[What does the Brazilian National Health Survey have to say about the influence of cigarette spending on household income?] / O que a Pesquisa Nacional de Saúde tem a dizer sobre a influência do gasto com cigarro no rendimento domiciliar?

In a country whose indicators of population impoverishment continue to increase, it is concerning that individuals spend money to buy cigarettes instead of using this resource in actions that strengthen aspects of the well-being of their lives and that of their families. Based on the Brazilian National Health Survey conducted in 2019, the influence of spending on manufactured cigarettes on the family budget in households with at least one smoker was estimated, stratified by sociodemographic characteristics. Brazilian smokers allocated around 8% of their average per capita monthly household income to the purchase of manufactured cigarettes. The percentage of average monthly expenditure on cigarettes reached almost 10% of this income among smokers aged 15 to 24 and was even higher for those with incomplete elementary education (approximately 11%). In the North and Northeast regions of the country, this expenditure exceeded 9%. The state with the most significant impact on household income was Acre (13.6%), followed by Alagoas (11.9%), Ceará, Pará, and Tocantins (all with approximately 11%). Our findings, therefore, reinforce the importance of strengthening the implementation of effective measures, such as tax policy, to reduce the proportion of smokers. Thus, the money that individuals currently allocate to purchase cigarettes can be used to meet their basic needs, contributing to the promotion of health and improving the quality of life.

Em um Brasil no qual os indicadores de empobrecimento da população seguem aumentando, preocupa o fato de que indivíduos gastem dinheiro para comprar cigarro em vez de usarem esse recurso em ações que fortaleçam aspectos do bem-estar de suas jornadas de vida e de suas famílias. Estimou-se, a partir da Pesquisa Nacional de Saúde de 2019, a influência que o gasto com cigarro industrializado teve no orçamento familiar nos domicílios com pelo menos um fumante, estratificada por características sociodemográficas. Os fumantes brasileiros destinaram cerca de 8% do rendimento médio mensal domiciliar per capita para a compra de cigarros industrializados. O percentual do gasto médio mensal chegou a quase 10% desse rendimento, entre os fumantes de 15 a 24 anos, e foi ainda maior para aqueles com Ensino Fundamental incompleto (aproximadamente 11%). Nas regiões Norte e Nordeste do país, esse gasto ultrapassou os 9%. O estado com o maior comprometimento da renda domiciliar foi o Acre (13,6%), seguido por Alagoas (11,9%), Ceará, Pará e Tocantins (todos com aproximadamente 11%). Nossos achados reforçam, portanto, a importância de fortalecer a implementação de medidas efetivas de redução da proporção de fumantes, tal como a política tributária. Dessa forma, o dinheiro que atualmente é destinado pelos indivíduos à compra de cigarros poderá ser revertido no atendimento de suas necessidades básicas, contribuindo para a promoção da saúde e melhoria da qualidade de vida.

En un Brasil donde los indicadores de empobrecimiento de la población siguen aumentando, es preocupante el hecho de que las personas gasten dinero para comprar cigarrillo en lugar de usarlo en acciones para fortalecer los aspectos del bienestar de sus vidas y la de sus familias. A partir de la Encuesta Nacional de Salud brasileña realizada en 2019, se estimó la influencia del gasto en cigarrillo industrializado en el presupuesto familiar de los hogares donde vivía al menos un fumador, estratificado por características sociodemográficas. Los fumadores brasileños destinaron alrededor del 8% del ingreso per cápita mensual promedio del hogar para la compra de cigarrillos industrializados. El porcentaje del gasto mensual promedio en cigarrillos alcanzó casi el 10% de este ingreso entre los fumadores de 15 a 24 años y fue aún mayor para los que tenían educación primaria incompleta (aproximadamente el 11%). En el Norte y Nordeste del país, ese gasto superó el 9%. El estado con un mayor compromiso con los ingresos del hogar fue Acre (el 13,6%), seguido por Alagoas (el 11,9%), Ceará, Pará y Tocantins (todos con aproximadamente el 11%). Por lo tanto, nuestros resultados resaltan la importancia de fortalecer la implementación de medidas efectivas para reducir la proporción de fumadores, tal como la política tributaria. Así, el dinero que actualmente las personas destinan a la compra de cigarrillos podría utilizarse en la atención de sus necesidades básicas, contribuyendo a promover la salud y la mejora de la calidad de vida.

