Tobacco Product Initiation Research Articles

Flavored combustible tobacco product initiation in two longitudinal youth cohorts in the US Population Assessment of Tobacco and Health Study: 2013–2016 and 2016–2019

IntroductionFlavored tobacco products increase appeal and lower barriers to nicotine addiction for young people. We compared environmental, psychosocial, behavioral, and demographic characteristics between youth who started with flavored and non-flavored (i.e., tobacco-flavored) combustible tobacco products (CTPs). MethodsWe analyzed two representative US youth cohorts (baseline age 12–15) from the Population Assessment of Tobacco and Health (PATH) Study (Wave 1 Cohort (W1) 2013–2016; Wave 4 Cohort (W4) 2016–2019). We first assessed baseline characteristics associated with any subsequent CTP initiation among youth with baseline never CTP use (W1 n=5,946; W4 n=8,240). Then, for baseline CTP-naïve youth with subsequent CTP initiation (new experimentation; W1 n=519; W4 n=538), we assessed baseline characteristics associated with subsequent initiation with flavored CTPs versus non-flavored. ResultsMost youth reporting new CTP experimentation initiated with flavored CTPs (W1:67.8%; W4:74.2%). Household norms, susceptibility, baseline experimentation with vaping, alcohol, and/or cannabis; and White race were associated with CTP experimentation. For both cohorts, frequent social media use was associated with flavored CTP initiation (W4 AOR:2.50, 95%CI:1.22,5.12) and Black youth (W4 AOR:0.12, 95%CI:0.06,0.25) were less likely to initiate with flavored CTPs than White youth. Among W1 Cohort youth, perceiving flavored product use as easier was positively associated with flavored CTP initiation (AOR:1.48, 95%CI:1.01,2.17). Among W4 Cohort youth, baseline vaping was negatively associated with flavored CTP initiation (AOR:0.10, 95%CI:0.05,0.20). ConclusionFrequent social media use was associated with flavored CTP initiation among youth who used CTPs. Youth who had ever vaped and Black youth were less likely to initiate with flavored CTPs.

Predicting longitudinal changes in patterns of tobacco and nicotine product use among adolescents: A Latent Transition Analysis based on the X:IT study

IntroductionUnderstanding factors influencing the transition from non-use to tobacco and nicotine product initiation among adolescents is crucial for designing and implementing effective preventive strategies. This study explores transition patterns among 13–15-year-old adolescents in lower secondary school, focusing on the transition from non-use to tobacco and nicotine product initiation and the influence of individual, social, risk behavioral, and mental health factors on this transition. MethodsBased on data from a Danish smoking prevention trial between 2017 and 2019, this study employed questionnaire surveys at three time points: baseline (start of seventh grade, n = 1,990, response rate = 86.3%), eight-month follow-up (end of seventh grade, n = 1,666, response rate = 74,8%), and 20-month follow-up (end of eighth grade, n = 1,149, response rate = 70,6%). Tobacco and nicotine use indicators included current and lifetime use of cigarettes and lifetime use of e-cigarettes, smokeless tobacco, and hookah. A latent transition analysis was applied to identify longitudinal transition patterns across waves and to explore predictors of these patterns. ResultsThree user classes emerged across all waves: none-use, lifetime e-cigarette and cigarette use, and poly-tobacco use. While the most prevalent class was the non-user class (71%–86%), the proportion of the lifetime e-cigarette and cigarette class increased over time (from 12% to 17%). Similarly, the poly-tobacco user class increased from 2% to 12%. The probability of transitioning from non-use to lifetime e-cigarette and cigarette use increased from 0.5% at baseline to 12% by the second follow-up, while the probability of transitioning from lifetime e-cigarette and cigarette use remained stable over time (12%–15%). Across all waves, elevated risk behavior predicted this transition. For instance, binge-drinking (OR = 3.76, 95% CI: 1.51–9.34), susceptibility to smoking (OR = 7.63, 95% CI: 3.68–16.83), and truancy (OR = 7.00, 95% CI: 1.98–24.59) influenced the transition from non-use at baseline to lifetime e-cigarette and cigarette use at first follow-up. Additionally, boys, adolescents with low socioeconomic status, low life satisfaction, and those with smoking friends or parents were more likely to transition from non-use to lifetime e-cigarette and cigarette use. ConclusionThis study demonstrates that sociodemographic, social risk, behavioral, and mental health factors impact the transition from non-use to lifetime e-cigarette and cigarette use. The findings provide valuable insights for developing targeted preventive strategies focusing on these influencing factors.

Application of inverse weighting analysis to assess the association of youth perceptions with the age of initiation of tobacco products.

