Biomarkers of Inflammation and Oxidative Stress among Adult Former Smoker, Current E-Cigarette Users-Results from Wave 1 PATH Study.

BACKGROUND: Former smokers who currently use e-cigarettes have lower concentrations of biomarkers of tobacco toxicant exposure than current smokers. It is unclear whether tobacco toxicant exposure reductions may lead to health risk reductions. METHODS: We compared inflammatory biomarkers (high-sensitivity C-reactive protein, IL6, fibrinogen, soluble intercellular adhesion molecule-1) and an oxidative stress marker (F2-isoprostane) among 3,712 adult participants in Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study by tobacco user groups: dual users of cigarettes and e-cigarettes; former smokers who currently use e-cigarettes-only; current cigarette-only smokers; former smokers who do not currently use any tobacco; and never tobacco users. We calculated geometric means (GM) and estimated adjusted GM ratios (GMR). RESULTS: Dual users experienced greater concentration of F2-isoprostane than current cigarette-only smokers [GMR 1.09 (95% confidence interval, CI, 1.03-1.15)]. Biomarkers were similar between former smokers who currently use e-cigarettes and both former smokers who do not use any tobacco and never tobacco users, but among these groups most biomarkers were lower than those of current cigarette-only smokers. The concentration of F2-isoprostane decreased by time since smoking cessation among both exclusive e-cigarette users (P trend = 0.03) and former smokers who do not currently use any tobacco (P trend = 0.0001). CONCLUSIONS: Dual users have greater concentration of F2-isoprostane than smokers. Exclusive e-cigarette users have biomarker concentrations that are similar to those of former smokers who do not currently use tobacco, and lower than those of exclusive cigarette smokers. IMPACT: This study contributes to an understanding of the health effects of e-cigarettes.

Association of Electronic Nicotine Delivery System Use With Cigarette Smoking Progression or Reduction Among Young Adults.

Importance: The prevalence of electronic nicotine delivery systems (ENDS) use, including e-cigarettes, among US young adults (YAs) has raised questions about how these products may affect future tobacco and nicotine use among YAs. Given this prevalence and that young adulthood is a critical period for the establishment of tobacco and nicotine use, it is important to consider the association between ENDS use and cigarette smoking specifically in this age group. Objective: To examine whether ENDS use frequency or intensity is associated with changes in cigarette smoking among US YA ever smokers during 1 year. Design, Setting, and Participants: This cohort study used 3 waves of data (2013-2014, 2014-2015, and 2015-2016) from the Population Assessment of Tobacco and Health (PATH) Study, an ongoing longitudinal cohort study of adults and youth. Unweighted 1:6 propensity score matching was used to match participants on wave 1 risk factors for ENDS use at wave 2. The changes in smoking between wave 2 and wave 3 were assessed using the matched sample. In total, 1096 ENDS-naive, ever cigarette-smoking YAs (18-24 years of age) at wave 1 who participated in wave 2 and wave 3 and who had complete data in the PATH Study were included in the analyses, which were conducted from August 2018 to October 2019. Exposures: Never ENDS use (n = 987), any previous 30-day ENDS use (n = 109), 1 to 5 days of ENDS use in the previous 30 days (n = 75), and 6 or more days ENDS use in the previous 30 days at wave 2 (n = 34). Main Outcomes and Measures: The analytic sample was selected using multiple variables based on peer-reviewed literature supporting associations with ENDS use. The main outcomes-changes in cigarette smoking behavior between wave 2 and wave 3-were defined using 2 measures: (1) change in smoking frequency, defined as the number of smoking days in the previous 30 days at wave 3 vs wave 2, and (2) change in smoking intensity, defined as the number smoking days in the previous 30 days multiplied by the mean number of cigarettes consumed on smoking days at wave 3 vs wave 2. Results: The present cohort analyses included 1096 YA ever smokers who were ENDS naive at wave 1. The majority of the sample were women (609 [55.6%]) and White individuals (698 [63.7%]), and the mean (SD) age was 21.4 (1.9) years. In wave 1, 161 YAs (14.7%) were daily smokers in the previous 30 days. After propensity score matching, no statistically significant associations were observed between any definition of wave 2 ENDS use and changes in either the frequency or intensity of smoking at wave 3. Conclusions and Relevance: In this cohort study of US YA ever smokers, ENDS use was not associated with either decreased or increased cigarette smoking during a 1-year period. However, it is possible that the rapidly evolving marketplace of vaping products may lead to different trajectories of YA cigarette and ENDS use in the future.

