E-Cigarette Use in the Past and Quitting Behavior in the Future: A Population-Based Study

Objectives. We examined whether smokers who used e-cigarettes are more likely to quit after 1 year than smokers who had never used e-cigarettes.Methods. We surveyed California smokers (n = 1000) at 2 time points 1 year apart. We conducted logistic regression analyses to determine whether history of e-cigarette use at baseline predicted quitting behavior at follow-up, adjusting for demographics and smoking behavior at baseline. We limited analyses to smokers who reported consistent e-cigarette behavior at baseline and follow-up.Results. Compared with smokers who never used e-cigarettes, smokers who ever used e-cigarettes were significantly less likely to decrease cigarette consumption (odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.30, 0.87), and significantly less likely to quit for 30 days or more at follow-up (OR = 0.41; 95% CI = 0.18, 0.93). Ever-users of e-cigarettes were more likely to report a quit attempt, although this was not statistically significant (OR = 1.15; 95% CI = 0.67, 1.97).Conclusions. Smokers who have used e-cigarettes may be at increased risk for not being able to quit smoking. These findings, which need to be confirmed by longer-term cohort studies, have important policy and regulation implications regarding the use of e-cigarettes among smokers.The use of electronic cigarettes (e-cigarettes)—also known as electronic nicotine delivery systems, personal vaporizers, and vaping cigarettes—is a recent and rapidly expanding phenomenon. These names refer to a battery-operated device that electronically heats a liquid (sometime referred to as “e-juice”) containing nicotine and propylene glycol, plus flavors, to create a misty vapor mimicking cigarette smoke that is inhaled by the smoker (who is commonly known as the “vaper”). This increasing use of e-cigarettes has become a controversial issue among health professionals, policymakers, vapers, and the general public. According to the surgeon general’s recent recommendations, e-cigarettes need to be regulated and their use in the population closely monitored, especially given the doubling of use among youths within just 1 year (between 2011 and 2012).1The main controversy surrounding the use of e-cigarettes is whether they are of benefit to smokers, as an alternative to cigarettes and for harm reduction, or whether they cause more harm to society by introducing and propagating new forms of nicotine addiction.2 At present, there is a scarcity of data to help guide decisions regarding the potential harm versus benefits of e-cigarettes, a situation that has led to claims and counterclaims by opponents and proponents of e-cigarette use.3 If smokers quit traditional cigarettes and instead use e-cigarettes to maintain their nicotine addiction (but without the degree of exposure to known carcinogenic byproducts of tobacco combustion), this may be a viable harm reduction strategy that can become a powerful tool for tobacco control.Most of the evidence that users and proponents of e-cigarettes employ have been anecdotal and not scientifically validated; recently, however, more studies on this topic have appeared. One of the first, a pilot study funded by the manufacturers of an e-cigarette brand from Italy, included 40 smokers who were given e-cigarettes and followed up for 24 weeks. The authors reported a 22.5% rate of sustained abstinence from cigarettes among e-cigarette users, a rate comparable to the effects of nicotine replacement therapy in experimental settings.4 However, this study was underpowered because of the small number of participants. A more recent and larger 3-arm trial of e-cigarette use from New Zealand randomized participants to use e-cigarettes (nicotine or placebo) or nicotine patches to quit smoking. Abstinence rates at 6-month follow-up were low across conditions (4.1%–7.8%), with the highest rate found with nicotine e-cigarettes and the lowest with placebo e-cigarettes,5 but no significant differences emerged. In addition to its low statistical power, the study included a potential methodological bias because those in the e-cigarette arm of the trial were mailed the device and cartridges while those in the nicotine patch arm were mailed a voucher (thus requiring that they obtain the nicotine patches). The difference in dose of nicotine and type of e-cigarettes is an additional major limiting factor in interpreting these results across different studies.An earlier study of a convenience sample of 81 ever-users of e-cigarettes concluded that most participants were using them to quit smoking,6 but it provided no clear indication of how successful they were. A larger follow-up survey of e-cigarette users by the same authors indicated that almost all former smokers (96%) agreed that e-cigarettes helped them quit smoking and 57.7% of current smokers believed that e-cigarettes would help them quit or avoid relapsing.7 However, these studies were biased toward self-selected current users without any comparison groups, and the actual influence on quitting among ever-users versus never-users is unknown. More recently, a meta-analysis by Grana et al. found that all 4 prospective studies that assessed the influence of e-cigarette use on quitting behavior found that e-cigarette use did not assist smokers in quitting.8We prospectively assessed how ever using e-cigarettes, compared with never using them, affected abstinence and smoking habits among smokers in the general population. Given that previous data suggest that smokers mostly use e-cigarettes to quit smoking, we hypothesized that smokers in the general population who have tried or who currently use e-cigarettes are more likely to succeed in quitting than smokers who never used them, after controlling for level of addiction, quitting intentions, and smoking behavior.     

The Impact of Trying Electronic Cigarettes on Cigarette Smoking by College Students: A Prospective Analysis

