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.     

Tobacco Retailer Proximity and Density and Nicotine Dependence Among Smokers With Serious Mental Illness

Objectives. We examined the density and proximity of tobacco retailers and associations with smoking behavior and mental health in a diverse sample of 1061 smokers with serious mental illness (SMI) residing in the San Francisco Bay Area of California.Methods. Participants’ addresses were geocoded and linked with retailer licensing data to determine the distance between participants’ residence and the nearest retailer (proximity) and the number of retailers within 500-meter and 1-kilometer service areas (density).Results. More than half of the sample lived within 250 meters of a tobacco retailer. A median of 3 retailers were within 500 meters of participants’ residences, and a median of 12 were within 1 kilometer. Among smokers with SMI, tobacco retailer densities were 2-fold greater than for the general population and were associated with poorer mental health, greater nicotine dependence, and lower self-efficacy for quitting.Conclusions. Our findings provide further evidence of the tobacco retail environment as a potential vector contributing to tobacco-related disparities among individuals with SMI and suggest that this group may benefit from progressive environmental protections that restrict tobacco retail licenses and reduce aggressive point-of-sale marketing.Tobacco use among people with serious mental illness (SMI) is common and has serious health and financial costs.1 Nationally, individuals with psychiatric or addictive disorders consume 44% to 46% of cigarettes purchased and are more likely than those in the general population to be daily and heavy smokers.2,3 In one study, it was estimated that smokers with SMI spend, on average, 27% of their income on tobacco.4 Individuals with SMI suffer disproportionately from tobacco-related diseases and, as a group, have a 25-year premature mortality rate.5 Increasingly, researchers and practitioners highlight the need for more targeted prevention and intervention strategies to reduce the burden of smoking-related diseases in this vulnerable group.6,7Cigarette smoking among people with SMI reflects a complex interplay of genetic, neurobiological, cultural, and psychosocial factors.6 Studies have examined shared genetic effects between smoking and SMI,8–11 as well as associations with attention and cognition, stress and mood, and reductions in the side effects of psychotropic medications.6 In addition to individual-level risk factors, a complete understanding of smoking disparities among individuals with SMI requires examination of “upstream” social determinants of health, including social, political, and economic contexts. Accordingly, research on the etiology and maintenance of cigarette use in this disproportionately affected group has increasingly focused on systemic factors outside of an individual’s control, such as tobacco industry targeting, reduced access to smoking cessation services, and tobacco control policies.7,12 Notably, smokers with SMI are responsive to tobacco control policies that have been effective in the general population, such as smoking bans and cigarette tax increases.13–16The built environment is another important social determinant of health that has the potential to affect smoking among people with SMI. In the general population, retail availability of tobacco, which includes the number of retailers per area or population (i.e., density) and the distance to the nearest retailer (i.e., proximity) from one’s home or school, is associated with earlier smoking initiation,17,18 increased current smoking19–22 and cigarette purchases,23 and reduced smoking cessation over time.24,25 Smokers who live in neighborhoods with higher densities of tobacco retailers have greater exposure to retail advertisements and promotions, which can obstruct quit attempts by increasing cues to smoke, provoking cravings, and triggering impulse purchases.26–29 Smokers are price sensitive,30,31 and the financial costs of smoking are lower in communities with more convenient tobacco access and reduced travel time to purchase.22 Moreover, retailers and point-of-sale tobacco advertisements are more prevalent in socially and economically disadvantaged neighborhoods.19,22,32–36The effects of increased tobacco availability may be particularly strong among smokers with SMI given that factors such as unreliable transportation and limited resources37 in this population may lead to a greater reliance on readily obtainable consumer goods. Furthermore, people with SMI have been targeted by the tobacco industry,12,38 and they may be especially sensitive to aggressive tobacco advertisements and promotions. Surprisingly, in spite of the public health relevance, to our knowledge no studies of the retail availability of tobacco have involved clinical samples of individuals with SMI.Our goals in this study, which included a diverse sample of adults with SMI, were to characterize the proximity (roadway distance to the nearest retailer) and density (number of retailers per acre) of tobacco retailers within 500 meters and 1 kilometer of participants’ residences and to assess whether retail availability of tobacco is associated with severity of mental illness, nicotine dependence, and readiness to quit smoking. We also evaluated whether these associations vary according to gender.We hypothesized that smokers with SMI would reside in neighborhoods with greater than average tobacco retailer density for their county area and that this neighborhood characteristic would be associated with greater severity of mental illness. Furthermore, we predicted that increased retail availability of tobacco would be associated with greater nicotine dependence and lower readiness to quit, regardless of severity of mental illness. We also examined gender differences given calls to assess such differences in tobacco control research, policy, and practice39 and recent evidence that proximity to a tobacco retailer is associated with a lower likelihood of smoking cessation among men but not women who are moderate to heavy smokers.24     

