Fear, Sadness and Hope: Which Emotions Maximize Impact of Anti-Tobacco Mass Media Advertisements among Lower and Higher SES Groups?

Emotive anti-tobacco advertisements can increase quitting. Discrete emotion theories suggest evoking fear may be more effective than sadness; less research has focused on hope. A weekly cross-sectional survey of smokers and recent quitters (N = 7683) measured past-month quit attempts. The main predictor was level of exposure to four different types of anti-tobacco advertisements broadcast in the two months prior to quit attempts: advertisements predominantly evoking fear, sadness, hope, or evoking multiple negative emotions (i.e., fear, guilt, and/or sadness). Greater exposure to fear-evoking advertisements (OR = 2.16, p < .01) increased odds of making a quit attempt and showed similar effectiveness among those in lower and higher SES areas. Greater exposure to advertisements evoking multiple negative emotions increased quit attempts (OR = 1.70, p < .01), but interactions indicated this was driven by those in lower SES, but not higher SES areas. Greater exposure to hope-evoking advertisements enhanced effects of fear-evoking advertisements among those in higher SES, but not lower SES areas. Findings suggest to be maximally effective across the whole population avoid messages evoking sadness and use messages eliciting fear. If the aim is to specifically motivate those living in lower SES areas where smoking rates are higher, multiple negative emotion messages, but not hope-evoking messages, may also be effective.

The New Product Watch: Successes and Challenges of Crowdsourcing as a Method of Surveillance.

New smokeless tobacco (eg, snus and dissolvable tobacco products) and nontobacco nicotine products (eg, e-cigarettes) have emerged in recent years amid widespread speculation about locations of test marketing, toxic constituents, and consumer targeting. The New Product Watch was a pilot online monitoring system aimed at filling these information gaps by using a form of crowdsourcing: recruiting volunteers to visit local retailers and report their findings. With very little funding, the New Product Watch gathered county-specific data on new product availability in 19 states as well as trend data on product marketing and demand, and completed 2 rounds of product purchases and subsequent toxic constituent analyses. Data were collected over a 2-year period, between 2009 and 2011. Despite the successes, we found that this small-scale, volunteer effort was not a sustainable method for ensuring continuous, systematic surveillance of new product availability, marketing, and toxicity.

Snus use and rejection in the USA.

OBJECTIVE: To determine whether snus might become a strategy for reducing the harm associated with cigarette smoking in the USA as appears to be the case in Sweden, we examined receptivity to snus use in two cities with the greatest exposure to the major brands. METHODS: A dual frame, telephone survey and a brief mail survey were conducted in 2011 and 2012 in Indianapolis, Indiana and Dallas/Fort Worth Texas. Over 5000 adults completed surveys. Trial, ever use, current use and reasons for using or quitting snus after trial were measured. RESULTS: Among male smokers, 29.9% had ever tried snus (CI 22.7 to 38.1) and 4.2% were current users (CI 1.6 to 10.7). Among female smokers, 8.5% ever tried snus (CI 4.4 to 15.7) and current use was unknown. Current use was virtually absent among former smokers and never smokers. A major predictor of any level of snus use was current use of conventional smokeless tobacco. Those who tried and gave up snus cited curiosity (41.3%) and the fact that it was available at low or no cost (30%) as reasons for trial; reasons for not continuing included preferring another form of tobacco (75.1%) and disliking the mouth feel (34.6%). Almost all current snus users indicated that they were trying to cut down on cigarettes, but few (3.9%) were using it to quit smoking entirely. CONCLUSIONS: The low rate of adoption of snus suggests that neither the hopes nor the fears surrounding this new product are likely to be realised in the USA with the current marketing patterns.

Electronic Cigarette Trial and Use among Young Adults: Reasons for Trial and Cessation of Vaping.