A reduced exposure heated tobacco product was introduced then abruptly taken off United States shelves: results from a tobacco harm reduction natural experiment.

BACKGROUND: A heated tobacco product (HTP) authorized for purchase in the United States by the Food and Drug Administration as a reduced harm product was removed from the market after about 2 years of sales. Adults who used the HTP were surveyed to determine the impact of the introduction and removal of the HTP on past and current tobacco behaviors. METHODS: Adults who were using the HTP before its United States market removal (n = 502) completed a cross-sectional online survey to determine their tobacco use behaviors at three timepoints: prior to HTP initiation, just before HTP market removal, and at the time of the survey which was administered approximately 10 months post-removal. Descriptive statistics summarized outcome variables and paired bivariate testing was used to compare percent change between timepoints. Multivariable logistic regression and general linear models estimated associations of tobacco use behaviors and cigarette consumption. RESULTS: Overall, significantly fewer adults consumed cigarettes while using HTP than before they tried the product (63.0% vs. 89.9%, p value < 0.0001) and the number of cigarettes consumed per week (CPW) decreased (106.3-39.0, p value < 0.0001). After HTP removal, the percent of adults who consumed cigarettes increased non-significantly (63.0-67.5%, p value = 0.0544) while CPW increased significantly (39.0-76.6 CPW, p value < 0.0001). At the time of the survey, over 25% of the sample continued to use the HTP and 7.2% reported use of no tobacco products. Electronic nicotine delivery system use had increased significantly from the prior period (27.4% increase, p value < 0.0001). CONCLUSION: This study demonstrates reduction or elimination of combustible cigarette smoking while adults were using HTPs and some increased smoking after market removal, albeit at lower levels. If unable to find satisfying alternatives, adults who smoke and transition to reduced harm products may return to smoking or purchase products illicitly if their preferred products are removed from the regulated market.

Sex and Racial/Ethnic Patterns of Tobacco Product Use Among Students at a U.S. University in 2021-2023.

Background: Although the prevalence of conventional tobacco product use among U.S. college students has declined, an increasing number of students use various novel tobacco products. Objectives: This study aims to examine up-to-date sex and racial/ethnic patterns of tobacco use among students at a U.S. university in 2021-2023. Methods: Data of 2,732 students at an urban university in the Southeast of the U.S. were collected in 2021-2023 as part of the National College Health Assessment of the American College Health Association. Self-reported past 3-month use of five tobacco products (cigarette, electronic vapor products, water pipe/hookah, smokeless tobacco, and cigars) was dichotomized. We conducted multinomial logistic regression analysis to examine sex (male or female) and racial/ethnic (non-Hispanic White, non-Hispanic Black, Hispanic, or non-Hispanic Other) differences in single and dual/poly (con-current use of two or more tobacco products) tobacco use compared to nonuse, adjusting for age, student status, parent education level, obese status, psychological distress level, and survey year. Results: Male students had higher odds of being dual/poly tobacco user than female students, adjusting for covariates (adjusted odds ratio [AOR] = 2.00, 95% confidence interval [CI] = 1.42, 2.82). Non-Hispanic Black students had lower odds of being single (AOR = 0.43, 95% CI = 0.26, 0.69) and dual/poly (AOR = 0.09, 95% CI = 0.02, 0.37) tobacco user compared to non-Hispanic White students, adjusting for covariates. Conclusions: Considering higher health risk of con-current use of multiple tobacco products, dual/poly tobacco use prevention strategies targeting male and non-Hispanic White students may be considered.

Ocular Symptoms in Adolescents and Young Adults With Electronic Cigarette, Cigarette, and Dual Use.

