Policy Support, Norms, and Secondhand Smoke Exposure Before and After Implementation of a Comprehensive Smoke-Free Law in Mexico City

Objectives. We assessed attitudes and beliefs about smoke-free laws, compliance, and secondhand smoke exposure before and after implementation of a comprehensive smoke-free law in Mexico City.Methods. Trends and odds of change in attitudes and beliefs were analyzed across 3 representative surveys of Mexico City inhabitants: before implementation of the policy (n = 800), 4 months after implementation (n = 961), and 8 months after implementation (n = 761).Results. Results indicated high and increasing support for 100% smoke-free policies, although support did not increase for smoke-free bars. Agreement that such policies improved health and reinforced rights was high before policy implementation and increased thereafter. Social unacceptability of smoking increased substantially, although 25% of nonsmokers and 50% of smokers agreed with smokers'' rights to smoke in public places at the final survey wave. Secondhand smoke exposure declined generally as well as in venues covered by the law, although compliance was incomplete, especially in bars.Conclusions. Comprehensive smoke-free legislation in Mexico City has been relatively successful, with changes in perceptions and behavior consistent with those revealed by studies conducted in high-income countries. Normative changes may prime populations for additional tobacco control interventions.Smoke-free policies can reduce involuntary exposure to toxic secondhand tobacco smoke (SHS), reduce tobacco consumption and promote quitting,^1,2 and shift social norms against smoking.^3–5 These policies are fundamental to the World Health Organization''s Framework Convention on Tobacco Control, an international treaty that promotes best-practices tobacco control policies across the world.⁶Evidence of successful implementation of smoke-free policies generally comes from high-income countries. Low- and middle-income countries increasingly bear the burden of tobacco use,⁷ however, and these countries may face particular challenges in implementing smoke-free policies, including greater social acceptability of tobacco use, shorter histories of programs and policies to combat tobacco-related dangers, and greater tolerance of law breaking.^8–10 There is a need for research that will help identify effective strategies for promoting and implementing smoke-free policies in low- and middle-income countries.Studies in high-income countries generally indicate that popular support for laws that ban smoking in public places and workplaces is strong and increases after such laws are passed.^11–15 Weaker laws that allow smoking in some workplaces can leave policy support unchanged.¹⁶ Policy-associated increases in support have been shown across populations that include smokers^{11,13,14,17,18} and bar owners and staff.^19,20 Beliefs about rights to work in smoke-free environments¹¹ and the health benefits of these environments²¹ have also been shown to increase with policy implementation. Support for banning smoking in all workplaces appears high in Latin American countries,²² but responses to smoke-free policies are less well known. In Uruguay, the first country in the Americas to prohibit smoking in all workplaces, including restaurants and bars,²³ support before the law was unknown. However, the level of support was high among both the general population²² and smokers²⁴ after the law''s implementation.Compliance with smoke-free laws in high-income countries has been good, particularly when laws apply across all workplaces, including restaurants and bars, and involve media campaigns. Self-reported declines in exposure in regulated venues^11,17,25 are consistent with findings from observational studies,^11,26 biomarkers of exposure,^11,25,27 and air quality assessments.^11,12Approximately 26% of Mexican adults residing in urban areas smoke.⁸ Most Mexicans recognize the harms of SHS and support smoke-free policies.^9,24,28,29 According to an opinion poll conducted before the August 2007 passage of a smoke-free law in Mexico City, about 80% of both Mexico City inhabitants and Mexicans in general supported prohibiting smoking in enclosed public places and workplaces.²⁸ In 2006, 60% of smokers reported that their workplace had a smoking ban, with Mexico City smokers reporting the lowest percentage of workplace bans at 37%.²⁴Mexico City''s smoke-free workplace law^30–32 initially allowed for designated smoking areas that were ventilated and physically separate.^22,33 Concerns about the inequity of this law for small business owners who could not afford to build designated smoking areas led the hospitality industry to support a comprehensive smoke-free law^31,32 that prohibited smoking inside all enclosed public places and workplaces, including public transport, restaurants, and bars. This law entered into force on April 3, 2008.Media coverage of the law was similar to that in high-income countries, pitting arguments about the government''s obligation to protect citizens from SHS dangers against arguments about discrimination toward smokers and the “slippery slope” of regulating behavior^4,32,34 (J. F. Thrasher et al., unpublished data, 2010). Most print media coverage was either positive or neutral, with much less coverage pitched against tobacco control policies.³⁴In the month before and after the law came into effect, the Mexico City Ministry of Health and nongovernmental organizations disseminated print materials and aired radio spots describing the dangers of SHS and the benefits of the law.³⁰ Community health promoters informed businesses about the law. From September through December 2008, a television, radio, print, and billboard campaign emphasized the law''s benefits.³⁵ We assessed, among Mexico City inhabitants, the prevalence of and increases in support, beliefs, norms, and compliance around the smoke-free law, as well as decreases in SHS exposure.     

