Racial/ethnic disparities in exposure to e-cigarette advertising among U.S. youth.

OBJECTIVES: This study aims to assess exposure to e-cigarette advertising across multiple marketing channels among U.S. youth and to examine whether racial/ethnic disparities exist in exposure to e-cigarette advertisements. STUDY DESIGN: This is a cross-sectional study. METHODS: Cross-sectional data were drawn from a longitudinal survey of participants recruited from two nationally representative panels (NORC's AmeriSpeak® and GfK's KnowledgePanel). A total of 2043 youth aged 13-17 completed the initial 2018 survey, and 2013 youth completed the follow-up survey in 2019 (including a replenishment sample of 690 youth). Outcome variables were self-reported e-cigarette advertisement exposure in the past three months through various sources, such as television, point of sale, and online/social media. Generalized estimating equation models were used to estimate the adjusted odds ratios (AOR) of the association between racial/ethnic identity and e-cigarette advertisement exposure. RESULTS: The prevalence of reported exposure to e-cigarette advertisements through any channel was 79.8% (95% CI: 77.1-82.2) in 2018 and 74.9% (95% CI: 72.5-77.1) in 2019, respectively. Point of sale was the most common source of e-cigarette advertisement exposure in both years. Non-Hispanic Black and non-Hispanic Asian youth were more likely to report exposure to e-cigarette advertisements through television (AOR = 2.07, 95% CI: 1.44-2.99 and AOR = 2.11, 95% CI: 1.17-3.82, respectively) and online/social media (AOR = 1.61; 95% CI: 1.11-2.33 and AOR = 1.99, 95% CI: 1.10-3.59, respectively) channels compared with non-Hispanic White youth. CONCLUSIONS: A substantial proportion of U.S. youth reported exposure to e-cigarette advertising through a variety of marketing channels. Significant racial/ethnic disparities existed, with non-Hispanic Black and Asian youth reporting more marketing exposure than their non-Hispanic White counterparts.

Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12-17 years old), young adults (18-29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014-2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and "usual" e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Women and smoking: issues and opportunities.

In March 2001, the U.S. Surgeon General released Women and Smoking, the second Surgeon General's report to focus on tobacco use among women, compelling the nation to make reducing tobacco use among women one of the highest priorities for women's health. Since 1980, 3 million women have died prematurely from smoking-related diseases and injuries. Lung cancer mortality rates among U.S. women have increased about 600% since 1950, and now lung cancer is the leading cause of cancer death among U.S. women, having surpassed breast cancer in 1987. Although the report documents the devastating impact of the tobacco epidemic among women, a growing arsenal of science-based recommendations for implementing comprehensive tobacco control programs suggests that achieving the nation's ambitious Healthy People 2010 objectives, including cutting in half the rates of smoking among women and girls, is within our reach. While states continue to debate the use of tobacco settlement funds, it is important to note that when significant resources have been devoted to the implementation of evidence-based strategies, the results have been dramatic for the population overall and for women in particular. For example, in California, which has had a comprehensive tobacco control program for 11 years, smoking prevalence has declined throughout the 1990s at rates two or three times faster than in the rest of the country, and while lung cancer incidence rates increased by 13% among women in other parts of the United States, they decreased by 4.8% among women in California. These promising findings indicate that although tobacco-related diseases have become a women's health issue of epidemic proportions, we have the ability to reverse these trends.

Factors associated with discrepancies between self-reports on cigarette smoking and measured serum cotinine levels among persons aged 17 years or older: Third National Health and Nutrition Examination Survey, 1988-1994.

