Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

INTRODUCTION: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the lung injuries outbreak, flavour bans, Tobacco 21 and the COVID-19 pandemic. METHODS: Using the Population Assessment of Tobacco and Health Study, we applied a multistate transition model to 28 061 adults in waves 4-5 (2017-2019) and 24 584 adults in waves 5-6 (2019-2021), estimating transition rates for initiation, cessation and switching products for each period overall and by age group. RESULTS: Cigarette initiation among adults who never used either product decreased from 2017-2019 to 2019-2021, but ENDS initiation did not significantly change. The persistence of ENDS-only use remained high (75%-80% after 1 year). Cigarette-only use transitions remained similar (88% remaining, 7% to non-current use and 5% to dual or ENDS-only use). In contrast, dual use to ENDS-only transitions increased from 9.5% (95% CI 7.3% to 11.7%) to 20.0% (95% CI 17.4% to 22.6%) per year, decreasing the persistence of dual use. The dual to cigarette-only use transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. CONCLUSIONS: The persistence of ENDS use among adults remained high in 2019-2021, but a larger fraction of dual users transitioned to ENDS-only use compared with 2017-2019. Because the fraction of cigarette-only users switching to dual use remained low, especially among older adults, the public health implications of this change are minimal.

Smoking patterns by birth cohort in Argentina: an age-period-cohort population-based modeling study.

Background: Argentina's smoking rates remain high. We aim to estimate Argentina age-specific histories of smoking initiation, cessation, prevalence, and intensity by birth-cohort to inform policy interventions. Methods: Modeling study. Data from three Argentinian nationally representative surveys conducted from 2004 to 2018 (n = 268,193) were used to generate smoking histories. The Cancer Intervention and Surveillance Modeling (CISNET) Network Lung Working Group age, period, and cohort modeling approach was used to calculate smoking initiation and cessation probabilities, ever and current smoking prevalence, and intensity (cigarettes per day, CPD) by age, sex, and birth cohort from 1950 to 2018. Findings: Ever smoking prevalence increases with age up to 25 and decreases with birth cohorts after 1990. Smoking initiation peaks between 15 and 18 years of age. Among females, initiation probabilities increased until the 1955 cohort, reaching a second peak in 1980-85 cohorts and declining thereafter. Males have higher initiation probabilities than females. Among males, initiation has decreased since the 1950 birth cohort, with a slight increase around the 1985 cohort. Current smoking prevalence has been decreasing since the 1960 birth cohort, except for a peak in 1980-85 cohorts. Cessation increases with age. Mean CPD increases with age and peaks around age 40, appearing flat in females since the 1985 cohort. Interpretation: Recent birth cohorts seem to be experiencing lower rates of initiation, stable rates of quitting and lower current and ever smoking prevalence. The stabilization of cessation probabilities and mean CPD indicate the need to strengthen existing tobacco control measures and advance new ones. Funding: NIH/NCI U01CA253858 grant.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021.

Introduction: The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019. Methods: Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group. Results: Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use. Conclusions: Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of youth and adults in the PATH Study in 2015-2017 vs 2017-2019.

INTRODUCTION: It is unknown how recent changes in the tobacco product marketplace have impacted transitions in cigarette and electronic nicotine delivery system (ENDS) use. METHODS: A multistate transition model was applied to 24 242 adults and 12 067 youth in waves 2-4 (2015-2017) and 28 061 adults and 12 538 youth in waves 4 and 5 (2017-2019) of the Population Assessment of Tobacco and Health Study. Transition rates for initiation, cessation and product transitions were estimated in multivariable models, accounting for gender, age group, race/ethnicity and daily versus non-daily product use. RESULTS: Changes in ENDS initiation/relapse rates depended on age, including among adults. Among youth who had never established tobacco use, the 1-year probability of ENDS initiation increased after 2017 from 1.6% (95% CI 1.4% to 1.8%) to 3.8% (95% CI 3.4% to 4.2%). Persistence of ENDS-only use (ie, 1-year probability of continuing to use ENDS only) increased for youth from 40.7% (95% CI 34.4% to 46.9%) to 65.7% (95% CI 60.5% to 71.1%) and for adults from 57.8% (95% CI 54.4% to 61.3%) to 78.2% (95% CI 76.0% to 80.4%). Persistence of dual use similarly increased for youth from 48.3% (95% CI 37.4% to 59.2%) to 60.9% (95% CI 43.0% to 78.8%) and for adults from 40.1% (95% CI 37.0% to 43.2%) to 63.8% (95% CI 59.6% to 67.6%). Youth and young adults who used both products became more likely to transition to ENDS-only use, but middle-aged and older adults did not. CONCLUSIONS: ENDS-only and dual use became more persistent. Middle-aged and older adults who used both products became less likely to transition to cigarette-only use but not more likely to discontinue cigarettes. Youth and young adults became more likely to transition to ENDS-only use.