Biomarkers of Exposure among USA Adult Hookah Users: Results from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2014).

Hookah smoking has become common in the USA, especially among young adults. This study measured biomarkers of exposure to known tobacco product toxicants in a population-based sample of exclusive, established hookah users. Urinary biomarker data from 1753 adults in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study were used to compare geometric mean concentrations of biomarkers of exposure in exclusive, established past 30-day hookah users to never users of tobacco. Geometric mean ratios were calculated comparing hookah user groups with never users adjusting for age, sex, race/ethnicity, education, past 30-day marijuana use, secondhand smoke exposure and creatinine. Past 30-day hookah users (n = 98) had 10.6 times the urinary cotinine level of never tobacco users. Compared to never tobacco users, past 30-day hookah users had 2.3 times the level of the carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a metabolite of the tobacco-specific nitrosamine (TSNA) 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), 1.3 times higher polycyclic aromatic hydrocarbons (PAHs) 3-hydroxyfluorene and 1-hydroxypyrene, 1.8 times higher levels of acrylonitrile, 1.3 times higher levels of acrylamide, and 1.2 times higher levels of acrolein exposure. These data indicate that hookah use is a significant source of exposure to nicotine, carcinogens, and respiratory toxicants.

Use of Electronic Cigarettes in Smoke-Free Spaces by Smokers: Results from the 2014-2015 Population Assessment on Tobacco and Health Study.

Background: Smoke-free air policies exist to protect users and nonusers from exposure to tobacco smoke. Although electronic nicotine delivery systems (ENDS) may expose passerby to nicotine and particulate matter, few US states regulate indoor use of ENDS. The purpose of this study was to investigate reported rationales for ENDS use and reported ENDS use in public smoke-free places by dual cigarette/ENDS users. Methods: A population of ENDS/cigarette co-users (n = 2051) was drawn from Wave 2 of the Population Assessment of Tobacco and Health (PATH) dataset (2014-2015). Harm reduction beliefs and cessation behavior of co-users were investigated as predictors of ENDS use in public smoke-free places using logistic regression. Results: Fifty-eight percent of dual users reported past 30-day ENDS use in public smoke-free places. Reported use of ENDS to cut down on cigarette smoking (OR: 2.38, 95% CI: 1.86, 3.05), as an alternative to quitting tobacco (OR: 1.71, 95% CI: 1.37, 2.13), or because of belief that ENDS help people to quit cigarettes (OR: 1.52, 95% CI: 1.20, 1.92) were significantly associated with increased odds of ENDS use in smoke-free places. Conclusions: Beliefs that ENDS were useful as cessation tools or posed modified risk to users and nonusers were associated with elevated odds of use ENDS in locations where conventional tobacco is prohibited. Due to limitations in the survey instrument, in-home ENDS use could not be directly assessed in this analysis. However, these self-reported findings suggest that use of ENDS in public places where cigarette use is prohibited is prevalent enough to be of concern for future regulation and enforcement efforts.

Biomarkers of Exposure among Adult Smokeless Tobacco Users in the Population Assessment of Tobacco and Health Study (Wave 1, 2013-2014).