Objectives. We assessed the impact of trying electronic cigarettes (e-cigarettes) on future cigarette smoking in a sample of smokers enrolled in college.Methods. In this longitudinal study, first-semester college students at 7 colleges in North Carolina and 4 in Virginia completed a baseline survey and 5 follow-up surveys between fall 2010 and fall 2013. Current cigarette smoking at wave 6 was the primary outcome. Participants (n = 271) reported current cigarette smoking at baseline and no history of e-cigarette use. We measured trying e-cigarettes at each wave, defined as use in the past 6 months.Results. By wave 5, 43.5% had tried e-cigarettes. Even after controlling for other variables associated with cigarette smoking, trying e-cigarettes was a significant predictor of cigarette smoking at wave 6 (adjusted odds ratio [AOR] = 2.48; 95% confidence interval [CI] = 1.32, 4.66), as were friends’ cigarette smoking (AOR = 4.20; 95% CI = 2.22, 7.96) and lifetime use of other tobacco products (AOR = 1.63; 95% CI = 1.22, 2.17).Conclusions. Trying e-cigarettes during college did not deter cigarette smoking and may have contributed to continued smoking.There has been considerable growth in the availability, marketing, sales, and use of electronic nicotine delivery systems, often referred to as “e-cigarettes,” over the past several years. Product sales in the United States have doubled every year since 2008, and securities analysts estimate the e-cigarette market is now approximately a $2.5 billion industry.1 E-cigarette use has rapidly increased among adolescents and adults. From 2011 to 2012, rates of ever using e-cigarettes among US middle and high school students doubled from 3.3% to 6.8%.2 Similar increases have been seen among US adults.3,4 Recent data suggest that e-cigarette use is highest among young adults. Data from the 2012–2013 National Adult Tobacco Survey show that young adults aged 18 to 24 years had a higher prevalence of e-cigarette use (8.3%) than did the adult population as a whole (4.2%).5 Similarly, with data from dual frame surveys of national probability samples of adults, McMillen et al. found that current e-cigarette use in 2013 by young adults aged 18 to 24 years (14.2%) was higher than was that among adults aged 25 to 44 years (8.6%), 45 to 65 years (5.5%), and older than 65 years (1.2%).4Available data on e-cigarette use by college students are limited, with most coming from single-state or individual campus studies.6–9 College students are an important group to study for several reasons. First, young adulthood is a period of many life transitions and accompanying stress.10 The tobacco industry is well aware of this vulnerable period and recognizes it as a promising period for tobacco use initiation and transition to addiction.11 Thus, college students are a target market for the tobacco industry.11,12 College students are often early adopters of novel products and have historically been at the forefront of societal changes in substance use that later materialize in the general population.13 In a cross-sectional study of college students in North Carolina in 2009, Sutfin et al.6 found that college students’ lifetime prevalence of e-cigarette use was 4.9%, which was higher than were rates of use among other adults at the time,14,15 suggesting that college students were early adopters of e-cigarettes.6Additionally, there was an association between e-cigarette use and sensation seeking in bivariate, but not multivariable, models. However, membership in Greek letter organizations was associated with e-cigarette use in multivariable models. These data suggest that college students may be drawn to e-cigarettes owing, at least in part, to their novelty. Finally, college students are an important group to study because they have a unique pattern of cigarette smoking that is often marked by social and occasional smoking.16–18 Studying how e-cigarettes are used by this group and how use may affect cigarette smoking is important for understanding the ultimate public health impact of this product.Only a handful of longitudinal studies have assessed the relationship between e-cigarette use and subsequent cigarette smoking behavior. However, studying how people use this product is critical to our understanding of the overall public health effects. To date, 6 observational longitudinal studies have been published, with just 3 using population-based samples. Five studies found either no association between e-cigarette use and quitting cigarettes or an association with lower odds of quitting cigarettes,19–23 with 1 study finding e-cigarette use associated with a reduction in the number of cigarettes smoked.19 However, only 1 study assessed the intensity of e-cigarette use and associations with quitting cigarettes.24 Results revealed that the most intensive e-cigarette users at follow-up (daily users for at least 1 month) were more likely to have quit smoking (1 month abstinence). However, intermittent e-cigarette use (using e-cigarettes regularly but not daily for more than 1 month) was not associated with increased quitting. Only 1 longitudinal study focused on young adults; to our knowledge, no longitudinal studies have focused on college students.22We measured the impact of e-cigarette use during the college years on current cigarette smoking. We included those who reported current cigarette smoking at baseline with no history of e-cigarette use. We measured trying e-cigarettes during the subsequent 4 waves and current cigarette smoking at wave 6, which corresponded to fall 2013. For most participants, wave 6 was during the fall of senior year.     

e-Cigarette Awareness,Use, and Harm Perceptions in US Adults

Objectives. We estimated e-cigarette (electronic nicotine delivery system) awareness, use, and harm perceptions among US adults.Methods. We drew data from 2 surveys conducted in 2010: a national online study (n = 2649) and the Legacy Longitudinal Smoker Cohort (n = 3658). We used multivariable models to examine e-cigarette awareness, use, and harm perceptions.Results. In the online survey, 40.2% (95% confidence interval [CI] = 37.3, 43.1) had heard of e-cigarettes, with awareness highest among current smokers. Utilization was higher among current smokers (11.4%; 95% CI = 9.3, 14.0) than in the total population (3.4%; 95% CI = 2.6, 4.2), with 2.0% (95% CI = 1.0, 3.8) of former smokers and 0.8% (95% CI = 0.35, 1.7) of never-smokers ever using e-cigarettes. In both surveys, non-Hispanic Whites, current smokers, young adults, and those with at least a high-school diploma were most likely to perceive e-cigarettes as less harmful than regular cigarettes.Conclusions. Awareness of e-cigarettes is high, and use among current and former smokers is evident. We recommend product regulation and careful surveillance to monitor public health impact and emerging utilization patterns, and to ascertain why, how, and under what conditions e-cigarettes are being used.A heterogeneous collection of battery-driven nicotine inhalers—“e-cigarettes” or electronic nicotine delivery systems (ENDS)—are emerging products receiving considerable advocacy, policy, and media attention.1 ENDS have been marketed as harm-reducing alternatives to smoking and used as cessation aids, though the US Food and Drug Administration (FDA) has not reviewed these claims or devices.2,3 Independent testing of ENDS has demonstrated poor quality control,2,4 low-level toxic contaminants,5 variable nicotine delivery,2,6,7 and insufficient evidence of overall public health benefit.8 Packaging and Web sites for ENDS reveal unsubstantiated health claims and erroneous nicotine content labeling.4 In addition, their wide combination of flavorings and “high-tech” image are potentially attractive to youths and young adults.2,4 In 2010, the World Health Organization recommended that ENDS products be regulated as combination drug and medical devices.1 Consistent with this recommendation, several countries, such as Australia and Canada, restricted or banned ENDS until reviewed by their regulatory agencies.9,10 A 2009 court decision (Sottera Inc v. Food and Drug Administration)11 blocked the FDA from regulating ENDS as drug delivery devices in the United States, ruling that products containing nicotine derived from tobacco are “tobacco products” under the 2009 Family Smoking Prevention and Tobacco Control Act unless they are sold as therapeutic aids for cessation.12 In keeping with this ruling, on April 25, 2011, the FDA announced its intention to regulate ENDS as tobacco products. The nature of the FDA’s ENDS regulation procedure has yet to be determined; until that time, ENDS will likely continue to be sold to consumers without regulation, raising serious concerns for public health.Although variations of ENDS have been on the market since at least 2007,13 little is known about the population prevalence of ENDS use in representative samples. One study examined Google searches and reported a sharp increase from 2008 to 2010 in queries, with ENDS search terms receiving more hits than nicotine patches and snus.14 Although this suggests relative increased interest, the denominators are unknown. In a European study, Etter et al.15 posted a survey in French for 34 days on a cessation Web site (http://www.stop-tabac.ch), which typically obtains about 120 000 visitors a month. Of 214 respondents, 81 eligible ENDS users reported mainly using ENDS for cessation or to avoid disturbing others; some were concerned about potential ENDS toxicity.16 Another online survey17 of first-time ENDS purchasers yielded a response proportion of only 4.5%; considering this low percentage, participants are not likely representative of ENDS purchasers and results are difficult to interpret. In a 2009 Zogby opinion poll, 59% of Americans supported FDA regulation of ENDS, with almost half (47%) saying that ENDS should be made available for people who want to quit smoking.18There are several widely cited and as yet unaddressed concerns regarding the effect of ENDS on public health. First is the concern that ENDS could act as a starter product for combustible cigarettes, especially among youths or young adults who may be attracted to their “tech” image or flavorings.3,19 Other concerns include that ENDS may lure former smokers to return to nicotine dependence, delay cessation among current smokers,2,3 serve as a dual-use product, or enable individuals to avoid smoking restrictions.19 Despite these gaps in our knowledge, there are no reliable national estimates of ENDS awareness, utilization, or harm perceptions in the peer-reviewed literature. Furthermore, other than the 2009 Zogby poll, no investigation of ENDS among nonsmokers is evident.18 This study makes an initial contribution to address some of these pressing knowledge gaps by using cross-sectional data from 2 separate surveys conducted in 2010, 1 nationally representative and 1 from the follow-up of a large cohort of current smokers and recent former smokers, to estimate ENDS awareness, use, and harm perceptions in the adult US population.     