Estimating the Risks and Benefits of Nicotine Replacement Therapy for Smoking Cessation in the United States

Objectives. To compare potential population-wide benefits and risks, we examined the potential impact of increased nicotine replacement therapy (NRT) use for smoking cessation on future US mortality.Methods. We developed a simulation model incorporating a Monte Carlo uncertainty analysis, with data from the 2005 National Health Interview Survey and Cancer Prevention Study II. We estimated the number of avoided premature deaths from smoking attributable to increased NRT use, before and after incorporating assumptions about NRT harm.Results. We estimate that a gradual increase in the proportion of NRT-aided quit attempts to 100% by 2025 would lead to 40 000 (95% credible interval = 31 000, 50 000) premature deaths avoided over a 20-year period. Most avoided deaths would be attributable to lung cancer and cardiovascular disease. After we incorporated assumptions about potential risk from long-term NRT, the estimate of avoided premature deaths from all causes declined to 32 000.Conclusions. Even after we assumed some harm from long-term NRT use, the benefits from increased cessation success far outweigh the risks. However, the projected reduction in premature mortality still reflects a small portion of the tobacco-related deaths expected over a 20-year period.Cigarette smoking is one of the leading modifiable causes of death in the United States, accounting for more than 400 000 deaths¹ and 5.5 million years of life lost annually.² It has been estimated that up to half of persistent smokers will be killed by their habit, and lifelong smokers lose, on average, 10 years of life compared with nonsmokers.³ Despite a decline in smoking prevalence in the United States, there were still approximately 36 million daily smokers in 2005.⁴ Further, although the majority of smokers express a desire to quit,⁵ the average smoker makes several quit attempts before succeeding.⁶The use of pharmacotherapy, including nicotine replacement therapy (NRT), has been shown to increase the likelihood of a successful quit attempt.⁷ Smoking cessation has numerous health benefits,⁶ including an increase in longevity, even among smokers who quit later in life.³ Effective smoking cessation policies, including increased NRT availability and use, would be expected to reduce smoking-attributable deaths in the United States.Some concerns have arisen about the safety of long-term NRT use, which could reduce the cessation-related benefits of NRT-aided quit attempts. Hemodynamic effects of nicotine intake have been described, which may have implications for cardiovascular disease risk.^8–10 However, tobacco smoke contains many toxic compounds that can damage the cardiovascular system, including combustion products such as carbon monoxide and nitrogen oxides^8,11,12; thus, it is not clear what fraction of smoking-related cardiovascular risk may be attributable to nicotine intake. Further, clinical trials have generally shown NRT use to be safe.^13,14 Concerns have also been raised about increased risk for cancer on the basis of evidence from in vitro and in vivo studies showing that nicotine can result in tumor promotion through increased cell proliferation, inhibition of apoptosis, and angiogenesis.^15–17To quantitatively compare the risks and benefits of NRT use, we developed a Monte Carlo simulation model to estimate future mortality patterns associated with changing patterns of NRT use and subsequent success in smoking cessation. We also incorporated assumptions about long-term NRT use and its potential harms to weigh the risks and benefits of NRT use for smoking cessation.     

