Factors Influencing Adoption of and Adherence to Indoor Smoking Bans Among Health Disparity Communities

Objectives. We assessed current home smoking behaviors and secondhand smoke (SHS) levels among parents of children in low-income, racial/ethnic minority communities in Massachusetts.Methods. We used a cross-sectional design to assess home smoking rules, smoking status, cigarettes smoked in the home, and barriers and benefits to attaining a smoke-free home among 138 caregivers (mean age = 30.0 years; 92% women) of children aged 0 to 6 years, between April 2010 and September 2012. Indoor SHS was assessed using a nicotine dosimeter.Results. Households with no ban reported a higher weekly mean number of cigarettes smoked in the home (114 cigarettes/week) than homes with partial (71 cigarettes/week) or complete (30 cigarettes/week) bans (P < .01). Smoking occurred outside more than inside homes with partial or complete bans. Air nicotine levels were positively associated with no household smoking ban, current smoking by the caregiver, and smoking indoors.Conclusions. Strategies to reduce home SHS should focus on a “complete” home smoking ban and smoking cessation. SHS mitigation strategies such as smoking outside were associated with lower SHS among participants unable to maintain a complete ban, and might enhance the likelihood of longer term success while immediately reducing home SHS.Secondhand smoke (SHS) exposure is associated with serious pediatric illnesses, yet is entirely preventable.1 Children’s exposure to SHS occurs chiefly in domestic environments, including the home and car.2,3 SHS exposure varies by income, race, and parental education,4 and the likelihood of exposure to SHS tends to be higher among African American and low socioeconomic status (SES) groups.5 Children from low-income backgrounds are at greater risk for SHS exposure and share a disproportionate burden of disease.6–8 Young children (aged 6 years and younger) from lower SES communities are 3 times more likely to be exposed to the highest levels of SHS in the home (≥ 4 days/week) as children from middle- and high-income groups.9 Recent data indicate that the percentage of households with a voluntary smoke-free rule has risen nationwide.3,10 In 1995, approximately 58% of homes in the United States were reportedly smoke-free, whereas more recent data suggest that this percentage now approaches 84%.11 This figure may be higher in homes in which children are present.10 Despite the increase in smoke-free homes, children’s cotinine levels (an index of SHS exposure) have remained steady since 2000.12 This may be explained, in part, by incomplete or diminishing adherence to self-imposed home smoking bans. However, little research has been conducted to understand the factors associated with implementation and adherence to home smoking bans, including facilitators and barriers to the maintenance of a smoke-free home.Although efficacious interventions to help families establish smoke-free home rules have been widely reported,13 strategies to tailor those interventions to the needs of low-income and minority race/ethnicity communities have so far been limited.14,15 Complete home smoking bans are associated with lower SHS16,17; however, a better understanding is needed of current home smoking behaviors and attitudes among parents of young children in low-income minority communities. Such questions might appropriately be posed in Massachusetts—a state in which the prevalence of children’s exposure to SHS in the home ranks well below the median of US states,4 yet where public health efforts have so far failed to provide protection from SHS exposure for 4.3% (an estimated 61 000) of Massachusetts children.4,18 Nevertheless, it is possible that microlevel changes directed at mitigating SHS exposure have occurred within homes that have not become completely smoke-free. Limiting the number of cigarettes smoked inside a home may directly reduce SHS,17 which, in turn, may influence children’s exposure to SHS.8 Behavioral strategies intended to mitigate SHS exposure, such as smoking outdoors, may be an underinvestigated (albeit suboptimal)19 strategy used in households where a ban has either not been implemented or successfully maintained.To more fully understand home smoking practices among communities of low income and racial and ethnic diversity, we sought to identify who adopted and who adhered to a voluntary home smoking ban, the barriers and perceived benefits to adherence, and the impact of those bans on home smoking behaviors (including mitigation strategies), using a cross-sectional study design. In addition, the number of smokers in the household, their age, race and ethnicity, the number and location (within the home or attached external structure) of cigarettes smoked, and strategies employed to reduce SHS exposure were documented. Finally, indoor air quality was measured by nicotine levels to characterize factors associated with home SHS levels.     

Transitions in Smoking Behavior During Emerging Adulthood: A Longitudinal Analysis of the Effect of Home Smoking Bans

Objectives. We studied the effect of home smoking bans on transitions in smoking behavior during emerging adulthood.Methods. We used latent transition analysis to examine movement between stages of smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) and the effect of a home smoking ban on these transitions. We used data from the Minnesota Adolescent Community Cohort study collected in 2004 to 2006.Results. Overall, we identified 4 stages of smoking: (1) never smokers, (2) experimental smokers, (3) light smokers, and (4) daily smokers. Transition probabilities varied by stage. Young adults with a home ban during late adolescence were less likely to be smokers and less likely to progress to higher use later. Furthermore, the protective effect of a home smoking ban on the prevalence of smoking behavior was evident even in the presence of parental smoking. However, this effect was less clear on transitions over time.Conclusions. In addition to protecting family members from exposure to secondhand smoke, home smoking bans appear to have the additional benefit of reducing initiation and escalation of smoking behavior among young adults.Cigarette smoking, particularly among young people, continues to be a major public health concern. Although initiation rates have declined for adolescents, initiation rates among young adults have risen.1 Also, of all age groups, young adults have the highest prevalence of current cigarette smoking.2 Therefore, developing effective interventions for this population is a public health priority.Young or emerging adulthood is typically defined as 18 to 25 years of age and is marked by important transitions such as increased autonomy in decision-making and fewer social constraints than during adolescence.3 It also represents a time for increased vulnerability for both the initiation of smoking and nicotine addiction.4 This period of emerging adulthood may be an important, yet often overlooked, age for formation of long-term health behaviors such as smoking.Relatively little research has examined transitions and trajectories of smoking behaviors among young adults.5 Most researchers have used person-centered techniques such as growth curve and growth mixture modeling to explicitly model the heterogeneity in developmental processes and, in the process, have identified several distinct patterns of smoking trajectories from adolescence to young adulthood.6–9 These approaches assume progression to be continuous instead of incremental (i.e., stage sequential); therefore, smoking must be modeled as a continuous function of time. Growth curves and growth mixture modeling are not as appropriate in situations characterized by a high degree of movement into and out of stages over time, which may be especially relevant to the onset and progression of smoking during emerging adulthood.10 An alternative approach is to take a person-centered approach such as Markov models10,11 and latent transition analysis2 to examine person-specific patterns of developmental stages. This approach has been applied to the study of smoking behavior2,11 but not extensively to the study of smoking behaviors in emerging adulthood.Multiple social, psychological, and environmental factors have been found to influence smoking progression and have been extensively studied as antecedents or correlates of trajectories of smoking.6,8 Among these, home smoking bans have emerged as an important yet understudied protective factor. Although the primary goal of a home ban is to protect children and adult nonsmokers from secondhand smoke,12 recent evidence suggests that home smoking restrictions promote antismoking attitudes and reduce initiation and progression of smoking behavior among adolescents by changing norms about the prevalence and social acceptability of smoking.13–15 Additionally, adult smokers with a home ban are more likely to quit and remain nonsmokers.16 As noted by Albers et al.,17 youths with a smoking ban in their parental homes are more likely to prefer smoke-free housing as independently living young adults. In essence, establishing a home ban has a long-term and even intergenerational effect on promoting nonsmoking attitudes and norms among young adults.17 Individuals with home bans also are more likely to support clean indoor air laws, crucial to tobacco prevention efforts.18A recent literature review on the association between home bans and youth smoking reported reduced smoking among adolescents with a home ban.19 As noted by Emory et al.,19 a few studies also investigated the moderating effect of parental smoking, and most studies found either an association or a stronger association between home smoking restrictions and reduced smoking in homes without parental smoking or an adult smoker. However, 2 studies found that home bans significantly lowered smoking rates, regardless of parental smoking, underscoring the salience of a home ban.14,20 All but 2 of the studies in this review were cross-sectional, and more important, none of the studies examined the effect of a home ban on stage-sequential transitions or the effect on smoking behaviors in emerging adulthood. Therefore, despite previous important findings, relatively little is known about the prospective effect of home smoking restrictions on smoking behavior during emerging adulthood, especially in the presence of parental smoking.19The main goals of this study were to (1) identify distinct stages of smoking behavior and examine within-individual transitions in smoking from late adolescence (ages 16–18 years) to young adulthood (ages 18–20 years) in a population-based cohort sample and (2) evaluate whether a home smoking ban during late adolescence influences the prevalence of smoking and transitions into and out of smoking stages in young adulthood and whether the effect of a home ban differs by parental smoking status.     

