Tobacco Smoke Exposure and Sleep Duration among U.S. Adolescents.

OBJECTIVES: Tobacco smoke exposure (TSE) and poor sleep are public health problems with their own set of consequences. This study assessed whether TSE was associated with sleep duration among U.S. adolescents. METHOD: We conducted a secondary analysis of 2013-2018 National Health and Nutrition Examination Survey data including 914 nontobacco-using adolescents ages 16-19 years. TSE measures included cotinine and self-reported home TSE groups including no home TSE, thirdhand smoke (THS) exposure, and secondhand smoke (SHS)+THS exposure. Sleep duration was assessed in hours and categorically as insufficient sleep (recommended hours). Weighted multiple linear regression and multinomial regression models were conducted. RESULTS: Adolescents with higher log-cotinine levels had higher number of sleep hours (ß = 0.31, 95%CI = 0.02,0.60) and were at increased odds of reporting excess sleep (AOR = 1.41, 95%CI = 1.40,1.42), but were at reduced odds of reporting insufficient sleep (AOR = 0.88, 95%CI = 0.87,0.89). Compared to adolescents with no home TSE, adolescents with home THS exposure and home SHS+THS exposure were at increased odds of reporting insufficient sleep (AOR = 2.27, 95%CI = 2.26,2.29; AOR = 2.75, 95%CI = 2.72,2.77, respectively) and excess sleep (AOR = 1.89, 95%CI = 1.87,1.90; AOR = 5.29, 95%CI = 5.23,5.34, respectively). CONCLUSIONS: TSE may affect insufficient and excess sleep duration among adolescents. Eliminating TSE may promote adolescent respiratory and sleep health.

Parent-Child Nativity, Race, Ethnicity, and Common Mental Health Conditions Among United States Children and Adolescents.

OBJECTIVE: To examine associations between race, ethnicity, and parent-child nativity, and common mental health conditions among U.S. children and adolescents. METHODS: Data were from 2016 to 2019 National Survey of Children's Health, a US population-based, serial cross-sectional survey, and restricted to children who had access to health care. We used weighted multivariable logistic regression to examine the associations between race and ethnicity (Asian, Black, Hispanic, White, Other-race); mental health outcomes (depression, anxiety, and behavior/conduct problems) stratified by household generation; and between household generation and outcomes stratified by race and ethnicity, adjusting for demographics (age, sex, family income to poverty ratio, parental education), and an adverse childhood experience (ACE) score. RESULTS: When stratifying by household generation, racial and ethnic minority children generally had similar to lower odds of outcomes compared with White children, with the exception of higher odds of behavior/conduct problems among third + -generation Black children. When stratifying by race and ethnicity, third + generation children had increased odds of depression compared to their first-generation counterparts. Third + generation, racial and ethnic minority children had increased odds of anxiety and behavior/conduct problems compared with their first-generation counterparts. The associations generally remained significant after adjusting for the ACE score. CONCLUSIONS: Lower odds of common mental health conditions in racial and ethnic minority children could be due to factors such as differential reporting, and higher estimates, including those in third + generation children, could be due to factors including discrimination; systemic racism; and other factors that vary by generation and need further investigation to advance health equity.

Electronic cigarette use and cigarette smoking associated with inadequate sleep duration among U.S. young adults.

