Association of metformin use and cancer incidence: a systematic review and meta-analysis.

BACKGROUND: Metformin is among the most widely used antidiabetics medications because of its minimal toxicity, favorable safety profile, availability, and low cost. In addition to its role in diabetes management, metformin may reduce cancer risk. METHODS: We conducted a comprehensive systematic review and meta-analysis to investigate the association between metformin use and cancer risk, with evaluation by specific cancer type when possible. Applicable studies were identified in PubMed/MEDLINE, Embase, Cochrane Library, Web of Science, and Scopus from inception through March 7, 2023, with metformin use categorized as "ever" or "yes" and a cancer diagnosis as the outcome. Article quality was evaluated using National Heart, Lung, and Blood Institute guidelines, and publication bias was evaluated using the Egger test, Begg test, and funnel plots. Pooled relative risk (RR) estimates were calculated using random-effects models, and sensitivity analysis was completed through leave-one-out cross-validation. RESULTS: We included 166 studies with cancer incidence information in the meta-analysis. Reduced risk for overall cancer was observed in case-control studies (RR = 0.55, 95% confidence interval [CI] = 0.30 to 0.80) and prospective cohort studies (RR = 0.65, 95% CI = 0.37 to 0.93). Metformin use was associated with reduced gastrointestinal (RR = 0.79, 95% CI = 0.73 to 0.85), urologic (RR = 0.88, 95% CI = 0.78 to 0.99), and hematologic (RR = 0.87, 95% CI = 0.75 to 0.99) cancer risk. Statistically significant publication bias was observed within the studies (Egger P < .001). CONCLUSIONS: Metformin may be associated with a decreased risk of many cancer types, but high heterogeneity and risk of publication bias limit confidence in these results. Additional studies in populations without diabetes are needed to better understand the utility of metformin in cancer prevention.

Effects of Modified Risk Tobacco Product Claims on Consumer Responses.

INTRODUCTION: US tobacco manufacturers can seek authorization from the US Food and Drug Administration (FDA) to market products using modified risk tobacco product (MRTP) claims. To inform regulatory decisions, we examined the impact of MRTP claim specificity and content, including whether the claims produced halo effects (ie, inferring health benefits beyond what is stated). AIMS AND METHODS: Participants were 3161 US adult cigarette smokers. Using a two (general vs. specific) × 2 (risk vs. exposure) plus independent control design, we randomized participants to view one message from these conditions: general risk claim (eg, "smoking-related diseases"), general exposure claim (eg, "chemicals in smoke"), specific risk claim (eg, "lung cancer"), specific exposure claim (eg, "arsenic"), or control. Claims described the benefits of completely switching from cigarettes to the heated tobacco product IQOS. RESULTS: MRTP claims of any sort elicited a higher willingness to try IQOS relative to control (d = 0.09, p = .043). Claims also elicited lower perceived risk of disease and exposure to harmful chemicals for completely switching from cigarettes to IQOS (d = -0.32 and -0.31) and partially switching (d = -0.25 and d = -0.26; all p < .05). Relative to specific MRTP claims, general MRTP claims led to lower perceived risk and exposure for complete switching (d = -0.13 and d = -0.16) and partial switching (d = -0.14 and d = -0.12; all p < .05). Risk and exposure MRTP claims had similar effects (all p > .05). DISCUSSION: MRTP claims led to lower perceived risk and exposure, and higher willingness to try IQOS. General claims elicited larger effects than specific claims. MRTP claims also promoted unintended halo effects (eg, lower perceived risk of disease and chemical exposure for partial switching). IMPLICATIONS: We found evidence that MRTP claims promoted health halo effects. In light of these findings, the FDA should require research on halo effects prior to authorization. Further, if an MRTP claim is authorized, FDA should require tobacco manufacturers to conduct post-market surveillance of how the claim affects consumer understanding, including partial switching perceived risk and exposure beliefs, as well as monitoring of dual-use behaviors.

E-cigarette Unit Sales by Product and Flavor Type, and Top-Selling Brands, United States, 2020-2022.