Smoking Disparities by Level of Educational Attainment and Birth Cohort in the U.S.

INTRODUCTION: Little is known about how U.S. smoking patterns of initiation, cessation, and intensity vary by birth cohort across education levels or how these patterns may be driven by other demographic characteristics. METHODS: Smoking data for adults aged ≥25 years was obtained from the National Health Interview Surveys 1966-2018. Age-period-cohort models were developed to estimate the probabilities of smoking initiation, cessation, intensity, and prevalence by age, cohort, calendar year, and gender for education levels: ≤8th grade, 9th-11th grade, high school graduate or GED, some college, and college degree or above. Further analyses were conducted to identify the demographic factors (race/ethnicity and birthplace) that may explain the smoking patterns by education. Analyses were conducted in 2020-2021. RESULTS: Smoking disparities by education have increased by birth cohort. In recent cohorts, initiation probabilities were highest among individuals with 9th-11th-grade education and lowest among individuals with at least a college degree. Cessation probabilities were higher among those with higher education. Current smoking prevalence decreased over time across all education groups, with important differences by gender. However, it decreased more rapidly among individuals with ≤8th grade education, resulting in this group having the second lowest prevalence in recent cohorts. This may be driven by the increasing proportion of non-U.S. born Hispanics in this group. CONCLUSIONS: Although smoking is decreasing by cohort across all education groups, disparities in smoking behaviors by education have widened in recent cohorts. Demographic changes for the ≤8th-grade education group need special consideration in analyses of tobacco use by education.

Summary and Concluding Remarks: Patterns of Birth Cohort‒Specific Smoking Histories.

The Cancer Intervention and Surveillance Modeling Network (CISNET) Lung Working Group age-period-cohort methodology to study smoking patterns can be applied to tackle important issues in tobacco control and public health. This paper summarizes the analyses of smoking patterns in the U.S. by race/ethnicity, educational attainment, and family income and for each of the 50 U.S. states using the CISNET Lung Working Group age-period-cohort approach. We describe how decision makers, policy advocates, and researchers can use the sociodemographic analyses in this supplement to project state smoking trends and develop effective state-level tobacco control strategies. The all-cause mortality RR estimates associated with smoking for U.S. race/ethnicity and education groups are also discussed in the context of research that measures and evaluates health disparities. Finally, the application of the CISNET Lung Working Group age-period-cohort methodology to Brazil is reviewed with a view to how the same types of analyses can be applied to other low- and middle-income countries.

Patterns of Birth Cohort‒Specific Smoking Histories in Brazil.

INTRODUCTION: Smoking prevalence has decreased considerably in Brazil from 34.8% in 1989 to 12.6% in 2019 owing to the implementation of strong tobacco control policies. However, recent data show that the downward trend may be stagnating. Detailed analyses of historical smoking patterns by birth cohort could guide tobacco control decision making in Brazil. METHODS: Using the 2008 Global Adult Tobacco Survey and the 2013 and 2019 National Health Surveys, historical smoking patterns in Brazil were estimated, supplemented with data from the 2006‒2019 Surveillance System of Risk Factors for Chronic Diseases by Telephone Interviews. Age‒period‒cohort models with constrained natural splines were applied to estimate the annual probabilities of smoking initiation and cessation, current smoker prevalence, and mean cigarettes smoked per day by age, gender, and birth cohort. Analysis was conducted in 2021‒2022. RESULTS: Current smoker prevalence has declined considerably since the 1950 and 1955 birth cohorts for males and females, respectively, reflecting decreased smoking initiation and increased smoking-cessation probabilities over time. Among female cohorts born on or after 2000, smoking initiation may be increasing even as their smoking cessation has increased considerably. Mean cigarettes smoked per day has remained relatively constant across period and cohorts, showing only a minor decrease among males. CONCLUSIONS: These detailed cohort-specific smoking parameters can be used to inform models that evaluate the impact of tobacco use and policies on long-term health outcomes and guide public health decision making in Brazil. Stagnant mean cigarettes smoked per day, increasing female smoking initiation, and limited improvement in male cessation among recent cohorts present challenges to tobacco control.

