Teens Less Susceptible to Vaping When Restricted to Tobacco-Flavored E-cigarettes: Implications for Flavored Tobacco Policies.

INTRODUCTION: Flavors added to tobacco products increase their appeal to youth and contribute to the youth vaping epidemic. To address this problem, over 340 localities have implemented various policies to restrict access to flavored tobacco products. Few studies have examined the extent to which restricting available e-cigarette flavors might affect e-cigarette initiation or cessation among youth. AIMS AND METHODS: A representative sample of Minnesota teens were asked about their use of e-cigarettes, symptoms of e-cigarette dependence and their willingness to use an e-cigarette under four flavor conditions: unspecified (any flavor); menthol, tobacco, or unflavored. Respondents with data on all four flavor conditions were included in the analysis (N = 2151). RESULTS: Cochran's Q, McNemar, and exact binomial tests revealed that susceptibility to e-cigarette use was highest when the flavor was unspecified (38.2%), lower for unflavored (29.7%) and menthol-flavored e-cigarettes (26.7%), and lowest when the flavor was tobacco (21.0%). Among the subsets of students who had never tried e-cigarettes and students who reported signs of e-cigarette dependence, the largest decrease in susceptibility from unspecified flavor e-cigarettes was observed for tobacco-flavor, a decrease of 12.7 and 19.6 percentage points, respectively. CONCLUSIONS: Whether teens had no experience using e-cigarettes or showed signs of dependence, the percentage of teens who were susceptible to using e-cigarettes was significantly lower when the flavor available was restricted. Susceptibility was lower for tobacco- and menthol-flavored than unflavored e-cigarettes, suggesting that teens consider these flavors aversive. IMPLICATIONS: These results suggest that policies that eliminate all e-cigarette flavors except tobacco may be a powerful tool for advancing youth e-cigarette prevention and cessation goals by reducing the appeal of e-cigarettes to teens with different levels of experience with them, including teens who have never tried e-cigarettes and those who may find it difficult to quit using them.

Local Tobacco 21 Policies are Associated With Lower Odds of Tobacco Use Among Adolescents.

INTRODUCTION: Tobacco 21 (T21) policies have shown promise in reducing cigarette use among adolescents. This study examined whether local T21 policies affected adolescent use of a variety of tobacco products and whether results differed by grade level. METHODS: We used repeated cross-sectional data from eighth, ninth, and eleventh-grade respondents to the 2016 (n = 107 981) and 2019 (n = 102 196) Minnesota Student Surveys. Generalized estimating equations modeled eight adolescent tobacco use outcomes in 2019 (past 30-day use of any tobacco, cigarettes, cigars, e-cigarettes, hookah, chewing tobacco, flavored tobacco, and multiple products) by T21 exposure, defined as respondents' attendance at a school within a jurisdiction with T21 policy implementation between the two surveys. Models controlled for demographic characteristics and product-specific baseline tobacco use at the school level in 2016 and were stratified by grade. RESULTS: After adjusting for baseline tobacco use and other demographics, T21-exposed eighth and ninth-grade students had significantly lower odds of tobacco use than unexposed peers in five of eight models, i.e. any tobacco (aOR = 0.80, 95% CI: 0.74, 0.87), cigarettes (aOR = 0.81, 95% CI: 0.67, 0.99), e-cigarettes (aOR = 0.78, 95% CI: 0.71, 0.85), flavored tobacco (aOR = 0.79, CI: 0.70, 0.89), and dual/poly tobacco (aOR = 0.77, 95% CI: 0.65, 0.92). T21-exposed eleventh-grade students did not differ significantly in their odds of any tobacco use outcomes relative to their unexposed peers. CONCLUSIONS: T21 exposure is associated with lower odds of multiple forms of tobacco use, particularly among younger adolescent populations, supporting the implementation of T21 policies to reduce tobacco use in this population.

"If Someone Has It, I'm Gonna Hit It": Lessons Learned From Minnesota Teens About Vaping.