BACKGROUND: Monitoring population-level toxicant exposures from smokeless tobacco (SLT) use is important for assessing population health risks due to product use. In this study, we assessed tobacco biomarkers of exposure (BOE) among SLT users from the Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. METHODS: Urinary biospecimens were collected from adults ages 18 and older. Biomarkers of nicotine, tobacco-specific nitrosamines (TSNA), polycyclic aromatic hydrocarbons (PAH), volatile organic compounds (VOC), metals, and inorganic arsenic were analyzed and reported among exclusive current established SLT users in comparison with exclusive current established cigarette smokers, dual SLT and cigarette users, and never tobacco users. RESULTS: In general, SLT users (n = 448) have significantly higher concentrations of BOE to nicotine, TSNAs, and PAHs compared with never tobacco users; significant dose-response relationships between frequency of SLT use and biomarker concentrations were also reported among exclusive SLT daily users. Exclusive SLT daily users have higher geometric mean concentrations of total nicotine equivalent-2 (TNE2) and TSNAs than exclusive cigarette daily smokers. In contrast, geometric mean concentrations of PAHs and VOCs were substantially lower among exclusive SLT daily users than exclusive cigarette daily smokers. CONCLUSIONS: Our study produced a comprehensive assessment of SLT product use and 52 biomarkers of tobacco exposure. Compared with cigarette smokers, SLT users experience greater concentrations of some tobacco toxicants, including nicotine and TSNAs. IMPACT: Our data add information on the risk assessment of exposure to SLT-related toxicants. High levels of harmful constituents in SLT remain a health concern.

Biomarkers of Exposure among U.S. Adult Cigar Smokers: Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014).

BACKGROUND: Given the diverse cigar market and limited data on biomarker patterns by cigar type, we compared biomarkers of nicotine and tobacco toxicants among cigar smokers and other groups. METHODS: Using Wave 1 urinary biomarker data from 5,604 adults in the Population Assessment of Tobacco and Health (PATH) Study, we compared geometric mean concentrations among cigar-only smokers (all cigars and separately for traditional, cigarillo, and filtered cigars), cigarette-only smokers, dual cigar/cigarette smokers, and never users of tobacco. We calculated geometric mean ratios comparing groups with never users adjusting for sex, age, race/ethnicity, education and creatinine. RESULTS: Some day cigar-only smokers had lower biomarker concentrations than every day cigar-only smokers, but higher than never users. Every day cigar-only smokers (n = 61) had lower TNE-2 (cotinine+trans-3'-hydroxycotinine) compared to every day cigarette-only (n = 2217; P < 0.0001) and dual cigar/cigarette smokers (n = 601; P < 0.0001). Several biomarkers, including NNAL (NNK metabolite) and CYMA (metabolite of acrylonitrile), were comparable in these groups. In exploratory analyses, every day filtered cigar-only (n = 7) smokers had higher biomarker concentrations compared with every day traditional cigar-only smokers (n = 12) and cigarillo-only smokers (n = 24). Every day smokers of each cigar type were similar to exclusive cigarette smokers. For some biomarkers, particularly for every day filtered cigar-only smokers, concentrations were higher. CONCLUSIONS: For some biomarkers, every day cigar-only smokers were comparable with every day cigarette-only smokers. Exploratory analyses suggest that biomarkers vary by cigar type with every day filtered cigar-only smokers having the highest concentrations. IMPACT: High exposure to harmful constituents among cigar smokers is a continuing health issue.

Longitudinal e-Cigarette and Cigarette Use Among US Youth in the PATH Study (2013-2015).