This paper identifies predictors of trial and current use, and reasons for trying and ceasing use of electronic cigarettes (e-cigarettes) among young adults, with particular attention to former and never smokers. Data are from a mail survey of a population-based sample of adults aged 18 to 35 (N = 4740) in three U.S. metropolitan areas. Survey items assessed trial and use of e-cigarettes, cigarette smoking status, and reasons for trial and for ceasing use of e-cigarettes. Almost 23% reported trial of e-cigarettes, and 8.4% reported using them in the past month. Current smokers were much more likely to have tried e-cigarettes (70.2%) than both former (32.3%) and never smokers (7.6%; p < 0.001) and to have used them in the past month (30.8%, 10.1%, 2.0% respectively; p < 0.001). Smoking status and scores on sensation seeking were significant independent predictors of both trial and current use of e-cigarettes. Never-smokers cite curiosity as the reason for trying e-cigarettes and also that their friends used them. The most frequent reason for ceasing use among never and former smokers was health concerns. For virtually none of them were e-cigarettes their first exposure to nicotine.

A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.

AIMS: Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit. METHODS: Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice). RESULTS: At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up. CONCLUSIONS: Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.

Public opinion about FDA regulation of menthol and nicotine.

OBJECTIVE: Regulations that reduce nicotine and eliminate menthol in cigarettes have been proposed to the US Food and Drug Administration (FDA) as product alterations that could reduce smoking prevalence in the USA. This study sought to assess the public response to either action. METHODS: A mail survey of a representative sample of 1074 adults was conducted in two major metropolitan areas to determine the level of support for immediate, gradual or no reduction of menthol and nicotine in cigarettes. RESULTS: There was more support for reducing nicotine (79%) than for reducing or removing menthol (59.5%). Most smokers (59.2%; 95% CI 50.7 to 67.2) and 36% of non-smokers (95% CI 31.7 to 40.8) opposed eliminating menthol, but few smokers (23.8%) or non-smokers (20.3%) were opposed to reducing nicotine. Logistic regression showed no significant effect of smoking status on support for reductions in nicotine, but that smokers were significantly less supportive than non-smokers of FDA action on menthol (OR=0.32, 95% CI 0.21 to 0.49). A significant race by smoking status interaction showed that African-American smokers were more supportive of removing menthol than non-African-American smokers. CONCLUSIONS: The greater smoker support for reductions in nicotine than menthol could be due to inaccurate beliefs about the disease risk associated with the two substances (ie, a belief that nicotine is more harmful than menthol), or to greater awareness of the sensory role that menthol plays in smokers' satisfaction. In any case, if FDA goes ahead with regulations to remove menthol, it will be important to develop strategies to reduce smoker resistance.

Monitoring tobacco-specific N-nitrosamines and nicotine in novel smokeless tobacco products: findings from round II of the new product watch.

INTRODUCTION: Analysis of novel smokeless tobacco products purchased in Round I of the New Product Watch (NPW)-a national tobacco monitoring network-demonstrated that some tobacco constituents vary not only across various brands but also regionally and over time within the same product. In this study, we analyzed snus and dissolvable tobacco products that were purchased in Round II of the NPW. METHODS: We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in snus and dissolvable tobacco products that were purchased in various regions of the country during the spring and summer of 2011. The results were compared against the Round I data, across different U.S. regions, and among products. RESULTS: A total of 216 samples were received from different states representing 6 regions of the country. Compared with the previous analyses, TSNA levels increased significantly in Marlboro and Camel Snus and some dissolvable Camel products. The levels of unprotonated nicotine in Marlboro Snus and Camel Snus in this study were not different from Round I but varied significantly by regions; the differences between the highest and the lowest average regional levels were ~3.2-fold in Marlboro Snus ~1.7-fold in Camel Snus. CONCLUSIONS: Our results indicate that some novel smokeless tobacco products contain TSNA at the levels found in the conventional moist snuff. Observation of regional variations in unprotonated nicotine content in both Round I and Round II of NPW suggest that manufacturers may tailor the levels of this constituent consistently to different regions.

Public education about the relative harm of tobacco products: an intervention for tobacco control professionals.