Comparison of Smoking Cessation Between Education Groups: Findings From 2 US National Surveys Over 2 Decades

Objectives. We examined smoking cessation rate by education and determined how much of the difference can be attributed to the rate of quit attempts and how much to the success of these attempts.Methods. We analyzed data from the National Health Interview Survey (NHIS, 1991–2010) and the Tobacco Use Supplement to the Current Population Survey (TUS-CPS, 1992–2011). Smokers (≥ 25 years) were divided into lower- and higher-education groups (≤ 12 years and > 12 years).Results. A significant difference in cessation rate between the lower- and the higher-education groups persisted over the last 2 decades. On average, the annual cessation rate for the former was about two thirds that of the latter (3.5% vs 5.2%; P < .001, for both NHIS and TUS-CPS). About half the difference in cessation rate can be attributed to the difference in quit attempt rate and half to the difference in success rate.Conclusions. Smokers in the lower-education group have consistently lagged behind their higher-education counterparts in quitting. In addition to the usual concern about improving their success in quitting, tobacco control programs need to find ways to increase quit attempts in this group.It is well established that smoking prevalence is much higher among those with lower education than among those with higher education.1–6 However, the literature on the difference in cessation rate by education level is inconsistent.7,8 Given that the smoking prevalence of any group is determined by the rate at which nonsmokers take up cigarettes and current smokers quit smoking, it is important to understand if the disparity in smoking prevalence comes from uptake or cessation or both.9 This study examined cessation.Some studies have reported that smokers with less education find it more difficult to quit smoking.4,10–13 It has also been suggested that the disparity in cessation rate by education has increased over time.4 Other studies, however, have suggested that the smoking cessation rates are not significantly different between education groups.8,14–18 These studies suggest that once people have become established smokers, they find it equally difficult to quit regardless of education level. One study even reported the reverse association between education and cessation; smokers with less education were more successful at quitting than were those with more education.19The inconsistency in these reports may stem partly from the use of different samples. Some studies were based on clinical samples13,20,21 and others on population surveys.11,14,15 Some had larger samples,10,16 and others had relatively small samples.4,17 In addition, some studies adjusted for covariates such as family or personal income11,19 and motivation14,15 in their analysis, whereas others did not.13,17 These adjustments may help researchers understand what factors are correlated with education level, but they divert attention from the simpler question of whether a difference in the cessation rate is seen between education groups. In short, heterogeneity in study samples and analytical approaches contributed to inconsistencies in reports of whether cessation rates differed between groups with different levels of education.This study attempted to resolve this issue by analyzing data from 2 US nationally representative surveys with very large samples collected over 2 decades. The strength of large, nationally representative samples is the ability to provide statistically reliable estimates. Also, the long period of study allowed us to check for trends in the difference between education groups over time. We used 2 national surveys to determine whether the difference found in 1 survey can be replicated in the other. In addition, we separately examined the quit attempt rates and success rates of those quit attempts. We further quantified the difference in cessation rates, if any, by partitioning the difference into the difference in the rate of making quit attempts and the difference in the success of these quit attempts.     

Characteristics Associated With Awareness,Perceptions, and Use of Electronic Nicotine Delivery Systems Among Young US Midwestern Adults

Objectives. We assessed the characteristics associated with the awareness, perceptions, and use of electronic nicotine delivery systems (e-cigarettes) among young adults.Methods. We collected data in 2010–2011 from a cohort of 2624 US Midwestern adults aged 20 to 28 years. We assessed awareness and use of e-cigarettes, perceptions of them as a smoking cessation aid, and beliefs about their harmfulness and addictiveness relative to cigarettes and estimated their associations with demographic characteristics, smoking status, and peer smoking.Results. Overall, 69.9% of respondents were aware of e-cigarettes, 7.0% had ever used e-cigarettes, and 1.2% had used e-cigarettes in the past 30 days. Men, current and former smokers, and participants who had at least 1 close friend who smoked were more likely to be aware of and to have used e-cigarettes. Among those who were aware of e-cigarettes, 44.5% agreed e-cigarettes can help people quit smoking, 52.8% agreed e-cigarettes are less harmful than cigarettes, and 26.3% agreed e-cigarettes are less addictive than cigarettes.Conclusions. Health communication interventions to provide correct information about e-cigarettes and regulation of e-cigarette marketing may be effective in reducing young adults’ experimentation with e-cigarettes.Electronic nicotine delivery systems (commonly known as electronic cigarettes or e-cigarettes) are battery-operated vaporizing devices in the shape of a cigarette that deliver nicotine vapor to users. Although the product has been marketed as a safe alternative to cigarettes because it contains only nicotine and not the other harmful ingredients found in cigarettes,1 the US Food and Drug Administration2 showed that some tested samples of e-cigarettes also contained toxic substances such as tobacco-specific nitrosamines, and 1 contained diethylene glycol. Public health professionals are also concerned that e-cigarettes may impede the reduction in prevalence of smoking in the United States for 3 reasons.1,3–5 First, the product may weaken the effect of clean indoor air policies on smokers because smokers can use e-cigarettes as bridging products indoors, which may lessen their motivation to quit smoking. Second, smokers may use e-cigarettes instead of proven-effective smoking cessation treatments when trying to quit smoking even though the e-cigarettes’ effectiveness as quit aids is still largely unknown. Third, e-cigarettes may be gateways to cigarette smoking. Nonsmokers may experiment with e-cigarettes (especially when these products are flavored), develop nicotine addiction, and subsequently switch to smoking cigarettes.Examining the awareness, perceptions, and use of e-cigarettes among young adults is important because they may still be in the stage of initiating tobacco use.6 Furthermore, young adults are in general more likely to try new things.7 They may therefore pay more attention to new products such as e-cigarettes and be more likely to try e-cigarettes. This hypothesis is partially supported by findings from a national survey of US adults in 2010 showing that young adults (aged 18–24 years) were most likely to have heard of e-cigarettes (41.0%, vs 32.2% among all adults).8 Young adults also have a higher prevalence of tobacco use than any other age group, with 1 in 3 young adults smoking.6 E-cigarettes may delay young adults from quitting smoking, making it even harder to reduce a nearly static trend in young adult tobacco use. However, little is known about the characteristics associated with awareness and use of e-cigarettes among young adults. Investigators of the previous national survey did not examine the characteristics of awareness and use of e-cigarettes specific to this age group. 8 Young adults’ perceptions of e-cigarettes are largely unknown. We identified only 1 study that assessed the perceptions of e-cigarettes among an international sample of e-cigarette users recruited through the Internet,9 which reported that 83.5% of users believed e-cigarettes are less toxic than tobacco and 76.8% used e-cigarettes to quit smoking or avoid relapse. However, the investigators did not report the prevalence of these perceptions specific to young adults and did not assess the characteristics associated with these perceptions.In this study, we assessed the characteristics associated with awareness and use of e-cigarettes among young adults, using data from a population-based cohort study. We also assessed the characteristics associated with selected perceptions of e-cigarettes (potential to aid smoking cessation and harmfulness and addictiveness relative to cigarettes), as well as the associations between these perceptions and use of e-cigarettes.     

