• To Ask or Not to Ask, that is the Question….

• March 17 WEBINAR: Learn about Health Justice in Tobacco Control.
• March 30 WEBINAR: Smoke-Free Tribal Housing Policies.
• April 14 WEBINAR: Joining Environmental and Health Advocacy to Reduce Tobacco's Burden on People and Ecosystems.
• Virtual Conference on April 27, 28: 3rd Annual Teaching Cannabis Awareness & Prevention Conference: A Focus on the Triangulum of Cannabis, Tobacco, and Vaping.

• Tips^® 2022 Update.
• FDA Finally Starting Process to Ban Menthol.
• State Initiative for Tobacco Equity Update.
• Incoming FDA Commissioner Dr. Robert Califf Must Stand up to the Tobacco Industry and Protect Youth from Nicotine Addiction.
• Tobacco Control Marks 30 Years of Publication.
• How Tobacco Companies have Used Women’s History and Equality Struggles to Sell Cigarettes.
• How the Tobacco Industry is Renewing its Assault on Science.
• March is National Problem Gambling Awareness Month (PGAM).
• SCLC's I COVID QUIT Social Media Campaign.

Quitlines

Bricker JB, Sullivan BM, Mull KE, Torres AJ, Carpenter KM.
Full-scale Randomized Trial Comparing Acceptance and Commitment Therapy (ACT) Telephone-delivered Coaching with Standard Telephone-delivered Coaching among Medicare/uninsured Quitline Callers.
Nicotine Tob Res. 2022 Feb 23:ntac052. doi: 10.1093/ntr/ntac052. Epub ahead of print. PMID: 35196381.

Introduction. The aim of this study was to compare Acceptance and Commitment Therapy (ACT) telephone-delivered coaching with standard quitline (QL) telephone-delivered coaching.
Methods. Medicare/uninsured adults (analyzable sample N = 1170) who smoked at least 10 cigarettes per day were recruited from Optum®, a major US provider of quitline services, in a two-arm stratified double-blind randomized trial with main outcome of self-reported missing=smoking 30-day point prevalence abstinence (PPA) at the 12-month follow-up. Participants were mean (SD) age 47.4 (12.7), 61% female, and 72% white race. Five-sessions of telephone-delivered ACT or QL interventions were offered. Both arms included combined nicotine patch (4 weeks) and gum or lozenge (2 weeks).
Results. The 12-month follow-up data retention rate was 67.8%. ACT participants reported their treatment was more useful for quitting smoking (92.0% for ACT vs. 82.3% for QL; OR = 2.48; 95% CI: 1.53, 4.00). Both arms had similar 12-month cessation outcomes (missing=smoking 30-day PPA: 24.6% for ACT vs. 28.8% for QL; OR = .81; 95% CI: .62, 1.05) and the ACT arm trended toward greater reductions in number cigarettes smoked per day (-5.6 for ACT vs. -1.7 QL, among smokers; p = .075).
Conclusions. ACT telephone-delivered coaching was more satisfying, engaging, and was as effective as standard quitline telephone-delivered coaching. ACT may help those who fail to quit after standard coaching or who choose not to use nicotine replacement therapy.
Implications. In a sample of Medicare and uninsured quitline callers, a large randomized trial with long term follow-up showed that Acceptance and Commitment Therapy (ACT) telephone-delivered coaching was more satisfying, engaging, and was as effective as standard quitline telephone-delivered coaching-which has followed the same behaviour change approach since the 1990s. This newer model of coaching might be a welcome addition to quitline services.

Wadlin J, Ford DE, Albert MC, Wang NY, Chander G.
Implementing an EMR-based Referral for Smoking Quitline Services with Additional Provider Education, a Cluster-randomized Trial.
J Gen Intern Med. 2022 Mar 8. doi: 10.1007/s11606-021-07275-6. Epub ahead of print. PMID: 35260960.