To examine if perceptions of harmfulness and addictiveness of hookah and cigarettes impact the age of initiation of hookah and cigarettes, respectively, among US youth. Youth (12-17 years old) users and never users of hookah and cigarettes during their first wave of PATH participation were analyzed by each tobacco product (TP) independently. The effect of perceptions of (i) harmfulness and (ii) addictiveness at the first wave of PATH participation on the age of initiation of ever use of hookah was estimated using interval-censoring Cox proportional hazards models. Users and never users of hookah at their first wave of PATH participation were balanced by multiplying the sampling weight and the 100 balance repeated replicate weights with the inverse probability weight (IPW). The IPW was based on the probability of being a user in their first wave of PATH participation. A Fay's factor of 0.3 was included for variance estimation. Crude hazard ratios (HR) and 95% confidence intervals (CIs) are reported. A similar process was repeated for cigarettes. Compared to youth who perceived each TP as "a lot of harm", youth who reported perceived "some harm" had younger ages of initiation of these tobacco products, HR: 2.53 (95% CI: 2.87-4.34) for hookah and HR: 2.35 (95% CI: 2.10-2.62) for cigarettes. Similarly, youth who perceived each TP as "no/little harm" had an earlier age of initiation of these TPs compared to those who perceived them as "a lot of harm", with an HR: 2.23 (95% CI: 1.82, 2.71) for hookah and an HR: 1.85 (95% CI: 1.72, 1.98) for cigarettes. Compared to youth who reported each TP as "somewhat/very likely" as their perception of addictiveness, youth who reported "neither likely nor unlikely" and "very/somewhat unlikely" as their perception of addictiveness of hookah had an older age of initiation, with an HR: 0.75 (95% CI: 0.67-0.83) and an HR: 0.55 (95% CI: 0.47, 0.63) respectively. Perceptions of the harmfulness and addictiveness of these tobacco products (TPs) should be addressed in education campaigns for youth to prevent early ages of initiation of cigarettes and hookah.

Abstract PR003: An examination of tobacco and alcohol outlet density in Boston to identify priority areas for cancer prevention efforts using environmental justice mapping

Abstract Background. Inequitable access to health-harming substances in the built environment can create and exacerbate race and SES-based disparities in cancer incidence and mortality. Availability and density of tobacco and alcohol outlets is associated with increased experimentation, initiation, and regular use of alcohol and tobacco products. Prior studies examining the sale of tobacco and alcohol indicate that these outlets tend to be concentrated in communities of color and low-income areas. Massachusetts has highlighted environmental justice (EJ), one’s right to be protected from hazards and live in clean, health-promoting environments, as a priority issue and identified block group populations who are at most risk of environmental burdens. The objective of this study was to (a) examine the distribution of tobacco and alcohol outlets in environmental justice block groups in Boston, and (b) compare outlet density in more deprived neighborhoods to more privileged neighborhoods. Methods. Publicly available licensing lists for tobacco and alcohol retailers with geocoded data were obtained from the City of Boston’s open data hub. Lists were de-duplicated so that retailers that sell both tobacco and alcohol products were only represented once. The environmental justice block group layer (2020) was downloaded from Mass.gov. EJ block groups meet one or more of the following criteria: ‘high minority’ (>40% non-white population), ‘low-income’, or ‘high English isolation.’ ArcGIS Pro software was used to spatially join retailer data to Boston block groups and calculate tobacco and alcohol outlet density (the number of retailers per 1,000 people). Sociodemographic and cancer mortality data from the Health of Boston Report was used to classify neighborhoods as ‘more privileged’ (Back Bay, Beacon Hill, North End, West End) or ‘more deprived’ (Dorchester, Hyde Park, Mattapan, Roslindale, Roxbury). Results. Of the 560 Boston block groups analyzed, 458 (81.8%) were considered environmental justice block groups with 60% of EJ block groups classified as ‘high minority’. There were 931 retailers that sell tobacco or alcohol products for off-premises consumption in Boston, with 86% of these retailers (n=811) located in EJ block groups. On average, tobacco and alcohol outlet density was greater in EJ block groups compared to non-EJ block groups (2.09 vs 1.25 retailers per 1,000 residents). Nearly half (48%) of environmental justice block groups in Boston are located in the most deprived neighborhoods compared to only 3.7% in the most privileged neighborhoods. Tobacco outlet density is significantly higher in deprived neighborhoods compared to privileged neighborhoods (1.25 vs 0.98, p < 0.01). However, alcohol density is lower in more deprived block groups compared to more privileged ones (0.35 vs 0.74, p < 0.01). Conclusion. Environmental justice mapping can be used as a tool to identify areas where cancer prevention efforts may be enhanced by modifying the built environment to reduce clusters of alcohol and tobacco outlets. Citation Format: Lindsay Kephart. An examination of tobacco and alcohol outlet density in Boston to identify priority areas for cancer prevention efforts using environmental justice mapping [abstract]. In: Proceedings of the 16th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2023 Sep 29-Oct 2;Orlando, FL. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2023;32(12 Suppl):Abstract nr PR003.