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.     

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.     

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).     

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.     

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

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

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.     

Quid pro quo: tobacco companies and the black press

Objectives. We explored the relationship between tobacco companies and the Black press, which plays an important role in conveying information and opinions to Black communities.Methods. In this archival case study, we analyzed data from internal tobacco industry documents and archives of the National Newspaper Publishers Association (NNPA), the trade association of the Black press.Results. In exchange for advertising dollars and other support, the tobacco industry expected and received support from Black newspapers for tobacco industry policy positions. Beginning in the 1990s, resistance from within the Black community and reduced advertising budgets created counterpressures. The tobacco industry, however, continued to sustain NNPA support.Conclusions. The quid pro quo between tobacco companies and the Black press violated journalistic standards and represented an unequal trade. Although numerous factors explain today''s tobacco-related health disparities, the Black press''s service to tobacco companies is problematic because of the trust that the community placed in such media. Understanding the relationship between the tobacco industry and the NNPA provides insight into strategies that the tobacco industry may use in other communities and countries.Tobacco use is a leading cause of health disparities affecting African Americans.^1–4 Older African Americans (≥ 44 years) have the highest smoking rates of any group (about 30%).⁵ Among lower-income African Americans, smoking rates are as high as 59%.^6,7 Over 45 000 African Americans die from tobacco-related diseases each year,^3,8,9 which constitutes the highest smoking-related disease burden of any US group.^7,10–12 African American communities also disproportionately bear lost productivity from tobacco-caused diseases. Although constituting only 6% of California''s population, African Americans account for 8% of smoking-attributable expenditures and 13% of smoking-attributable mortality costs.¹³Although smoking prevalence results from complex interactions of multiple factors, including socioeconomic status, cultural characteristics, acculturation, stress, advertising, cigarette prices, parental and community disapproval, and abilities of local communities to mount effective tobacco-control initiatives,¹⁴ the disproportionate tobacco-related disease burden among African Americans suggests the need for closer examination of the factors related to smoking prevalence that may be unique to the community. One factor in creating a climate in which smoking seems acceptable is the influence of the tobacco industry on cultural and social institutions,¹⁵ including the media.African American communities have long been targeted with tobacco advertisements, products, and philanthropy.^7,16–18 Tobacco companies have also sought to influence journalism¹⁹ and sustain extensive ties with African American leadership groups¹⁵ to undermine tobacco control. Although some research has previously recognized tobacco company support of minority-targeted media,^20,21 no previous studies have examined the longstanding relationship between tobacco companies and the National Newspaper Publishers Association (NNPA), the most important Black media organization. We explored the role of tobacco industry patronage of African American newspaper publishers and the expectations that such patronage involved. (Note that we use the terms Black and African American here interchangeably, as is common in US minority health research.²² Additional terms may be used, depending on the context and historical period; for instance, Negro was a common term used to refer to people of African descent through the 1970s.)     