Background. Despite evidence of their effectiveness, free smoking quitlines are underused. The best way to educate providers about and encourage use of quitlines is not established. We examined if electronic medical record (EMR)-integrated best practices alerts (BPAs) with or without additional provider education resulted in increased quitline referrals.
Methods. Waitlist-controlled, cluster-randomized trial of primary care practices assigned to three arms. Providers in participating sites received a new EMR-based BPA for quitline referral and additional education outreach visits, the BPA alone, or usual care. The study was conducted in 2 phases: phase 1 from April 17 to October 16, 2017, and phase 2 from November 9, 2017, to May 8, 2018. In phase 2, the usual-care sites were randomized to either of the two intervention arms. The unit of randomization was primary care practice site. All in-office, primary care provider visits with smokers were included. The primary outcome was referral to the quitline. Secondary outcomes included patient acceptance and enrollment in quitline services.
Results. Twenty-two practice sites were enrolled. Smoking prevalence at sites ranged from 4.4 to 23%. In phase 1, the BPA-plus-education arm had 5636 eligible encounters and 405 referrals (referral rate 7.2%) while the BPA-only arm had 6857 eligible encounters and 623 referrals (referral rate 9.1%). The usual-care arm had 7434 encounters but no referrals. Comparing the BPA-plus arm to the BPA-only arm, the odds ratio of referral was 0.76 (CI 0.3-1.8). In phase 2, the combined BPA-plus-education sites had 8516 eligible encounters and 475 referrals (rate 5.6%). The BPA-only sites had 9134 eligible encounters and 470 referrals (rate 5.2%). The odds ratio comparing the 2 groups in phase 2 was 1.06 (0.5-2.2).
Conclusions. An EMR-based BPA can improve the number of referrals to quitline services, though more work is needed to improve providers' use of quitlines and low patient acceptance of services.

Sinicrope PS, Young CD, Resnicow K, Merritt ZT, McConnell CR, Hughes CA, Koller KR, Bock MJ, Decker PA, Flanagan CA, Meade CD, Thomas TK, Prochaska JJ, Patten CA.
Lessons Learned from Beta-testing a Facebook Group Prototype to Promote Treatment Use in the "Connecting Alaska Native People to Quit smoking" (CAN Quit) Study.
J Med Internet Res. 2022 Feb 17;24(2):e28704. doi: 10.2196/28704. PMID: 35175208; PMCID: PMC8895280.

Social media provides an effective tool to reach, engage, and connect smokers in cessation efforts. Our team developed a Facebook group, CAN Quit (Connecting Alaska Native People to Quit smoking), to promote use of evidence-based smoking cessation resources for Alaska Native people living in Alaska, which are underused despite their effectiveness. Often separated by geography and climate, Alaska Native people prefer group-based approaches for tobacco cessation that support their culture and values. Such preferences make Alaska Native people candidates for social media-based interventions that promote connection. This viewpoint discusses the steps involved and lessons learned in building and beta-testing our Facebook group prototype, which will then be evaluated in a pilot randomized controlled trial. We describe the process of training moderators to facilitate group engagement and foster community, and we describe how we developed and tested our intervention prototype and Facebook group. All parts of the prototype were designed to facilitate use of evidence-based cessation treatments. We include recommendations for best practices with the hope that lessons learned from the CAN Quit prototype could provide a model for others to create similar platforms that benefit Alaska Native and American Indian people in the context of smoking cessation.

Kraus A, Moskowitz DA, Ma J, Macapagal K.
Cigarette Use and Vaping among Sexual and Gender Minority (SGM) Adolescents Assigned Male at Birth: Patterns of use and Associations with Demographic and Psychosocial Factors.
Int J Behav Med. 2022 Feb 25. doi: 10.1007/s12529-021-10037-7. Epub ahead of print. PMID: 35217994.

Background. This study described cigarette and electronic nicotine delivery systems (ENDs) use and their demographic and psychosocial correlates in a sample of sexual and gender minority (SGM) adolescents assigned male at birth.
Methods. One-way ANOVA, multivariate linear regression, and correlation analyses were conducted to examine correlates of cigarettes/ENDs use on 159 SGM adolescent users, ages 15-18.
Results. Fifty-three percent of the sample used cigarettes/ENDs, with differences based on sexual orientation: bisexual, pansexual, and queer adolescents used ENDs more than gay adolescents. White adolescents smoked more cigarettes than adolescents of color, independent of ENDs use. Regarding psychosocial correlates, alcohol use and depression were associated with greater daily cigarette use, while sexual orientation identity was associated with greater daily ENDs use.
Conclusions. This study characterized frequency and psychosocial correlates of cigarettes/ENDs use among SGM adolescents. Findings highlighted several risk factors for tobacco use and will inform future interventions for SGM adolescents.

