Butt Why? Exploring factors associated with cigarette scavenging behaviors among adult smokers enrolling in a clinical trial for smoking cessation

IntroductionCigarette smoking is associated with many adverse health effects and is an important public health concern. Increased understanding of smokers' behavior is central to developing effective interventions. Cigarette scavenging, a behavior that involves smoking shared or previously used cigarettes has thus far only been shown to be prevalent among homeless or incarcerated populations. The current study examines whether cigarette scavenging is prevalent in a more general population of adult smokers enrolling in a smoking cessation clinical trial, and whether engagement in this behavior is associated with demographic or smoking-related psychosocial factors.MethodsBaseline data was obtained from adult smokers (N = 227) enrolling in a randomized clinical trial for smoking cessation. Cigarette scavenging was assessed using three items: a) sharing a cigarette with a stranger; b) smoking a “found” cigarette and c) smoking a previously used cigarette “butt”. Participants who endorsed engaging in at least one of these three behaviors were categorized as a scavenger.ResultsApproximately 32% of participants endorsed at least one cigarette scavenging behavior. A multiple logistic regression analysis found that scavengers were more likely to be: men (p < 0.001), of younger age at smoking onset (p = 0.012), unemployed (p = 0.003), more likely to have used marijuana in the past 30 days (p = 0.005), single or living alone (p = 0.003), and to have experienced higher withdrawal symptoms during previous quit attempts (p = 0.044) as compared to non-scavengers.ConclusionsScavenging is common among adult smokers. Interventions that address cigarette scavenging behaviors may better meet the needs of this unique smoking subgroup.     

A pilot investigation of the effect of electronic cigarettes on smoking behavior among opioid-dependent smokers

IntroductionCompared to the general population, smoking rates are 2–4 times higher among individuals with opioid use disorders (OUDs). These smokers also have poor long-term cessation rates, even with pharmacotherapy or other interventions. Low success rates with traditional approaches may prompt smokers with OUDs to try more novel products like electronic cigarettes (ECIGs). This pilot study was designed to examine the feasibility, acceptability, and effect of ECIGs on smoking behavior among smokers with OUD.MethodsParticipants (N = 25) were daily smokers receiving buprenorphine/naloxone for OUD at an outpatient clinic. They were randomized to use a second-generation ECIG (0 or 18 ng/ml nicotine) ad libitum for two weeks while completing assessments via text messaging daily, and also via in-person visits at baseline, end of the two-week intervention, and a 4-week follow-up.ResultsFeasibility was evidenced by high enrollment (93.9%) and retention (70.9%) rates. ECIG adherence was relatively high as measured by self-report (80.6% active, 91.7% placebo), while the average volume of liquid used per week was low (~3 ml). Both ECIG doses produced reductions in self-reported cigarettes per day that were not supported by average carbon monoxide levels. Biologically-confirmed smoking abstinence was observed in 8% of participants.ConclusionsPreliminary results suggest that smokers with OUD are interested in using ECIGs, but their adherence may be less than ideal. Poor medication adherence rates are often observed in this disparate population, and future work should consider the use of other ECIG device types and a combination of methods to verify and quantify ECIG use.     

Other tobacco product and electronic cigarette use among homeless cigarette smokers

ObjectiveWe determined the prevalence and correlates of other tobacco product and electronic cigarette (e-cigarette) use in a clinic-based sample of homeless cigarette smokers.MethodsIn April–July 2014, we used time-location sampling to conduct a cross-sectional, in-person survey of 306 currently homeless adult cigarette smokers recruited from 5 clinical sites at Boston Health Care for the Homeless Program. We assessed past-month use of large cigars, little cigars, smokeless tobacco, and e-cigarettes. Among those who had used e-cigarettes, we assessed the reasons for doing so. We used logistic regression analysis to identify the participant characteristics associated with the use of each product.ResultsEighty-six percent of eligible individuals participated in the survey. In the past month, 37% of respondents used large cigars, 44% used little cigars, 8% used smokeless tobacco, 24% used an e-cigarette, and 68% used any of these products. Reasons for e-cigarette use included curiosity (85%) and to help quit conventional cigarettes (69%). In multivariable regression analyses, homeless smokers with greater subsistence difficulties were more likely to use little cigars (p = 0.01) and less likely to use e-cigarettes (p = 0.001). Non-Hispanic black (p = 0.01), Hispanic (p < 0.001), and rough-sleeping (p = 0.04) participants were more likely to use large cigars. Readiness to quit was not associated with other tobacco product use but was significantly associated with e-cigarette use to help quit smoking (p = 0.02).ConclusionsHealth care providers who serve homeless people should consider routine screening for the use of other tobacco products and e-cigarettes to help guide smoking cessation discussions and tobacco treatment planning.     