��Everywhere the Soldier Will Be��: Wartime Tobacco Promotion in the US Military

Deployment of young Americans in military engagements places them at increased risk for not only war hazards but also tobacco addiction and disease. Tobacco use diminishes troop health and readiness, and increases medical and training costs.Military tobacco control efforts began in 1986, yet tobacco use remains high. To determine whether and how the tobacco industry targets military personnel in wartime, we analyzed internal industry documents about the Gulf War (1990–1991) and constructed a historical case study. During this conflict, tobacco companies targeted troops with free cigarettes, direct advertising, branded items, ways to communicate with family, and “welcome home” events. Military authorities sometimes restricted this activity, but frequently enabled it; tobacco companies were regarded as benefactors.Considering tobacco use a benefit undermines military health priorities. Stronger policy is needed to reframe tobacco use as incompatible with military ideals.DESPITE DECLINES IN CIVILIAN smoking rates in the United States and tobacco control efforts in the US military, tobacco use prevalence in the military remains high, at 32.2% in 2005.¹ Prevalence decreased between 1980 and 1998 (51.0% to 29.9%)¹; however, it has increased since then.² The military population of 1.4 million active duty service members skews toward likely smokers: young adults, high-school educated, and African Americans³ near the typical age of smoking uptake.⁴ Recruits are more often established smokers than are those who do not enlist,⁵ and despite mandatory abstinence from tobacco use during basic training, subsequent relapse or new uptake is common.⁶ The Veterans Health Administration estimates that veterans also have significantly higher rates of smoking than do civilians.⁷ Smoking diminishes even short-term troop health and readiness^8,9 and increases medical and training costs.^10,11During the first Gulf War (1990–1991), smoking prevalence rose among deployed US Naval personnel¹² and US Air Force women,¹³ and US Navy personnel who were already tobacco users increased their use.¹² We mined internal tobacco industry documents to explore how tobacco industry and military activity during this period may have contributed to this increased tobacco use.     

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.     

Branding the Rodeo: A Case Study of Tobacco Sports Sponsorship

Rodeo is one of the few sports still sponsored by the tobacco industry, particularly the US Smokeless Tobacco Company. Rodeo is popular in rural communities, where smokeless tobacco use is more prevalent.We used previously secret tobacco industry documents to examine the history and internal motivations for tobacco company rodeo sponsorship. Rodeos allow tobacco companies to reach rural audiences and young people, enhance brand image, conduct market research, and generate positive press. Relationships with athletes and fans were used to fight proposed restrictions on tobacco sports sponsorship. Rodeo sponsorship was intended to enhance tobacco sales, not the sport.Rural communities should question the tradition of tobacco sponsorship of rodeo sports and reject these predatory marketing practices.SPORTS SPONSORSHIP HAS been part of tobacco promotion since the industry invented baseball cards to associate cigarettes with sport,¹ and it continues to represent a challenge for tobacco control worldwide.^2–5 Sports sponsorship is associated with smoking behavior⁴ and appeals to youths,² maintains presence on television in restricted markets,^3,6,7 and recruits third-party allies to fight marketing restrictions.⁸Rodeo originated in the 1800s. The Cowboy''s Turtle Association was formed in 1936 and became the Professional Rodeo Cowboys Association (PRCA) in 1975.⁹ Cigarette companies explored rodeo sponsorship during the early 1970s, when tobacco advertising was banned from broadcast media in the United States.^3,5,6,10 The US Smokeless Tobacco Company (USST)^11,12 has sponsored the PRCA since 1986 and the National Intercollegiate Rodeo Association (NIRA) since 1974. The 1998 Smokeless Tobacco Master Settlement Agreement limits USST to 1 sponsorship per year bearing a product''s brand name. In 2008 USST made Professional Bull Riding (PBR) its single branded sponsorship (Copenhagen).¹³ USST uses its PRCA corporate sponsorship to continue other marketing activities at rodeos.Spending on advertising and promotion by the 5 major smokeless tobacco companies reached a record high of $251 million in 2005, including $15.8 million specifically on sports and sporting events.¹⁴ The PRCA stated in 2007 that it had 650 rodeos annually in 41 states, with more than 33 million attending, ranking it seventh in overall attendance among all sports.¹¹ Both PRCA and PBR events are televised.¹⁵ Although tobacco advertising on television is banned, television cameras may pick up branded banners, chute signs, scoreboards, and cowboys'' vest patches during televised rodeo events.Smokeless tobacco use is associated with oral cancer, gum disease, and nicotine addiction.^16,17 Although the overall prevalence of smokeless tobacco use among adults and adolescents declined between 1986 and 2003,¹⁸ sales of moist snuff products (USST''s main products) increased by 109% from 36.1 million pounds in 1986 to 75.7 million pounds in 2005, as did overall sales revenues.¹⁴ Rodeos provide tobacco companies access to rural audiences, which have higher rates of tobacco use¹⁹ and are reached less effectively by anti-tobacco media campaigns.²⁰ Rodeos are also attended by and popular with children.Previously secret tobacco industry documents can help guide tobacco control efforts by providing insights into how and why tobacco companies pursue marketing activities.²¹ We analyzed tobacco industry documents to address 3 questions: (1) What audiences did tobacco companies hope to reach at rodeos? (2) What marketing strategies were used to promote tobacco products at rodeos? (3) In addition to increasing sales, what other benefits did tobacco companies obtain through rodeo sponsorship?     