Gu D, Max WB, Yao T, et al.
Association Between E-cigarette Use and Food Insecurity among Low-income Adults.
Tobacco Control Published Online First: 12 March 2022. doi: 10.1136/tobaccocontrol-2021-057110

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.

Wackowski OA, Gratale SK, Jeong M, et al.
Over 1 Year Later: Smokers’ EVALI Awareness, Knowledge and Perceived Impact on E-cigarette Interest.
Tobacco Control Published Online First: 28 February 2022. doi: 10.1136/tobaccocontrol-2021-057190

Objectives. The e-cigarette or vaping product use-associated lung injury (EVALI) outbreak caused serious lung injuries in over 2800 people in the USA in 2019. By February 2020, most cases were determined as linked with vaping tetrahydrocannabinol (THC), including black market products using vitamin E acetate. This study examined smokers’ EVALI awareness, knowledge and perceived impact on their e-cigarette interest approximately 16 months after its peak.
Design. Between January and February 2021, we surveyed 1018 adult current smokers from a nationally representative US research panel. Participants were asked if they had heard about EVALI prior to COVID-19, knew its main cause, and if EVALI had impacted their interest in future e-cigarette use.
Results. Approximately 54% of smokers had heard of EVALI. Among those who had heard of EVALI (n=542), 37.3% believed its main cause was e-cigarettes used to vape nicotine, like JUUL. Fewer (16.6%) thought the main cause was products for vaping marijuana/THC, and 20.2% did not know. About 29% had heard vitamin E acetate was associated with EVALI, and 50.9% indicated EVALI made them less interested in using e-cigarettes in the future. EVALI awareness was significantly associated with e-cigarette risk perceptions (ie, that e-cigarettes are as harmful as smoking).
Conclusions. Despite the passage of time, considerable lack of knowledge and misperceptions about EVALI remain among those who smoke. Our findings suggest the need for continued efforts to promote better understanding of EVALI and appropriate behavioural and policy responses.

Technology

Fradkin N, Zbikowski SM, Christensen T.
Analysis of Demographic Characteristics of Users of a Free Tobacco Cessation Smartphone App: Observational Study.
JMIR Public Health Surveill. 2022 Mar 9;8(3):e32499. doi: 10.2196/32499. PMID: 35262491.

Background. Tobacco use continues to be the leading preventable cause of death, disease, and disability in the United States. Since 2000, Washington state has offered free tobacco "quitline" services to help its residents stop using tobacco. In 2015, the state began offering free access to a tobacco cessation smartphone app to absorb excess quitline demand. Since most publicly funded tobacco cessation programs are designed to provide access to populations disproportionately impacted by tobacco use, it is important to consider who these public health interventions reach.
Objective. The aim of this study is to understand who used a free cessation app and the extent to which users represented populations disproportionately impacted by tobacco use.
Methods. This is an observational study of 1280 adult Washington state residents who registered for and activated the cessation app. Demographic data were collected as part of the sign-up process, examined using standard descriptive measures, and assessed against state-level surveillance data for representativeness.
Results. Participants were primarily non-Hispanic White (978/1218, 80.3%), identified as female (780/1236, 63.1%), were between ages 25-54 years (903/1186, 76.1%), had at least some college education (836/1222, 68.4%), and reported a household income under US $50,000 (742/1055, 70.3%). Fewer respondents were from rural counties (359/1220, 29.4%); identified as lesbian, gay, bisexual, pansexual, queer, questioning, or asexual (LGBQA; 153/1222, 12.5%); were uninsured (147/1206, 12.2%); or were currently pregnant, planning pregnancy, or breastfeeding (42/624, 6.7%). However, relative to available state data for tobacco users, there was high representation of women, 35- to 54-year-olds, college graduates, and LGBQA individuals, as well as individuals with low household income, poor mental health, Medicaid insurance, and those residing in rural counties.
Conclusions. A diverse population of tobacco users will use a free cessation app, including some demographic groups disproportionately impacted by tobacco use. With high reach and high efficacy, it is possible to address health disparities associated with tobacco use and dependence treatment among certain underserved and at-risk groups.