Household smoking bans and adolescent antismoking attitudes and smoking initiation: findings from a longitudinal study of a Massachusetts youth cohort

Objectives. We sought to determine whether adolescents living in households in which smoking was banned were more likely to develop antismoking attitudes and less likely to progress to smoking compared with those living in households in which smoking was not banned.Methods. We completed a longitudinal 4-year, 3-wave study of a representative sample of 3834 Massachusetts youths aged 12 to 17 years at baseline; 2791 (72.8%) were reinterviewed after 2 years, and 2217 (57.8%) were reinterviewed after 4 years. We used a 3-level hierarchical linear model to analyze the effect of a household ban on antismoking attitudes and smoking behaviors.Results. The absence of a household smoking ban increased the odds that youths perceived a high prevalence of adult smoking, among both youths living with a smoker (odds ratio [OR] = 1.56; 95% confidence interval [CI] = 1.15, 2.13) and those living with nonsmokers (OR = 1.75; 95% CI = 1.29, 2.37). Among youths who lived with nonsmokers, those with no home ban were more likely to transition from nonsmoking to early experimentation (OR = 1.89; 95% CI = 1.30, 2.74) than were those with a ban.Conclusions. Home smoking bans may promote antismoking attitudes among youths and reduce progression to smoking experimentation among youths who live with nonsmokers.The proliferation of US smoke-free workplace policies and laws over the past decade has been accompanied by increased attention to private household smoking restrictions. The number of US households with comprehensive rules that make homes smoke free in all areas at all times has increased substantially.¹ The proportion of US households with smoke-free home rules increased from 43% in 1992 to 1993 to 72% in 2003.² Even smokers appear to be increasingly adopting such rules, particularly in homes in which they live with a nonsmoking adult.Although smoke-free home bans are typically implemented to reduce or eliminate environmental tobacco smoke exposure in the household, these bans may have the additional benefit of reducing the initiation of smoking among youths by changing norms about the prevalence and social acceptability of smoking. Very little is known about the specific effect of a household smoking ban on youth smoking behavior or on smoking-related attitudes and norms that may mediate an effect on smoking behavior. In particular, few studies have addressed the independent effect of bans on youths who live with smokers—those who are at the greatest risk for becoming smokers themselves.Recent studies showed that strong smoking regulations in local restaurants and bars were associated with more negative attitudes among youths toward the social acceptability of smoking in restaurants and bars.^3–6 Establishing household smoking bans conveys to youths living within these smoke-free home environments the message that smoking is unacceptable. Some supportive evidence, derived from cross-sectional data, indicates that a household smoking ban is associated with antismoking attitudes and norms. A recent cross-sectional study found that a household ban was associated with a lower perceived prevalence of adult smoking and more-negative attitudes about the social acceptability of smoking, 2 factors that affect the likelihood of smoking initiation.⁷Several cross-sectional studies have reported that a smoking ban in the household was associated with a lower likelihood of being in an earlier stage of smoking and a lower current smoking prevalence among adolescents.^8–11 Conversely, other studies found no statistically significant association between a household smoking ban and reduced adolescent smoking.^12–14 Several factors may account for these conflicting results, including varying sample sizes, age groups, and smoking measures used in these cross-sectional studies.A critical question is whether antismoking socialization occurs when parents themselves smoke. One study found that a household smoking ban was related to lower levels of smoking onset for children with nonsmoking parents but not for children with 1 or more parent who smoked.¹⁵ Another study reported that a household smoking ban was not associated with trying smoking among high school students who had 1 or more parents who were current or former smokers.¹⁶ Only 1 study reported an association between a household smoking ban and a reduced likelihood of smoking among 12th graders whose parents were smokers but not among those whose parents were nonsmokers.¹⁷ In summary, more evidence supports an association between home smoking bans and lower levels of smoking behaviors among youths who live with nonsmokers.Current research on household smoking bans has significant limitations. First, these studies rely on cross-sectional data that limit the ability to indicate causality in the relation between home smoking bans and trajectories of attitudes and smoking. Second, most studies have focused on individual-level predictors of attitudes and smoking behaviors, despite evidence that part of the explanation lies within the community context.¹⁸ Third, few studies have investigated the unique effects of a household smoking ban among adolescents living in home environments with parental smokers compared with those living with nonsmokers.In this study, our goal was to improve existing research by (1) using longitudinal data that followed up a cohort of youths and young adults who lived in parental homes over a 4-year period, with a total of 3 repeated observations for each participant; (2) using a multilevel model that simultaneously examined the effects of individual-level and town-level factors; and (3) investigating separately the effects of a household ban on youths who live with at least 1 smoker and youths who live with nonsmokers.     

A Minimal Intervention to Promote Smoke-Free Homes Among 2-1-1 Callers: A Randomized Controlled Trial

Objectives. We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services.Methods. We conducted a randomized controlled trial (n = 498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call.Results. Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of $10 000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P = .002). The intervention worked for smokers and nonsmokers, as well as those with or without children.Conclusions. Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.Despite declines in exposure to secondhand smoke (SHS) over the last 2 decades, children and nonsmoking adults who live with a person who smokes still experience significant exposure to SHS.1–3 SHS exposure causes lung cancer, coronary heart disease, and stroke in nonsmoking adults, aexacerbates asthma, and causes impaired lung function, middle ear disease, respiratory illness, and sudden infant death syndrome in children.3–5Exposure differs markedly between those who live with someone who smokes in the home and those who do not. In 2007 and 2008, 93.4% of nonsmoking adults who lived with someone who smoked inside the home had elevated serum cotinine levels compared with 33.4% of those who did not live with someone who smoked inside the home.6 This pattern was similar, but more striking, for children and youths.6 Certain subgroups of the US population are less likely to have household smoking restrictions and are disproportionately affected by SHS exposure in the home. For instance, African American nonsmokers have an increased prevalence of detectable serum cotinine compared with other major racial/ethnic groups and are less likely to report home smoking bans.6–8 Low income families and those with less education are less likely to have full smoking bans.6,8–11 Other predictors of household smoking bans include the presence of children, the presence of a nonsmoking adult in the home, and fewer friends and family members who smoke.9,10,12–17Home smoking bans can lead to lower levels of SHS exposure, less smoking, and increased attempts to quit.7,13,18–22 The prevalence of smoke-free homes has increased as states and communities have legislated smoke-free public places.23,24 Intervention studies have typically examined the effects of counseling parents of children with asthma, infants, or medically compromised children on exposure levels.25–29 Effective interventions involve multiple counseling sessions and often combine smoking cessation and smoke-free home messages.30–32 Much of the existing intervention research has taken place or recruited participants through clinical settings.30–33 Minimal interventions to create smoke-free homes in community-based settings have not been adequately studied.31,33,34Minimal interventions have the potential for greater reach than more intensive interventions, and thus, have the potential for a greater impact at the population level.35–38 Similarly, interventions that target general populations, including households with no young children, can help to achieve population-level reductions in SHS exposure. We tested the efficacy of a minimal intervention with callers to the United Way of Greater Atlanta, Georgia, 2-1-1 number. The 2-1-1 information and referral system consists of more than 200 nonprofit state and local call centers operating in all 50 states and connects more than 16 million callers per year to local health and social services.39 Callers to 2-1-1 are disproportionately low-income, unemployed, uninsured, and have fewer years of education relative to the general population.40 2-1-1 callers have a higher rate of smoking and lower likelihood of a home smoking ban than the general population.41,42 Because 2-1-1 provides extensive reach to vulnerable populations, they are strategic partners for testing, delivering, and ultimately sustaining interventions to reduce risk and improve the lives of low-income persons in the United States.40We tested the efficacy of a minimal intervention to create smoke-free homes among 2-1-1 callers. Our study builds on formative research on family dynamics related to establishing household smoking bans,43,44 a pilot study to test a brief intervention,45 and a cross-site survey of 2-1-1 callers that showed a relatively low prevalence of smoke-free homes.41 This randomized controlled trial is the first in a series of studies that will move from testing efficacy to effectiveness to dissemination of the intervention through 2-1-1 centers nationally.     

The Impact of Quitting Smoking on Weight Among Women Prisoners Participating in a Smoking Cessation Intervention

Objectives. We examined the impact of smoking cessation on weight change in a population of women prisoners.Methods. Women prisoners (n = 360) enrolled in a smoking cessation intervention; 250 received a 10-week group intervention plus transdermal nicotine replacement.Results. Women who quit smoking had significant weight gain at 3- and 6-month follow-ups, with a net difference of 10 pounds between smokers and abstainers at 6 months. By the 12-month follow-up, weight gain decreased among abstainers.Conclusions. We are the first, to our knowledge, to demonstrate weight gain associated with smoking cessation among women prisoners. Smoking cessation interventions that address postcessation weight gain as a preventative measure may be beneficial in improving health and reducing the high prevalence of smoking in prisoner populations.Smoking and obesity are the 2 major causes of mortality and morbidity in the United States.^1,2 Although smoking is the leading preventable cause of death, resulting in approximately 440 000 deaths each year,³ obesity is a growing epidemic and is the second leading cause of preventable death, resulting in more than 300 000 deaths annually.^4,5 Whereas smoking rates have declined from their peak in the 1960s, obesity rates have been steadily climbing each year, and obesity is expected to soon eclipse smoking as the most preventable cause of mortality in the United States.¹The relationship between smoking and weight is complex, and the mechanisms by which smoking influences weight are not fully understood. Smoking affects weight by increasing metabolic rate and decreasing caloric absorption, which is thought to help suppress appetite.⁶ Sympathoadrenal activation by nicotine is thought to be primarily responsible for the metabolic effect of smoking.⁷ Smoking is also associated with increased energy expenditure.⁸ Smoking a single cigarette also decreases caloric consumption by 3% within 20 minutes.⁹Compared with light smokers and nonsmokers, heavy smokers tend to have greater body weight, which likely reflects a clustering of risk behaviors (i.e., little physical activity and poor diet) and increased insulin resistance and accumulation of abdominal fat.^6,10,11 Overall, smokers tend to be less physically active than nonsmokers, which may confound explanations of weight differences between smokers and nonsmokers.¹²Most studies on weight and smoking have reported postcessation weight gain. Smoking cessation has been associated with approximately 10 pounds of weight gain after 1 year of abstinence,¹³ suggesting that health benefits from smoking cessation may be mitigated to some degree by increased health risks associated with weight gain.¹⁴ To prevent or reduce weight gain, those administering cessation programs are recommended to integrate follow-up support for weight control, provide regular body weight measurement, provide recommendations for dietary change, and encourage increased physical activity.¹⁴ Despite concerns about weight, few studies have systematically investigated weight gain following smoking cessation, particularly with underserved populations such as prisoners.Correctional populations especially are vulnerable to the negative health consequences of smoking. Smoking rates are 3 to 4 times higher among correctional populations than among the general population, and smoking is normative within the correctional environment.^15–17 Smoking prevalence is 70% to 80% among male and female prisoners,^15–20 while almost half (46%) of adolescents in juvenile justice are daily smokers.²¹ This compared to about 21% of adults in the general population who are current smokers.²² However, in the research literature, the emphasis on smoking prevalence, prevention, cessation, and policies is much greater among other populations than it is among criminal justice populations—despite the human, health, and economic costs that occur in prison and in the community.^20,23In addition to the larger prevalence of smoking in prisons, there is less access to interventions for smoking cessation in correctional facilities. Lack of resources amplifies the negative health risks associated with smoking, such as heart, circulatory, and respiratory problems. Over the past 2 decades, correctional facilities in the United States have implemented tobacco-control policies ranging from restrictions on indoor smoking to complete tobacco bans.²⁴ Tobacco restrictions and bans have not succeeded in suppressing smoking, and reduced access to programs and materials that might increase long-term smoking cessation have paralleled them.^16,17,24,25We recently conducted a randomized controlled trial of smoking cessation with women prisoners and found 7-day point prevalence cessation rates comparable to those seen in community smoking cessation interventions.¹⁵ The intervention combined nicotine replacement with a 10-week group therapy intervention.²⁶ The community-tested intervention was modified for the prison environment and included a discussion of weight gain and weekly monitoring of weight during the intervention and follow-up assessments.¹⁵ Point prevalence quit rates for intervention participants were 18% at end of treatment, 17% at 3-month follow-up, 14% at 6-month follow-up, and 12% at 12-month follow-up, compared with less than 1% at these same time points for control participants.¹⁵ We examined differences in weight change over time for (1) women in the intervention condition compared with women in the control condition and (2) women in the intervention condition who quit smoking compared with those who continued to smoke. To our knowledge, ours is the first study to conduct such a trial among women prisoners.     