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.     

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.     

Association of Strong Smoke-Free Laws With Dentists’ Advice to Quit Smoking, 2006–2007

Objectives. We examined the association of smoke-free laws with dentists’ advice to quit smoking and referral to a quit line, among smokers who reported visiting the dentist in the past 12 months.Methods. We used the 2006 to 2007 Tobacco Use Supplement of the Current Population Survey merged with the American Nonsmokers'' Rights Foundation Local Ordinance Database of smoke-free laws. The dependent variables were advice from a dentist to quit smoking and referral to a quit line, and the independent variable of interest was 100% smoke-free law coverage. We controlled for respondent demographics and an index of state-level smoking ban attitudes (included to ensure that the effect detected was not the result of social attitudes).Results. Smoke-free law coverage was associated with dental advice to quit smoking (odds ratio [OR] = 1.27; 95% confidence interval [CI] = 1.01, 1.59; P = .041), but not with referral to a quit line (OR = 1.33; 95% CI = 0.79, 2.25; P = .283).Conclusions. Interventions with dentists are needed to increase referrals to quit lines and other smoking cessation efforts.Smoking causes oral disease and dental therapy failures.1–8 Tobacco cessation interventions delivered by dentists during oral examination are associated with cessation.9–12 Although dentists can effectively promote cessation, particularly when they receive training to do so,13–17 such practices are not widespread.18–22 The US Public Health Service clinical practice guidelines promote the 5A''s—ask about tobacco use, advise to quit, assess willingness to make a quit attempt, assist in the quit attempt, and arrange follow-up—as a standard tobacco use intervention.1 Implementing just part of the 5A''s, such as advising patients to quit, can affect patient behavior.16,17,23,24Several studies found that although oral health care providers are willing to implement the first 2 steps of the 5A''s (ask, advise) they are reluctant to implement the last 3 (assess, assist, and arrange).10,16,18,23,25 A survey of dentists in California, Pennsylvania, and West Virginia found that most dentists reported asking patients about tobacco use and advising them to quit, but fewer than half the dentists who asked about smoking provided follow-up or assistance with quitting.25 These low rates are similar to those of health care providers in other areas.18 As a result, some organizations advocate the 2A''s+R (ask, advise, refer to a quit line) model of intervention.26 A study that compared the effectiveness of the 5A''s and 2A''s+R models in dental settings found that a greater proportion of patients receiving the 5A''s intervention quit but that the 2 groups showed no significant difference in abstinence at the 12-month follow-up.26Strong smoke-free laws are associated with changes in norms, attitudes, and behaviors surrounding tobacco use. These smoke-free laws may also encourage dental care providers to perceive smoking as denormalized or increase the salience of tobacco use for these providers, so that they are more likely to recommend a smoking cessation intervention. In the United States, implementation of 100% smoke-free laws is associated with a reduction in smoking prevalence and consumption,27 decreased cardiovascular and pulmonary hospital admissions,28 voluntary smoke-free home rules,29 and reduced maternal smoking.30,31 We hypothesized that the implementation of 100% smoke-free laws would affect not only individual health-related behavior, but also health care provider behavior, particularly in an area, such as oral health, where cessation training is not yet routinely implemented. We examined the effect of 100% smoke-free laws on dentist implementation of the 2A''s+R model of intervention, particularly dental advice to quit and referral to a quit line, or cessation help line.     

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.     

A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors

Objectives. We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults.Methods. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data.Results. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy.Conclusions. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.Racial/ethnic minorities in the United States experience a disproportionate burden of smoking-related diseases, including cancer and heart disease, despite having larger proportions of light and intermittent smokers and generally lower adult smoking prevalence rates than non-Hispanic Whites.^1–3 Racial/ethnic minorities are also less likely to quit smoking successfully than are non-Hispanic Whites.^4–8 For example, rates of successful smoking cessation among African American smokers are lower than they are among non-Hispanic Whites, despite reports citing lower cigarette consumption.^2,5,7,9 Similarly, Hispanics/Latinos do not experience higher rates of successful quitting than non-Hispanic Whites, despite being more likely to be light and intermittent smokers.^2,9 There is currently no evidence indicating that Asian Americans quit at higher rates than non-Hispanic Whites in the United States.¹⁰ The examination of racial/ethnic disparities in smoking behaviors, successful quitting, and factors associated with quitting can provide valuable information for focusing strategies for groups currently experiencing lower rates of successful smoking cessation, and can lead to decreases in smoking-related disease rates across all racial/ethnic populations.Previous research on population-level data has found several factors to be associated with successful smoking cessation. For example, banning smoking in one''s home can greatly increase the chances of successfully quitting smoking. The presence of a complete ban on smoking in one''s home is associated with being quit for at least 90 days¹¹ and with being a former smoker.¹² However, an analysis of national data found that smaller percentages of non-Hispanic Whites (64.0%) and African Americans (64.4%) have a complete home smoking ban than do Hispanics/Latinos (78.0%) and Asian Americans/Pacific Islanders (79.2%).¹³ Being advised to quit smoking by health care professionals, especially physicians, has also been associated with increased rates of smoking cessation.^14–17 Despite progress in smokers being advised to quit by health care practitioners in the past 5 years, African American and Hispanic/Latino smokers remain less likely than non-Hispanic Whites to be advised to quit.^16,18 Finally, although evidence of the effectiveness of nicotine replacement therapy (NRT) at the population level has been challenged recently,^19,20 there is evidence that NRT can aid successful cessation.^17,21–23 There is substantial evidence that racial/ethnic minorities are less likely to be prescribed NRT^14,15,18 and to use NRT to quit smoking.^23–25The Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) have provided invaluable data for the examination of various smoking-related issues at the national level.^11,13 In 2003, the TUS-CPS included a special supplement that focused heavily on smoking cessation. This supplement was the first TUS-CPS with this focus (and is the only one to date), and it provides arguably the richest representative national-level data on smoking cessation in the United States. This special supplement thus presented a unique opportunity to examine in detail the disparities between racial/ethnic groups in smoking cessation and important related factors.For our study, we hypothesized the following: (1) African Americans would experience less success in quitting smoking than would non-Hispanic Whites, (2) Asian Americans/Pacific Islanders and Hispanics/Latinos would be more likely to have a complete home smoking ban than would non-Hispanic Whites, (3) African Americans and Hispanics/Latinos would be less likely than would non-Hispanic Whites to report being advised by a health professional to quit smoking, and (4) racial/ethnic minorities would be less likely to use NRT than would non-Hispanic Whites.To examine these hypotheses, we conducted a secondary data analysis of the 2003 TUS-CPS to assess smoking cessation rates and examine how factors associated with successful smoking cessation differed across racial/ethnic groups among adults in the United States. Findings from this report may provide insight into optimal design of targeted smoking cessation interventions for members of specific racial/ethnic groups.     