BACKGROUND: In the USA, new regulations require the collection of information on tobacco constituents by brand and variety and publication of this information in a way not likely to be misconstrued by consumers. Understanding of such information becomes increasingly important as new tobacco products are marketed and modifications are made to reduce the toxicity of some products. This pilot study assessed the current knowledge of tobacco control professionals regarding the relative harmfulness of several tobacco products, and evaluated an online educational intervention aimed at improving understanding of variations in nicotine and tobacco-specific N-nitrosamines (TSNAs). METHODS: Fifty-two tobacco control professionals participated in an online intervention which presented and discussed the results of constituent analyses of Camel Snus and Marlboro Snus compared to several conventional smokeless tobacco products. Comparisons with cigarettes were also discussed. Pre- and post-intervention questions assessed understanding of the concepts. RESULTS: Pre-intervention responses demonstrated that 31% did not know that cigarettes are more harmful than smokeless tobacco, 67% did not know that smokeless products higher in nicotine are likely to be more effective substitutes for cigarettes, 52% did not know TSNAs are the major carcinogens in tobacco and 81% did not know new snus products tend to be lower in TSNAs than conventional spit tobacco. After intervention participation, knowledge increased on all points except one where pretest results were 100% correct. CONCLUSIONS: Public education campaigns are urgently needed for tobacco control professionals and consumers to increase awareness and understanding of the continuum of risk among tobacco products.

A prospective cohort study challenging the effectiveness of population-based medical intervention for smoking cessation.

OBJECTIVE: To examine the population effectiveness of nicotine replacement therapies (NRTs), either with or without professional counselling, and provide evidence needed to better inform healthcare coverage decisions. METHODS: A prospective cohort study was conducted in three waves on a probability sample of 787 Massachusetts adult smokers who had recently quit smoking. The baseline response rate was 46%; follow-up was completed with 56% of the designated cohort at wave 2 and 68% at wave 3. The relationship between relapse to smoking at follow-up interviews and assistance used, including NRT with or without professional help, was examined. RESULTS: About one-fourth of recent quitters at each wave reported to have relapsed by the subsequent interview. Odds of relapse were unaffected by use of NRT for >6 weeks either with (p=0.117) or without (p=0.159) professional counselling and were highest among prior heavily dependent persons who reported NRT use for any length of time without professional counselling (OR 2.68). CONCLUSIONS: This study finds that persons who have quit smoking relapsed at equivalent rates, whether or not they used NRT to help them in their quit attempts. Cessation medication policy should be made in the larger context of public health, and increasing individual treatment coverage should not be at the expense of population evidence-based programmes and policies.

Increased pouch sizes and resulting changes in the amounts of nicotine and tobacco-specific N-nitrosamines in single pouches of Camel Snus and Marlboro Snus.

INTRODUCTION: Initial analyses of the novel smokeless tobacco products Camel Snus and Marlboro Snus demonstrated that these products contain relatively low amounts of nicotine and the carcinogenic tobacco-specific nitrosamines N'-nitrosonornicotine (NNN) and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK), as compared with traditional smokeless products. It is unknown whether the modifications in packaging, flavors, and pouch sizes that occurred for both Camel Snus and Marlboro Snus since their first introduction to the market were accompanied by any changes in nicotine or nitrosamine levels. METHODS: We examined the available data on nicotine and NNN and NNK levels in 60 samples of Camel Snus and 87 samples of Marlboro Snus that were analyzed in our laboratory between 2006 and 2010. RESULTS: Due to the increase in pouch size, the amounts of total nicotine, unprotonated nicotine, and the sum of NNN and NNK present in the large Camel Snus pouches released in 2010 are 1.9-fold, 2.4-fold, and 3.3-fold higher, respectively, than in the original smaller pouches that entered the market in 2006. Total and unprotonated nicotine content in the current version of Marlboro Snus pouches are 2.1-fold and 1.9-fold higher, respectively, and the sum of NNN and NNK is 1.5-fold lower than in the original version. CONCLUSIONS: We observed an increase in nicotine content in single portions of Camel Snus and Marlboro Snus, and an increase in tobacco-specific N-nitrosamine content in single portions of Camel Snus, due to the increases in pouch size that occurred between 2006 and 2010. This finding stresses the importance of tobacco product regulation and ingredient disclosures.

Tobacco and nicotine product testing.

