Non-cigarette Tobacco Use Research Articles

Non-cigarette tobacco products, aryl-hydrocarbon receptor repressor gene methylation and smoking-related health outcomes

IntroductionCigarette smoking leads to altered DNA methylation at the aryl-hydrocarbon receptor repressor (AHRR) gene. However, it remains unknown whether pipe or cigar smoking is associated with AHRR methylation. We evaluated...

Abstract A091: Beliefs and behaviors regarding non-cigarette tobacco use cessation care differ between providers at substance use treatment centers and community health centers serving rural and/or medically underserved areas of Texas

Abstract Purpose: Cancer mortality rates are higher in rural versus urban areas of the US, partly due to elevated tobacco use (including non-cigarette tobacco products (NCTPs); e.g., dip, snuff, vapes). Clinical practice guidelines call for tobacco use screening and brief intervention at every patient contact. Limited literature examines actual practices with respect to NCTP use in healthcare centers in rural and/or medically underserved areas (MUAs). This study examines if providers at substance use treatment centers (SUTCs) and community health centers (CHCs; e.g., Federally Qualified Health Centers) in such areas of Texas view NCTP cessation counseling as an important part of their job and if they use the 5As (Ask, Advise, Assess, Assist, Arrange) and motivational interventions to address their patients’ NCTP use. Methods: Providers from 21 healthcare centers (12 SUTCs, 9 CHCs) that had been solicited to later receive resources to improve their tobacco cessation care responded to face-valid survey items about their tobacco use screening and intervention delivery over the last month, along with their view on whether NCTP cessation counseling is an important part of their job. In total, 347 providers from SUTCs (n=174) and CHCs (n=173) serving 126 of Texas’ 254 counties responded. Linear mixed models and generalized linear mixed models were used to assess the differences between SUTCs and CHCs for continuous and binary variables, respectively. Results: Only 52% of providers agreed that NCTP cessation counseling is an important part of their job, with a significantly greater percentage (p=0.0023) agreeing at CHCs (63%) than at SUTCs (40%). Providers Asked 62% of their patients whether they used NCTPs. Of patients who endorsed use (20%), providers Advised 58% to quit and Assessed 53% about their interest in quitting. However, providers only Assisted 34% of use-endorsing patients in making a quit attempt and only Arranged follow-up for 23% of them. A significantly greater percentage (p=0.0025) of those patients were Advised to quit at CHCs (72%) than at SUTCs (44%). Providers delivered brief motivational interventions to 74% of patients who were not ready to quit, with significantly greater percentages advising patients to consider quitting in the future (p=0.0365) and telling patients they would revisit the topic at the next visit (p=0.0264) at CHCs (63% and 37%, respectively) than at SUTCs (45% and 24%, respectively). However, providers encouraged only 39% of use-endorsing patients to stop NCTP use completely, with a significantly greater percentage (p=0.0010) doing so at CHCs (50%) than at SUTCs (28%). Conclusion: Providers surveyed at healthcare centers in rural and/or MUAs of Texas were more likely to deliver evidence-based NCTP cessation care at CHCs than at SUTCs. Patients at both CHCs and SUTCs would benefit from their providers placing greater value on NCTP cessation care and more consistently delivering such care per guidelines. These data will inform healthcare centers’ implementation of best practices in treating their patients’ NCTP use. Citation Format: Brian J. Carter, Maggie Britton, Tzuan A. Chen, Isabel Martinez Leal, Ammar D. Siddiqi, Teresa Williams, Kathleen Casey, Hector Sanchez, Sriya Kakarla, Lorraine R. Reitzel. Beliefs and behaviors regarding non-cigarette tobacco use cessation care differ between providers at substance use treatment centers and community health centers serving rural and/or medically underserved areas of Texas [abstract]. In: Proceedings of the 17th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2024 Sep 21-24; Los Angeles, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2024;33(9 Suppl):Abstract nr A091.

A decomposition analysis of sociodemographic factors and non-cigarette tobacco use as contributors to the change in smoking rates in South Africa between 2017/18 and 2021.