Stavaux E, Goupil F, Barreau G, Septans AL, Dautzenberg B, Foulet-Rogé A, Padilla N, Urban T, Denis F.
Use of a Smartphone Self-assessment App for a Tobacco-induced Disease (COPD, cardiovascular diseases, cancer) Screening Strategy and to Encourage Smoking Cessation: Observational Study.
JMIR Public Health Surveill. 2022 Feb 23;8(2):e19877. doi: 10.2196/19877. PMID: 35195530; PMCID: PMC8908192.

Background. Patient self-assessment via a mobile app detects actionable symptoms and has been shown to detect lung cancer relapses early, thereby lengthening survival.
Objective. The purpose of this study was to assess the incidence of chief symptoms associated with the main tobacco-induced pathologies in both current and ex-smokers through a self-assessment smartphone app and to evaluate the app's capacity to encourage users to quit smoking or reduce consumption, as well as its impact on early lung cancer stages at the time of diagnosis.
Methods. Current and ex-smokers were recruited through an advertising campaign in Sarthe county (France) proposing the free download of a smartphone app. App users were asked to answer 13 questions related to symptoms associated with tobacco-induced diseases (chronic obstructive pulmonary disease [COPD], cardiovascular diseases, cancer). In the event of any positive answer, a message was displayed recommending the user to consult a physician. In addition, they were asked about smoking cessation intention before and after answering these 13 questions. Finally, incidence of stage 1 or 2 lung cancers diagnosed during the launch period of our application was evaluated by comparing data from various sources to those from the same period during the previous year.
Results. Of the 5671 users who were eligible for evaluation, an alert was sent to the majority (4118/5671, 72.6%), with a higher incidence for current smokers (2833/3679, 77.0% vs 1298/1992, 65.2%; P<.001). The most frequent symptoms triggering the notifications were fatigue (2023/5671, 35.7%), cough (1658/5671, 29.2%), dyspnea (1502/5671, 26.5%), and persistent chest pain (1286/5671, 22.7%). Of the current smokers, 14.0% (515/3679) showed symptoms suggesting COPD, 15.5% (571/3679) showed symptoms suggesting stable angina, 12.4% (455/3679) probably had lower extremity artery disease, and 6.8% (249/3679) had possible cancer. Of the users, 36.5% (1343/3679) claimed that they thought about quitting smoking, and 48.7% (1795/3679) had thought about reducing their consumption. Surgery-eligible stage 1 and 2 lung cancer incidence was 24% (14/58) during the study period versus 9% (5/54) during the previous year in Sarthe county (P=.04), whereas it remained unchanged in the neighboring county of Maine-et-Loire.
Conclusions. A majority of current and ex-smokers showed worrying symptoms, and the use of a self-assessment smartphone app may drive a majority of smokers toward the intention of smoking cessation or decreasing consumption. A randomized study should be performed to confirm this intention and to support the potential increase of symptomatic lung cancer detection at early, surgery-accessible stages.

Houston TK, Chen J, Amante DJ, Blok AC, Nagawa CS, Wijesundara JG, Kamberi A, Allison JJ, Person SD, Flahive J, Morley J, Conigliaro J, Mattocks KM, Garber L, Sadasivam RS.
Effect of Technology-assisted Brief Abstinence Game on Long-term Smoking Cessation in Individuals not yet Ready to Quit: A Randomized Clinical Trial.
JAMA Intern Med. 2022 Mar 1;182(3):303-312. doi: 10.1001/jamainternmed.2021.7866. PMID: 35072714; PMCID: PMC8787683.

