• Webinar on March 22: SCLC Live Webinar, “Tobacco Regulation in an Evolving Landscape: Update from FDA’s Center for Tobacco Products”.
• 30th Annual Nicotine Dependence Center Conference: Tobacco Treatment and Digital Care.
• March 31, 2023 - Take Down Tobacco National Day of Action.
• Deadline of April 11 - Drug-Free Communities Support Program: Application Period is Open.

• Tips from Former Smokers® Campaign 2023 Launched March 6!
• Looking Back, Looking Ahead: FDA’s Progress on Tobacco Product Regulation in 2022
• SAMHSA Releases Improved Treatment Services Locator.
• New Online Training from ALA and AAP.
• New Publication from WHO - "It’s Time to Invest in Cessation: the Global Investment Case for Tobacco Cessation”.
• Dr. Carolyn Dresler, 2022 C. Everett Koop Unsung Hero Award Recipient, Joins ASH Board of Trustees.
• Tobacco Imagery Featured in More Oscar-nominated Movies this Year, Including 90% of Best Picture Nominees.
• New Documentary Takes Hard Look at Tobacco Industry’s Predatory Tactics for New Generations. 

Kowitt SD, Mendel Sheldon J, Vereen RN, Kurtzman RT, Gottfredson NC, Hall MG, Brewer NT, Noar SM.
The Impact of The Real Cost Vaping and Smoking Ads Across Tobacco Products.
Nicotine Tob Res. 2023 Feb 9;25(3):430-437. doi: 10.1093/ntr/ntac206. PMID: 36006858; PMCID: PMC9910139.

Introduction. Little research has examined the spillover effects of tobacco communication campaigns, such as how anti-smoking ads affect vaping.
Aims and methods. Participants were a national sample of 623 U.S. adolescents (ages 13-17 years) from a probability-based panel. In a between-subjects experiment, we randomly assigned adolescents to view one of four videos online: (1) a smoking prevention video ad from the Food and Drug Administration's (FDA) The Real Cost campaign, (2) a neutral control video about smoking, (3) a vaping prevention video ad from The Real Cost campaign, or (4) a neutral control video about vaping. We present effect sizes as Cohen's d, standardized mean differences, with 95% confidence intervals (CIs).
Results. Exposure to The Real Cost vaping prevention ads led to more negative attitudes toward vaping compared with control (d = 0.30, 95% CI: 0.07, 0.53), while exposure to The Real Cost smoking prevention ads did not affect smoking-related outcomes compared with control (p-values > .05). Turning to spillover effects, exposure to The Real Cost smoking prevention ads led to less susceptibility to vaping (d = -0.34, 95% CI: -0.56, -0.12), more negative attitudes toward vaping (d = 0.43, 95% CI: 0.20, 0.65) and higher perceived likelihood of harm from vaping (d = 0.26, 95% CI: 0.04, 0.48), compared with control. Exposure to The Real Cost vaping prevention ads did not affect smoking-related outcomes compared with control (p-values > .05).
Conclusions. This experiment found evidence of beneficial spillover effects of smoking prevention ads on vaping outcomes and found no detrimental effects of vaping prevention ads on smoking outcomes.
Implications. Little research has examined the spillover effects of tobacco communication campaigns, such as how anti-smoking ads affect vaping. Using a national sample of 623 U.S. adolescents, we found beneficial evidence of spillover effects of smoking prevention ads on vaping outcomes, which is promising since it suggests that smoking prevention campaigns may have the additional benefit of reducing both smoking and vaping among adolescents. Additionally, we found that vaping prevention campaigns did not elicit unintended consequences on smoking-related outcomes, an important finding given concerns that vaping prevention campaigns could drive youth to increase or switch to using combustible cigarettes instead of vaping.

Chang JT, Mayer M, Jackson RA, Rostron BL, Coleman B, Lee T, Ambrose BK, Chang CM.
Characteristics and Patterns of Cigarette Smoking and Vaping by Past-year Smokers who Reported Using Electronic Nicotine Delivery System to Help Quit Smoking in the Past Year: Findings from the 2018-2019 Tobacco Use Supplement to the Current Population Survey.
Nicotine Tob Res. 2023 Feb 9;25(3):596-601. doi: 10.1093/ntr/ntac199. PMID: 35973818.

Introduction. Cigarette smoking has declined, while electronic nicotine delivery system (ENDS) use has increased in the United States. Understanding the role of ENDS in adult smoking quit attempts and cessation is important for estimating their population health impact.
Aims and methods. We used data from 2018 to 2019 tobacco use supplement to the current population survey to examine demographic characteristics and ENDS use patterns among adult ENDS users who reported quitting smoking in the past year by trying to switch to ENDS ("switchers") and smokers who did or did not make a quit attempt in the past year. χ2 tests of proportions and t-tests were used to compare characteristics between groups.
Results. In 2018-2019, about three-quarters of switchers reported daily use of ENDS compared to only one-third of dual users with a recent quit attempt by trying to switch to ENDS. Compared to dual users who made a quit attempt by trying to switch to ENDS, switchers were more likely to use menthol/mint-flavored ENDS exclusively (5.6% vs. 13.1%; p = .004) but less likely to use tobacco-flavored ENDS exclusively (21.2% vs. 13.7%; p = .01).
Conclusions. ENDS users who quit smoking in the past year and reported trying to quit by switching to ENDS were more likely to use menthol/mint flavors exclusively and use ENDS daily compared to dual users who made a quit attempt by trying to switch to ENDS. Longer-term prospective data may better clarify the role of ENDS in smoking quit attempts and cessation.
Implications. This study provides information on patterns of ENDS use in former smokers and current smokers who tried to quit smoking by switching to ENDS in a national sample of U.S. adults. These results can inform policy actions concerning ENDS products.