Importance: Despite increasing use of cigarettes and electronic cigarettes (e-cigarettes) and related health effects among youth, few studies have reported their effects on eyes. Objective: To examine the frequency and severity of ocular symptoms (ocular discomfort, pain, burning, itching, redness, dryness, glare, blurriness, strain, and headaches) in young e-cigarette and cigarette users. Design, Setting, and Participants: In an observational cross-sectional study, a survey conducted in May 6 to 14, 2020, asked participants about use (ever, past 30 days, and past 7 days) of e-cigarettes and cigarettes. The participants included US individuals aged 13 to 24 years. Main Outcomes and Measures: Associations between vision-related outcomes (general vision, severity/frequency of ocular symptoms) and tobacco use were analyzed using weighted multivariable logistic regressions, adjusting for sociodemographic factors, contact lens use, and other combustible use. Results: There were 2168 never users, 2183 ever users, 1092 past 30-day users, and 919 past 7-day users of e-cigarettes; 55.9% of e-cigarette ever users also used cigarettes (dual users). Of the 4351 respondents, 63.8% identified as female, and mean (SD) age was 19.1 (2.9) years. Between 1.1% and 3.9% of ever dual users reported severe to very severe ocular symptoms; between 0.9% and 4.3% reported daily symptoms, which was higher than the proportion of symptoms in e-cigarette- or cigarette-only users. Past 7-day dual users had more severe itching (adjusted odds ratio [AOR], 2.37; 95% CI, 1.36-4.13; P = .002), redness (AOR, 2.58; 95% CI, 1.50-4.46; P = .001), dryness (AOR, 2.89; 95% CI, 1.64-5.08; P < .001), glare (AOR, 2.56; 95% CI, 1.50-4.35; P = .001), blurriness (AOR, 2.47; 95% CI, 1.36-4.50; P = .003), headaches (AOR, 2.31; 95% CI, 1.34-4.00; P = .003); and more frequent pain (AOR, 3.45; 95% CI, 2.09-5.68; P < .001), burning (AOR, 3.08; 95% CI, 1.86-5.09; P < .001), and redness (AOR, 2.72; 95% CI, 1.69-4.36; P < .001) than all other participants. Past 30-day dual users had more severe dryness (AOR, 2.65; 95% CI, 1.61-4.36; P < .001) and more frequent pain (AOR, 3.33; 95% CI, 2.12-5.21; P < .001) than all other participants. Ever dual users experienced more severe dryness (AOR, 1.60; 95% CI, 1.05-2.43; P = .03) and blurriness (AOR, 1.79; 95% CI, 1.21-2.64; P = .003) and more frequent pain (AOR, 1.69; 95% CI, 1.13-2.53; P = .01) and blurriness (AOR, 1.63; 95% CI, 1.13-2.36; P = .009) than never users. Conclusions and Relevance: In this cross-sectional US study, adolescents and young adult users of both e-cigarettes and cigarettes had a higher likelihood of experiencing severe and frequent ocular symptoms, with past 7-day users reporting more symptoms than past 30-day users or ever users. These findings provide additional reasons for users of e-cigarettes and cigarettes to reduce their tobacco use to possibly prevent or minimize ocular symptoms.

Support for and potential impacts of key Smokefree 2025 strategies among Maori who smoke.

AIM: The recently passed Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act has the potential to profoundly reduce smoking prevalence and related health inequities experienced among Maori. This study examined support for, and potential impacts of, key measures included within the legislation. METHOD: Data came from Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study, which was conducted in partnership with five primary health organisations serving Maori communities. Participants were 701 Maori who smoked. Analysis included both descriptive analysis and logistic regression. RESULTS: More Maori participants supported than did not support the Smokefree 2025 (SF2025) goal of reducing smoking prevalence to below 5%, and the key associated measures. Support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants also believed VLNCs would prompt high rates of quitting. Participants who had made more quit attempts or reported less control over their life were more likely to support VLNCs. CONCLUSION: There was support for the SF2025 goal and for key measures that could achieve it. In particular, VLNCs may have significant potential to reduce smoking prevalence among Maori. As part of developing and implementing these measures it will be important to engage with Maori who smoke and their communities.

COMPARISON OF PREVALENCE OF TOBACCO USE AMONG YOUNG PEOPLE IN DIFFERENT COUNTRIES.