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.     

A Systematic Review of Neighborhood Disparities in Point-of-Sale Tobacco Marketing

We systematically reviewed evidence of disparities in tobacco marketing at tobacco retailers by sociodemographic neighborhood characteristics. We identified 43 relevant articles from 893 results of a systematic search in 10 databases updated May 28, 2014. We found 148 associations of marketing (price, placement, promotion, or product availability) with a neighborhood demographic of interest (socioeconomic disadvantage, race, ethnicity, and urbanicity).Neighborhoods with lower income have more tobacco marketing. There is more menthol marketing targeting urban neighborhoods and neighborhoods with more Black residents. Smokeless tobacco products are targeted more toward rural neighborhoods and neighborhoods with more White residents. Differences in store type partially explain these disparities.There are more inducements to start and continue smoking in lower-income neighborhoods and in neighborhoods with more Black residents. Retailer marketing may contribute to disparities in tobacco use. Clinicians should be aware of the pervasiveness of these environmental cues.Tobacco products and their marketing materials are ubiquitous in US retailers from pharmacies to corner stores.1 A similar presence is found across the globe, except in countries that ban point-of-sale (POS) tobacco marketing (e.g., Australia, Canada, Thailand2). In the United States, the POS has become the main communications channel for tobacco marketing3,4 and is reported as a source of exposure to tobacco marketing by more than 75% of US youths.5 Burgeoning evidence6,7 suggests that marketing at the POS is associated with youths’ brand preference,8 smoking initiation,9 impulse purchases,10,11 and compromised quit attempts.12,13The marketing of tobacco products is not uniform; it is clear from industry documents that the tobacco industry has calibrated its marketing to target specific demographic groups defined by race,14 ethnicity,15 income,16 mental health status,17 gender,18,19 and sexual orientation.20 Framed as an issue of social and environmental justice,14 research has documented historical racial, ethnic, and socioeconomic disparities in the presence of tobacco billboards,21–25 racial disparities in total tobacco marketing volume,24 and targeting of menthol cigarettes to communities with more Black residents.25,26 Targeted marketing of a consumer product that kills up to half27 of its users when used as directed exacerbates inequities in morbidity and mortality. Smoking is estimated to be responsible for close to half of the difference in mortality between men in the lowest and highest socioeconomic groups.28 However, evidence of marketing disparities is scattered across multiple disciplines and marketing outcomes, such as product availability, advertising quantity, presence of promotional discounts, and price. A synthesis of this literature would provide valuable information for intervention on tobacco marketing in the retail environment and inform etiological research on health disparities.To address this gap in the literature, we systematically reviewed observational studies that examined the presence and quantity of POS tobacco marketing to determine the extent to which marketing disparities exist by neighborhood demographic characteristic (i.e., socioeconomic disadvantage, race, ethnicity, and urbanicity).     

Patterns of Cigarette Smoking Initiation in Two Culturally Distinct American Indian Tribes