Smoking characteristics of adults with selected lifetime mental illnesses: results from the 2007 National Health Interview Survey

Objectives. We estimated smoking prevalence, frequency, intensity, and cessation attempts among US adults with selected diagnosed lifetime mental illnesses.Methods. We used data from the 2007 National Health Interview Survey on 23 393 noninstitutionalized US adults to obtain age-adjusted estimates of smoking prevalence, frequency, intensity, and cessation attempts for adults screened as having serious psychological distress and persons self-reporting bipolar disorder, schizophrenia, attention deficit disorder or hyperactivity, dementia, or phobias or fears.Results. The age-adjusted smoking prevalence of adults with mental illness or serious psychological distress ranged from 34.3% (phobias or fears) to 59.1% (schizophrenia) compared with 18.3% of adults with no such illness. Smoking prevalence increased with the number of comorbid mental illnesses. Cessation attempts among persons with diagnosed mental illness or serious psychological distress were comparable to attempts among adults without mental illnesses or distress; however, lower quit ratios were observed among adults with these diagnoses, indicating lower success in quitting.Conclusions. The prevalence of current smoking was higher among persons with mental illnesses than among adults without mental illnesses. Our findings stress the need for prevention and cessation efforts targeting adults with mental illnesses.Smoking is the leading cause of preventable death in the United States and accounts for approximately 1 of every 5 deaths each year.^1,2 Although rates of cigarette use have dropped substantially among the general population,³ smoking continues to be a major public health problem, particularly for persons with mental illness. Between 40% and 85% of persons with various forms of mental illness currently smoke cigarettes,^4,5 and these estimates are as much as 4 times as high as the current prevalence of smoking among the US adult population (19.8%).³ Additionally, persons with mental illness suffer from tobacco-related diseases at twice the rate of same-aged adults without mental illness.^6,7 Given these high rates of smoking and increased morbidity and mortality, it is pertinent to investigate and understand the smoking patterns and cessation behaviors of persons with mental illnesses to inform and guide programs and policies that can reach and assist this population.Recent clinical research has effectively addressed the association of cigarette smoking and cessation attempts of persons with specific mental health disorders^4,5,8,9; however, population-based data are scant. Lasser et al.¹⁰ used population-based data collected from the National Comorbidity Study in the early 1990s to examine smoking prevalence and behaviors. They found that persons with a mental disorder were twice as likely to smoke as were persons without a mental disorder, yet persons with a mental disorder had a self-reported quit rate between 30% and 37%. Breslau et al.,¹¹ using the same data to examine smoking intensity and frequency, found that preexisting disorders predicted an increased risk for the first onset of daily smoking and for smokers’ progression to nicotine dependence. Using data from the 2002 National Survey of Drug Use and Health, a population-based study, Hagman et al.¹² examined serious psychological distress by use of the Kessler-6 (K6) measure and found that persons with serious psychological distress were more likely to be daily smokers, were less likely to quit smoking, and appeared to smoke more heavily as symptom severity increased. In yet another study, Grant et al.¹³ used the National Epidemiologic Survey on Alcohol and Related Conditions and found that nicotine-dependent smokers with a mental health disorder consumed 34.2% of all cigarettes smoked in the United States.Although these population-based studies have added valuable prevalence data on tobacco use by those with mental health disorders, the studies are not without limitations. The Lasser et al.¹⁰ and Breslau et al.¹¹ studies were based on data collected from 1991 to 1992, a time when overall smoking prevalence in the United States was 26.5%, almost 7 percentage points higher than current reported estimates. With major advances in tobacco control and with similar decreases of smoking prevalence seen among other population subgroups (i.e., Hispanics, Asian/Pacific Islanders, and pregnant smokers), it would be worthwhile to use more current data to determine whether smoking rates of persons with mental health disorders have followed a similar decline.^3,14 Additionally, because of the design and scope of many population-based surveys, none of the previous studies was able to comprehensively assess both mental health disorders and cigarette use.¹² Hagman et al.¹² attempted to address this issue with their study; however, they relied solely on the K6 scale. Although the K6 is a validated instrument that is intended to be a proxy measure for current serious psychological distress and mental health impairments, the scale does not measure specific types of mental health disorders or assess the diagnosis of a mental health disorder over the lifespan.To that end, in this study, we sought to specifically examine the prevalence, frequency, and intensity of smoking and cessation attempts by adults with previously diagnosed mental illnesses or serious psychological distress by using 2007 data from the National Health Interview Survey (NHIS). The NHIS is a nationally representative survey that provides extensive information on smoking behaviors and self-reported lifetime diagnoses of specific mental health disorders as well as serious psychological distress by use of the K6 measure.     