E-cigarette products, related policies, and use patterns change rapidly. In the United States, the prevalence of e-cigarette use is markedly higher among youths and young adults than it is among adults overall. In 2021, 4.5% of all adults aged ≥18 years (an estimated 11.1 million) and 11.0% of young adults aged 18-24 years (an estimated 3.1 million) currently (≥1 day during the previous 30 days) used e-cigarettes; during 2022, 14.1% of high school students (an estimated 2.14 million) currently used e-cigarettes (1,2). E-cigarettes often contain high concentrations of nicotine. Nicotine is highly addictive and can harm the adolescent brain, which continues to develop through approximately age 25 years (3). Since 2020, the availability of e-cigarette products has changed in response to multiple factors, including local and state policies to address flavored e-cigarette sales, actions undertaken by the Food and Drug Administration (FDA), COVID-19-related closures, and global supply chain disruptions. To assess trends in unit sales of e-cigarettes in the United States, by product and flavor, and top-selling brands, the CDC Foundation, Truth Initiative,* and CDC analyzed retail scanner data during January 26, 2020-December 25, 2022, from Information Resources, Inc. (IRI), a U.S. data analytics and market research company. Overall, unit sales increased by 46.6% during the study period. The unit share of menthol-flavored product sales remained relatively stable during this period, whereas nonmenthol flavor unit shares changed. During January 26, 2020-December 25, 2022, unit shares of tobacco-flavored and mint-flavored products decreased (from 28.4% to 20.1% and from 10.1% to 5.9%, respectively), whereas shares of other flavor sales increased (from 29.2% to 41.3%). In addition, during January 2020-December 2022, unit shares of prefilled cartridges decreased from 75.2% to 48.0%, and disposable e-cigarette unit share increased from 24.7% to 51.8% of total unit sales. The five top-selling e-cigarette brands for the 4-week period ending December 25, 2022, were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. Analysis of information on e-cigarette retail sales can guide strategies to prevent youth access to and use of e-cigarettes, including restrictions on flavored tobacco products (4).

MRTP claim authorisation and General Snus sales in the USA: evidence from a difference-in-differences model.

BACKGROUND: The 2009 Tobacco Control Act granted the US Food and Drug Administration (FDA) regulatory authority over tobacco products, including the ability to authorise modified-risk tobacco product (MRTP) claims. In October 2019, the FDA authorised the first-ever MRTP claim for General Snus, which allowed the product to be marketed as reduced risk (relative to cigarettes). MRTP authorisation may increase otherwise low rates of snus use in the USA (<0.5% for children and adults). METHODS: Using 2017-2021 Nielsen sales data from 19 US states, we conducted a difference-in-differences analysis to determine whether logged unit sales of General Snus were affected by the MRTP authorisation, compared with (1) sales of other snus brands and (2) sales of non-snus smokeless products; we also examined (3) if sales of non-General Snus brands were affected by General Snus's MRTP authorisation, compared with sales of non-snus smokeless tobacco products. RESULTS: Although sales declined in absolute terms, sales of General Snus relative to other snus brands were unchanged after MRTP authorisation (-9.0%, 95% CI -19.6% to 1.60%, p=0.098). However, compared with non-snus smokeless brand sales, sales of General Snus (+14.7%, 95% CI 5.23% to 24.2%, p=0.002) rose after MRTP authorisation. Compared with non-snus smokeless products, sales of non-General Snus brands also rose after MRTP authorisation (+23.7%, 95% CI 9.5% to 38.0%, p=0.001). CONCLUSIONS: Although only General Snus received MRTP authorisation, this designation appears to have slowed declines for the entire snus category. This suggests consumers may make determinations regarding product risk to a product class rather than individual products.

Synthetic nicotine descriptors: awareness and impact on perceptions of e-cigarettes among US youth.

