Examining Use and Dual Use of Tobacco Products and Marijuana among Minnesota Adults.

BACKGROUND: An increasing number of states are legalizing the medicinal and/or recreational use of marijuana. Adult perceptions of harm have decreased and marijuana use has increased. This is in contrast to declining cigarette smoking. In this article we examine independent use and dual use of marijuana and tobacco products. METHODS: Data are from the 2018 Minnesota Adult Tobacco Survey (N = 6055). Estimates were calibrated on sex, race, location, and education from the American Community Survey. RESULTS: In 2018, 15.4% of adults smoked cigarettes in the past 30 days, 7.6% used marijuana and 6.0%, 3.0%, and 1.1% used e-cigarettes, cigars, and waterpipe, respectively. Use of marijuana and cigarettes was 3.3% and use of marijuana and e-cigarettes was 2.2%. Among past 30-day marijuana users, 89.7% smoked it as a joint, blunt, or in waterpipes, 22.1% vaped it in an e-cigarette or a vaping device. Across multinomial regression models, marijuana use and dual use with tobacco products was more likely among males, younger age groups, and African Americans. CONCLUSIONS: As policies to expand the sale and use of marijuana are considered, states should anticipate the need to monitor trends and to plan surveys of sufficient sample size with specific questions on marijuana use. Understanding the proportion of the population that uses both marijuana and tobacco has implications for prevention and treatment of both substances.

Projecting the future impact of past accomplishments in tobacco control.

BACKGROUND: The benefits to adults who quit smoking increase over time as former smokers live longer, healthier lives. Youth who never smoke will benefit for decades. Thus, the long-term population effects of tobacco prevention and control policies may be substantial. Yet they are rarely quantified in evaluations of state tobacco control programmes. METHODS: Using a microsimulation model, we predicted the benefits to Minnesotans from 2018 to 2037 of having reduced cigarette smoking prevalence from 1998 to 2017. We first simulated the health and economic harms of tobacco that would have occurred had smoking prevalence stayed at 1997 levels. The harms produced by that scenario were then compared with harms in scenarios with smoking declining at observed rates from 1998 to 2017 and either expected declines from 2018 to 2037 or a greater decline to 5% prevalence in 2037. RESULTS: With expected smoking prevalence decreases from 2018 to 2037, Minnesotans will experience 12 298 fewer cancers, 72 208 fewer hospitalisations for cardiovascular disease and diabetes, 31 913 fewer respiratory disease hospitalisations, 14 063 fewer smoking-attributable deaths, $10.2 billion less in smoking-attributable medical expenditures and $9.4 billion in productivity gains than if prevalence had stayed at 1997 levels. These gains are two to four times greater than for the previous 20 years, and would be about 15% higher if Minnesota achieves a 5% adult prevalence rate by 2037. CONCLUSIONS: The tobacco control measures implemented from 1998 to 2017 will produce accelerated benefits during 2018-2037 if modest progress in tobacco prevalence rates is maintained.

Defining adult e-cigarette prevalence: comparing a categorical definition with days of use.

INTRODUCTION: Electronic cigarette use has grown substantially and the health effects are being closely monitored. Tracking the evolving market place and the profile of adult users is important for tobacco control efforts; however, several different ways of measuring current use have been reported. This paper examines how well a categorical definition aligns with days of use. METHODS: Data from the 2018 Minnesota Adult Tobacco Survey assessed e-cigarette use based on days of use in the past month and currently using 'every day, some days, or not at all'. Prevalence of current use and agreement of >1, >5 and >20 days of use with every day or some days were calculated. RESULTS: The prevalence of e-cigarette use varied by category of use from 2.4% (≥20 days/30) to 6.0% (≥1 day/30). The highest prevalence was found among young adults reporting any use in the past 30 days (21.9%). Never smokers had low prevalence overall; however, 4.4% reported using in the past 30 days. Using at least 1 day in the past 30 days included a higher proportion of young adults (p<0.001) and never smokers (p<0.001) compared with other current use categories. Compared with every day or some days, the per cent agreement with days of use categories ranged from 89.7% to 94.4% and kappa ranged from 0.60 to 0.81. CONCLUSIONS: Prevalence and sociodemographics varied by definition of use. Asking 'every day, some days or not at all' in population-based studies has the advantage of aligning with cigarette smoking current use definition.