OBJECTIVE: Nicotine use can influence inadequate sleep, but less is known about the associations of exclusive and dual use of electronic cigarettes (e-cigarettes) with combustible cigarettes in U.S. young adults. This study assessed the associations between current exclusive e-cigarette use, exclusive cigarette smoking, and dual e-cigarette and combustible cigarette use and inadequate sleep duration among U.S. young adults. METHODS: We performed a secondary analysis of 2020 Behavioral Risk Factor Surveillance System (BRFSS) data including 13,978 U.S. young adults ages 18-24 years. Inadequate sleep duration was assessed categorically using the National Sleep Foundation's age-specific recommendations that define <7 h as inadequate sleep. Weighted logistic regression models were performed while adjusting for participants' sex, race/ethnicity, education level, annual household income level, body mass index, current physical activity, mental health status, disability status, current alcohol use, and current smokeless tobacco use. RESULTS: Concerning use patterns, 11.8% of young adults were exclusive e-cigarette users, 4.7% were exclusive cigarette smokers, and 3.8% were dual e-cigarette and combustible cigarette users. Exclusive e-cigarette users (adjusted odds ratio [AOR] = 1.41, 95% confidence interval [CI] = 1.16-1.72), exclusive cigarette smokers (AOR = 1.63, 95%CI = 1.22-2.18), and dual product users (AOR = 2.03, 95%CI = 1.44-2.86) were at increased odds of having inadequate sleep duration compared to non-users, while adjusting for the covariates. Additionally, dual product users were at increased odds (AOR = 1.52, 95%CI = 1.06-2.19) of reporting inadequate sleep duration compared to exclusive e-cigarette users, while adjusting for the covariates. CONCLUSIONS: Current e-cigarette and cigarette use may influence inadequate sleep among U.S. young adults. Tobacco cessation efforts may encourage increased sleep health.

Sources of Tobacco Smoke Exposure and Their Associations With Serum Cotinine Levels Among US Children and Adolescents.

INTRODUCTION: We assessed tobacco smoke exposure (TSE) levels based on private and public locations of TSE according to race and ethnicity among US school-aged children ages 6-11 years and adolescents ages 12-17 years. AIMS AND METHODS: Data were from 5296 children and adolescents who participated in the National Health and Nutrition Examination Survey (NHANES) 2013-2018. Racial and ethnic groups were non-Hispanic white, black, other or multiracial, and Hispanic. NHANES assessed serum cotinine and the following TSE locations: homes and whether smokers did not smoke indoors (home thirdhand smoke [THS] exposure proxy) or smoked indoors (secondhand [SHS] and THS exposure proxy), cars, in other homes, restaurants, or any other indoor area. We used stratified weighted linear regression models by racial and ethnic groups and assessed the variance in cotinine levels explained by each location within each age group. RESULTS: Among 6-11-year-olds, exposure to home THS only and home SHS + THS predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic white children exposed to car TSE had higher log-cotinine (ß = 1.64, 95% confidence interval [CI] = 0.91% to 2.37%) compared to those unexposed. Non-Hispanic other/multiracial children exposed to restaurant TSE had higher log-cotinine (ß = 1.13, 95% CI = 0.23% to 2.03%) compared to those unexposed. Among 12-17-year-olds, home SHS + THS exposure predicted higher log-cotinine among all racial and ethnic groups, except for non-Hispanic black adolescents. Car TSE predicted higher log-cotinine among all racial and ethnic groups. Non-Hispanic black adolescents with TSE in another indoor area had higher log-cotinine (ß = 2.84, 95% CI = 0.85% to 4.83%) compared to those unexposed. CONCLUSIONS: TSE location was uniquely associated with cotinine levels by race and ethnicity. Smoke-free home and car legislation are needed to reduce TSE among children and adolescents of all racial and ethnic backgrounds. IMPLICATIONS: Racial and ethnic disparities in TSE trends have remained stable among US children and adolescents over time. This study's results indicate that TSE locations differentially contribute to biochemically measured TSE within racial and ethnic groups. Home TSE significantly contributed to cotinine levels among school-aged children 6-11 years old, and car TSE significantly contributed to cotinine levels among adolescents 12-17 years old. Racial and ethnic differences in locations of TSE were observed among each age group. Study findings provide unique insight into TSE sources, and indicate that home and car smoke-free legislation have great potential to reduce TSE among youth of all racial and ethnic backgrounds.

Trends in Education-Related Smoking Disparities Among U.S. Black or African American and White Adults: Intersections of Race, Sex, and Region.

INTRODUCTION: Despite its overall decline in the United States, trends in cigarette smoking could vary by intersection with demographic characteristics. We explored trends in education-related disparities in current smoking among U.S. adults by race (Black or African American and White), sex, and U.S. census region. AIMS AND METHODS: Data were from U.S. civilian non-institutionalized adults (aged ≥18 years) who self-identified as Black or African American and White and participated in the 1995-2019 Tobacco Use Supplement to the Current Population Survey. We estimated average annual percent changes in current cigarette smoking by the intersections of race, sex, census region, and educational attainment. We calculated educated-related prevalence differences in current cigarette smoking by subtracting the prevalence of bachelor's degrees from that of

Exploring Young Adults' Beliefs About Cigar Smoking by Susceptibility: A Belief Elicitation Study.