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.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Financial Strain and Smoking Cessation Among Racially/Ethnically Diverse Smokers

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

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

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

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

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

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.     

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.     

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.     

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.     

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.     

Intergenerational relationships between the smoking patterns of a population-representative sample of US mothers and the smoking trajectories of their children

Objectives. We assessed intergenerational transmission of smoking in mother-child dyads.Methods. We identified classes of youth smoking trajectories using mixture latent trajectory analyses with data from the Children and Young Adults of the National Longitudinal Survey of Youth (n = 6349). We regressed class membership on prenatal and postnatal exposure to maternal smoking, including social and behavioral variables, to control for selection.Results. Youth smoking trajectories entailed early-onset persistent smoking, early-onset experimental discontinued smoking, late-onset persistent smoking, and nonsmoking. The likelihood of early onset versus late onset and early onset versus nonsmoking were significantly higher among youths exposed prenatally and postnatally versus either postnatally alone or unexposed. Controlling for selection, the increased likelihood of early onset versus nonsmoking remained significant for each exposure group versus unexposed, as did early onset versus late onset and late onset versus nonsmoking for youths exposed prenatally and postnatally versus unexposed. Experimental smoking was notable among youths whose mothers smoked but quit before the child''s birth.Conclusions. Both physiological and social role-modeling mechanisms of intergenerational transmission are evident. Prioritization of tobacco control for pregnant women, mothers, and youths remains a critical, interrelated objective.Women who smoke during pregnancy are more likely to have offspring who become adolescent smokers.^1–7 Studies link mother''s smoking during pregnancy with youths'' earlier smoking initiation,^3,7–9 greater persistence in regular smoking,^3,7 and stronger nicotine dependency.^6,8,10,11Hypothesized physiological pathways for mother-to-child transmission of smoking are reviewed elsewhere^12–14 and may include inherited susceptibility to addiction alone or in combination with in utero neurodevelopmental exposure and scarring that activates nicotine susceptibility. Furthermore, because few women who smoke during pregnancy quit after delivery^15,16 higher rates of smoking among offspring may reflect role modeling of maternal smoking behavior. Notably, parental smoking is hypothesized to demonstrate pro-smoking norms and solidify pro-smoking attitudes.^17,18Studies considering both smoking during pregnancy and subsequent maternal smoking outcomes have sought to distinguish between these proposed social and physiological transmission pathways.^{1–4,6,7,9,19} Similarly, studies controlling for family sociodemographic factors^{1,2,4,5,7,8,10,11,19,20} or maternal propensity for health or risk taking^1,2,9,10 have sought to further distinguish direct physiological or social transmission from selection. Studies considering children''s cognitive and behavioral outcomes have shown that selection by maternal social and behavioral precursors to smoking during pregnancy strongly biases findings on smoking during pregnancy^21,22; however, it remains unclear whether this is also the case for youth smoking. Some studies^2,3,5,6,19 have observed that smoking during pregnancy operates independently of subsequent maternal smoking. A few have found that smoking during pregnancy is only independently associated in select analyses (e.g., for initiation but not frequency or number of cigarettes^6,9 or only among females^7,20). Several have found that smoking during pregnancy does not operate independently of subsequent maternal smoking behavior,^1,4 and the remaining studies do not address postnatal maternal smoking.^8,9,11We explored whether these inconsistencies in findings supporting social or physiological mechanisms for intergenerational transmission can be accounted for by more comprehensively examining maternal and child smoking behavior. Previous work has established the advantages of statistical models for youth smoking trajectories that capture initiation, experimentation, cessation, or continued use.^23–28 Studies focusing on parental smoking concurrent with youth smoking suggest that postnatal exposures may differentially predispose youths for specific smoking trajectories.^24,26–28 Only 3 known studies have considered whether smoking during pregnancy influences youth smoking progression, and these have shown greater likelihood of early regular use^3,11 and telescoping to dependence.⁸ However, limitations of sample selectivity and measurement and modeling of maternal and youth smoking outcomes restrict the generalizability and scope of these findings.²⁹ To specifically address these limitations and more comprehensively assess hypothesized intergenerational transmission pathways, we used US population–representative data, latent variable techniques, and a rich set of data on maternal and youth smoking and social and behavioral selection factors. We characterized trajectories of youth smoking from adolescence through young adulthood and considered exposure to various maternal smoking patterns from prebirth to the child''s early adolescence.     