Location and duration of secondhand smoke exposure among Minnesota Nonsmokers, 2018.

In 2007 Minnesota passed into law a comprehensive ban on indoor smoking of tobacco products in public places including bars, restaurants, and workplaces. Despite reductions in smoking prevalence in the past 12 years, people are still exposed to secondhand smoke (SHS). It remains important to understand where and how long nonsmokers face exposure to SHS. The 2018 Minnesota Adult Tobacco Survey was analyzed to examine self-reported SHS exposure among nonsmoking adults. We report prevalence and 95 percent confidence intervals of SHS exposure overall, by specific locations, and by demographics. Length of exposure to SHS was summarized in median minutes. Overall, 30 percent of nonsmokers reported exposure in the past seven days. A total of 1382 participants indicated a location of exposure. The most common locations other than one's own home or car included building entrances (18.7 [16.2-21.1] percent), somewhere else outdoors (17.7 [15.1-20.3] percent), and restaurant/bar patios (12.8 [10.5-15.0] percent). Exposure was more likely to be reported by young adults (44.6 percent) and males (33.7 percent). The locations with the longest duration of SHS exposure in the prior seven days were a gambling venue (117.2 [72.2-162.2] minutes), another person's home (26.1 [15.4-36.8] minutes), and a bus stop (10.8 [4.7-16.9] minutes). Monitoring nonsmokers' self-reported exposure to SHS remains important as a way to measure the impact and compliance with smoke-free policies. Additional information on the location and duration of exposure can be used programmatically to address high levels of exposure and consider additional policies or strategies.

The 20-year impact of tobacco price and tobacco control expenditure increases in Minnesota, 1998-2017.

INTRODUCTION: Tobacco control programs and policies reduce tobacco use and prevent health and economic harms. The majority of tobacco control programs and policies in the United States are implemented at local and state levels. Yet the literature on state-level initiatives reports a limited set of outcomes. To facilitate decision-making that is increasingly focused on costs, we provide estimates of a broader set of measures of the impact of tobacco control policy, including smoking prevalence, disease events, deaths, medical costs, productivity and tobacco tax revenues, using the experience of Minnesota as an example. METHODS: Using the HealthPartners Institute's ModelHealth™: Tobacco MN microsimulation, we assessed the impact of the stream of tobacco control expenditures and cigarette price increases from 1998 to 2017. We simulated 1.3 million individuals representative of the Minnesota population. RESULTS: The simulation estimated that increased expenditures on tobacco control above 1997 levels prevented 38,400 cancer, cardiovascular, diabetes and respiratory disease events and 4,100 deaths over 20 years. Increased prices prevented 14,600 additional events and 1,700 additional deaths. Both the net increase in tax revenues and the reduction in medical costs were greater than the additional investments in tobacco control. CONCLUSION: Combined, the policies address both short-term and long-term goals to reduce the harms of tobacco by helping adults who wish to quit smoking and deterring youth from starting to smoke. States can pay for initial investments in tobacco control through tax increases and recoup those investments through reduced expenditures on medical care.

The Minnesota SimSmoke Tobacco Control Policy Model of Smokeless Tobacco and Cigarette Use.