Youth e-cigarette use or "vaping" has increased substantially in the past few years, an escalation attributable to flavored "pod mod" e-cigarette devices that deliver higher levels of nicotine compared with free-base nicotine found in other types of e-cigarettes. Use rates, addiction, and harms are alarming as negative effects from nicotine on adolescent brain development are well documented, and e-cigarette use is predictive of cigarette smoking initiation. This qualitative study examined what drives the appeal of these products through 10 focus groups conducted in 2019 with 67 Minnesota high school students. Focus groups aimed to understand students' personal experiences and contextual factors that may contribute to current vaping trends and explore opportunities for improved prevention messaging. Study results revealed participants' divergent perceptions of tobacco products (i.e., vaping vs. e-cigarettes vs. cigarettes) and the benefits and harms of each product. Participants provided insights into why youth vape, describing vaping as an easily accessible coping method to help teens manage stress and anxiety. Peer normalization and invincibility beliefs about harms were also present. Participants generated ideas about prevention messaging, describing the ineffectiveness of prevention messages they currently receive, and expressing the need for accurate information about e-cigarette health risks presented in personalized, nonjudgmental contexts by people they know care about them. These results have clear implications for prevention initiatives and can be used to inform effective prevention strategies, messaging, programming, and policies, some of which are specific to e-cigarette prevention and others that align with the theory of positive youth development.

Restricting Sales of Menthol Tobacco Products: Lessons Learned from Policy Passage and Implementation in Minneapolis, St. Paul, and Duluth, Minnesota.

Purpose: Commercial tobacco products have historically been target marketed to African American, Latinx, Asian American Pacific Islander, Indigenous, and Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ) communities, as well as to youth. Menthol cigarettes increase smoking initiation and decrease smoking cessation, particularly among African Americans who smoke menthol cigarettes at higher rates than their white peers. Due to disproportionate tobacco-related health consequences for members of these communities, effective tobacco control policies that restrict availability of menthol products by focusing on retail sales are an important element of addressing health disparities, and require policy efforts informed by leadership and the voice of communities most impacted. This study examines the organizing efforts of three successful policy initiatives in 2017-2018 in Minneapolis, St. Paul, and Duluth, Minnesota, and identifies facilitators and barriers of these campaigns. Methods: We conducted 50 key informant interviews with city council/staff, advocates, and community members and analyzed them for emerging themes. The analysis employed a process-oriented qualitative matrix process to identify emerging themes and divergent perspectives. Results: Following policy implementation, outlets selling commercial menthol tobacco products substantially decreased. Facilitators included strong city council support, leadership from impacted communities, community awareness-building campaigns, and understanding tobacco industry counter-tactics. Challenges included the need to counter tobacco industry misinformation and retailer attempts to circumvent the intent of restrictions. Conclusion: Well-planned advocacy campaigns led by community members most impacted by commercial tobacco can overcome opposition and challenges to restrict sales of menthol tobacco products and successfully reduce availability of these products in their communities.

Perceived racial discrimination and healthy behavior among African Americans.

OBJECTIVE: Numerous studies have found evidence of a link between perceived discrimination and unhealthy behavior, especially substance use. Within this body of literature, however, several studies have found unexpected evidence of a positive relation between perceived racial discrimination among African Americans-mostly women-and certain types of healthy behavior, primarily exercise and healthy eating. The current study further examined this positive relation, including an anticipated moderator: optimism. It also examined the relation between perceived racial discrimination and a correlate of unhealthy behavior: BMI. METHOD: Six waves of data were collected over 14 years in three related samples of African Americans from families participating in the Family and Community Health Study. Each family included an adolescent (Mage = 10.5 at Wave 1), the adolescent's primary caregiver (Mage = 37), and, in some cases, an older sibling of that adolescent (Mage = 13). Wave 1 Ns were 889, 889, and 295, respectively. Healthy behavior was defined as diet and exercise. RESULTS: There was very little evidence of a long-term relation between perceived racial discrimination and BMI in any sample, and no evidence of a relation between discrimination and healthy behavior among the males. However, correlational analyses revealed a positive prospective relation between discrimination and healthy behavior among all three groups of females; structural equation modeling indicated that this relation was stronger among women who were high in optimism. CONCLUSIONS: Perceived racial discrimination does not appear to be related to BMI among African Americans, but it is related to healthy behavior among Black females who are high in dispositional optimism. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Local sales restrictions significantly reduce the availability of menthol tobacco: findings from four Minnesota cities.