Efficacy of Initiating Tobacco Dependence Treatment in Inpatient Psychiatry: A Randomized Controlled Trial

Objectives. We evaluated the efficacy of a motivational tobacco cessation treatment combined with nicotine replacement relative to usual care initiated in inpatient psychiatry.Methods. We randomized participants (n = 224; 79% recruitment rate) recruited from a locked acute psychiatry unit with a 100% smoking ban to intervention or usual care. Prior to hospitalization, participants averaged 19 (SD = 12) cigarettes per day; only 16% intended to quit smoking in the next 30 days.Results. Verified smoking 7-day point prevalence abstinence was significantly higher for intervention than usual care at month 3 (13.9% vs 3.2%), 6 (14.4% vs 6.5%), 12 (19.4% vs 10.9%), and 18 (20.0% vs 7.7%; odds ratio [OR] = 3.15; 95% confidence interval [CI] = 1.22, 8.14; P = .018; retention > 80%). Psychiatric measures did not predict abstinence; measures of motivation and tobacco dependence did. The usual care group had a significantly greater likelihood than the intervention group of psychiatric rehospitalization (adjusted OR = 1.92; 95% CI = 1.06, 3.49).Conclusions. The findings support initiation of motivationally tailored tobacco cessation treatment during acute psychiatric hospitalization. Psychiatric severity did not moderate treatment efficacy, and cessation treatment appeared to decrease rehospitalization risk, perhaps by providing broader therapeutic benefit.Tobacco use among persons with mental illness is 2 to 4 times as great as among the general US population, with costly and deadly consequences.1–3 Persons with serious mental illness have an average life expectancy 25 years shorter than in the general population; the chief causes of death are chronic tobacco-related diseases such as cardiovascular disease, lung disease, and cancer.4 Annually, 200 000 of the 435 000 deaths in the United States attributed to smoking are believed to be among individuals with mental illness or addictive disorders.5Despite the significant health effects, smoking remains ignored or—even worse—encouraged in mental health settings.6,7 A minority of patients with mental illness report that a mental health provider has advised them to quit smoking, and some report active discouragement of quitting.8,9 Staff at some psychiatric hospitals still smoke with patients, rationalized as effective for building clinician–client rapport.10Since 1993, US hospitals have banned tobacco use under mandate of the Joint Commission on the Accreditation of Healthcare Organizations.11 In response to outcries from patient advocacy groups, however, the commission permitted an exception for inpatient psychiatry; similar policy exemptions have been granted to psychiatric facilities in Europe and Australia.12–14 Nearly 20 years later, more than half of state inpatient psychiatry units in the United States permit smoking, and half sell cigarettes to patients.15 Even among hospitals that ban tobacco use, cessation advice and treatment are rare.15,16 Without intervention, almost all patients return to smoking after a smoke-free psychiatric hospitalization, most within minutes of hospital discharge.8 Integrated treatments are needed.Nearly 8800 studies inform tobacco treatment clinical practice guidelines,17 and an extensive literature documents the efficacy of initiating treatment of tobacco dependence in hospital settings with general medical patients.18 Yet fewer than 2 dozen randomized clinical trials have treated smoking in persons with current mental illness,19 and the only published randomized trial examining inpatient psychiatry for initiating tobacco treatment was conducted with adolescents. The intervention group increased in motivation to quit, but the treatment effect on abstinence was not significant.20 The American Psychiatric Association identifies psychiatric hospitalizations as an ideal opportunity to treat tobacco dependence.21 Hospital-based tobacco treatment trials with the seriously mentally ill are needed to inform clinical practice guidelines.An obstacle to tobacco treatment in mental health settings has been concern that termination of cigarette smoking will increase psychiatric symptoms. Many in the clinical, research, and public arenas believe that tobacco use serves as a form of self-medication for persons with psychiatric disorders.22,23 If this were true, psychiatric symptoms would be expected to worsen and mental health service use to increase following treatment of tobacco use. Tobacco treatment trials with smokers with clinical depression, posttraumatic stress disorder, and schizophrenia, however, have demonstrated no adverse effect of treating tobacco dependence or of quitting smoking on mental health recovery.24–29Research has not examined the impact of treating tobacco dependence during an acute psychiatric hospitalization on mental health recovery. Patients for whom inpatient psychiatric care is deemed necessary typically present as suicidal, homicidal, or gravely disabled. The average length of inpatient psychiatric stay in the United States is about a week, and readmissions are common.8,16 Among patients hospitalized for mental illness in California in 2005 and 2006, 44% were rehospitalized within 12 months, reflecting the remitting and recurring natural course of many mental illnesses.30 In the literature, predictors of psychiatric hospitalization include psychosis, race/ethnicity (higher for African Americans), low socioeconomic status, and previous hospitalizations.24,31We evaluated the efficacy of a tobacco cessation intervention initiated with adult smokers during an acute inpatient psychiatric hospitalization. The setting was a locked unit with a complete smoking ban that managed patients’ nicotine withdrawal with nicotine replacement therapy (NRT) during hospitalization but did not provide cessation services, discharge NRT, or treatment referrals. Hospitalization in the acute psychiatric setting tends to be brief and unrelated to smoking. Furthermore, few patients hospitalized for psychiatric illness intend to quit smoking in the next 30 days.8,32,33 For this reason, we focused on increasing motivation and engagement during a brief period of institutionalized abstinence and offered cessation treatment and access to 10 weeks of NRT up to 6 months following hospital discharge.Our primary hypothesis was that participants randomized to the smoking cessation intervention would achieve greater 7-day point prevalence tobacco abstinence over 18 months after hospitalization than participants randomized to the usual care control condition. We examined psychiatric variables predictive of cessation success or failure. Our secondary aim was to assess the impact of the tobacco cessation intervention on mental health recovery and prediction of rehospitalization over the 18-month study follow-up, with adjustment for relevant clinical covariates.     