Yingst J, Wang X, Lopez AA, Breland A, Soule E, Barnes A, Cohen J, Underwood M, Crabtree M, Foulds J.
Changes in Nicotine Dependence among Smokers Using Electronic Cigarettes to Reduce Cigarette Smoking in a Randomized Controlled Trial.
Nicotine Tob Res. 2023 Feb 9;25(3):372-378. doi: 10.1093/ntr/ntac153. PMID: 35752091; PMCID: PMC9910150.

Introduction. How nicotine dependence will be affected when current smokers initiate electronic cigarette (e-cigarette) use to reduce cigarette smoking is unknown. This study evaluated cigarette, e-cigarette, and total nicotine dependence more than 6 months among smokers reducing cigarette consumption by replacing with e-cigarettes.
Aims and methods. Adult cigarette smokers were randomized to one of four conditions (36 mg/ml e-cigarette, 8 mg/ml e-cigarette, 0 mg/ml e-cigarette, or cigarette-substitute [CS] [provided at no cost]) and instructed to reduce their cigarette smoking by 75% at 1 month. Participants completed follow-up at 1, 3, and 6 months. The Penn State Nicotine Dependence Index (PSNDI) measured dependence on cigarettes (PSCDI) and e-cigarettes (PSECDI). Urine cotinine measured total nicotine exposure. Linear mixed effects models for each outcome were conducted and included interaction terms between visit and condition.
Results. Participants (n = 520) were 58.8% female, 67.3% White, and 48.0 years old. At baseline, the median number of cigarettes smoked per day was 17.3 and the mean PSCDI score was 13.4, with no significant differences between conditions. Participants in the e-cigarette conditions reported significantly lower PSCDI scores, compared with baseline, and with the CS condition at all follow-up visits. Those in the 36 mg/ml e-cigarette condition reported greater PSECDI scores at 6 months, compared with baseline and the 0 mg/ml and 8 mg/ml conditions. At all follow-up visits, there were no differences in total nicotine exposure compared to baseline, nor between any conditions.
Conclusions. E-cigarette use was associated with reduced cigarette dependence, compared to the CS, without significant increases in total nicotine exposure.
Implications. Initiation of electronic cigarette use while continuing to smoke could potentially increase nicotine dependence. In this randomized trial aimed at helping smokers to reduce their cigarette intake, we found that use of an e-cigarette was associated with a reduction in cigarette dependence and an increase in e-cigarette dependence (in the condition with the highest nicotine concentration only), with no long term increase in total nicotine dependence or nicotine exposure.

Tattan-Birch H, Kock L, Brown J, Beard E, Bauld L, West R, Shahab L.
E-cigarettes to Augment Stop Smoking In-person Support and Treatment with Varenicline (E-ASSIST): A Pragmatic Randomized Controlled Trial.
Nicotine Tob Res. 2023 Feb 9;25(3):395-403. doi: 10.1093/ntr/ntac149. PMID: 35738868; PMCID: PMC9384384.

Aim. To examine whether, in adults receiving behavioral support, offering e-cigarettes together with varenicline helps more people stop smoking cigarettes than varenicline alone.
Methods. A two-group, parallel arm, pragmatic randomized controlled trial was conducted in six English stop smoking services from 2019-2020. Adults enrolled onto a 12-week programme of in-person one-to-one behavioral smoking cessation support (N = 92) were randomized to receive either (1) a nicotine e-cigarette starter kit alongside varenicline or (2) varenicline alone. The primary outcome was biochemically verified abstinence from cigarette smoking between weeks 9-to-12 post quit date, with those lost to follow-up considered not abstinent. The trial was stopped early due to COVID-19 restrictions and a varenicline recall (92/1266 participants used).
Results. Nine-to-12-week smoking abstinence rates were 47.9% (23/48) in the e-cigarette-varenicline group compared with 31.8% (14/44) in the varenicline-only group, a 51% increase in abstinence among those offered e-cigarettes; however, the confidence interval (CI) was wide, including the possibility of no difference (risk ratio [RR] = 1.51, 95% CI = 0.91-2.64). The e-cigarette-varenicline group had 43% lower hazards of relapse from continuous abstinence than the varenicline-only group (hazards ratio [HR] = 0.57, 95% CI = 0.34-0.96). Attendance for 12 weeks was higher in the e-cigarette-varenicline than varenicline-only group (54.2% vs. 36.4%; RR = 1.49, 95% CI = 0.95-2.47), but similar proportions of participants in both groups used varenicline daily for ≥8 weeks after quitting (22.9% versus 22.7%; RR = 1.01, 95% CI = 0.47-2.20). Estimates were too imprecise to determine how adverse events differed by group.
Conclusion. Tentative evidence suggests that offering e-cigarettes alongside varenicline to people receiving behavioral support may be more effective for smoking cessation than varenicline alone.
Implications. Offering e-cigarettes to people quitting smoking with varenicline may help them remain abstinent from cigarettes, but the evidence is tentative because our sample size was smaller than planned-caused by Coronavirus Disease 2019 (COVID-19) restrictions and a manufacturing recall. This meant our effect estimates were imprecise, and additional evidence is needed to confirm that providing e-cigarettes and varenicline together helps more people remain abstinent than varenicline alone.

