Concept flavor e-cigarette unit sales in the U.S.: 2019-2022.

Introduction: Concept flavor e-cigarettes, defined as products with vague/ambiguous flavor (tobacco flavor and non-tobacco flavor) names, may limit the intended impact and enforcement of flavored tobacco restrictions. This study assessed trends in unit sales of concept flavor e-cigarettes in the U.S. by volume, nicotine concentration levels (NCL), flavor and device type. Methods: We analyzed NielsenIQ Retail Scanner point-of-sales data collected from 2182 Local Trade Areas in the contiguous 48 U.S. states and the District of Columbia aggregated weekly from August 10, 2019, through April 9, 2022. Concept flavors were categorized by: flavor type (tobacco, fruity, menthol, mint, and other); device type (pods/refillable cartridges, disposables, e-liquids, and other); and NCL (0 %-2.0 %, 2.1 %-4.0 %, > 4.1 %, unknown). Joinpoint regression was used to assess sales trends. Results: Overall unit sales during the study period increased by 33.63 % from 1040.85 to 1390.88 thousand units per month (p = 0.006). Between August 2019 and September 2021, unit sales increased and peaked; between September 2021 and April 2022 sales decreased by 14.46 % (from 1626.02 to 1390.88 thousand units; p = 0.002). Sales of fruity, menthol and mint flavors concept flavor e-cigarettes increased by > 1000 %; disposable devices by 302.18 %; pods and refillable cartridges by 33.81 % overall; and products NCL > 4.0 % increased by 110.18 %. Tobacco flavor concept flavors (93.28 %), pods (94.63 %), and products with 2.1 %-4.0 % NCL (88.40 %) dominated unit share. Conclusion: Sustaining the recent overall decline in the unit sales of concept flavor e-cigarettes and monitoring the sales of products with nicotine concentration greater than 2.0%, non-tobacco flavor, and pod products warrant prioritization in tobacco control efforts.

Estimating own-price and cross-price elasticity of cigarette consumption by price tiers in Bangladesh.

OBJECTIVES: The overall price elasticity of cigarette consumption in Bangladesh has been studied extensively. The estimates of price elasticity by price tiers are not available in the existing literature. METHODS: Using cohort data of nearly 6000 individuals from the International Tobacco Control Bangladesh survey, this study estimated the own-price and cross-price elasticity and income elasticity of cigarette demand by price tiers in Bangladesh. The elasticity was estimated in three stages of consumer decisions: whether to smoke, which brand to smoke and finally, how many cigarettes to smoke per day. The decision to smoke cigarettes and the choice of cigarette brands were modelled using instrumental variable probability regression. The cigarette consumption per day was modelled using seemingly unrelated regression. RESULTS: The price elasticity of cigarette smoking prevalence with respect to the price of low-price cigarettes is -0.0487. The total elasticity for low-price cigarette consumption with respect to its own price is -0.1678. The own-price elasticity of smoking intensity of high-priced brands is -0.2512. The cross-price elasticity of low-price cigarette consumption with respect to high-price brand prices is 0.2643. The income elasticity of smoking prevalence overall is 0.0564. The income elasticity of daily consumption of low-price cigarettes is -0.1934 and for high-price cigarettes, it is 1.4044. The total income elasticity is 1.4608 for high-price cigarettes. CONCLUSION: A cigarette tax policy that raises the prices of both low-price and high-price brands-but increases prices in the low-price tier at a faster rate than in the high-price tier and increases prices of all brands at a pace faster than income growth-can effectively reduce cigarette consumption in Bangladesh. JEL CODES: H29, L66, I18.

Price elasticity of cigarette smoking in Bangladesh: evidence from the Global Adult Tobacco Surveys (GATS).