BACKGROUND: Electronic cigarettes (e-cigarettes) are being advertised and sold with synthetic nicotine. Little research has examined youth awareness of synthetic nicotine or the impact of synthetic nicotine descriptors on perceptions of e-cigarettes. METHODS: Participants were a sample of 1603 US adolescents (aged 13-17 years) from a probability-based panel. The survey assessed knowledge of nicotine source in e-cigarettes (from 'tobacco plants' or 'other sources besides tobacco plants') and awareness of e-cigarettes containing synthetic nicotine. Then, in a between-subjects experiment with a 2×3 factorial design, we manipulated descriptors on e-cigarette products: (1) nicotine label (inclusion of the word 'nicotine': present or absent) and (2) source label (inclusion of a source: 'tobacco-free', 'synthetic' or absent). RESULTS: Most youth were either unsure (48.1%) or did not think (20.2%) that nicotine in e-cigarettes comes from tobacco plants; similarly, most were unsure (48.2%) or did not think (8.1%) that nicotine in e-cigarettes comes from other sources. There was low-to-moderate awareness of e-cigarettes containing synthetic nicotine (28.7%), with higher awareness among youth who use e-cigarettes (48.0%). While no main effects were observed, there was a significant three-way interaction between e-cigarette status and the experimental manipulations. The 'tobacco-free nicotine' descriptor increased purchase intentions relative to 'synthetic nicotine' (simple slope: 1.20, 95% CI 0.65 to 1.75) and 'nicotine' (simple slope: 1.20, 95% CI 0.67 to 1.73) for youth who use e-cigarettes. CONCLUSIONS: Most US youth do not know or have incorrect beliefs about the sources of nicotine in e-cigarettes and describing synthetic nicotine as 'tobacco-free nicotine' increases purchase intentions among youth who use e-cigarettes.

Skin Cancer Diagnosis Among People With Disabilities.

INTRODUCTION: People with disabilities face unique challenges that may affect skin cancer prevention, diagnosis, and access to treatment. These challenges could be exacerbated by the COVID-19 pandemic. In 2022, the prevalence of self-reported skin cancer diagnoses, delayed medical care because of the coronavirus disease 2019 (COVID-19) pandemic, and skin cancer risk factors among people with disabilities were estimated. METHODS: Data from the 2020 National Health Interview Survey (N=31,568 U.S. adults) were analyzed. Skin cancer diagnosis, age at the time of skin cancer diagnosis, skin cancer risk factors (e.g., sun protection), and delayed medical care because of the COVID-19 pandemic were included. Disability status was measured using the Washington Group Short Set on Functioning, which includes vision, hearing, mobility, communication, self-care, and cognitive disabilities. RESULTS: Although 8.8% of U.S. adults reported having a disability, people with disabilities accounted for 14.7% of all self-reported skin cancer diagnoses, including 17.5% of melanoma diagnoses. Notably, people with disabilities were on average, older (mean age=59.8 years) than people without disabilities (mean age=46.8 years). Models that adjusted for age and other demographics revealed that people with disabilities had higher odds of delaying medical care because of the COVID-19 pandemic (OR=1.65, 95% CI=1.41, 1.94); people with disabilities reported being diagnosed with skin cancer later in life (age 61.5 vs 54.0 years; p<0.001) but had odds of reporting any skin cancer (OR=1.11, 95% CI=0.93, 1.32) or melanoma diagnosis (OR=1.33, 95% CI=0.95, 1.87) similar to those of people without disabilities. CONCLUSIONS: Because of disability-related challenges, older age, and delaying medical care during the pandemic, people with disabilities may be at increased risk for inequitable skin cancer outcomes.

Exploring correlates of support for restricting breast cancer awareness marketing on alcohol containers among women.

BACKGROUND: Although alcohol consumption increases breast cancer risk, some alcohol products include breast cancer awareness marketing (i.e., pink ribbons) on alcohol containers, which poses a contradiction. Some researchers and advocacy groups have called for restrictions on use of the pink ribbon and other breast cancer awareness marketing on alcohol products. This exploratory study aimed to describe individual and behavioral correlates (age, knowledge, attitudes, purchase intention) of reported support for potential policy restrictions of pink ribbon labeling on alcohol containers. METHODS: The study sample was drawn from the Prolific crowd-sourced research platform in September 2020. Eligible participants included U.S. women aged 21+ years. The primary outcome was policy position for restrictions on pink ribbon labeling on alcohol containers, coded as support, neutral, or oppose. The association between pink ribbon labeling attitudes and support or opposition (vs neutral) was examined using multinomial logistic regression. Covariates were 1) knowledge of the alcohol-cancer link; 2) likelihood of buying an alcohol product with pink ribbon labeling; and 3) age. Models were used to calculate adjusted predicted probabilities for support, oppose, and neutral. RESULTS: The analytic sample included 511 women. Overall, 46% of women opposed, 34% were neutral, and 20% supported restricting pink ribbon labeling on alcohol containers. Controlling for all covariates, women who reported that wine increases cancer risk had the highest probability of opposing restrictions on pink ribbon labeling (56.4% [95%CI: 48.1%-64.8%]). Women who reported wine had no effect on cancer risk had the highest probability of being neutral about restrictions on pink ribbon labeling (45.5% [95% CI: 35.7%-55.3%]). Across levels of knowledge about the alcohol-cancer risk association, as favorable attitudes toward pink ribbon labeling increased, the probability of policy opposition increased and the probability of being policy neutral decreased. CONCLUSION: Findings from this study suggest women's favorable attitudes toward pink ribbon labeling on alcohol containers are a stronger predictor of support or opposition for restrictions on pink ribbon labeling than knowledge of the alcohol-cancer link. Future research could examine whether pink ribbon labeling may interact with potential or current health warnings on alcohol containers.

