A qualitative assessment of blunt smokers' perceptions and receptivity to non-tobacco blunt wraps.

OBJECTIVE: The recent debut of the non-tobacco blunt wrap (N-TBW) for smoking cannabis has received little attention from the tobacco control community. The present study is intended to assess blunt smokers' perceptions and receptivity to N-TBWs, which are being marketed as an alternative to cigarillos and other tobacco products used for making blunts. METHODS: Current blunt smokers (n=41) were recruited from social media platforms to participate in one of nine two-hour focus groups held between October 2022 and May 2023. Six topics ranging from social aspects of blunt smoking to impediments to switching to N-TBWs were discussed. A domain analysis was utilized in uncovering semantic relationships between a given variable (e.g., uneven burn rate) and outcome (e.g., not using N-TBWs). RESULTS: Blunt smokers conveyed interest in the N-TBWs because of health concerns about tobacco. Yet, the following three main barriers impede blunt smokers use of N-TBWs: lack of awareness and accessibility of the N-TBW, familiarity with preparing and smoking a traditional blunt, and incomparability of the tobacco blunt wrap (e.g., cigarillo). The latter was the most formidable challenge as participants expressed several negative product features of N-TBWs (e.g., flimsy material) relative to cigarillos. CONCLUSIONS: The N-TBW is unlikely to displace the cigarillo in the near-term future. A more likely scenario is that blunt smokers will continue to use cigarillos with intermittent use of N-TBWs in situational settings. If this occurs, then blunt smokers will continue to be exposed to harmful tobacco products.

The Marketing and Perceptions of Non-Tobacco Blunt Wraps on Twitter.

OBJECTIVE: Non-tobacco blunt wraps (N-TBWs), which entered the marketplace in 2017, are being promoted as an alternative to traditional TBWs (e.g., cigarillos) for blunt smoking. The lack of studies on these novel products warrants an investigation. This study was the first to explore blunt smokers' perceptions about N-TBWs and the extent of product marketing on Twitter. METHODS: A corpus of tweets from Twitter, posted between January 2017 and November 2021, were identified by a Boolean search string (N = 149,343), where 48,695 tweets were classified as relevant by a machine learning algorithm. These relevant tweets were further screened and labeled as promotional or organic based on product URLs, usernames, keywords, or hashtags. Topic modeling using Dirichlet Allocation was then employed for identifying latent patterns of words among relevant tweets. The Social Networking Potential (SNP) score was employed for identifying influential accounts. RESULTS: Most relevant tweets (89%) were organic, non-promotional expressions about N-TBWs. Account users who only posted non-promotional tweets had a significantly higher SNP than those who only posted promotional tweets. Yet, neither of the two groups of account users consisted of known celebrities. Topic modeling revealed three broad groups of topics (7 in total) denoting the attributes of hemp N-TBWs, interest in non-hemp N-TBWs, and product marketing. CONCLUSIONS: The large proportion of organic tweets is indicative of the nascency of N-TBWs, which will need to be marketed more extensively if they are to replace cigar products used by blunt smokers.

Cannabis Vape Product Sales in California Following CDC's Initial Advisory About Lung Injuries.

Introduction: The 2019 outbreak of e-cigarette or vaping product use-associated lung injury (EVALI) is believed to have been caused by vitamin E acetate, an additive used in some cannabis vaporizer products. Previous studies have primarily focused on changes in sales of electronic nicotine delivery systems following the initial advisory issued by the Centers for Disease Control (CDC) on August 17, 2019. The present study is intended to examine variation by age groups in sales of regulated cannabis vape products in the state of California before, during, and after the outbreak. Methods: Weekly sales revenue of cannabis vape products (from January 1, 2018, to December 31, 2020) was obtained from a sample of recreational cannabis retailers licensed in California. An interrupted time series analysis, using AutoRegressive, Integrated, Moving Average methods, was employed to estimate changes in the sales and market share of cannabis vape products in the weeks following the CDC advisory. Results: The total volume of regulated cannabis vape product sales increased substantially over the 3-year study period (2018-2020). Sales and market share of cannabis vape products, however, declined in both young and older adults immediately following the advisory, rebounding to pre-EVALI levels only for the young adults. For sales, the potential EVALI effect following the CDC's advisory equates to an 8.0% and 2.2% decline below expected levels in the older and young adults, respectively. Conclusions: The differential age effect on sales may reflect concerns regarding health effects of cannabis vaping products and greater awareness of the outbreak among older adults. Findings highlight the importance of informing consumers about health risks associated with using cannabis vape products acquired from regulated versus illicit sources.