Racial and Ethnic Differences in Initiation of Menthol Tobacco Smoking and Subsequent Tobacco Use in the Population Assessment of Tobacco and Health Study, Waves 1-4 (2013-2018).

Certain subpopulations in the United States are highly vulnerable to tobacco initiation and addiction, and elimination of disparities among those groups is crucial to reducing the burden of tobacco use. This study evaluated the racial and ethnic differences in smoking initiation of menthol flavored cigarettes and cigars among never-users, and in subsequent tobacco use among new users of menthol-flavored products, using longitudinal data from waves 1-4 of the Population Assessment of Tobacco and Health Study. The outcomes of interest were new use of menthol-flavored products, and subsequent past 30-day and past 12-month cigarette and cigar smoking, irrespective of flavors, after initiation. The percentages of new users of menthol-flavored cigarettes and cigars at waves 2-4 were disproportionately higher in non-Hispanic black and Hispanic than in non-Hispanic white people. Adjusting for age and sex, black people who first used any menthol cigars had higher risk of past 30-day use of the same cigar category at the subsequent wave (adjusted risk ratio, aRR 1.48; 95% confidence interval [CI] 1.11 to 1.96) and past 12 months (aRR 1.74; 95% CI 1.55 to 2.63) compared to non-Hispanic white smokers. Black people who first used menthol-flavored cigarettes had marginally higher risk of subsequent past 30-day cigarette use (aRR 1.44; 95% CI 0.99 to 2.10) compared with their non-Hispanic white counterparts. This study shows that racial and ethnic differences exist in both initiation of menthol-flavored tobacco products and product-specific subsequent use after first using menthol-flavored products; black and Hispanic people have higher rates of initiation; black people also have higher rates of subsequent use. Use of menthol flavors in tobacco products is confirmed to be a contributor to large disparities in tobacco use; black and Hispanic people are more likely to maintain smoking through use of mentholated products than non-Hispanic white people. The findings suggest educational and regulatory actions on menthol-flavored tobacco products including restricting the selective marketing to vulnerable communities and banning characterizing flavors in cigarettes and cigars may reduce tobacco-related disparities and inform the Food And Drug Administration's evidence-based rulemaking process.

Precise Estimation for the Age of Initiation of Tobacco Use Among U.S. Youth: Finding from the Population Assessment of Tobacco and Health (PATH) Study, 2013-2017.

Youth tobacco use remains a prominent United States public health issue with a high economic and health burden. We pooled never and ever users at youth's first wave of PATH participation (waves 1-3) to estimate age of initiation for hookah, e-cigarettes, cigarettes, traditional cigars, cigarillos, and smokeless tobacco prospectively (waves 2-4). Age of initiation of each tobacco product was estimated using weighted interval-censored survival analyses. Weighted interval censoring Cox-proportional hazards regression models were used to assess the association of ever use of the TP at the first wave of PATH participation, sex, and race/ethnicity on the age of initiation of ever use of each tobacco product. Sensitivity analyses were performed to understand the impact of the recalled age of initiation for the left-censored participants by replacing the recalled age of initiation with a uniform "6" years lower bound. The proportion of those who ever used each tobacco product at the first wave of PATH participation ranged from 1.8% for traditional cigars to 10.4% for cigarettes. There was a significant increase in ever use of each tobacco product after the age of 14, with e-cigarettes and cigarettes showing the highest cumulative incidence of initiation by age 21, while smokeless and cigarillos recorded the lowest cumulative incidence by age 21. The adjusted Cox models showed boys initiated at earlier ages for all of these tobacco products except for hookah, which showed no difference. Similarly, apart from ever use of hookah, non-Hispanic White youth were more likely to initiate each tobacco product at earlier ages compared to Hispanic, non-Hispanic Black, and non-Hispanic Other youth. The increased sample size and the inclusion of ever users yielded greater precision for age of initiation of each tobacco product than analyses limited to never users at the first wave of PATH participation. These analyses can help elucidate population selection criteria for estimating the age of initiation of tobacco products.

Associations Between Internalizing and Externalizing Symptoms on Subsequent Tobacco Product Initiation and Sustained Use as a Function of Sex Among Adolescents Ages 12-17.