Snus Use and Smoking Behaviors: Preliminary Findings From a Prospective Cohort Study Among US Midwest Young Adults

The effect of snus use on smoking behaviors among US young adults is largely unknown. Data from the Minnesota Adolescent Community Cohort Study collected in 2010 to 2011 and 2011 to 2012 (participants aged 20–28 years) showed that young adult nonsmokers who had tried snus were subsequently more likely than those who had not tried snus to become current smokers (n = 1696; adjusted odds ratio = 1.79; 95% confidence interval = 1.01, 3.14). Snus use was not associated with subsequent smoking cessation or reduction among young adult current smokers (n = 488; P > .46).Tobacco use is the leading preventable cause of death in the United States.1 Snus, made of finely cut smokeless tobacco leaves packaged in small bags, was recently introduced in the United States and sales reached more than 1 million pounds in 2011.2 Swedish studies found that snus use was not associated with smoking initiation but was positively associated with smoking cessation.3,4 However, a US study showed that the effect of snus use in Sweden is unlikely to be replicated in the United States, at least on smoking cessation.5To date, no longitudinal studies have examined whether snus use promotes smoking among nonsmokers, or cessation among smokers, in young adults in the United States, who are still developing their tobacco use behaviors and have the highest prevalence of smoking in all ages.6,7 We used data collected from the Minnesota Adolescent Community Cohort Study to examine if snus use was associated with progression of smoking among young adult nonsmokers and smoking cessation and reduction among young adult current smokers.     

Influence of Point-of-Sale Tobacco Displays and Graphic Health Warning Signs on Adults: Evidence From a Virtual Store Experimental Study

Objectives. We tested the impact of banning tobacco displays and posting graphic health warning signs at the point of sale (POS).Methods. We designed 3 variations of the tobacco product display (open, enclosed [not visible], enclosed with pro-tobacco ads) and 2 variations of the warning sign (present vs absent) with virtual store software. In December 2011 and January 2012, we randomized a national convenience sample of 1216 adult smokers and recent quitters to 1 of 6 store conditions and gave them a shopping task. We tested for the main effects of the enclosed display, the sign, and their interaction on urge to smoke and tobacco purchase attempts.Results. The enclosed display significantly lowered current smokers’ (B = −7.05; 95% confidence interval [CI] = −13.20, −0.91; P < .05) and recent quitters’ (Β = −6.00, 95% CI = −11.00, −1.00; P < .01) urge to smoke and current smokers’ purchase attempts (adjusted odds ratio = 0.06; 95% CI = 0.03, 0.11; P < .01). The warning sign had no significant main effect on study outcomes or interaction with enclosed display.Conclusions. These data show that POS tobacco displays influence purchase behavior. Banning them may reduce cues to smoke and unplanned tobacco purchases.Smoking is the leading cause of preventable mortality in the United States, accounting for approximately 443 000 deaths each year.1 Currently, 19.3% of US adults smoke cigarettes, and nearly half attempt to quit smoking each year.2 However, approximately 90% of smokers who attempt to quit relapse within 6 months,3–6 and relapses may occur years after quitting.7 The tobacco industry aggressively markets its products to consumers, spending nearly 90% of its $8 billion marketing budget on promotional allowances to retailers and advertising and price promotions at the point of sale (POS), making retail stores the most important advertising channel for the industry.8 Retail cigarette advertising and promotions have increased over time,9,10 and cigarette products are prominently placed on shelves behind checkout counters, exposing all store customers to tobacco products, including youths and adults who do not smoke or have recently quit.Tobacco ads and displays may act as cues to smoke,11–13 stimulate purchases among customers who did not intend to buy cigarettes,14,15 and influence relapse among recent quitters by stimulating cravings for cigarettes.16 In a telephone survey of Australian adults, Wakefield et al. found that 55.3% noticed POS displays often or always and 25.2% bought cigarettes as a result of seeing displays when shopping for something other than cigarettes.15 Among respondents who had attempted to quit smoking in the past 12 months, 37.7% reported that seeing the tobacco displays increased their urge to purchase cigarettes and 60.9% bought cigarettes even though they were trying to quit. Carter et al. conducted intercept surveys with shoppers outside supermarkets to examine the influence of tobacco displays at the time of purchase and found similar patterns: approximately 22% reported unplanned cigarette purchases, with nearly half (47%) influenced by tobacco displays.14 In a cohort study, Germain et al. found that smokers with moderate or high sensitivity to tobacco displays at baseline were significantly less likely to quit smoking at follow-up than were those with low sensitivity (moderate, odds ratio [OR] = 0.32; 95% confidence interval [CI] = 0.14, 0.74; P = .007; high, OR = 0.27; 95% CI = 0.08, 0.91; P = .035).16 Laboratory-based cue reactivity studies show that drug-dependent individuals react strongly to cues associated with past or current drug use, including nicotine; viewing images such as cigarette packs or other people smoking can elicit subjective cigarette craving and psychophysiological arousal (e.g., increased heart rate).17,18The federal Family Smoking Prevention and Tobacco Control Act of 200919 gives state and local governments legal authority to regulate the time, place, and manner of tobacco advertising. To date, state and local governments have attempted to ban tobacco displays and mandate graphic health warning signs at the POS. Tobacco product displays have been banned in Ireland, Canada, and Australia, but not in the United States. Studies show that graphic antismoking advertising can elicit strong emotional responses from smokers and influence them to quit.20 However, these studies have largely focused on media campaign advertising and cigarette pack warning labels, and it is unclear whether posting similar messages at the POS will have the same impact. In 2009, New York City required licensed tobacco retailers to post graphic warning signs at the POS. Coady et al. conducted street intercept surveys with adult smokers and recent quitters before and after policy implementation and found that signs increased awareness about the health risks of smoking and thoughts about quitting smoking but did not deter smokers from purchasing cigarettes.21 However, street intercept interviews are subject to social response bias and cannot adequately control for potential confounders.To test the potential impact of these policies on US adults, we designed a virtual store experiment. Virtual reality applications simulate real-world environments and are useful for studying behavioral responses to environmental cues that may be difficult to assess in a real-life setting.22–24 Virtual environments have been used to examine the impact of banning POS tobacco displays and ads on youths,25 consumer food-purchasing decisions,26 and the effects of smoking cues on cigarette cravings among adults.27,28 Virtual reality studies examining cravings in smokers suggest that these techniques may be more effective and have stronger ecological validity than traditional methods (e.g., photos) for triggering and assessing craving.28–32 We randomized adult smokers and recent quitters to virtual store conditions and had them conduct a shopping task to assess whether exposure to an enclosed tobacco product display and a graphic health warning sign decreased urges to smoke and tobacco purchase attempts.     