BACKGROUND: In 2017 and 2018, Minneapolis, St. Paul, Duluth and Falcon Heights, Minnesota were among the first US cities to restrict the sale of menthol tobacco to adult-only stores. The study examined changes in the availability and marketing of these products following policy implementation. METHODS: Retail store audits were conducted approximately 2 months pre-policy and post-policy implementation. Tobacco retail stores (n=299) were sampled from tobacco licensing lists in Minneapolis, St. Paul, Duluth and Falcon Heights, as well as six comparison cities without menthol policies. The presence of menthol tobacco was assessed, along with the number of interior and exterior tobacco ads and promotions at each store. RESULTS: The majority of policy intervention stores (grocery, convenience stores and pharmacies) were compliant (Minneapolis, 84.4%; Duluth, 97.5%; and St. Paul and Falcon Heights, 100.0%) and did not sell menthol tobacco. In contrast, menthol tobacco was available in all comparison city stores, and most (96.0%) exempted tobacco shops and liquor stores post-policy implementation. Two Minneapolis convenience stores added interior tobacco shops, allowing them to continue selling menthol tobacco. Significant decreases in menthol tobacco marketing post-policy were observed in the stores' interior in Minneapolis, St. Paul and Duluth (p<0.001) and on the stores' exterior in Duluth (p=0.023). CONCLUSIONS: Findings demonstrate high rates of compliance, indicating that sales restrictions can significantly reduce the availability of menthol tobacco. However, challenges to policy adherence underscore the need for continued monitoring and enforcement action.

Perceptions of Menthol Cigarettes and Reasons for Unsuccessful Quits in an African American Community Sample.

This study aimed to better understand African Americans' perceptions of menthol tobacco and reasons for unsuccessful quit attempts among menthol smokers. A cross-sectional survey of 407 U.S.-born African American adults from Minnesota assessed menthol perceptions and experiences trying to quit menthol cigarettes. A majority of the sample (59%) was either unsure of the relative harm of menthol cigarettes or perceived that menthol cigarettes are less harmful than non-menthol cigarettes. Menthol smokers were more likely than nonsmokers to perceive that menthol makes it easier to start smoking and harder to quit, and that menthol cigarettes are marketed to African Americans more than other groups (ps < .05). Nearly half (45%) of menthol smokers who reported a failed quit attempt identified cravings as a reason why they were unsuccessful. Media campaigns and educational interventions that highlight the dangers of menthol and promote cessation resources are needed to help reduce the pernicious effects of menthol in the African American community.

Perceived harm of menthol cigarettes and quitting behaviors among menthol smokers in Minnesota.

Although overall smoking prevalence in Minnesota has declined, the proportion of current smokers who smoke menthol cigarettes has increased. While studies have examined associations between smokers' perceived risks of smoking and quitting, similar studies on menthol smoking are lacking. This study examined whether perceived harm of menthol cigarettes was associated with menthol smokers' quitting behaviors. Data from the 2018 Minnesota Adult Tobacco Survey were examined. Respondents were categorized as current menthol smokers (n = 200), current nonmenthol smokers (n = 527), or nonsmokers (n = 5324). All were asked four questions to assess their perceptions of menthol cigarettes' harm compared to nonmenthols. Sum scores were calculated (range 0-4); higher scores indicated perceptions of similar or greater harm. Data on menthol smokers' quitting behaviors were analyzed to identify associations between sum scores and quitting behavior. Data were analyzed using Wilcoxon Rank Sum tests and Spearman Rank Correlation tests. Additional analyses examined whether gender, age, race/ethnicity, education or income moderated the association between sum scores and past 12-month quit attempts. Menthol smokers were less likely to answer the harm perception questions correctly than nonmenthol smokers. Among menthol smokers, perceived harm of menthol cigarettes was positively associated with past 12-month quit attempts (p = 0.006), use of counseling/behavioral support (p = 0.012), and number of quit attempts (p = 0.004). No demographic characteristics moderated the association between sum scores and past 12-month quit attempts. Findings suggest that efforts to increase menthol smokers' perceptions of menthol cigarettes' harm may potentially increase quitting behaviors. Understanding this association can inform interventions to increase quit attempts.