Al-Shawaf M, Grooms KN, Mahoney M, Buchanan Lunsford N, Lawrence Kittner D.
Support for Policies to Prohibit the Sale of Menthol Cigarettes and all Tobacco Products among Adults, 2021.
Prev Chronic Dis. 2023 Feb 2;20:E05. doi: 10.5888/pcd20.220128. PMID: 36729702.

This study assessed support for commercial tobacco retail policies among adults. Data came from SpringStyles 2021, a web panel survey of adults in the US aged 18 years or older (N = 6,455). Overall, 62.3% of adults supported a policy prohibiting the sale of menthol cigarettes, and 57.3% supported a policy prohibiting the sale of all tobacco products. A majority of adults supported tobacco retail policies aimed at preventing initiation, promoting quitting, and reducing tobacco-related disparities. These findings can help inform federal, state, and local efforts to prohibit the sale of tobacco products, including menthol cigarettes.

Priority Populations

McQuoid J, Durazo A, Mooney E, Heffner J, Tan ASL, Kong AY, Clifton S, Horn E.
Tobacco Cessation and Prevention Interventions for Sexual and/or Gender Minority-identified People and the Theories that Underpin Them: A Scoping Review.
Nicotine Tob Res. 2023 Jan 31:ntad018. doi: 10.1093/ntr/ntad018. Epub ahead of print. PMID: 36721977.

Introduction. This scoping review takes stock of the social and behavior change theories that have underpinned tobacco interventions tailored to sexual and/or gender minority (SGM) people and reflects on the need to target contextually-based drivers of SGM tobacco use inequities.
Methods. Data sources were Medline (Ovid), Scopus, PubMed, Google Scholar (01/01/1946 - 10/27/2022). Peer-reviewed publications in English from anywhere in the world describing SGM-tailored tobacco cessation and/or prevention interventions were independently identified by a librarian and screened by the first and third authors. 367 articles were extracted; an additional 2 were found by hand searching. 369 articles were assessed for eligibility. Exclusion criteria were: not an intervention, review article, not SGM-tailored or tobacco-focused. We documented intervention name, intervention components, theoretical frameworks cited in reference to intervention design and/or implementation, and evaluation outcomes. All authors provided input on theoretical framework categorization.
Results. We identified 22 publications corresponding to 15 unique interventions. Individual-level behavior change theories (i.e., those focusing on within-person behavior change processes) were the most prominent. Among these, the Transtheoretical Model was the most frequently utilized, while Social Inoculation Theory, Theory of Reasoned Action, and Theory of Psychological Reactance were also employed. A minority of interventions referenced frameworks that more explicitly engaged with SGM people's social contexts, namely, Theory of Diffusion of Innovations and Minority Stress Model.
Conclusions. Future SGM-tailored tobacco interventions should leverage both the strengths of individual-level behavior change theories and those of frameworks that understand tobacco use inequities as indivisible from place, context, and policy.
Implications. This scoping review describes the theoretical underpinnings of sexual and/or gender minority (SGM)-tailored tobacco interventions published in the peer-review literature in English. It reflects on the need for greater utilization of social and behavior change theoretical frameworks that can engage with unique drivers of SGM tobacco use and barriers to cessation.

E-Cigarettes and Heated Tobacco Products

Yong HH, Chow R, East K, Thrasher JF, Hitchman SC, Borland R, Cummings KM, Fong GT.
Do Social Norms for Cigarette Smoking and Nicotine Vaping Product Use Predict Trying Nicotine Vaping Products and Attempts to Quit Cigarette Smoking amongst Adult Smokers? Findings from the 2016-2020 International Tobacco Control Four Country Smoking And Vaping Surveys.
Nicotine Tob Res. 2023 Feb 9;25(3):505-513. doi: 10.1093/ntr/ntac212. PMID: 36082962; PMCID: PMC9910125.

Introduction. To examine whether perceived injunctive and descriptive social norms towards cigarette and nicotine vaping product (NVP) use predicted subsequent trying NVPs and attempts to quit cigarette smoking amongst current smokers and whether associations varied across countries.
Aims and methods. Three waves of longitudinal cohort data from the International Tobacco Control Four Country Smoking and Vaping Survey were collected between 2016 and 2020 from 2290 adult smokers in Canada, Australia, England, and the United States who had never used NVPs at baseline (either wave 1 or wave 2) and followed up at the subsequent wave (wave 2 or wave 3, respectively) were analyzed using Generalized Estimating Equations.
Results. Of the injunctive and descriptive norm measures for smoking and NVP use, NVP initiation was only independently predicted by the injunctive interpersonal norm for NVP use, with perceived approval of NVP use by important others predicting higher odds of trying NVPs (AOR = 1.65, 95% CI = 1.20 to 2.27). This predictive effect was independent of baseline quit intention with no country variations found. By contrast, making cigarette smoking quit attempts were independently predicted by both injunctive and descriptive interpersonal norms with perceived disapproval of smoking by important others (AOR = 1.65, 95% CI = 1.38 to 1.99) and close friends using NVPs (AOR = 1.37, 95% CI = 1.04 to 1.79), both associated with higher odds of smoking quit attempts.
Conclusions. Adult smokers who perceive NVP use as normative, either because such behavior is socially approved or common within their close social networks, appear more inclined to try NVPs or make smoking quit attempts than smokers who do not.
Implications. Social norms can shape a person's behavior and result in behavior change. This study shows that initiation of NVP use behavior among smokers can be reliably predicted by their perception of whether NVP use is acceptable to those important to them within their close social networks. Similarly, any attempts to stop cigarette smoking can be predicted by their perception of how acceptable cigarette smoking is among those who are important to them and whether any of their close friends use NVPs. Changing social norms towards cigarette smoking and NVP use could therefore be incorporated into smoking cessation interventions to help smokers to quit and/or switch to NVP use.