INTRODUCTION: The overall prevalence of cigarette smoking has not changed significantly for over a decade in Bangladesh. Raising the price of cigarettes through taxation is an important policy instrument for reducing consumption and achieving public health goals. The price elasticity of cigarette demand is an important parameter for evaluating the effectiveness of raising prices through tax increases in reducing cigarette consumption. The objective of the study was to estimate the price elasticity of cigarette demand in Bangladesh using Global Adult Tobacco Survey 2009 and 2017 data. METHODS: Smoking prevalence and smoking intensity were estimated using a two-part model. Endogeneity of prices was minimised using the average consumption-weighted cigarette price in a cluster, for both smokers and non-smokers residing in a specific cluster. RESULTS: Cigarette demand was found to be price inelastic and ranged between -0.51 and -0.73. It is also price inelastic across wealth groups and areas of residence in Bangladesh. Although the total price elasticity did not differ considerably between rural and urban locations, it is evident that individuals in the lower-wealth group are more than twice as responsive to price increases as their high-wealth counterparts. CONCLUSION: A significant increase in cigarette prices through a tax increase would decrease smoking prevalence and increase tax revenue in Bangladesh. The greater price sensitivity among smokers in lower-wealth groups indicates that a tax-induced cigarette price increase would provide more health benefits to them, thereby contributing to improved health equity.

Trend over time on knowledge of the health effects of cigarette smoking and smokeless tobacco use in Bangladesh: Findings from the International Tobacco Control Policy Evaluation Bangladesh Surveys.

INTRODUCTION: Cigarette smoking and smokeless tobacco (ST) use are prevalent in Bangladesh. This longitudinal study examined how knowledge of the health effects of smoking and ST use in Bangladesh has changed overtime with the country's acceleration of tobacco control efforts. METHODS: Data were analysed from the International Tobacco Control Survey, a nationally representative longitudinal study of users and non-users of tobacco (aged 15 and older) in Bangladesh, across four waves conducted in 2009 (n = 4378), 2010 (n = 4359), 2012 (n = 4223) and 2015 (n = 4242). Generalised estimating equations assessed the level of knowledge about harms of tobacco use across four waves. Multivariable logistic regressions assessed whether knowledge of health effects from cigarette smoking and ST use in 2015 differed by user group. RESULTS: In 2015 survey, most tobacco users were aware that cigarette smoking causes stroke (92%), lung cancer (97%), pulmonary tuberculosis (97%) and ST use causes mouth cancer (97%) and difficulty in opening mouth (80%). There were significant increases in the total knowledge score of smoking related health harm from 2010 to 2012 (mean difference = 0.640; 95% confidence interval [CI] 0.537, 0.742) and 2012 to 2015 (mean difference = 0.555; 95% CI 0.465, 0.645). Participants had greater odds of awareness for ST health effects from 2010 to 2015. DISCUSSION AND CONCLUSIONS: The results suggest that increasing efforts of awareness policy interventions is having a positive effect on tobacco-related knowledge in Bangladesh. These policy initiatives should be continued to identify optimal methods to facilitate behaviour change and improve cessation of smoking and ST use.

A longitudinal study of transitions between smoking and smokeless tobacco use from the ITC Bangladesh Surveys: implications for tobacco control in the Southeast Asia region.

Background: In Southeast Asia, tobacco use is a major public health threat. Tobacco users in this region may switch between or concurrently use smoked tobacco and smokeless tobacco (SLT), which makes effective tobacco control challenging. This study tracks transitions of use among different product users (cigarettes, bidis, and SLT) in Bangladesh, one of the largest consumers of tobacco in the region, and examines factors related to transitions and cessation. Methods: Four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey with a cohort sample of 3245 tobacco users were analysed. Generalized Estimating Equations (GEE) models were used to explore the socioeconomic correlates of transitions from the exclusive use of cigarettes, bidis, or SLT to the use of other tobacco products or quitting over time. Findings: Among exclusive cigarette users, most remained as exclusive cigarette users (68.1%). However, rural smokers were more likely than urban smokers to transition to bidi use (odds ratio [OR] = 3.02, 95% confidence interval [CI] = 1.45-6.29); to SLT use (OR = 2.68, 95% CI = 1.79-4.02) and to quit tobacco (OR = 1.57, 95% CI = 1.06-2.33). Among exclusive bidi users, transitional patterns were more volatile. Fewer than half (43.3%) of the exclusive bidi users maintained their status throughout the waves. Those with higher socio-economic status (SES) were more likely to quit (OR = 4.16, 95% CI = 1.08-13.12) compared to low SES smokers. Exclusive SLT users either continued using SLT or quit with minimal transitions to other products (≤2%). Nevertheless, males were more likely to switch to other tobacco products; younger (OR = 2.94, 95% CI = 1.23-6.90 vs. older), more educated (OR = 1.55, 95% CI = 1.77-3.12 vs. less educated), and urban SLT users (OR = 0.52, 95% CI = 0.30-0.86 for rural vs. urban users) were more likely to quit. Interpretation: Complex transitional patterns were found among different types of tobacco product users over time in Bangladesh. These findings can inform more comprehensive and multi-faceted approaches to tackle diversified tobacco use in Bangladesh and neighbouring countries in the Southeast Asia region with similar tobacco user profiles of smoked tobacco and SLT products. Funding: This is an unfunded observational study with the use the ITC Bangladesh datasets. The ITC Bangladesh Surveys were supported by grants from the US National Cancer Institute (P01 CA138389), the International Development Research Centre (IDRC Grant 104831-003), and Canadian Institutes of Health Research (MOP-79551, MOP-115016).