Loose Cigarette Purchasing and Nondaily Smoking Among Young Adult Bar Patrons in New York City

Objectives. We examined loose cigarette (loosie) purchasing behavior among young adult (aged 18–26 years) smokers at bars in New York City and factors associated with purchase and use.Methods. Between June and December 2013, we conducted cross-sectional surveys (n = 1916) in randomly selected bars and nightclubs. Using multivariable logistic regression models, we examined associations of loose cigarette purchasing and use with smoking frequency, price, social norms, cessation behaviors, and demographics.Results. Forty-five percent (n = 621) of nondaily smokers and 57% (n = 133) of daily smokers had ever purchased a loosie; 15% of nondaily smokers and 4% of daily smokers reported that their last cigarette was a loosie. Nondaily smokers who never smoked daily were more likely than were daily smokers to have last smoked a loosie (odds ratio = 7.27; 95% confidence interval = 2.35, 22.48). Quitting behaviors and perceived approval of smoking were associated with ever purchasing and recently smoking loosies.Conclusions. Loosie purchase and use is common among young adults, especially nondaily smokers. Smoking patterns and attitudes should be considered to reduce loose cigarette purchasing among young adults in New York City.Widespread adoption of clean indoor air laws and cigarette tax increases denormalize smoking behavior1 and decrease smoking rates.2,3 Although increasing taxes is one of the most effective means of smoking prevention and reduction,3 the increased price of cigarettes can also lead to tax-avoidant behaviors, such as buying untaxed packs smuggled from states with lower cigarette taxes and purchasing loose cigarettes, or “loosies.”4–6 In New York City (NYC), where a cigarette pack costs about $11.50, it has become common for smokers to purchase discounted packs and individual cigarettes from street peddlers and friends.7,8Much of the research exploring loosie purchasing in the United States has focused on underage or low-income minority populations, often in urban areas.7,9,10 One study found that in early 1993, 70% of stores in central Harlem sold loosies to minors.7 Another study conducted with a 2005–2006 convenience sample in inner-city Baltimore found that 77% of African American smokers aged 18 to 24 years had purchased loosies in the past month.11 Similarly, loosie purchasing in Mexico was more common among younger smokers with lower incomes.12Availability and visibility of loosies can promote smoking and encourage relapse.13 We defined nondaily smokers as those who smoked on 1 to 29 of the past 30 days.14,15 Shiffman et al. found that nondaily smokers were more likely than daily smokers to report that social and environmental stimuli motivated their smoking behavior.16 More specifically, cues such as taste, smell, social goading to smoke, and specific situations (e.g., smoking after meals) are more likely to be reported as motivators to smoke by nondaily smokers than by daily smokers.16 Because social–environmental cues have substantial impact on nondaily smokers’ motivation to smoke, it is likely that the cue of seeing loosies in one’s environment also motivates nondaily smokers to smoke.16Previous research substantiates this claim, with 1 study showing that people who regularly saw loosies available for purchase were more likely to be current smokers.17 Therefore, the widespread availability of loosies may have a greater impact on nondaily smokers. Nondaily smokers make up a third of US smokers,18,19 and nondaily smoking is increasingly common among young adults.20 Many young adults who smoke on only some days do not self-identify as smokers,21 and nondaily smoking is frequently paired with alcohol consumption.22–24 Nondaily and light smoking carry a lower, but substantial, risk for lung cancer and a similar risk as does daily smoking for cardiovascular disease.25–27 Occasional smokers also have higher smoking-related morbidity and mortality than do people who have never smoked.26,28–30Nondaily smoking can be a long-term behavior pattern31,32 or a transition to or from daily smoking.31 Nondaily smokers include different subgroups that may have very different smoking patterns or motivations to quit.33,34 Nondaily smokers who previously smoked daily have been defined in previous research as converted nondaily smokers. Nondaily smokers who have never smoked daily are defined as native nondaily smokers.18,19 Important differences exist between these subgroups of smokers: converted nondaily smokers are more likely to quit smoking than are native nondaily smokers and daily smokers,18,19 although most converted and native nondaily smokers were unable to remain abstinent for more than 90 days.19Loosie purchasing and use may play an important role in promoting continued tobacco use among nondaily smokers. The 2010 NYC Community Health Survey35 found that more than one third (34%) of young adult nondaily smokers (aged 18–26 years) reported that their last cigarette smoked was a loosie, compared with 14% of young adult daily smokers. Another study of NYC adults demonstrated that nondaily smokers were more likely to purchase loose cigarettes than were light and heavy smokers.36 To the best of our knowledge, little is known about the factors associated with loosie purchasing among nondaily smokers in the United States.We sought to better understand the factors associated with loosie purchasing among NYC young adults, specifically to determine (1) loosie purchase and use rates among converted nondaily, native nondaily, and daily smokers; (2) whether loosie purchase or use are associated with perceived social norms of smoking behavior; and (3) whether loosie purchasing is associated with smoking cessation intention or behavior.     

Effects of Household Socialization on Youth Susceptibility to Smoke: Differences Between Youth Age Groups and Trends Over Time

A Canadian biennial youth survey facilitated repeating investigation of susceptibility to smoke and household socialization. We operationalized susceptibility to smoke by 3 levels on the basis of intention and behavior. Variables consistently predicting greater susceptibility across time and age groups were sibling smoking, household restrictions, and vehicle smoke exposure. Gender was predictive among older youths. Household restrictions and emerging legislation to ban smoking in vehicles with youth passengers provide protection against secondhand smoke exposure and sustained resolve to remain smoke-free.Supporting youths to remain smoke-free is an ongoing global public health priority.1 Preventative strategies, clean air policies, higher tobacco taxes, community- or school-based programs, tobacco-marketing bans, and age restrictions on tobacco purchases1–3 are effective in diminishing tobacco use among those aged 18 years and younger. Still, because every youth begins life as a nonsmoker with no intention of using tobacco, it is imperative to research socialization mechanisms in diverse contexts.4Youth smoking rates in developed countries vary,5–8 but a common trend among youths older than 15 years is higher rates of both tobacco use and weakened certainty of never smoking in the future.5–8 Tobacco use among youths’ social networks appears to have a stronger influence on their smoking behaviors than do population health strategies.9–15 Alternately, household smoking bans prevent secondhand smoke exposure and function as a denormalization strategy to support sustained resolve to remain smoke-free and not start smoking,16–18 regardless of the smoking status of parents living in the home.19 Prohibiting smoking in cars with children is in early phases of legislation adoption globally; Canada and Australia have widely adopted this law, and 4 of the 50 states in the United States have taken this action.20 When youths reported riding in a vehicle with a person who was smoking in the past week, they were less likely to feel certain about never smoking in the future; thus, their resolve to remain smoke-free was weaker.19Household context has a role in shaping youths’ resolve to remain smoke-free; one’s perception of susceptibility (i.e., future intention) to smoke is strongly associated with future smoking behaviors.4 We performed a secondary analysis of the Canadian 2006–2007 Youth Smoking Survey (YSS) to examine household contextual variables’ influence on youths’ (grades 5–12) intentions and behaviors related to smoking. The study partially replicates a study of the 2004–2005 YSS that included youths in grades 5 to 9.19     