Ozga JE, Stroup AM, Abadi MH, Cheney MK, Majmundar A, Garrison KA, Chen-Sankey J, Shamblen S, Dunlap C, Stanton CA.
E-cigarette Marketing Expenditures in the United States from 2016 to 2021: Targeted Media Outlets Geared Toward People who are at Increased Risk for Tobacco Use.
Nicotine Tob Res. 2023 Feb 9;25(3):581-585. doi: 10.1093/ntr/ntac209. PMID: 36070398; PMCID: PMC9910151.

Introduction. E-cigarette advertising exposure is linked to e-cigarette initiation and use. Thus, monitoring trends in e-cigarette advertising practices is important to understand e-cigarette use patterns observed over recent years.
Aims and methods. E-cigarette advertising expenditures (January 2016-July 2021; Numerator Ad Intel) for 154 U.S. market areas were harmonized with U.S. Census sociodemographic data through Nielsen zip code designations by market area. Descriptive statistics and multivariable linear regressions were used to examine trends in e-cigarette advertising expenditures across media outlets and associations between sociodemographic characteristics and e-cigarette advertising over time.
Results. E-cigarette advertising expenditures peaked in 2018/2019, followed by a sharp decline in 2020. Expenditures were concentrated primarily on print (58.9%), TV (20.6%), and radio (14.4%). Major print outlets were Sports Illustrated, Rolling Stone, and Star magazines. Top TV channels were AMC, Investigation Discovery, and TBS. TV advertisements were purchased commonly during popular movies and TV series (eg King of Queens, Everybody Loves Raymond, The Walking Dead). Higher expenditures were associated with U.S. market areas that had (1) a larger percentage of non-rural zip codes (radio), (2) smaller male populations (radio), and (3) larger White or Caucasian, Black or African American, American Indian or Alaska Native, Asian, and Other or Multiracial populations (radio, print, online display, and online video).
Conclusions. E-cigarette companies advertised in print magazines geared toward males and youth and young adults, radio commercials focused in urban areas with smaller male populations, and nationwide TV commercials. Declines in e-cigarette advertising expenditures in 2020 demonstrate the potential impact that federal policies may have on protecting populations who are at higher risk for tobacco use from predatory advertising practices.
Implications. E-cigarette advertising exposure is associated with the initiation and use of e-cigarettes. This study shows how e-cigarette marketing expenditures in the United States may have targeted specific consumers (eg youth and young adults) between 2016 and 2021. The precipitous drop in advertising expenditures across all outlets during early 2020 corresponds with the implementation of the Tobacco 21 federal policy, the federal enforcement policy to remove most unauthorized flavored e-cigarette cartridges from the U.S. market, preparations for FDA's premarket review of e-cigarette products, and the decision by several TV broadcast companies to stop showing e-cigarette ads. The potential impact of federal policies may have far-reaching implications for protecting populations who are at high risk for tobacco use and its health consequences.

Stone MD, Braymiller JL, Strong DR, Cwalina SN, Dimofte CV, Barrington-Trimis JL.
Differentiating Reasons for Young Adult E-cigarette Use Using Maximum Difference Choice Models. Nicotine Tob Res. 2023 Jan 31:ntad017. doi: 10.1093/ntr/ntad017. Epub ahead of print. PMID: 36719042.

Introduction. Understanding the reasons young adults use e-cigarettes (i.e., vape) - and whether these motivations vary across groups - is essential for informing tobacco regulatory efforts.
Methods. An online panel of young adults who vape (n=230; age=18-30) completed a maximum difference discrete choice task for 15 reasons for vaping. Over 9 choice sets, participants were presented a subset of 5 reasons and selected the most and least important. Hierarchical bayesian analysis estimated the relative importance of each reason. Latent class analysis (LCA) identified groups with similarly ranked reasons for use. Multinomial regression evaluated the association between sample characteristics and class membership.
Results. Overall, relaxation had the highest probability of being the most important reason for use (14.8%), followed by harm reduction (13.2%), and flavors (10.3%). LCA identified five distinct classes, based on top reasons for use: (1) cessation (cigarette cessation [20.2%]; n=80); (2) dependence (relaxation [20.5%] and unable to quit [19.2%]; n=21); (3) relaxation (relaxation [20.6%]; n=66); (4) socializing (socializing [22.2%]; n=27); and (5) variable (boredom [10.5%] and acceptability [10.2%]; n=36). Participants who were older, smoked cigarettes, or vaped more frequently were more likely to belong to the cessation class while those who were younger or more e-cigarette dependent were more likely to belong to the dependence class.
Conclusions. Perceived reasons why young adults vape are highly heterogeneous and dependent on the type of user. Tobacco regulatory efforts targeting distinct types of vapers are needed to minimize the adverse public health impact of vaping without compromising appeal for smoking cessation.
Implications. E-cigarette use remains high among young adults, with flavors, cost, and harm reduction (vs. combustible cigarettes) among the mostly commonly reported reasons for use. Yet, little is known about how relatively important these reasons are to the individual. Leveraging a maximum difference task, young adults' reasons for use were evaluated on a common interval scale and groups sharing similar reasons identified. Smoking cessation, dependence, relaxation, socialization, and boredom were respectively the most important reasons for use among five classes of vapers. E-cigarette regulatory policies should consider the distinct reasons for use as to not compromise their appeal for smoking cessation.