Changes in E-Cigarette Use Among U.S. Adults, 2019-2021.

INTRODUCTION: E-cigarette use increased between 2014 and 2018 among younger U.S. adults who had never smoked combustible cigarettes, potentially increasing nicotine addiction risk and progression to combustible tobacco products. It is unknown how prevalence changed after the E-cigarette, or vaping, product use-associated lung injury epidemic (late 2019) and COVID-19 pandemic (March 2020) by age group and combustible cigarette smoking status. METHODS: Data from cross-sectional, nationally representative National Health Interview Surveys in 2019, 2020, and 2021 (analyzed in 2022) were used to estimate current E-cigarette use prevalence, adjusted prevalence difference between survey years, and population counts, by age group (younger, 18-29 years, n=11,700; middle age, 30-44 years, n=21,300, 45-59 years, n=21,308; older, ≥60 years, n=36,224) and cigarette smoking status (current, former, and never). RESULTS: E-cigarette use prevalence increased among younger adults between 2019 and 2021 (8.8%-10.2%, adjusted prevalence difference=1.7% points, 95% CI=0.1, 3.3), primarily owing to an increase among those who never smoked cigarettes (4.9%-6.4%, adjusted prevalence difference=1.7% points, 95% CI=0.3, 3.1). People who never smoked cigarettes constituted 53% (2.68 million) of younger adults who used E-cigarettes in 2021, increasing by 0.71 million from 2019. Conversely, among middle age and older adults, the prevalence was similar in 2019 and 2021 irrespective of cigarette smoking status, and those who formerly smoked cigarettes constituted the largest proportion of people who used E-cigarettes in 2021 (age 30-44 years: 51.8%, 1.8 million; age 45-59 years: 51.6%, 0.85 million; age ≥60 years: 47.5%, 0.45 million). CONCLUSIONS: Efforts must address the rise in E-cigarette use among younger adults who never smoked cigarettes. At the same time, assistance is needed to help those who switched to E-cigarettes to stop smoking to transition to non-use of all products.

Association between cigarette sales in the USA and FDA's announcement of its intention to prohibit menthol as a characterising flavour in cigarettes.