Importance. Most trials of behavioral or pharmaceutical interventions for people who smoke are limited to individuals reporting they are ready to quit smoking. Engaging individuals who initially report they are not yet ready to quit in brief, precessation, skills-building interventions (eg, practice quit attempts or nicotine replacement therapy [NRT] sampling) is challenging.
Objective. To test an integrated behavioral plus NRT-sampling intervention using a gamification approach supported by mobile health.
Design, setting, and participants. A multisite randomized clinical trial with site-level 1-to-1 allocation into 2 conditions was conducted in 4 US health care systems. A total of 433 individuals who were currently smoking and reported at enrollment that they were not ready to quit smoking were enrolled. The study was conducted from November 7, 2016, to July 31, 2020.
Interventions. Take a Break (TAB) was a 3-week game experience and included 5 behavioral components (motivational messaging, challenge quizzes, brief abstinence goal setting, mobile health apps for cravings management, and reward points for participation) integrated with NRT sampling. TAB draws on social cognitive theory and game mechanics concepts to engage participants in health behavior change. The comparison included NRT sampling only.
Main outcomes and measures. Time to first quit attempt (duration from TAB experience to primary outcome) and carbon monoxide level-verified smoking cessation at 6-month follow-up. All analyses used an intention-to-treat approach.
Results. Of the 433 individuals included in the trial, 223 were women (52%); mean (SD) age was 54 (13) years. More than half (53% [112 of 213]) of the TAB participants completed 100% of the daily challenge quizzes in the first week, 73% (145 of 199) of participants who completed the goal-setting call set a brief abstinence goal (most frequently 1-2 days of abstinence from cigarettes), and 75% (159 of 213) of participants used the mobile health apps to manage nicotine cravings. Time to the first quit attempt was lower for the TAB vs comparison group (hazard ratio, 1.68; 95% CI, 1.09-2.60; P = .02). At the 6-month follow-up, 18% (28 of 160) of TAB participants and 10% (17 of 171) of the comparison (χ2 test, P = .045) participants obtained carbon monoxide level-verified smoking cessation (accounting for clustering of outcomes by site; odds ratio, 1.92; 95% CI, 1.01-3.68; P = .048).
Conclusions and relevance. The findings of this randomized clinical trial demonstrate that individuals not yet ready to quit smoking could be engaged in a brief abstinence game. Six months later, the TAB group had nearly double the rate of smoking cessation vs the NRT sampling comparison group. Integrating a skills-building game experience with brief NRT sampling can enhance long-term cessation among those not yet ready to quit smoking.

Tobacco Use

Hrywna M, Gonsalves NJ, Delnevo CD, et al.
Nicotine Pouch Product Awareness, Interest and Ever Use among US Adults who Smoke, 2021.
Tobacco Control Published Online First: 25 February 2022. doi: 10.1136/tobaccocontrol-2021-057156

Background. Tobacco-free nicotine pouches are one of the fastest growing tobacco product categories in the US market. However, data on awareness, appeal or ever use of these products in the USA are limited.
Methods. We surveyed a population-based sample of US adults who smoked (n=1018) between January and February 2021 about awareness, ever use of or interest in nicotine pouches. Multivariable logistic regression models explored the relationship between nicotine pouch variables and demographic and tobacco use characteristics.
Results. In early 2021, 29.2% of adults who smoked had ever seen or heard of nicotine pouches, 5.6% had ever tried pouches and 16.8% reported interest in using pouches in the next 6 months. Adults who smoked aged 18–44 years and those who had ever used smokeless tobacco (SLT) were more likely to be aware of nicotine pouches. Interest in using nicotine pouches was more prevalent among adult smokers who were Hispanic, planned to quit within 6 months, attempted to quit before using counselling or another tobacco product and had ever used pouches. Among adults who smoked, those with more education had lower odds of ever using nicotine pouches while those who had attempted to quit before using traditional methods or ever used SLT had higher odds of ever use.
Conclusion. Levels of awareness, appeal and trial of nicotine pouches among US adults who smoke were modest, with variation by age, education, quit plans and quit attempt methods. Continued surveillance is warranted, including among naïve users and users of other tobacco and nicotine products.

Gentzke AS, Wang TW, Cornelius M, et al.
Tobacco Product Use and Associated Factors among Middle and High School Students — National Youth Tobacco Survey, United States, 2021.
MMWR Surveill Summ 2022;71(No. SS-5):1–29. DOI: http://dx.doi.org/10.15585/mmwr.ss7105a1external icon.