Milstred AR, Douglas AE, Romm KF, Blank MD.
Evaluation of the Psychometric Properties of Dependence Measures for Exclusive Electronic Cigarette Users.
Nicotine Tob Res. 2023 Feb 9;25(3):563-570. doi: 10.1093/ntr/ntac260. PMID: 36377569; PMCID: PMC9910153.

Introduction. Extant electronic cigarette (ECIG) dependence measures are largely adapted from those designed for cigarette smoking, though few have been evaluated for their psychometric properties.
Aims and methods. Never-smoking ECIG users (N = 134) participating in an online survey completed four dependence measures: Penn state electronic cigarette dependence index (PSECDI), e-cigarette dependence scale (EDS-4), diagnostic and statistical manual for tobacco use disorder (DSM-5), and Glover Nilsson behavioral questionnaire (GNBQ). They also reported on their ECIG use characteristics (eg, behaviors and reasons).
Results. Internal consistency was highest for the EDS-4 (Cronbach's α = 0.88) followed by the GNBQ (α = 0.75), PSECDI (α = 0.72), and DSM (α = 0.71). Confirmatory factor analyses revealed a single-factor structure for the PSECDI, EDS-4, and GNBQ. For the DSM-5, however, two items did not load significantly (ECIG use interferes with responsibilities; reduce/give up activities because of ECIG use). Significant correlations were observed between all measures and the number of ECIG use days/week and/or years using ECIGs, as well as between DSM-5 scores and the number of ECIG quit attempts and initiation age. Endorsement of using ECIGs because "I like flavors" was correlated positively with DSM-5 and GNBQ scores.
Conclusions. All dependence measures evaluated herein demonstrated adequate reliability and construct validity. Future work should focus on determining which aspects of dependence are those that are unique to ECIG use, and subsequently developing a more comprehensive measure of ECIG dependence.
Implications. The measures assessed herein-PSECDI, EDS-4, DSM-5, and GNBQ-demonstrated adequate to good reliability and construct validity among a sample of never-smoking ECIG users. The dependence domains covered across measures were related yet distinct. Findings demonstrate the need for future evaluation of these different domains to determine which are the most salient characteristics of ECIG dependence.

Mok Y, Jeon J, Levy DT, Meza R.
Associations Between E-cigarette Use and E-cigarette Flavors with Cigarette Smoking Quit Attempts and Quit Success: Evidence from a U.S. Large, Nationally Representative 2018-2019 Survey.
Nicotine Tob Res. 2023 Feb 9;25(3):541-552. doi: 10.1093/ntr/ntac241. PMID: 36250607; PMCID: PMC9910159.

Introduction. Although many studies have examined the association between e-cigarette use and smoking cessation, fewer have considered the impact of e-cigarette flavors on cessation outcomes. This study extends previous studies by examining the effects of e-cigarette use and e-cigarette flavors on quit attempts and quit success of smoking.
Aims and methods. We used data from the 2018-2019 Tobacco Use Supplement-Current Population Survey (TUS-CPS) survey. Multivariate logistic regression analyses were used to investigate the associations between flavored e-cigarette use with quit attempts and quit success of smoking among individuals who smoked 12 months ago. Two current e-cigarette use definitions were used in these logistic regression analyses; currently use every day or some days versus 20+ days in the past 30 days.
Results. Compared to those not using e-cigarettes, current every day or someday e-cigarette use with all nontobacco flavors had an adjusted odds ratio (AOR) of 2.9 (95% CI: 2.4 to 3.5) for quit attempts and 1.7 (95% CI: 1.3 to 2.2) for quit success. 20+ days e-cigarette use with flavors had stronger associations with quit attempts (AOR = 4.2, 95% CI: 3.1 to 5.5) and quit success (AOR = 4.0, 95% CI: 2.9 to 5.4). E-cigarette users with nontobacco flavors were more likely to succeed in quitting compared to those exclusively using non-flavored or tobacco-flavored e-cigarettes. Menthol or mint flavor users had slightly higher odds of quit attempts and success than users of other nontobacco flavors.
Conclusions. E-cigarette use is positively associated with both making smoking quit attempts and quit success. Those using flavored e-cigarettes, particularly menthol or mint, are more likely to quit successfully.
Implications. E-cigarette use is positively associated with both making a quit attempt and quit success, and those using flavored e-cigarettes are more likely to successfully quit smoking, with no statistically significant differences between the use of menthol or mint-flavored e-cigarettes versus the use of other nontobacco flavored products. This suggests that the potential for e-cigarettes to help people who currently smoke quit could be maintained with the availability of menthol or mint-flavored e-cigarettes, even if other nontobacco flavored products, which are associated with e-cigarette use among youth, were removed from the market.

Felicione NJ, Kaiser L, Leigh NJ, Page MK, Block AC, Schurr BE, O'Connor RJ, Goniewicz ML.
Comparing POD and MOD Ends Users' Product Characteristics, Use Behaviors, and Nicotine Exposure.
Nicotine Tob Res. 2023 Feb 9;25(3):498-504. doi: 10.1093/ntr/ntac211. PMID: 36073762; PMCID: PMC9910144.