OBJECTIVE: The aim: The prevalence analysis of three ways of tobacco use among young adults: traditional (smoking of cigarillos or cigars) and alternative (hookah smoking and use of E-cigarettes) as well as the development of ways of tobacco smoking prevention. PATIENTS AND METHODS: Materials and methods: Cross-section anonymous survey among young adults 18-44 years of age (n=410) has been conducted. The obtained results were compared with the data of the similar studies from different countries. The statistical methods (analysis of the mean and relative values), structural and logical analysis and systemic approach. RESULTS: Results: Among those who were interviewed, aged 18-44 years, there are 24.15±2.11 % of respondents - hookah smokers, 9.02±1.42 % persons prefer the traditional method of tobacco use (smoking of cigarillos or cigars), while 6.34±1.20 % ones use E-cigarettes. Such forms of smoking are more common among males. The smokers of cigarillos, cigars and hookahs have appreciated their high availability when buying - 9 (7;10) points out of 10 possible. The study has found that 11.54±1.58 % of smokers of E-cigarettes and 8.08±1.35 % of hookah smokers consider them safe types of smoking and harmless to their health. CONCLUSION: Conclusions: The prevention methods of smoking prevalence among young people must be based on the tougher rules of tobacco market and latest devices for smoking at the legislative level.

Use of electronic cigarettes and heated tobacco products during the Covid-19 pandemic.

Only a few studies investigated changes in electronic cigarette (e-cigarette) and heated tobacco product (HTP) use during pandemic restrictions. We conducted a web-based cross-sectional study of a representative sample of 6,003 Italian adults during the strictest phase of the Covid-19 lockdown (April-May 2020). Participants were asked to report changes in e-cigarette and HTP use compared to before the pandemic. E-cigarette users increased from 8.1% to 9.1% and HTP users from 4.0% to 4.5%. Among e-cigarette non-users before lockdown, 1.8% started using e-cigarettes during lockdown. New users were more frequently younger (p for trend 0.001), men (odds ratio, OR 1.56; 95% confidence interval, CI: 1.03-2.34), cannabis users (OR 2.35; 95% CI: 1.33-4.13), gamblers (OR 3.34; 95% CI: 2.18-5.11) and individuals with anxiety symptoms (OR 1.58; 95% CI: 1.00-2.52). 1.0% of HTP non-users started using it during lockdown. New users were less frequently current than never cigarette smokers (OR 0.19; 95% CI: 0.06-0.61) and more frequently gamblers (OR 2.23; 95% CI: 1.22-4.07). E-cigarettes and HTPs played little role as smoking cessation tools for hardcore smokers but rather provided opportunities for young never smokers to engage in socially acceptable activities, perhaps reflecting the obstacles they faced in obtaining other addictive substances during confinement.

Inclusion of Smoking Data in Cardiovascular Disease Risk Estimation.

Importance: Former heavy smokers (ie, those with ≥20 pack-years of smoking) may have higher atherosclerotic cardiovascular disease (ASCVD) risk than never smokers for up to 16 years after smoking cessation. However, the 2013 pooled cohort equations (PCE) do not account for pack-years of smoking and only consider current vs noncurrent smoking status without distinguishing former smokers from never smokers. Objective: To assess the predictive utility of smoking history when added to the PCE using data from 18 400 person examinations among Framingham offspring participants. Design, Setting, and Participants: This is a retrospective analysis of prospectively collected data from the Framingham Heart Study, a community-based cohort. Framingham Heart Study offspring cohort participants attending their first examination (1971-1975) who were followed-up through December 2016 were included. Exposures: Self-reported current/former/never smoking status, pack-years smoked, and years since quitting. Main Outcomes and Measures: Incident ASCVD (myocardial infarction, fatal/nonfatal ischemic stroke, coronary heart disease death). Results: Of 3908 patients, there were 358 and 197 events among 1895 men and 2013 women, respectively, with a mean (SD) age of 55 (9.5) years. Ever smoking prevalence was high (6474 men [77%] and 7760 women [78%]), as were median pack-years (men: 39; women: 32 overall person examinations). Four sex-specific ASCVD risk prediction models were built using pooled-repeated Cox proportional hazards regression. The PCEs were was fit in this sample with continuous predictors on their natural scale (ie, not logarithmically transformed) as well as polynomials accounting for nonlinearity and then cumulatively adjusted for former smoking, pack-years, and years since quitting. Models were compared via change in C statistic, continuous net reclassification improvement (NRI[>0]), and relative integrated discrimination improvement (rIDI). Including former smoking status, pack-years, and years since quitting had significant but modest NRI(>0) and rIDI values compared with the PCE with continuous variables on their natural scale in both sexes (men: NRI[>0] = 0.23; rIDI = 0.19; women: NRI[>0] = 0.34, rIDI = 0.11; change in C statistic = 0.01 for both). Conclusions and Relevance: Former smoking, pack-years, and years since quitting significantly improved ASCVD risk prediction in this sample. The Framingham Heart Study offspring cohort is largely composed of non-Hispanic White participants of European ancestry. If results are validated in cohorts of race and ethnicity groups other than White, these variables could be considered for inclusion in future ASCVD risk prediction models.