INTRODUCTION: On 29 April 2021, the US Food and Drug Administration (FDA) announced its intention to prohibit menthol as a characterising flavour in cigarettes. METHODS: We assessed the changes in cigarette sales associated with the FDA's announcement using interrupted time series analysis based on monthly retail point-of-sale data on cigarettes from the NielsenIQ Local Trade Area (LTA) data from September 2019 to April 2022. Main outcome variables included LTA-level monthly menthol and non-menthol cigarette sales per 1000-persons. RESULTS: Monthly cigarette sales were declining before the FDA's announcement (menthol vs non-menthol: -1.68 (95% CI -1.92, -1.45) vs -3.14 (95% CI -3.33, -2.96) packs per 1000-persons). Monthly menthol cigarette sales increased immediately in May 2021 after the FDA's announcement by 6.44 packs per 1000-persons (95% CI 3.83, 9.05). Analysis stratified by LTA-level racial/ethnic compositions showed that LTAs with a relatively higher proportion of non-Hispanic Black population (>8.94%) experienced higher spike in menthol cigarette sales in May 2021 immediately after the announcement and higher post-announcement 12-month menthol cigarette sales than expected. CONCLUSIONS: Areas with a relatively higher proportion of non-Hispanic Black population are potentially at risk of experiencing increased burden of menthol cigarette consumption. Targeted community level cessation support in non-Hispanic Black majority areas may help mitigate the growing burden of menthol cigarette smoking and improve health equity. The findings of this study also suggest that FDA's prompt finalisation and enforcement of such ban may help avoid extending the increased burden of menthol cigarette consumptions in non-Hispanic Black majority areas.

Declining trend in cigarette smoking among U.S. adults over 2008-2018: A decomposition analysis.

The United States (U.S.) witnessed considerable reduction in cigarette smoking prevalence in the recent past. While the correlates of smoking prevalence and related disparities among U.S. adults are well documented, there is limited information on how this success was shared among different population sub-groups. Based on data from the National Health Interview Surveys, 2008 and 2018, representative of non-institutionalized U.S. adults (18 years and above), we applied the threefold Kitawaga-Oaxaca-Blinder linear decomposition analysis. We decomposed the trends in cigarette smoking prevalence, smoking initiation, and successful cessation into changes in population characteristics holding smoking propensities constant (compositional change), changes in smoking propensities by population characteristics holding population composition constant (structural change), and the unmeasured macro-level changes affecting smoking behavior in different population sub-groups at differential rates (residual change) to quantify the shares of population sub-groups by sex, age, race/ethnicity, education, marital status, employment status, health insurance coverage, family income, and region of residence in the overall change in smoking rates. The analysis shows that decreases in smoking propensities regardless of the changes in population composition accounted for 66.4% of the reduction in smoking prevalence and 88.7% of the reduction in smoking initiation. The major reductions in smoking propensity were among Medicaid recipients and young adults (ages 18-24 years). The 25-44-year-olds experienced moderate increase in successful smoking cessation, while the overall successful smoking cessation rate remained steady. Taken together, consistent reduction in smoking among U.S. adults by all major population characteristics, accompanied by disproportionately larger reduction in smoking propensities among the population sub-groups with initially higher smoking propensity compared to the national average, characterized the decline in overall cigarette smoking. Strengthening proven tobacco control measures with targeted interventions to reduce smoking propensities among underserved populations is key to continued success in reducing smoking overall and remedying inequities in smoking and population health.

Updated Review of Major Cancer Risk Factors and Screening Test use in the United States, with a Focus on Changes During the COVID-19 Pandemic.

We present national and state representative prevalence estimates of modifiable cancer risk factors, preventive behaviors and services, and screening, with a focus on changes during the COVID-19 pandemic. Between 2019 and 2021, current smoking, physical inactivity, and heavy alcohol consumption declined, and human papillomavirus vaccination and stool testing for colorectal cancer screening uptake increased. In contrast, obesity prevalence increased, while fruit consumption and cervical cancer screening declined during the same timeframe. Favorable and unfavorable trends were evident during the second year of the COVID-19 pandemic that must be monitored as more years of consistent data are collected. Yet disparities by racial/ethnic and socioeconomic status persisted, highlighting the continued need for interventions to address suboptimal levels among these population subgroups.

Association of nicotine replacement therapy product sales with menthol cigarette sales restriction in Massachusetts.