Statewide Prevalence of Smoke-Free and Vape-Free Homes, by Tobacco Product Use, Minnesota, 2018.

INTRODUCTION: Securing clean indoor air laws is a major tobacco control accomplishment of the past 15 years. The public quickly adopted and supported such policies both in public and private spaces. Clean indoor air is now threatened by the emergence of e-cigarettes. E-cigarette aerosol contains nicotine, heavy metals, and carcinogens, and the long-term effect of secondhand exposure is unknown. Surveillance is necessary to track voluntary rules on smoking and vaping in the home. METHODS: The Minnesota Adult Tobacco Survey (MATS) is a series of cross-sectional, random-digit-dial telephone surveys on smoking, vaping, and other tobacco-related behaviors, attitudes, and beliefs among Minnesota adults. MATS measured voluntary smoke-free rules in the home in 2014 (N = 9,304) and measured both smoke-free and vape-free home rules in 2018 (N = 6,055). RESULTS: The prevalence of smoke-free home rules among Minnesota adults in 2018 was 91.5% (95% CI, 90.5%-92.5%), up slightly from 89.3% (95% CI, 88.4%-90.2%) in 2014. In comparison, 84.0% (95% CI, 82.7%-85.3%) reported vape-free home rules. Although 70.0% (95% CI, 66.0%-73.0%) of smokers in 2018 reported smoke-free home rules, only 23.3% (95% CI, 15.0%-31.6%) of e-cigarette users reported vape-free home rules. Living with children younger than 18 years significantly increased the odds of having smoke-free and vape-free home rules. CONCLUSION: Although widespread adoption of voluntary smoke-free and vape-free home rules demonstrates a positive change in social norms, most e-cigarette users allow vaping in their homes, including those who live with children younger than 18. Tracking voluntary smoke-free and vape-free home rules and efforts to encourage them are important to improve the public's health.

Reducing Socioeconomic Disparities in Comprehensive Smoke-Free Rules among Households with Children: A Pilot Intervention Implemented through a National Cancer Program.

Most households with a smoker do not implement comprehensive smoke-free rules (smoke-free homes and cars), and secondhand smoke (SHS) exposure remains prevalent among children and low-socioeconomic status (SES) populations. This pilot project aimed to assess implementation feasibility and impact of an intervention designed to increase smoke-free rules among socioeconomically disadvantaged households with children. The pilot was implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (NBCCEDP). NBCCEDPs provide cancer prevention services to low-income individuals experiencing health disparities. We successfully utilized and adapted the Smoke-Free Homes Program (SFHP) to address comprehensive smoke-free rules among households with children. We used two recruitment methods: (a) direct mail (DM) and (b) opportunistic referral (OR) by patient navigators in the NBCCEDP call center. We used descriptive statistics to assess implementation outcomes and hierarchical logistic regression models (HLM) to assess change in smoke-free rules and SHS exposure over the study period. There was no comparison group, and HLM was used to examine within-person change. A total of 64 participants were recruited. Results showed 83% of participants were recruited through DM. OR had a high recruitment rate, and DM recruited more participants with a low response rate but higher retention rate. Among recruited participants with data (n = 47), smoke-free home rules increased by 50.4 percentage points during the study period (p < 0.001). Among recruited participants who had a vehicle (n = 38), smoke-free car rules increased by 37.6 percentage points (p < 0.01) and comprehensive smoke-free rules rose 40.9 percentage points (p < 0.01). Home SHS exposure declined, and within-person increase in smoke-free home rules was significantly related to less home SHS exposure (p < 0.05). It is feasible to adapt and implement the evidence-based SFHP intervention through a national cancer program, but the current pilot demonstrated recruitment is a challenge. DM produced a low response rate and therefore OR is the recommended recruitment route. Despite low recruitment rates, we conclude that the SFHP can successfully increase comprehensive smoke-free rules and reduce SHS exposure among socioeconomically disadvantaged households with children recruited through a NBCCEDP.