National Trends of Adolescent Exposure to Tobacco Advertisements: 2012-2020.

BACKGROUND AND OBJECTIVES: The objective of the current study is to evaluate the temporal trends in the prevalence of cigarette and electronic cigarette (e-cigarette) advertisement exposure by venue and sociodemographic correlates among US adolescents from 2012 to 2020. METHODS: We conducted a serial cross-sectional analysis of nationally representative samples of middle and high school youth from the 2012-2020 National Youth Tobacco Survey. Advertisement exposure was defined as self-report of seeing advertisements "sometimes," "most of the time," and "always." The prevalence of cigarette (and other tobacco products) and e-cigarette advertisement exposure, including overall and at specific venues (Internet, press, screen, and retail stores), was estimated by survey year. RESULTS: A total of 139 795 adolescents aged 11 to 19 years old were included in the analysis. The prevalence of exposure to combustible cigarette marketing remained high across all years (any venue ranging from 77.0% [2018] to 91.1% [2014]). An increasing trend for cigarette advertisement exposure was observed from 2017 to 2020 after a drop in 2015 (ß2012-2015 = 2.8, P for trend < .001; ß2017-2020 = .7, P for trend = .03), driven by retail store-based and Internet-based exposure. A similar increasing pattern in the estimated prevalence of e-cigarette marketing was observed (ß2014-2016 = 4.6, P for trend < .001; ß2017-2020 = 5.1, P for trend < .001). CONCLUSIONS: Given the high estimated prevalence of cigarette and e-cigarette marketing exposure among US adolescents, further regulation efforts for both off-line and online tobacco marketing are needed to mitigate adolescent exposure to content regarding these products, reducing susceptibility to uptake.

Age of initiation of hookah use among young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study, 2013-2017.

OBJECTIVE: To prospectively estimate the age of initiation of ever, past 30-day, and fairly regular hookah use among young adults (ages 18-24) overall, by sex, by race/ethnicity, and to explore the association of prior use of other tobacco products with these hookah use behaviors. METHODS: Secondary data analyses of the first four waves (2013-2017) of the PATH study, a nationally representative longitudinal cohort study of US young adults. Young adult never hookah users at the first wave of adult participation in PATH waves 1-3 (2013-2016) were followed-up into waves 2-4 (2014-2017) to estimate the age of initiation of three outcomes: (i) ever use, (ii) past 30-day use, and (iii) fairly regular hookah use. Weighted interval-censoring Cox proportional hazards regression models were used to examine the differences in the estimated age of initiation by sex and by race/ethnicity while controlling for the total number of other tobacco products ever used at participants' first wave of PATH participation. In addition, to examine if prior use of other tobacco products was associated with the age of hookah initiation behaviors, six additional Cox models are reported for each hookah initiation behaviors. RESULTS: The largest increase in hookah use occurred between ages 18 and 19: 5.8% for ever use and 2.7% for past 30-day hookah use. By age 21, 10.5%, 4.7% and 1.2% reported initiation of ever, past 30-day and fairly regular hookah use, respectively. There were statistically significance differences in the age of initiation of hookah use behaviors by race/ethnicity. CONCLUSION: Educational interventions should target young adults before the age of 21, focusing efforts specifically on males, non-Hispanic Blacks and Hispanics, to stall initiation and progression of hookah use behaviors.