Objectives. To better understand patterns of initiation among American Indians we examined age-related patterns of smoking initiation during adolescence and young adulthood in 2 American Indian tribes. Methods. We used log-rank comparison and a Cox proportional hazard regression model to analyze data from a population-based study of Southwest and Northern Plains American Indians aged 18 to 95 years who initiated smoking by age 18 years or younger.Results. The cumulative incidence of smoking initiation was much higher among the Northern Plains Indians (47%) than among the Southwest Indians (28%; P < .01). In the Southwest, men were more likely than women to initiate smoking at a younger age (P < .01); there was no such difference in the Northern Plains sample. Northern Plains men and women in more recent birth cohorts initiated smoking at an earlier age than did those born in older birth cohorts. Southwest men and women differed in the pattern of smoking initiation across birth cohorts as evidenced by the significant test for interaction (P = .01).Conclusion. Our findings underscore the need to implement tobacco prevention and control measures within American Indian communities.Smoking rates in the US population have declined overall in the past several decades, from a high of 42% in 1960 to an estimate of 21% in 2007.¹ However, this decline has not been observed among all racial/ethnic groups nor among all age groups. The prevalence of smoking among American Indians and Alaska Natives, for example, is greater than 50% in many communities, roughly 2.5 times the prevalence in the US general population.^2–7 Furthermore, over the past 3 decades, rates of smoking have been rising in some tribal communities that have historically low rates,^2,8 roughly paralleling the increases in smoking-related diseases, including lung cancer and respiratory and cardiovascular diseases, in American Indians and Alaska Natives.^9,10 Smoking also contributes to the observation that American Indians and Alaska Natives trail only African Americans in years of potential life lost,¹¹ a key indicator of population health. Finally, adverse health outcomes associated with smoking are adding inordinately high health care costs to a dramatically underfunded Indian Health Service.¹²One of the key factors linked to nicotine dependence is age of smoking initiation. Studies have shown that an earlier age of smoking initiation is related to current and daily smoking^13,14 and that the transition from smoking initiation to established smoking generally takes 2 to 3 years.^15,16 However, a more recent study among a cohort of sixth graders reported that youth were susceptible to a rapid loss of autonomy over tobacco. This occurred within 1 or 2 days of first inhalation, and dependency was likely to appear before reaching a consumption rate of 2 cigarettes per day.¹⁷ In addition, smokers who begin smoking at younger ages are more likely than those starting later to develop nicotine dependence, thus making quitting more difficult.^13,14,18Studies among African Americans have revealed major declines in smoking prevalence among adolescents during the 1980s, which were offset by increased initiation among young adults during this period.¹⁹ Such data helped to enhance public health efforts to promote cessation and discourage initiation among African Americans. However, little is known about patterns of smoking initiation among American Indians and Alaska Natives. In a recent survey of South Dakota high school students, more than 45% of American Indian adolescents who were smoking reported starting to smoke before the age of 13 years.²⁰ To better understand the patterns of smoking initiation among American Indians, we conducted a study that examined the age of smoking initiation in 2 culturally distinct American Indian tribal groups across birth cohorts.     

Changes in Age Trajectories of Smoking Experimentation During the California Tobacco Control Program

Objectives. We aimed to investigate population-level changes in smoking initiation during California''s Tobacco Control (CTC) Program from 1990 to 2005, a period during which tobacco industry marketing practices also changed.Methods. We used a discrete time survival analysis of data from the California Tobacco Survey to model changes in age of first smoking experimentation across birth cohorts.Results. Smoking initiation patterns were stable across cohorts aged 9 years or older at the start of the CTC program. For children entering preadolescence since 1990, initiation declined with each more recent cohort. By 2005, the observed decline in experimentation was 80% for male participants and 92% for female participants at age 12 to 14 years; by age 15 to 17 years, 10% of Californian adolescents had experimented in 2005 compared with 45% in preprogram cohorts. However, rates of new experimentation after age 17 years did not change, except for a recent increase in late experimentation (after age 20 years) among young adult men.Conclusion. Our models suggest that the CTC program greatly reduced adolescent smoking initiation among younger adolescents. Late experimentation may have recently increased among young adult men in California, coincident with an increase in tobacco industry marketing aimed at young adults.Since the 1960s, adolescent smoking rates have changed in response to the competing influences of tobacco industry marketing campaigns^1–3 and public health tobacco control programs.^4,5 Reducing adolescent smoking has been a primary goal of the California Tobacco Control (CTC) Program,⁶ the longest-running large tobacco control program in the world. As an evaluation component, this program sponsors a population survey of tobacco use every 3 years. Previous survey estimates indicated that the CTC Program was associated with a lower age-specific prevalence of smoking from age 12 years, which was probably a consequence of reduced experimentation.⁵ However, it is not clear whether these age-specific changes led to an overall reduction in lifetime smoking initiation within a birth cohort, especially given the apparent effectiveness of recent tobacco advertising targeting young adults. We investigated changes in the trajectories of smoking experimentation across the age window of 10 to 24 years, in which almost all first experimentation has been documented to occur.⁷Previously, an age-period-cohort model⁸ identified that smoking experimentation for California was stable for cohorts born before 1979. Subsequent cohorts, those aged 12 years or younger when the California program started in 1990, had lower experimentation levels on average over the adolescent years. However, the model in that analysis used additive effects for age, period, and cohort, with the consequence that, for example, changes in experimentation rates at a given time were averaged across cohorts and ages. Period and cohort effects, which can identify time changes, applied equally across all ages. Thus, that analysis was unable to identify changes in smoking uptake at specific ages within the age window of 10 to 24 years. This may be of concern, because other interventions that reduced smoking in early adolescence were shown to not be associated with reduced smoking in later years.^9,10 In addition, there is specific concern that tobacco industry marketing campaigns have changed to target young adults, and this may have increased rates of smoking initiation in young adulthood.¹¹Recent contributions to the methodologic literature^12–17 have addressed shortcomings of age-period-cohort models in identifying age- and period-specific effects.^18,19 Incorporating suggestions from this literature, we modeled age-specific changes in the trajectory of smoking initiation among young Californians from 1990 to 2005. We hypothesized that age-specific changes have occurred in the pattern of smoking uptake among recent birth cohorts.     