Previous studies have found positive associations between internalizing and externalizing symptoms and the initiation of tobacco use among adolescents. However, few studies have examined the relationship between these symptoms and sustained tobacco use patterns or how they may vary as a function of sex. The current study examined whether these symptoms predict initiation and sustained use of multiple tobacco products within a longitudinal cohort design. Waves 1-3 of the Population Assessment of Tobacco and Health Study (2013-2016) were used to assess relationships between internalizing and externalizing symptoms, sex, and tobacco use categories (cigarettes, e-cigarettes, poly-tobacco use, other tobacco use) in 6,170 adolescents (M age = 13.42, SD = 1.10) who were tobacco naive at Wave 1. Internalizing and externalizing symptoms predicted initiation of several tobacco categories at the 2-year follow-up. Examining sustained use patterns revealed a more consistent relationship with externalizing symptoms across tobacco categories, whereas associations with internalizing symptoms were limited. Sex moderated the relationship between elevated internalizing symptoms and increased odds of subsequent e-cigarette and poly-tobacco initiation, with stronger relationships observed among females. In addition, the relationship between elevated externalizing symptoms and sustained other tobacco use was stronger in females as compared with males. Although both internalizing and externalizing symptoms predict tobacco initiation across several product categories, externalizing symptoms may reflect a more reliable signal of sustained tobacco use in adolescents. Mental health symptoms and subsequent tobacco use differed by sex, with females demonstrating stronger relationships for several products.

Predicting tobacco product initiation from intentions to use: Comparing the validity of item analysis methods

Items measuring tobacco use intentions are used to predict future use. Researchers combine items using different methods; however, no research has compared these methods’ predictive validity. Here, we compare how well six methods of analyzing four intention items predict initiation of cigarettes, e-cigarettes, snus pouches, and other smokeless tobacco one year later. We analyzed youth and young adult never users from the US Population Assessment of Tobacco and Health Study. We compared six methods of analyzing Wave 3 intention items in predicting Wave 4 use: susceptibility scoring (susceptible is not answering “definitely no” to all items); dichotomizing the four-item average using two cut-points on the 1–4 response scale; and dichotomizing one item (next year use intention) with three cut-points. Analyses (1) tested whether each single-item predicted initiation; and (2) compared each method’s (a) true positive rate (rate of correctly identifying future initiators), (b) true negative rate (rate of correctly identifying future non-initiators), and (c) model fit. Results were similar across products and age groups. Averaging items best predicted initiation in regression. Susceptibility scoring had the highest true positive rate but lowest true negative rate. False positives (incorrectly identifying someone as a future initiator) were best minimized by averaging items with a cutoff of 3, or using the single item with a 3 or 4 cutoff. Findings suggest researchers predicting tobacco use initiation using regression should average the four items; and researchers seeking to identify likely initiators should use different analytic methods depending on if they seek to maximize true positives or minimize false positives.

Correlates of tobacco product initiation among youth and young adults between waves 1–4 of the population assessment of tobacco and Health (PATH) study (2013–2018)

IntroductionWhile risk factors for cigarette smoking among youth and young adults are well-documented, less is known about the correlates of initiation of other tobacco products. This study aims to provide estimates and correlates of initiation among U.S. youth and young adults. MethodsData on youth aged 12–17 (n = 10,072) and young adults aged 18–24 (N = 5,727) who provided information on cigarettes, electronic nicotine delivery systems (ENDS), cigars, pipe, hookah and smokeless tobacco use in Wave 1 (W1: 2013–2014)-Wave 4 (W4: 2016–2018) of the nationally-representative PATH Study were used to calculate ever use initiation and correlates of initiation by W4. ResultsNearly 6 million youth and 2.5 million young adults used tobacco for the first time between W1-W4. Approximately one quarter of youth and young adult ENDS never users initiated ENDS between W1-W4 of the PATH Study. Among youth, use of other tobacco products, ever substance use, and high externalizing problems were associated with initiation of most products. Among young adults, use of other tobacco products and ever substance use were associated with initiation of most products. In both youth and young adults, Hispanics were more likely to initiate hookah use than their non-Hispanic White counterparts. While male sex was a risk factor for most tobacco product initiation across both age groups, it was not associated with hookah initiation. ConclusionsCigarette and non-cigarette products shared many correlates of initiation, although there are noteworthy demographic differences. Findings can help tailor product specific interventions to reach populations at risk during preliminary stages of use.

Synthetic Cooling Agents in US-marketed E-cigarette Refill Liquids and Popular Disposable E-cigarettes: Chemical Analysis and Risk Assessment.