The discrepancy between cigarette smoking status reported during an interview and measured level of serum cotinine, a nicotine biomarker, was investigated in a representative sample of the US population aged >/=17 years (N = 15,357). Data were collected from participants in the Third National Health and Nutrition Examination Survey (1988-1994). Among self-reported smokers, 7.5% (95% confidence interval: 6.3, 8.7) had a serum cotinine level less than or equal to 15.0 ng/ml, the selected cutoff point for identifying nonsmokers. Age (p < 0.01), race/ethnicity (p < 0.01), and average number of cigarettes smoked per day (p < 0.01) were associated with these discrepant findings. Among self-reported nonsmokers, 1.4% (95% confidence interval: 1.1, 1.7) had a serum cotinine level greater than 15.0 ng/ml, the selected cutoff point for identifying smokers. Race/ethnicity (p < 0.01), education (p < 0.01), number of household members who smoked in the home (p = 0.03), and self-reported smoking status from an earlier home interview (p < 0.01) were associated with these discrepant findings. Differences in smoking patterns, including the extent of nicotine dosing, may explain most of the discrepancy observed among self-reported smokers, whereas deception regarding smoking status may explain most of the discrepancy among self-reported nonsmokers. This study provides evidence that self-reported smoking status among adult respondents to a population-based survey conducted in a private medical setting is accurate.

Racial and ethnic differences in serum cotinine levels of cigarette smokers: Third National Health and Nutrition Examination Survey, 1988-1991.

CONTEXT: Cotinine, a metabolite of nicotine, is a marker of exposure to tobacco smoke. Previous studies suggest that non-Hispanic blacks have higher levels of serum cotinine than non-Hispanic whites who report similar levels of cigarette smoking. OBJECTIVE: To investigate differences in levels of serum cotinine in black, white, and Mexican American cigarette smokers in the US adult population. DESIGN: Third National Health and Nutrition Examination Survey, 1988-1991. PARTICIPANTS: A nationally representative sample of persons aged 17 years or older who participated in the survey. OUTCOME MEASURES: Serum cotinine levels by reported number of cigarettes smoked per day and by race and ethnicity. RESULTS: A total of 7182 subjects were involved in the study; 2136 subjects reported smoking at least 1 cigarette in the last 5 days. Black smokers had cotinine concentrations substantially higher at all levels of cigarette smoking than did white or Mexican American smokers (P<.001). Serum cotinine levels for blacks were 125 nmol/L (22 ng/mL) (95% confidence interval [CI], 79-176 nmol/L [14-31 ng/mL]) to 539 nmol/L (95 ng/mL) (95% CI, 289-630 nmol/L [51-111 ng/mL]) higher than for whites and 136 nmol/L (24 ng/mL) (95% CI, 85-182 nmol/L [15-32 ng/mL]) to 641 nmol/L (113 ng/mL) (95% CI, 386-897 nmol/L [68-158 ng/mL]) higher than for Mexican Americans. These differences do not appear to be attributable to differences in environmental tobacco smoke exposure or in number of cigarettes smoked. CONCLUSIONS: To our knowledge, this study provides the first evidence from a national study that serum cotinine levels are higher among black smokers than among white or Mexican American smokers. If higher cotinine levels among blacks indicate higher nicotine intake or differential pharmacokinetics and possibly serve as a marker of higher exposure to cigarette carcinogenic components, they may help explain why blacks find it harder to quit and are more likely to experience higher rates of lung cancer than white smokers.

Evaluation of an enforcement program to reduce tobacco sales to minors.

OBJECTIVES: This study evaluated an active enforcement program to increase retailers' compliance with the law prohibiting tobacco sales to minors. METHODS: Tobacco sales to minors were monitored in 319 outlets in 6 pairs of communities in Erie County, New York. One community in each pair was randomly assigned to an enforcement intervention. RESULTS: Retailers' compliance with the law increased from 35% in 1994 to 73% in 1995. However, the change in compliance rates was roughly the same for stores in the enforcement and nonenforcement communities. CONCLUSIONS: Active compliance checking of retail outlets as a strategy to reduce illegal tobacco sales to minors may only be necessary insofar as it contributes to an increase in retailers' perception that the threat of enforcement is real.

Workplace smoking policies in the United States: results from a national survey of more than 100,000 workers.