Location and duration of secondhand smoke exposure among Minnesota Nonsmokers, 2018.

In 2007 Minnesota passed into law a comprehensive ban on indoor smoking of tobacco products in public places including bars, restaurants, and workplaces. Despite reductions in smoking prevalence in the past 12 years, people are still exposed to secondhand smoke (SHS). It remains important to understand where and how long nonsmokers face exposure to SHS. The 2018 Minnesota Adult Tobacco Survey was analyzed to examine self-reported SHS exposure among nonsmoking adults. We report prevalence and 95 percent confidence intervals of SHS exposure overall, by specific locations, and by demographics. Length of exposure to SHS was summarized in median minutes. Overall, 30 percent of nonsmokers reported exposure in the past seven days. A total of 1382 participants indicated a location of exposure. The most common locations other than one's own home or car included building entrances (18.7 [16.2-21.1] percent), somewhere else outdoors (17.7 [15.1-20.3] percent), and restaurant/bar patios (12.8 [10.5-15.0] percent). Exposure was more likely to be reported by young adults (44.6 percent) and males (33.7 percent). The locations with the longest duration of SHS exposure in the prior seven days were a gambling venue (117.2 [72.2-162.2] minutes), another person's home (26.1 [15.4-36.8] minutes), and a bus stop (10.8 [4.7-16.9] minutes). Monitoring nonsmokers' self-reported exposure to SHS remains important as a way to measure the impact and compliance with smoke-free policies. Additional information on the location and duration of exposure can be used programmatically to address high levels of exposure and consider additional policies or strategies.

Community-Led Action to Reduce Menthol Cigarette Use in the African American Community.

Background. African Americans suffer a disproportionate burden of tobacco harm and researchers have posited that menthol cigarettes are a key contributor to this disparity. In 2015, a county health department and African American community-based organization (CBO) in Minnesota partnered to educate and engage the African American community on menthol and its role in tobacco-related health disparities. The following case study describes successes, challenges, and recommendations from this work. We focus on the role of a public health and community partnership in menthol policy adoption so others can more effectively implement a community-driven approach in their own communities. Methods. Interviews were conducted with local and state public health staff, leadership from the CBO, youth coordinators, and change agents-that is, leaders in the African American community recruited to educate and engage the community on menthol. Interviews were transcribed verbatim and analyzed in Atlas.ti using thematic analysis. Results. Participants identified several successes: (1) assessment data from community members helped inform policy decision making, (2) collaboration between local public health and CBO was powerful and a key to success, and (3) change agents were trusted communicators and effectively engaged and provided education to the community. Participants faced challenges related to stylistic and cultural differences in communication. Participants recommended engaging youth and incorporating cessation into the broader context of issues systemically affecting African American communities (e.g., economic inequity, police violence, incarceration). Implications. Menthol tobacco restrictions have the potential to reduce tobacco-related health inequities for African Americans. Findings highlight the role that public health and community partnerships can play in supporting this critical work to effect policy change.

Adverse Childhood Experiences and Youth Cigarette Use in 2013 and 2016: Emerging Disparities in the Context of Declining Smoking Rates.