BACKGROUND: Massachusetts was the first to implement a state-wide menthol cigarette sales restriction in the USA. Following its implementation in June 2020, evidence showed declines in cigarette sales in Massachusetts; however, changes in nicotine replacement therapy (NRT) product sales are unknown. METHODS: This cohort study analysed NRT products sold by US-based retailers available in 26 states from the Nielsen Retail Scanner Data. Outcomes were state-level 4-week aggregate sales of gum, lozenge and patch NRT products converted into pieces per 1000 adults (aged ≥18 years) who smoke cigarettes based on smoking rates from the Behavioral Risk Factor Surveillance System and corresponding population from the US Census Bureau. We used a difference-in-differences method to compare changes in NRT product sales in Massachusetts before (1 January 2017 to 13 June 2020) and after (14 June 2020 to 4 December 2021) the policy with sales in 25 states. RESULTS: The analysis included 1664 observations for each NRT product, with 1170 from before and 494 from after the policy change. The 4-week NRT product sales per 1000 adults who smoke cigarettes in Massachusetts compared with the comparison states increased for gums by 643.11 (95% CI 365.33 to 920.89; p<0.001) pieces or 12.9% and for lozenges by 436.97 (95% CI 292.88 to 581.06; p<0.001) pieces or 17.9% but no statistically significant change in patches after implementing the policy. CONCLUSION: The increases in sales of gum and lozenge NRT products in Massachusetts after implementing the policy suggest that a nationwide ban on menthol cigarettes can increase NRT product use; therefore, interventions are needed to strengthen cessation support for adults who smoke cigarettes but intend to quit.

Perceptions and reasons for quitting and transitioning between smoking and smokeless tobacco products: Findings from four waves of the ITC Bangladesh survey.

INTRODUCTION: Transitions between different tobacco products are frequent among tobacco users in Bangladesh; however, the reasons leading to such transitions and why they quit are not well researched. The aim of the study is to examine perceptions and reasons reported by tobacco users in Bangladesh to transition to other products or quit. METHODS: Data from four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach. RESULTS: Common reasonsig for respondents switching to other tobacco products were influence of friends/family (73.8-86.0%), and curiosity (44.4-71.3%). The perceived calming effect of smoking cigarettes and bidis (43.2-56.9%), and the impression that bidis were less harmful (52.3%) and taste better (71.2%) were major reasons for exclusive SLT users to switch products. Health concerns (16.5-62.7%) and disapproval from friends/family (29.8-56.4%) were generally the main reasons for quitting. For smoked tobacco users, doctor's advice (41.6%), package warning labels (32.3%), and price (32.4%) seemed to be the major driving factors to quit. CONCLUSIONS: Results highlight that the reasons for switching between tobacco products and quitting include social factors (e.g. friends/family) and (mis) perceptions regarding the products. Tobacco control policy could emphasize cessation support, increased price and education campaigns as key policies to reduce overall tobacco use in Bangladesh. Data from four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach.

Association of Comprehensive Menthol Flavor Ban With Current Cigarette Smoking in Massachusetts From 2017 to 2021.

This cross-sectional study compares self-reported smoking by adults before vs after prohibition of menthol-flavored cigarettes.

Healthy People Countdown 2030: reaching 5% cigarette smoking prevalence among US adults through state cigarette excise tax increases.

OBJECTIVE: The Healthy People 2030 goal is to reduce US current adult cigarette smoking prevalence to 5% by 2030. The objective of this report is to investigate if this goal is achievable using state cigarette excise tax increases. METHODS: State-specific linear trends in smoking prevalence over 2011-2019 were determined using fractional logit regression and compared with the desired linear trends for achieving 5% smoking prevalence by 2030 in individual states and the District of Columbia (DC). The gaps between price-adjusted and desired trends were used in a simulation model for identifying state-specific systematic annual increases in state cigarette excise tax rates based on state-specific price elasticity of smoking prevalence, maintaining the status quo in other non-tax tobacco control measures. RESULTS: The price-adjusted trends in smoking prevalence observed over 2011-2019 exceed the desired trends for achieving 5% smoking prevalence target by 2030 in only five states (eg, Washington, Utah, Rhode Island, Massachusetts and Maryland) and the DC. It suggests that majority of states and USA overall will miss the target smoking prevalence at the current rate of reduction in smoking. 45 states would need systematic annual increases in cigarette excise tax rate in a range of $0.02-$1.37 per pack over 2022-2030 to meet the target. CONCLUSIONS: The feasibility of reaching the Healthy People 2030 goal would critically depend on the acceleration of progress in tobacco control. Tax increases tailored to the needs of individual states combined with scaled-up non-tax tobacco control policy interventions can help achieve the desired progress.