[Patterns of electronic cigarette and tobacco heating products use in Spain.] / Patrones de consumo del cigarrillo electrónico y de los productos de tabaco calentado en España.

OBJECTIVE: The new tobacco related products (TRP) have modified the smoking patterns, which have been scarcely evaluated by independent studies. Our objective was to describe the patterns of electronic cigarette (e-cig) and tobacco heating products (THP) use among Spanish population. METHODS: An electronic survey aimed to population who had used at least once in their lifetime e-cigs or THPs was used to gather personal data, patterns of e-cig and THP use, as well as risk perceptions and intention to quit these products. Chi-square and Kruskal-Wallis test were used to analyze qualitative and non-parametric quantitative variables, respectively, establishing statistical significance if p values <0.05. RESULTS: The responses of 175 subjects were included. From them, 107 had consumed e-cig, 33 THP and 35 both devices. The daily use was more common among THP users, who were older than e-cig and both devices' consumers (median age 43 vs 38 vs 35 years old, p=0.013). Of the overall group, 94% referred to have smoked conventional cigarettes at least once in their lifetime, and from them 36% referred a daily cigarette consumption at the time of the survey. Regarding the risk perception of the TRP, 70%, 55% y 63% of the subjects that had used e-cig, THP, and both devices, respectively, considered that these products were less harmful for their own health than conventional cigarettes. Concerning their intention to quit any tobacco product, 51% and 64% of e-cig and THP users respectively, showed interest in quitting these devices. CONCLUSIONS: The previous and current conventional cigarettes use is frequent among TRPs consumers. The risk perception of these products is low; however, a considerable intention to quit these products is reported.

OBJETIVO: Los nuevos productos relacionados al tabaco (PRT) han diversificado la forma en que se fuma, sin embargo, existen pocos estudios independientes que analicen los patrones de este consumo. Nuestro objetivo fue describir los patrones de uso del cigarrillo electrónico (CE) y de los productos de tabaco calentado (PTC) en España. METODOS: A través de una encuesta digital dirigida a población que había usado al menos una vez CE y/o PTC se recabaron datos personales, patrones de consumo, percepción de riesgo e intención de abandono. Se utilizaron chi-cuadrada y Kruskal-Wallis para analizar variables cualitativas y cuantitativas no paramétricas respectivamente, estableciendo significancia estadística con un p valor <0,05. RESULTADOS: Se incluyeron a 175 personas, de las cuales 107 habían usado CE, 33 PTC y 35 ambos dispositivos. El uso diario fue más frecuente entre la población que había consumido PTC (p=0,018) cuya mediana de edad fue mayor a la de la que había usado CE o ambos dispositivos (43 vs 38 vs 35 años p=0,013). El 94% del grupo total había consumido cigarrillos convencionales con anterioridad y el 36% de éstos los usaba diariamente al momento de la encuesta. El 70%, 55% y 63% de las personas que habían usado CE, PTC y ambos productos, respectivamente, consideraba que el riesgo de estos dispositivos era menor frente al de los cigarrillos convencionales. El 51% y 64% de los usuarios habituales y ocasionales de CE y PTC, respectivamente, querían abandonar estos productos. CONCLUSIONES: El consumo previo y actual de cigarrillos convencionales entre la población usuaria de PRT es frecuente. A pesar de una baja percepción de riesgo, se observa una alta intención de abandonar el consumo de CE y PTC.

Trends in Nicotine Product Use Among US Adolescents, 1999-2020.

Importance: With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications. Objective: To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999. Design, Setting, and Participants: This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants. Exposures: Nicotine product use in the past 30 days. Main Outcomes and Measures: Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products. Results: This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students. Conclusions and Relevance: This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.

Polygenic scores for smoking and educational attainment have independent influences on academic success and adjustment in adolescence and educational attainment in adulthood.