Quit attempts and quit rates among menthol and nonmenthol smokers in the United States

Objectives. We compared quit attempts and quit rates among menthol and nonmenthol cigarette smokers in the United States.Methods. We used data from the 2003 and 2006–2007 waves of the large, nationally representative Tobacco Use Supplement to the Current Population Survey with control for state-level tobacco control spending, prices, and smoke-free air laws. We estimated mean prevalence, quit rates, and multivariate logistic regression equations by using self-respondent weights for menthol and nonmenthol smokers.Results. In 2003 and 2007, 70% of smokers smoked nonmenthol cigarettes, 26% smoked menthol cigarettes, and 4% had no preference. Quit attempts were 4.3% higher in 2003 and 8.8% higher in 2007 among menthol than nonmenthol smokers. The likelihood of quitting was 3.5% lower for quitting in the past year and 6% lower for quitting in the past 5 years in menthol compared with nonmenthol smokers. Quit success in the past 5 years was further eroded among menthol-smoking Blacks and young adults.Conclusions. Menthol smokers are more likely to make quit attempts, but are less successful at staying quit. The creation of menthol preference through marketing may reduce quit success.On June 22, 2009, the Family Smoking Prevention and Tobacco Control Act was signed into law, granting the US Food and Drug Administration (FDA) the authority to regulate tobacco products by establishing the Center for Tobacco Products (CTP). As one of the first activities of the CTP, the FDA will review evidence on the impact of menthol in cigarettes on the public health to determine whether to recommend removal of mentholated cigarettes from the US market. Regarding the process of making decisions for a proposed ban on menthol in cigarettes, the act specifies that scientific evidence be considered with a broad population-based standard rather than a narrow individual standard. Specifically, the CTP must consider (1) the risks and benefits to the population as a whole, including users and nonusers of tobacco products, (2) the increased or decreased likelihood that existing users of tobacco products will stop using such products, and (3) the increased or decreased likelihood that those who do not use tobacco products will start using such products.¹In 2008, more than one third (33.9%) of past-month smokers aged 12 years and older reported smoking menthol cigarettes²; this rate equates to more than 10 million menthol smokers in the United States.³ The prevalence of menthol cigarette use is highest among Black smokers (82.6%) and young smokers (44.8%)²—2 groups that have been the target of menthol cigarette marketing by the tobacco industry.^4–6 Studies of youths indicate that menthol flavoring affects smoking initiation, with higher proportions of recent initiates smoking mentholated cigarettes compared with those who have been smoking more than 1 year,^2,7 and that middle-school smokers are more likely to smoke menthol cigarettes than are high-school smokers.⁷Recent research also suggests that smoking menthol cigarettes negatively influences smoking cessation among adults. One randomized controlled study showed no difference in 7-day point prevalence abstinence between menthol and nonmenthol smokers at 6 months,⁸ but 2 other studies^9,10 reported reduced cessation among menthol smokers, though results were not consistent across all follow-up time points. Of 5 population studies examining differences in smoking cessation by menthol cigarette use,^11–15 the 2 more recent studies reported significantly lower quit rates among menthol smokers compared with nonmenthol smokers at follow-up.^13,15 Gandhi et al.¹⁵ and Gundersen et al.¹³ also highlighted reduced cessation among Black and Latino menthol smokers. Few studies have explored the impact of menthol cigarette use on smoking cessation in large population-based studies. We used a large, recent national- and state-representative data set to examine quit rates among menthol and nonmenthol cigarette smokers. Unlike previous population studies, we explicitly considered the role of quit attempts and also controlled for the state tobacco control policies.     

Recall of Anti-Tobacco Advertisements and Effects on Quitting Behavior: Results From the California Smokers Cohort

Objectives. We assessed whether an anti-tobacco television advertisement called “Stages,” which depicted a woman giving a brief emotional narrative of her experiences with tobacco use, would be recalled more often and have a greater effect on smoking cessation than 3 other advertisements with different intended themes.Methods. Our data were derived from a sample of 2596 California adult smokers. We used multivariable log-binomial and modified Poisson regression models to calculate respondents’ probability of quitting as a result of advertisement recall.Results. More respondents recalled the “Stages” ad (58.5%) than the 3 other ads (23.1%, 23.4%, and 25.6%; P < .001). Respondents who recalled “Stages” at baseline had a higher probability than those who did not recall the ad of making a quit attempt between baseline and follow-up (adjusted risk ratio [RR] = 1.18; 95% confidence interval [CI] = 1.03, 1.34) and a higher probability of being in a period of smoking abstinence for at least a month at follow-up (adjusted RR = 1.55; 95% CI = 1.02, 2.37).Conclusions. Anti-tobacco television advertisements that depict visceral and personal messages may be recalled by a larger percentage of smokers and may have a greater impact on smoking cessation than other types of advertisements.Globally, one person dies from exposure to tobacco smoke every 6 seconds.1 Even in the United States, tobacco smoke exposure remains the leading cause of preventable death, with an estimated 480 000 adults dying from tobacco smoke exposure each year.2 Although the effects of tobacco smoke exposure are most severe among individuals who smoke on a daily basis, nondaily smoking and secondhand smoke exposure can lead to the same negative health consequences that result from daily smoking.3 Increasing smoking cessation, however, can significantly improve life expectancy; lower the risk of cancer, diabetes, heart disease, and lung disease; and, among women, lower the risk of infertility or low-birthweight children.2,4–7 Although the benefits of cessation are most prominent among the young, cessation at any age can immediately improve health outcomes.4It is recommended that tobacco control programs develop mass-reach health communication interventions to increase cessation among current smokers and reduce smoking initiation among nonsmokers.8 There are multiple pathways through which mass media are intended to promote cessation, including directly marketing cessation assistance to smokers, changing public opinions about tobacco use to create a social norm against smoking, and increasing interpersonal discussions about tobacco use.9–11 The majority of evidence indicates that these mass media campaigns are effective in motivating individuals to think about quitting, make quit attempts, obtain help in quitting, and maintain abstinence.12–31At the population level, advertisements are also associated with decreases in cigarette consumption and smoking prevalence.13,15,16,19,32–36 The magnitude of the effect of media campaigns on cessation is estimated to be relatively small; however, when this small effect is applied across an entire population, the reductions can be very meaningful. The United States Centers for Disease Control and Prevention (CDC), for example, recently estimated that its Tips From Former Smokers (TIPS) national ad campaign led to 1.64 million quit attempts and more than 100 000 Americans quitting smoking in just 1 year.19Despite this current weight of evidence and the recommendations of Article 12 of the Framework Convention on Tobacco Control,8 there are several barriers that make it difficult for many countries to develop mass media campaigns.37 One of the main barriers is the expense of developing and airing advertisements. To provide a perspective, CDC reported receiving $54 million in US federal funding to carry out the TIPS campaign,19 and since the launch of the California Tobacco Control Program (CTCP) in 1990, approximately $464 million has been spent on mass media campaigns in California, with $13.4 million currently being spent annually.38 In funding climates that are restrictive, tobacco control programs may be able to reduce costs by focusing on high-impact advertisements.39In the past decade, tobacco control advocates have begun promoting the use of mass media that rely on emotional messages, deal with the health consequences of smoking, or use personal narratives to convey their messages. These advertisements are intended to promote behavior change by evoking visceral reactions of sadness, fear, disgust, or anger in what has been referred to as a “fear appeal.”40,41 Although this concept of “scaring” smokers into quitting is anathema to many public health advocates,42,43 several researchers have demonstrated that advertisements that deal with the negative consequences of smoking in an emotionally evocative or personal way are effective. They are typically recalled more frequently even when they are aired at lower volumes,44–46 they reach socioeconomic groups equitably,34,47–50 and they are typically rated as more effective than advertisements with different themes.44,46,50–55 In addition, they promote more frequent use of quit lines12,14,26,29,47 and confer greater effects on quitting behavior.12,14,26,27,29,34,47–50Thus far, evaluations of fear appeal advertisements have predominantly relied on group-level measures of exposure rather than individual-level measures of recognition. Exposure, in evaluations of advertisements, typically refers to whether a person has viewed an advertisement, but it does not necessarily imply that the person processed the message or remembered the ad. Exposure is usually estimated via group-level measures (e.g., Nielsen ratings or gross rating points) that assess the average number of people in a given population who are likely to have viewed an advertisement.56–58 These group-level measures can be very valuable to public health programs in their assessments of how well an advertisement is reaching a population; however, when behavior change resulting from advertisements is assessed at the individual level, these group-level instruments serve only as ecological measures.By contrast, advertisement recall, a measure of an individual’s recognition of an advertisement, may reduce the possibility of ecological bias and serves as an indicator of message processing, an expected direct effect of exposure to mass media campaigns.59 Although ad recall has long been used in mass media evaluations,12,60,61 to our knowledge it has not been employed in evaluations of behavior change resulting from fear appeal advertisements.We sought to provide further evidence for the use of advertisements that deal with the health consequences of smoking in a personal and emotional way by assessing recall of 4 anti-tobacco television advertisements developed by the CTCP and demonstrating the effects of recall of these ads on smoking cessation. We tested the following hypotheses: an ad called “Stages” that depicted a woman giving a personal narrative of her negative experiences with tobacco use would be recalled more often than 3 other ads with different intended themes among the current smokers in our cohort (hypothesis 1); recall of “Stages” would be distributed more equitably across individual characteristics in multivariable analyses than would recall of the 3 other ads (hypothesis 2); and recall of “Stages” would have a greater effect on cessation than recall of the 3 other ads (hypothesis 3).     