Trends in public interest in shopping and point-of-sales of JUUL and Puff Bar 2019-2021.

INTRODUCTION: We investigated public interest in shopping and point-of-sales (POS) of JUUL and Puff Bar products in the context of five regulatory, company sales policy and other events of interest that may have influenced the trajectory of these products during 2019-2021. METHODS: Outcome variables included relative search volume (RSV) from Google search queries indicative of shopping interest in and aggregate dollar sales from Nielsen POS for JUUL and Puff Bar in the USA from March 2019 to May 2021. Adjusted autoregressive integrated moving average assessed the observed and predicted trends and adjusted linear regression analysis measured the relative rate of change in the outcome variables for each time period of interest. RESULTS: After the Trump administration announced its plans to ban flavoured e-cigarettes and JUUL Labs, Inc.'s decided to suspend the sales of its sweet and fruity flavoured products, JUUL's shopping interest RSV and sales declined while Puff Bar's shopping interest RSV peaked, and its sales increased. From the period following FDA's announcement of its enforcement guidance policy on unauthorised flavoured cartridge-based e-cigarettes until May 2021, JUUL's shopping interest RSV and sales continued to decline. Puff Bar's shopping interest RSV increased, and its sales peaked until the House approved the flavoured e-cigarette ban bill. Puff Bar's sales steeply declined following suspension of its sales in February 2020. The decline, however, slowed after Puff Bar products were relaunched as 'synthetic nicotine' e-cigarettes. CONCLUSIONS: Puff Bar's unprecedented peak in the shopping interest and sales of Puff Bar warrants continued surveillance.

Changes in State-Level Cigarette Sales During the COVID-19 Pandemic.

This cohort study estimates state-level changes in cigarette sales in the US during the COVID-19 pandemic.

Nicotine Pouch Sales Trends in the US by Volume and Nicotine Concentration Levels From 2019 to 2022.

This cross-sectional study examines the sale of 4 nicotine pouch brands in the contiguous 48 states and Washington, DC.

Economic loss attributable to cigarette smoking in the USA: an economic modelling study.

BACKGROUND: Despite large geographical disparities in the prevalence of cigarette smoking across the USA, there is a paucity of state-level estimates of economic loss attributable to smoking to inform tobacco control policies at the national and state levels. We aimed to estimate the state-level economic loss attributable to cigarette smoking in the USA. METHODS: In this economic modelling study, we used a dynamic macroeconomic model of personal income per capita at the state level. Based on publicly available data on state-level income, its determinants, and smoking status for 2011-20, we first estimated the elasticity of personal income per capita with respect to the prevalence of non-smoking adults (aged ≥18 years) in the USA using a mixed-effects, generalised linear, dynamic panel data model. We used the estimated elasticity to measure the state-specific, annual, avoidable economic loss attributable to cigarette smoking in 2020 under the counterfactual 5% prevalence of cigarette smoking. We then estimated the state-specific cumulative economic loss attributable to cigarette smoking in 2020 using the coefficient of lagged income in the dynamic model. National estimates on economic loss attributable to cigarette smoking were obtained by summing state-specific estimates. FINDINGS: In the mixed-effects model, the elasticity of personal income per capita with respect to the prevalence of non-smoking adults was 0·143 (p=0·063). The estimated annual income loss per capita in 2020 ranged from US$331 in Utah to $1674 in Kentucky. The state mean population-weighted loss per capita was $1100. The annual combined loss of income and unpaid household production at the national level was $436·7 billion (equivalent to 2·1% of US gross domestic product [GDP] in 2020). The cumulative loss of income and unpaid household production was $864·5 billion (equivalent to 4·3% of US GDP in 2020). INTERPRETATION: Smoking causes substantial economic loss in the USA. Tobacco control efforts that lower the prevalence of smoking equitably can contribute considerably to improved macroeconomic performance in the short and long term by reducing health expenditures and avoiding productivity losses. FUNDING: American Cancer Society.