Problem/Condition. Commercial tobacco use is the leading cause of preventable disease, disability, and death in the United States. Most tobacco product use begins during adolescence. In recent years, tobacco products have evolved to include various combusted, smokeless, and electronic products.
Period Covered. 2021.
Description of System. The National Youth Tobacco Survey (NYTS) is an annual, cross-sectional, school-based, self-administered survey of U.S. middle school (grades 6–8) and high school (grades 9–12) students. A three-stage cluster sampling procedure is used to generate a nationally representative sample of U.S. students attending public and private schools. NYTS is the only nationally representative survey of U.S. middle and high school students that focuses exclusively on tobacco use patterns and associated factors. NYTS provides data to support the design, implementation, and evaluation of comprehensive youth tobacco use prevention and control programs and to guide tobacco regulatory activities. Since 2019, NYTS has been administered electronically via tablet computers. Because of emergency COVID-19 protocols that were in place across the United States during the 2021 NYTS fielding window (January 18–May 21, 2021), the 2021 survey was administered using a web URL to allow participation by eligible students learning under varying instructional models (in-person, distance/virtual, and hybrid). In total, 50.8% of student respondents reported completing the survey in a school building or classroom and 49.2% at home or some other place. CDC and the Food and Drug Administration (FDA) analyzed data from the 2021 NYTS to assess tobacco product use patterns and associated factors among U.S. middle and high school students. Overall, 20,413 students (out of 25,149 sampled students; student response rate: 81.2%) completed the questionnaire from 279 schools (out of 508 sampled schools; school response rate: 54.9%). The overall response rate, defined as the product of the student and school response rates, was 44.6%. The sample was weighted to represent approximately 11.97 million middle school students and 15.44 million high school students. Students with missing information about grade level were excluded from the school-level analyses (n = 135).
Results. In 2021, an estimated 34.0% of high school students (5.22 million) and 11.3% of middle school students (1.34 million) reported ever using a tobacco product (i.e., electronic cigarettes [e-cigarettes], cigarettes, cigars, smokeless tobacco, hookahs, pipe tobacco, heated tobacco products, nicotine pouches, and bidis [small brown cigarettes wrapped in a leaf]). Current (past 30-day) use of a tobacco product was 13.4% for high school students (2.06 million) and 4.0% for middle school students (470,000). E-cigarettes were the most commonly currently used tobacco product, cited by 11.3% of high school students (1.72 million) and 2.8% of middle school students (320,000), followed by cigarettes, cigars, smokeless tobacco, hookahs, nicotine pouches, heated tobacco products, and pipe tobacco. Current use of any tobacco product was reported by 14.2% of students identifying as lesbian, gay, or bisexual (LGB) (versus 7.9% of heterosexual); 18.9% of students identifying as transgender (versus 8.2% of not transgender); and 14.2% of students reporting severe psychological distress (versus 5.5% with no distress). Among students who currently used each respective tobacco product, frequent use (on ≥20 days of the past 30 days) ranged from 17.2% for nicotine pouches to 39.4% for e-cigarettes. Among current users of any tobacco product, 79.1% reported using a flavored tobacco product; by product, e-cigarettes were the most commonly used flavored tobacco product. Among current users of any tobacco product, the most commonly reported source of access was from a friend (32.8%). Among students who currently used e-cigarettes, 53.7% used a disposable device, 28.7% used a prefilled/refillable pod or cartridge device, 9.0% used a tank or mod system (a system that can be customized by the user), and 8.6% did not know the device type. Among students who had ever used e-cigarettes, the most common reason for first trying them was “a friend used them” (57.8%); among current e-cigarette users, the most commonly cited reason for current use was “I am feeling anxious, stressed, or depressed” (43.4%). Among all middle and high school students, 75.2% reported past-year recognition of any antitobacco public education campaign ads. Exposure to marketing or advertising for any tobacco product was reported by 75.7% of students who had contact with an assessed potential source of tobacco product advertisements or promotions (going to a convenience store, supermarket, or gas station; using the Internet; watching television or streaming services or going to the movies; or reading newspapers or magazines). Among students who reported using social media, 73.5% had ever seen e-cigarette–related content. Among all students, perceiving “no” or “little” harm from intermittent tobacco product use was highest for e-cigarettes (16.6%) and lowest for cigarettes (9.6%). Among students who currently used any tobacco product, 27.2% had experienced cravings during the past 30 days; 19.5% reported wanting to use a tobacco product within 30 minutes of waking. Moreover, 65.3% of students who currently used tobacco products were seriously thinking about quitting the use of all products, and 60.2% had stopped using all products for ≥1 day because they were trying to quit during the past 12 months.
Interpretation. In 2021, approximately one in 10 U.S. middle and high school students (9.3%) had used a tobacco product during the preceding 30 days. By school level, this represented more than one in eight high school students (13.4%) and approximately one in 25 middle school students (4.0%). E-cigarettes were the most commonly used tobacco product in 2021. Tobacco product use was higher among certain subpopulations, such as those identifying as LGB or transgender, or those reporting psychological distress. Importantly, approximately two thirds of students who currently used tobacco products were seriously thinking about quitting. However, factors that might continue to promote tobacco product use among U.S. youths, such as the availability of flavors, access to tobacco products, exposure to tobacco product marketing, and misperceptions about harm from tobacco product use, remained prevalent in 2021.
Public Health Action. The continued monitoring of all forms of youth tobacco product use and associated factors through surveillance efforts including NYTS is important to the development of public health policy and action at national, state, and local levels. The 2021 NYTS was successfully administered during the COVID-19 pandemic using a web URL to allow participation by eligible students learning under varying instructional models. As a result of these modifications to the fielding procedures, any comparison of results between 2021 NYTS findings with previous years, including the direct attribution of any potential changes in tobacco product use, is not possible. Parents, educators, youth advocates, and health care providers can help protect youths from the harms of tobacco products, including e-cigarettes. In addition, the comprehensive and sustained implementation of evidence-based tobacco control strategies, combined with FDA’s regulation of tobacco products, is important for reducing all forms of tobacco product use among U.S. youths.