Effects of six weeks of electronic cigarette use on smoking rate,CO, cigarette dependence,and motivation to quit smoking: A pilot study

ObjectivesSwitching from combustible tobacco cigarettes to electronic cigarettes (e-cigs) may or may not help smokers to reduce cigarette consumption and toxicant exposure. This pilot study investigated the effects of asking smokers to switch to e-cigs for 6 weeks on smoking, exhaled carbon monoxide (CO) concentration, dependence, and motivation to quit smoking.MethodsNon-treatment seeking daily smokers (n = 18) were given free e-cigs and instructed to use them instead of smoking cigarettes for 6 weeks. Smokers were assessed at baseline, weekly for 6 weeks, and at 8 and 10 weeks for cigarettes/day, e-cig use, CO, cigarette dependence, and Contemplation Ladder.ResultsAll participants completed 6 weeks; 17 completed 10 weeks. At Week 6, cigarettes/day were reduced by two-thirds and CO by 45% from baseline (p's < .001), with reductions maintained at Week 10 (p's < .005). Cigarette dependence scores were a third lower at Weeks 6 (p < .002) and 10 (p < .001) than at baseline. Contemplation Ladder scores were higher at Weeks 6 and 10 (p's < .001) than at baseline. All these statistical effect sizes were large. At Week 6, number of reasons not to use e-cigs increased (p < .011).ConclusionsResults show preliminary evidence for beneficial effects of short-term switching to e-cigs by non-treatment seeking smokers in terms of reduced smoke toxicant exposure and cigarette dependence, and increased motivation to quit, all maintained at least 4 weeks after free e-cigs were no longer provided.     

The relationship of waterpipe use with cigarette smoking susceptibility and nicotine dependence: A cross-sectional study among Hong Kong adolescents

IntroductionWaterpipe smoking has become increasingly popular in adolescents. We examined the association of waterpipe smoking with cigarette smoking susceptibility and nicotine dependence among adolescents in Hong Kong.MethodsWe analyzed the data of School-based Survey on Smoking among Students 2012/13 from a representative sample of 45,857 secondary school students (US grades 7–12) in Hong Kong. Among never cigarette smokers (n = 37,740), we conducted chi-square test to compare cigarette smoking susceptibility by current (past 30-day) waterpipe smoking status, and used multivariate logistic regression to examine the association between current waterpipe smoking and cigarette smoking susceptibility controlling for age, sex, peer cigarette smoking, and living with a cigarette smoker. Then we conducted chi-square test and multivariate logistic regression among current cigarette smokers (n = 1694) to examine the relationship of current waterpipe smoking with two nicotine dependence outcomes, including heavier smoking (≥ 5 cigarettes/day) and first cigarette within 30 min of waking, controlling for demographics and the number of smoking days in the past 30 days.ResultsAmong never cigarette smokers, current waterpipe use was associated with cigarette smoking susceptibility (adjusted odds ratio [AOR] = 3.58, 95% confidence interval [CI]: 1.61–7.97). Of current cigarette smokers, waterpipe use was associated with heavier smoking (AOR = 1.56, 95% CI: 1.00–2.43) and first cigarette within 30 min of waking (AOR = 2.08, 95% CI: 1.35–3.19).ConclusionsSurveillance, prevention, and intervention programs should address waterpipe use in addition to cigarette smoking. Educational programs need to inform youth about the harmful and addictive effects of waterpipe smoking. Public health campaigns deglamourizing waterpipe use may help reduce waterpipe smoking among youth.     