Do Beliefs about Alcohol and Cancer Risk Vary by Alcoholic Beverage Type and Heart Disease Risk Beliefs?

BACKGROUND: Alcohol is a leading risk factor for cancer, yet awareness of the alcohol-cancer link is low. Awareness may be influenced by perceptions of potential health benefits of alcohol consumption or certain alcoholic beverage types. The purpose of this study was to estimate awareness of the alcohol-cancer link by beverage type and to examine the relationship between this awareness and concomitant beliefs about alcohol and heart disease risk. METHODS: We analyzed data from the 2020 Health Information National Trends Survey 5 Cycle 4, a nationally representative survey of U.S. adults. RESULTS: Awareness of the alcohol-cancer link was highest for liquor (31.2%), followed by beer (24.9%) and wine (20.3%). More U.S. adults believed wine (10.3%) decreased cancer risk, compared with beer (2.2%) and liquor (1.7%). Most U.S. adults (>50%) reported not knowing how these beverages affected cancer risk. U.S. adults believing alcoholic beverages increased heart disease risk had higher adjusted predicted probabilities of being aware of the alcohol-cancer link (wine: 58.6%; beer: 52.4%; liquor: 59.4%) compared with those unsure (wine: 6.0%; beer: 8.6%; liquor: 13.2%), or believing alcoholic beverages reduced (wine: 16.2%; beer: 21.6%; liquor: 23.8%) or had no effect on heart disease risk (wine: 10.2%; beer: 12.0%; liquor: 16.9%). CONCLUSIONS: Awareness of the alcohol-cancer link was low, varied by beverage type, and was higher among those recognizing that alcohol use increased heart disease risk. IMPACT: These findings underscore the need to educate U.S. adults about the alcohol-cancer link, including raising awareness that drinking all alcoholic beverage types increases cancer risk. See related commentary by Hay et al., p. 9.

Sunless and Indoor Tanning Among U.S. Non-Hispanic White Women Ages 18-49 Years.

The use of indoor UV tanning devices (also known as "indoor tanning") has declined in recent years. Less is known about use of dihydroxyacetone-containing products used for tanning (also known as "sunless tanning"). We analyzed data from the 2015 National Health Interview Survey. Analysis was limited to non-Hispanic White women ages 18-49 years. We estimated the proportion of women reporting spray tanning, self-applied lotion tanning, and indoor tanning and used weighted multivariable logistic regression models to examine the relationships between socio-demographic characteristics, skin cancer risk factors, and other cancer risk factors with sunless and indoor tanning. Overall, 17.7% of women reported sunless tanning. Lotion tanning was more common (15.3%) than spray tanning (6.8%), while 12.0% of women engaged in indoor tanning. Among sunless tanners, 23.7% also engaged in indoor tanning. Younger age, ever having a skin exam, skin reactions to the sun, binge drinking, and being at a healthy weight were associated with sunless tanning. While sunless tanning may be less harmful for skin cancer risk than indoor tanning, the frequency with which the two behaviors co-occur suggests that efforts to address societal pressures for women to alter their skin color may have important public health benefits.

Public Support for Cigarette Pack Pictorial Health Warnings Among US Adults: A Cross-sectional Analysis of the 2020 Health Information National Trends Survey.