Educational success is associated with greater quality of life and depends, in part, on heritable cognitive and non-cognitive traits. We used polygenic scores (PGS) for smoking and educational attainment to examine different genetic influences on facets of academic adjustment in adolescence and educational attainment in adulthood. PGSs were calculated for participants of the Minnesota Twin Family Study (N = 3225) and included as predictors of grades, academic motivation, and discipline problems at ages 11, 14, and 17 years-old, cigarettes per day from ages 14 to 24 years old, and educational attainment in adulthood (mean age 29.4 years). Smoking and educational attainment PGSs had significant incremental associations with each academic variable and cigarettes per day. About half of the adjusted effects of the smoking and education PGSs on educational attainment in adulthood were mediated by the academic variables in adolescence. Cigarettes per day from ages 14 to 24 years old did not account for the effect of the smoking PGS on educational attainment, suggesting the smoking PGS indexes genetic influences related to general behavioral disinhibition. In sum, distinct genetic influences measured by the smoking and educational attainment PGSs contribute to academic adjustment in adolescence and educational attainment in adulthood.

Cigarette Consumption Patterns of Non-Smokers, Occasional Smokers, and Daily Smokers in Selected ASEAN Countries.

BACKGROUND: This study investigates the socio-demographic factors associated with smoking status in five Southeast Asian countries: Malaysia, Thailand, Indonesia, Vietnam, and Philippines. METHODS: This cross-sectional study utilizes data of adults ≥15 years who completed the Global Adult Tobacco Surveys. Ordered probit analysis is used to account for the smoking statuses of non-smokers, occasional smokers, and daily smokers. RESULTS: Malaysian and Vietnamese households with more family members face lower smoking likelihoods than otherwise. Urbanites in Philippines and rural residents in Thailand and Indonesia are more likely to smoke on occasional and daily basis than others. Males are consistently more likely to smoke occasionally or daily and less likely to be non-smokers than females across all countries. Younger middle-age (retiree) individuals aged 30-35 (≥60) years in Malaysia and Thailand exhibit higher (lower) likelihoods to smoke occasionally or daily than their younger cohorts aged 15-29 years. Individuals aged 30 years and above in Indonesia, Vietnam, and Philippines display higher daily smoking propensities than others. Higher education levels dampens smoking likelihoods and increases non-smoking propensities in all countries. Non-government or self-employed workers in all countries are more likely to smoke occasionally or daily than unemployed persons. Being married is associated with higher non-smoking likelihoods in Thailand although this association is not evident in Malaysia. CONCLUSION: These findings suggest that a portfolio of targeted interventions is necessary to meet the needs of specific subpopulations within the various countries.
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Characterization of Respiratory Symptoms Among Youth Using Heated Tobacco Products in Hong Kong.

Importance: Heated tobacco products (HTPs) are promoted as less harmful than combustible cigarettes but epidemiological evidence is scarce, especially in youth. Objective: To investigate the associations of persistent respiratory symptoms with HTP use, cigarette use, and dual use among Hong Kong youth. Design, Setting, and Participants: This was a territorywide cross-sectional school-based survey conducted from October 2018 to July 2019 using an anonymous questionnaire. Schools were randomly invited from a proportionate stratified sample in all 18 districts of Hong Kong. Poisson regression models using generalized estimating equations yielded adjusted prevalence ratios (APRs) of respiratory symptoms in (1) former and current HTP (vs never) users in the whole sample and stratified by cigarette use status and (2) exclusive HTP and dual users vs exclusive cigarette users. Statistical analysis was performed from October 2020 to March 2021. Exposures: Former and current use of cigarettes, HTPs, e-cigarettes, and other tobacco products. Main Outcomes and Measures: Respiratory symptoms for 3 consecutive months in the past 12 months. Results: The study included 33 627 students with a mean (SD) age of 14.8 (1.9) years; 51.3% (18 171) were boys. Respiratory symptoms were reported by 16.3% (n = 5549) of all students, 29.3% (n = 226) of current users of e-cigarettes, 31.2% (n = 314) of current users of cigarettes, and 33.5% (n = 179) of current users of HTPs. Respiratory symptoms were associated with former (APR, 1.30; 95% CI, 1.06-1.59) and current (APR, 1.59; 95% CI, 1.23-2.06) vs never HTP use and current vs never cigarette use (APR, 1.50; 95% CI, 1.30-1.74) after adjusting for various tobacco use. Associations between respiratory symptoms and current vs never HTP use were observed in never (APR, 1.88; 95% CI, 1.36-2.59) and former (APR, 2.15; 95% CI, 1.12-4.12) cigarette users, but not in current cigarette users (APR, 1.24; 95% CI, 0.97-1.59). Respiratory symptoms were associated with exclusive ever HTP use (APR, 1.46, 95% CI, 1.15-1.86) and ever dual use (APR, 1.29; 95% CI, 1.08-1.54) vs exclusive ever cigarette use. There was no association between exclusive current HTP (vs cigarette) use and respiratory symptoms (1.40; 95% CI, 0.93-2.11). Conclusions and Relevance: This cross-sectional study found that former and current HTP use were associated with persistent respiratory symptoms among youth, especially among never and former cigarette users. Respiratory symptoms were more prevalent in ever exclusive HTP users and ever dual users than ever exclusive cigarette users. These findings suggest that using HTPs instead of cigarettes may not reduce health risks.