Menthol, through its cooling and pleasant sensory effects, facilitates smoking and tobacco product initiation, resulting in the high popularity of mint/menthol-flavored E-cigarettes. More recently, E-cigarette vendors started marketing synthetic cooling agents as additives that impart a cooling effect but lack a characteristic minty odor. Knowledge about content of synthetic coolants in US-marketed E-cigarette products and associated health risks is limited. E-liquid vendor sites were searched with the terms "koolada", "kool/cool", "ice", or WS-3/WS-23, denoting individual cooling agents, and relevant refill E-liquids were purchased. "Ice" flavor varieties of Puffbar, the most popular disposable E-cigarette brand, were compared with non-"Ice" varieties. E-liquids were characterized, and synthetic coolants quantified using GC/MS. Margin of exposure (MOE), a risk assessment parameter, was calculated to assess the risk associated with synthetic coolant exposure from E-cigarette use. WS-3 was detected in 24/25 refill E-liquids analyzed. All Puffbar flavor varieties contained either WS-23 (13/14) or WS-3 (5/14), in both "Ice"- and non-"Ice" flavors. Modeling consumption of WS-3 from vaped E-liquids, resulted in MOEs below the safe margin of 100 for most daily use scenarios. MOEs for WS-23 were <100 for 10/13 Puffbar flavors in all use scenarios. Puffbar power specifications are identical to Juul devices. Synthetic cooling agents (WS-3/WS-23) were present in US-marketed E-cigarettes, at levels that may result in consumer exposures exceeding safety thresholds set by regulatory agencies. Synthetic coolants are not only found in mint- or menthol-flavored products but also in fruit- and candy-flavored products, including popular disposable E-cigarette products such as Puffbar. Synthetic cooling agents are widely used in "kool/cool"- and "ice"-flavored E-liquids and in E-liquids without these labels, both as a potential replacement for menthol or to add cooling "notes" to nonmenthol flavors. These agents may be used to bypass current and future regulatory limits on menthol content in tobacco products, and not just E-cigarettes. Because synthetic cooling agents are odorless, they may not fall under the category of "characterizing flavor", potentially circumventing regulatory measures based on this concept. Regulators need to consider the additional health risks associated with exposure to synthetic cooling agents.

Correlates of tobacco use among Asian and Pacific Islander youth and young adults in the U.S.: A systematic review of the literature.

Rates of tobacco product use, including the use of combustible and electronic cigarettes, remain high in youth and young adults within the U.S. Though a substantial body of work has examined risk factors associated with initiation and ongoing use of tobacco products, research on tobacco use and associated correlates among Asian and Pacific Islanders (APIs) has been more limited despite high rates in select API subgroups. This systematic review outlines recent research (2010-2020) on the correlates of tobacco use in APIs aged 9-29. To better understand determinants of tobacco use and identify gaps in the literature, we framed correlates based on the National Institute on Minority Health and Health Disparities (NIMHD) multidimensional research framework. Database and author-focused searches were conducted, followed by article abstract and full-text reviews, much of which were guided by a discrete set of inclusionary and exclusionary criteria related to tobacco use and youth/young adults. A total of 24 articles were included in this review. The majority of articles focused on individual-level correlates, with a high number of studies demonstrating association between behavioral and sociocultural factors and tobacco product use behavior. Interpersonal factors also made up a substantial portion of the literature, commonly focusing on peer, family, and social norms. Gaps related to the NIMHD model are addressed. Future research should examine biological and community/societal factors associated with API smoking to better understand unique correlates in this population and to inform tobacco prevention and intervention approaches. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The Flavor Train: The Nature and Extent of Flavored Cigarettes in Low- and Middle-Income Countries.

IntroductionFlavors and depictions of flavors are attractive and facilitate initiation and use of tobacco products. However, little is known about the types of flavored products on the market, particularly in low- and middle-income countries. We describe the nature and extent of flavored cigarettes sold in nine low- and middle-income countries from four of the six World Health Organization (WHO) regions.Aims and MethodsWe employed a systematic protocol to purchase unique cigarette packs in Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam. Packs were double coded for flavor descriptors and imagery using a standard codebook. Frequencies and crosstabs were conducted to examine the proportion of packs with flavor descriptors and/or flavor imagery, and flavor capsules, by country and by major manufacturer.ResultsOverall, 15.4% of the country-unique cigarette packs had flavor descriptors and/or imagery, representing a variety of flavors: menthol or mint (8.2%), “concept” descriptors (3.5%) (eg, Fusion blast), fruit or citrus (3.3%), beverages (1.4%), and others (1.4%). Flavor was mostly communicated using descriptors (15.2%), with flavor imagery being less common (2.2%). Flavor capsules were prevalent (6.2%), with almost half having “concept” descriptors. All major tobacco companies produced cigarettes with flavors, and with capsules.ConclusionsA range of flavored cigarettes remain on the market in the low- and middle-income countries with the greatest number of smokers. This finding is particularly concerning given the appeal of flavored cigarettes among youth and their potential to circumvent country bans on flavored tobacco products if those laws are not sufficiently comprehensive. Laws addressing flavored tobacco products need to account for flavor capsules and concept descriptors.ImplicationsWhile a number of countries have restricted flavors in tobacco products to reduce their appeal and attractiveness, a range of flavors continue to be on the market in low- and middle-income countries, putting people in these countries at increased risk for tobacco use and subsequent tobacco-caused death and disease. The presence of capsules and concept descriptors is particularly concerning given their appeal among youth and their potential to circumvent country bans on flavored tobacco products if those laws are not sufficiently comprehensive.