Possible mechanism by which zinc protects the testicular function of rats exposed to cigarette smoke

BackgroundThe aim of this study was to evaluate the changes in testicular function of rats due to cigarette smoke exposure and the possible mechanism by which zinc protects against these alterations.MethodsMale Wistar rats (60 days old) were randomly divided into 3 groups: control (G1, n = 10); exposed to cigarette smoke (G2, n = 10; 20 cigarettes/day/9 weeks) and exposed to cigarette smoke and supplemented with zinc (G3, n = 8; 20 cigarettes/day/9 weeks; 20 mg/kg zinc chloride daily for 9 weeks, by gavage). After the treatment period, the animals were euthanized, and materials were collected for analyses.ResultsG2 rats showed a reduction in body mass; impaired sperm concentration, motility, morphology and vitality; and increased malonaldehyde and thiol group levels and superoxide dismutase activity as compared to G1. Zinc prevented the reduction of sperm concentration and the excessive increase of lipid peroxidation and induced an increase in plasma testosterone levels, wet weight of testis and thiol group concentration.ConclusionsExposure to cigarette smoke led to harmful effects on testicular function at least partially due to the exacerbation of oxidative stress. Supplementary zinc had an important modulator/protector effect on certain parameters. The mechanism of zinc protection can be through an increase of SH concentration. Thus, zinc supplementation may be a promising addition to conventional treatments for male infertility related to smoking.     

Electronic cigarette awareness and use among adults in Hong Kong

IntroductionElectronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong.MethodsCross-sectional data were collected in 2014 from Chinese adults aged 15–65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status.Results75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p = .03), younger adults (aged 15–29, 5.2%, p = .002), and current cigarette smokers (11.8%, p < .001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%).ConclusionsAwareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation.     

Emergence of electronic cigarette use in US adolescents and the link to traditional cigarette use

BackgroundElectronic cigarettes (e-cigarettes) are increasingly used by US adolescents and may be a gateway to traditional cigarette use. We examine rates of both products by age and examine differences in age-varying rates by sex and race/ethnicity.MethodsData are from the 2014 National Youth Tobacco Survey, a national sample of US middle and high school students (n = 22.007); students ages 11–19 were included. Past 30-day e-cigarette and traditional cigarette use were examined as a function of age; sex and race/ethnicity were included as moderators. The age-varying association between e-cigarette and traditional cigarette use was also examined.ResultsRates of e-cigarette use increase faster than traditional cigarette use from ages 13–16. Compared to females, males had higher rates of e-cigarette use from ages 14–17.5 and traditional cigarette use from ages 15–18. Between ages 12–14, more Hispanic adolescents used e-cigarettes compared to White or Black adolescents; after age 14 Hispanics and Whites reported similar rates, peaking at twice the rate for Blacks. Hispanic adolescents report greater traditional cigarette use versus Whites between ages 12–13, but lower rates between ages 15–18. E-cigarette use was strongly associated with traditional cigarette use, particularly during early adolescence [OR > 40 before age 12].ConclusionsYoung Hispanic adolescents are at elevated risk for use of e-cigarettes and traditional cigarettes during early adolescence. During early adolescence, youth using e-cigarettes are more likely to smoke traditional cigarettes compared to youth not using e-cigarettes. The study of age-varying effects holds promise for advancing understanding of disparities in health risk behaviors.     

Transitioning from adequate to inadequate sleep duration associated with higher smoking rate and greater nicotine dependence in a population sample