INTRODUCTION: The US Food and Drug Administration issued a final rule requiring new warnings for cigarette packages and advertisements. This study examines population-level characteristics of support for-versus neutrality or opposition toward-cigarette pack warnings that use text and images to portray the negative health effects of smoking. METHODS: We used nationally representative cross-sectional data of US adults age 18 and older from the 2020 Health Information National Trends Survey (n = 3865). Frequencies and weighted proportions were calculated for neutrality toward, opposition to, and support for pictorial warnings across sociodemographics and other predictors. Weighted, multivariable logistic regression examined predictors of being neutral or opposed versus supportive of pictorial warnings. RESULTS: In 2020, an estimated 69.9% of US adults supported pictorial warnings, 9.1% opposed, and 20.9% neither supported nor opposed them. In fully adjusted models, current smokers had almost twice the odds of being neutral or opposed to pictorial warnings as never smokers (odds ratio [OR] = 1.99, confidence interval [CI] 1.12, 3.52). Adults 75 years and older (vs. 18-34) (OR = 0.55, CI 0.33, 0.94) and those with children under 18 in their household (vs. no children) (OR = 0.67, CI 0.46, 0.98) were less likely to be neutral or opposed. CONCLUSIONS: In advance of the Food and Drug Administration's implementation of pictorial warnings on cigarette packages, nearly 70% of American adults support this policy. Disseminating information about the effectiveness of pictorial warnings may further strengthen support among current smokers who are less supportive than never smokers. Furthermore, framing messages around the benefits of pictorial warnings for protecting youth may increase public support. IMPLICATIONS: While public support for pictorial warnings on cigarette packages is high in the United States, it may increase further after policy implementation and be strengthened by utilizing information campaigns that convey the evidence that pictorial warnings are an effective public health strategy.

Awareness of Alcohol as a Carcinogen and Support for Alcohol Control Policies.

INTRODUCTION: Alcohol use increases cancer risk, yet awareness of this association is low. Alcohol control policies have the potential to reduce alcohol-caused cancer morbidity and mortality. Research outside the U.S. has found awareness of the alcohol-cancer link to be associated with support for alcohol control policies. The purpose of this study is to estimate the prevalence of support for 3 communication-focused alcohol policies and examine how awareness of the alcohol-cancer link and drinking status are associated with policy support among U.S. residents. METHODS: Investigators analyzed data from the 2020 Health Information National Trends Survey 5 Cycle 4. Analyses were performed in 2021. The proportion of Americans who supported banning outdoor alcohol advertising and adding warning labels and drinking guidelines to alcohol containers was estimated. Weighted multivariable logistic regression was used to examine how awareness of the alcohol-cancer link and drinking status were associated with policy support. RESULTS: Most Americans supported adding warning labels (65.1%) and drinking guidelines (63.9%), whereas only 34.4% supported banning outdoor alcohol advertising. Americans reporting that alcohol had no effect/decreased cancer risk had lower odds of support for advertising ban (OR=0.56), warning labels (OR=0.43), and guidelines (OR=0.46) than Americans aware of the alcohol-cancer link. Moreover, heavier drinkers had lower odds of support for advertising ban (OR=0.41), warning labels (OR=0.59), and guidelines (OR=0.60) than nondrinkers. CONCLUSIONS: Awareness of the alcohol-cancer link was associated with policy support. Increasing public awareness of the alcohol-cancer link may increase support for alcohol control policies.

Cigarette Promotions in U.S. Pharmacies.

INTRODUCTION: The sale of tobacco products within American pharmacies has generated controversy for several decades, leading two U.S. states and 45 municipalities to adopt tobacco-free pharmacy policies. While previous research has reported cheaper cigarette prices in pharmacies, compared to other retailers, little is known about cigarette promotions in pharmacies, which are associated with increased youth smoking and unplanned cigarette purchases among adults. AIMS AND METHODS: Between May and August 2015, trained data collectors conducted store audits at 2128 tobacco retailers located within 97 U.S. counties in 40 states. Observations were made for three types of cigarette promotions: special price (e.g., $0.30 off/pack), multi-pack promotions (e.g., buy one pack, get one free), and cross-product promotions (e.g., buy a pack of cigarettes and a get free can of snus). We calculated weighted estimates of the proportion of pharmacies and other retailer types with cigarette promotions and used weighted multivariable logistic regression to compare cigarette promotions by tobacco retailer type, accounting for clustering at the county level and controlling for county-level demographic characteristics. RESULTS: Cigarette promotions were observed in 94.0% of pharmacies, more than any other retailer type (e.g., convenience stores: 82.0%, tobacco stores: 77.0%). All retailer types had lower odds of promotions for Marlboro, Newport, Camel, menthol, or any interior cigarette promotion, compared to pharmacies. CONCLUSIONS: Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. Whether voluntarily or legislatively, tobacco-free pharmacies would eliminate a prevalent retail source of cigarette promotions. IMPLICATIONS: This is the first known national study to examine prevalence of cigarette promotions in U.S. pharmacies compared to other retailer types. Nearly all pharmacies offered in-store cigarette promotions and pharmacies had greater odds of offering cigarette promotions than all other retailer types. These findings underscore the inherent contradiction of pharmacies serving both as an important component of the health care system, but also as purveyors and promotors of addictive and lethal tobacco products. Whether voluntarily or legislatively, tobacco-free pharmacy policies would eliminate a prevalent retail source of cigarette promotions.