College Students' Reasons for Using JUULs.

To identify reasons that college students use JUUL and explore associations between reasons for using JUUL and social and behavioral (tobacco use) factors. On-line, cross-sectional survey. Large southwestern university in the US. Undergraduate students (n = 605) who owned JUUL and used it weekly. The study measured age of JUUL initiation, JUUL dependence, and use of other e-cigarettes and other tobacco products. Participants described reasons for JUUL use as brief open-ended responses. Responses were categorized by 2 researchers using an inductive procedure. Logistic regressions examined associations between demographics and use frequency and categorized reasons for using JUUL. Four reasons for using JUUL emerged: self-help (48.4%), social (30.4%), experience (42.8%), and substance use/addiction (42.3%). Daily JUUL users were 1.66 (95% CI: 1.05-2.63) times as likely to use JUUL for self-help than those who used JUUL 1-3 days/week. Those who had never tried a cigarette were twice (OR = 2.08; 95% CI: 1.22-3.54) as likely as cigarette-first users to use JUUL for social reasons. Males (OR = 1.87; 95% CI: 1.32-2.65) had higher odds of using JUUL for the experience than females, and JUUL and other e-cigarettes users were 4.37 (95% CI: 1.83-10.45) times as likely as JUUL-only users to use JUUL due to substance use/addiction. JUUL users report unique reasons for use (e.g., addiction) not previously reported for older models of e-cigarette devices.

Shared Environmental Influences on Electronic Cigarette Use Among Adolescent and Young Adult Females.

Electronic cigarettes are now the most commonly used form of tobacco product among youth in the United States. Current evidence suggests that although e-cigarettes are perceived as less harmful and preferred over combustible cigarettes by adolescents, adolescents who try e-cigarettes are at greater risk of transitioning to combustible cigarettes. The genetic and environmental contributions to liability for e-cigarette use have not yet been examined using a behavioral genetic design. Behavioral genetic models of lifetime and current e-cigarette use and friends who use e-cigarettes were examined among female monozygotic and dizygotic twins. A total of 41 female twin pairs (65.9% monozygotic twins; age = 19.7, SD = 1.6) with complete data on the study variables were included in the present analyses. The majority of the sample (68.1%) had at least some friends who use e-cigarettes. Additive genetic effects on e-cigarette use were not present, but the shared environment explained 98.7% of the variance in lifetime e-cigarette use, 96.6% in current e-cigarette use, and 94.9% in affiliation with friends who use e-cigarettes. This first study on the behavioral genetics of e-cigarette use among adolescents and young adults suggest that environmental factors shared by twins within a family seem to play a predominant role in the initial stages of e-cigarette use, a finding that is consistent with what has been found for tobacco. The findings emphasize the importance of continuing population-based tobacco control interventions to reduce the burden of e-cigarette use among adolescents. The shared environment significantly influences the initiation and regular use of electronic cigarettes and affiliation with friends who use electronic cigarettes among adolescent and young adult females. These findings underscore the importance of formulating preventive interventions that mitigate the social effects of familial influences on e-cigarette use through social skills training, education on harms of e-cigarettes for young people, or altering social norms regarding initiation of novel tobacco products.

Tobacco product use and susceptibility to use among sexual minority and heterosexual adolescents

Sexual identity is associated with tobacco use in adults. We examined tobacco use and susceptibility to use by sexual identity in adolescents. Data were collected in February 2019 via Qualtrics research participant panels. Data analyses were performed in June 2019 and updated in October 2020. Respondents aged 13–17 reported sexual identity (heterosexual vs. sexual minority [lesbian, gay, bisexual, or other]), past-month and lifetime tobacco product use, susceptibility to e-cigarette use, friend(s)’ e-cigarette use, tobacco marketing exposure, and demographic characteristics. The sample (n=983) was 72.9% female, 46.5% non-Hispanic white, and 26.1% sexual minority with a mean age of 15.0 years (SD=1.4). Sexual minority adolescents were more likely to have friend(s) who vape (53.0% versus 42.0%; p=0.003). In adjusted models, sexual minority adolescents had greater odds of ever smoking tobacco (odds ratio [OR]=2.06; 95% confidence interval [CI]: 1.42–2.98) or using e-cigarettes (OR=1.55; 95% CI: 1.08–2.25) relative to heterosexual adolescents. Past-month tobacco smoking and e-cigarette use did not differ by sexual identity. Among participants who had never used tobacco products, sexual minority adolescents reported greater susceptibility to e-cigarette use (OR=1.62; 95% CI: 1.04–2.52) compared to heterosexual adolescents. Exposure to cigarette and e-cigarette marketing, e-cigarette use by friends, and respondent sex were significant covariates in all models. The current findings indicate greater susceptibility to use e-cigarettes and greater tobacco product initiation, but not continuation, among sexual minority adolescents. Sexual minority-tailored interventions may be warranted to prevent tobacco product initiation. Worth exploring are the associations between sexual identity, tobacco marketing exposure, and friend(s)’ e-cigarette use.