Variation in adults' use of flavored tobacco products by sales restrictions in California jurisdictions.

BACKGROUND: State and local policies prohibiting the sales of flavored tobacco have been effective in curtailing retail availability and sales of products across the United States. Less is known about the use of flavored tobacco which could vary as a function of type of ordinance, product category, policy implementation, and other factors. METHODS: The 2019-2020 California Health Interview Surveys were used to estimate flavored and non-flavored tobacco use among adults (n = 43,681) residing in a California jurisdiction with a comprehensive (n = 48), partial (n = 35), or no flavored tobacco sales restriction (FTSR) (n = 427). Multinomial logistic regression models, which accounted for clustering within jurisdictions (n = 510), were separately developed for outcomes corresponding to use of any tobacco, non-cigarette tobacco products (NCTPs), electronic nicotine delivery systems, and conventional cigarettes. Individual-level effects of policy on tobacco use were estimated due to the overlap between the survey periods and effective policy dates. RESULTS: Approximately 22% of Californians were subject to a partial or comprehensive FTSR by December 31, 2020. Accounting for potential confounders, residents of jurisdictions with a comprehensive FTSR (vs. no ban) had 30% lower odds of using any flavored tobacco. The strongest and only statistically significant association by product category was exposure to a comprehensive FTSR and use of a flavored NCTP (aOR=0.4 (0.2, 0.8); p=0.008). Null or positive associations were primarily observed between a partial FTSR and flavored tobacco use, as well as associations between any FTSR and non-flavored tobacco use. CONCLUSION: Recent passage of a statewide ban in California will close gaps from the patchwork of local policies and eliminate most partial FTSR exemptions. However, state law still exempts the sales of some flavored tobacco products (e.g., hookah), leaving jurisdictions the option of enacting comprehensive FTSRs that may be more effective than partial FTSRs in reducing use of flavored tobacco.

Concentration of Cannabis and Tobacco Retailers in Los Angeles County, California: A Spatial Analysis of Potential Effects on Youth and Ethnic Minorities.

OBJECTIVE: Cannabis and tobacco retailers are believed to cluster in areas with more racial/ethnic minorities, which could account for the disproportionate use of blunts in Black and Hispanic communities. The current study examined the spatial relationship between cannabis and licensed tobacco retailers in Los Angeles County, California, and assessed whether various neighborhood and business factors influenced the spatial patterning. METHOD: Generalized additive models were used to test the association between the location of cannabis retailers (N = 429) and their accessibility potential (AP) to tobacco retailers (N = 8,033). The covariates included cannabis licensure status, median household income, population density, percentages of racial/ ethnic minorities and young adults (18-34), unemployment status, families living in poverty, minimum completion of high school/General Educational Development (GED) credential, and industrial businesses by census tract. RESULTS: The location of cannabis retailers was significantly associated with AP in all adjusted models (p < .005). The percentage of racial/ethnic minorities, age (18-34 years), and nonlicensure of cannabis retailers, which were positively correlated with AP (p < .05), confounded the association between AP and cannabis retailer location. CONCLUSIONS: The concentration of unlicensed cannabis retailers and tobacco retailers in young and racially/ethnically diverse neighborhoods may increase access to and use of cigarillos for blunt smoking. Jurisdictions within Los Angeles County should consider passing ordinances requiring minimum distances between cannabis and tobacco retailers.