Health Among Caregivers of Children With Health Problems: Findings From a Canadian Population-Based Study

Objectives. We used population-based data to evaluate whether caring for a child with health problems had implications for caregiver health after we controlled for relevant covariates.Methods. We used data on 9401 children and their caregivers from a population-based Canadian study. We performed analyses to compare 3633 healthy children with 2485 children with health problems. Caregiver health outcomes included chronic conditions, activity limitations, self-reported general health, depressive symptoms, social support, family functioning, and marital satisfaction. Covariates included family (single-parent status, number of children, income adequacy), caregiver (gender, age, education, smoking status, biological relationship to child), and child (age, gender) characteristics.Results. Logistic regression showed that caregivers of children with health problems had more than twice the odds of reporting chronic conditions, activity limitations, and elevated depressive symptoms, and had greater odds of reporting poorer general health than did caregivers of healthy children.Conclusions. Caregivers of children with health problems had substantially greater odds of health problems than did caregivers of healthy children. The findings are consistent with the movement toward family-centered services recognizing the link between caregivers'' health and health of the children for whom they care.Caring for a child with health problems can entail greater than average time demands,^1,2 medical costs,^3,4 employment constraints,^5,6 and childcare challenges.^6–8 These demands may affect the health of caregivers, a notion supported by a variety of small-scale observational studies that have shown increased levels of stress, distress, emotional problems, and depression among caregivers of children with health problems.^1,2,5,9–12Whether these problems are caused by the additional demands of caring for children with health problems or by confounding variables is difficult to answer definitively. The literature reports the identification of a variety of factors purported to be associated with caregiver health, including contextual factors such as socioeconomic status^13–17; child factors such as level of disability,^{1,11,13,18–21} presence of behavior problems,^22–25 and overall child adjustment²⁶; and caregiver-related characteristics such as coping strategies^11,22,27 and support from friends and family.^15,17,28,29 In general, this work has been based on small clinic-based samples^9,30 or specific child populations (e.g., cerebral palsy,^5,25 attention-deficit/hyperactivity disorder^31,32), and typically has been hampered by limited generalizability and a lack of careful, multivariate analysis. Furthermore, most studies have focused on caregivers'' psychological health,^1,2,5,9–12 although physical health effects may also exist among caregivers.^5,19,25,33One of the few studies to involve large-scale, population-based data compared the health of 468 caregivers of children with cerebral palsy to the health of a population-based sample of Canadian parents.⁵ The study showed that caregivers of children with cerebral palsy had poorer health on a variety of physical and psychological health measures. Furthermore, the data were consistent with a stress process model,^5,25 which proposes that additional stresses associated with caring for a child with cerebral palsy directly contribute to poorer caregiver health. However, these findings were based on a specific subpopulation of caregivers and univariate comparisons that could not control for potentially important confounders such as variation in caregiver education, income, and other demographic factors.We used population-based data to test the hypothesis that the health of caregivers of children with health problems would be significantly poorer than that of caregivers of healthy children, even after we controlled for relevant covariates. Our approach of using large-scale, population-based data representing a broad spectrum of childhood health problems³⁴ makes 4 key contributions to the current literature. First, our use of population-based data rather than small-scale, clinic-based studies yielded results that are potentially generalizable to a wide group of caregivers caring for children with health problems. Second, our examination of children with and without health problems allowed us to examine caregiver health effects across a wide variety of caregiving situations. Third, consideration of physical health outcomes (in addition to more regularly studied psychological outcomes) increased our knowledge of the breadth of caregiver health issues. Finally, controlling for relevant covariates allowed us to rule out a number of alternative explanations for caregiver health effects.     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