OBJECTIVE: To determine the prevalence of smoking policies in indoor work environments as reported by a nationally representative sample of workers in the United States. DESIGN: Cross-sectional survey of households within the United States. SETTING: All 50 state and the District of Columbia, 1992-93. PARTICIPANTS: Currently employed indoor workers 15 years of age and older who responded to the National Cancer Institute's Tobacco Use Supplement to the Current Population Survey (n = 100,561). MAIN OUTCOME MEASURES: The prevalence and restrictiveness of workplace smoking policies as reported by workers currently employed in indoor workplaces in the United States. RESULTS: Most of the indoor workers surveyed (81.6%) reported that their place of work had an official policy that addressed smoking in the workplace; 46.0% reported that their workplace policy did not permit smoking in either the public/common areas--for example, restrooms and cafeterias--or the work areas of the workplace. The reporting of these "smoke-free" policies varied significantly by gender, age, race/ethnicity, smoking status, and occupation of the worker. CONCLUSIONS: Although nearly half of all indoor workers in this survey reported that they had a smoke-free policy in their workplace, significant numbers of workers, especially those in blue-collar and service occupations, reported smoke-free rates well below the national average. If implemented, the US Occupational Safety and Health Administration's proposed regulation to require worksites to be smoke-free has the potential to increase significantly the percentage of American workers covered by these policies and to eliminate most of the disparity currently found across occupational groups.

Incorporating social support into a community-wide smoking-cessation contest.

Social support for smoking cessation has been identified as a key factor differentiating which individuals are most likely to quit smoking. Attempts to enhance social support in clinic-based programs have generally been unsuccessful. This study investigated a strategy for increasing the involvement of supportive others among participants in a community-based smoking-cessation contest. These smokers were undertaking quit attempts without the supportive environment offered in clinic-based group programs. Subjects included 734 adult smokers who had participated in a smoking-cessation contest in their local community. Contest participants had the option of designating a "support person" who would assist them in quitting smoking and be eligible for prizes if the participant was a contest winner. Follow-up was by telephone survey 3 months after the end of the contest. No differences were observed in demographic or smoking history variables between those who did and did not elect to name a support person. A relatively high proportion (60%) of contest participants elected to identify a support person and self-reported smoking-cessation rates were significantly better among those who named a support person than among those who did not. Identifying a support person was a particularly effective strategy for those with smoking or nonsupportive spouses.

Comparison of recent trends in adolescent and adult cigarette smoking behaviour and brand preferences.

OBJECTIVE: To compare trends in smoking behaviour and use of cigarette brands by adults and adolescents. DESIGN: Data analysed in this paper come from tobacco use surveys of adults and teenagers conducted in 18 communities in the United States, as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. Data on adult smoking behaviour were obtained from two cross-sectional telephone surveys, one conducted from January to May 1988 (n = 99348), and the second conducted between August 1993 and January 1994 (n = 79890). Data on adolescent smoking behaviour were obtained from two school-based surveys of ninth-grade students (aged 13-16 years), one conducted in autumn 1990 (n = 7097), and the second conducted in autumn 1992 (n = 7277). OUTCOME MEASURES: Adult cigarette smoking prevalence was estimated as the percentage of adults (18+ years) who were identified either by interview or by proxy as a current smoker. Among adolescents, current smokers were defined as those who reported having smoked on one or more of the 30 days preceding the interview. Cigarette brand use by adults was measured by asking current smokers to report the six digit UPC code on the side of the pack of their current cigarettes. A master list of UPC code numbers was developed so that reported codes could be associated with specific brand names. Among adolescents, cigarette brand use was measured by asking current smokers who reported that they usually buy their own cigarettes: "What brand do you usually buy?" RESULTS: In ninth-grade students, smoking prevalence rates increased between 1990 and 1992 in 13 of the 18 communities. Among adults, smoking rates declined between 1988 and 1993 in 17 out of 18 communities. Within the same communities, cigarette brand use was found to be much more tightly concentrated in adolescent smokers compared with adults, with teenage smokers more likely to report using the most heavily advertised cigarette brands--Marlboro, Newport, and Camel. CONCLUSIONS: Smoking prevalence rates have increased among teenagers, but have dropped among adults in the same communities. Among adolescents who smoke, and buy their own cigarettes, the three most heavily advertised brands--Marlboro, Camel, and Newport--have a substantially higher market concentration than among adult smokers.

Predictors of smoking cessation in a cohort of adult smokers followed for five years.