Reframing the banning of flavored tobacco in unprecedented times- an example from California's Senate bill 793.

Several cities, but only two U.S states, have passed a law banning the sales of flavored tobacco products. It has been suggested that framing tobacco control policy solely in terms of the youth could send the erroneous message that tobacco use is an acceptable behavior for adults. This study was intended to compare the framing of policy between California's Senate Bill (SB) 38 and 793. Seven audio files of hearings on SB-38 (N = 2) and SB-793 (N = 5), held between March 2019 and August 2020, were transcribed and coded for youth issues and the unprecedented events of 2020 that shaped society's views of health and racial/social justice. The Framework Method was used for organizing and analyzing content of the legislative hearings. Many of the same arguments pertaining to youth were presented in hearings on the two bills. The one notable difference was legislators' sense of obligation to younger constituents, which was expressed in hearings on SB-793, but not SB-38. The hearings on SB-793 also differed with respect to greater discussion about the relevance of a tobacco flavor ban to society as a whole. These discussions revolved around the COVID-19 pandemic and potential impact of a ban on communities of color. Discussions on SB-793 about the larger societal impact of flavored tobacco may be a more effective strategy than focusing exclusively on the youth. Thus, legislators from other U.S. states who are contemplating a statewide ban should consider reframing the issue according to California's SB-793.

Do smokers' harm perceptions of cigarillos differ by modified use of the tobacco product? Findings from waves 3 and 4 of the PATH study.

OBJECTIVE: The harm perceptions of individuals who smoke either blunts or the Black & Mild (B&M) brand, which is often "freaked," have seldom been investigated. Since these practices could affect users' perceived health risks of the cigarillo, this study was intended to compare such risks among cigarillo users by modified use of the tobacco product. METHOD: Adult cigarillo and blunt smokers were selected from the Population Assessment of Tobacco and Health Study for cross-sectional (Wave 4; n = 3,331) and longitudinal (Waves 3-4; n = 1,898) analyses of predictors of general and relative harm perceptions of cigarillos. Ordinal and multinomial logistic regression methods were employed for testing whether adjusted odds of perceiving cigarillo harms were greater in blunt versus cigarillo smokers. In a separate model (n = 1,258), preference for B&M cigarillos was examined as a correlate of harm perception due to the perceived health benefits of removing the inner tobacco liner. RESULTS: Cross-sectional estimates indicated that blunt smokers, mixed cigarillo/blunt smokers, and those who preferred B&M brand perceived significantly more risk than conventional cigarillo smokers. Longitudinal estimates indicated that among those who underwent a transition in use, former blunt and former cigarillo smokers had significantly greater odds of reporting an increase in perceived harm compared to new users. CONCLUSIONS: The change in blunt smokers' harm perceptions upon transitioning in blunt use suggests acknowledgment of the harm of using cigarillos in some form. Given their high perceived risk of cigarillos, blunt smokers might be receptive to replacing the tobacco product with a nontobacco wrap. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Impact of California's tobacco and cannabis policies on the retail availability of little cigars/cigarillos and blunt wraps.