BACKGROUND: Evidence is accumulating that youth who try Electronic Nicotine Delivery Systems (ENDS, e-cigarettes) may go on to try cigarettes. This analysis examines the bidirectional patterns of ENDS and cigarette use among US youth over one year and uses propensity score matching (PSM) to examine frequency of ENDS use on changes in cigarette smoking. METHODS: Our analysis included 11 996 participants who had two waves of available data (Wave 1 [W1] 2013-2014; Wave 2 [W2] 2014-2015) drawn from the longitudinal Population Assessment of Tobacco and Health Study. Cross-sectional weighted prevalence estimates are reported for cigarettes and ENDS. We used PSM to estimate the likelihood of ENDS use at W1 and to draw matched analytic samples, then used regression (logistic or linear) models to examine the effect of W1 ENDS use on W2 cigarette smoking. All statistical tests were two-sided. RESULTS: In weighted analyses, 69.3% of W1 past-30-day cigarette smokers exhibited past-30-day smoking at W2; 42.2% of W1 past-30-day ENDS users were using ENDS at W2. W1 ever use of either product was similarly associated with W2 new use of the other product. Unweighted PSM models indicated W1 cigarette-naïve ENDS use was associated with W2 ever-cigarette smoking (n = 676; adjusted odds ratio = 3.21, 95% confidence interval [CI] = 1.95 to 5.45, P < .001); W1 ever-ENDS use did not affect change in cigarette frequency at W2 (n = 1020, beta = 0.31, 95% CI = -0.76 to 1.39, P = .57); 1-5 days ENDS use compared with ever, no past-30-day ENDS use was associated with a statistically significant decrease of W2 smoking days (n = 256, beta = -2.64, 95% CI = -4.96 to -0.32; P = .03); and W1 6+ day ENDS users did not show a decrease in frequency of cigarette smoking. CONCLUSIONS: Ever-ENDS use predicts future cigarette smoking, and frequency of ENDS use has a differential impact on subsequent cigarette smoking uptake or reduction. These results suggest that both cigarettes and ENDS should be targeted in early tobacco prevention efforts with youth.

Air quality and presence of air ventilation systems inside waterpipe cafés in North Carolina.

BACKGROUND: After North Carolina (NC) fire inspectors detected unsafe carbon monoxide (CO) levels inside several waterpipe cafés, the state fire code was amended to include provisions regulating waterpipe cafés, adding a requirement for air ventilation. These regulations apply to new buildings constructed after 1 January 2016, but can be enforced for older buildings where there exists a distinct hazard to life. We measured air quality at a sample of waterpipe cafés before and after the starting date of this regulation and collected information on presence of air ventilation. METHODS: Air quality (CO, fine particulate matter (PM2.5)) monitoring was conducted inside and outside of six waterpipe cafés in NC in September of 2015 (time 1) and September of 2016 (time 2). In addition, questionnaires were administered to managers from each waterpipe café at time 2 to determine the presence of air ventilation systems. RESULTS: Elevated levels of CO and PM2.5 were found inside waterpipe cafés at time 1 (median CO=42 ppm; median PM2.5=379.3 µg/m3) and time 2 (median CO=65 ppm; median PM2.5=484.0 µg/m3), with no significant differences between time periods (p>0.05). Indoor levels were significantly higher than levels outside cafés at both time periods (p<0.05). All waterpipe cafés reported having an air ventilation system that was installed prior to time 1 air monitoring. CONCLUSIONS: Unsafe levels of CO and PM2.5 were observed in waterpipe cafés in NC, despite reported use of air ventilation systems. Prohibiting indoor waterpipe smoking may be necessary to ensure clean air for employees and patrons.

Examining the Association between Body Burdens of Harmful Chemicals and Heaviness of Marijuana Smoking.

Marijuana is seeing increased use both globally and domestically. However, the scientific community has not fully reached a consensus about what negative health effects and to what extent marijuana smoking may cause. In this study, we evaluated the associations between the body burdens of polycyclic aromatic hydrocarbons (PAHs) among marijuana smokers and the smoking heaviness. We observed clear, increasing trends of PAH body burdens as marijuana smoking increased. The findings highlight the importance of capturing the heaviness of marijuana smoking in future studies and support the need for well-designed toxicological and epidemiological studies for understanding the health effects of marijuana use in a changing environment.