OBJECTIVE: To identify variables predictive of smoking cessation in a cohort of cigarette smokers followed for five years. DESIGN: Data analysed in this paper come from a cohort tracking telephone survey of 13415 cigarette smokers aged 25-64 years from 20 American and two Canadian communities who were interviewed in 1988 and re-interviewed in 1993 as part of the National Cancer Institute's Community Intervention Trial for Smoking Cessation. Predictors of smoking cessation evaluated in this study included measures of past and current smoking behaviour, past quit attempts, stated desire to quit smoking, and demographic characteristics. OUTCOME MEASURES: Smoking cessation was based on self report. A "quitter" was defined as a cohort member who, at the final annual contact in 1993, reported not smoking any cigarettes for the preceding six months or longer. Any smoker who reported having made a serious quit attempt between 1988 and 1993 was asked to indicate reasons that contributed to their decision to try to stop smoking. RESULTS: 67% of smokers reported making at least one serious attempt to stop smoking between 1988 and 1993 and, of these, 33% were classified as having quit smoking in 1993. The most common reasons given for quitting smoking were concern over health (91%), expense (60%), concern about exposing others to secondhand smoke (56%), and wanting to set a good example for others (55%). Statistically significant predictors of smoking cessation included male gender, older age, higher income, less frequent alcohol intake, lower levels of daily cigarette consumption, longer time to first cigarette in the morning, the use of premium cigarettes, initiation of smoking after age 20, history of past quit attempts, a strong desire to stop smoking, and the absence of other smokers in the household. Predictor variations with the largest relative risks for smoking cessation were those associated with nicotine dependence such as amount smoked daily and time to first cigarette in the morning. CONCLUSIONS: Despite the fact that most smokers expressed a strong desire to stop smoking in 1988, the majority, especially the most dependent heavy smokers (>25 cigarettes/day), struggled unsuccessfully to achieve this goal.

Changes in adult cigarette smoking in the Minnesota Heart Health Program.

OBJECTIVES: The Minnesota Heart Health Program was a research and demonstration project designed to reduce risk factors for heart disease in whole communities. This paper describes smoking-specific interventions and outcomes. METHODS: Three pairs of matched communities were included in the study. After baseline surveys, one community in each pair received a 5-year education program, while both cross-sectional and cohort surveys continued in all sites. Adult education programs for smoking cessation included Quit and Win contests, classes, self-help materials, telephone support, and home correspondence programs. RESULTS: Encouraging short-term results were obtained for several adult education programs. Overall long-term outcomes were mixed, with evidence of an intervention effect only for women in cross-sectional survey data. Unexpectedly strong secular declines in smoking prevalence were observed in comparison communities. CONCLUSIONS: The findings suggest that community education may be unlikely to exceed dramatic secular reductions in smoking prevalence. The success of several key interventions and the incorporation of Minnesota Heart Health Program interventions by education communities are encouraging, however.

Promoting smoking cessation at the workplace. Results of a randomized controlled intervention study.

This paper presents results from a preliminary short-term work-site intervention study aimed at smoking cessation. The 3-month intervention included consultation for employers on the adoption of a nonsmoking policy, training for nonsmokers to provide assistance to smokers attempting to quit, and cessation classes for smokers. Eight work sites from Bloomington, Minnesota were recruited to the study and randomly assigned to an intervention or comparison condition after a baseline survey of all employees. To assess the effect of the intervention, smokers were surveyed 1 and 6 months after the intervention was completed. At the 1-month follow-up, the overall quit rate in the intervention group was 12% compared to 5% in the control group (P < .05). At the 6-month follow-up, 12% of smokers in the intervention group reported quitting, compared to 9% in the control group (P < .05). Co-worker support for quitting was higher in the intervention group compared to the comparison group. Cessation was highest overall among smokers whose co-workers frequently asked them not to smoke and among those who worked with a high proportion of nonsmokers. These results indicate that a short-term, multifaceted smoking cessation program implemented in work sites can affect smoking cessation rates as well as the work-site norms about smoking.

Aspects of statistical design for the Community Intervention Trial for Smoking Cessation (COMMIT).