Cigarette Smoking Among Adults With Mobility Impairments: A US Population-Based Survey

Objectives. Smokers with mobility impairments have greater health risks than the general population. We report the prevalence of cigarette smoking and quit attempts among people with mobility impairments.Methods. We conducted an analysis of 13 308 adults (aged 21–85 years) with mobility impairments (special ambulatory equipment and difficulty walking 0.25 miles without equipment) responding to the National Health Interview Survey (2011).Results. Among 21- to 44-year-old adults with mobility impairments, 39.2% were smokers, compared with only 21.5% of adults without mobility impairments (odds ratio [OR] = 1.64; 95% confidence interval [CI] = 1.07, 2.52). Among 45- to 64-year-old adults with mobility impairments, 31.2% were smokers versus 20.7% without mobility impairments (OR = 1.35; 95% CI = 1.09, 1.68). Women aged 21 to 44 years with mobility impairments had the highest smoking prevalence (45.9%), exceeding same-aged women without mobility impairments(18.9%; OR = 2.56; 95% CI = 1.32, 4.97). Men with mobility impairments had greater smoking prevalence (24.1%) than women with mobility impairments (15.1%; P < .01). Smokers with mobility impairments were less likely to attempt quitting (19.9%) than smokers without mobility impairments (27.3%; P < .01).Conclusions. Smokers with mobility impairments should be targeted for cessation, particularly those who are younger and female.The prevalence of cigarette smoking has reached an asymptote: 19.0% of US adults are smokers, which is not significantly different from the smoking prevalence in 2004 (20.9%).1,2 A reason for this stagnancy may be the high smoking rates within underserved populations, coupled with lack of targeting underserved smokers for cessation treatment.3 Smokers with physical disabilities are underserved, as they are less likely to receive smoking cessation counseling4 and less likely to use evidenced based treatments.5 Furthermore, smokers with physical disabilities encounter numerous barriers to treatment engagement and attendance, such as lack of transportation, architectural access issues, pain, fatigue, energy fluctuations, and procedures of daily care.6–9 Smokers with physical disabilities also have greater risk factors for smoking, such as greater levels of depression and stress, and low income.10–14 Continued smoking exacerbates physical disabilities15–17 and causes or contributes to many secondary conditions including respiratory and circulatory difficulties, muscle weakness, delayed wound healing, worsening arthritis, and osteoporosis.18–22People with physical disabilities constitute 16.2% of the US population,14 and the majority of the population will experience physical disability at during their lifetime.23 Yet the prevalence of smoking among people with physical disabilities is unknown. Previous studies report on smoking prevalence for people with disabilities by collapsing across several types of disabilities (psychiatric, sensory and physical disabilities)2,10,24 rather than reporting smoking prevalence within each type. This has led to a wide range of smoking prevalence rates (24%–43%), depending upon which disability groups were included.The smoking rate among people with mobility impairments, a subpopulation of people with physical disabilities, is unknown. Mobility impairments and use of assistive devices are highly associated with reduced quality of life, development of secondary conditions, and depression,4,11,13,18,21,25 factors known to impede quitting smoking.26–28 Therefore, smoking prevalence might be greater among people with mobility limitations who use an assistive device. Brawarsky et al.29 used the 1996–1999 Massachusetts Behavioral Risk Factor Surveillance and found a 26.9% smoking prevalence among people with orthopedic problems, but their study used a heterogeneous sample including people with back or neck problems as well as people with mobility problems. In addition to being outdated and state specific, their study combines people needing ambulatory assistance with those who do not. Two other studies assessed smoking prevalence among different disability subtypes using national data from The National Health Interview Survey (NHIS): one measured smoking prevalence among people with movement difficulties (including fingers and hands),24 and one measured smoking prevalence among people with mobility limitations.30 Both studies report data more than 10 years old, and neither study reports on smoking cessation behaviors, or whether an assistive device was used.The current study uses a national sample to examine smoking prevalence and quit attempts among people with mobility impairments who use an assistive ambulatory device, compared with people without mobility impairments. We define “mobility impairments” as the use of special ambulatory equipment (e.g., cane, wheelchair, or leg braces) and difficulty walking a quarter mile without the use of special equipment. We do not propose mobility impairments as a proxy for physical disability. Rather, we believe that people with mobility impairments are an important underserved subpopulation among those with physical disabilities. Furthermore, we do not propose that people with mobility impairments are particularly underserved compared with other people with disabilities, but rather that those with mobility impairments are clearly underserved compared with the general population. Because physical disability (including mobility impairment) increases with age4,14 and smoking prevalence decreases with age,2 we also examined smoking prevalence across 3 different age groups between people with and without mobility impairments. We also explored gender differences in smoking prevalence for men and women with mobility impairments.