INTRODUCTION: Young adults are at risk for cigar smoking, which is associated with cancers and pulmonary and cardiovascular diseases. Little is known about young adults' beliefs about smoking cigarillos, little filtered cigars, and large cigars, and how these beliefs may vary across cigar types and by cigar susceptibility. AIMS AND METHODS: The larger study surveyed a U.S. sample of young adults (18-30 years old) who never used tobacco products (n = 948) through Qualtrics online panel services in August 2021-January 2022. We assessed participants' susceptibility to using different cigar types. Participants were randomly assigned to open-ended questions about one of the three cigar types to elicit behavioral, normative, and control beliefs. We conducted thematic analysis to code emergent themes within each belief and examined the frequency of reported themes at the intersection of cigar type and cigar susceptibility. RESULTS: Cigar susceptible participants reported positive behavioral beliefs (eg, anticipated relaxation, mood regulation, being cool), friends as supportive referents, and easy-to-smoke control beliefs (eg, high accessibility, low cost) more frequently than non-susceptible participants. Varied frequency by cigar type also emerged. For example, cigarillo and little filtered cigar features were mentioned more frequently as easy-to-smoke control beliefs, while low accessibility was reported more frequently as a hard-to-smoke control belief for large cigars. CONCLUSIONS: Findings identify salient beliefs about cigarillo, little filtered cigar, and large cigar smoking among young adult tobacco never-users. Future research should investigate the potential importance of these beliefs in cigar smoking susceptibility and initiation among young adults, and their potential utility in prevention research. IMPLICATIONS: This thematic analysis identified salient beliefs about cigarillos, little filtered cigars, and large cigars among a U.S. young adult sample, and differentiated emergent beliefs by cigar susceptibility status and by cigar type. Given the lack of cigar smoking prevention media campaigns, identifying these beliefs is the one of the first steps in developing effective cigar smoking prevention strategies. Future quantitative studies are needed to confirm the relationships between these beliefs and smoking initiation of each cigar type to further inform the types of beliefs to be targeted in strategic communication and help prevent cigar smoking initiation among susceptible young adults.

Awareness of electronic cigarette industry practices and their associations with anti-electronic cigarette attitudes among susceptible US young adults.

BACKGROUND: Public education exposing cigarette industry practices have been effective in changing attitudes and preventing smoking among young people. It is unclear how much young adults are aware of e-cigarette industry practices, and how this awareness relates to anti-e-cigarette attitudes. We examined demographic correlates of awareness of e-cigarette industry practices and anti-e-cigarette attitudes, and the association between awareness of these practices with anti-e-cigarette attitudes. METHODS: A US sample of young adults aged 18-30 years who do not use commercial tobacco products but are susceptible to e-cigarette use were cross-sectionally surveyed through online panel services from August 2021 to January 2022. Respondents reported their demographics, awareness of cigarette industry practices, awareness of e-cigarette industry practices and their level of agreement with four anti-e-cigarette attitude statements. We used multivariable linear regressions to examine demographic associations and the relationship between awareness of e-cigarette industry practices with each anti-e-cigarette attitude, adjusting for demographics and awareness of cigarette industry practices. RESULTS: Generally, Hispanic and Black young adults (vs White) and those with

Effect of a 'tobacco-free nicotine' claim on intentions and perceptions of Puff Bar e-cigarette use among non-tobacco-using young adults.