Trends data up to 2018 suggest that tobacco smoking was increasing in South Africa (SA), but only limited information is available on the impact of the COVID-19 pandemic on the current pattern of use of tobacco and nicotine products (TNPs). To assess trends in sociodemographic patterns in the use of TNPs and the extent to which sociodemographic factors and non-cigarette tobacco use may explain possible changes in rates of TNP use between 2017/18 and 2021. Data from three waves (2017, 2018 and 2021) of the South African Social Attitudes Survey (total N=8 140) were analysed. The sociodemographic correlates of current daily and non-daily use of factory-manufactured cigarettes (FMCs), roll-your-own (RYO) cigarettes, waterpipe/hubbly, electronic cigarettes (ECigs), snuff (a smokeless tobacco) and any combination of FMCs, RYO cigarettes and waterpipe/hubbly ('current smoking') in 2017/18 (pre-pandemic) were compared with those for 2021 (during the pandemic). Chi-square analyses and generalised linear models were used to compare the prevalence of TNP use between the two periods. A Blinda-Oaxaca decomposition analysis was also used to explore the roles of various sociodemographic factors, including any differences in the use of TNPs, that may explain any observed differences in smoking rates between 2017/18 and 2021. Current smoking increased significantly from 22.4% (95% confidence interval (CI) 20.4 - 24.5) in 2017/18 to 27.6% (95% CI 24.3 - 31.1) in 2021 (p=0.009). Smoking of FMCs did not change significantly overall between these two periods (20.1% v. 22.1%; p=0.240), except for a significant increase among those who self-identified as black African and a decrease among those who self-identified as coloured and those currently employed. However, the use of waterpipe/hubbly, ECigs, RYO cigarettes and snuff increased significantly. Women, individuals aged <35 years and black Africans had the largest increase in waterpipe/hubbly and ECig use. A decomposition analysis showed that increased waterpipe/hubbly and RYO use explained 52% and 15%, respectively, of the increase in smoking rates, while lower employment during 2021 compared with 2017/18 explained 15% of the increase in smoking rates during 2021. The use of all TNPs continued to increase in SA, particularly among women and unemployed people. These findings have policy and practice implications for addressing socioeconomic disparities in tobacco-related diseases.

Noncigarette Tobacco Product Use Among Smoking-Susceptible and Nonsusceptible Adolescent Never Smokers, 2009–2021

PurposeExamine trends in noncigarette tobacco use among smoking susceptible and nonsusceptible adolescents from 2009–2021. MethodsData came from cross-sectional samples of the National Youth Tobacco Survey (N = 183,198). Using Pierce's smoking susceptibility scale, participants were classified as either susceptible or nonsusceptible to cigarette smoking. Their use of noncigarette tobacco products was classified into four mutually exclusive categories: nonuse, noncigarette combustibles use, noncombustibles use, and noncigarette combustibles and noncombustibles dual use. We produced covariate-adjusted predicted marginal proportions of noncigarette tobacco use for 12 National Youth Tobacco Survey years, which were entered into Joinpoint trend analysis software to determine (a) trends in noncigarette tobacco use from 2009–2021 using the average annual percent changes (AAPCs) and (b) changes in each time segment using the average percent change. Models were fitted by smoking susceptibility, sex, and race/ethnicity. ResultsNonuse was lower among susceptible (vs. nonsusceptible) adolescents whereas noncigarette tobacco use was higher. Trends show significant declines in nonuse (nonsusceptible: AAPC = −0.3%) and noncigarette combustibles use (susceptible: AAPC = −12%) between 2009–2021, increases in noncombustibles use (susceptible: AAPC = 18%, nonsusceptible: AAPC = 19%) between 2009 and 2019, and steadiness in dual use. Parallel trends were observed when stratified by sex and race/ethnicity with notable increases in noncombustibles use among females and Latinos. DiscussionNoncigarette tobacco use differed by smoking susceptibility. Observed trends, especially when stratified by sex and race/ethnicity, raise concerns about tobacco use disparities among females and Latinos. Smoking susceptibility can help identify at-risk adolescents for current or future tobacco use.

Non-cigarette Tobacco Use and Stroke Among West Africans: Evidence From the SIREN Study.

Non-cigarette tobacco (NCT) represents a form of tobacco use with a misperceived significance in chronic disease events. Whether NCT use is sufficient to promote stroke events, especially among Africans, is yet to be understood. This study assessed the relationship between NCT use and stroke among indigenous Africans. A total of 7617 respondents (NCT users: 41 vs. non-NCT: 7576) from the Stroke Investigative Research and Educational Network (SIREN) study were included in the current analysis. NCT use was defined as self-reported use of smoked (cigars or piper) or smokeless (snuff or chewed) tobacco in the past year preceding stroke events. Stroke was defined based on clinical presentation and confirmed with a cranial computed tomography/magnetic resonance imaging. Multivariable-adjusted logistic regression was applied to estimate the odds ratio (OR) and 95% confidence interval (CI) for the relationship of NCT with stroke at a two-sided p < .05. Out of the 41 (0.54%) who reported NCT use, 27 (65.9%) reported using smokeless NCT. NCT users were older than non-NCT users (62.8 ± 15.7 vs. 57.7 ± 14.8 years). Overall, NCT use was associated with first-ever stroke (OR: 2.08; 95% CI: 1.02, 4.23) in the entire sample. Notably, smokeless NCT use was independently associated with higher odds of stroke (OR: 2.74; 95% CI: 1.15, 6.54), but smoked NCT use (OR: 0.16; 95% CI: 0.02, 1.63) presented a statistically insignificant association after adjusting for hypertension and other covariates. NCT use was associated with higher odds of stroke, and public health interventions targeting NCT use might be promising in reducing the burden of stroke among indigenous Africans. A detailed understanding of the relationship between NCT use and stroke will likely inform well-articulated policy guidance and evidence-based recommendations for public health prevention and management of stroke on the African continent.