Birth Cohort‒Specific Smoking Patterns by Family Income in the U.S.

INTRODUCTION: In the U.S., low-income individuals generally smoke more than high-income individuals. However, detailed information about how smoking patterns differ by income, especially differences by birth cohort, is lacking. METHODS: Using the National Health Interview Survey 1983-2018 data, individual family income was calculated as a ratio of the federal poverty level. Missing income data from 1983 to 1996 were imputed using sequential regression multivariate imputation. Age‒period‒cohort models with constrained natural splines were used to estimate annual probabilities of smoking initiation and cessation and smoking prevalence and intensity by gender and birth cohort (1900-2000) for 5 income groups: <100%, 100%-199%, 200%-299%, 300%-399%, and ≥400% of the federal poverty level. Analysis was conducted in 2020-2021. RESULTS: Across all income groups, smoking prevalence and initiation probabilities are decreasing by birth cohort, whereas cessation probabilities are increasing. However, relative differences between low- and high-income groups are increasing markedly, such that there were greater declines in prevalence among those in high-income groups in more recent cohorts. Smoking initiation probabilities are lowest in the ≥400% federal poverty level group for males across birth cohorts, whereas for females, this income group has the highest initiation probabilities in older cohorts but the lowest in recent cohorts. People living below the federal poverty level have the lowest cessation probabilities across cohorts. CONCLUSIONS: Smoking prevalence has been decreasing in all income groups; however, disparities in smoking by family income are widening in recent birth cohorts. Future studies evaluating smoking disparities should account for cohort differences. Intervention strategies should focus on reducing initiation and improving quit success among low-income groups.

Patterns of Birth Cohort‒Specific Smoking Histories by Race and Ethnicity in the U.S.

INTRODUCTION: U.S. smoking prevalence varies greatly by race/ethnicity. However, little is known about how smoking initiation, cessation, and intensity vary by birth cohort and race/ethnicity. METHODS: Adult smoking data were obtained from the 1978-2018 National Health Interview Surveys. Age‒period‒cohort models with constrained natural splines were developed to estimate historical smoking patterns among non-Hispanic White, non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, and non-Hispanic American Indian and Alaskan Native individuals. Annual smoking prevalence and probabilities of smoking initiation, cessation, and intensity by age, year, gender, and race/ethnicity were estimated for the 1900 to 2000 birth cohorts. Analysis was conducted in 2020-2021. RESULTS: Smoking initiation probabilities were highest for the American Indian and Alaskan Native population, second highest among the non-Hispanic White population, and lowest among Asian and Pacific Islander and Hispanic populations across birth cohorts. Historically, initiation probabilities among non-Hispanic Black populations were comparable with those among non-Hispanic White populations but have decreased since the 1970 birth cohort. Cessation probabilities were lowest among American Indian and Alaskan Native and non-Hispanic Black populations and highest among non-Hispanic White and Asian and Pacific Islander populations across cohorts and ages. Initiation and cessation probabilities produce observed patterns of smoking where prevalence among American Indian and Alaskan Native populations is highest across all ages and cohorts. Across cohorts, smoking prevalence among non-Hispanic Black populations, particularly males, is lower than among non-Hispanic White populations at younger ages but higher at older ages. CONCLUSIONS: There are important and persistent racial/ethnic differences in smoking prevalence, initiation, cessation, and intensity across U.S. birth cohorts. Targeted interventions should address widening smoking disparities by race/ethnicity, particularly for American Indian and Alaskan Native and non-Hispanic Black populations.