U.S. public opinion toward policy restrictions to limit tobacco product placement and advertising at point-of-sale and on social media.

The Family Smoking Prevention and Tobacco Control Act granted the U.S. Food and Drug Administration authority to regulate tobacco advertising and promotion, including at the retail level, and preserved state, tribal, and local tobacco advertising and promotion authorities. Public health experts have proposed prohibiting point-of-sale tobacco advertisements and product displays, among other tobacco advertising restrictions. We examined the prevalence and correlates of public support, opposition, and neutrality toward proposed tobacco product placement and advertising restrictions at point-of-sale and on social media utilizing the National Cancer Institute's 2020 Health Information National Trends Survey (HINTS) (N = 3865), a cross-sectional, probability-based postal survey of U.S. addresses conducted from Feb 24, 2020 to June 15, 2020 (Bethesda, MD). Frequencies and unadjusted, weighted proportions were calculated for support, neutrality, and opposition toward the three policies under study, and weighted, adjusted multivariable logistic regression was employed to examine predictors of neutrality and opposition. Tests of significance were conducted at the p < 0.05 level. Sixty-two percent of U.S. adults supported a policy prohibiting tobacco product advertising on social media; 55% supported a policy restricting the location of tobacco product advertising at point-of-sale; and nearly 50% supported a policy to keep tobacco products out of view at the checkout counter. Neutrality and opposition varied by sociodemographic characteristics including age, sex, education, rurality, and presence of children in the household. Understanding public opinion toward tobacco product placement and advertising restrictions may inform policy planning and implementation.

Inferences beyond a claim: a typology of potential halo effects related to modified risk tobacco product claims.

When tobacco products are marketed with modified risk tobacco product (MRTP) claims, consumers may infer additional health benefits not directly stated in the claims. We propose a typology of seven potential 'halo effects' (ie, an unintended generalisation) that may occur with MRTP marketing. Evidence currently exists that some of these types of halo effects occur after exposure to MRTP claims. These generalisations are likely unavoidable in certain situations and may sometimes produce accurate inferences. However, some halo effects may be problematic if they mislead consumers into false inferences and result in unintended consequences that have a negative public health impact (eg, reinitiation, dual tobacco product use). To help mitigate unintended consequences and guide regulatory decisions about MRTP claims, we encourage researchers studying MRTP claims to test for halo effects. Regulatory agencies should include potential unintended consequences associated with halo effects when assessing individual-level and population-level health impacts of MRTP claims. Moreover, tobacco manufacturers should be required to report both premarket and postmarket surveillance of halo effects to relevant regulatory agencies. If MRTP claims are to play a role in tobacco harm reduction, it is imperative that they be communicated and interpreted in ways that minimise harms and maximise public health benefits.

Association of tobacco control policies with cigarette smoking among school youth aged 13-15 years in the Philippines, 2000-2015.