COVID-19

Luk TT, Cheung DY, Chan HC, Wai-Yin Fok P, Ho KS, Sze CD, Lam TH, Wang MP.
Mobile Chat Messaging for Preventing Smoking Relapse Amid the COVID-19 Pandemic: A Pilot Randomized Controlled Trial.
Nicotine Tob Res. 2022 Feb 15:ntac045. doi: 10.1093/ntr/ntac045. Epub ahead of print. PMID: 35166327.

Introduction. The ongoing COVID-19 pandemic had reduced access to traditional, in-person smoking cessation treatment. We examined the feasibility, acceptability, and potential effectiveness of mobile chat messaging in preventing smoking relapse in smokers who have recently quit smoking.
Methods. In this assessor-blinded, pilot randomized controlled trial in 5 cessation clinics, we recruited adult daily smokers who had been receiving cessation treatments and abstained for 3 to 30 days. The intervention group received real-time, personalized chat messaging on relapse prevention via WhatsApp for 3 months. The control group received generic text messaging on the harms of smoking and benefits of quitting for 3 months. The primary outcome was carbon monoxide-validated abstinence at 6 months post-treatment initiation. The trial was registered with ClinicalTrials.gov (NCT04409496).
Results. From June to July 2020, 108 of 130 (83%) eligible subjects were randomized to the intervention (N=54) or control (N=54) groups. The retention rate was 93% at 3 months (end of treatment) and 85% at 6 months. In the intervention group, 80% of participants responded to the chat messages at least once; 43% continuously engaged with the intervention over the 3-month intervention period. By intention-to-treat, validated abstinence at 6 months was higher in the intervention than control group (31% vs 22%), with an RR of 1.72 (95% CI 0.91-3.23; P=0.09) after adjusting for pre-quit nicotine dependence, duration of abstinence and cessation treatment at baseline.
Conclusions. This pilot trial showed the feasibility and acceptability of mobile chat messaging for relapse prevention with preliminary evidence on its effectiveness in increasing validated abstinence.
Implications. Smoking relapse is the most likely outcome of smoking cessation attempts and an undertreated problem. This pilot trial showed the feasibility and acceptability of personalized chat messaging via WhatsApp for relapse prevention in recent abstainers amid the COVID-19 pandemic. The higher carbon monoxide-validated abstinence rate in participants who received chat messaging than controls showed preliminary evidence on the effectiveness of the intervention. Fully-powered trials are warranted to test the intervention.

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