Neighborhood distribution of availability of newer tobacco products: A US four-site study, 2021.

Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.

Centering equity in flavored tobacco ban policies: Implications for tobacco control researchers.

To achieve equity in protection from poor health outcomes due to tobacco use, tobacco control policies and interventions need to affect socially disadvantaged groups more strongly than advantaged groups. Flavored tobacco bans have been seen as a policy with this potential. However, tobacco control researchers, in close concert with policy advocates, need to consider how to center equity throughout the policy process to achieve equitable outcomes from banning flavored tobacco. In this commentary, we outline the rationale for how and why tobacco control researchers should consider equity throughout the policy process to help fully achieve the potential of flavored tobacco ban policies. These recommendations emerged from a presentation at the Vermont Center on Behavior and Health 2021 Conference. Specifically, we focus on recommendations for tobacco control researchers to center equity including partnering with communities in agenda setting, examining how various policy formulations or exemptions may increase or decrease disparities, determining where flavor policies need to reach and whether policies are equitably reaching all populations disproportionately burdened by flavored tobacco, assessing whether policy implementation/enforcement is carried out equitably to maximize policy benefits, and evaluating policy impact with as much granularity as possible. Considering the entire policy process is central to enhancing equitable outcomes from banning flavored tobacco. Tobacco control researchers can play a key role in ensuring that these policies are viewed through an equity lens to, not just improve population health, but also to reduce harms to those disproportionately burdened by use of flavored products.

Inequitable Distribution of FTP Marketing by Neighborhood Characteristics: Further Evidence for Targeted Marketing.

INTRODUCTION: Flavored tobacco products (FTPs) are disproportionately used among young people and racial/ethnic minority populations. However, few studies have examined the retail distribution of such product marketing beyond menthol cigarettes. This study created geographic-based predictions about marketing of FTPs (overall, cigarettes, cigars, e-cigarettes, and smokeless) in stores across Washington, DC neighborhoods. We examined neighborhood-level demographic correlates of the amount of FTP and non-FTP marketing. METHODS: We conducted photographic audits of interior and exterior tobacco marketing in 96 Washington, DC tobacco retailers visited by 149 young adult respondents between 2018-2019. We created a geographic predictive surface of overall and product-specific tobacco marketing and then estimated the average predicted amount of marketing at the census-tract level using zonal statistics. Using linear regression, we examined neighborhood demographic correlates (race/ethnicity, family poverty, and youth population under 18) of FTP and non-FTP marketing. RESULTS: The predicted amount of non-FTP ads/displays were evenly distributed with no neighborhood variability (Range 8.46-8.46). FTP marketing overall was geographically concentrated with greater range across neighborhoods (Range 6.27-16.77). Greater FTP marketing overall and flavored cigar marketing was available in neighborhoods with higher percentages of Black residents. Flavored cigar marketing was less available in neighborhoods with more Hispanic residents, but there was greater flavored smokeless tobacco marketing. Nonflavored marketing overall and by product did not vary across neighborhoods. CONCLUSIONS: This study provides evidence of disproportionate distribution of FTP marketing in Black neighborhoods, especially for flavored cigars, at the point-of-sale. Policies that restrict the sale of FTPs may enhance health equity. IMPLICATIONS: Tobacco marketing has frequently been shown to be more prevalent in neighborhoods with lower household income and more Black residents. Using geographic-based predictions, we find that greater flavored tobacco marketing in these neighborhoods, not decreased marketing for nonflavored tobacco, is driving this disparity. Targeting Black neighborhoods with increased marketing of flavored tobacco products, which has been found to be more appealing, easier to use, and harder to quit is a social justice issue.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults.

BACKGROUND: Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs). PURPOSE: This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA). METHODS: This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context. RESULTS: Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined. CONCLUSIONS: Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Sex Differences in Mental Health Outcomes of Suicide Exposure.