INTRODUCTION: In 2003, the Philippines implemented legislation that prohibited the sale of tobacco products to youth, placed text warning labels on tobacco products, and prohibited tobacco smoking in public places. This study assessed if this legislation was associated with reduced cigarette smoking among youth. METHODS: Data came from the 2000-2015 Philippines Global Youth Tobacco Survey (GYTS), a nationally representative, cross-sectional survey of students aged 13-15 years. GYTS data were used to determine associations between tobacco control legislation and current, past 30-day, current cigarette smoking (CCS). Logistic regression models were adjusted for age, sex, current other tobacco product use (COTPU), and price per cigarette stick (PPCS). RESULTS: In the unadjusted model, the 2003 legislation was not associated with CCS (OR=0.77; 95% CI: 0.54-1.10). After adjusting for covariates, it was negatively associated (AOR=0.65; 95% CI: 0.53-0.80). Being 15 years old (OR=1.31; 95% CI: 1.08-1.58), male (OR=2.54; 95% CI: 2.17-2.98), and COTPU (OR=4.12; 95% CI: 3.47-4.91) were positively associated with CCS in unadjusted models. In adjusted models, being 14 years old (AOR=1.29; 95% CI: 1.08-1.53), 15 years old (AOR=1.55; 95% CI: 1.31-1.84), male (AOR=2.49; 95% CI: 2.13-2.91), and COTPU (AOR=3.96; 95% CI: 3.32-4.73), were associated with CCS. PPCS was not associated with CCS in either the unadjusted (OR=1.32; 95% CI: 0.82-2.11) or adjusted (AOR=1.32; 95% CI: 0.79-2.18) models. CONCLUSIONS: After adjusting for covariates, the 2003 tobacco control legislation was associated with lower current cigarette smoking, but price per cigarette stick was not.

Percentage of current tobacco smoking students receiving help or advice to quit: Evidence from the Global Youth Tobacco Survey, 56 countries, 2012-2015.

INTRODUCTION: We assessed self-reported receipt of help or advice to stop smoking among current tobacco smoking students enrolled in school. METHODS: Using cross-sectional data collected between 2012-2015 from the Global Youth Tobacco Survey (GYTS), and representing the latest year for which data were collected, we calculated prevalence of receipt of help or advice to stop smoking among current tobacco smoking students aged 13-15 years from 56 countries. The sources of help or advice assessed in the GYTS were: 1) from a program or professional, 2) from a friend, and 3) from a family member. Overall response rates ranged from 60.3% in Nicaragua to 99.2% in Sudan. The analytic sample size ranged from 55 in Gabon to 950 in Bulgaria. RESULTS: In 53 of the 56 assessed countries, more than half of current tobacco smoking students received help or advice to quit from either a program or professional, friend, or family member (range=39.9% San Marino to 96.9% Timor-Leste). From a friend or family member only, the range was 37.2% Bahamas to 69.9% Montenegro, and from a program or professional only, the range was 3.7% Latvia to 34.2% Togo. CONCLUSIONS: Family and friends are the most common sources of help or advice to quit smoking among current tobacco smoking students in the GYTS countries assessed, while programs and professionals were the least common. The use of evidence-based measures is critical to prevent and reduce tobacco use among youth and to ensure they are receiving appropriate help or advice to quit.

Adverse symptoms users attribute to e-cigarettes: Results from a national survey of US adults.

BACKGROUND: Little is known about the prevalence of adverse symptoms electronic cigarette (e-cigarette) users report experiencing. METHODS: Between August 2016 and May 2017, we conducted a nationally representative cross-sectional telephone survey of 4964 US adults age 18 and over. Respondents who reported ever trying e-cigarettes were asked whether they ever experienced six symptoms they thought were caused by e-cigarette use. In weighted analyses, we assessed whether symptoms varied by demographics, e-cigarette use frequency, and cigarette smoking status. RESULTS: Approximately one-fourth of respondents (n = 1,624, 26.8%) reported ever trying e-cigarettes. Most were current (40.3%) or former (30.7%) cigarette smokers, with 29.0% never smokers. Just over half (58.2%) reported at least one symptom and on average 1.6 (SE = 0.1) symptoms. Symptoms included cough (40.0%), dry or irritated mouth or throat (31.0%), dizziness or lightheadedness (27.1%), headache or migraine (21.9%), shortness of breath (18.1%), change in or loss of taste (12.9%), or other (6.2%; most commonly nausea, tight chest, congestion). Among past 30-day e-cigarette users, current and never cigarette smokers were more likely than former smokers to report any symptoms (AOR = 5.25, CI = 2.05-13.46 and AOR = 2.58, CI = 0.85-7.81, respectively). CONCLUSIONS: A majority of e-cigarette users reported at least one symptom, most commonly cough or dry or irritated mouth or throat. Former cigarette smokers who used e-cigarettes in the past 30 days were less likely than current or never smokers to report adverse symptoms of e-cigarette use. Future research should examine frequency of symptoms among different user groups to understand how e-cigarettes may influence public health.

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

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