Association between e-cigarette use and food insecurity among low-income adults.

INTRODUCTION: Previous research quantifying the relationship between tobacco use and food insecurity has focused on cigarette smoking. E-cigarette use has become popular in recent years. Drawing on large, population-based survey data, this study augments the previous research, considering the association of e-cigarette use with food insecurity among low-income adults. METHODS: We analysed data from the California Health Interview Survey in 2014-2019. The study sample consisted of 25 948 respondents aged 18-64 who lived in low-income (<200% of the Federal Poverty Level) households. Multivariable logistic regression models were estimated to examine the associations of e-cigarette use as well as dual use of e-cigarettes and cigarettes with food insecurity. RESULTS: Of California low-income adults, 6.4% identified as current e-cigarette users (3.0% dual users of e-cigarettes and cigarettes, and 3.4% sole e-cigarette users) and 43.0% reported food insecurity. After controlling for confounding factors, food insecurity was significantly more likely to be reported among current e-cigarette users (adjusted OR (AOR)=1.67; 95% CI 1.25 to 2.23) compared with never e-cigarette users, and among dual users (AOR=2.21; 95% CI 1.63 to 3.00), current sole e-cigarette users (AOR=1.66; 95% CI 1.15 to 2.40), and current sole cigarette smokers (AOR=1.46; 95% CI 1.22 to 1.76) compared with never tobacco users. The odds of food insecurity among dual users were significantly greater than sole cigarette smokers but not statistically different from sole e-cigarette users. CONCLUSIONS: Using e-cigarette is an associated risk factor for food insecurity among low-income adults. Dual use of e-cigarettes and cigarettes has a significantly greater risk of food insecurity compared with smoking cigarettes alone.

Healthcare utilisation and expenditures attributable to current e-cigarette use among US adults.

AIMS: This study estimated annual healthcare expenditures attributable to current e-cigarette use among US adults, including current exclusive and dual/poly e-cigarette use. METHODS: Analysing the 2015-2018 National Health Interview Survey data, we estimated the impacts of e-cigarette use on healthcare utilisation among adults aged 18+ years. Healthcare utilisation outcomes were hospital nights, emergency room (ER) visits, doctor visits and home visits. Current e-cigarette use was categorised as exclusive and dual/poly e-cigarette use. The econometric model included two equations: health status as a function of e-cigarette use and other independent variables, and healthcare utilisation as a function of health status, e-cigarette use, and other independent variables. Using an 'excess utilisation' approach, we multiplied the e-cigarette-attributable fraction derived from the model by annual health expenditures to calculate healthcare expenditures attributable to current exclusive and dual/poly e-cigarette use, the sum of which were expenditures attributable to all current e-cigarette use. RESULTS: Current exclusive and dual/poly e-cigarette use, with 0.2% and 3.5% prevalence in 2015-2018, were associated with higher odds of reporting poor health status than never tobacco users. Poor health status was associated with higher odds of using the four healthcare services and a greater number of ER and doctor visits. Annual healthcare expenditures attributable to all current e-cigarette use was $15.1 billion ($2024 per user) in 2018, including $1.3 billion attributable to exclusive e-cigarette use ($1796 per user) and $13.8 billion attributable to dual/poly e-cigarette use ($2050 per user). CONCLUSION: Adult current e-cigarette use was associated with substantial excess healthcare utilisation and expenditures.

Changes in e-cigarette use and subsequent cigarette smoking cessation in the USA: evidence from a prospective PATH study, 2013-2018.

AIMS: To examine the relationship between changes in electronic cigarette (e-cigarette) use and subsequent cigarette smoking cessation. METHODS: Using data from the Population Assessment of Tobacco and Health Study (wave 1-wave 4), we analysed a study cohort of 3014 current adult cigarette smokers at wave 1 who tried to quit during the past 12 months. We categorised changes in e-cigarette use from wave 1 to wave 2 as: daily initiation, non-daily initiation, increase to daily use, increase to non-daily use, stable daily use, stable non-daily use, decrease from daily use, quit non-daily use and non-use. We estimated multivariable logistic regressions on short-term (≥1 month and <12 months) cigarette smoking cessation at wave 3 and long-term (≥12 months) cigarette smoking cessation at wave 4. We conducted sensitivity analyses using alternative study cohorts. RESULTS: Among the study cohort, 2.4% initiated daily, 7.5% initiated non-daily, 1.0% increased to daily, 1.4% increased to non-daily, 1.5% maintained daily, 3.0% maintained non-daily, 2.4% decreased from daily and 3.8% quit non-daily e-cigarette use between waves 1 and 2; 7.9% and 6.9% reported short-term and long-term cigarette smoking cessation. 15.1% of short-term and 16.3% of long-term cigarette quitters used e-cigarettes. Compared with non-users, smokers who initiated daily, increased to daily or quit non-daily e-cigarette use between waves 1 and 2 had higher odds of short-term cigarette smoking cessation at wave 3. These results are robust to different study cohort specifications. CONCLUSION: The findings suggest a complex relationship between changes in e-cigarette use and subsequent cigarette smoking cessation.