INTRODUCTION: Puff Bar disposable e-cigarettes are now marketed with a 'tobacco-free nicotine' claim. We assessed the effect of this claim on non-tobacco-using young adults' perceptions of and intentions of using Puff Bar. METHODS: We conducted an online randomised between-subjects experiment among non-tobacco-using young adults (ages 18-29 years; n=1822). Participants viewed depictions of Puff Bar e-cigarettes with the claim that the product contains 'tobacco-free nicotine' (experimental group; n=909) or simply 'nicotine' (control group; n=913). Multivariable regressions were used to assess the associations between experimental conditions and Puff Bar use intentions, harm perceptions, use expectancies and perceived relative use of Puff Bar versus other e-cigarettes, controlling for participant characteristics. RESULTS: Compared with the control group, the experimental group who saw the 'tobacco-free nicotine' claim reported higher intentions of using Puff Bar (coefficient=0.17, p<0.001). The experimental group had a lower likelihood of perceiving Puff Bar use as 'extremely or very harmful' (OR=0.63, p<0.001) and 'strongly or somewhat' agreeing with the negative expectancy of using Puff Bar (OR=0.67, p<0.001). Additionally, the experimental group reported being 'much more or more likely' to use Puff Bar over other e-cigarettes (OR=1.67, p<0.001). DISCUSSION: Puff Bar's tobacco-free nicotine claim may increase non-tobacco-using young adults' intentions of using Puff Bar and reduce harm perceptions and negative expectancy towards using Puff Bar. The claim may also prompt the use of Puff Bar over other e-cigarette brands and types. These findings are concerning given the health effects and regulations for tobacco-free nicotine products are not immediately clear.

Cumulative cigarette discount coupon exposure and trajectories of cigarette smoking: a longitudinal analysis in US adults.

INTRODUCTION: Exposure to cigarette discount coupons is associated with short-term increase in cigarette smoking; however, long-term impact is unclear. This study examined associations of cumulative exposure to cigarette coupons with trajectories of cigarette smoking in US adults. METHODS: Data were from the US Population Assessment of Tobacco and Health Study Adult Surveys (n=19 824; waves 2-5). We examined the number of waves participants received cigarette discount coupons/promotions during waves 2-4 and smoking behaviours at wave 5. Weighted logistic multivariable regression models were used, adjusting for wave 2 demographics and stratified by wave 2 smoking status. RESULTS: Among wave 2 adults who never smoked, each increment wave of exposure to cigarette discount coupons was associated with greater odds of wave 5 current smoking (adjusted OR (aOR)=2.09, 95% CI 1.24-3.52). Among wave 2 adults who smoked daily, each wave of coupon exposure was associated with lower odds of quitting smoking at wave 5 (aOR=0.67, 95% CI 0.62-0.73). Among wave 2 adults who had quit smoking, each increment wave of exposure was associated with greater odds of wave 5 current smoking (aOR=1.61, 95% CI 1.41-1.85). Additionally, women (vs men) and adults with lower socioeconomic status (SES) (vs higher SES) were more frequently exposed to cigarette coupons for a higher number of waves (p<0.05). DISCUSSION: Exposure to cigarette coupons exhibited a dose-response relationship with changes in cigarette smoking behaviours over time, promoting smoking progression and hindering smoking cessation especially among women and people with lower SES. Prohibiting these coupons can be an important tobacco control strategy.

Price promotion receipt and use progression of any tobacco, cigarettes, e-cigarettes and cigars among US youth between 2016 and 2018.

BACKGROUND: Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression. METHODS: The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates. RESULTS: At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation. DISCUSSION: Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.

Financial hardship during the COVID-19 pandemic and increased receipt of commercial tobacco discount coupons among US adults who use commercial tobacco.

INTRODUCTION: Many individuals experienced financial hardship during the COVID-19 pandemic; yet commercial tobacco (CT) sales increased in the USA. We examined how experiencing financial hardships relates to increased CT discount coupon reception during the pandemic. METHODS: A nationally representative sample of 1700 US adults who used CT during the 12 months prior to the survey were surveyed online during January to February 2021. Participants reported if they had received more discount coupons for various CT products during (compared with before) the pandemic. They also reported whether they experienced six different types of financial hardships since the pandemic, and the total number of hardships experienced was counted. Weighted multivariable logistic regressions were used to examine the associations between financial hardships and increased coupon reception, adjusting for demographics and CT product use. RESULTS: During the first 10-11 months of the pandemic, 21.3% of US adults who used CT during the 12 months prior to the survey reported receiving more CT discount coupons. Experiencing financial hardship during the pandemic was associated with higher odds of receiving more coupons for all types of CT products: every additional count of financial hardship was associated with higher odds of increased reception of discount coupons for all CT products (adjusted odds ratios ranging from 1.13 to 1.23 across products). CONCLUSIONS: Over one-fifth of US adults who used CT received more discount coupons during the pandemic. Those facing financial hardships had higher discount coupon reception, suggesting potential targeted marketing to financially vulnerable individuals by the tobacco industry.