Abstract 4184: Congruent views among substance use treatment center leadership on organizational readiness to implement a tobacco-free workplace program is linked to provider uptake of non-cigarette tobacco use treatment

Abstract Purpose: Tobacco use, linked to 17 cancers, is the leading cause of preventable death in the US. Despite elevated tobacco use among patients, substance use treatment centers (SUTCs) do not routinely address tobacco use. A tobacco-free workplace program (TFWP) implemented in SUTCs included tobacco-free policy guidance, provision of resources, and education for providers on evidence-based tobacco use treatment, which emphasized use of the 5As: Asking about tobacco use, Advising to quit, Assessing willingness to quit, Assisting with quitting, and Arranging follow-up. Congruent SUTC leadership views on readiness for TFWP implementation may forecast greater organizational support for implementation and thus enhanced provider uptake. Given the increasing use of non-cigarette tobacco products, this study examined associations between congruent views among SUTC leadership on readiness to implement the TFWP and changes in providers’ delivery of the 5As for non-cigarette tobacco-using patients (i.e., uptake) from pre- to post- program implementation. Methods: Post-enrollment but before TFWP implementation, CEOs and Directors from each of 15 participating SUTCs (n=84) completed the Organizational Readiness for Implementing Change (ORIC), which has an overall readiness score and 5 subscale scores (resource availability, change efficacy, change valence, change commitment, and task knowledge). Center-level ORIC congruence was measured by calculating the difference between CEO-reported ORIC and mean Director-reported ORIC scores. Providers from each SUTC completed pre- and post-implementation surveys (pre n=259, post n=194) on their delivery of the 5As to non-cigarette tobacco-using patients during the prior month. Generalized linear regression analyses explored the effect of ORIC congruence on changes in the use of each of the 5As over time. Results: Use of each of the 5As increased over time. Providers from SUTCs with more leadership congruence on (a) task knowledge and overall readiness had greater increases in Assisting with quitting and (b) resource availability, change efficacy, task knowledge, and overall readiness had larger increases in Arranging follow-up. Conclusion: Reducing the research-to-practice translation gap in tobacco control through TFWP implementation in settings where users receive care is a critical cancer prevention strategy. TFWPs may facilitate greater provider uptake of evidence-based treatment and more effectively address patients’ non-cigarette tobacco use in SUTCs by purposefully aligning leadership support for change. Strategies to align leadership support may include convening CEOs and Directors to identify multi-level organizational barriers and facilitators and engage in group problem-solving with respect to any barriers. Citation Format: Brian J. Carter, Tzuan A. Chen, Maggie Britton, Isabel Martinez Leal, Virmarie Correa-Fernández, Anastasia Rogova, Bryce Kyburz, Teresa Williams, Kathleen Casey, Lorraine R. Reitzel. Congruent views among substance use treatment center leadership on organizational readiness to implement a tobacco-free workplace program is linked to provider uptake of non-cigarette tobacco use treatment. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4184.

Changes in Substance Use Treatment Providers' Delivery of the 5A's for Non-Cigarette Tobacco Use in the Context of a Comprehensive Tobacco-Free Workplace Program Implementation.