INTRODUCTION: Cigarette use has dropped dramatically among youth since 2013, but smoking-related disparities persist. We examine who still smokes in the context of declining smoking rates. Using the Minnesota Student Survey, we examine adverse childhood experiences (ACEs) and cigarette use in 2013 and 2016. We assess how cigarette use rates changed, how ACEs relate to cigarette use, and the degree to which youth with ACEs comprise the current smoking population. METHODS: Data came from the 2013 and 2016 Minnesota Student Survey. We assessed past 30-day any and daily cigarette use statewide and among youth with no ACEs, high cumulative ACEs, and seven separate ACEs. We used descriptive statistics and multivariate logistic regression analyses. RESULTS: Cigarette use significantly declined for all groups from 2013 to 2016. Youth with no ACEs exhibited the highest percent decrease in any and daily cigarette use. Youth with ACEs were more likely to report any and daily cigarette use in 2013 and 2016, adjusting for demographics. Among youth with any 30-day use, the rate of ACEs increased from 2013 to 2016. Youth with ACEs disproportionately accounted for youth smoking populations in 2013 and 2016. For example, although 16% of all youth experienced parental incarceration, approximately 43% and 55% of youth with any and daily cigarette use experienced parental incarceration in 2016, respectively. CONCLUSIONS: Cigarette use declined from 2013 to 2016 for all Minnesota youth, but the decline among youth with no ACEs was faster than those with ACEs. Youth with ACEs now account for an increasingly high percent of youth smokers. IMPLICATIONS: Even though cigarette use is declining among Minnesota youth, the decline among youth without ACEs is faster than the decline among youth with ACEs. Youth with ACEs disproportionately account for all youth smokers, and this disproportionality has increased since 2013. Tobacco control efforts should focus on youth with ACEs, and parental incarceration is a specific ACE that warrants attention. Rates of parental incarceration remain high in the United States and youth who experience parental incarceration now account for a near majority of current youth smokers. Future research should consider mechanisms for the ACE-smoking relationship and emerging tobacco products (eg, electronic cigarettes).

Financial incentives and proactive calling for reducing barriers to tobacco treatment among socioeconomically disadvantaged women: A factorial randomized trial.

Improved strategies and scalable interventions to engage low-socioeconomic status (SES) smokers in tobacco treatment are needed. We tested an intervention designed to connect low-SES smokers to treatment services, implemented through Minnesota's National Breast and Cervical Cancer Early Detection Program (Sage) in 2017; the trial was designed to last 3 months (July through October). Participants were female smokers who were 250% below the federal poverty level (randomized N = 3723; analyzed N = 3365). Using a factorial design, participants were randomized to six intervention groups consisting of a proactive call (no call vs call) and/or a financial incentive offered for being connected to treatment services ($0 vs $10 vs $20). Simple randomization was conducted using Stata v.13. All individuals received direct mail. Participants and staff were blinded to allocation. The outcome was connection via phone to QUITPLAN Services®, Minnesota's population-based cessation services. Groups that received $10 or $20 incentives had higher odds of treatment engagement compared to the no incentive group [respectively, OR = 1.94; 95% CI (1.19-3.14); OR = 2.18; 95% CI (1.36-3.51)]. Individuals that received proactive calls had higher odds of treatment engagement compared to individuals not called [OR = 1.59; 95% CI (1.11-2.29)]. Economic evaluation revealed that the $10 incentive, no call group had the best cost-benefit ratio compared to the no incentive, no call group. Direct mail with moderate incentives or proactive calling can successfully encourage connections to population-based tobacco treatment services among low-SES smokers. The intervention could be disseminated to similar programs serving low-SES populations. This trial is registered at ClinicalTrials.gov (NCT03760107).

Household Implementation of Smoke-Free Rules in Homes and Cars: A Focus on Adolescent Smoking Behavior and Secondhand Smoke Exposure.