Examining Hookah as an Introduction to Nicotine Products among College Students.

BACKGROUND: Limited data exist on what young adults report as their first-ever nicotine product; some evidence suggests that they report hookah as their first product smoked. OBJECTIVES: This study reports on the first nicotine product used among undergraduates who had ever tried tobacco, and explores correlates of hookah as that first product. METHODS: Participants included a convenience sample of undergraduate students (n = 1538) at four universities in upstate New York during fall 2013. Descriptive statistics assessed first nicotine product used and prevalence of current use. Logistic regression was used to examine correlates of hookah as the first nicotine product used. RESULTS: Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. Among students who ever smoked cigarettes, most reported cigarettes as their introductory product. Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. Among ever nicotine users, current hookah smoking was common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. Never users of cigarettes, females, and non-Hispanic African Americans, had higher adjusted odds of reporting hookah as their introductory product. CONCLUSIONS: The results of this study have implications for the identification of risk factors for tobacco initiation, the assessment of tobacco use patterns and behaviors, and the tailoring of tobacco prevention initiatives among youth. Our findings suggest that broadening prevention efforts beyond a focus on combustible cigarettes may be warranted.

Patterns and Trends of Hookah Use among New Jersey Youth: New Jersey Youth Tobacco Survey 2008-2014.

OBJECTIVES: In this study, the aim was to document trends of ever, past 30-day, and frequent (use on > 10 days/month) hookah use among New Jersey (NJ) high school students. METHODS: Data were analyzed from the 2008-2014 waves of the NJ Youth Tobacco Survey, a biennial survey of public high school students in grades 9-12 with a mean age of 15 years. Multivariable logistic regressions assessed trends and correlates of hookah use. Descriptive statistics were used to summarize the use of cigarettes, electronic cigarettes, and other tobacco products (including cigars, smokeless tobacco, and bidis). RESULTS: In 2014, past 30-day hookah use (11.8%) was as high as e-cigarette use (12.1%) and higher than other tobacco products. The adjusted odds of ever, past 30-day, and frequent hookah use were significantly higher in 2014 than 2008. Past 30-day hookah use was more common among users of other tobacco products. CONCLUSIONS: Effective strategies have been used in cigarette tobacco control, and cigarette consumption has decreased as a result. Similar strategies should be employed to encompass emerging tobacco products, with necessary modifications to reduce the prevalence of all tobacco use among youth.

Brief Report: Lead Levels in Selected Electronic Cigarettes from Canada and the United States.

Few published studies have investigated the presence of lead in the e-liquid of electronic nicotine delivery systems (ENDS). Lead inhalation is associated with increased risk of stroke, heart disease, and other diseases. This study used a novel application of graphite furnace technology to compare the concentration of lead between e-liquids of different packaging and product designs using e-liquids that are or were commercially available in the United States and Canada. Eleven nicotine-free disposable ENDS devices and 12 bottled refill solutions that contained nicotine were purchased from retailers in Canada and the United States between 2015 and 2017. E-liquids extracted from the disposable products and individual containers were analyzed for lead content by graphite furnace using atomic absorption detection. The lead concentration of open-wick ENDS devices ranged from 25.2 ppb to 838.4 ppb, with a standard deviation of 187.4 ppb. None of the bottled e-liquids contained quantifiable levels of lead. This study found that quantifiable levels of lead are present in certain disposable e-cigarette devices, and there is evidence from this study that the design of ENDS devices may contribute to lead exposure. These findings suggest that lead testing should be incorporated into future chemical analyses of ENDS devices.

Urinary Metabolite Levels of Flame Retardants in Electronic Cigarette Users: A Study Using the Data from NHANES 2013-2014.