Tobacco use treatment is not prioritized in substance use treatment centers (SUTCs), leading to tobacco-related health inequities for patients with substance use disorders (SUDs) and necessitating efforts to enhance providers' care provision. Training providers on how to treat tobacco use increases their intervention on patients' smoking, but limited work addresses its effects on their non-cigarette tobacco use intervention provision. This study redressed this gap using data from 15 unaffiliated SUTCs in Texas (serving 82,927 patients/year) participating in a tobacco-free workplace program (TFWP) that included provider education on treating tobacco use, including non-cigarette tobacco use. SUTC providers completed surveys before (n = 259) and after (n = 194) TFWP implementation. Past-month screening/intervention provision for non-cigarette tobacco use (the 5A's; ask, advise, assess, assist, arrange) and provider factors theoretically and practically presumed to underlie change [i.e., beliefs about concurrently treating tobacco use disorder (TUD) and other SUDs, self-efficacy for tobacco use assessment (TUA) delivery, barriers to treating tobacco dependence, receipt of tobacco intervention training] were assessed. Generalized linear or linear mixed models assessed changes over time from before to after TFWP implementation; low vs. high SUTC-level changes in provider factors were examined as moderators of changes in 5A's delivery. Results indicated significant improvement in each provider factor and increases in providers' asking, assisting, and arranging for non-cigarette tobacco use over time (ps < 0.04). Relative to their counterparts, SUTCs with high changes in providers' beliefs in favor of treating patients' tobacco use had greater odds of advising, assessing, assisting, and arranging patients, and SUTCs with greater barrier reductions had greater odds of advising and assisting patients. Results suggest that TFWPs can address training deficits and alter providers' beliefs about treating non-tobacco TUD during SUD care, improve their TUA delivery self-efficacy, and reduce intervention barriers, ultimately increasing intervention provision for patients' non-cigarette tobacco use. SUTCs with the greatest room for improvement in provider beliefs and barriers to care provision seem excellent candidates for TFWP implementation aimed at increasing non-cigarette tobacco use care delivery.

Providers' Non-Cigarette Tobacco Use Intervention Practices in Relation to Beliefs about Patients, Prioritization of and Skills for Intervention, and Referral Knowledge in Texas Healthcare Centers Providing Care to Persons with Behavioral Health Needs.

Rates of non-cigarette (colloquially, other) tobacco use is elevated among adults with behavioral health conditions. Little is known about whether behavioral health providers are using brief interventions, including the evidence-based 5As (Ask, Advise, Assess, Assist, and Arrange) for other tobacco use, or what provider factors may be associated with use of these interventions. The current study redressed this gap. Overall, 86 providers in Texas (9 Federally Qualified Health Centers, 16 Local Mental Health Authorities (LMHAs) that provide a broad range of mental and behavioral health services, 6 substance use treatment programs in LMHAs, and 55 stand-alone substance use treatment programs) took a survey assessing their beliefs regarding (1) patients' concerns about other tobacco use; (2) their desire to quit; (3) importance of intervening on other tobacco use with cessation counseling; (4) perceived skills to intervene; (5) knowledge of referral options for treatment. Logistic regression analyses were conducted to determine the association between each factor and use of the 5As. Results showed that 70.9% of providers asked patients about other tobacco use status, 65.1% advised them to quit, 59.3% assessed quit interest, 54.7% assisted with a quit attempt, and 31.4% arranged a follow-up. Providers who believed patients were concerned about other tobacco use, recognized the importance of offering other tobacco use cessation counseling, believed they had the necessary skills to treat other tobacco use, and possessed knowledge of referral options, respectively, were more likely to deliver the 5As (ps < 0.05). Results add to a limited literature on provider intervention practices for other tobacco use in settings where behavioral health care is provided, highlighting the significance of provider beliefs, perceived skills, and referral knowledge to care delivery. Findings reveal opportunities to increase delivery of the 5As for other tobacco use to behavioral health patients and suggest provider factors that could be targeted to build this capacity.

Co-substance use of nicotine vaping and non-cigarette tobacco products among U.S. grade 12 students from 2017-2019

BackgroundNicotine vaping among U.S. adolescents has risen rapidly over the past decade, particularly for youth in grade 12. While previous studies examined the relationship between nicotine vaping and combustible cigarette use, less is known about the co-occurrence between vaping and other tobacco products. MethodsUsing Monitoring the Future grade 12 data (2017-2019), we investigated associations between past 30-day nicotine vaping and non-vaping, non-cigarette tobacco use (smokeless tobacco, large cigars, cigarillos, hookah). Population prevalences of four categories were assessed: neither, vaping only, non-vaping of non-cigarette tobacco only, or both. We further investigated these relationships with logistic regressions accounting for the complex survey design (unadjusted, demographic-adjusted, and further adjusted for other substance use). Finally, analyses were stratified by combustible cigarette use. ResultsDepending on the non-cigarette tobacco product, 2.5% to 5.4% of grade 12 students vaped nicotine and used a non-cigarette tobacco product. Controlling for demographics, cigarillo use was associated with nicotine vaping (adjusted RR = 3.44, 95% CI: 3.08, 3.84), as was hookah use (aRR = 3.51, 95% CI: 2.92, 4.23), smokeless tobacco (aRR = 2.97, 95% CI: 2.51, 3.52), and cigar use (aRR = 2.90, 95% CI: 2.49, 3.37). Controlling for cannabis and all non-cigarette tobacco products simultaneously attenuated associations. Associations were stronger among students who did not use cigarettes. DiscussionNicotine vaping is associated with use of many non-cigarette tobacco products, including smokeless tobacco, cigarillos, cigars, and hookah. As prevalence of nicotine vaping remains high among adolescents, we should monitor co-use of vaping and other tobacco products.