PURPOSE: This study addresses the dearth of population-based research on how comprehensive household smoke-free rules (ie, in the home and car) relate to tobacco use and secondhand smoke (SHS) exposure among adolescents. DESIGN: Analysis of 2014 Minnesota Youth Tobacco Survey. SETTING: Representative sample of Minnesota youth. PARTICIPANTS: A total of 1287 youth who lived with a smoker. MEASURES: Measures included household smoke-free rules (no rules, partial rules-home or car, but not both-and comprehensive rules), lifetime and 30-day cigarette use, 30-day cigarette and other product use, and SHS exposure in past 7 days in home and car. ANALYSIS: Weighted multivariate logistic, zero-inflated Poisson, and zero-inflated negative binomial regressions were used. RESULTS: Compared to comprehensive rules, partial and no smoke-free rules were significantly and positively related to lifetime cigarette use (respectively, adjusted odds ratio [AOR] = 1.80, 95% confidence interval [CI] = 1.24-2.61; AOR = 2.87, 95% CI = 1.93-4.25), and a similar significant pattern was found for 30-day cigarette use (respectively, AOR = 2.20, 95% CI = 1.21-4.02; AOR = 2.45, 95% CI = 1.34-4.50). No smoke-free rules significantly predicted using cigarettes and other tobacco products compared to comprehensive rules. In both descriptive and regression analyses, we found SHS exposure rates in both the home and car were significantly lower among youth whose household implemented comprehensive smoke-free rules. CONCLUSIONS: Comprehensive smoke-free rules protect youth from the harms of caregiver tobacco use. Relative to both partial and no smoke-free rules, comprehensive smoke-free rules have a marked impact on tobacco use and SHS exposure among youth who live with a smoker. Health promotion efforts should promote comprehensive smoke-free rules among all households and particularly households with children and adolescents.

Changing patterns in E-cigarette use among Minnesota adults between 2014 and 2018.

Minnesota has observed declining combustible tobacco use and a large increase in e-cigarette use among youth and young adults. Less is known about adult e-cigarette users' frequency of use, smoking status, use of flavors, and demographic differences. The Minnesota Adult Tobacco Survey (MATS) is a cross-sectional, random digit-dial telephone survey representative of Minnesotans aged 18 and over. MATS measured e-cigarette use in 2014 (N = 9304) and 2018 (N = 6065). In 2018, 6.0% of adult Minnesotans used an e-cigarette in the past 30 days; this was unchanged from 2014 (5.9%). While past 30-day e-cigarette use declined for current smokers (2014: 27.3%; 2018: 16.1% p < 0.001), it increased for never smokers (2014: 1.2%; 2018: 4.4% p < 0.001) and 18-24-year-olds (2014: 12.8%; 2018: 21.9% p = 0.001). Daily e-cigarette use increased from 2014 to 2018 for current smokers (p = 0.001), 25-44-year-olds (p < 0.001), females (p = 0.001), and those with a high-school education (p = 0.006). Among e-cigarette users in 2018, use of flavored e-cigarettes was associated with smoking status (p = 0.041), age (p < 0.001), and using e-cigarettes to quit smoking (p = 0.011). E-cigarettes appeal primarily to younger adults. Of concern are increases in never smokers initiating e-cigarette use, increasing their exposure to nicotine, addiction, and the risk of future combustible tobacco use. Simultaneously, fewer smokers are using e-cigarettes but those who do are using them more frequently. Use of flavored e-cigarettes was common and correlated with interest in quitting combustible cigarettes. These findings can inform recent calls for additional tobacco control policy and programs aimed at reducing e-cigarette use.

Smoke-Free Rules in Homes and Cars Among Smokers and Nonsmokers in Minnesota.

We examined prevalence and predictors of comprehensive smoke-free household rules (ie, smoke-free homes and cars) among smokers and nonsmokers in Minnesota. Data came from the 2014 Minnesota Adult Tobacco Survey; weighted analyses consisted of descriptive analyses and multivariate logistic regression analyses. Most adult smokers implemented home-only smoke-free rules (43%) while most nonsmokers implemented comprehensive smoke-free rules (home and car; 85%). Comprehensive smoke-free rules were more common among people with high socioeconomic status (SES), married people, and people who did not live with a smoker; those with a child in the home were more likely to implement smoke-free homes but not smoke-free cars. Public health practitioners should focus on addressing the majority of smokers who do not implement comprehensive smoke-free household rules, such as low-SES populations, and addressing caregivers who do not implement smoke-free car rules.

Behavioral change in response to a statewide tobacco tax increase and differences across socioeconomic status.