Social smoking among young adults: investigation of intentions and attempts to quit

Objectives. We compared the association between 3 different definitions of social smoking—a common pattern of smoking among young adults—and cessation indicators.Methods. We used a Web-enabled, cross-sectional national survey of 1528 young adults (aged 18–25 years) from a panel (recruited by random-digit dialing) maintained by the research group Knowledge Networks.Results. Among 455 smokers, 62% self-identified or behaved as social smokers. Compared with established smokers, self-identified social smokers were less likely to have cessation intentions (odds ratio [OR] = 0.83; 95% confidence interval [CI] = 0.70, 0.98) and cessation attempts lasting 1 month or longer (OR = 0.54; 95% CI = 0.45, 0.66). Behavioral social smokers (mainly or only smoking with others) were more likely than were self-identified social smokers (those who did not report these behavior patterns) to have cessation intentions (mainly OR_mainly = 1.66; 95% CI = 1.05, 2.63; and OR_only = 2.02; 95% CI = 1.02, 3.97) and cessation attempts (OR_mainly = 4.33; 95% CI = 2.68, 7.00; and OR_only = 6.82; 95% CI = 3.29, 14.15).Conclusions. Self-identified social smokers may be considered a high-risk group with particular challenges for cessation. Behavioral social smokers may represent a group primed for cessation. Public health efforts should address these differences when developing smoking cessation strategies.Young adults (aged 18–25 years) represent the highest risk group for smoking, with 35.7% reporting having smoked cigarettes in the past 30 days.¹ Young adults are also more likely than are older adults to quit smoking,^2,3 and young adult smoking cessation is particularly important because cessation before age 30 years avoids virtually all the long-term ill effects of smoking.⁴ In addition, young adult smoking uptake is important because, although most smokers try their first cigarette before age 18 years, the process of becoming an addicted smoker with typical adult consumption levels takes years, extending well into young adulthood.^5–9 Evidence from previously secret tobacco industry documents reveals that the industry identified young adults as a vulnerable population susceptible to marketing strategies linking smoking with social activities, such as drinking alcohol and the club scene.¹⁰A common pattern of smoking among young adults is nondaily smoking: Wortley et al., found that 19.9% of young adults reported smoking fewer than 30 days out of the month,¹¹ and a prevalent pattern of nondaily smoking is social smoking, which is generally thought of as limiting smoking to social situations.^12–15 Compared with research on young adult daily smoking, research on social smoking is less common and usually limited to college samples.^14,15 These findings suggest that social smokers smoke less and are less dependent on nicotine compared with regular smokers. Previous research also suggests that occasional smokers take 1 of 3 trajectories. Approximately 50% quit smoking, 25% transition to habitual smoking, and 25% continue to sustain their intermittent smoking pattern after a 7-year follow up.¹⁶ In this regard, about half of those who occasionally smoke continue to smoke for years.Although the health consequences of social smoking have not been specifically studied, light smoking (fewer than 10 cigarettes per day) is associated with increased cardiovascular risk¹⁷ and an increased risk of cancer, respiratory tract infections, cataracts, impaired fertility, and fractures.¹⁸ Thus, clinicians should address these smoking patterns. Published studies on social smoking are not consistent in the definitions and conceptualization of social smoking. Two studies defined social smoking as smokers who say they are social smokers.^14,19 One study defined social smoking as having smoked in the past 30 days, but mainly with others.²⁰ Another study defined social smoking as smoking in the past 30 days, but mainly with others or equally alone as with others.¹⁵ Another approach has been to include smokers who smoke weekly, less than weekly, or smoke only when going out to clubs, bars, or restaurants.²¹ A more exclusive approach has been to restrict social smoking to those who report only smoking with others.¹²These differing definitions have theoretical and methodological issues. Self-identification as a social smoker includes those who act like daily smokers, but deny being a smoker (i.e., identification only as a social smoker). The “mainly smokes with others” definition, like self-identification as a social smoker, may also include daily smokers. This inclusion may have important ramifications both for addiction assessments and cessation strategies. Limiting social smokers to those who “smoke only with others” is a strict behavioral definition that includes only a subset of those people who may think of themselves as social smokers; social smokers by this definition smoked fewer cigarettes, were more likely to think they could quit any time, and were less likely to think they were addicted or that their smoking was harmful to their health.¹² Given the differing operational definitions used to measure social smoking, it remains unclear whether social smokers are more apt to quit compared with regular smokers.We aimed to (1) compare 3 different definitions of social smokers (self-identified social smokers, mainly smoking with others, only smoking with others) and (2) assess the association between these different definitions of social smoking and quitting intentions and behaviors.     