Past research has robustly supported differences in prevalence and severity of mental health disorders between males and females in general. Less is known in regards to how suicide exposure and related factors may be associated with these mental health outcomes in men and women. This study seeks to explore similarities and differences between suicide exposure experiences of males and females in regards to number of exposures to suicide, relationships to the deceased, perceptions of closeness to the deceased, and related mental health correlates. Clinical applications are then discussed. A dual-frame, random digit dial survey was utilized to identify sex-differentiated demographic and suicide-related factors associated with these correlates in a statewide sample of 1,736 adults. t-tests revealed statistically higher depression, anxiety, and prolonged grief mean scores for suicide-exposed females; statistically higher suicide ideation levels in suicide-exposed males, and no statistical differences between sexes in PTSD scores. Logistic regression analyses provided an in-depth look at similarities and differences in risk and protective factors between male and female outcomes with perceptions of closeness and kinship levels as most salient risk factors. Cross-sectional design limits assertions of causality and retrospective nature of study may introduce recall bias. Males and females may differ in mental health impacts after suicide exposure. Implications for future research, prevention program planning, and bereavement counseling approaches are discussed.

How Many People Are Exposed to Suicide? Not Six.

It has long been stated that six people are left behind following every suicide. Despite a lack of empirical evidence, this has been extensively cited for over 30 years. Using data from a random-digit dial survey, a more accurate number of people exposed to each suicide is calculated. A sample of 1,736 adults included 812 lifetime suicide-exposed respondents who reported age and number of exposures. Each suicide resulted in 135 people exposed (knew the person). Each suicide affects a large circle of people, who may be in need of clinician services or support following exposure.

Suicide Exposure in the Population: Perceptions of Impact and Closeness.

Recent studies of people exposed to suicide point to a continuum of effects moderated by a perception of closeness to the deceased. We investigated the importance of perception of impact of the death on mental health outcomes of those exposed to suicide. Female sex, younger age, and multiple exposures to suicide were associated with greater risk for poorer outcomes. Suicide exposed with high impact was more likely to have depression, anxiety, posttraumatic stress disorder, prolonged grief, and suicide ideation. Findings can help focus postvention resources for suicide-exposed individuals.

Predictors of Suicide Ideation in a Random Digit Dial Study: Exposure to Suicide Matters.

Suicide is an important public health concern requiring ongoing research to understand risk factors for suicide ideation. A dual-frame, random digit dial survey was utilized to identify demographic and suicide-related factors associated with suicide ideation in a statewide sample of 1,736 adults. The PH-Q 9 Depression scale suicide ideation question was used to assess current suicide ideation in both the full sample and suicide exposed sub-sample. Being non-married and having previous suicide exposure were separately associated with higher risks of suicide ideation in the full sample. Being male, having increased suicide exposures, and having increased perceptions of closeness to the decedent increased risks, while older age decreased risks for the suicide exposed. Implications for future screening and research are discussed.

Exposure to Suicide in the Community: Prevalence and Correlates in One U.S. State.

OBJECTIVE: Suicide has been identified as a major public health issue. Exposure to suicide (i.e., knowing someone who died by suicide) is far more pervasive than previously considered and might be associated with significant adverse outcomes. As suicide becomes more commonly discussed in the public arena, a compelling need exists to determine who is exposed to suicide and how this exposure affects those left behind. This study estimated the proportion of the population exposed to suicide and delineated factors that predict significant psychiatric and psychosocial morbidity following that exposure. METHODS: A dual-frame random-digit-dial survey was conducted on a sample of 1,736 U.S. adults in the Commonwealth of Kentucky. Depression and anxiety were compared in suicide-exposed and suicide-unexposed individuals. Relationships were examined between psychiatric outcomes and perceptions of closeness to the decedent. RESULTS: Forty-eight percent of weighted participants (n=816/1,687) reported lifetime exposure to suicide. Current depression and anxiety symptoms were higher in suicide-exposed than in suicide-unexposed individuals. Suicide-exposed individuals were twice as likely as suicide-unexposed individuals to have diagnosable depression and almost twice as likely to have diagnosable anxiety. Suicide-exposed individuals were more likely than suicide-unexposed individuals to report suicide ideation (9% vs. 5%). Closeness to the decedent increased the odds of depression and anxiety and almost quadrupled the odds of posttraumatic stress disorder. CONCLUSION: Exposure to suicide is pervasive and occurs beyond family; as such, it is imperative to identify those with perceived closeness to the decedent. This hidden cohort of suicide-exposed people is at elevated risk for psychopathology and suicidal ideation.

Veteran exposure to suicide: Prevalence and correlates.