INTRODUCTION: A previous Minnesota SimSmoke tobacco control policy model is extended to more recent years and to include smokeless tobacco use. METHODS: Using data from the 1993 Tobacco Use Supplement and information on state policies, the Minnesota SimSmoke model was updated and extended to incorporate smokeless tobacco (both exclusive and dual use) and smokeless tobacco-attributable deaths. The model was then validated against the 2002, 2006/2007, and 2014/2015 Tobacco Use Supplement and the 1999, 2007, 2014, and 2018 Minnesota Adult Tobacco Survey and used to estimate the impact of policies implemented between 1993 and 2018. Analysis was conducted in April 2019. RESULTS: The model validated well for cigarette and earlier smokeless tobacco use, but it predicted smokeless tobacco use less well in recent years. The model projected that male (female) smoking prevalence was 35% (36%) lower in relative terms by 2018 and 43% (44%) lower by 2040 owing to policies, with lesser reductions projected for male smokeless tobacco use. Tobacco-attributable deaths were reduced by 7,800 by 2018 and 46,900 by 2040. Price increases, primarily through taxes, were projected to have had the greatest impact on cigarette use followed by smoke-free air laws, cessation treatment policies, tobacco control campaign expenditures, and youth access enforcement. Similar effects were projected for smokeless tobacco use, except that smoke-free air laws had smaller effects. CONCLUSIONS: As cigarettes remain the dominant form of nicotine delivery product, cigarette-oriented policies may be an effective means of reducing the use of all nicotine delivery products. However, noncigarette-oriented policies may also play an important role.

Changing patterns in E-cigarette use among Minnesota adults between 2014 and 2018.

Minnesota has observed declining combustible tobacco use and a large increase in e-cigarette use among youth and young adults. Less is known about adult e-cigarette users' frequency of use, smoking status, use of flavors, and demographic differences. The Minnesota Adult Tobacco Survey (MATS) is a cross-sectional, random digit-dial telephone survey representative of Minnesotans aged 18 and over. MATS measured e-cigarette use in 2014 (N = 9304) and 2018 (N = 6065). In 2018, 6.0% of adult Minnesotans used an e-cigarette in the past 30 days; this was unchanged from 2014 (5.9%). While past 30-day e-cigarette use declined for current smokers (2014: 27.3%; 2018: 16.1% p < 0.001), it increased for never smokers (2014: 1.2%; 2018: 4.4% p < 0.001) and 18-24-year-olds (2014: 12.8%; 2018: 21.9% p = 0.001). Daily e-cigarette use increased from 2014 to 2018 for current smokers (p = 0.001), 25-44-year-olds (p < 0.001), females (p = 0.001), and those with a high-school education (p = 0.006). Among e-cigarette users in 2018, use of flavored e-cigarettes was associated with smoking status (p = 0.041), age (p < 0.001), and using e-cigarettes to quit smoking (p = 0.011). E-cigarettes appeal primarily to younger adults. Of concern are increases in never smokers initiating e-cigarette use, increasing their exposure to nicotine, addiction, and the risk of future combustible tobacco use. Simultaneously, fewer smokers are using e-cigarettes but those who do are using them more frequently. Use of flavored e-cigarettes was common and correlated with interest in quitting combustible cigarettes. These findings can inform recent calls for additional tobacco control policy and programs aimed at reducing e-cigarette use.

Testing and Refining Measures of Secondhand Smoke Exposure Among Smokers and Nonsmokers.

Introduction: Over the past few decades, tobacco control efforts have made great strides in making smoke-free air the norm; 30 states in the United States have implemented 100% smoke-free laws. Despite this progress, the evolution of the measurement of secondhand smoke (SHS) exposure has lagged. Methods: Cognitive testing was used to explore the functioning and limitations of current SHS surveillance items; many items are frequently used for statewide or national surveillance. A total of 20 nonsmokers and 17 smokers participated in a cognitive interview. Results: Overreporting of SHS was evidenced in our analysis as thirdhand smoke exposure was being included in the assessment of SHS exposure, likely due to the successful implementation of indoor smoking bans. Also asking about locations of SHS exposure outside of work, home, or a personal vehicle is important because these alternative locations were sometimes the only incidence of SHS exposure. Conclusions: Survey questions about SHS should: (1) reduce the ambiguity in words and phrases of items; (2) measure location of exposure; (3) measure duration of exposure; and (4) consider alternative strategies for asking smokers questions about SHS. Assessing location and duration of exposure can inform decision-makers about future SHS programming and policy work. Implications: Commonly accepted survey measures of SHS exposure need to be reevaluated to assure that the intended interpretation of them is still accurate given significant policy and social norm change. This paper assesses current SHS surveillance items and provides recommendations for revisions.