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.     

Smokers Who Try E-Cigarettes to Quit Smoking: Findings From a Multiethnic Study in Hawaii

Objectives. We characterized smokers who are likely to use electronic or “e-”cigarettes to quit smoking.Methods. We obtained cross-sectional data in 2010–2012 from 1567 adult daily smokers in Hawaii using a paper-and-pencil survey. Analyses were conducted using logistic regression.Results. Of the participants, 13% reported having ever used e-cigarettes to quit smoking. Smokers who had used them reported higher motivation to quit, higher quitting self-efficacy, and longer recent quit duration than did other smokers. Age (odds ratio [OR] = 0.98; 95% confidence interval [CI] = 0.97, 0.99) and Native Hawaiian ethnicity (OR = 0.68; 95% CI = 0.45, 0.99) were inversely associated with increased likelihood of ever using e-cigarettes for cessation. Other significant correlates were higher motivation to quit (OR = 1.14; 95% CI = 1.08, 1.21), quitting self-efficacy (OR = 1.18; 95% CI = 1.06, 1.36), and ever using US Food and Drug Administration (FDA)–approved cessation aids such as nicotine gum (OR = 3.72; 95% CI = 2.67, 5.19).Conclusions. Smokers who try e-cigarettes to quit smoking appear to be serious about wanting to quit. Despite lack of evidence regarding efficacy, smokers treat e-cigarettes as valid alternatives to FDA-approved cessation aids. Research is needed to test the safety and efficacy of e-cigarettes as cessation aids.Electronic cigarettes, or e-cigarettes, are battery-powered devices that generate vaporized nicotine or non-nicotine vapor that may be inhaled orally in the manner in which conventional cigarettes are smoked. E-cigarettes deliver the vapor when a cartridge containing nicotine solution is heated. Because e-cigarettes are likely to contain lower levels of toxins or carcinogens than combustible tobacco products,1 e-cigarettes are commonly promoted as safer alternatives to regular cigarettes and even as smoking cessation aids.2,3 Currently, the US Food and Drug Administration (FDA) lacks regulations for e-cigarettes as therapeutic drug delivery devices and intends to regulate them as tobacco products.3Whether e-cigarettes deserve consideration as possibly effective cessation aids is a subject of ongoing debate.1,4 Much of the debate has been fueled by the uncertainties regarding the public health risks and benefits of e-cigarette use.5,6 The FDA has maintained that most available e-cigarettes lack quality control, tend to deliver inconsistent levels of nicotine (which at higher doses can be lethal), and may not be entirely free of toxins or carcinogens.3 Moreover, the FDA is concerned that e-cigarette use may facilitate tobacco use initiation and increased nicotine addiction among youths and young adults.3 Recently, however, researchers have drawn attention to the promising aspects of e-cigarettes as cessation or harm reduction devices.4,7–10E-cigarettes appear promising as cessation aids because e-cigarettes not only deliver nicotine in the manner in which nicotine replacement therapy does but also closely simulate the experience of smoking combustible tobacco. Moreover, e-cigarettes may have a comparative advantage over current FDA-approved cessation aids in terms of user satisfaction because e-cigarettes seem better