BACKGROUND: Recent changes in California's tobacco and cannabis policies could impact the retail availability of little cigars/cigarillos (LCCs) and blunt wraps that are used for blunt smoking. This study was intended to test whether tobacco flavor bans and minimum pack sizes of LCCs have reduced tobacco availability in California jurisdictions, whereas, permissive policies on sales and marketing of cannabis increased availability. METHODS: Measures of retail availability of LCCs and blunt wraps were obtained from the 2016-2019 longitudinal sample of licensed tobacco retailers (LTRs, n = 4062) from California's Healthy Stores for Healthy Communities campaign. Additional data sources included the California Cannabis Local Laws database and geographic location of 1063 cannabis retailers used for constructing a spatial index of accessibility to the LTRs. Two-level generalized structural equation models were developed to assess effects of store- and jurisdiction-level predictors of change in tobacco availability (+, -, no change). RESULTS: Neither permissive cannabis policies nor accessibility to cannabis retailers were associated with an increase in retail availability of the tobacco products. Enactment of a tobacco flavor ban, however, was associated with reduced availability of LCCs and blunt wraps, which was more pronounced in jurisdictions that had permissive cannabis policies (i.e. policy interaction). CONCLUSIONS: A tobacco flavor ban may be an effective strategy to reduce retail availability of LCCs, blunt wraps and possibly other tobacco in California jurisdictions. This finding is of particular relevance as the tobacco industry has successfully petitioned for a referendum vote on California's statewide flavor ban in the 2022 election.

Use of internal documents to investigate a tobacco company's strategies to market snus in the United States.

INTRODUCTION: Prior studies indicate that cigarette manufacturers have been interested for decades in developing a smokeless tobacco (SLT) product for smokers and non-users of SLT. The current study aims to assess a tobacco company's use of novel marketing strategies and intent to promote snus in the US as either a replacement or situational substitute for the cigarette. METHODS: A Boolean search string was used to search R. J. Reynolds' (RJR) Records in UCSF's Truth Tobacco Industry Documents Library. A total of 358 documents, from 2005-2009, met our initial search criteria and were selected for their relevance to the marketing of Camel Snus. A content analysis was subsequently conducted using the Framework Method to identify themes and strategies for promoting Camel Snus. RESULTS: Four major themes about Camel Snus emerged from the documents: 1) promotion by third parties including retailers, snus ambassadors and secret shoppers, 2) expansion of the target population of SLT users to include female smokers and dual users of cigarettes and SLT, 3) emphasis on the difference between Camel Snus and other SLT, and 4) a shift from promoting the practical uses of Camel Snus to using emotional messages conveying freedom. CONCLUSIONS: The findings align with other studies suggesting that RJR intended to market snus to non-users of SLT. The findings also reveal that RJR employed creative marketing strategies (e.g. snus ambassadors) and may have intended to promote snus as a situational substitute for the cigarette, as evidenced by the company's recruitment of dual tobacco users.

Broadcast reach and self-reported exposure to court-ordered corrective statements on cigarette harms.

In August 2006, U.S. District Court Judge Gladys Kessler ordered four tobacco companies to disseminate court-approved corrective statements on five topics pertaining to health hazards of cigarette smoking. Based on the 2018 Health Information National Trends Survey (HINTS), approximately 50% of U.S. smokers viewed at least one corrective statement via television or newspaper during the first six months of the airings/publications (November 2017-April 2018). Using televised gross rating points (GRPs) and cross-sectional data from the 2018 HINTS (n = 3484) and 2019 HINTS (n = 3331), the current study extends previous ones by estimating broadcast reach/frequency and the moderating effect of survey year on smokers' exposure to a corrective statement. The weighted percentage of participants who viewed a corrective statement was significantly greater in the 2019 versus 2018 HINTS for smokers (64.3% vs. 50.5%, χ2 1df = 5.85, p = .01), but not for non-smokers (39% in 2018/2019, χ2 1df = 0.02; p = .88); this differential effect was evidenced by a significant interaction term (OR = 2.0(1.2, 3.2), p < .001). This study also revealed that the televised reach of the corrective statements to the U.S. population (43.5 GRPs/43.5%) was comparable to the published estimate from the 2018 HINTS (40.6%). The frequency of exposure to any corrective statement in the first six months of televised airings was only 0.68 exposures/month, an estimate that does not meet CDC Best Practices. Yet, as evidenced by the significant interaction with survey year, it is likely that the addition of messages to tobacco company websites and cigarette package onserts may have contributed to smokers' greater exposure to a corrective statement.