INTRODUCTION: Tobacco product testing is a critical component of the Family Smoking Prevention and Tobacco Control Act (FSPTCA), which grants the Food and Drug Administration the authority to regulate tobacco products. The availability of methods and measures that can provide accurate data on the relative health risks across types of tobacco products, brands, and subbrands of tobacco products on the validity of any health claims associated with a product, and on how consumers perceive information on products toxicity or risks is crucial for making decisions on the product's potential impact on public health. These tools are also necessary for making assessments of the impact of new indications for medicinal products (other than cessation) but more importantly of tobacco products that may in the future be marketed as cessation tools. OBJECTIVE: To identify research opportunities to develop empirically based and comprehensive methods and measures for testing tobacco and other nicotine-containing products so that the best science is available when decisions are made about products or policies. METHODS: Literature was reviewed to address sections of the FSPTCA relevant to tobacco product evaluation; research questions were generated and then reviewed by a committee of research experts. RESULTS: A research agenda was developed for tobacco product evaluation in the general areas of toxicity and health risks, abuse liability, consumer perception, and population effects. CONCLUSION: A cohesive, systematic, and comprehensive assessment of tobacco products is important and will require building consensus and addressing some crucial research questions.

Monitoring tobacco-specific N-nitrosamines and nicotine in novel Marlboro and Camel smokeless tobacco products: findings from Round 1 of the New Product Watch.

INTRODUCTION: Information on chemical composition of the new oral "spitless" smokeless tobacco products is scarce, and it is not clear whether there is some variability as a function of purchase place or time due to either unintended or intended manufacturing variations or other conditions. METHODS: We analyzed tobacco-specific N-nitrosamines (TSNA) and nicotine in Marlboro Snus, Camel Snus, and dissolvable Camel products Orbs, Sticks, and Strips that were purchased in various regions of the country during the summer of 2010. RESULTS: A total of 117 samples were received from different states representing six regions of the country. Levels of unprotonated nicotine in Marlboro Snus and Camel Snus varied significantly by regions, with the differences between the highest and the lowest average regional levels being relatively small in Marlboro Snus (∼1.3-fold) and large in Camel Snus (∼3-fold). Some regional variations in TSNA levels were also observed. Overall, Camel Snus had significantly higher TSNA levels than Marlboro Snus, and Camel Strips had the lowest TSNA levels among all novel products analyzed here. The amount of unprotonated nicotine in the dissolvable Camel products was comparable to the levels found in Marlboro Snus. CONCLUSIONS: Our study demonstrates some regional variations in the levels of nicotine and TSNA in Marlboro and Camel novel smokeless tobacco products. Continued monitoring of this category of products is needed as the existing products are being test marketed and modified, and new products are being introduced. This information is particularly important given its relevance to Food and Drug Administration regulation of tobacco products.

Prevalence of trial of snus products among adult smokers.

A 2008 survey assessed the proportion of smokers in 8 geographic areas who reported trying snus. In test markets, 10% of smokers had tried snus in the past year. Among young adult men, the trial rate was 29%. Trial was more likely among Whites than among minorities, among respondents with lower education than among those with higher education, and among those without immediate plans to quit smoking than among those intending to quit in the next 30 days. The association between trial and low cessation motivation is an important target for research.

Test marketing of new smokeless tobacco products in four U.S. cities.

INTRODUCTION: This exploratory study was designed to assess the availability, price, and point-of-purchase marketing strategies for new smokeless tobacco products in 4 test market areas. METHODS: A random sample of 50 gas stations, convenience and food stores, and tobacco shops was selected in each of 4 test market areas. Pairs of observers visited each store, recorded product information, and engaged vendors in conversation about product demand. RESULTS: Snus was available in 64% of the stores, but availability and price differed by brand. Point-of-purchase marketing also varied by brand on a variety of dimensions and all brands appeared to be marketed primarily to smokers. Camel Snus was described by store attendants as having the highest demand and was also the most expensive of the observed products. In light of the number of test market cities and intensity of promotion at retail locations, Camel Snus was the most intensively marketed product. DISCUSSION: The results appear to reflect differences in marketing strategy by American snus manufacturers. These strategies may help to predict future marketing of snus and other tobacco products and may provide a baseline for later assessments of product acceptance.