Non-cigarette combustible tobacco use and its associations with subsequent cessation of smoking among daily cigarette smokers: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2016-20).

To examine whether polyuse of cigarettes and other smoked products (polysmoking) is predictive of quit attempts and quit success. A prospective multi-country cohort design. Australia, Canada, England and the United States. A total of 3983 adult daily cigarette smokers were surveyed in 2016 (wave 1 of data collection) and were re-contacted in 2018 (wave 2) (i.e. waves 1-2 cohort) in the International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) surveys; and 3736 smokers were surveyed in 2018 and re-contacted in 2020 (wave 3) (i.e. waves 2-3 cohort). Participants were asked about their cigarette smoking and use of cigars, cigarillos, pipes and waterpipes. Outcomes were quit attempts between two survey waves and success, defined as having quit smoking all the combustible tobacco at the subsequent survey for 1month or more. Levels of polysmoking were 12.7% in the waves 1-2 cohort and 10.5% for the waves 2-3 cohort. Compared with cigarette-only smokers, polysmokers were more likely to attempt to quit between waves 1 and 2 [54.9 versus 42.7%, adjusted odds ratio (aOR) = 1.37, 95% confidence interval (CI) = 1.08-1.74, P < 0.01], but not between waves 2 and 3 (43.8 versus 40.1%, aOR = 0.94, 95% CI = 0.72-1.22). Polysmoking predicted reduced likelihood of success in both cohorts among attempters and the overall samples. Between waves 2 and 3 there were significantly more transitions to non-daily smoking among the polysmokers (12.4 versus 5.3%, χ2 = 40.4, P < 0.001). There is a consistent association between polysmoking (use of cigarettes together with other smoked products) and reduced quit success for combustible tobacco, but it is probably due to increased likelihood of transitioning to non-daily use rather than complete cessation.

Tobacco Use among School-Going Adolescents in Comoros: A Secondary Analysis of the 2015 Comoros Global Youth Tobacco Survey.

Background Tobacco use among adolescents has long-term adverse health consequences, especially during adulthood. Currently, little is known about tobacco use behaviour among adolescents in Comoros. Our study aims at estimating the prevalence and identifying key factors associated with tobacco use among adolescents in Comoros using the 2015 Comoros Global Youth Tobacco Survey data. Methods A national cross-sectional survey secondary data of 2,810 eligible school-going adolescents aged between 11 and 17 years was analysed. Complex sample logistic regression analyses were used to determine the correlates of current cigarette smoking and current use of noncigarette tobacco products. Results The overall prevalence of current cigarette smoking was 14.3% [males (18.5%) and females (9.9%)]. The prevalence of current use of noncigarette tobacco products was 5.8% [males (6.7%) and females (4.9%)]. Being male (AOR = 2.24; 95% CI:1.39-3.63), exposure to secondhand smoke inside (AOR =3.88; 95% CI:2.84-5.31) and outside (AOR =1.49; 95% CI: 1.08-2.03) their home, and exposure to tobacco industry promotion (AOR =2.90; 95% CI:2.21-3.80) were associated with current cigarette use among school-going adolescents. However, parental smoke (AOR = 1.20; 95% CI:0.78-1.87) and not exposed to antismoking education in schools (AOR = 0.97; 95% CI:0.76-1.22) were not associated with current cigarette use. On the other hand, being male (AOR = 1.24; 95% CI:0.82-1.86) was not associated with the current use of noncigarette tobacco products. Adolescents who were exposed to tobacco industry promotion (AOR = .2.58; 95% CI:1.54-4.32) and not exposed to antismoking education in school (AOR = 0.52; 95% CI:0.32-0.85) were more and less likely associated with noncigarette tobacco use. Conclusion One in seven school-going adolescents smokes cigarettes, and approximately one in 20 school-going adolescents uses noncigarette tobacco products in Comoros. Exposure to secondhand smoke within and outside the home and exposure to tobacco industry promotion were associated with tobacco use in school-going adolescents in Comoros. Our findings suggest the need for adolescent-friendly gender-sensitive tobacco interventions, including strengthening existing tobacco control laws to prevent and reduce tobacco use among school-going adolescents in Comoros.

A descriptive study of cervical cancer survivors' persistent smoking behavior and perceived barriers to quitting.