U.S. young adults' awareness of the Master Settlement Agreement and cigarette industry practices and their associations with electronic cigarette industry and health risk perceptions.

BACKGROUND: The lawsuit that led to the U.S. Master Settlement Agreement (MSA) exposed the cigarette industry's deceptive marketing practices, which changed population perceptions about the cigarette industry and helped prevent cigarette smoking. The cigarette industry now owns many electronic cigarette (e-cigarette) companies and make their own e-cigarettes. Given that the MSA occurred in previous decades, many millennial and generation Z young adults may not know about the MSA and the cigarette industry's marketing practices. It is unknown whether awareness about the MSA and cigarette industry practices may influence these young adults' e-cigarette industry and e-cigarette health risk perceptions, which may inform e-cigarette prevention efforts. METHODS: Cross-sectional data were collected from a U.S. sample of tobacco-naïve young adults, 18-30 years-old, susceptible to e-cigarette use (n = 1,329) through an online panel service in August 2021-January 2022. Participants reported their demographic characteristics, awareness of the MSA, awareness of cigarette industry practices, e-cigarette industry perceptions, and e-cigarette health risk perceptions. We examined the relationships between awareness of the MSA and cigarette industry practices with e-cigarette industry and e-cigarette health risk perceptions using multivariable linear regressions, adjusted for demographic characteristics. RESULTS: Overall, 36.2%, 24.1%, and 39.3% of participants had heard of the MSA and knew a lot about it, had heard of the MSA, but did not know much about it, and did not hear of the MSA, respectively. On average, participants were aware of 5.2 (SD = 3.0) of the 11 cigarette industry practices included. Hearing about the MSA and knowing a lot about it and awareness of more cigarette industry practices were associated with less positive e-cigarette industry and higher e-cigarette health risk perceptions, whereas having heard of the MSA but not knowing much about it was associated with more positive e-cigarette industry and lower e-cigarette health risk perceptions. CONCLUSIONS: Findings suggest that increasing comprehensive awareness of the MSA and cigarette industry practices may influence young adults' e-cigarette-related perceptions, and may importantly prevent detrimental information gaps about the cigarette industry. Future research should investigate the potential impact of increasing awareness of the MSA and cigarette industry practices in changing e-cigarette-related perceptions, which may help prevent e-cigarette use.

Mortality Risks Associated With Dual- and Poly-Tobacco-Product Use in the United States.

Increasing numbers of adults in the United States use more than 1 tobacco product. Most use cigarettes in combination with other tobacco products. However, little is known about the all-cause and cancer-specific mortality risks of dual- and poly-tobacco-product use. We examined these associations by pooling nationally representative data from the 1991, 1992, 1998, 2000, 2005, and 2010 National Health Interview Surveys (n = 118,144). Mortality information was obtained through linkage to the National Death Index. Cigarette smokers who additionally used other tobacco products smoked as many if not more cigarettes per day than exclusive cigarette smokers. Furthermore, cigarette smokers who additionally used other tobacco products had mortality risks that were as high as and sometimes higher than those of exclusive cigarette smokers. As tobacco use patterns continue to change and diversify, investigators in future studies need to carefully assess the impact of noncigarette tobacco products on cigarette use and determine associated disease risks.

Parent-Child Nativity, Race, Ethnicity, and Adverse Childhood Experiences Among U.S. Children.

We examined the relationship between parent-child nativity, race/ethnicity, and adverse childhood experiences (ACEs) among US children. We found that a high proportion of Black/Hispanic children experienced ACEs, with variation by generation for Hispanic but not Black children, and a lower but increasing proportion of White children experienced ACEs by generation.