Individual, social-normative, and policy predictors of smoking cessation: a multilevel longitudinal analysis.

OBJECTIVES: We assessed the prospective impact of individual, social-normative, and policy predictors of quit attempts and smoking cessation among Massachusetts adults. METHODS: We interviewed a representative sample of current and recent smokers in Massachusetts by telephone in 2001 through 2002 and then again twice at 2-year intervals. The unit of analysis was the 2-year transition from wave 1 to wave 2 and from wave 2 to wave 3. Predictors of quit attempts and abstinence of longer than 3 months were analyzed using multilevel analysis. Predictors included individual, social-normative, and policy factors. RESULTS: Multivariate analyses of 2-year transitions showed that perceptions of strong antismoking town norms were predictive of abstinence (odds ratio = 2.06; P < .01). Household smoking bans were the only policy associated with abstinence, but smoking bans at one's worksite were significant predictors of quit attempts. CONCLUSIONS: Although previous research showed a strong relation between local policy and norms, we found no observable, prospective impact of local policy on smoking cessation over 2 years. Our findings provide clear support for the importance of strong antismoking social norms as a facilitator of smoking cessation.

Surveillance indicators for potential reduced exposure products (PREPs): developing survey items to measure awareness.

BACKGROUND: Over the past decade, tobacco companies have introduced cigarettes and smokeless tobacco products (known as Potential Reduced Exposure Products, PREPs) with purportedly lower levels of some toxins than conventional cigarettes and smokeless products. It is essential that public health agencies monitor awareness, interest, use, and perceptions of these products so that their impact on population health can be detected at the earliest stages. METHODS: This paper reviews and critiques existing strategies for measuring awareness of PREPs from 16 published and unpublished studies. From these measures, we developed new surveillance items and subjected them to two rounds of cognitive testing, a common and accepted method for evaluating questionnaire wording. RESULTS: Our review suggests that high levels of awareness of PREPs reported in some studies are likely to be inaccurate. Two likely sources of inaccuracy in awareness measures were identified: 1) the tendency of respondents to misclassify "no additive" and "natural" cigarettes as PREPs and 2) the tendency of respondents to mistakenly report awareness as a result of confusion between PREPs brands and similarly named familiar products, for example, Eclipse chewing gum and Accord automobiles. CONCLUSION: After evaluating new measures with cognitive interviews, we conclude that as of winter 2006, awareness of reduced exposure products among U.S. smokers was likely to be between 1% and 8%, with the higher estimates for some products occurring in test markets. Recommended measurement strategies for future surveys are presented.

Effects of different types of antismoking ads on reducing disparities in smoking cessation among socioeconomic subgroups.

OBJECTIVES: We assessed which types of mass media messages might reduce disparities in smoking prevalence among disadvantaged population subgroups. METHODS: We followed 1491 adult smokers over 24 months and related quitting status at follow-up to exposure to antismoking ads in the 2 years prior to the baseline assessment. RESULTS: On average, smokers were exposed to more than 200 antismoking ads during the 2-year period, as estimated by televised gross ratings points (GRPs). The odds of having quit at follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points, odds ratio [OR]=1.11; 95% confidence interval [CI]=1.00, 1.23; P<.05). Greater exposure to ads that contained highly emotional elements or personal stories drove this effect (OR=1.14; 95% CI 1.02, 1.29; P<.05), which was greater among respondents with low and mid-socioeconomic status than among high-socioeconomic status groups. CONCLUSIONS: Emotionally evocative ads and ads that contain personalized stories about the effects of smoking and quitting hold promise for efforts to promote smoking cessation and reduce socioeconomic disparities in smoking.

Receptivity to Taboka and Camel Snus in a U.S. test market.