Smokers' Receipt of Cessation Advice from Healthcare Professionals in National Samples of People Diagnosed with HIV and the General Population.

Background: The high prevalence of smoking in persons living with HIV (PLWH) warrants an accurate estimation of smokers' receipt of advice on smoking cessation. Prior studies on the topic have been limited by convenience samples. Objective: This study aims to be the first to estimate PLWH smokers' receipt of cessation advice from a healthcare professional in a nationally representative sample. Methods: PLWH smokers were selected from the 2015-2016 Medical Monitoring Project (MMP; n = 1179), and smokers from the general population were selected from the 2014-2015 Tobacco Use Supplement to the Current Population Survey (TUS-CPS; n = 15,635) and 2015 National Health Interview Survey (NHIS; n = 4,219). Prevalence ratios in MMP were estimated for testing the hypothesis that PLWH smokers, who are treated by other provider types, have a greater likelihood of receiving advice to quit smoking. Results: The weighted estimate of PLWH smokers from the MMP who received cessation advice (82.2%) was higher than weighted estimates from the TUS-CPS (70.9%) and NHIS (68.7%). While the higher estimate can be partially attributed to a higher percentage of daily smokers, the finding was still observed in stratified samples of daily and non-daily smokers. Statistically significant differences in cessation advice, however, were not observed by other provider types. Conclusions: The study's primary finding indicates that most PLWH smokers in care are receiving advice to quit smoking. The next steps are to train HIV care providers in all 5 A's of smoking cessation through the Ryan White HIV/AIDS Program's AIDS Education and Training Centers.

Strategies and barriers to achieving the goal of Finland's tobacco endgame.

OBJECTIVES: Finland boldly legislated the end of tobacco use in its 2010 Tobacco Act, and subsequently expanded the goal in 2016 to eradicate other nicotine-containing products. This study explored stakeholders' perceptions about the strengths, barriers, solutions and rationale for Finland's comprehensive but conventional strategy to achieve its nicotine-free goal. DESIGN: Study participants were selected based on expertise in policy or practice of tobacco control (n=32). Semi-structured interviews, conducted in 2017 and 2018, covered topics ranging from consensus among stakeholders to Finland's ranking on the 2016 Tobacco Control Scale. The framework method was chosen for analysing interview transcripts. RESULTS: A perceived strength of Tobacco-Free Finland 2030 was the consensus and cooperation among members of the tobacco control community. The objective of becoming a nicotine- versus smoke-free society had almost unanimous support, challenged by a small minority who argued for greater discussion of harm reduction approaches. The need for maintaining legitimacy and historical successes in tobacco control were reasons for using a conventional strategy. Barriers to achieving the endgame goal included insufficient funding and over-reliance on non-governmental organisations, political/legal constraints, impact of institutional practices on tobacco disparities, ambivalence about the role of mass media and lack of prioritising smoking cessation. CONCLUSIONS: Stakeholders' broad confidence in reaching the goal of Finland's tobacco endgame suggests that future policy initiatives will reflect the current, conventional strategy. If the Finnish government chooses to continue this approach, then it should designate separate funds for Tobacco-Free Finland 2030 and implement structural changes that will facilitate tobacco control initiatives.

Examining retail purchases of cigarettes and nicotine replacement therapy in Finland.