Financial Strain and Smoking Cessation Among Racially/Ethnically Diverse Smokers

Objectives. We evaluated the influence of financial strain on smoking cessation among Latino, African American, and Caucasian smokers of predominantly low socioeconomic status.Methods. Smokers enrolled in a smoking cessation study (N = 424) were followed from 1 week prequit through 26 weeks postquit. We conducted a logistic regression analysis to evaluate the association between baseline financial strain and smoking abstinence at 26 weeks postquit after control for age, gender, race/ethnicity, educational level, annual household income, marital status, number of cigarettes smoked per day, and time to first cigarette of the day.Results. Greater financial strain at baseline was significantly associated with reduced odds of abstinence at 26 weeks postquit among those who completed the study (odds ratio [OR] = 0.77; 95% confidence interval [CI] = 0.62, 0.94; P = .01). There was a significant association as well in analyses that included those who completed the study in addition to those lost to follow-up who were categorized as smokers (OR = 0.78; 95% CI = 0.64, 0.96; P = .02).Conclusions. Greater financial strain predicted lower cessation rates among racially/ethnically diverse smokers. Our findings highlight the impact of economic concerns on smoking cessation and the need to address financial strain in smoking cessation interventions.An estimated 30.6% of US adults living in poverty smoke cigarettes, as compared with 20.4% of those living above the poverty level.¹ Current economic conditions in the United States will likely lead to increased financial strain for many smokers, particularly those of low socioeconomic status (SES). The ongoing global financial crisis and economic recession are expected to force millions of Americans into poverty as a result of increased unemployment rates and reduced availability of government assistance.²Furthermore, the increases in the US federal excise tax on tobacco implemented in April 2009, in combination with existing state tobacco excise taxes, have resulted in a significant rise in the cost of cigarettes. Although increases in cigarette pack prices have historically contributed to reductions in smoking prevalence rates, research suggests that increased taxation has had a declining influence on smoking in recent years.³ Moreover, there is evidence that increases in cigarette prices are associated with the purchase of cigarettes with higher tar and nicotine yields.⁴There is emerging evidence that financial strain may have an undesirable impact on tobacco use. Specifically, financial strain is associated with current smoking as well as greater daily cigarette consumption and smoking relapse.^5,6 Furthermore, smokers and individuals living in smoking households report greater financial strain than nonsmokers and those living in nonsmoking households.^7,8 The expense of smoking has been shown to “crowd out” other expenditures, including those associated with basic necessities.^9,10 Plausibly, this situation may lead to further increases in both financial strain and cigarette smoking. Thus, the current economic climate has made it increasingly important to characterize the association between financial strain and smoking, particularly within low-SES populations.Although a link between financial strain and smoking prevalence has been established, little is known about the impact of financial strain on smoking cessation. Low-SES smokers are as likely as smokers of higher SES to attempt smoking cessation, but they are less likely to quit successfully.¹¹ The economic recession and increased taxation on cigarettes may place a disproportionate financial burden on low-SES smokers, who may have difficulty quitting as a result of high levels of nicotine dependence,¹² reduced access to smoking cessation resources,¹³ and a variety of other factors.Recent findings from a large-scale national study in Australia indicated that smokers facing greater financial strain were less likely to quit smoking over a 1-year period, and financially strained ex-smokers were more likely to relapse over 1 year.¹⁴ In another study, ex-smokers were more likely to relapse after an involuntary job loss (possibly indicating greater financial strain).⁵ However, little is known about the impact of financial strain on a specific quit attempt among smokers receiving smoking cessation treatment. Studies have indicated that financial strain decreases after smoking cessation and that quitters experience less financial strain than those who have not quit.^15,16 Thus, quitting may attenuate smoking-related financial strain among low-SES smokers.In this study, we sought to characterize the influence of financial strain on smoking cessation among smokers of primarily low SES and diverse racial/ethnic backgrounds. We hypothesized that smokers who reported greater financial strain prior to the initiation of smoking cessation treatment would have lower cessation rates. To the best of our knowledge, this is the first study to examine the impact of financial strain on smoking cessation during a specific quit attempt in a racially/ethnically diverse sample of smokers.     

Smoking behavior of US youths: a comparison between child welfare system and community populations

Objectives. We compared rates of smoking for 2 groups of youths aged 12 to 14 years: those involved in the child welfare system (CW) and their counterparts in the community population. We then investigated factors associated with smoking for each group.Methods. We drew data from 2 national-level US sources: the National Survey of Child and Adolescent Well-Being and the National Longitudinal Study of Adolescent Health. We estimated logistic regression models for 3 binary outcome measures of smoking behavior: lifetime, current, and regular smoking.Results. CW-involved youths had significantly higher rates of lifetime smoking (43% vs 32%) and current smoking (23% vs 18%) than did youths in the community population. For CW-involved youths, delinquency and smoking were strongly linked. Among youths in the community population, multiple factors, including youth demographics and emotional and behavioral health, affected smoking behavior.Conclusions. Smoking prevalence was notably higher among CW-involved youths than among the community population. In light of the persistent public health impact of smoking, more attention should be focused on identification of risk factors for prevention and early intervention efforts among the CW-involved population.Cigarette smoking among US youths persists as a critical public health problem. Notably, 80% to 90% of adult smokers initiate smoking by age 18 years.^1–3 Trends in smoking behavior among youths have not paralleled the steady decline evident among adult smokers.² Tobacco use is related to more than 400 000 US deaths per year, and direct medical costs attributable to smoking total more than $50 billion in the United States annually.^1,4 The public health importance of tobacco use is underscored by the Obama administration''s prioritization of smoking prevention and cessation.⁵Youths involved with the child welfare system (CW) face unique experiences that may put them at elevated risk for smoking compared with youths without similar experiences.^6,7 Youths enter the CW system as a result of case investigations conducted by local child protective services agencies. This population includes both youths receiving services in their homes and those in out-of-home care. The lives of CW-involved youths are characterized by problems such as child abuse, neglect, poverty, domestic violence, and parental substance abuse.⁸ Although CW cases are typically referred on the basis of parent behavior, these youths are also at high risk for mental health disorders, substance use, and other psychosocial problems.^6,8–10 However, we are unaware of any studies examining cigarette smoking among CW youths in comparison with community samples to determine whether a difference in smoking-prevalence risk exists for these youths. It is important to determine whether CW-involved youths are at higher risk for smoking so that targeted prevention and intervention strategies can be developed.Among community youths, studies have demonstrated that some subgroups (e.g., age, gender, race/ethnicity, region) are at higher risk for both lifetime and current smoking.² Boys are more likely to initiate smoking, but they smoke more infrequently than girls do.^2,11,12 Racial/ethnic minority youths smoke less than do their White peers.^11–13 Parent education and family structure are associated with lifetime, current, and regular smoking, with youths from households of lower socioeconomic status smoking at higher rates.^14–17Smoking is also linked to emotional well-being, including internalizing and externalizing behaviors and parent–child closeness. Depression is related to increased smoking behavior.^18–23 Engaging in delinquent acts is associated with increased youth smoking.^11,15,24 Youths who report having a close relationship with their parents are less likely to be regular smokers.²⁵Several longitudinal studies have connected youth smoking with behavioral outcomes in adolescence and adulthood. Early-onset smokers are 3 times more likely by grade 12 to regularly use tobacco and marijuana, use hard drugs, sell drugs, have multiple drug problems, drop out of school, and engage in stealing and other delinquent behaviors.²⁶ In addition, long-term emotional and physical health—such as reduced adult life satisfaction, more severe nicotine dependence, and higher smoking quantities—are associated with youth smoking.^27,28Our purpose in the current study was to investigate whether CW-involved youths were at greater risk for smoking than were community youths and to determine whether factors associated with smoking behavior were similar among both populations. We focused explicitly on early adolescence because smoking initiation occurs most often between the ages of 12 and 14 years,^29,30 and early smokers face greater risk of later negative outcomes. We examined 3 distinct measures of smoking behavior: lifetime, current, and regular smoking. Each of these outcomes has a unique public health impact, and investigating them together provides a comprehensive picture of smoking across the 2 youth populations. We expected smoking rates to be higher for CW-involved youths than for community youths. Although there is a dearth of previous research on factors related to smoking behavior in the CW population, we expected some similarities between the groups, with demographic characteristics, family structure, and emotional and behavioral health being associated with smoking among CW-involved youths.     

Impact of Alcohol Use and Bar Attendance on Smoking and Quit Attempts Among Young Adult Bar Patrons

Objectives. We examined cigarette smoking and quit attempts in the context of alcohol use and bar attendance among young adult bar patrons with different smoking patterns.Methods. We used randomized time location sampling to collect data among adult bar patrons aged 21 to 26 years in San Diego, California (n = 1235; response rate = 73%). We used multinomial and multivariate logistic regression models to analyze the association between smoking and quit attempts and both drinking and binge drinking among occasional, regular, very light, and heavier smokers, controlling for age, gender, race/ethnicity, and education.Results. Young adult bar patrons reported high rates of smoking and co-use of cigarettes and alcohol. Binge drinking predicted smoking status, especially occasional and very light smoking. All types of smokers reported alcohol use, and bar attendance made it harder to quit. Alcohol use was negatively associated with quit attempts for very light smokers, but positively associated with quitting among heavier smokers.Conclusions. Smoking and co-use of cigarettes and alcohol are common among young adult bar patrons, but there are important differences by smoking patterns. Tobacco interventions for young adults should prioritize bars and address alcohol use.Tobacco is responsible for approximately 443 000 deaths in the United States annually,1,2 but cessation before the age of 30 years avoids most of the long-term health consequences of smoking.3 As smoking prevalence has declined,4 nondaily smoking and low-level daily cigarette consumption,5–7 also referred to as occasional or light smoking patterns, have increased.8–11 Nondaily smokers made up 4.1% of the US adult population in 2006,12 increasing from 3.2% in 1997 and 1998.6 Nondaily smokers accounted for 19.9% of current smokers in 2006,12 increasing from 16.0% in 1997 and 1998.6 Younger age is associated with occasional smoking,9,13 and nondaily smoking is common among young adults. In 1997 and 1998, 5.5% of young adults aged 18 to 24 years were nondaily smokers, accounting for 19.9% of young adult smokers, the highest proportion of nondaily smoking among all age groups.6Alcohol complicates occasional or light smoking in young adults, and it often plays a powerful catalyst role in facilitating and maintaining smoking.14 Young adults report that alcohol increases the enjoyment of and desire for cigarettes,15,16 and tobacco enhances the desired effect of alcohol.17–19 The co-use of cigarettes and alcohol has been described as like “milk and cookies” or “peanut butter with jelly.”20The co-use of tobacco and alcohol among young adults15,21,22 poses a serious health threat. Use of both cigarettes and alcohol increases the risk for certain cancers (e.g., mouth, throat, esophagus, upper aerodigestive tract)23–25 and makes it more difficult to quit either substance.26–28 In a 2001–2002 national study, 2.9% of adults aged 18 years and older (6.2 million) reported both alcohol use disorders and a dependence on nicotine by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria, and young adults aged 18 to 24 years exhibited the highest rates of this comorbidity.22Bars and nightclubs are key public venues where young adults congregate and use both alcohol and tobacco. Tobacco companies have targeted young adults, using entertaining events to reinforce a smoker-friendly atmosphere in bars and nightclubs.16,29–31 Many tobacco marketing events have encouraged alcohol use by offering alcohol discounts, paraphernalia, or by holding alcohol drinking contests.16,29,30,32 The strong rewarding effects of nicotine paired with alcohol,33–35 the aggressive tobacco marketing linked with alcohol,32 and the peer acceptance of smoking while drinking at parties in bars and nightclubs20 have put young adult bar patrons at high risk for tobacco use and co-use of tobacco and alcohol, even for occasional and light smokers.To our knowledge, no study has examined the co-use of tobacco and alcohol among young adult bar patrons. This is a hard-to-reach population often underrepresented in national surveillance studies. Additionally, no study has assessed co-use behavior among young adult occasional and light smokers, an increasingly common behavior. We examined patterns of smoking and quit attempts in the context of alcohol use and bar attendance among 4 groups of young adult smokers attending bars in San Diego, California, including occasional, regular, very light, and heavier smokers.     