Cervical cancer survivors (CCS) tend to smoke cigarettes at rates much higher than other cancer survivors and women in the general population. However, few studies take a deep dive into the smoking behavior of cervical cancer survivors and none focus on the barriers they experience related to smoking cessation. This study aimed to describe CCS' tobacco use characteristics, quit attempts, and barriers to quit success. In a concurrent mixed-method design, 50 CCS (94% White nonHispanic) who were diagnosed in the past 5 years and were current smokers at diagnosis provided data via standardized questionnaire and semi-structured interview. More than three-quarters of participants were current smokers at the time of study participation, 25.6% of whom also reported noncigarette tobacco use (e.g., electronic cigarette, cigar, snus). Seventy percent of participants reported making at least one 24 hr quit attempt postdiagnosis, with 61.5% of current smokers preferring to quit without professional advice or counseling and 51.3% preferring to quit without medication assistance. Four themes emerged regarding barriers to smoking cessation: motivation and readiness; confidence and uncertainty; triggers; and social and environmental factors. The rate of smoking in CCS is remarkably high, which may partly be explained by negative attitudes toward and low use of evidence-based treatment as well as multi-level barriers to smoking cessation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Association of tobacco product use with chronic obstructive pulmonary disease (COPD) prevalence and incidence in Waves 1 through 5 (2013–2019) of the Population Assessment of Tobacco and Health (PATH) Study

BackgroundWe examined the association of non-cigarette tobacco use on chronic obstructive pulmonary disease (COPD) risk in the Population Assessment of Tobacco and Health (PATH) Study.MethodsThere were 13,752 participants ≥ 40 years with Wave 1 (W1) data for prevalence analyses, including 6945 adults without COPD for incidence analyses; W1–5 (2013–2019) data were analyzed. W1 tobacco use was modeled as 12 mutually-exclusive categories of past 30-day (P30D) single and polyuse, with two reference categories (current exclusive cigarette and never tobacco). Prevalence and incidence ratios of self-reported physician-diagnosed COPD were estimated using weighted multivariable Poisson regression.ResultsW1 mean (SE) age was 58.1(0.1) years; mean cigarette pack-years was similar for all categories involving cigarettes and exclusive use of e-cigarettes (all > 20), greater than exclusive cigar users (< 10); and COPD prevalence was 7.7%. Compared to P30D cigarette use, never tobacco, former tobacco, and cigar use were associated with lower COPD prevalence (RR = 0.33, (95% confidence interval—CI) [0.26, 0.42]; RR = 0.57, CI [0.47, 0.70]; RR = 0.46, CI [0.28, 0.76], respectively); compared to never tobacco use, all categories except cigar and smokeless tobacco use were associated with higher COPD prevalence (RR former = 1.72, CI [1.33, 2.23]; RR cigarette = 3.00, CI [2.37, 3.80]; RR e-cigarette = 2.22, CI [1.44, 3.42]; RR cigarette + e-cigarette = 3.10, CI [2.39, 4.02]; RR polycombusted = 3.37, CI [2.44, 4.65]; RR polycombusted plus noncombusted = 2.75, CI]1.99, 3.81]). COPD incidence from W2-5 was 5.8%. Never and former tobacco users had lower COPD risk compared to current cigarette smokers (RR = 0.52, CI [0.35, 0.77]; RR = 0.47, CI [0.32, 0.70], respectively). Compared to never use, cigarette, smokeless, cigarette plus e-cigarette, and polycombusted tobacco use were associated with higher COPD incidence (RR = 1.92, CI [1.29, 2.86]; RR = 2.08, CI [1.07, 4.03]; RR = 1.99, CI [1.29, 3.07]; RR = 2.59, CI [1.60, 4.21], respectively); exclusive use of e-cigarettes was not (RR = 1.36, CI [0.55, 3.39]).ConclusionsE-cigarettes and all use categories involving cigarettes were associated with higher COPD prevalence compared to never use, reflecting, in part, the high burden of cigarette exposure in these groups. Cigarette—but not exclusive e-cigarette—use was also strongly associated with higher COPD incidence. Compared to cigarette use, only quitting tobacco was protective against COPD development.

Patterns of Non-Cigarette Tobacco and Nicotine Use Among Current Cigarette Smokers and Recent Quitters: Findings From the 2020 ITC Four Country Smoking and Vaping Survey.

This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender, and age. Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the United States. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); noncombustible tobacco (smokeless tobacco, and heated tobacco products [HTPs]); and non-tobacco nicotine products (nicotine vaping products [NVPs], nicotine replacement therapy [NRT], and nicotine pouches). Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and noncombustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco. Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation. The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and noncombustible nicotine-containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.

Parental Awareness of Youth Tobacco Use and the Role of Household Tobacco Rules in Use Prevention.