Adolescent Use of and Susceptibility to Heated Tobacco Products.

BACKGROUND AND OBJECTIVES: A leading brand of heated tobacco products (HTPs), IQOS, was authorized to be sold in the United States in 2019. Researchers have examined the awareness and use of HTPs among US adults. In this study, we examined high school students' awareness, use, and susceptibility pertaining to HTPs. METHODS: A large, cross-sectional population survey of randomly sampled 10th- and 12th-graders in California (N = 150 516) was conducted online during school hours from September 2019 to March 2020. RESULTS: Overall, 8.9% (95% confidence interval [CI], 8.7%-9.1%) of California high school students had heard of HTPs. Approximately 0.67% (95% CI, 0.61%-0.73%) had ever tried HTPs, and 0.20% (95% CI, 0.17%-0.23%) were current users (ie, ∼30% of ever users continued to use HTPs at the time of survey). Among those who never tried HTPs, 18.3% (95% CI, 17.9%-18.8%) were susceptible to future use. The susceptibility to HTP use was greater among users of cigarettes or e-cigarettes than among nonusers. CONCLUSIONS: The awareness of HTPs among adolescents was remarkable given the low availability of products at the time of survey. Only a small percentage of adolescents experimented with HTPs. However, almost a third of those who had experimented with HTPs continued to use them. This high ratio and the fact that almost 1 out of 5 never users were susceptible to future HTP use should put the public health community on high alert as more HTP products are coming into the market, with promotion of these products likely to increase.

Trends in use of e-cigarette device types and heated tobacco products from 2016 to 2020 in England.

This study examined use trends of e-cigarette devices types, heated tobacco products (HTPs) and e-liquid nicotine concentrations in England from 2016 to 2020. Data were from a representative repeat cross-sectional survey of adults aged 16 or older. Bayesian logistic regression was used to estimate proportions and 95% credible intervals (CrIs). Of 75,355 participants, 5.3% (weighted = 5.5%) were currently using e-cigarettes or HTPs, with the majority (98.7%) using e-cigarettes. Among e-cigarette users, 53.7% (CrI 52.0-55.1%) used tank devices, 23.7% (22.4-25.1%) mods, 17.3% (16.1-18.4%) pods, and 5.4% (4.7-6.2%) disposables. Tanks were the most widely used device type throughout 2016-2020. Mods were second until 2020, when pods overtook them. Among all e-cigarette/HTP users, prevalence of HTP use remains rare (3.4% in 2016 versus 4.2% in 2020), whereas JUUL use has risen from 3.4% in 2018 to 11.8% in 2020. Across all years, nicotine concentrations of ≤ 6 mg/ml were most widely (41.0%; 39.4-42.4%) and ≥ 20 mg/ml least widely used (4.1%; 3.4-4.9%). Among e-cigarette/HTP users, ex-smokers were more likely than current smokers to use mod and tank e-cigarettes, but less likely to use pods, disposables, JUUL and HTPs. In conclusion, despite growing popularity of pods and HTPs worldwide, refillable tank e-cigarettes remain the most widely used device type in England.