The Effectiveness of Cigarette Price and Smoke-Free Homes on Low-Income Smokers in the United States

Objectives. We examined the effectiveness of state cigarette price and smoke-free homes on smoking behaviors of low-income and high-income populations in the United States.Methods. We used the 2006–2007 Tobacco Use Supplement to the Current Population Survey. The primary outcomes were average daily cigarette consumption and successful quitting. We used multivariable regression to examine the association of cigarette price and smoke-free home policies on these outcomes.Results. High state cigarette price (pack price ≥ $4.50) was associated with lower consumption across all income levels. Although low-income individuals were least likely to adopt smoke-free homes, those who adopted them had consumption levels and successful quit rates that were similar to those among higher-income individuals. In multivariable analysis, both policies were independently associated with lower consumption, but only smoke-free homes were associated with sustained cessation at 90 days.Conclusions. High cigarette prices and especially smoke-free homes have the potential to reduce smoking behaviors among low-income individuals. Interventions are needed to increase adoption of smoke-free homes among low-income populations to increase cessation rates and prevent relapse.High state cigarette prices1–3 and clean indoor air laws4–8 are 2 of the most effective tobacco control policies for decreasing tobacco use5 and increasing cessation on a population level.4–6 These policies have been included in national surveillance surveys of tobacco use.9 Whether these policies are effective among lower-income as well as higher-income smokers is unclear. Some studies, including an econometric analysis,10 have suggested that price and clean air laws have a similar effect in reducing smoking behavior among lower- and higher-income smokers.2,10,11 Others have suggested that such policies may be less effective for lower-income smokers12–14 as they have a higher smoking prevalence,15 higher consumption rate per smoker,16 and lower rates of successful quitting17–19 compared with higher-income smokers. Indeed, the prevalence of smoking among adults living below the federal poverty level (FPL) is almost 50% higher than the prevalence in the general population.15Economic theory suggests that rising cigarette prices should reduce cigarette consumption more in low-income smokers compared with those with higher incomes.2,12,13,20–23 However, studies have shown that low-income smokers vary in their response to rising cigarette prices. Some individuals may compensate for higher prices by relying on lower-priced cigarette products (e.g., generic vs premium brands, discount vs convenience stores, or non–state-taxed products [e.g., from Indian reservations] vs taxed products).23–29 Others who are motivated to quit may react to a price increase as an opportunity to quit smoking or reduce cigarette consumption.3,21 One concern is that the higher prevalence of heavy smoking among low-income smokers may be evidence of impaired personal autonomy such that fewer are able to quit even with a price increase.30 This in combination with the stress of coping with material or environmental constraints may pose significant challenges to smoking cessation.31 Another concern is that high cigarette prices can result in a significant financial burden for low-income smokers.32Social cognitive theory predicts that a person’s motivation to change behavior varies with the social norms of his or her environment.33 Variability in smoking behaviors between low- and high-income smokers may result from different social norms related to smoking.34 The passage of smoke-free policies in communities is one indicator of social norms related to smoking35; a stronger marker is the prevalence of households with smokers who have voluntarily established a smoke-free home.6 Strong clean indoor air laws are associated with increased adoption of smoke-free homes among smokers and nonsmokers.36,37 Smoke-free homes have been associated with reduced exposure to second-hand smoke among nonsmokers, and reduced smoking behaviors among smokers.5,6,38 Lower-income adults are less likely than higher-income adults to adopt smoke-free homes,39,40 reflecting differential smoking norms in the respective communities.To determine whether cigarette prices and smoke-free home policies are effective among smokers of different income levels, we used the 2006–2007 Tobacco Use Supplement to the Current Population Survey (TUS-CPS), a nationally representative cross-sectional survey, to explore the association of these policies with smoking behaviors by income categories indexed on poverty status. The level of excise tax on tobacco products has differed considerably across states.41 Thus, we aggregated self-reported purchase price of cigarettes and compared across states. We examined whether average daily consumption and successful quitting differed by income levels among adults living in states with higher average cigarette prices compared with those with lower prices. We similarly assessed whether an income gradient existed in cigarette consumption and successful quitting among adults living in smoke-free homes relative to non–smoke-free homes. We examined the independent association of state cigarette price and smoke-free homes on smoking behaviors. We hypothesized that smoke-free homes would be a stronger predictor than price in reducing smoking behaviors because smokers may have access to a number of price-minimizing strategies23,26 but lack similar strategies to minimize the effects of smoking restrictions.     

Social Branding to Decrease Smoking Among Young Adults in Bars

Objectives. We evaluated a Social Branding antitobacco intervention for “hipster” young adults that was implemented between 2008 and 2011 in San Diego, California.Methods. We conducted repeated cross-sectional surveys of random samples of young adults going to bars at baseline and over a 3-year follow-up. We used multinomial logistic regression to evaluate changes in daily smoking, nondaily smoking, and binge drinking, controlling for demographic characteristics, alcohol use, advertising receptivity, trend sensitivity, and tobacco-related attitudes.Results. During the intervention, current (past 30 day) smoking decreased from 57% (baseline) to 48% (at follow-up 3; P = .002), and daily smoking decreased from 22% to 15% (P < .001). There were significant interactions between hipster affiliation and alcohol use on smoking. Among hipster binge drinkers, the odds of daily smoking (odds ratio [OR] = 0.44; 95% confidence interval [CI] = 0.30, 0.63) and nondaily smoking (OR = 0.57; 95% CI = 0.42, 0.77) decreased significantly at follow-up 3. Binge drinking also decreased significantly at follow-up 3 (OR = 0.64; 95% CI = 0.53, 0.78).Conclusions. Social Branding campaigns are a promising strategy to decrease smoking in young adult bar patrons.Tobacco companies1 and public health authorities2–5 recognize young adulthood as a critical time when experimenters either quit or transition to regular tobacco use. Young adults are also aspirational role models for youths.1,6,7 Tobacco companies devote considerable resources to reaching young adults to encourage tobacco use,1,8–11 and young adults have a high prevalence of smoking.12 In California in 2011, young adults had the highest smoking prevalence of any age group, and the Department of Health estimated that 32% of California smokers started smoking between the ages of 18 and 26 years.13 Although they are more likely to intend to quit and successfully quit than older adults,14–17 young adults are less likely to receive assistance with smoking cessation.18,19 Although there are few proven interventions to discourage young adult smoking,20 cessation before age 30 years avoids virtually all of the long-term adverse health effects of smoking.21Tobacco companies have a long history of using bars and nightclubs to reach young adults and to encourage smoking.1,6,9–11,22–24 Bar attendance and exposure to tobacco bar marketing is strongly associated with smoking.25 The 1998 Master Settlement Agreement and Food and Drug Administration regulations that limit tobacco advertising to youths, explicitly permit tobacco marketing in “adult only” venues, including bars and nightclubs.26,27Aggressive tobacco marketing may actually be more intensive in smoke-free bars: a 2010 study of college students attending bars found that students in the community with a smoke-free bar law were more likely to be approached by tobacco marketers, offered free gifts, and to take free gifts for themselves than in communities without a smoke-free bar law.28 Bars and nightclubs also attract young adults who are more likely to exhibit personality traits such as sensation seeking,29 increasing their risk30 independently of receptivity to tobacco advertising; tobacco promotional messages resonate with these personality traits.8,31 Tobacco marketing campaigns are tailored to specific segments of the population defined by psychographics (e.g., values, attitudes, shared interests, such as tastes in music and fashion, and friend groups) and demographic criteria, and they aim to create positive smoker images, identities, and social norms for smoking.1,8 Tobacco marketing campaigns also focus on young adult trendsetters to leverage peer influence to promote smoking.6,10In contrast to the tobacco companies’ efforts, most young adult health interventions take place in colleges or health centers rather than social environments.32–39 Bars and nightclub venues represent an opportunity to reach those at highest risk for long-term smoking morbidity and mortality.40 We evaluated the effectiveness of an intervention to decrease cigarette smoking by countering tobacco industry marketing strategies targeting young adults attending bars and nightclubs in the San Diego, California, “hipster” scene. Because tobacco and alcohol use are strongly linked,41,42 we also examined the effects of the intervention on alcohol use and among binge drinkers. We found a significant decrease in smoking in the community where the intervention took place, including significant decreases among nondaily smokers and binge drinkers, as well as a significant decrease in binge drinking.     