suited to address both the pharmacological and the sensorimotor aspects of smoking.7,11 However, at present the research examining the efficacy of e-cigarettes as cessation aids is in its early stages. In a study involving 40 non–treatment-seeking daily smokers who were assigned to use a particular brand of e-cigarette with the purpose of helping them quit or reduce smoking, 22.5% of participants showed sustained abstinence at 24-week follow-up and an additional 32.5% were found to have reduced their cigarette consumption by half.12 In another study, a group of first-time purchasers of a brand of e-cigarettes were contacted 6 months after the purchase date.13 Of the 4.5% of potential participants who responded, 31% reported point prevalence abstinence. Thus, the studies that have suggested that e-cigarettes are likely to be effective as cessation aids have been nonexperimental and based on convenience samples. In addition, although studies have tended to agree that e-cigarettes reduce craving and withdrawal symptoms in abstinent smokers,14–16 whether e-cigarettes are efficient as nicotine delivery devices is not clear.14,15,17,18 Hence, the usefulness of e-cigarettes as cessation aids is not certain.However, the popularity of e-cigarettes has continued to soar in the United States and elsewhere.19–22 According to a recent study, approximately 6% of all adults and 21% of adult current daily smokers in the United States report ever using e-cigarettes.19 Although the majority of current e-cigarette users seem to report smoking cessation or reduction as the primary motive for e-cigarette use,11,23–24 limited evidence currently exists regarding smokers’ use of e-cigarettes as cessation aids, especially in the United States.22 Moreover, limited or no data are available on how smokers’ sociodemographic characteristics, nicotine dependence, smoking behavior, motivation and self-efficacy to quit, quit attempts, and use of FDA-approved cessation aids are related to the likelihood of having ever used e-cigarettes as cessation aids. We addressed these gaps in the literature. Specifically, we examined the prevalence of use of e-cigarettes as cessation aids in a multiethnic sample of adult current daily smokers from Hawaii and examined the associations of sociodemographic factors and smoking- and cessation-related characteristics with ever having used e-cigarettes for smoking cessation. Thus, the results of this study will help guide future research by quantifying the nature of the relationships between e-cigarette use for cessation and smokers’ characteristics, including their cessation-related attitudes and behavior. For example, knowledge about the extent of statistically significant associations of e-cigarette use with demographic and cognitive correlates will help guide the design and analytic aspects of future studies on the etiology of e-cigarette use among current smokers. In addition, the results of this study will help guide future studies testing the efficacy of e-cigarettes as cessation aids. For example, cessation-related variables found to be significant correlates of e-cigarette use for cessation may be tested as potential moderators of the efficacy of e-cigarettes as cessation aids. Thus, this study is likely to advance the research on e-cigarette use, especially among smokers.     