Secondhand Smoke Exposure 7 Years After an Indoor Smoke-Free Law.

PURPOSE: To examine locations of secondhand smoke (SHS) exposure among nonsmokers, 7 years after a statewide smoke-free policy. DESIGN: Data collected via statewide, random digit dial telephone survey. Response rates were 64.7% for landline and 73.5% for cell phone. SETTING: Minnesota, 2014. PARTICIPANTS: Representative sample of 7887 nonsmoking adults. MEASURES: Self-reported locations of SHS exposure and opinions on smoke-free restrictions. ANALYSIS: Descriptive statistics and logistic regression. RESULTS: A total of 35.5% of nonsmokers reported SHS exposure in the past 7 days. The greatest proportion of exposure occurred in community settings (31.7%) followed by cars (6.9%) and in the home (3.2%). Young adults were more likely to be exposed in a home or car than older adults. Nonsmokers living with a smoker were 39.6 (20.6-75.8) times more likely to be exposed to SHS in their home and 5.3 (4.1-6.8) times more likely to be exposed in a car, compared to those who did not live with a smoker. CONCLUSION: SHS exposure continues after comprehensive smoke-free policies restricted it from public places. Disparities in exposure rates exist for those who live with a smoker, are young, and have low incomes. Findings suggest the need for additional policies that will have the greatest public health benefit.

Price-Minimizing Behaviors in a Cohort of Smokers before and after a Cigarette Tax Increase.

Cigarette tax increases result in a reduced demand for cigarettes and increased efforts by smokers to reduce their cost of smoking. Less is known about how smokers think about their expenditures for cigarettes and the possible mechanisms that underlie price-minimizing behaviors. In-depth longitudinal interviews were conducted with Minnesota smokers to explore the factors that influence smokers' decisions one month prior to a $1.75 cigarette tax increase and again one and three months after the increase. A total of 42 were sampled with 35 completed interviews at all three time points, resulting in 106 interviews across all participants at all time points. A qualitative descriptive approach examined smoking and buying habits, as well as reasons behind these decisions. A hierarchy of ways to save money on cigarettes included saving the most money by changing to roll your own pipe tobacco, changing to a cheaper brand, cutting down or quitting, changing to cigarillos, and buying online. Using coupons, shopping around, buying by the carton, changing the style of cigarette, and stocking up prior to the tax increase were described as less effective. Five factors emerged as impacting smokers' efforts to save money on cigarettes after the tax: brand loyalty, frugality, addiction, stress, and acclimation.

The Clinician's Role in Addressing Disparities in Tobacco Use.

Although the overall smoking rate in Minnesota is now less than 15%, the rates among certain populations are much higher. For example, 60% of American Indian adults smoke. The rates are also higher for people with low incomes and little education, those who have a mental illness or are substance abusers, and those who are transgender or identify as lesbian, gay, bisexual, transgender or queer. With more people covered by health insurance and smoking-cessation treatment now included in insurance plans thanks to recent health care reforms, physicians and other members of the health care team have a new opportunity to address tobacco use This article discusses ways they can tailor the discussion as they seek to help patients in populations with the highest smoking rates.

Tobacco Use among Minnesota Adults, 2014.