IntroductionInadequate sleep (≤ 6 and ≥ 9 h) is more prevalent in smokers than non-smokers but the extent to which sleep duration in smokers relates to smoking behaviors and cessation outcomes, is not yet clear. To begin to address this knowledge gap, we investigated the extent to which sleep duration predicted smoking behaviors and quitting intention in a population sample.MethodsData from current smokers who completed the baseline (N = 635) and 5-year follow-up (N = 477) assessment in the United Kingdom Biobank cohort study were analyzed. Multivariable regression models using smoking behavior outcomes (cigarettes per day, time to first cigarette, difficulty not smoking for a day, quitting intention) and sleep duration (adequate (7–8 h) versus inadequate (≤ 6 and ≥ 9 h) as the predictor were generated. All models adjusted for age, sex, race, and education.ResultsWorsening sleep duration (adequate to inadequate) predicted a more than three-fold higher odds in increased cigarettes per day (OR = 3.18; 95% CI = 1.25–8.06), a more than three-fold increased odds of not smoking for the day remaining difficult (OR = 3.90; 95% CI = 1.27–12.01), and a > 8-fold increased odds of higher nicotine dependence (OR = 8.98; 95% CI = 2.81–28.66). Improving sleep duration (i.e., inadequate to adequate sleep) did not predict reduced cigarette consumption or nicotine dependence in this population sample.ConclusionTransitioning from adequate to inadequate sleep duration may be a risk factor for developing a more “hard-core” smoking profile. The extent to which achieving healthy sleep may promote, or optimize smoking cessation treatment response, warrants investigation.     

Exclusive e-cigarette use predicts cigarette initiation among college students

IntroductionAn increasing body of research indicates that use of electronic nicotine delivery systems (ENDS) predicts cigarette initiation. However, no studies examine if risk for cigarette initiation varies for exclusive ENDS users versus users of ENDS and other tobacco products. This study examined if: a) cigarette-naïve young adults (i.e., never cigarette users) who ever used ENDS had a greater odds of initiating cigarettes than non-ENDS users over a 1.5 year period and b) the odds of cigarette initiation was consistent across exclusive ENDS users and users of ENDS and at least one tobacco product.MethodsParticipants were 2558 cigarette-naïve 18–25 year old (M = 19.71; SD = 1.61) students from 24 Texas colleges who participated in a four-wave study, with six months between each wave.ResultsOverall, 11% of students reported cigarette initiation by wave 4. Of those, 20.1% were wave 1 ENDS users and 8.4% were non-ENDS users. Multivariable, multilevel discrete-time hazard models indicated that wave 1 ENDS use predicted subsequent cigarette initiation, over and above the significant effects of cigarette use susceptibility, family-of-origin tobacco use, friend cigarette use, and other tobacco use. Additional findings indicated that exclusive ENDS users had a greater odds than non-users of subsequent cigarette initiation. Among users of alternative tobacco products, ENDS users did not have a greater odds of initiation than non-ENDS users.ConclusionFindings extend existing research by showing that ENDS use by young adults is a specific risk factor for later cigarette initiation and not an extension of a constellation of existing tobacco use behaviors.     

Impact of self-initiated pre-quit smoking reduction on cessation rates: results of a clinical trial of smoking cessation among female prisoners

ObjectivesThis study examined differences in cessation success based on smokers' self-initiated pre-quit reductions in cigarettes per day (cpd).MethodsThe study utilized data from a nicotine replacement + behavioral therapy smoking cessation intervention conducted in a female prison facility with 179 participants who were wait-listed for 6 months prior to intervention. We compared two groups of smokers based on whether they self-selected to reduce smoking prior to their cessation attempt (n = 77) or whether they increased smoking or did not reduce (n = 102). General Estimating Equations (GEE) were used to model smoking cessation through 12-month follow-up.ResultsExamination of pre-cessation cpd showed that those who reduced were heavier smokers at baseline, relative to those who did not reduce (p < 0.001). By the week prior to the quit attempt (week 3) heavier smokers at baseline smoked significantly fewer cigarettes (p < 0.001) and had lower CO levels (p < 0.05) compared to baseline lighter smokers. GEE analyses showed that individuals who reduced prior to their quit attempt had significantly higher quit rates during early treatment but these gains were not sustained by follow-up points.ConclusionsParticipant-initiated pre-cessation smoking reduction may be initially helpful in preparing to quit smoking, or may serve as a marker for participant motivation to quit smoking, but these differences do not sustain over time. More intensive interventions are still needed for successful cessation.     