Age of Onset of Susceptibility to Different Tobacco Products Among Non-Susceptible US Young Adults: Findings from the Population Assessment of Tobacco and Health Study Waves 2-4 (2014-2017).

IntroductionInitiation of tobacco products is increasing in young adulthood. This study prospectively estimated the age of onset of susceptibility to cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos among young adults, which is a cognitive precursor to initiation.MethodsSecondary data analyses of the Population Assessment of Tobacco and Health (PATH) study, a nationally representative longitudinal cohort study of US adults. Young adults (18-24 years) who were non-susceptible to each tobacco product (cigarettes, e-cigarettes, hookah, smokeless tobacco, and cigarillos) at waves 2 or 3 were followed-up into waves 3-4 to prospectively estimate the age of onset of susceptibility to each tobacco product. Weighted interval-censored survival methods and interval-censored Cox regression models were implemented to estimate the age of onset of susceptibility, and to estimate differences in the hazard function by sex and by race/ethnicity, while controlling for the total number of other tobacco products ever used at their first wave of participation in PATH.ResultsBy age 21, 16.5%, 16.0%, 12.6%, 12.4%, and 5.9% of young adults reported onset of susceptibility to hookah, e-cigarettes, cigarillos, cigarettes, and smokeless tobacco, respectively. Among young adults who were non-susceptible to each tobacco product at waves 2 or 3, the highest increase in onset of susceptibility occurred between ages 18 and 19 for cigarettes, e-cigarettes, and hookah, while the highest increase in onset of susceptibility occurs between ages 22 and 23 for cigarillos. Young adult males had increased risk of onset of susceptibility to cigarillos and smokeless tobacco at earlier ages than young adult females. Differences in onset of susceptibility to each tobacco product were also observed by race/ethnicity among young adults.ConclusionsWith the changing landscape of tobacco products, monitoring the age of onset of susceptibility of tobacco product use among non-susceptible young adults longitudinally is critical to prevent initiation. Communication and education campaigns tailored to address differences in susceptibility among young adults by tobacco product and sociodemographic factors will be useful.

Effectiveness of a web-based tobacco product use prevention videogame intervention on young adolescents’ beliefs and knowledge

Background Preventing tobacco product initiation in youth is a critical need. While cigarette smoking among youth has been on the decline, tobacco use in other forms, such as e-cigarettes and vaping, continue to be a major concern. The purpose of this study was to conduct a real-world, quasi-experimental test of the effectiveness of a web-based videogame, smokeSCREEN, aimed at developing healthy beliefs and knowledge associated with tobacco product use prevention, including electronic cigarettes. Methods: Adolescents (N = 560) aged 10–16 years were enrolled from schools and afterschool programs in a single-group pre–post study. Measures included a pre- and post-survey of beliefs and knowledge about tobacco product use. At post-survey, participants were asked questions regarding their gameplay experience. Paired responses for the tobacco product use in the beliefs and knowledge survey before and after the smokeSCREEN videogame intervention were compared using McNemar’s test. Descriptive statistics were generated to assess overall participant gameplay experience. Results: McNemar’s test showed significant differences in the proportions of correct answers before (pre-survey) and after (post-survey) the intervention in seven out of eight belief questions (p < . 0001). It also suggested significant differences in the proportions of correct answers before (pre-survey) and after (post-survey) the intervention in all six knowledge questions (p < . 0001). Several gender and age differences were noted for belief and knowledge questions related to e-cigarettes and vaping. There was no association between gameplay duration at post-survey or to the answers of the beliefs or knowledge questions. Overall, participants reported that they enjoyed playing the game. Conclusions: Findings suggest that the videogame intervention, smokeSCREEN, has a promising effect on participants’ beliefs and knowledge about tobacco product use, including electronic cigarettes and vaping, and is well accepted by adolescents.

Trends in Tobacco Use among Young Adults Presenting for Military Service in the United States Air Force between 2013 and 2018

Background: The US military has historically higher tobacco use compared to civilians, and tobacco use increases following enlistment. While the military is vulnerable to tobacco use, current surveillance of tobacco among this high-risk population is lacking. Methods: Recently enlisted Airmen (N = 43,597) between 2013 and 2018 were asked about tobacco use prior to enlistment across ten products: (1) cigarettes/roll your own tobacco, (2) smokeless tobacco/snus, (3) cigars, cigarillos/little cigars, (4) hookah/pipe, and (5) e-cigarettes. Results: Hookah/pipe use, cigarettes/roll your own, smokeless tobacco/snus, and cigars/little cigars/cigarillos use decreased significantly between 2013 and 2018, while the prevalence of e-cigarette use increased (p’s < 0.0001). The relationships between the time and each tobacco product(s) use outcomes were influenced differently by different age, race, education and marital status. Conclusion: While e-cigarette use has increased in the civilian sector, the use of e-cigarettes among new recruits increased much more drastically (i.e. prevalence 15.3% in 2018). Further, demographic characteristics influenced tobacco trends; specifically, recruits of racial minorities increased their use of e-cigarettes over the past five years faster than Whites. Of concern is what impact this dramatic increase in e-cigarette use will have on overall health and later initiation of combustible tobacco products in the military.