Smoking Histories by State in the U.S.

INTRODUCTION: Smoking rates across U.S. states have declined at different rates over time because some states have progressive tobacco control policies, whereas others have yet to adopt them. Therefore, each state has its own unique historical experience of smoking initiation, cessation, and prevalence. This study characterizes smoking histories for each U.S. state by birth cohort. METHODS: Using 1965-2018 National Health Interview Survey and 1992-2019 Tobacco Use Supplement to the Current Population Survey data, statistical methods applied an age‒period‒cohort modeling framework to reconstruct population-level smoking histories for each state. Smoking initiation, cessation, and intensity by age, gender, and cohort were estimated for each state. These were used to construct state-specific trends in the prevalence of current, former, and never smoking as well as the mean smoking duration and pack years. Analysis was conducted from 2017 to 2022. RESULTS: California and Kentucky, respectively, are exemplar states of more and less aggressive tobacco control. Initiation probabilities were consistently lower in California than in Kentucky, and cessation probabilities were higher. Hence, the smoking prevalence derived from these parameters is higher in Kentucky. The intensity of cigarette smoking was higher in Kentucky than in California, yielding considerably higher estimated pack years when used with the other parameters. Summaries of smoking trends are given for all states. CONCLUSIONS: Smoking initiation, cessation, and intensity trends vary substantially across states, resulting in major differences in estimated smoking prevalence, duration, and pack years. Some states show improvements in smoking metrics over time with more recent birth cohorts, but others have shown very little.

Childhood asthma and household exposures to nitrogen dioxide and fine particles: a triple-crossover randomized intervention trial.

OBJECTIVE: Triple-crossover randomized controlled intervention trial to test whether reduced exposure to household NO2 or fine particles results in reduced symptoms among children with persistent asthma. METHODS: Children (n = 126) aged 5-11 years with persistent asthma living in homes with gas stoves and levels of NO2 15 ppb or greater recruited in Connecticut and Massachusetts (2015-2019) participated in an intervention involving three air cleaners configured for: (1) NO2 reduction: sham particle filtration and real NO2 scrubbing; (2) particle filtration: HEPA filter and sham NO2 scrubbing; (3) control: sham particle filtration and sham NO2 scrubbing. Air cleaners were randomly assigned for 5-week treatment periods using a three-arm crossover design. Outcome was number of asthma symptom-days during final 14 days of treatment. Treatment effects were assessed using repeated measures, linear mixed models. RESULTS: Measured NO2 was lower (by 4 ppb, p < .0001) for NO2-reducing compared to control or particle-reducing treatments. NO2-reducing treatment did not reduce asthma morbidity compared to control. In analysis controlling for measured NO2, there were 1.8 (95% CI -0.3 to 3.9, p = .10) fewer symptom days out of 14 in the particle-reducing treatment compared to control. CONCLUSIONS: It remains unknown if using an air cleaner alone can achieve levels of NO2 reduction large enough to observe reductions in asthma symptoms. We observed that in small, urban homes with gas stoves, modest reductions in asthma symptoms occurred using air cleaners that remove fine particles. An intervention targeting exposures to both NO2 and fine particles is complicated and further research is warranted. REGISTRATION NUMBER: NCT02258893.

The Impact of Menthol Cigarette Flavor in the U.S.: Cigarette and ENDS Transitions by Sociodemographic Group.