Noncigarette tobacco use is increasing. In this study, we reexamined (1) parental knowledge or suspicion of their children's tobacco use and (2) associations of household tobacco-free rules with youth initiation. Participants were youth (aged 12-17) in waves 1 to 4 (2013-2018) of the Population Assessment of Tobacco and Health Study. A pseudo cross-sectional time-series analysis (N = 23 170) was used to examine parent or guardian knowledge or suspicion of their child's tobacco use according to youth-reported use categories: cigarette only, electronic cigarette only, smokeless tobacco only, noncigarette combustible only, and poly use. A longitudinal analysis among wave 1 never users (n = 8994) was used to examine rules barring tobacco inside the home and whether parents talked with youth about not using tobacco as predictors of youth tobacco initiation after 1 to 3 years. Survey-weighted multivariable models were adjusted for tobacco use risk factors. In all waves, parents or guardians much less often knew or suspected that their children used tobacco if youth only reported use of electronic cigarettes, noncigarette combustible products, or smokeless tobacco compared with cigarettes. Youth tobacco initiation was lower when youth and parents agreed that rules prohibited all tobacco use throughout the home (1-year adjusted odds ratio: 0.74; 95% confidence interval: 0.59-0.94) but not when parents talked with youth about tobacco (adjusted odds ratio: 1.08; 95% confidence interval: 0.94-1.23). Many parents are unaware of their children's noncigarette tobacco use. Setting expectations for tobacco-free environments appears more effective at preventing youth tobacco initiation than parents advising children not to use tobacco.

Menthol Smoking and Subjective Response To the First Cigarette Smoked

Objectives: Using the Population Assessment of Tobacco and Health (PATH) study, this study examined whether pleasant and unpleasant subjective responses to the first cigarette smoked differed by initiation with a menthol versus non-menthol cigarette and whether subjective response was associated with current tobacco use behaviors, independent of, and in interaction with menthol initiation. Methods: Data were from youth and young adult ever smokers in Wave 2 (2014-2015) of the PATH study. Results: In adjusted multivariable logistic regression models, menthol initiators reported a more pleasant first smoking experience compared to non-menthol initiators and increased odds of past 30-day smoking, non-cigarette tobacco use, and menthol smoking. In adjusted models, pleasant experience was associated with increased odds of past 30-day smoking, non-cigarette tobacco use, and heavy smoking. Unpleasant experience was associated with decreased odds of past 30-day smoking. Interactions of menthol initiation with subjective response were not significant. Conclusions: Smokers who initiate with a menthol cigarette experience a more pleasant first smoking experience, and pleasant experience is associated with regular smoking and use of non-cigarette tobacco products. Findings underscore the potential abuse liability of menthol cigarettes and provide further evidence that a ban on menthol may help reduce tobacco use among young people.

Tobacco use and the interplay of internalizing, externalizing and substance use problems: A latent class analysis of data from the Population Assessment of Tobacco and Health Study

BackgroundCigarette smoking is disproportionately high among adults with two or more psychiatric disorders (psychiatric comorbidities), yet research on non-cigarette tobacco use among this population is scant. Additionally, most studies on tobacco use this among this population rely on psychiatric diagnoses rather than individual symptoms, potentially excluding individuals with symptom-specific issues that increase their risk for tobacco use but do not meet the criteria for diagnosis. The objectives of this study were to identify unique classes of individuals based on symptoms of psychiatric disorders and to assess differences in demographic characteristics and tobacco use behaviors between classes. MethodsThis study used data from Wave 2 of the Population Assessment of Tobacco and Health Study adult dataset. Latent class analysis was used to classify individuals based on internalizing, externalizing and substance use problems. Bivariate and multivariable models examined the association between latent class membership and current use of cigarettes, cigar products, electronic nicotine delivery systems, pipe, hookah and smokeless tobacco products. Poly tobacco use was also examined. ResultsThree latent classes were identified. The “normative” class reported low prevalence of all symptoms, the “severe internalizing and non-violent externalizing” class reported severe internalizing problems and non-violent externalizing problems and the “severe” class reported high prevalence of all symptoms. Tobacco use was highest for the “severe” class and lowest for the “normative” class across products. ConclusionsIndividuals in the “severe” class may be at elevated risk of tobacco-related morbidity and mortality and would likely benefit from targeted tobacco control interventions.

Trends in Cigar Use in the United States, 2002-2016: Diverging Trends by Race/Ethnicity.