We present statistical considerations for the design of the Community Intervention Trial for Smoking Cessation (COMMIT). One outcome measurement, the quit rate in randomly selected cohorts of smokers, is compared with another outcome measurement, the decrease in smoking prevalence, in terms of statistical efficiency and interpretability. The COMMIT study uses both types of outcome measurements. The merits of pair-matching the communities are considered, and sample size calculations take into account heterogeneity among pair-matched communities. In addition to significance tests based on the permutational (randomization) distribution, we also describe approaches for covariate adjustment. The COMMIT design includes 11 pair-matched communities, which should provide good power to detect a 10% or greater difference in quit rates between the intervention and control communities in cohorts of heavy smokers and in cohorts of light or moderate smokers. The power is only moderate to detect intervention effects on the decreases in overall smoking prevalence or in the prevalence of heavy smoking.

Smoking-attributable cancer mortality in 1991: is lung cancer now the leading cause of death among smokers in the United States?

Findings from the new American Cancer Society prospective study of 1.2 million men and women indicate that mortality risks among smokers have increased substantially for most of the eight major cancer sites causally associated with cigarette smoking. Lung cancer risk for male smokers doubled, while the risk for females increased more than fourfold. On the basis of the new American Cancer Society relative risks, we project that cigarette smoking alone will contribute to slightly more than 157,000 of the 514,000 total cancer deaths expected to occur in the United States in 1991. Overall, smoking directly contributes to 21.5% of all cancer deaths in women but 45% of all cancer deaths in men. It would also appear that lung cancer has now displaced coronary heart disease as the single leading cause of excess mortality among smokers in the United States.

Needs and recommendations for behavior research in the prevention and early detection of cancer.

Because life-style patterns affect many cancer risks, research on health-risk behavior and behavior change is critical to cancer prevention. This report recommends priorities for the next decade of psychosocial research on cancer prevention and detection. The leading priority for future research is to fill gaps in basic knowledge left by the rush to intervention and outcome studies. Such research must be theoretically driven and should aim to develop broad principles applicable to diverse health behaviors. Studies that include relevant process data on various stages of behavior change are considered more desirable than simple outcome studies. Epidemiologic investigations should be expanded to include measures of relevant behaviors, so that their impact on clinical outcomes might be established. More research is needed on lay perception of health risks and on individual and health-system barriers to effective cancer prevention and detection. Studies that address the needs of minority and underprivileged populations are crucial. Funding agencies' narrow categorical mandates impede interdisciplinary research on multiple risk factors and their interactions; these boundaries must be relaxed to promote such approaches. Funding agencies should also consider basic research as a long-term investment towards the development of effective interventions.

A comparison of self-help approaches to smoking cessation.

The current study evaluated the effectiveness of widely used self-help materials for quitting smoking. Five hundred and seventy smokers volunteered during a baseline survey to participate in the evaluation. After random assignment, 200 were mailed National Cancer Institute (NCI) "Quit for Good" materials, 200 the Minnesota "Quit and Win" program, and the remaining 170 were assigned to a nonintervention control condition. Results at 7-month follow-up failed to indicate treatment effects either for abstinence or for reported quit attempts. A number of smokers quit prior to the mailing of self-help materials, suggesting that a telephone prompt in itself may have been an important stimulus to cessation. Overall abstinence at follow-up was 10%. Contrary to expectation, successful participants were less likely to use a number of specific preparation strategies for quitting. The results are instructive in providing a large-scale assessment of self-help materials in a population of smokers that was not specifically seeking treatment.

A comparison of smoking patterns in the People's Republic of China with the United States. An impending health catastrophe in the middle kingdom.

Half of the global increase in tobacco use from 1976 to 1986 occurred in the People's Republic of China. In 1984, the first national smoking survey was conducted in China, involving over a half-million subjects. Sixty-one percent of Chinese males over age 15 smoke, with higher rates in all occupational groups than for corresponding groups in the United States. Current smoking patterns in China are similar to those in the United States during the 1950s, and these patterns forecast a steadily increasing epidemic of smoking-related deaths. It is estimated that by 2025, two million Chinese men will die annually from smoking. Foreign tobacco companies are mounting massive production and advertising campaigns in China. Government health education programs lack funds to counter these influences with sustained and comprehensive educational and interventional campaigns. To avert an impending national health catastrophe, China must launch a comprehensive smoking-control initiative aimed at public education, cessation, and legislation and policy.