INTRODUCTION: Finland's success in achieving the goal of its tobacco endgame largely depends on rectifying deficiencies in the delivery of smoking cessation services. One such weakness, which has not been documented with empirical data, is misuse of nicotine replacement therapy (NRT). This study's objective was to examine purchase patterns of NRT for estimating improper use of the medication. The study was based on the assumption that duration of a purchase episode is indicative of either proper use or misuse of NRT. METHODS: The participants (n=728), who purchased at least one NRT product in 2016 (mostly gum/lozenge), were selected through enrollment in a large customer loyalty program in Finland (LoCard). Participants were categorized into one of five groups according to their longest purchase episode of NRT, defined by purchases made in consecutive, 4-week intervals. RESULTS: Most participants, who did not adhere to NRT guidelines, either purchased the medication for too short (≤4 weeks, 63.5%) or too long (>24 weeks, 13.2%) of a purchase episode. Median purchases of NRT in the first month of use were one and four in the former and latter, respectively. In contrast to other groups, persistent users (>24 weeks) did not curtail purchases of NRT across several 4-week intervals, suggesting potential for dependence on NRT. CONCLUSIONS: The observation that most purchase episodes were terminated prematurely is consistent with surveys reporting widespread NRT misuse. Given uncertainty of greater regulation of NRT sales through legislation, it would be prudent for Finnish retailers to promote proper use of the therapy.

Nicotine matters in predicting subsequent smoking after e-cigarette experimentation: A longitudinal study among Finnish adolescents.

BACKGROUND: Several studies indicate an association between e-cigarette use and subsequent smoking among youth. However, most previous studies lack measures of the nicotine content of e-liquid and have not usually measured regular smoking. METHODS: We tested the association between e-cigarette use, with and without nicotine, and subsequent daily use of conventional cigarettes and nicotine e-cigarettes among study population of 3474 students. A survey was conducted in lower secondary schools of the Helsinki metropolitan area, Finland, with 15 - 16-year-olds in 2014 (baseline) and in upper secondary schools in 2016 when the cohort was 17 - 18-year-olds (follow-up). Firth logistic regression and generalized linear mixed models (GLMM) were used. RESULTS: Of students, 25% had experimented with nicotine e-cigarettes at baseline and 40% at follow-up. Among baseline never-smokers, experimentation with or use of nicotine e-cigarettes predicted the uptake of daily smoking at follow-up (AOR 2.92; 95% CI 1.09-7.85), but baseline experimentation with non-nicotine e-cigarettes did not when compared with the non-e-cigarette experimenters. Nicotine e-cigarette experimentation at baseline predicted daily nicotine e-cigarette use at follow-up (AOR 2.96; 95% CI 1.22-7.22). Non-nicotine e-cigarette experimentation at baseline did not predict statistically significantly daily nicotine e-cigarette use at follow-up (AOR 3.13; 95% CI 0.98-10.02). The small number of cases may have diminished the statistical significance. CONCLUSIONS: The findings suggest that experimentation with nicotine e-cigarettes serves as a gateway to subsequent use of conventional cigarettes as well as nicotine e-cigarettes. Our results support the actions to limit youths' access to e-cigarettes in order to prevent nicotine addiction.

Adolescents notice fewer tobacco displays after implementation of the point-of-sale tobacco display ban in Finland.

INTRODUCTION: Finland implemented a point-of-sale (POS) display ban for tobacco products and their trademarks in 2012, and for electronic cigarettes in 2016. In this study we examine whether noticing tobacco products changed among adolescents after the implementation of the display ban and describe the noticing of e-cigarette displays post-implementation. METHODS: Repeated cross-sectional national survey data of 12-to 16-year-olds from years 2011, 2013, 2015 and 2017 were used. Measures included adolescent self-report on noticing displays of tobacco and e-cigarettes in shops, kiosks and service stations. Adjusting for age, gender, smoking and academic achievement, logistic regression analyses were conducted by retailer type to test the association between survey year and noticing POS tobacco displays. RESULTS: The proportions of adolescents noticing tobacco displayed in shops, kiosks and service stations decreased from 2011 to 2013 (from over 80% to about 30%). Between 2013 and 2017, exposure to tobacco displays decreased for kiosks but slightly increased for shops and service stations. However, in all retailer types, rates in 2017 were still well below the pre-ban levels of 2011. In 2017, noticing e-cigarette displays by 12- to16-year-old adolescents was reported by 5.6% in shops, 20.5% in kiosks and 5.1% in service stations. CONCLUSIONS: The pronounced decline in adolescents' exposure to tobacco products at POS observed in the current study implies adherence to the ban, as intended by the law. We encourage more countries to enact POS tobacco advertising and display bans, and to enforce the POS regulations to all tobacco products and novel nicotine delivery systems.