Evaluating the safety of e-cigarettes and making informed judgement about developing potential standards require sufficient scientific evidence. Since e-cigarettes are highly engineered products containing plastic, glass and metal parts, and e-liquids are largely different matrices, many toxic compounds which are not typical hazards for the users of combustible tobacco products (e.g., cigarettes), could exist in e-liquids, and consequently, posing potential health risk to e-cigarette users. We combined the measurements of urinary metabolites of organophosphate flame retardants (OPFRs) with questionnaire data collected in the National Health and Nutrition Examination Surveys (NHANES) from 2013 to 2014, and we compared adjusted geometric means (GM) for each biomarker in e-cigarette users with levels in non-users and users of various tobacco products using multiple regression analyses to adjust for potential confounders. We found diphenyl phosphate (DPhP), bis(1,3-dichloro-2-propyl) phosphate (BDCPP), bis(2-chloroethyl) phosphate (BCEP), and dibutyl phosphate (DBUP) were detected in all e-cigarette users. The adjusted GM of BCEP, the metabolite of tris(2-chloroethyl) phosphate (TCEP), was 81% higher than nonusers (p = 0.0124) and significantly higher than those for both cigarette and cigar users (p < 0.05). The findings in this pilot study suggest that certain OPFRs may present in e-cigarettes as contaminants, and consequently, resulting in higher exposure levels in e-cigarette users compared to nonusers. As we only identified 14 e-cigarette users in the survey, the findings in this study need to be confirmed in future study at a larger scale. A better examination of the types and levels of FRs and their potential contamination sources in e-cigarettes is also needed.

Attitudes and experiences with secondhand smoke and smoke-free policies among subsidised and market-rate multiunit housing residents living in six diverse communities in the USA.

BACKGROUND: Given that higher smoking rates persist among lower socioeconomic populations, multiunit housing (MUH) environments may result in higher secondhand smoke (SHS) exposures among subsidised MUH residents. This cross-sectional assessment compares experiences with SHS and smoke-free policies among subsidised and market-rate MUH residents living in six US communities. METHODS: MUH residents (n=1565) were surveyed regarding their smoke-free rules (home and building), SHS exposures and preferences towards smoke-free policies. Binary logistic regression identified predictors of each outcome, focusing on differences by subsidised housing status (subsidised vs market rate). RESULTS: Among residents enforcing smoke-free home rules (76%, overall), 50% reported SHS incursions into their unit. Only 23% reported living in a smoke-free building; 56% of those living in smoking-allowable buildings reported preferences towards smoke-free building policies. Among market-rate housing residents, smoke-free home (OR=4.18) and building (OR=2.26) rules were significantly higher when children were present. Smoke-free building rules reduced the odds of SHS incursions among market-rate housing residents (OR=0.50), but no association was observed among subsidised housing residents. Non-smoking subsidised housing residents exhibited stronger preferences for smoke-free policies compared with those in market-rate housing. DISCUSSION: Smoke-free home rules may not protect MUH residents from SHS exposures, particularly in subsidised MUH. Although strong preferences towards smoke-free policies were present overall, subsidised MUH residents may have fewer alternative smoke-free housing options available. Therefore, all publicly funded housing should be smoke free to protect these vulnerable populations. However, continued efforts to encourage privately owned MUH operators to adopt smoke-free policies are also necessary.

Waterpipe cafés are hazardous to your health: Determination of a waterpipe specific calibration factor.