Adults’ E-Cigarette Flavor Use and Cigarette Quit Attempts: Population Assessment of Tobacco and Health Study Findings

Prevalence of use of e-cigarettes among youth 1 Cullen KA Gentzke AS Sawdey MD et al. E-cigarette use among youth in the United States, 2019. JAMA. 2019; 322: 2095-2103https://doi.org/10.1001/jama.2019.18387 Crossref PubMed Scopus (383) Google Scholar and adults 2 Creamer MR Wang TW Babb S et al. Tobacco product use and cessation indicators among adults - United States, 2018. MMWR Morb Mortal Wkly Rep. 2019; 68: 1013-1019https://doi.org/10.15585/mmwr.mm6845a2 Crossref PubMed Scopus (448) Google Scholar in the U.S. continues to rise, and flavored tobacco product use is associated with initiation and subsequent use of tobacco products. 3 Villanti AC Johnson AL Glasser AM et al. Association of flavored tobacco use with tobacco initiation and subsequent use among U.S. youth and adults, 2013-2015. JAMA Netw Open. 2019; 2e1913804 https://doi.org/10.1001/jamanetworkopen.2019.13804 Crossref PubMed Scopus (46) Google Scholar However, little data exist on whether flavored e-cigarettes are associated with cigarette-cessation behaviors, 4 National Academies of Sciences Engineering and MedicinePublic Health Consequences of e-Cigarettes. The National Academies Press, Washington, DC2018https://doi.org/10.17226/24952 Google Scholar including attempting to quit cigarette smoking and quit success among those who attempt to quit, 5 Kasza KA Edwards KC Tang Z et al. Correlates of tobacco product cessation among youth and adults in the USA: findings from the PATH study waves 1-3 (2013-2016). Tob Control. 2020; 29: s203-s215https://doi.org/10.1136/tobaccocontrol-2019-055255 Crossref PubMed Scopus (20) Google Scholar although Buu et al. 6 Buu A Hu YH Piper ME Lin HC The association between e-cigarette use characteristics and combustible cigarette consumption and dependence symptoms: results from a national longitudinal study. Addict Behav. 2018; 84: 69-74https://doi.org/10.1016/j.addbeh.2018.03.035 Crossref PubMed Scopus (29) Google Scholar found that among exclusive cigarette smokers, using flavored e-cigarettes 1 year later was associated with lower quantity of cigarette smoking. This study uses U.S. nationally representative data from the Population Assessment of Tobacco and Health (PATH) Study to report on e-cigarette flavor use among adult past 30–day dual users of e-cigarettes and cigarettes and to longitudinally evaluate the relationship between flavor use and attempting to quit cigarette smoking approximately 1 year later.

The Recalled Age of Initiation of Multiple Tobacco Products among 26-34 Year Olds: Findings from the Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013-2014).

This study examined the recalled age of initiation of seven different tobacco products (TPs) and explored potential influences of sex, race/ethnicity, and cigarette-smoking status on tobacco use initiation among adults 26–34 years old using the PATH study. Methods: Secondary analyses were conducted in the adult restricted PATH wave 1 (2013–2014) dataset. Weighted statistics are reported using the balanced repeated replication method and Fay’s correction to account for PATH’s complex study design. Distributions and histograms of the recalled age of initiation of seven different TPs (cigarettes, cigarillos, traditional cigars, filtered cigars, hookah, smokeless tobacco, and e-cigarettes) are reported, as well as the impact of sex and race/ethnicity using Cox proportional hazard models. The impact of cigarette-smoking status on the recalled age of initiation of each tobacco product other than cigarettes was explored. Results: The highest modes of the recalled age of initiation of cigarette use were at 14–15 and 15–16 years old. The distributions of the recalled age of initiation of cigarillos, traditional cigars, filtered cigars, hookah, and smokeless tobacco occurred later, with the highest modes at 15–16 and 17–18 years old. The distribution of the recalled age of initiation of e-cigarettes had a different shape than the other TPs, with the highest mode reported at 27–28 years old. Conclusion: Due to the ever-changing tobacco marketplace, understanding when contemporary adults aged 26–34 years recall initiating TP use is important and will inform prevention researchers.