Predictors of Tobacco Use Among New York State Addiction Treatment Patients

Objectives. We used admissions data from the New York State addiction treatment system to assess patient self-reported tobacco use and factors associated with tobacco use.Methods. We compared prevalence of tobacco use in the state addiction treatment system with that of a national sample of people receiving addiction treatment and with that of the New York general population in 2005 to 2008. A random effects logistic model assessed relationships between patient- and program-level variables and tobacco use.Results. Prevalence of tobacco use in the New York treatment system was similar to that in national addiction treatment data and was 3 to 4 times higher than that in the general population. Co-occurring mental illness, opiate use, methadone treatment, and being a child of a substance-abusing parent were associated with higher rates of tobacco use.Conclusions. We call on federal leadership to build capacity to address tobacco use in addiction treatment, and we call on state leadership to implement tobacco-free grounds policies in addiction treatment systems.Since the 1964 Surgeon General’s report,1 public health and policy efforts have decreased smoking prevalence in the United States from 40% to 18%.2,3 The decrease in smoking since 2005 has been slight,4 however, and smoking is now concentrated in subgroups defined by demographics,5 diagnosis,6 or behavior.7–9 Behavioral health populations, especially, have not benefited from the overall population decline in smoking prevalence.10 People with mental health diagnoses are twice as likely to smoke as those without,11 and the highest prevalence rates reported are among people who seek treatment for alcohol or drug addiction. National Survey on Drug Use and Health (NSDUH) data show that, among people who reported past-year addiction treatment, annual smoking prevalence for 2000 to 2009 ranged from 67% to 75%.12Four million people receive addiction treatment annually, and 2.3 million receive services in specialty addiction programs.13 If 70% are smokers,12 then 1.6 million smokers enter such programs annually. Year after year, these settings serve a substantive proportion of the 43.8 million US adult smokers.5 Despite high rates of tobacco use, only 1 in 5 addiction treatment facilities in the United States has the financial resources to provide tobacco cessation services.14 Availability of nicotine replacement therapy in addiction programs decreased over 4 years (from 38% to 34%),15 and 40% of programs providing cessation counseling in 2006 to 2008 later discontinued this service.16 According to the 2011 National Survey of Substance Abuse Treatment Services (N-SSATS), only half of all addiction treatment programs screen clients for tobacco use.17Three fourths of all addiction treatment is provided in the public sector,18,19 and regulation and policy setting for these programs are centralized in Single State Agencies for Substance Abuse Services. Such agencies could disseminate tobacco practice guidelines, mandate counselor education on tobacco dependence,20 or reimburse programs for tobacco-related services.21 Several state addiction treatment systems have initiated or contemplated tobacco control efforts.22–24In July 2008, the New York Office of Alcoholism and Substance Abuse Services (OASAS) mandated smoke-free grounds and treatment of tobacco dependence for patients in addiction treatment.25 The largest such policy in the United States, it affects approximately 1000 programs, 20 000 staff, and 300 000 annual treatment admissions. Interviewing program administrators before and after the regulation, Brown et al.26 found increased tobacco screening and cessation services for patients. Surveying patients before and after the policy, another study found that smoking prevalence decreased from 69% to 63% (P < .05) and that tobacco-related services increased in methadone treatment settings but decreased in residential treatment.27 Studies assessing clinicians’ perspectives on implementation of the OASAS tobacco regulation identified both positive experiences (e.g., increased patient awareness about tobacco abuse) and negative experiences (e.g., enforcement difficulties),28 coupled with perceived increases in program-level commitment of resources and enforcement efforts over time.29,30Before implementing its tobacco control policy, OASAS included tobacco use status in the patient admission record. The resulting data set permits assessment of the relationships between tobacco use and other factors in statewide addiction treatment samples. By comparison, a review of 42 addiction treatment studies reporting smoking prevalence included sample sizes ranging from 29 to 3472.12NSDUH epidemiological data have been used to assess smoking prevalence among people with mental illness,31 people with concurrent alcohol and illicit drug misuse,32 and people receiving addictions treatment in the past year.12 We know of no studies using NSDUH or similar national data sets to explore factors associated with tobacco use in the addiction treatment population. Such data are of interest because tobacco policies in addictions treatment have potential to reduce tobacco use in a population in which use is highest, in which users are concentrated, and in which the burden of tobacco-related mortality is disproportionate.33,34We used admissions data from the New York State addiction treatment system (OASAS) over a 6-year period to estimate prevalence of tobacco use. Comparison with statewide data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with all New York State residents. Comparison with NSDUH data reflects how much people enrolled in the New York addiction treatment system may smoke in comparison with a national sample of people receiving addiction treatment. We also assessed how program and patient characteristics may be associated with tobacco use in this population.