INTRODUCTION: A better understanding of how menthol cigarette flavoring and ENDS impact smoking initiation, cessation, and transitions between tobacco products could help elucidate the potential impact of a U.S. menthol ban on combustible tobacco products. METHODS: A multistate transition model was applied to data on 23,232 adults from Waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health Study (analysis was conducted in 2020-2021). Transition rates among never, noncurrent, nonmenthol versus menthol cigarette, ENDS, and dual everyday/someday use were estimated, as were transition-specific hazard ratios for age, sex, race/ethnicity, education, and income. RESULTS: Non-Hispanic Blacks who smoked menthol discontinued smoking at a much lower rate than those who smoked nonmenthol (hazard ratio=0.43, 95% CI=0.29, 0.64), but there was no statistically significant difference in the discontinuation rates among non-Hispanic Whites (hazard ratio=0.97, 95% CI=0.80, 1.16) or Hispanics (hazard ratio=0.81, 95% CI=0.56, 1.16). Non-Hispanic Whites who smoked menthol were more likely to become dual users than those who smoked nonmenthol (hazard ratio=1.43, 95% CI=1.14, 1.80). Young adults initiated menthol smoking at a higher rate than older adults (age 18-24 years versus ≥55 years: hazard ratio=2.45, 95% CI=1.44, 4.15) but not nonmenthol smoking (hazard ratio=1.02, 95% CI=0.62, 1.69). There were differences by sex in the impact of menthol flavor on smoking initiation and discontinuation but little difference by education or income. CONCLUSIONS: Sociodemographic differences in product transitions should be accounted for when estimating the potential impact of a menthol ban.

Analysis of the time course of COVID-19 cases and deaths from countries with extensive testing allows accurate early estimates of the age specific symptomatic CFR values.

BACKGROUND: Knowing the true infected and symptomatic case fatality ratios (IFR and CFR) for COVID-19 is of high importance for epidemiological model projections. Early in the pandemic many locations had limited testing and reporting, so that standard methods for determining IFR and CFR required large adjustments for missed cases. We present an alternate approach, based on results from the countries at the time that had a high test to positive case ratio to estimate symptomatic CFR. METHODS: We calculated age specific (0-69, 70-79, 80+ years old) time corrected crude symptomatic CFR values from 7 countries using two independent time to fatality correction methods. Data was obtained through May 7, 2020. We applied linear regression to determine whether the mean of these coefficients had converged to the true symptomatic CFR values. We then tested these coefficients against values derived in later studies as well as a large random serological study in NYC at that time. RESULTS: The age dependent symptomatic CFR values accurately predicted the percentage of the population infected as reported by two random testing studies in NYC. They also were in good agreement with later studies that estimated age specific IFR and CFR values from serological studies and more extensive data sets available later in the pandemic. CONCLUSIONS: We found that for regions with extensive testing it is possible to get early accurate symptomatic CFR coefficients. These values, in combination with an estimate of the age dependence of infection, allows symptomatic CFR values and percentage of the population that is infected to be determined in similar regions with limited testing.

Dataset of testicular germ cell tumors (TGCT) risk associated with serum polychlorinated biphenyl (PCB) by age at diagnosis and histologic types.

In a population-based case control study of testicular germ cell tumors (TGCT), we reported a strong positive association between serum levels of Wolff's Group 1 (potentially estrogenic) polychlorinated biphenyl (PCBs) and risk of TGCT, and the observed associations were similar for both seminoma and non-seminoma. While the observed specific associations between TGCT and Wolff's Group 1 PCBs cannot be easily explained by bias or confounding, a question can still be asked, that is, could the relationship between PCBs and TGCT differ by age at diagnosis? PCBs tend to bioaccumulate, with more heavily chlorinated PCB congeners tending to have longer half-lives. Half-lives of PCB congeners were reported ranging from 4.6 years for PCB-28 to 41.0 years for PCB-156. The half-life for the heavy PCB congeners (17.8 years) was found to be approximately twice that for the light PCBs (9.6 years) in early studies. Therefore, the same PCB concentration measured in a 20-year-old vs. a 55-year-old is unlikely to represent the same lifetime PCB exposure or type of PCB exposure. In this analysis, we stratified the data by median age of diagnosis of TGCT and further stratified by histologic type of TGCT (seminoma vs non-seminoma) to explore if the risk of TGCT associated with PCB exposures differs by age.

Serum polychlorinated biphenyl (PCB) levels and risk of testicular germ cell tumors: A population-based case-control study in Connecticut and Massachusetts.