Tests for confounding with cigarette smoking in the association of E-cigarette use with respiratory disorder: 2020 National-Sample Data.

Associations of e-cigarette use with respiratory disorder have been demonstrated but it has been unclear whether these are confounded by current or previous cigarette smoking. We address this question through studying different time frames for e-cigarette use and respiratory disorders in 2020 BRFSS data (N = 214,945). E-cigarette use and combustible cigarette smoking were classified into four categories: Participant never used either (Nonuse); used e-cigarettes/cigarettes but not in the past 30 days (Former Use), used in past 30 days on some days (Nondaily Use), or used past 30 days on all days (Daily Use). Contrasts for e-cigarette status and cigarette status (with nonuse as reference group) were entered with covariates in logistic regression with asthma or COPD as criterion. Stratified analyses of e-cigarette use were also performed for smokers and nonsmokers. In the total sample, results showed independent positive associations with both lifetime and current asthma for Former, Nondaily, and Daily e-cigarette use (mostly p < .0001) and the three cigarette indices. Significant positive associations with COPD were found for the three e-cigarette indices (p < .0001) and all the cigarette indices. Stratified analyses showed significant associations of e-cigarette use with respiratory disorder among nonsmokers as well as among smokers. We conclude that independent associations for former e-cigarette use (controlling for current/former smoking) and significant associations of e-cigarette use with respiratory disorder among nonsmokers indicate these associations are not confounded with cigarette smoking and suggest reverse causation is implausible. Findings for former use are discussed with reference to possible mechanisms including sensitization effects.

Correlates of behavior change intents in response to a hypothetical flavored cigar sales restriction among U.S. adult flavored cigar smokers.

Flavored cigar sales restrictions (FCSRs) may reduce cigar smoking and protect public health. This study examined the correlates of behavior change intents in response to a hypothetical FCSR. Data were from a nationally representative sample of adult flavored cigar smokers (ages ≥21; n = 343) collected through an online survey in 2021. Respondents selected their behavior change intents in response to a hypothetical FCSR, including (1) quitting cigars altogether; (2) smoking plain or non-flavored cigars; (3) smoking other flavored tobacco products; (4) smoking cannabis; and (5) other options. Weighted logistic regressions were used to examine the associations of socio-demographic backgrounds, tobacco use history, and tobacco dependence with behavioral change intents. In response to an FCSR, 15.1% of respondents would quit smoking cigars altogether, 41.6% would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, and 29.2% would substitute flavored cigars with cannabis. Large cigar smokers and blunt smokers were less likely to quit cigars altogether than non-smokers of those products; females and racial/ethnic minorities were more likely to substitute flavored cigars with other flavored tobacco and cannabis products, respectively, than males and non-Hispanic White respondents. Results suggest that FCSRs may reduce cigar smoking among a portion of U.S. flavored cigar smokers while leaving more continuing to smoke plain cigars or transitioning to use other flavored tobacco products or cannabis. Implementing FCSRs should be accompanied by comprehensive flavored tobacco sales restrictions, cessation programs, and educational messages aimed at reducing the use of cigars and other substances.

Association of exposure to environmental tobacco smoke at home and risk of mortality among US never smokers by race/ethnicity, education, and income.

Environmental tobacco smoke (ETS) increases the risk of mortality among nonsmokers. Yet, few studies have examined this association among racial/ethnic minorities or among people with less education or income. We assessed self-reported ETS exposure at home among never smoking participants (n = 110,945) of the 1991-2010 National Health Interview Surveys. Deaths through 2015 were identified by the National Death Index. Hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality were estimated using Cox proportional hazards regression models with age as the underlying time metric and adjusted for sex, race/ethnicity, education, household income, body mass index, region of residence, and survey year. We further stratified all-cause mortality analyses by race/ethnicity, household income, and education. Relative to no ETS at home, every day exposure was associated with higher risk of all-cause mortality (HR = 1.33, 95%CI: 1.23, 1.45), with similar HRs observed across strata of education and income. HRs were similar among non-Hispanic Black (HR = 1.28, 95%CI: 1.08, 1.53) and non-Hispanic White adults (HR = 1.34, 95%CI: 1.21, 1.48) although somewhat higher among Hispanic adults (HR = 1.65, 95%CI: 1.29, 2.10; P for pairwise comparison = 0.04). ETS exposure at home is an important contributor to mortality across strata of race/ethnicity, education, and income in the US.

Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020.

INTRODUCTION: Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults. AIMS AND METHODS: Using 2020 cross-sectional data from 2,470 young adults (ages 18-34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively. RESULTS: 19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (ß = 0.26, 95%CI = 0.21, 0.30; ß = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (ß = -0.06, 95%CI = -0.10, -0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users. CONCLUSIONS: Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims. IMPLICATIONS: Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.

E-cigarette-inclusive smoke-free policies, excise taxes, tobacco 21 and changes in youth e-cigarette use: 2017-2019.

BACKGROUND: We examined whether the implementation of electronic cigarette (e-cigarette) policies at the state level (e-cigarette-inclusive smoke-free (ESF) policies, excise taxes on e-cigarettes and raising tobacco legal purchasing age to 21 years (T21)) affected recent upward trends in youth e-cigarette use. METHODS: Data were from participants from 34 US states who completed the Youth Risk Behavior Survey (YRBS) state surveys in 2017 and 2019 (n=278 271). States were classified as having or not having ESF policies, any e-cigarette excise tax and T21 policies by 1 January 2019. Participants reported ever, past 30-day and frequent (≥20 days) e-cigarette use; past 30-day combustible cigarette smoking; and age, sex and race/ethnicity. Weighted multivariable logistic regression models assessed whether changes in e-cigarette use over time differed by policy status, adjusting for participants' demographics and combustible cigarette smoking. RESULTS: Prevalence of ever and past 30-day youth e-cigarette use in states with ESF policies decreased during 2017-2019, while the prevalence of these measures in states without ESF policies increased. States with T21 policies showed non-significant changes in prevalence of ever and past 30-day youth e-cigarette use, whereas states without T21 policies showed significant increases in ever and past 30-day youth e-cigarette use. States with ESF and T21 policies showed slower increases in youth frequent e-cigarette use. E-cigarette excise taxes were not associated with decreasing prevalence of youth e-cigarette use. CONCLUSIONS: State-level ESF and T21 policies could be effective for limiting growth of youth e-cigarette use despite an overall national increase. Higher e-cigarette excise tax rates may be needed to effectively reduce youth e-cigarette use.

Point-of-sale cigarette pricing strategies and young adult smokers' intention to purchase cigarettes: an online experiment.

BACKGROUND: Point-of-sale tobacco marketing has been shown to be related to tobacco use behaviours; however, specific influences of cigarette price discounts, price tiers and pack/carton availability on cigarette purchasing intention are less understood by the tobacco control community. METHODS: We conducted discrete choice experiments among an online sample of US young adult smokers (aged 18-30 years; n=1823). Participants were presented scenarios depicting their presence at a tobacco retail outlet with varying availability of cigarette price discounts, price tiers and pack/carton. At each scenario, participants were asked whether they would purchase cigarettes. Generalised linear regression models were used to examine the associations between of cigarette price discounts, price tiers and pack/carton with intention to purchase cigarettes overall and stratified by educational attainment. RESULTS: Participants chose to purchase cigarettes in 70.9% of the scenarios. Offering price discounts were associated with higher odds of choosing to purchase cigarettes. Reducing the number of cigarette price tiers available in the store was associated with lower odds of choosing to purchase cigarettes. Stratified analysis showed that offering discounts on high-tier cigarette packs increased odds of choosing to purchase cigarettes among young adult smokers with at least some college education, while offering discounts on medium-tier cigarette packs increased odds of choosing to purchase cigarettes among those with some college education or less (eg, with a 10% discount, adjusted odds ratio [AOR]some college=1.62, 95% confidence interval [CI] 1.21 to 2.16; AOR≤high school=1.44, 95% CI 1.08 to 1.93). CONCLUSIONS: Availability of cigarette price discounts, price tiers and pack/carton could potentially influence cigarette purchasing behaviours among young adult smokers. Regulating these marketing strategies may, therefore, reduce education-related smoking disparities.