Arguments for amending smoke-free legislation in U.S. states to restrict use of electronic nicotine delivery systems.

The uneven diffusion of local and state laws restricting the use of electronic nicotine delivery systems (ENDS) in the United States may be a function of inconclusive scientific evidence and lack of guidance from the federal government. The objective of this study was to assess whether the rationale for amending clean indoor air acts (CIAAs) is being conflated by issues that are not directly relevant to protecting the health of ENDS non-users. Online sources were used in identifying bills (n = 25) that were presented in U.S. state legislatures from January 2009 to December 2015. The bills were categorized into one of three groups: 1) bills amending comprehensive CIAAs (n = 11), 2) bills prohibiting use of ENDS in places frequented by youth (n = 5), and 3) remaining bills that varied between the two categories (n = 9). Arguments presented in committee hearings were coded as scientific, public health, economic, enforcement, freedom, or regulatory. Arguments pertaining to amendment of clean indoor air acts spanned several categories, many of which were not directly relevant to the aims of the legislation. This finding could assist lawmakers and expert witnesses in making arguments that yield greater success in amending legislation. Alternatively, inconclusive scientific data on the hazards of ENDS aerosols might encourage lawmakers to propose legislation that prohibits ENDS use in places frequented by youths.

Characterizing Blunt Smokers by Their Acquisition of Cannabis.

BACKGROUND: Ethnographers have reported that young, urban males embraced blunt smoking in response to the crack cocaine epidemic that ravaged their neighborhoods in the 1980s. But, recent survey data has indicated high rates of other illicit drug use among blunt smokers. OBJECTIVES: The objective of this study was to examine the association between blunt smoking and cannabis acquisition as a potential explanation for the correlation with other illicit drug use. METHODS: The sample consisted of participants from the 2014 National Survey on Drug Use and Health (NSDUH) who reported use of cannabis or blunts in the prior month (n = 6,040). Logistic regression was used in estimating measures of demographics, access to illicit drugs, access to medical cannabis, frequency of cannabis/blunt use, and type of blunt smoker as correlates of a cannabis purchase versus other means of acquisition (e.g. sharing it). RESULTS: Accounting for other variables, current blunt smokers had 1.4 times the odds of purchasing cannabis relative to the cannabis users who had never smoked a blunt. Furthermore, the current blunt smokers had greater odds of purchasing cannabis frequently and making the purchases in outdoor settings. Conclusions/Importance: The findings suggest that current blunt smokers compared to other cannabis users are at greater risk of the dangers associated with illegal drug transactions. The legalization of recreational cannabis in some U.S. states is coinciding with the growth of a cannabis black market, highlighting the need for the continued assessment of cannabis acquisition in NSDUH questionnaires.

Linking the content to demographic reach of online advertising of electronic nicotine delivery systems.