Tobacco use harm reduction, elimination, and escalation in a large military cohort

Objectives. We evaluated changing patterns of tobacco use following a period of forced tobacco abstinence in a US military cohort to determine rates of harm elimination (e.g., tobacco cessation), harm reduction (e.g., from smoking to smokeless tobacco use), and harm escalation (e.g., from smoking to dual use or from smokeless tobacco use to smoking or dual use).Methods. Participants were 5225 Air Force airmen assigned to the health education control condition in a smoking cessation and prevention trial. Tobacco use was assessed by self-report at baseline and 12 months.Results. Among 114 baseline smokers initiating smokeless tobacco use after basic military training, most demonstrated harm escalation (87%), which was 5.4 times more likely to occur than was harm reduction (e.g., smoking to smokeless tobacco use). Harm reduction was predicted, in part, by higher family income and belief that switching from cigarettes to smokeless tobacco is beneficial to health. Harm escalation predictors included younger age, alcohol use, longer smoking history, and risk-taking.Conclusions. When considering a harm reduction strategy with smokeless tobacco, the tobacco control community should balance anticipated benefits of harm reduction with the risk of harm escalation and the potential for adversely affecting public health.Cigarette smoking is the number 1 preventable cause of death and disability in the United States.^1,2 Although a vast array of smoking cessation strategies exist,³ nearly 20% of the US population are current smokers.⁴ Impeding efforts for a tobacco-free society are the facts that nicotine is highly addictive⁵ and, at any given time, only about 20% of smokers are ready, willing, or able to make a serious attempt to stop smoking.⁶ Although research efforts are under way to evaluate the efficacy of approaches for smokers not ready or able to quit (e.g., motivational interviewing),⁷ no method has demonstrated success.An alternative approach to providing treatment to smokers unable to quit is to “reduce the harm” associated with cigarette smoking.⁸ Proposed harm reduction strategies have included risk factor modification (e.g., dietary intake and physical activity) and chemoprevention strategies (e.g., antioxidants).⁹ However, the most controversial method of harm reduction is encouraging smokers to switch from cigarette smoking to other forms of tobacco, such as smokeless tobacco,^10,11 a known human carcinogen.^12,13Although switching from cigarettes to smokeless tobacco reduces risk related to heart disease and lung cancer,^14,15 critics of this strategy suggest that harm reduction may be associated with unintended consequences. A recent review by Tomar et al. concluded that the effectiveness of smokeless tobacco as a smoking-cessation strategy remains unknown and that available evidence suggests that smokeless tobacco use may be a gateway to smoking initiation in the United States.¹⁶ Furthermore, promoting smokeless tobacco for harm reduction has the potential to increase harm by opening the door to dual use of cigarettes and ST, with the latter used in venues where smoking is prohibited; this could undermine cessation attempts.^16,17 In the INTERHEART study, an international case–control study, dual use (i.e., concomitant use of cigarettes and smokeless tobacco) was associated with higher odds for acute myocardial infarction than was cigarette smoking alone.¹⁸ Finally, it is important to point out that, although switching from cigarette smoking to smokeless tobacco is safer than smoking cigarettes, smokeless tobacco is still far from safe.^12,13Proponents of harm reduction claim that for cigarette smokers who find complete smoking cessation an unobtainable goal, reducing harm through use of alternative nicotine sources with fewer health risks is better than continuing to smoke. These advocates often cite Sweden''s promotion of the smokeless product “snus” as an example of effective harm reduction.¹⁹ Swedish snus use has been linked to a decrease in smoking prevalence and a net population health benefit.^20,21 However, available data suggest that the Swedish and US populations behave differently.²² Specifically, both US male and female smokers have higher quit rates than in Sweden despite the higher rate of snus use in Sweden. Analysis of data in populations with high rates of tobacco use (both cigarettes and smokeless tobacco), such as the US military,²³ may provide additional information regarding the behavior of US tobacco users.We explored tobacco use patterns in a large military cohort from basic military training to 12-month follow-up. During basic military training, all tobacco use is forbidden (a well-enforced prohibition) for a 6-week period; therefore, smokers and smokeless tobacco users undergo forced tobacco abstinence. We assessed the extent to which cigarette smokers in this population switched to smokeless tobacco (e.g., harm reduction) following the smoking ban during basic military training.^12,13,24 We also explored the extent to which smokers increased their potential risk by switching to dual tobacco use (e.g., harm escalation).