Introduction. POD electronic nicotine delivery systems (ENDS), often containing high concentrations of nicotine salts, have replaced MODs (ie, open/modifiable devices) as the most popular devices. The purpose of this study was to compare device/liquid characteristics, use behavior, and nicotine exposure between POD and MOD users.
Methods. Data from the initial visit of a prospective observational study of exclusive ENDS users compared MOD (n = 48) and POD (n = 37) users. Participants completed questionnaires on demographic characteristics, patterns of ENDS use, and ENDS features. A urine sample was collected to test for cotinine and an ENDS liquid sample was collected to test for nicotine and salts. Puff topography was captured during an ad libitum bout at the end of the session.
Results. MOD and POD users did not differ on demographic characteristics. MOD users reported purchasing more liquid in the past month than POD users (180.4 ± 28.0 vs. 50.9 ± 9.0 ml, p < .001). Differences in characteristics of devices used by MOD and POD users included flavor type (p = .029), nicotine concentration (liquids used by MOD users contained less nicotine than those used by POD users: 8.9 ± 2.0 vs. 41.6 ± 3.2 mg/ml, p < .001), and presence of the nicotine salt (fewer MOD liquids had salts present than POD liquids: 11.9% vs. 77.4%, p < .001). User groups did not differ on urinary cotinine levels or puff topography (ps > .05).
Conclusions. Despite different characteristics of MOD and POD ENDS, users of those products are exposed to similar amounts of nicotine, likely due to using more liquid among MOD users.
Implications. This study directly compares ENDS product characteristics, user behavior, and nicotine exposure between MOD and POD ENDS users. Although POD products contained higher nicotine concentrations compared to MOD products, users of PODs reported consuming less liquid than MOD users. Ultimately, MOD and POD users were exposed to similar levels of nicotine, suggesting users behaviorally compensate for differences in product characteristics.

Shafie-Khorassani F, Piper ME, Jorenby DE, Baker TB, Benowitz NL, Hayes-Birchler T, Meza R, Brouwer AF.
Associations of Demographics, Dependence, and Biomarkers with Transitions in Tobacco Product Use in a Cohort of Cigarette Users and Dual Users of Cigarettes and E-cigarettes.
Nicotine Tob Res. 2023 Feb 9;25(3):462-469. doi: 10.1093/ntr/ntac207. PMID: 36037523; PMCID: PMC9910158.

Introduction. It is uncertain whether e-cigarettes facilitate smoking cessation in the real world. We aimed to understand whether and how transitions among cigarette, e-cigarette, and dual use are associated with sociodemographics, dependence measures, and biomarkers.
Aims and methods. We followed 380 adult daily cigarette users and dual users every 2 months for up to 2 years. We estimated transition rates between noncurrent, cigarette-only, e-cigarette-only, and dual use states using a multistate transition model. We estimated univariable hazard ratios (HR) for demographics, dependence measures for cigarettes and e-cigarettes, biomarkers, spousal or partner behaviors, and other measures.
Results. We estimated that participants transitioned from cigarette-only to e-cigarette-only through a period of dual use. Dual users ceased smoking (transitioning to e-cigarette-only use) at a greater rate than cigarette-only users did (HR 2.44, 95% CI: 1.49, 4.02). However, of the 60% of dual users estimated to transition to single product use in 1 year, 83% would transition to cigarette-only use and only 17% to e-cigarette-only use. E-cigarette dependence measures were generally associated with reduced e-cigarette cessation rather than enhanced cigarette cessation. E-cigarette users motivated by harm or toxicity reduction or because of restrictions on where or when they could smoke had reduced rates of smoking relapse. Cigarette dependence and spousal smoking were barriers to cigarette cessation for dual users, while using e-cigarettes first in the morning, motivation to quit smoking, and sensory, social, and emotional enjoyment of e-cigarettes (secondary dependence motives) were facilitators of smoking cessation among dual users.
Conclusions. Tobacco control policy and interventions may be informed by the barriers and facilitators of product transitions.
Implications. Although e-cigarettes have the potential to promote smoking cessation, their real-world impact is uncertain. In this cohort, dual users were more likely to quit smoking than cigarette-only users, but the overall impact was small because most dual users returned to cigarette-only use. Moreover, e-cigarette dependence promoted continued dual use rather than smoking cessation. Yet, high motivation to quit smoking and the sensory, social, and emotional enjoyment of e-cigarettes facilitated smoking cessation in dual users. Better understanding the barriers and facilitators of transitions can help to develop regulations and interventions that lead to more effective use of e-cigarettes for smoking cessation.

Azagba S, Ebling T, Shan L.
Sexual Minority Youth E-cigarette Use.
Pediatrics. 2023 Mar 1;151(3):e2022058414. doi: 10.1542/peds.2022-058414. PMID: 36808534.