Effects of Different Types of Antismoking Ads on Reducing Disparities in Smoking Cessation Among Socioeconomic Subgroups

Objectives. We assessed which types of mass media messages might reduce disparities in smoking prevalence among disadvantaged population subgroups.Methods. We followed 1491 adult smokers over 24 months and related quitting status at follow-up to exposure to antismoking ads in the 2 years prior to the baseline assessment.Results. On average, smokers were exposed to more than 200 antismoking ads during the 2-year period, as estimated by televised gross ratings points (GRPs). The odds of having quit at follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points, odds ratio [OR] = 1.11; 95% confidence interval [CI] = 1.00, 1.23; P < .05). Greater exposure to ads that contained highly emotional elements or personal stories drove this effect (OR = 1.14; 95% CI 1.02, 1.29; P < .05), which was greater among respondents with low and mid-socioeconomic status than among high–socioeconomic status groups.Conclusions. Emotionally evocative ads and ads that contain personalized stories about the effects of smoking and quitting hold promise for efforts to promote smoking cessation and reduce socioeconomic disparities in smoking.Tobacco use inflicts the greatest burden of illness on those least able to afford it.^1,2 An enormous challenge for tobacco control is how to tackle the consistently higher levels of smoking prevalence found among disadvantaged groups,^3–5 especially because these gaps may be widening.^6,7 Televised antismoking campaigns provide an effective population-wide method of preventing smoking uptake,^8,9 promoting adult smoking cessation,¹⁰ and reducing adult smoking prevalence,¹¹ and research indicates that some types of ads may be more effective than others. Antismoking messages that produce strong emotional arousal, particularly personal stories or graphic portrayals of the health effects of smoking, tend to perform well¹²; they are perceived to be more effective than others, are more memorable, and generate more thought and discussion.^13–16 However, it is unclear whether different types of messages might maintain, increase, or mitigate the disparities in smoking prevalence across population subgroups.Research on subgroup differences in responses to a range of anti-tobacco ads has not found systematic differences by gender, race/ethnicity, or nationality.^13,17–19 A review of the literature on the use of mass media concluded that in comparison with their effects on other populations, campaigns have often been less effective, sometimes equally effective, but rarely more effective in promoting cessation among socioeconomically disadvantaged populations.²⁰ However, many of the less effective general-audience campaigns were hampered by minimal reach to smokers of low socioeconomic status (SES) because they were low-cost campaigns unable to afford extensive media exposure.²⁰Most research examining longer-term quit rates in the context of large-scale, well-funded antismoking campaigns found comparable quit rates or reductions in smoking prevalence in low- and high-SES groups.^21–28 However, to our knowledge, no population-based research has examined the relationship between the degree of exposure to different types of antismoking messages and quit rates between low- and high-SES groups.A variety of theories^29–38 provide guidance about which styles of ads may best encourage quitting, especially among members of lower socioeconomic groups. Consistent with these theories, reviews of the effects of antismoking advertising have concluded that advertisements that evoke strong emotional responses through negative visceral imagery or personal stories about the health effects of smoking can increase attention, generate greater recall and appeal, and influence smoking beliefs and intentions.^12,39,40 Recent research indicates that self-relevant emotional reactions (i.e., emotional reflections about one''s life, body, or behavior that are triggered by the ad⁴¹) may be especially persuasive, because they affect perceptions of future risk of becoming ill,⁴² which in turn have been linked with reduced cigarette consumption, increased intentions to quit, and quit attempts.⁴³Antismoking ads that use strong graphic imagery of the health effects of smoking are likely to be predominately associated with high negative emotional arousal, but personal stories of the consequences of smoking may evoke high or low levels of emotion depending on the particular story and the degree to which smokers relate to the characters.³⁸ However, less emotional personal testimonials may still be more effective than other types of less emotional ads because there is no explicit persuasive intent against which smokers may react^38,44 and because health information is presented in a story-based format, which people learn to process naturally from an early age.⁴⁵Because lower-SES groups tend to have a greater degree of resistance to messages from the health care sector,⁴⁶ lower health literacy levels,^47,48 greater likelihood of belief in myths about cancer risks and prevention,⁴⁹ and less perception that smoking increases a person''s chance of getting cancer,⁴⁸ we proposed that emotional messages and personal stories might be especially influential. Presenting antismoking messages in an emotional or personal testimonial format may convey health information to these smokers in a way that is difficult to discount, natural and easy to process, and likely to arouse emotions that lead to increased perceptions of susceptibility to smoking-related diseases and motivation to quit.^38,42,44Drawing on the only previous study to examine the effect on adult quitting of the degree of exposure to antismoking ads,¹⁰ we first hypothesized that when all types of advertisements were considered together, greater exposure to these antismoking ads would be associated with greater likelihood of quitting by follow-up. Our second hypothesis was that particular types of antismoking ads (those containing highly emotional elements or personal testimonials about the effects of smoking) would be associated with a greater chance of successful quitting by follow-up than would exposure to ads without these elements. Finally, we hypothesized that highly emotional or personal testimonial ads would be especially effective among lower-SES groups.     

Household Crowding and Food Insecurity Among Inuit Families With School-Aged Children in the Canadian Arctic

Objectives. We examined the relation of household crowding to food insecurity among Inuit families with school-aged children in Arctic Quebec.Methods. We analyzed data collected between October 2005 and February 2010 from 292 primary caregiver–child dyads from 14 Inuit communities. We collected information about household conditions, food security, and family socioeconomic characteristics by interviews. We used logistic regression models to examine the association between household crowding and food insecurity.Results. Nearly 62% of Inuit families in the Canadian Arctic resided in more crowded households, placing them at risk for food insecurity. About 27% of the families reported reducing the size of their children’s meals because of lack of money. The likelihood of reducing the size of children’s meals was greater in crowded households (odds ratio = 3.73; 95% confidence interval = 1.96, 7.12). After we adjusted for different socioeconomic characteristics, results remained statistically significant.Conclusions. Interventions operating across different levels (community, regional, national) are needed to ensure food security in the region. Targeting families living in crowded conditions as part of social and public health policies aiming to reduce food insecurity in the Arctic could be beneficial.Inadequate housing conditions (e.g., crowding and structural damage) are prevalent among First Nations and Inuit communities in Canada and elsewhere.1 In Nunavik, the Inuit homeland in Arctic Quebec, Canada, the government promoted the relocation of many Inuit families to fledgling communities during the 1950s. Relocated families were moved to small, poorly heated and insulated accommodations. Since then, different programs have been designed by the federal, provincial, territorial, and regional governments to address the housing problem in Nunavik and across the Canadian Arctic.2 At present, more than 90% of the Nunavik population has reported living in social (subsidized) housing.3 In this region, social housing units are allocated locally through a point-based system set according to specific criteria, so that applicants most in need are given first priority (e.g., families with lower income, with young children, and living in overcrowded dwellings).2 Rent is set according to household income, while also considering the cost of living.4 Thus, in Nunavik, housing tenure does not differentiate between households on the basis of financial security or income level, given that nearly all of the population resides in social housing. Such organization rather highlights the high degree of financial need throughout this population and a limited private residential market unattainable by most of the population.Household overcrowding, generally defined as more than 1 person per room,5 is particularly problematic in Nunavik. According to Statistics Canada, 49% of the 2006 population lived in overcrowded houses.5 Often, overcrowding is approached as a consequence of economic difficulties. Living in smaller homes or in shared accommodation has been known as a way to lower living costs to dedicate the available financial resources to other basic necessities.6 In such situations, overcrowded households may experience higher food insecurity as a result of a precarious economic situation. In the particular case of Nunavik, however, crowding is a direct consequence of an underlying, and persistent, lack of housing. Household crowding in Nunavik is not only a product of financial difficulties but also an effect of the rapidly growing and young population. Between 2001 and 2006, the population in Nunavik increased by 12% compared with 4% for the province of Quebec. During the past 3 decades, the population has doubled from 5860 in 1986 to 12 090 in 2011.7 In 2008, it was estimated that more than 900 new housing units were needed, but only 239 units were constructed.8 The housing backlog is further compounded by high costs of construction and short building seasons.The housing situation in Nunavik and throughout the Canadian Arctic raises concerns, in terms of both public health and the health of each individual resident, especially that of children.9–14 Indeed, studies have shown that household crowding is associated with poorer respiratory health, especially among children.12,15 In crowded dwellings, the lack of privacy and the difficulty of withdrawing from (unwanted) social interactions may limit the ability of controlling one’s home situation and lead to “overarousal.”16 Household crowding also has been identified as eliciting chronic stress responses in adults,17 anger and depression18 with possible repercussions on behaviors,19–22 withdrawal,23 and reduced social support24 that, we contend, could influence household food insecurity.Food insecurity occurs when it is not possible to obtain safe, sufficient, and nutritiously adequate foods for a healthy life in socially and culturally acceptable ways.25–27 Studies have shown that in a situation of food insecurity, adults generally first reduce their own food consumption. As the situation becomes more severe, children’s diets also will be reduced, particularly in low-income households with single mothers.28,29 In 2012, 14% of the households in Canada experienced food insecurity.30 In Canadian Arctic communities, food insecurity is high: 62.2% and 31.6% of children live in food-insecure households in Nunavut and Northwest Territories, respectively.30 In Nunavik, the proportion of Inuit children experiencing food insecurity reached 30% in 2006.31 Studies emphasize that a reduction of the quality in diet and nutrient intake resulting from food insecurity is linked to various health issues in children, including poor health,25,32–34 developmental delays,35 and poor mental health.36Access to food products supplied from southern regions of Quebec comes at a very high cost to Nunavik, with an average price 57% higher than in the provincial capital.37 Despite efforts to redress this situation, food costs remain very high and often inaccessible to many Nunavik families who must resort to reducing the amount of food supplies or buying products of lower nutritional quality,38 which compromises health and well-being.36,37,39In a study conducted among low-income families in the United States, Cutts et al.40 found a higher risk of food insecurity and child food insecurity in households with higher housing insecurity. In their study, crowding and multiple moves were considered as indicators of housing insecurity. This association was independent of maternal and family characteristics such as education and household employment. In a recent study involving Inuit households from Nunavut, in the eastern Canadian Arctic, Huet et al.41 reported higher food insecurity among Inuit living in overcrowded households and in houses requiring major repairs. This observation, however, was based on bivariate associations between housing conditions and food insecurity and did not account for other factors such as socioeconomic conditions. These studies nonetheless suggest that food insecurity is not only explained in terms of low socioeconomic status and poverty.40,42We examined whether household crowding was associated with food insecurity among Inuit families with school-aged children, independently of socioeconomic disadvantage.     