Maternal trajectories of cigarette use as a function of maternal age and race

BackgroundPatterns of smoking vary as a function of age and race. The goals of this study were to identify trajectories of maternal cigarette use over a 17-year span, and to determine if maternal age at first birth and race were associated with smoking trajectories.MethodsPregnant women (N = 690) were recruited at an urban prenatal clinic. The women (13–42 years old; 62% African-American, 38% White) were interviewed about cigarette use during pregnancy and 6, 10, 14, and 16 years postpartum. Growth mixture modeling (GMM) was used to identify trajectories. Regressions were used to determine if maternal age at first birth and race predicted trajectory class membership.ResultsA GMM of maternal cigarette use delineated 5 groups: none/unlikely to use (33%), decreasing likelihood of use (6%), late desistance (5%), increasing likelihood of use (17%), and chronic use (39%). Women who became mothers at a younger age were more likely to be classified as late desisters or increasingly likely to smoke. White mothers were more likely to be chronic smokers. Different smoking trajectories and predictors of trajectories were identified for the African-American and White mothers. Covariates including prenatal substance use, hostility, education, and economic hardship also differentiated smoking trajectories.ConclusionsBoth prevention and treatment of smoking should be targeted to specific groups by age of first pregnancy and race. Pregnant smokers should be provided with more information and resources to help them avoid cigarettes during pregnancy and maintain abstinence after pregnancy.     

Tobacco use and nicotine dependence among HIV-infected and uninfected injection drug users

IntroductionUrban U.S. populations are burdened by intersecting epidemics of HIV infection, injection drug use, and cigarette smoking. Given the substantial morbidity attributable to tobacco in these populations, we characterized smoking behaviors, nicotine addiction, and tobacco exposure among HIV-infected and HIV-uninfected injection drug users (IDUs) in Baltimore, Maryland.MethodsSmoking behaviors among participants in the ALIVE Study were assessed using interviewer-administered questionnaires. Smoking history and nicotine dependence (Fagerstrom Index scores) were compared by HIV and drug injecting status. Serum cotinine (a nicotine metabolite) was measured for a sample of participants by enzyme immunoassay.ResultsAmong 1052 participants (29.7% HIV-infected, 39.8% active injectors), 85.2% were current smokers and 9.3% were former smokers. Smoking prevalence, age at smoking initiation, and cumulative tobacco exposure were similar by HIV status. Median Fagerstrom scores of 4 for HIV-infected and HIV-uninfected smokers indicated moderate nicotine dependence. Daily cigarette consumption was identical by HIV status (median 10 cigarettes), although HIV-infected participants were less likely to smoke 1+ pack daily compared to HIV-uninfected participants (18.0% vs. 26.9%, p = 0.001). Compared to former injectors, active injectors had higher smoking prevalence (90.5% vs. 81.7%, p = 0.0001), greater daily cigarette consumption (30.7% vs. 19.6% smoked 1+ pack daily, p = 0.0001), and slightly higher Fagerstrom scores (median 5 vs. 4). Cotinine levels paralleled self-reported cigarette consumption.DiscussionTobacco use is extremely common among inner-city IDUs. Smoking behavior and nicotine dependence did not materially differ by HIV status but were associated with active drug injection. Cessation efforts should target the dual dependence of cigarettes and drugs experienced among this population.     

Enhanced motivational interviewing versus brief advice for adolescent smoking cessation: results from a randomized clinical trial

BackgroundMotivational interviewing (MI) is widely used for adolescent smoking cessation but empirical support for this approach is mixed.MethodsAdolescent cigarette smokers 14–18 years old (N = 162) were recruited from medical, school, and community settings and randomly assigned to enhanced MI or brief advice (BA) for smoking cessation. MI comprised an in-person individual session, a telephone booster session one week later, and a brief telephone-based parent intervention. BA consisted of standardized brief advice to quit smoking. Assessments occurred at baseline, post-treatment and at 1-, 3-, and 6-month follow ups.ResultsBiochemically-confirmed 7-day point prevalence abstinence rates were low (e.g., 4.5% for MI; 1.4% for BA at 1 month) and did not differ significantly by group at any follow up. Only those in MI reported significant decreases in cigarettes smoked per day (CPD) from baseline to 1 month. At 3 and 6 months, smokers in both groups reported significantly reduced CPD with no differences between groups. MI reduced perceived norms regarding peer and adult smoking rates, while BA had no effect on normative perceptions. No group differences emerged for self-reported motivation or self-efficacy to quit smoking.ConclusionsFindings support the efficacy of MI for addressing normative misperceptions regarding peer and adult smoking and for modestly reducing CPD in the short-term; however, these effects did not translate to greater smoking abstinence. MI may have more promise as a prelude to more intensive smoking intervention with adolescents than as a stand-alone intervention.     