Background and objectives. There is consistent evidence that sexual minority youth (SMY) use more traditional cigarettes than their non-SMY counterparts. However, there is relatively less information on e-cigarettes and, importantly, differences between and within SMY populations by race and ethnicity and sex. This study examines e-cigarette use by sexual orientation status and the intersection of race and ethnicity and sex.
Methods. Data come from high school students in the 2020 and 2021 National Youth Tobacco Surveys (N = 16 633). Current e-cigarette use prevalence by sexual identity categories was calculated for racial and ethnic subgroups. Multivariable logistic regression analysis examined the association between sexual identity and e-cigarette use by race and ethnicity groups and sex.
Results. E-cigarette use prevalence was higher for most SMY racial and ethnic groups than their non-SMY counterparts. However, multivariable logistic analysis showed varied results by race and ethnic groups, with higher e-cigarette use odds for SMY populations, although not statistically significant for some race and ethnic groups. Black gay or lesbian (adjusted odds ratio: 3.86, 95% confidence interval, 1.61-9.24) and bisexual (adjusted odds ratio: 3.31, 95% confidence interval, 1.32-8.30) high school students had significantly higher e-cigarette use odds than Black heterosexuals. Non-Hispanic Black females e-cigarettes use odds are 0.45 times that of non-Hispanic white males, and non-Hispanic other gay or lesbian had 3.15 times higher e-cigarette use odds than non-Hispanic white heterosexuals.
Conclusions. E-cigarette use is more prevalent among SMY populations. Disparities in e-cigarette use vary depending on race and ethnicity and sex.

Technology

Bricker J, Miao Z, Mull K, Santiago-Torres M, Vock DM.
Can a Single Variable Predict Early Dropout from Digital Health Interventions? Comparison of Predictive Models from Two Large Randomized Trials.
J Med Internet Res. 2023 Jan 20;25:e43629. doi: 10.2196/43629. PMID: 36662550; PMCID: PMC9898835.

Background. A single generalizable metric that accurately predicts early dropout from digital health interventions has the potential to readily inform intervention targets and treatment augmentations that could boost retention and intervention outcomes. We recently identified a type of early dropout from digital health interventions for smoking cessation, specifically, users who logged in during the first week of the intervention and had little to no activity thereafter. These users also had a substantially lower smoking cessation rate with our iCanQuit smoking cessation app compared with users who used the app for longer periods.
Objective. This study aimed to explore whether log-in count data, using standard statistical methods, can precisely predict whether an individual will become an iCanQuit early dropout while validating the approach using other statistical methods and randomized trial data from 3 other digital interventions for smoking cessation (combined randomized N=4529).
Methods. Standard logistic regression models were used to predict early dropouts for individuals receiving the iCanQuit smoking cessation intervention app, the National Cancer Institute QuitGuide smoking cessation intervention app, the WebQuit.org smoking cessation intervention website, and the Smokefree.gov smoking cessation intervention website. The main predictors were the number of times a participant logged in per day during the first 7 days following randomization. The area under the curve (AUC) assessed the performance of the logistic regression models, which were compared with decision trees, support vector machine, and neural network models. We also examined whether 13 baseline variables that included a variety of demographics (eg, race and ethnicity, gender, and age) and smoking characteristics (eg, use of e-cigarettes and confidence in being smoke free) might improve this prediction.
Results. The AUC for each logistic regression model using only the first 7 days of log-in count variables was 0.94 (95% CI 0.90-0.97) for iCanQuit, 0.88 (95% CI 0.83-0.93) for QuitGuide, 0.85 (95% CI 0.80-0.88) for WebQuit.org, and 0.60 (95% CI 0.54-0.66) for Smokefree.gov. Replacing logistic regression models with more complex decision trees, support vector machines, or neural network models did not significantly increase the AUC, nor did including additional baseline variables as predictors. The sensitivity and specificity were generally good, and they were excellent for iCanQuit (ie, 0.91 and 0.85, respectively, at the 0.5 classification threshold).
Conclusions. Logistic regression models using only the first 7 days of log-in count data were generally good at predicting early dropouts. These models performed well when using simple, automated, and readily available log-in count data, whereas including self-reported baseline variables did not improve the prediction. The results will inform the early identification of people at risk of early dropout from digital health interventions with the goal of intervening further by providing them with augmented treatments to increase their retention and, ultimately, their intervention outcomes.

Elling JM, Crutzen R, Talhout R, de Vries H.
Effects of Providing Tailored Information About E-cigarettes in a Digital Smoking Cessation Intervention: Randomized Controlled Trial.
Health Educ Res. 2023 Feb 2:cyad004. doi: 10.1093/her/cyad004. Epub ahead of print. PMID: 36727168.

The effectiveness of e-cigarettes in smoking cessation is under debate. Informing smokers who are motivated to quit smoking about e-cigarettes may help them to make an informed decision about their use for smoking cessation, which, however, may also lead to unintended effects such as less quitting. This experimental study assessed the influence of providing tailored information about e-cigarettes in a web-based tailored smoking cessation intervention on participants' decision-making and smoking behavior. Adult smokers (N = 331) were randomized into a personalized eHealth intervention on (i) smoking cessation (control condition) or (ii) smoking cessation and information about e-cigarettes (intervention condition). Directly postintervention, participants in the intervention condition had more knowledge about e-cigarettes than participants in the control condition. Attitudes toward e-cigarettes were more positive among intervention participants than control participants, but the differences in attitude were less pronounced than the differences in knowledge and not consistent across items. At a 6-month follow-up, no between-condition differences were observed in the use of e-cigarettes as a smoking cessation method, the number of tobacco cigarettes smoked in the past 7 days, or other smoking outcomes.

Tobacco Use

Dai HD, Leventhal AM.
Use of Traditional Smokeless, Snus, and Dissolvable Tobacco among U.S. Youth.
Am J Prev Med. 2023 Feb;64(2):204-212. doi: 10.1016/j.amepre.2022.09.011. Epub 2022 Nov 3. PMID: 36335080.