The Association Between Social Stressors and Home Smoking Rules Among Women With Infants in the United States

Objectives. We examined the role of social stressors on home-smoking rules (HSRs) among women with infants in the United States, with attention on the moderating role of smoking status and depression.Methods. We analyzed data for 118 062 women with recent births in the United States who participated in the Pregnancy Risk Assessment Monitoring System (2004–2010), which is a population-based surveillance data set. We fit multinomial logistic models to predict the odds of partial or no HSRs by a cumulative index of prenatal social stressors.Results. Compared with those with no stressors, mothers with high levels of social stressors had 2.5 times higher odds of partial or no HSRs. Smokers in the 1–2, 3–5, and ≥ 6 stressor categories were 9.0%, 9.6%, and 10.8% more likely to have partial or no HSRs, respectively. Under the highest levels of stress (≥ 6), nonsmokers were almost as likely as smokers to have partial or no HSRs. In addition, the effects of stress on HSRs were more pronounced for nonsmoker, nondepressed mothers.Conclusions. Increases in social stressors represented an important risk factor for partial or no HSRs and might have potential negative implications for infants.The home environment constitutes the most important determinant of infant exposure to secondhand smoke (SHS). SHS is a preventable burden in the US health care system. SHS has pernicious effects on children and infants, with exposure linked to an increased risk of acute respiratory infection, ear infections, asthma, and sudden infant death syndrome.1,2 Although information regarding the dangers of SHS is widespread and generally acknowledged by all sociodemographic groups within the United States, individuals continue to smoke or allow smoking in their households, putting their health and their children’s health at risk. Home smoking rules (HSRs), which limit the amount of smoking allowed in the home, are generally acknowledged as an effective way to minimize SHS, but little is known about how social stressors affect HSRs in households with infants.Mounting societal pressures have led to restrictions in public smoking as a means to limit exposure to SHS in common areas.3,4 Similarly, individual HSRs, partial (smoking disallowed in designated areas of the home) and full (smoking disallowed anywhere in the home), have increasingly been used to limit SHS exposure in the home.5–7 However, SHS exposure remains a significant public health concern. Although little information is available on SHS for infants, approximately 50% of children aged 3 to 11 years were exposed to secondhand smoking in 2005 to 2008.8 National health objectives in Healthy People 2020 aim to reduce childhood exposure to SHS and to increase the proportion of smoke-free homes from 69.1% in 2006 to 2007 to 87% by the year 2020.8 The prevalence of HSRs varies by sociodemographic characteristics and within subpopulations.9,10 For example, Gibbs et al.10 showed that although an overwhelming majority of homes with infants have complete HSRs, the prevalence varies by state, education level, and race/ethnicity; lower socioeconomic status and racial/ethnic minority groups are more likely to have partial or no HSRs.High levels of social stress may impede the practice of HSRs. Social stress may have an independent relationship with HSRs through the loss of social control, self-efficacy, or power within a household context. Individuals facing compromised resources are likely to have fewer options to cope with stress and may have diminished control over enforcing health-promoting norms.11 They may also have lower levels of social support or external locus of control within their environment.12 HSRs are less likely among former or current smokers, regardless of socioeconomic status.9,10 Smoking, a health compromising behavior, may be a coping mechanism in resource-limited social or environmental settings, and stress may trigger the need for smoking among current or previous smokers.13–15 Stressors may precipitate postpartum depressive symptoms, reducing HSRs through intrapersonal characteristics of self-determination or self-efficacy, thereby moderating the relationship between stressors and HSRs. Maternal depression has been consistently associated with negative child-rearing behaviors.16,17 In addition, depression may indirectly be negatively associated with HSRs because of the higher prevalence of smoking behavior18,19 or the lower likelihood of smoking cessation among depressed people.20We aimed to explore the relationship between prebirth stressors and postpartum HSRs in a population-based sample of women with infants in the United States. We present 2 primary hypotheses: (1) cumulative stressors are associated with a lower likelihood of HSRs among recent mothers, controlling for smoking status and depression; and (2) current smoking will moderate the relationship between stress and HSRs; stress will have a stronger negative association with HSRs among current smokers, and the moderating effect of smoking status will be stronger for those who are not depressed.     

Effect of Network Social Capital on the Chances of Smoking Relapse: A Two-Year Follow-up Study of Urban-Dwelling Adults

Objectives. We sought to examine the prospective influence of social capital and social network ties on smoking relapse among adults.Methods. In 2010, a 2-year follow-up study was conducted with the 2008 Montreal Neighborhood Networks and Healthy Aging Study (MoNNET-HA) participants. We asked participants in 2008 and 2010 whether they had smoked in the past 30 days. Position and name generators were used to collect data on social capital and social connections. We used multilevel logistic analysis adjusting for demographic and socioeconomic factors to predict smoking relapse in 2010.Results. Of the 1400 MoNNET-HA follow-up participants, 1087 were nonsmokers in 2008. Among nonsmokers, 42 were smokers in 2010. Results revealed that participants with higher network social capital were less likely (odds ratio [OR] = 0.68; 95% confidence interval [CI] = 0.47, 0.96), whereas socially isolated participants (OR = 3.69; 95% CI = 1.36, 10.01) or those who had ties to smokers within the household (OR = 4.22; 95% CI = 1.52, 11.73) were more likely to report smoking in 2010.Conclusions. Social network capital reduced the chances of smoking relapse. Smoking cessation programs might aim to increase network diversity so as to prevent relapse.Tobacco smoking is a risk factor for a range of ill health conditions, including lung cancer, stroke, heart disease, and chronic respiratory disease.1 In 2010, worldwide tobacco smoking, including secondhand smoking, was ranked as the second highest risk factor contributing to the overall global burden of disease with estimates placing global smoking prevalence at 23.7%.1,2 Researchers have suggested that cessation by current smokers offers the only practical way to avoid a substantial proportion of global tobacco-related deaths in the coming decades.3 Relapse is common during smoking cessation attempts.4,5 Social support interventions, which involve a person’s close social relationships, have been shown to be important in preventing relapse.5 Developing effective network interventions to reduce smoking requires a greater understanding of the range of social network influences beyond social support that might be leveraged to encourage cessation and prevent relapse.Research on social influences and smoking have highlighted the importance of social networks on a range of smoking behaviors, including initiation, cessation, and relapse.6–8 Network influences on smoking might operate in a positive or negative fashion: being connected to others who smoke might lead to an increased risk of smoking, whereas being connected to people who do not smoke might reduce the risk.9 Although much research has focused on youth smoking, studies have also shown the importance of social networks and support for adult smoking.10,11 For example, using data from the Framingham Heart Study, Christakis and Fowler reported that smoking cessation clustered among more connected groups of people, suggesting the diffusion of cessation behavior within social networks.7 Research has also shown the importance of social support in smoking cessation and relapse.10,12 For example, Holahan et al. showed that general social support reduced the chances of smoking relapse among adult women.10 Social support resources might emerge from formal (e.g., clinics or support groups) or informal sources; when informal, support for smoking cessation tends to come from a person’s close friends or family members (e.g., spouse or partner).13 Although the importance of support and close ties in smoking behaviors is thus recognized, less is known about the influence of network social capital on smoking.In this study, we examined 3 social network influences on smoking relapse: social capital, social isolation, and having strong ties to other smokers (i.e., smoking alters). First, social capital refers to the resources to which individuals and possibly groups have access through their social networks. In contrast to social support, which tends to emerge from a person’s strong, core social connections, social capital often emerges from a person’s weaker and more heterogeneous social connections.14,15 Most studies on social capital and smoking have applied proxy measures of social capital such as generalized trust and social participation to examine its link to smoking behavior. These studies have shown that those persons with higher levels of social participation or generalized trust are less likely to smoke16,17 and more likely to cease smoking.11 Few studies have examined network social capital and smoking prospectively, and, therefore, less is known about the potential influence of network capital on smoking behavior. Second, social isolation (i.e., not having social connections) can also impact smoking behavior.18 Choi and Smith, for example, showed that social isolation can lead to smoking as a means of managing negative moods that might emerge from the lack of social connections and support.19 Finally, being socially isolated might increase smoking risk but having social connections can also increase risk, if those connections tend to be to smokers. Strong ties to smokers might lead to smoking initiation or relapse through various mechanisms, including normative or social learning mechanisms.20 For example, Homish and Leonard showed that spouses actually exercised a stronger influence on a partner’s chances of relapse than cessation.21 Living with smokers regardless of relationship status has also been shown associated with smoking.22 Despite such findings, little is known on whether the influence of having strong ties to smokers on adult smoking relapse is similar across different spatial units (e.g., sharing a household compared with residing in the same neighborhood).In this study, we examined the importance of 3 social network influences on smoking relapse and whether there are protective effects of network social capital on relapse. Based on previous research, we expected network social capital, social isolation, and having strong ties to smokers to have independent and different relationships to smoking relapse. Four hypotheses on the relationship between adult social network characteristics and smoking relapse guided the study: (1) the higher a person’s network social capital, the lower that person’s chances of smoking relapse; (2) adults who are socially isolated have increased chances of smoking relapse; (3) the greater the number of strong ties to smokers that a person has, the greater their chances of smoking relapse; and (4) the more spatially proximate smoking alters are to participants, the more likely they are to relapse. To test these hypotheses, we examined prospectively the influence of baseline levels of network social capital and social network characteristics on adult smoking behavior 2 years later.     