Patterns of intermittent smoking: An analysis using Ecological Momentary Assessment

Non-daily smokers comprise a substantial proportion of US smokers, but there has been little study of their patterns of smoking, which are often assumed to reflect “social smoking.” We used Ecological Momentary Assessment methods to study smoking patterns in 27 non-daily smoking adults who recorded each cigarette smoked over three weeks by leaving a voice mail message indicating their circumstances at the time of smoking. All told, 689 cigarettes were recorded over 589 person-days of observation. On average, participants smoked on 67% of days, averaging 2.1 (SD = 0.91) cigarettes per day on days they smoked; 22% of all cigarettes were smoked in bouts (within an hour of another cigarette). Altogether, 19% of cigarettes were smoked when drinking alcohol and 29% when participants were socializing. Smoking patterns varied widely across participants. A pair of hierarchical cluster analyses distinguished three groups: Those who smoked primarily (81% of cigarettes) in the daytime (Early smokers; n = 15, 58% of total sample), those who smoked primarily (75% of cigarettes) at night (Late smokers; n = 7, 27%), and a distinct, classic “Social smoking” group (n = 4, 15% of total sample), who smoked mostly at night but also primarily when socializing or drinking (86% of their cigarettes), in the evening (71% of their cigarettes), on weekends (65% of their cigarettes), and in bouts (71% of their cigarettes). Overall, results suggest that non-daily smoking patterns are quite heterogeneous, and that many non-daily smokers may not be primarily social smokers.     

Predictors of tobacco abstinence in outpatient smokers with schizophrenia or bipolar disorder treated with varenicline and cognitive behavioral smoking cessation therapy

BackgroundThe estimated mortality gap between those with and without serious mental illness (SMI) is increasing, now estimated at 28 years, which is largely due to smoking-related diseases.AimsWe sought to identify predictors of 14-day continuous abstinence in stable outpatient smokers with SMI.MethodAdult smokers with schizophrenia spectrum (n = 130) or bipolar disorder (n = 23) were enrolled in a 12-week course of varenicline and cognitive-behavioral therapy for smoking cessation.ResultsIndependent predictors of abstinence included reduction in withdrawal symptoms prior to the quit day, fewer cigarettes smoked per day at baseline, better baseline attention, remitted alcohol dependence, and lower expectation of peer support to aid quitting.ConclusionsInterventions that consider these targets may improve smoking cessation outcomes in those with SMI.     

Is smokeless tobacco use becoming more common among U.S. male smokers? Trends in Alaska

IntroductionThe tobacco industry has promoted the use of smokeless tobacco (SLT) to smokers as a substitution for cigarettes when smoking is not possible, and some smokers are using SLT this way. However, few publications have examined recent trends in dual cigarette and SLT use (dual use) over time in the U.S.Materials and methodsWe examined trends in the use of SLT among current, former and never cigarette smokers using data on adult (aged 18+ years) males (n = 16,590) from the 1996–2008 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We also examined trends from 2004 to 2008 in cigarette consumption among dual users.ResultsBetween 1996 and 2008, the overall prevalence of current SLT use and prevalence of current smoking among Alaskan men did not significantly change over time (p-value from age-adjusted models p = .63, p = .09, respectively). When we examined trends in SLT use by smoking status, we found that the prevalence of current SLT use remained unchanged between 1996 and 2008 among former and never smokers, but almost doubled among current smokers (age-adjusted p = .004). Between 2004 and 2008, cigarette consumption remained steady among current smokers who did not use SLT, but significantly decreased among dual users (age-adjusted p < .001).ConclusionsOur findings suggest that male smokers in Alaska are increasingly likely to use SLT, but do not appear to be switching to SLT use exclusively. We recommend that other state tobacco control programs examine trends in dual use to confirm our findings, and for programs to continue encouraging cessation of all tobacco products.