Deaths from smoking and from HIV/AIDS among gay and bisexual men in California, 2005-2050.

INTRODUCTION: Deaths from HIV/AIDS have long been of concern to the gay community, but less attention has focused on smoking-attributable deaths despite the relatively high smoking rates among gay and bisexual men. This study compared deaths from HIV/AIDS with smoking-attributable deaths among California gay and bisexual men from 2005 to 2050. METHODS: Smoking-attributable fractions (SAFs) were estimated using smoking prevalence for gay and bisexual men from the 2011-2014 California Health Interview Surveys and published relative risks of death. Smoking-attributable deaths were calculated by multiplying the SAFs by deaths among gay and bisexual men. Deaths from HIV/AIDS among men who have sex with men was obtained from the California Department of Public Health. Future deaths from smoking and HIV/AIDS were projected using regression equations based on time trends. RESULTS: From 2005 to 2014, smoking caused over 6800 deaths among gay and bisexual men, while nearly 9500 died from HIV/AIDS. Mortality from both causes has been falling, but deaths from HIV/AIDS have been falling more rapidly. Projections suggest that in the mid-2040s, more gay/bisexual men will die from smoking than from HIV/AIDS. CONCLUSION: Smoking will surpass HIV/AIDS as a cause of death among gay and bisexual men in California within a few decades. The lesbian, gay, bisexual and transgender (LGBT) community was highly effective in drawing attention and resources to the fight against HIV/AIDS, saving untold lives by hastening effective treatments. Lessons learnt in the fight against AIDS should be used to help fight the tobacco epidemic.

A Community Choir Intervention to Promote Well-Being Among Diverse Older Adults: Results From the Community of Voices Trial.

OBJECTIVES: To test effects of the Community of Voices choir intervention on the health, well-being, and health care costs of racial/ethnically diverse older adults. METHOD: Twelve Administration-on-Aging-supported senior centers were cluster randomized into two groups: the intervention group started the choir immediately and a wait-list control group began the choir 6 months later. The choir program was designed for community-dwelling adults aged 60 years and older. The multimodal intervention comprises activities that engage participants cognitively, physically, and socially. Outcome measures assessed these three domains as well as health care utilization and costs. The intention-to-treat comparison was at 6 months. RESULTS: The sample (N = 390) had a mean age of 71.3 years (SD = 7.2); 65% were nonwhite. Six-month retention was 92%. Compared to controls, intervention group members experienced significantly greater improvements in loneliness (p = .02; standardized effect size [ES = 0.34] and interest in life (p = .008, ES = 0.39). No significant group differences were observed for cognitive or physical outcomes or for health care costs. DISCUSSION: Findings support adoption of community choirs for reducing loneliness and increasing interest in life among diverse older adults. Further efforts need to examine the mechanisms by which engagement in choirs improves aspects of well-being and reduces health disparities among older adults, including potential longer-term effects. CLINICALTRIALS.GOV REGISTRATION: NCT01869179 registered January 9, 2013.

Modelling the impact of a new tobacco product: review of Philip Morris International's Population Health Impact Model as applied to the IQOS heated tobacco product.

OBJECTIVES: We review the Population Health Impact Model (PHIM) developed by Philip Morris International and used in its application to the US Food and Drug Administration (FDA) to market its heated tobacco product (HTP), IQOS, as a modified-risk tobacco product (MRTP). We assess the model against FDA guidelines for MRTP applications and consider more general criteria for evaluating reduced-risk tobacco products. METHODS: In assessing the PHIM against FDA guidelines, we consider two key components of the model: the assumptions implicit in the model (outcomes included, relative harm of the new product vs cigarettes, tobacco-related diseases considered, whether dual or polyuse of the new product is modelled, and what other tobacco products are included) and data used to estimate and validate model parameters (transition rates between non-smoking, cigarette-only smoking, dual use of cigarettes and MRTP, and MRTP-only use; and starting tobacco use prevalence). RESULTS: The PHIM is a dynamic state transition model which models the impact of cigarette and MRTP use on mortality from four tobacco-attributable diseases. The PHIM excludes morbidity, underestimates mortality, excludes tobacco products other than cigarettes, does not include FDA-recommended impacts on non-users and underestimates the impact on other population groups. CONCLUSION: The PHIM underestimates the health impact of HTP products and cannot be used to justify an MRTP claim. An assessment of the impact of a potential MRTP on population health should include a comprehensive measure of health impacts, consideration of all groups impacted, and documented and justifiable assumptions regarding model parameters.