INTRODUCTION: The two largest U.S. cigarette manufacturers introduced Swedish-style low-nitrosamine smokeless tobacco (snus) to several U.S. test markets in summer 2006. Since then, snus brands and test markets have proliferated. METHODS: This article assesses consumer response by analyzing data from the 2006 and 2007 Indiana Adult Tobacco Survey (IATS), a statewide telephone survey of 3,544 adults. During those years, the IATS included questions on awareness and trial of Camel Snus and Taboka. Analyses examined rates and predictors of awareness and trial statewide, and within the central Indiana test market. RESULTS: Nineteen percent of Indiana adults were aware of either Taboka or Camel Snus in 2006 and 2007. Estimates are larger (29%) for central Indiana and larger still (70%) for central Indiana smokers. Trial of snus, however, was very low (1.5% statewide), except among male smokers in central Indiana, 20% of whom are estimated to have tried it. Multivariate analyses showed that trial was more likely among men than women (odds ratio [OR] 13.85), residents of central Indiana than those farther from Indianapolis (OR 2.96), recipients than nonrecipients of tobacco promotions (OR 6.08), and those believing that smokeless tobacco is less harmful than cigarettes compared with those who believe it is equally or more harmful (OR 3.86). DISCUSSION: Results from this study suggest substantial initial interest in the new products among male smokers in this test market, especially those who receive promotional mailings from tobacco companies, which often include coupons for free or discounted products.

The natural history of light smokers: a population-based cohort study.

INTRODUCTION: Among cigarette smokers, lower levels of consumption, defined as smoking fewer cigarettes per day (CPD) or not smoking daily, are becoming more common. The relationship between cigarette consumption and smoking frequency (daily or nondaily) is not well characterized, and the natural history of light smoking (defined here as smoking < or =10 CPD) is poorly understood. METHODS: We assessed changes in CPD and smoking frequency over time among light smokers (< or =10 CPD) and very light smokers (< or =5 CPD), using a population-based longitudinal survey of 3,083 adult smokers in Massachusetts who were interviewed three times over a 4-year follow-up period (in 2000-2001, 2002-2003, and 2005-2006). We used logistic regression to identify factors associated with light smokers' progression to heavier smoking or smoking reduction/quitting. RESULTS: Seventy percent of very light smokers were nondaily smokers. Very light nondaily smokers differed from very light daily smokers by younger age, higher socioeconomic status, a social smoking pattern, later smoking initiation, less evidence of nicotine addiction, and more recent and planned cessation efforts. Very light nondaily smokers and smokers consuming 6-10 CPD were more likely to remain in the same smoking category and were less likely to increase consumption than were very light daily smokers. Factors independently associated with increasing consumption among very light smokers were smoking daily, nicotine dependence, White ethnicity, social smoking, and having more friends who smoked; among smokers consuming 6-10 CPD, male gender and lack of quitting self-efficacy were associated with increasing consumption. CONCLUSION: Our findings indicate that most light smoking is not a gateway to heavier smoking.

Monitoring the tobacco use epidemic I. Overview: Optimizing measurement to facilitate change.

OBJECTIVE: This Overview paper (I of V) summarizes research work to date on monitoring the tobacco use epidemic, discusses the recommendations made at the November, 2002 National Tobacco Monitoring, Research and Evaluation Workshop sponsored by the U.S. National Cancer Institute (NCI), Centers for Disease Control and Prevention (CDC), the American Legacy Foundation, and the Robert Wood Johnson Foundation on the topic of tobacco surveillance and evaluation, and discusses the current state of affairs. METHODS: A conceptual model based on the classical infectious diseases framework/paradigm focusing on the Agent, Host, Vector and Environment is used to integrate the work presented in the four other papers that appear in this supplemental issue of Preventive Medicine. RESULTS: The Agent paper (II) describes surveillance on tobacco products and biomarkers; the Host paper (III) describes surveillance on the smoker/user, or potential smoker/user; the Vector paper (IV) describes monitoring of industry activity; and the Environment paper (V) describes several key strategies for monitoring influential environmental factors. Overall, some improvements to the nation's surveillance system have been made in recent years. However, additional steps are needed to optimize measurement of tobacco use and factors influencing use in the United States. CONCLUSIONS: Tobacco monitoring efforts play a vital role in combating the epidemic of addiction and disease produced by various tobacco products. The knowledge and experience gained by the tobacco use prevention and control community through this commitment to linkages of data collected in the domains of Vector and Environment, in addition to Agent and Host, could inform monitoring of a wide range of other public health issues as well, including diet and nutrition, physical activity, overweight and obesity, and substance abuse.