The incidence rate of testicular germ cell tumors (TGCT) has continuously increased in Western countries over the last several decades. Some epidemiologic studies have reported that the endocrine disrupting polychlorinated biphenyls (PCBs) in serum may be associated with TGCT risk, but the evidence is inconsistent. Our goal was to investigate whether serum levels of PCBs are associated with the increase of TGCT risk. We conducted a population-based case-control study of 308 TGCT cases and 323 controls, all residents of Connecticut and Massachusetts. Serum levels of 56 PCBs congeners were measured using gas chromatography and unconditional logistic regression model was used to evaluate the risk of TGCT associated with total PCBs exposure, groups of PCBs categorized by Wolff's functional groups, and individual PCB congeners. The results showed that there was no association between total serum levels of PCBs and risk of TGCT overall (quartile 4 (Q4) vs. quartile 1 (Q1) odds ratio (OR) and 95% confidence interval (C.I.) = 1.0 (0.6-1.9), ρ trend = 0.9). However, strong positive association was observed between total serum levels of Wolff's Group 1 (potentially estrogenic) PCBs and risk of overall TGCT (Q4 vs. Q1 OR = 2.5, 95% CI = 1.3-4.7, ρ trend <0.05) as well as seminoma and non-seminoma subtypes. Wolff's Group 1 PCB congeners that showed an increased risk of TGCT included: 25, 44, 49, 52, 70, 101, 174, and 201/177. Considering the continuing increase of TGCT, these associations should be replicated in different populations with larger sample size.

Estimated Prevalence of Smoking and Smoking-Attributable Mortality Associated With Graphic Health Warnings on Cigarette Packages in the US From 2022 to 2100.

Importance: Starting in 2022, the US Food and Drug Administration (FDA) plans to require all cigarette packages in the US to display graphic health warnings depicting health harms associated with smoking. The FDA originally planned to implement such warnings in 2012, but tobacco industry litigation delayed the effort. Objective: To assess the estimated population health outcomes associated with a policy requiring graphic health warnings on cigarette packages in the US and with a 10-year delay in implementation. Design Setting and Participants: This decision analytical model used simulation modeling of smoking prevalence and smoking-attributable mortality in the US from 2012 to 2100, using the Cancer Intervention and Surveillance Modeling Network smoking population model. The study was conducted from October 2020 to July 2021. Main Outcomes and Measures: The primary outcomes were annual adult smoking prevalence, smoking-attributable deaths averted, and life-years gained vs the baseline scenario. A baseline scenario assuming no graphic health warnings was compared with expected outcomes of implementing graphic health warnings in 2022 vs 2012. Policy effects were considered under varying assumptions of the association of the policy with smoking initiation and cessation, ranging from most conservative to most optimistic. A maximum smoking reduction scenario in which all smoking would stop by the end of 2022 was evaluated. Results: In the baseline scenario, an estimated 13.2 million smoking-attributable deaths would have occurred from 2012 to 2100. Under a maximum smoking-reduction scenario, 5.5 million of these deaths would be averted. Implementation of graphic health warnings from 2022 to 2100 would be associated with 539 000 (range, 275 000-794 000) smoking-attributable deaths averted and 7.9 million (range, 4.0-11.6 million) life-years gained, representing less than 10% of the 5.5 million estimated smoking-attributable deaths averted and 81.8 million life-years gained in the maximum smoking-reduction scenario. Implementation from 2012 to 2100 would be associated with 33.2% (range, 32.9%-33.5%) more deaths averted (718 000; range, 365 000 to 1.1 million) and 42.7% (range, 42.3%-43.1%) more life-years gained (11.2 million; range, 5.7-16.6 million) compared with implementation in 2022. Conclusions and Relevance: This decision analytical model estimated that FDA cigarette graphic health warnings, if implemented in 2022, would be associated with public health benefits. The model also estimated that more smoking-attributable deaths would have been averted if the policy had been implemented in 2012. Industry litigation and delays to implementing tobacco regulations may have been harmful for public health.

Smoking patterns based on birth-cohort-specific histories from 1965 to 2013, with projections to 2041.

