigarettes and E-Cigarettes, U.S., 2011-2015.

INTRODUCTION: In recent years, self-reported cigarette smoking has declined among youth and adults, while electronic cigarette (e-cigarette) use has increased. However, sales trends for these products are less certain. This study assessed national and state patterns of U.S. cigarette and e-cigarette unit sales. METHODS: Trends in cigarette and e-cigarette unit sales were analyzed using retail scanner data from September 25, 2011 through January 9, 2016 for: (1) convenience stores; and (2) all other outlets combined, including supermarkets, mass merchandisers, drug, dollar, and club stores, and military commissaries (online, tobacco-only, and "vape" shops were not available). Data by store type were available for the total contiguous U.S. and 29 states; combined data were available for the remaining states, except Alaska, Hawaii, and DC. RESULTS: During 2011-2015, cigarette sales exhibited a small, significant decrease; however, positive year-over-year growth occurred in convenience stores throughout most of 2015. E-cigarette unit sales significantly increased during 2011-2015, but year-over-year growth slowed and was occasionally negative. Cigarette unit sales exceeded e-cigarettes by 64:1 during the last 4-week period. During 2014-2015, cigarette sales increases occurred in 15 of 48 assessed states; e-cigarette sales increased in 18 states. CONCLUSIONS: Despite overall declines during 2011-2015, cigarette sales in 2015 grew for the first time in a decade. E-cigarette sales growth was positive, but slowed over the study period in assessed stores. Cigarette sales continued to exceed e-cigarette sales, reinforcing the importance of efforts to reduce the appeal and accessibility of cigarettes and other combusted tobacco products.