BACKGROUND: The aim of this study was to determine rates and consequences of suicide exposure in a veteran population and variables related to psychiatric morbidity. METHODS: 931 veterans from a random digit dial survey conducted July 2012-June 2013 in the Commonwealth of Kentucky was utilized to examine associations between suicide exposure and depression and anxiety. For those with lifetime suicide exposure, perceptions of closeness to the decedent and additional traumatic death exposure were also examined. RESULTS: Almost half of veterans (47.1%, n=434) reported lifetime exposure to suicide. Suicide-exposed individuals were almost twice as likely to have diagnosable depression (OR=1.92, CI=1.31-2.8) and more than twice as likely to have diagnosable anxiety (OR=2.37, CI=1.55-3.61). Suicide-exposed were also more likely than non-exposed to report suicide ideation (9.9% vs. 4.3%). Perceived closeness to decedent increased the odds of depression (OR=1.38, CI=1.12-1.69), anxiety (OR=1.51, CI=1.21-1.89) and PTSD (OR=1.65, CI=1.27-2.16) and more than doubled the odds of Prolonged Grief (OR=2.47, CI=1.60-3.83). A model examined time sequence of suicide and traumatic death exposure. Experiencing a suicide exposure first and subsequent traumatic death exposure in their military career almost quadrupled the odds of suicide ideation (OR=3.56, p=.01, CI=1.34-9.46). LIMITATIONS: Major study limitations include use of only one US state and random digit dial response rate. CONCLUSIONS: Suicide exposure confers psychiatric risks in veterans. Perceptions of closeness to decedents, which may extend beyond familial lines, may heighten these risks in the suicide exposed. Multiple exposures to suicide and traumatic death may lead to significant suicide risk.

Who leaves suicide notes? A six-year population-based study.

Popular culture insists on the significance of suicide notes, but research has yielded conflicting results about who leaves notes. Utilizing 6 years of suicides from a comprehensive statewide data surveillance system, differences were examined between cases with suicide notes and those without in terms of demographics, circumstances of the suicide, and precipitating circumstances. Of the 2,936 suicides, 18.25% included a note. Demographics and circumstances did not differ for cases with a note compared to cases with no note. Results have implications for working with people bereaved by suicide in helping understand that the notes are uncommon and not systematic. However, it is also possible that for some individuals, the content of a note is meaningful and can help or hinder their course of bereavement.

Exposure to suicide and identification as survivor. Results from a random-digit dial survey.

BACKGROUND: There is little empirical evidence regarding lifetime exposure to suicide or identification of those impacted by suicide deaths. Studies previously conducted used only convenience samples. AIMS: To determine the prevalence of suicide exposure in the community and those affected by suicide deaths. METHODS: A random digit dial sample of 302 adults. RESULTS: 64% of the sample knew someone who had attempted or died by suicide, and 40% knew someone who died by suicide. No demographic variables differentiated exposed versus unexposed, indicating that exposure to suicide cuts across demographics. Almost 20% said they were a "survivor" and had been significantly affected by a suicide death. Demographic variables did not differentiate groups. The relationship to the decedent was not related to self-identified survivor status; what did differentiate those individuals impacted by the death from those who did not was their perception of their relationship with the decedent. CONCLUSIONS: Kinship proximity and relationship category to the deceased appeared to be unrelated to survivor status, but perceived psychological closeness to the deceased showed a robust association with self-identified survivor status. We need an expanded definition of "suicide survivor" to account for the profound impact of suicide in the community.

Depression, sensation seeking, and maternal smoking as predictors of adolescent cigarette smoking.

The purpose of this study was to examine maternal and adolescent depression, maternal and teen sensation seeking, and maternal smoking, and their associations with adolescent smoking. Data were collected from a sample of 47 male and 66 female adolescents (ages 11-18 years) and their mothers from three different health clinics. The findings indicated that maternal sensation seeking was linked indirectly with adolescent smoking through teen sensation seeking, both of which were significantly associated with teen smoking (beta = 0.29, p < 0.001 and beta = 0.32, p < 0.001, respectively). Teen depression was associated positively with teen smoking (beta = 0.24, p < 0.01) when controlling for sensation seeking behaviors. Maternal smoking was also directly linked to adolescent smoking (beta = 0.20, p < 0.05). These findings underscore a potentially important role of sensation seeking in the origins of adolescent smoking, and clarify pathways of influence with regard to maternal attitudes and behaviors in subsequent teenage nicotine use.