INTRODUCTION: The use of a waterpipe to smoke tobacco has emerged as a popular trend in the United States. Waterpipe smoking establishments have had an increasing presence in the U.S., despite smoke-free air legislation. Dangers of waterpipe smoking have been documented, but less data has been gathered about the waterpipe café itself. This project sought to determine a waterpipe-specific calibration factor (CF) for measuring waterpipe aerosol, and field-test this CF by conducting surveillance on the existing waterpipe cafés of western and central New York. METHODS: Nine laboratory-controlled experiments were conducted to determine a waterpipe-specific CF. In the lab, two TSI SidePak AM510 Personal Aerosol Monitors and two sampling trains for gravimetric PM2.5 sampling were present during waterpipe smoking sessions (lasting 1-3h). Indoor air quality was assessed in 7 waterpipe cafés in three counties of New York, and real-time measurements of particulate matter (PM2.5) and carbon monoxide (CO) were obtained. RESULTS: Results from the 9 controlled waterpipe experiments determined a calibration factor of 0.38 (SD 0.08), which should be used to convert SidePak measurements to true PM2.5 measurements. When applying the CF to the measurements taken in the 7 public waterpipe venues, the mean PM2.5 concentration was 515µg/m3 micrograms per cubic meter (SD=338.8) while the mean ambient CO was 20.5ppm (SD=18.3). The mean active smoking density was 2.41 waterpipes per 100m3 of air. The PM2.5 levels increased with increasing active smoking density (rho=0.68, p=0.09). CONCLUSIONS: Applying the waterpipe-specific CF for the SidePak, 0.38, allowed for field assessments to be conducted in locations with waterpipe smoke to determine accurate particle exposure concentrations. The concentrations of both particulate matter and carbon monoxide were above established air quality standards and therefore increase the health risks of both patrons and workers of these establishments.

Patterns of Use of Smokeless Tobacco in US Adults, 2013-2014.

OBJECTIVES: To examine patterns of smokeless tobacco (SLT) use, by type, in wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study in the United States. METHODS: We analyzed data from 32 320 adults (aged ≥ 18 years) to assess the use of pouched snus and other SLT products (loose snus, moist snuff, dip, spit, and chewing tobacco). RESULTS: Overall, SLT use was most common among men, younger adults, non-Hispanic Whites, and nonurban respondents. Pouched snus users were more likely to report nondaily and polytobacco use than users of other SLT products. Respondents who used SLT some days were more likely to be current established cigarette smokers than those who used SLT every day (57.9% vs 20.2%). Furthermore, current established smokers who used SLT some days were more likely to smoke every day and had a higher median number of cigarettes smoked per day than smokers who used SLT every day. CONCLUSIONS: Polytobacco use, especially cigarette smoking, is common among SLT users. Pouched snus users are more likely to report nondaily snus use and polytobacco use than users of other SLT products.

Tobacco-Product Use by Adults and Youths in the United States in 2013 and 2014.

BACKGROUND: Noncigarette tobacco products are evolving rapidly, with increasing popularity in the United States. METHODS: We present prevalence estimates for 12 types of tobacco products, using data from 45,971 adult and youth participants (≥12 years of age) from Wave 1 (September 2013 through December 2014) of the Population Assessment of Tobacco and Health (PATH) Study, a large, nationally representative, longitudinal study of tobacco use and health in the United States. Participants were asked about their use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe tobacco, hookah, snus pouches, other smokeless tobacco, dissolvable tobacco, bidis, and kreteks. Estimates of the prevalence of use for each product were determined according to use category (e.g., current use or use in the previous 30 days) and demographic subgroup, and the prevalence of multiple-product use was explored. RESULTS: More than a quarter (27.6%) of adults were current users of at least one type of tobacco product in 2013 and 2014, although the prevalence varied depending on use category. A total of 8.9% of youths had used a tobacco product in the previous 30 days; 1.6% of youths were daily users. Approximately 40% of tobacco users, adults and youths alike, used multiple tobacco products; cigarettes plus e-cigarettes was the most common combination. Young adults (18 to 24 years of age), male adults and youths, members of racial minorities, and members of sexual minorities generally had higher use of tobacco than their counterparts. CONCLUSIONS: During this study, 28% of U.S. adults were current users of tobacco, and 9% of youths had used tobacco in the previous 30 days. Use of multiple products was common among tobacco users. These findings will serve as baseline data to examine between-person differences and within-person changes over time in the use of tobacco products. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration.).

Tobacco Smoke Pollution in Hospitality Venues Before and After Passage of Statewide Smoke-Free Legislation.