Although there are racial/ethnic differences in cigarette use, little is known about how non-cigarette tobacco use differs among racial/ethnic groups. This study investigated trends in cigar use from 2002 to 2016, by racial/ethnic group, in nationally representative US data. Data were drawn from the 2002-2016 National Survey on Drug Use and Health public use data files (total analytic sample n = 630 547 including 54 060 past-month cigar users). Linear time trends of past-month cigar use were examined by racial/ethnic group (Non-Hispanic [NH] White, NH Black, Hispanic, NH Other/Mixed Race/Ethnicity) using logistic regression models. In 2016, the prevalence of past-month cigar use was significantly higher among NH Black respondents than among other racial/ethnic groups (ps < .001). Cigar use was also higher among NH White respondents than among Hispanic and NH Other/Mixed Race/Ethnicity respondents. The year by racial/ethnic group interaction was significant (p < .001). Past-month cigar use decreased significantly from 2002 to 2016 among NH White and Hispanic respondents (ps = .001), whereas no change in prevalence was observed among NH Black (p = .779) and NH Other/Mixed Race/Ethnicity respondents (p = .152). Cigar use decreased for NH White men (p < .001) and did not change for NH White women (p = .884). Conversely, cigar use increased for NH Black women (p < .001) and did not change for NH Black men (p = .546). Cigar use remains significantly more common among NH Black individuals in the United States and is not declining among NH Black and NH Other/Mixed Race/Ethnicity individuals over time, in contrast to declines among NH White and Hispanic individuals. This study identified racial/ethnic differences in trends in past-month cigar use over 15 years among annual cross-sectional samples of US individuals. The highest prevalence of cigar use in 2016 was found among NH Black individuals. In addition, cigar use prevalence did not decline from 2002 to 2016 among NH Black and NH Other/Mixed Race/Ethnicity groups over time, in contrast to NH White and Hispanic groups. Further, cigar use increased over time for NH Black women. Targeted public health and clinical efforts may be needed to decrease the prevalence of cigar use, especially for NH Black individuals.

Abstract P391: Association of Peripheral Artery Disease With the Use of Smokeless Tobacco, Cigars, or Pipes in the Atherosclerosis Risk in Communities Study

Background: Cigarette smoking is one of the strongest modifiable risk factors for peripheral artery disease (PAD), a disease which affects over 200 million people worldwide. Though cigarette use has decreased across time, use of cigars, pipes and smokeless tobacco remains unchanged or slightly increased. The association of PAD and non-cigarette tobacco use is not well described. Thus, we tested the hypothesis that the use of cigars, pipes or smokeless tobacco is associated with incident PAD even after adjustment for cigarette use. Methods: A total of 14,395 Atherosclerosis Risk in Communities (ARIC) Study participants with no history of prevalent PAD were followed from 1987 to 2015 for PAD events (hospitalizations with PAD diagnosis or leg revascularization). Baseline pipe, cigar smoking and smokeless tobacco use was self-reported. Multivariable-adjusted Cox proportional hazards regression was used. Results: At enrollment the 14,395 participants included in the study were on average (SD) 54 (6) years old, 55% female and 27% African American; 489 (3.4%) were current users of smokeless tobacco and 481 (3.3%) current users of cigars or pipes. A total of 1,289 incident PAD events occurred during a median of 25.9 years of follow-up. After adjustment for demographics and cigarette smoking status, risk of incident PAD was higher among current (versus never) users of smokeless tobacco [HR (95% CI): 1.66 (1.29-2.12)], though this association was attenuated with adjustment for CVD risk factors (Table). Cigar and pipe use were not associated with PAD incidence, regardless of degree of adjustment (Table). Conclusion: Active use of smokeless tobacco was associated with increased risk for incident PAD compared to non-use, independent of cigarette smoking, although this relationship was not statistically significant after adjustment for cardiovascular risk factors. No association was observed with use of pipes or cigars. Use of smokeless tobacco may increase PAD risk and could be a potential target for intervention.

Longitudinal predictors of cigarette use among students from 24 Texas colleges

ABSTRACTObjective: The purpose of this study is to examine differences between current and non-current cigarette users, focusing on sociodemographic factors, non-cigarette tobacco product use, parental and friend use, and alcohol and marijuana use; and to identify predictors of cigarette use sixmonths later. Participants: Participants included young adults (n = 4,296) from 24 Texas colleges, participating in a young adult cohort study, beginning in fall 2014. Methods: Mixed effects logistic regressions were conducted accounting for school-level variability. Results: Cigarette users were older, more likely to report use of non-cigarette tobacco products and peer use of cigarettes than non-current users. Wave 1 cigarette and non-cigarette tobacco product use, marijuana use and binge drinking, and peer use all uniquely predicted cigarette use at wave 2. Conclusions: Colleges need prevention programs targeting multiple tobacco products, because non-cigarette tobacco use and other risky behaviors appear to be independent risk factors for cigarette use in young adults.