BACKGROUND: Characterizing smoking patterns over time is essential for evaluating the impact of tobacco control interventions and predicting smoking-related mortality. Beginning with a 1920s birth cohort, smoking histories (i.e., estimates of smoking initiation and cessation, and prevalence of current and former smokers) were generated. DATA: The Ontario sample (n = 238,411) of the 2003 to 2013 cycles of the Canadian Community Health Survey, which is conducted biennially, was used to obtain cross-sectional information on current smoking behaviour. METHODS: Age at smoking initiation and age at smoking cessation were used to construct smoking histories for each respondent, up to the survey date. An age-period-cohort model was generated and used to examine survival differences by smoking status. Using the model, and adjusting for survival differences in smoking status, the prevalence of current, former and never smokers was estimated in cohorts from 1920 to 1985. Smoking initiation, cessation and intensity were then estimated for age-specific distributions of each birth cohort. These rates were projected forward through to 2041. Smoking patterns by highest level of education were generated using education-stratified models. RESULTS: Smoking histories show clear trends over time by sex, cohort and age. If current patterns persist, smoking prevalence is projected to decline to single digits (below 10%) by 2023 for women and 2040 for men. DISCUSSION: Birth-cohort-specific smoking histories can be generated using cross-sectional health surveys. These cohort histories can describe smoking patterns over time and into the future. In turn, these histories can be used in micro-simulation models to evaluate historic or planned tobacco control interventions, and to project smoking prevalence.

Transitions between cigarette, ENDS and dual use in adults in the PATH study (waves 1-4): multistate transition modelling accounting for complex survey design.

INTRODUCTION: Even prior to 2018, electronic nicotine delivery systems (ENDS) began to dramatically change the landscape of tobacco products and product use patterns in the USA. METHODS: Using a Markov multistate transition model accounting for complex survey design, transition rates between never, non-current, cigarette, ENDS and dual use states were estimated for 23 253 adult participants in waves 1-4 (approximately 2013-2017) of the Population Assessment of Tobacco and Health study. We made short-term transition projections and estimated HRs for age, sex, race/ethnicity, education and income. RESULTS: Cigarette use was persistent among adults, with 89.7% (95% CI 89.1% to 90.3%) of exclusive cigarette users and 86.1% (95% CI 84.4% to 87.9%) of dual users remaining cigarette users (either exclusive or dual) after one wave. In contrast, ENDS use was less persistent, with 72.1% (95% CI 69.6% to 74.6%) of exclusive ENDS users and 50.5% (95% CI 47.8% to 53.3%) of dual users remaining ENDS users (with or without cigarettes) after one wave. Exclusive ENDS users were more likely to start cigarette use after one wave than either never users (HR 25.2; 95% CI 20.9 to 30.5) or non-current users (HR 5.0; 95% CI 4.3 to 5.8). Dual users of ENDS and cigarettes were more likely to stop using cigarettes than exclusive cigarette users (HR 1.9; 95% CI 1.6 to 2.3). Transition rates varied among sociodemographic groups. CONCLUSIONS: Multistate transition models are an effective tool for uncovering and characterising longitudinal patterns and determinants of tobacco use from complex survey data. ENDS use among US adults was less persistent than cigarette use prior to 2018.

CP*Trends: An Online Tool for Comparing Cohort and Period Trends Across Cancer Sites.

Cohort or period components of trends can provide a rationale for new research or point to clues on the effectiveness of control strategies. Graphical display of trends guides models that quantify the experience of a population. In this paper, a method for smoothing rates by single year of age and year is developed and displayed to show the contributions of period and cohort to trends. The magnitude of the contribution of period and/or cohort in a model for trends may be assessed by the percentage of deviance explained and the relative contributions of cohort (C) and period (P) individually, known as the C-P score. The method is illustrated using Surveillance, Epidemiology, and End Results data (1975-2014) on lung and bronchial cancer mortality in females and prostate and colorectal cancer incidence in males. Smoothed age-period and age-cohort rates provide a useful first step in studies of etiology and the impact of disease control without imposing a restrictive model. We found that, in this data set, cohort predominates for female lung and bronchial cancer and period predominates for male prostate cancer. However, the effects change with age for male colorectal cancer incidence, indicating an age shift in relevant exposures. These methods are applied on an interactive website for both incidence and mortality at over 20 cancer sites in the United States.