Implementation of Workplace-Based Smoking Cessation Support Activities and Smoking Cessation Among Employees: The Finnish Public Sector Study

Objectives. We investigated the relationship between implementation of workplace smoking cessation support activities and employee smoking cessation.Methods. In 2 cohort studies, participants were 6179 Finnish public-sector employees who self-reported as smokers at baseline in 2004 (study 1) or 2008 (study 2) and responded to follow-up surveys in 2008 (study 1; n = 3298; response rate = 71%) or 2010 (study 2; n = 2881; response rate = 83%). Supervisors’ reports were used to assess workplace smoking cessation support activities. We conducted multilevel logistic regression analyses to examine changes in smoking status.Results. After adjustment for sociodemographic characteristics, number of cigarettes smoked per day, work unit size, shift work, type of job contract, health status, and health behaviors, baseline smokers whose supervisors reported that the employing agency had offered pharmacological treatments or financial incentives were more likely than those in workplaces that did not offer such support to have quit smoking. In general, associations were stronger among moderate or heavy smokers (≥ 10 cigarettes/day) than among light smokers (< 10 cigarettes/day).Conclusions. Cessation activities offered by employers may encourage smokers, particularly moderate or heavy smokers, to quit smoking.Smoking bans are increasingly used to reduce smoking and exposure to secondhand smoke. Bans have been widely implemented in the European Union countries, and the Centers for Disease Control and Prevention predicts that by 2020 or sooner, all US states will have laws banning smoking in all indoor areas of private-sector work sites, restaurants, and bars.1 Smoke-free work environments are associated with higher smoking cessation rates.2,3Workplaces are often the setting for efforts to promote smoking cessation. Beyond workplace smoking restrictions and campaigns to reduce smoking, employers offer various types of support for smoking cessation, including support groups, nicotine replacement therapy, other pharmacological treatments, and financial incentives.4 A review of workplace interventions showed strong evidence that interventions directed toward individual smokers, such as individual and group counseling and pharmacological treatment, increase the likelihood of smoking cessation.4 By contrast, there was only limited evidence that participation in cessation programs can be increased by competitions and incentives.5Another review showed that worksite-based multicomponent programs involving incentives and competitions in combination with other interventions can be effective.6 Similarly, a recent study conducted at a large company revealed that financial incentives significantly increase cessation rates.7 Self-help interventions and social support have been found to be less effective.4It is not clear whether the effectiveness of interventions varies according to initial smoking intensity, that is, number of cigarettes smoked per day. Hyland et al.8 suggested that low-level smokers may have different intervention needs than heavier smokers. Most studies have been limited by small sample sizes or have been conducted in a small number of work sites, so the extent to which findings are generalizable to other populations and settings is uncertain.In a large sample of smokers from more than 1000 public-sector work units, we examined whether employer-offered smoking cessation support activities were associated with a higher likelihood of quitting smoking independently of a number of other factors, including sociodemographic characteristics, work-related factors, health status, and health behaviors. In addition, we examined whether the effects of smoking cessation support activities on smoking cessation varied according to prior smoking intensity.     

Connecting Discovery and Delivery: The Need For More Evidence on Effective Smoking Cessation Strategies for People Living With HIV/AIDS

Smoking prevalence among the 1.1 million Americans living with HIV/AIDS is 2 to 3 times higher than the 19.8% rate among the general population. Since 1990, scientists have worked toward the discovery of health risks related to smoking in people living with HIV/AIDS; however, few studies have evaluated the delivery of smoking cessation interventions for this population. Increasing linkages between discovery science and delivery science may facilitate a faster transition to delivery of smoking cessation interventions for people living with HIV/AIDS.Health research often focuses on the discovery of risk factors associated with disease and death.¹ Although discovery of health risks is necessary to protect health, the delivery of interventions to improve health is equally important.^1–5 Information regarding how science moves from discovery to delivery points to substantial time lag and little cross-talk between discovery and delivery research.^1,6 This may be especially problematic in areas such as HIV/AIDS and smoking, where delay between discovery of smoking-related health outcomes in people living with HIV/AIDS and the delivery of interventions to reduce smoking among this population has serious consequences.Smoking prevalence in people living with HIV/AIDS is 2 to 3 times higher than is the 19.8% rate among the general population.^7–16 Discovery research has concluded that smokers with HIV/AIDS are more likely to be nonadherent to treatment, have a greater chance of being diagnosed with an AIDS-defining condition or dying, and report lower quality of life than do nonsmoking persons with HIV/AIDS.^13,17–21 Smokers living with HIV/AIDS have a higher risk of disease and opportunistic infection than do smokers who do not have HIV/AIDS.^9,22–34Delivery research indicates that population-specific smoking cessation interventions can be effective.^35–52 Although few studies have examined such strategies for persons living with HIV/AIDS,³⁵ a recent study found that 86% of smokers with HIV/AIDS would not benefit from standard cessation programs.⁵³ I used citation network analysis^54–56 to examine the characteristics of—and possible relationships between—discovery research relating health outcomes to smoking in persons living with HIV/AIDS and delivery research on interventions to reduce smoking among this population.     

Prevalence,Harm Perceptions,and Reasons for Using Noncombustible Tobacco Products Among Current and Former Smokers

Objectives. We provided estimates of noncombustible tobacco product (electronic nicotine delivery systems [ENDS]; snus; chewing tobacco, dip, or snuff; and dissolvables) use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.Methods. We assessed awareness of, prevalence of, purchase of, harm perceptions of, and reasons for using noncombustible tobacco products among 1487 current and former smokers from 8 US designated market areas. We used adjusted logistic regression to identify correlates of noncombustible tobacco product use.Results. Of the sample, 96% were aware of at least 1 noncombustible tobacco product, but only 33% had used and 21% had purchased one. Noncombustible tobacco product use was associated with being male, non-Hispanic White, younger, and more nicotine dependent. Respondents used noncombustible tobacco products to cut down or quit cigarettes, but only snus was associated with a higher likelihood of making a quit attempt. Users of noncombustible tobacco products, particularly ENDS, were most likely to endorse the product as less harmful than cigarettes.Conclusions. Smokers may use noncombustible tobacco products to cut down or quit smoking. However, noncombustible tobacco product use was not associated with a reduction in cigarettes per day or cessation.The use of noncombustible tobacco products has increased rapidly in recent years1–3 and may continue to rise in response to restrictions such as smoke-free indoor air laws and rising cigarette taxes.4–8 Noncombustible tobacco products can be grouped into 2 broad categories—aerosolized products such as e-cigarettes, or more accurately termed electronic nicotine delivery systems (ENDS), which deliver nicotine primarily through vapor inhalation that mimics smoking a traditional cigarette,9 and smokeless tobacco products such as chew, dip, or snuff; snus; and dissolvables, which deliver nicotine via oral mucosal absorption.10 These products are marketed to appeal to unique target audiences,9,11–13 such as smokers and young adults, and vary in levels of harmful constituents.9Noncombustible tobacco products are a critical part of the tobacco industry’s strategy to navigate the changing tobacco product landscape. Phillip Morris14,15 and RJ Reynolds16 have announced their intent to develop and market noncombustible tobacco products as part of a shift to reduced harm products.17 In some cases, noncombustible tobacco products have been used to expand the appeal of established cigarette brands to a broader spectrum of consumers, as with RJ Reynolds’s Camel Snus product.18 Most ENDS are marketed and sold independently; however, this is changing with Lorillard’s acquisition of blu eCigs in 201219,20 and the recent launches of RJ Reynolds’s Vuse digital vapor cigarettes21,22 and Altria’s MarkTen e-cigarettes.23Noncombustible tobacco product awareness and prevalence vary by product. In 2010, approximately 40% of adults reported awareness of e-cigarettes,24,25 rising to nearly 60% in 201125; awareness approached 75% among current and former smokers in 2010 to 2011.26 Between 1.8% and 3.4% of the adult general population has tried an e-cigarette,24,25,27,28 including up to 21.2% of current smokers.25,26 More than 40% of adults have heard of snus,29 5% have tried the product,29 and 1.4% are current users.30 Awareness of dissolvables is low (10%), and use is even lower (0.5%).29 Noncombustible tobacco product use is highest among young adults26,31 and smokers.24,27,28Although use of noncombustible tobacco products could potentially reduce harm associated with smoking if they replace cigarettes,32,33 some studies suggest that current smokers who use noncombustible tobacco products do not reduce combustible use and may delay cessation.12,34–37 For example, a study by Wetter et al.38 found that dual users of smokeless tobacco products and cigarettes were less likely to quit than were either smokeless tobacco product or cigarette users alone. This is of concern given the rising rates of dual use; a recent study reported that 30% of young adults who smoke cigarettes use at least 1 other tobacco product.31 Dual use is more prevalent among men,39,40 those of lower socioeconomic status,39,41 and youths and young adults.35,41,42Studies show that most users (65%–85%) perceive ENDS as less harmful than cigarettes,24,26,43 and 40% to 50% perceive snus and dissolvables as equally harmful as cigarettes.29 Few studies have examined reasons for use; one study of visitors to ENDS and smoking cessation Web sites found that nearly 85% used ENDS because they believed that they were less toxic than tobacco; other responses included use of ENDS to deal with cravings or withdrawal, to quit smoking, and to save money.43 Focus group research has shown that adults associate snus and dissolvables with historic images of chewing tobacco,34,44 express skepticism that the products are safer than cigarettes,34 do not view them as substitutes for cigarettes,34,44 and express concern about the user’s lack of control of nicotine ingestion relative to cigarettes.44 By contrast, young adults expressed positive perceptions of snus, dissolvables, and ENDS, in part because of a willingness to experiment with new products and because they are available in flavors.45With the ever-changing tobacco marketplace and the tobacco companies’ commitment to the development and promotion of noncombustible tobacco products, surveillance is critical. This study built on previous research to provide current estimates of noncombustible tobacco product use among current and former smokers and examined harm perceptions of noncombustible tobacco products and reasons for their use.