OBJECTIVE: In 2012, North Dakota enacted a comprehensive statewide law prohibiting smoking in enclosed public places. Disparities in tobacco control exist in rural areas. This study's objective was to determine the extent to which the passage of a comprehensive, statewide, smoke-free law in a predominantly rural state influenced tobacco smoke pollution in rural and nonrural venues. DESIGN AND SAMPLE: A longitudinal cohort design study comparing the levels of tobacco smoke pollution before and after passage of the statewide smoke-free law was conducted in 64 restaurants and bars statewide in North Dakota. MEASURES: Particulate matter with a median aerodynamic diameter of <2.5 µm (a valid atmospheric marker of tobacco smoke pollution) was assessed. RESULTS: A significant 83% reduction in tobacco smoke pollution levels occurred after passage of the law. Significant reductions in tobacco smoke pollution levels occurred in each of the rural categories; however, no difference by rurality was noted in the analysis after passage of the law, in contrast to the study before passage. CONCLUSIONS: To our knowledge, this was the largest, single, rural postlaw study globally. A comprehensive statewide smoke-free law implemented in North Dakota dramatically decreased the level of tobacco smoke pollution in bars and restaurants.

Tobacco smoke exposure and impact of smoking legislation on rural and non-rural hospitality venues in North Dakota.

The purpose of this cross-sectional study in a stratified random sample of 135 bars and restaurants in North Dakota was to describe factors that influenced tobacco smoke pollution levels in the venues; to compare the quantity of tobacco smoke pollution by rurality and by presence of local ordinances; and to assess compliance with state and local laws. In data collection in 2012, we measured the indoor air quality indicator of particulate matter (2.5 microns aerodynamic diameter or smaller), calculated average smoking density and occupant density, and determined compliance with state and local smoking ordinances using observational methods. As rurality increased, tobacco smoke pollution in bars increased. A significant association was found between stringency of local laws and level of tobacco smoke pollution, but the strength of the association varied by venue type. Compliance was significantly lower in venues in communities without local ordinances. Controlling for venue type, 69.2% of smoke-free policy's impact on tobacco smoke pollution levels was mediated by observed smoking. This study advances scientific knowledge on the factors influencing tobacco smoke pollution and informs public health advocates and decision makers on policy needs, especially in rural areas.

Design Characteristics and Tobacco Metal Concentrations in Filtered Cigars.

INTRODUCTION: While U.S. cigarette consumption has declined, cigar use has steadily increased, for reasons including price compared to cigarettes and the availability of filtered varieties resembling cigarettes, and flavors that have been banned in cigarettes (excluding menthol). Little published data exists on the design characteristics of such cigars. METHODS: A variety of filtered cigar brands were tested for design characteristics such as whole cigar weight, ventilation, and per-cigar tobacco weight. Cigar sticks were then sent to the University of St. Andrews for metal concentration testing of As, Pb, Cr, Ni, and Cd. RESULTS: Large and small cigars were statistically different between cigar weight (p ≤ .001), per-cigar tobacco weight (p = .001), rod diameter (p = .006), and filter diameter (p = .012). The differences in mean ventilation (overall mean = 19.6%, min. = 0.84%, max. = 57.6%) across filtered cigar brands were found to be statistically significant (p = .031), and can be compared to the ventilation of the average of 2013 U.S. Marlboro Red, Gold, and Silver packs at 29% ventilation. There were no significant differences for metal concentrations between cigar types (p = .650), with Pb and As levels being similar to U.S. 2009 cigarette concentrations, Cd cigar levels being slightly higher, and Cr and Ni levels much lower than cigarette levels. CONCLUSIONS: With cigar use rising, and filtered cigars displaying substantial similarities to filtered cigarettes, more research on product characteristics is warranted. Future plans include testing tobacco alkaloid and more observation of cigar weight for tax bracket purposes.