OBJECTIVES: The changing landscape of tobacco including the introduction of new products such as smokeless tobaccos and electronic delivery devices has highlighted the need for continued surveillance of tobacco use. METHODS: Minnesota has conducted an in-depth surveillance of adult tobacco use since 1999. For the fifth in the series, conducted in 2014, 9304 telephone interviews were completed. RESULTS: The 2014 prevalence of cigarette smoking (14.4%) continues a downward trend that remains lower than the national smoking prevalence (17.3%). Among all Minnesota adults, use prevalence of other tobacco products was as follows: e-cigarettes 5.9%, all smokeless tobaccos 3.6%, cigars 3.0%, water pipe 1.4%, and regular pipe 0.7%. Among individuals who have never smoked cigarettes, smokeless tobacco was the most common product used (2.0%), nearly twice the prevalence of e-cigarette use (1.2%). Former smokers were equally likely to use smokeless tobacco (4.9%) or e-cigarettes (4.8%). Among smokers, 27.3% reported current use of e-cigarettes. CONCLUSION: In the past 15 years, cigarette smoking prevalence in Minnesota has dropped by an average of 0.51 percentage points annually, and prevalence could drop to less than 5% by 2034.

The land of 10,000 tobacco products: how Minnesota led the way in regulating tobacco products.

As state and local governments increase restrictions on cigarette smoking, tobacco manufacturers have shifted to marketing alternative tobacco products. Tobacco control laws need to be updated to reflect this shifting marketplace. With the 2010 enactment of the Tobacco Modernization and Compliance Act, Minnesota addressed regulatory gaps and created a model law for other states. We have detailed the updated definitions of tobacco and tobacco products and identified ways that future laws could be strengthened.

Smoker identity among occasional smokers: findings from Minnesota.

OBJECTIVES: To investigate characteristics of occasional smokers who deny being smokers (ie, deniers). METHODS: Data were from 3 rounds of the Minnesota Adult Tobacco Survey (MATS 2003, 2007, and 2010), a statewide, cross-sectional, and random-digit-dial telephone survey. RESULTS: Nearly half of occasional smokers did not view themselves as smokers. Characteristics that were predictive of being a denier included less perceived harm from secondhand smoke, fewer days smoked, and fewer cigarettes smoked per day. CONCLUSIONS: Denial of being a smoker is primarily characterized by very light smoking. Future communication efforts should be tailored for this group.

Smokefree home rules adoption by smokers and nonsmokers: Minnesota, 1999-2010.

BACKGROUND: Smokefree workplace policies have successfully limited indoor exposure to secondhand smoke. However, exposure still exists in other indoor locations, most notably in the home. PURPOSE: This paper examines change in the public's awareness of secondhand smoke harm, exposure to secondhand smoke, and prevalence of smokefree home rules between 1999 and 2010 in Minnesota. METHODS: The Minnesota Adult Tobacco Survey is a statewide, cross-sectional, random-digit-dial telephone-based survey. The survey measures tobacco use, behaviors, attitudes, and beliefs among adults aged 18 and older in 1999, 2003, 2007, and 2010. Analysis was conducted in 2011. RESULTS: There was a significant decrease in self-reported exposure to secondhand smoke among all nonsmokers in Minnesota from 2003 (60.9%) to 2010 (37.7%) (p<0.05). The prevalence of smokefree home rules adoption among all Minnesotans increased significantly between each time point: 1999 (64.5%); 2003 (74.8%); 2007 (83.2%); 2010 (87.2%) (p<0.05). Although smokers tended to adopt smokefree home rules at rates lower than nonsmokers, the percentage of smokefree home rules among smokers nearly doubled between 1999 (31.4%) and 2010 (58.1%) (p<0.05). CONCLUSIONS: Over 10 years, Minnesotans reported a significant decline in exposure to secondhand smoke and a significant increase in voluntary smokefree home rules. Such a trend is notable as virtually all public tobacco control efforts were aimed at raising awareness and support for smokefree policies within workplaces. These findings demonstrate positive changes in social norms and suggest that behavior change in public settings might also be translated into practice in private settings.