Introduction. Snus, dissolvable, and traditional smokeless tobacco product use is often amalgamated in youth epidemiologic research despite differences across these products. Prevalence, trends, and correlates of U.S. youth use across different classes of oral tobacco products are unknown.
Methods. Using 2011-2020 National Youth Tobacco Survey (N=193,933) data, the authors tested for cross-year linear and quadratic trends in the weighted prevalence of ever and current use of traditional smokeless tobacco, snus, and dissolvable tobacco. Multivariable logistic regressions estimated the demographic and tobacco use factors associated with the use of different oral tobacco products in 2020. Analyses were conducted in 2022.
Results. During 2011-2020, there were declines in the prevalence of ever use of traditional smokeless tobacco (11.0% to 5.6%; linear trend, p<0.0001) and snus (5.2% to 2.4%; p<0.0001) but no change in ever dissolvable tobacco use (0.8%-1.2%). In 2020, an estimated 1,546,000 U.S. youth ever used traditional smokeless tobacco (7.7% high school, 3.0% middle school), 662,000 ever used snus (high school: 3.5%, middle school: 1.0%), and 326,000 ever used dissolvables (high school: 1.5%, middle school: 0.8%). In 2020, females and non-Hispanic Blacks and Hispanics had lower smokeless or snus ever use odds than males and non-Hispanic Whites, respectively, whereas sexual minorities (than heterosexuals) or those speaking a language other than English at home were more likely to report ever use of dissolvable tobacco. Flavored tobacco use was common, particularly for dissolvable current users (72.8% used any flavor).
Conclusions. Differences in the epidemiology of oral tobacco use across product types among U.S. youth suggest that oral tobacco products should be disaggregated in future research and policy strategies.

Parms TA, Valverde R, Park-Lee E, Graham-Glover BS, Cunningham CS, Sawdey MD, Cullen KA.
Symptoms of Tobacco Dependence among Middle and High School Tobacco Users - Data from the 2019-2020 National Youth Tobacco Survey.
Addict Behav. 2023 Feb;137:107537. doi: 10.1016/j.addbeh.2022.107537. Epub 2022 Oct 29. PMID: 36332518; PMCID: PMC9712249.

Introduction. Previous studies have indicated that youth who use tobacco products, including cigarettes, cigars, and smokeless tobacco, demonstrate dependence symptoms. However, the tobacco marketplace has expanded dramatically in recent years, and few studies have examined dependence symptoms among youth who use novel products. This study combined 2019-2020 National Youth Tobacco Survey data to report the prevalence and determinants of tobacco dependence symptoms among U.S. middle and high school current (past 30-day) tobacco users.
Methods. Prevalence estimates were calculated to examine dependence outcomes and other covariates by user groups (single product users and multiple product users). Multivariable logistic regression analyses were used to identify independent predictors of tobacco dependence among current users of cigarettes, cigars (regular cigars, cigarillos, and little cigars), e-cigarettes, heated tobacco products, hookah, pipe tobacco, bidis, and smokeless tobacco products (chew, snuff, dip, snus, and dissolvables).
Results. Among current tobacco users, 15.7 % (95 % CI: 14.2-17.3) reported wanting to use tobacco within 30 min of waking and 28.3 % (95 % CI: 26.3-30.5) reported strong cravings for tobacco in the past 30 days. Nearly-two-thirds of current users were single product users, of which 80.5 % reported using e-cigarettes. Reporting of dependence symptoms was generally associated with multiple product use, higher frequency of use, earlier initiation age, and use of flavored products.
Conclusions. Among U.S. adolescents, a considerable amount of current tobacco product users, even infrequent users, reported symptoms of dependence. These findings highlight the continued importance of prevention strategies for youth tobacco experimentation and progression to regular use.

Tynan MA, Cohen MA, Harris JR.
What Happens in Vegas, Stays in your Lungs: An Assessment of Fine Particulate Matter in Casinos that Prohibit and Allow Smoking in Las Vegas, Nevada, USA.
Tobacco Control Published Online First: 23 February 2023. doi: 10.1136/tc-2022-057861
 
Introduction. Despite progress in adoption of smoke-free policies, smoking in casinos is allowed in some US states, including Nevada. In 2020, for the first time, a resort-style casino in Las Vegas prohibited smoking voluntarily. This study is the first to assess air quality in this casino and compare results with similar casinos that allow smoking.
Methods. A real-time personal aerosol monitor evaluated particulate matter with a diameter <2.5 µm (PM2.5), a surrogate for secondhand smoke (SHS). PM2.5 was measured at eight Las Vegas casinos, including the smoke-free casino. Each casino was visited twice, and PM2.5 was assessed in smoking-permitted gaming areas and areas where smoking is otherwise prohibited.
Results. Average PM2.5 levels were significantly higher in casinos that allow smoking, for both casino gaming areas and areas where smoking is otherwise prohibited (p<0.05). Mean PM2.5 in gaming areas was 164.9 µg/m³ in casinos that allow smoking and 30.5 µg/m³ in the smoke-free casino. Mean PM2.5 in areas where smoking is otherwise prohibited was 83.2 µg/m³ in casinos which allowed smoking in gaming areas, and 48.1 µg/m³ in the smoke-free casino.
Conclusion. Despite robust evidence about the harms of SHS, tens of thousands of casino employees and tens of millions of tourists are exposed to high levels of SHS in Las Vegas casinos annually, with PM2.5 levels 5.4 times higher in gaming areas when compared with a smoke-free casino. The only way to protect people from SHS exposure is to prohibit smoking in all indoor areas.