INTRODUCTION: Recent studies have separately examined the content and demographic reach of the advertising of electronic nicotine delivery systems (ENDS). No study to our knowledge has linked the two in investigating whether racial/ethnic groups are differentially exposed to the comparative messages conveyed in online ENDS advertisements. METHODS: 932 unique ENDS advertisements (6311 total), which were posted on 3435 websites between December, 2009 and October, 2015, were categorized as either comparative or non-comparative with respect to the traditional cigarette. The race/ethnicity of website visitors was obtained from a proprietary source and used in constructing variables for racial/ethnic viewership. The variables for advertising content and website racial/ethnic viewership were then linked yielding a final sample of 551 unique ENDS advertisements (2498 total) on 1206 websites. A two-level hierarchical generalized linear model, used in estimating website racial/ethnic viewership as a predictor of comparative advertising, accounted for the nesting of advertisements (level 1) within 152 ENDS brands (level 2). RESULTS: In contrast to racial/ethnic minorities, a greater proportion of non-Hispanic whites visited websites with ENDS advertisements than the overall proportion of nonHispanic white U.S. Internet users. Yet, it was the advertisements on websites that appealed to Hispanics that had greater odds of comparing ENDS to traditional cigarettes. CONCLUSIONS: The lower exposure to ENDS advertising among racial/ethnic minorities versus non-Hispanic whites is consistent with survey data. Yet, the greater odds of comparative advertising of ENDS on websites that appeal to racial/ethnic minorities (ie, Hispanics) could impact the longterm health of minority smokers. IMPLICATIONS: This study's findings have important implications for the uptake of ENDS among minority smokers. If the comparative advertising yields greater interest and eventual use of ENDS, then minority smokers could either benefit from smoking cessation because they switch to ENDS, or adopt dual tobacco use. The fate of comparative advertising of ENDS versus the traditional cigarette will depend on the Food and Drug Administration enforcement of its deeming rules and the ensuing changes in the ENDS marketplace.

A longitudinal study of smokeless tobacco use and mortality in the United States.

Few studies in the United States have examined longitudinally the mortality risks associated with use of smokeless tobacco (SLT). The sample of our study was composed of participants from the National Longitudinal Mortality Study who completed a single Tobacco Use Supplement to the Current Population Survey between the years 1985 and 2011. Using survival methods, SLT use at the baseline survey was examined as a predictor of all-cause mortality and cause-specific mortalities in models that excluded individuals who had ever smoked cigarettes, cigars or used pipes (final n = 349,282). The participants had median and maximum follow-up times of 8.8 and 26.3 years, respectively. Regression analyses indicated that compared to the never tobacco users, the current SLT users did not have elevated mortality risks from all cancers combined, the digestive system cancers and cerebrovascular disease. However, current SLT users had a higher mortality risk for coronary heart disease (CHD) [hazard ratio (HR) (95% CI) = 1.24 (1.05, 1.46)] relative to never tobacco users. In a separate model, the elevated risk for CHD mortality corresponded to the use of moist snuff [HR (95% CI) = 1.30 (1.03, 1.63)]. The associations with CHD mortality could be attributed to long-term nicotine exposure, other SLT constituents (e.g., metals) or the confounding effects of CHD risk factors not accounted for in our study. The study's findings contribute to the ongoing dialogue on tobacco harm reduction and the US FDA's evaluation of Modified Risk Tobacco Product applications submitted by American SLT manufacturers.

The Reach and Impact of Direct Marketing via Brand Websites of Moist Snuff.

OBJECTIVE: Restricting tobacco marketing is a key element in the US Food and Drug Administration's (FDA) public health framework for regulating tobacco. Given the dearth of empirical data on direct marketing, the objective of this study was to assess the reach and impact of promotions on sales through snuff websites. METHODS: Nine brands of snuff, representing more than 90% of market share, were monitored for content of coupons, sweepstakes, contests, and other promotions on their respective websites. Monthly sales data and website traffic for the 9 brands, corresponding to the 48-month period of January 2011 through December 2014, were obtained from proprietary sources. A time-series analysis, based on the autoregressive, integrated, moving average (ARIMA) method, was employed for testing the relationships among sales, website visits, and promotions. RESULTS: Website traffic increased substantially during the promotion periods for most brands. Time-series analyses, however, revealed that promotion periods for 5 of 7 brands did not significantly correlate with monthly snuff sales. CONCLUSIONS: The success in attracting tobacco consumers to website promotions demonstrates the marketing reach of snuff manufacturers. This form of direct marketing should be monitored by the FDA given evidence of adolescents' exposure to cigarette brand websites.