Concurrent use of cigarettes and smokeless tobacco in Minnesota.

Cigarette smokers are being encouraged to use smokeless tobacco (SLT) in locations where smoking is banned. We examined state-wide data from Minnesota to measure changes over time in the use of SLT and concurrent use of cigarettes and SLT. The Minnesota Adult Tobacco Survey was conducted four times between 1999 and 2010 and has provided state-wide estimates of cigarette smoking, SLT use and concurrent use of SLT by smokers. The prevalence of SLT was essentially unchanged through 2007, then increased significantly between 2007 and 2010 (3.1% versus 4.3%, P < 0.05). Similarly, the prevalence of cigarette smokers who reported using SLT was stable then increased between 2007 and 2010 (4.4% versus 9.6%, P < 0.05). The finding of higher SLT use by smokers could indicate that smokers in Minnesota are in an experimental phase of testing alternative products as they adjust to recent public policies restricting smoking in public places. The findings are suggestive that some Minnesota smokers are switching to concurrent use of cigarettes and SLT. Future surveillance reports will be necessary to confirm the results.

Use of price-minimizing strategies by smokers and their effects on subsequent smoking behaviors.

INTRODUCTION: Use of cigarette price-minimizing strategies may reduce the effectiveness of cigarette excise taxes on the prevalence of smoking. We examined the use of different price-minimizing strategies by smokers and their associations with subsequent smoking behaviors. METHODS: Seven hundred eighteen current smokers from the Minnesota Adult Tobacco Survey Cohort Study provided information on the use of six different price-minimizing strategies in 2009; 602 of them were resurveyed in 2010 to assess their smoking behavior. Logistic regression was used to assess the effects of use of each strategy, use of at least one strategy, and the number of strategies used on quit smoking, attempted to quit, or cut back on cigarette consumption. RESULTS: Overall, 78% of participants used at least one price-minimizing strategy in 2009 to save money on cigarettes. About 53% reported buying from less expensive places, 49% used coupons or promotions, 42% purchased by the carton, and 34% changed to a cheaper brand. Participants' characteristics differed somewhat by strategy. Participants who reported buying by the carton were less likely to attempt to quit smoking and cut back on cigarette consumption subsequently; those who used more strategies were less likely to cut back on their cigarette consumption. CONCLUSIONS: Use of cigarette price-minimizing strategies is common among smokers and appears to hinder smokers from attempting to quit and reducing cigarette consumption. Prohibiting the use of coupons and promotions may uphold the effect of cigarette taxes to reduce the prevalence of smoking.

Findings and implications from a national study on potential reduced exposure products (PREPs).

Tobacco companies have recently introduced products that they claim have reduced toxins and carcinogens, and that they say may be less harmful to smokers. These are potential reduced exposure products, or PREPs. This study measured smokers' awareness of PREPs, use of PREPs, interest in trying PREPs, and beliefs about the regulation of PREPs. This study was based on nationally representative data collected in 2002 and 2003 through the American Smoking and Health Survey. The final sample included 1,174 adult smokers. Descriptive and multivariate analyses were conducted to produce estimates and explore potential correlates of the outcomes. A total of 41.9% of adult smokers reported having heard of at least one of the PREPs measured, and 11.0% reported having tried one of these products. Half of adult smokers (49.9%) said they would like to try PREPs. Interest in trying PREPs was associated with having made a quit attempt, being concerned about the effect of smoking on one's health, and having a household income of less than US dollars 20,000. About half of adult smokers (49.1%) incorrectly believed that PREPs are evaluated for safety by the government before being placed on the market, and 84.2% believed that the government should evaluate the safety of PREPs before they are sold to consumers. This study provides new and timely information on the use of, interest in trying, and beliefs about the regulation of PREPs among a nationally representative sample of adult smokers. With half of adult smokers interested in trying PREPs, the need for concrete scientific evidence on the potential impact of these products is critical.