BACKGROUND: Tobacco use is a leading behavioral risk factor for morbidity and mortality, and the tobacco epidemic disproportionately affects low-socioeconomic status (SES) populations. Taxation is effective for reducing cigarette use, and it is an effective population-based policy for reducing SES-related tobacco disparities. However, progress in implementing cigarette excise taxes has stalled across the United States, and there is a dearth of research on the full spectrum of behavioral shifts that result from taxes, particularly among low-SES populations. This project documents the impact of Minnesota's $1.75 cigarette tax increase implemented in 2013. METHODS: Data come from the 2014 Minnesota Adult Tobacco Survey. Descriptive analyses and Latent Class Analysis (LCA) were used to provide a typology of the tax impact. RESULTS: From the LCA, six classes were identified, and 42% of respondents were classified as reporting action-oriented behavioral change related to the tax-8% reported sustained smoking abstinence. We found differential behavior change across levels of SES. Low-SES and medium/high-SES individuals were equally likely to report complete tobacco cessation, but the prevalence of daily smokers who reported action-oriented behavior without sustained cessation was nearly double for low-SES individuals. CONCLUSIONS: Smokers report a range of behavioral changes in response to cigarette taxes, with differences across SES. The majority of smokers, and particularly low-SES smokers, report behavioral steps toward quitting or achieving sustained tobacco cessation in response to cigarette taxes. Complementary population-based programs geared toward assisting individuals, especially low-SES individuals, to achieve continuous tobacco cessation could increase the reach and effectiveness of cigarette taxes.

Raising the Minimum Legal Sale Age for Tobacco to 21: The Estimated Effect for Minnesota.

A campaign to raise the minimum legal sale age for tobacco products from 18 to 21 years known as Tobacco 21 is having a nationwide impact, with at least 200 localities in 14 states having already implemented a Tobacco 21 policy. A 2015 report from the Institute of Medicine (IOM) estimated the effects of such policy on cigarette use at the national level; however, little is known about the expected effects for individual states. The purpose of this study was to consider the effect on smoking initiation in Minnesota if the minimum sale age were 21 in 2015. Estimates from the Minnesota Adolescent Community Cohort and Minnesota Adult Tobacco Survey were used to calculate the uptake of smoking in a hypothetical cohort of Minnesota adolescents 15 to 20 years of age. Expected reductions in initiation in the IOM report were used to calculate the effects of Tobacco 21 policy on smoking uptake in this cohort. Results revealed that raising the sale age to 21 in 2015 would prevent 3,355 young Minnesotans from starting to smoke.

Clearing the Air: Smoke-Free Housing Policies, Smoking, and Secondhand Smoke Exposure Among Affordable Housing Residents in Minnesota, 2014-2015.

INTRODUCTION: During the past 30 years, local and state tobacco use control laws in the United States have helped reduce smoking prevalence and exposure to secondhand smoke, but progress among low socioeconomic populations has been slow. Implementing smoke-free housing policies in affordable housing may help address this issue. The purpose of our study was to assess how such policies affect smoking rates and exposure to secondhand smoke among residents of affordable housing. METHODS: We conducted a pretest-posttest longitudinal study of 180 residents from 8 affordable housing properties in Minnesota. Participating properties agreed to adopt a smoke-free housing policy covering indoor grounds, and 3 of these properties also prohibited smoking on all outdoor grounds. Policies were implemented with assistance from local public health departments and the Statewide Health Improvement Program. Participants completed surveys one month before policy implementation and 6 months postimplementation. Surveys assessed smoking, quit attempts, and indoor and outdoor secondhand smoke exposure. RESULTS: Results indicated a significant reduction in nonsmokers' indoor exposure to secondhand smoke (F1,144 = 22.69, P < .001) and no change in outdoor exposure to secondhand smoke from Time 1 (pretest) to Time 2 (posttest) (F1,140 = 2.17, P = .14). However, when examining sites that only prohibited smoking indoors, we observed an increase in outdoor secondhand smoke exposure that approached significance (F1,118 = 3.76, P = .055). Results showed no change in quit attempts over time, but 77% of residents who smoked at pretest reported reducing the amount that they smoked at posttest, and an additional 5% reported that they had quit. CONCLUSIONS: Smoke-free housing policies may be an effective strategy to reduce exposure to indoor secondhand exposure and promote decreased cigarette smoking among residents of affordable housing.