Sexual Identity Disparities in Smoking and Secondhand Smoke Exposure in California: 2003-2013.

OBJECTIVES: To determine smoking prevalence, smoking behavior, and secondhand smoke (SHS) exposure of lesbian, gay, and bisexual (LGB)-identified Californians; compare these with that of heterosexuals; and analyze changes over time. METHODS: We analyzed self-reported variables from 111 965 heterosexual, 1667 lesbian, and 1706 bisexual women, and 79 881 heterosexual, 2505 gay, and 911 bisexual men, aged 18 to 70 years, in the 2003-2013 California Health Interview Surveys. RESULTS: Sexual minority women had higher smoking prevalence, and female bisexual smokers were less likely to be light smokers, than heterosexuals. Smoking prevalence was higher among sexual minority men, and gay smokers were more likely to be daily smokers than were heterosexuals; and male bisexual smokers were more likely to be light smokers than were gay or heterosexual smokers. Sexual minority adults were more likely to have SHS exposure at home than were heterosexuals. Current smoking prevalence decreased annually 4% and 7% for lesbian and bisexual women, and 5% and 6% for gay and bisexual men, respectively. Exposure to SHS fell an average of 11% annually for sexual minority men and women. CONCLUSIONS: Sexual identity disparities in smoking and SHS exposure exist in California, with bisexuals particularly at risk.

Study protocol for a cluster randomized trial of the Community of Voices choir intervention to promote the health and well-being of diverse older adults.

BACKGROUND: Older adults are the fastest growing segment of the United States population. There is an immediate need to identify novel, cost-effective community-based approaches that promote health and well-being for older adults, particularly those from diverse racial/ethnic and socioeconomic backgrounds. Because choral singing is multi-modal (requires cognitive, physical, and psychosocial engagement), it has the potential to improve health outcomes across several dimensions to help older adults remain active and independent. The purpose of this study is to examine the effect of a community choir program (Community of Voices) on health and well-being and to examine its costs and cost-effectiveness in a large sample of diverse, community-dwelling older adults. METHOD/DESIGN: In this cluster randomized controlled trial, diverse adults age 60 and older were enrolled at Administration on Aging-supported senior centers and completed baseline assessments. The senior centers were randomly assigned to either start the choir immediately (intervention group) or wait 6 months to start (control). Community of Voices is a culturally tailored choir program delivered at the senior centers by professional music conductors that reflects three components of engagement (cognitive, physical, and psychosocial). We describe the nature of the study including the cluster randomized trial study design, sampling frame, sample size calculation, methods of recruitment and assessment, and primary and secondary outcomes. DISCUSSION: The study involves conducting a randomized trial of an intervention as delivered in "real-world" settings. The choir program was designed using a novel translational approach that integrated evidence-based research on the benefits of singing for older adults, community best practices related to community choirs for older adults, and the perspective of the participating communities. The practicality and relatively low cost of the choir intervention means it can be incorporated into a variety of community settings and adapted to diverse cultures and languages. If successful, this program will be a practical and acceptable community-based approach for promoting health and well-being of older adults. TRIAL REGISTRATION: ClinicalTrials.gov NCT01869179 registered 9 January 2013.

Counting 15 million more poor in India, thanks to tobacco.

OBJECTIVE: To quantify the impact of tobacco use and the related medical expenditure on poverty in India. METHODS: Tobacco expenditure and associated medical expenditure attributable to tobacco use were subtracted from the household monthly consumption expenditure in order to derive an appropriate measure of household disposable income. The 2004 National Sample Survey, a nationally representative survey of Indian households, was used to estimate the true level of poverty. RESULTS: Our estimates indicate that accounting for direct expenditure on tobacco would increase the rural and the urban poverty rates by 1.5% (affecting 11.8 million people) and 0.72% (affecting 2.3 million people), respectively. Similarly, the out-of-pocket costs of tobacco-attributable medical care result in 0.09% higher poverty rates in rural areas (affecting 0.7 million people) and in 0.07% higher poverty rates in urban locations (affecting 0.23 million people). CONCLUSIONS: Tobacco consumption impoverishes roughly 15 million people in India. Hence tobacco control measures would not only improve public health, but would also reduce poverty in India.