Retailers' Compliance with Federal Age of Cigarette Sales Policies -- Pitt County, North Carolina, January-March 2022.

BACKGROUND: Tobacco use remains a leading cause of preventable morbidity and premature mortality. In December 2019, the federal age of sale for tobacco products increased from 18 to 21 years of age. This study aimed to evaluate the implementation of federal tobacco 21 policies in Pitt County, North Carolina (NC), by conducting multiple purchase attempts for cigarettes. METHOD: Stores in Pitt County that sold cigarettes were randomly sampled and visited by up to six different underage (18-20) buyers who attempted to buy cigarettes from January-March 2022. Buyers made a total of 217 cigarette purchase attempts from 49 Pitt County retailers. Analyses were conducted using SPSS Complex Samples (v.28/Macintosh) and estimate retailer prevalence of requesting identification (ID) and selling to underage buyers across multiple purchase attempts. RESULTS: On average, retailers failed to request ID in 15.4% of purchase attempts (95% CI: 9.4%-21.3%) and sold to an underage buyer 34.2% of the time (95% CI: 27.0-41.4%). Additionally, 75.5% (95% CI: 63.4%-84.6%) of retailers sold to an underage buyer at least once. LIMITATIONS: This study is limited to a single county in NC and to underage buyers aged 18 to 20. CONCLUSION: There is widespread non-compliance with federal age of sale policies for tobacco products in Pitt County, NC. State enforcement is warranted, and NC's youth access law should be amended to match the federal age of sale. Changes to the law should allow research involving underage purchases.

Perceived relative harm and addictiveness compared with cigarettes and intentions to use modified risk tobacco products utilizing FDA-authorized marketing claims among adults in the United States.

INTRODUCTION: We assessed adults' perceived relative harm and addictiveness of products using FDA-authorized modified risk tobacco products (MRTP) claims and associations with intentions to use MRTPs. METHODS: Data were from the May 2022 Rutgers Omnibus study among US 18-45-year-old adults (n=2964), collected by the Rutgers Institute for Nicotine and Tobacco Studies (INTS). Outcomes were perceived relative harm and addictiveness versus a typical cigarette and intentions to use a product stating a reduced harm claim (General Snus) or a reduced exposure claim (VLN King). We conducted regression analyses of associations between perceived relative harm and addictiveness and intentions to use each product, stratified by smoking status. RESULTS: The minority of participants perceived products with a reduced harm claim as much less harmful vs. cigarettes (21 %, 19 %, 7 %, and 8 % among persons who smoked daily, smoked some days, formerly smoked, and never smoked respectively) and products with a reduced exposure claim as much less addictive vs. cigarettes (24 %, 26 %, 14 %, 20 % respectively). Perceived lower relative harm and addictiveness were significantly associated with higher intentions to use products stating reduced harm or reduced exposure claim across all smoking statuses with one exception (relative addictiveness was not associated with intention to use products stating the reduced harm claim among persons who formerly smoked). CONCLUSIONS: Two current FDA-authorized MRTP claims were not effective in conveying that MRTPs were less harmful or addictive than cigarettes to most participants. Perceiving products as less harmful or addictive were significantly associated with intentions to use MRTPs.

The impact of exposure to FDA e-cigarette authorization messages on product perceptions and interest - an experiment with adults who smoke and youth.

INTRODUCTION: In the United States, e-cigarettes have entered a new regulatory era, needing authorizations from FDA to remain on or enter the marketplace. This study explored the impact of e-cigarette authorization messages on product perceptions and interest. METHODS: We conducted an online experiment in June 2022 with nationally-representative samples of adults (21+) who smoke cigarettes (n=866) and youth ages 15-20 (n=859). They were randomized to one of five conditions: viewing an ad for a fictional e-cigarette brand with no reference to FDA (control), an ad with an "authorized for sale by FDA" claim in varying presentation styles (plain text, FDA "approved" stamp, FDA logo), or reading a fictional news excerpt about the product's authorization plus control ad. We compared group differences on product interest, susceptibility, harm perceptions and message perceptions. RESULTS: Among adults who smoke, there were no effects on product interest nor susceptibility, but ratings of the product's harmfulness compared to cigarettes were lower among those in the news versus control condition (ß=-0.25, p=.04). Among youth, odds of susceptibility were higher among ever e-cigarette users who viewed the ad with the FDA logo authorization message relative to the control ad (OR=6.3, 95% CI:1.67-23.9, p<0.01). About 40% of all participants agreed the authorization claim makes them think the product is safe to use, but fewer (14-19%) agreed it makes them more interested in trying it. CONCLUSIONS: FDA e-cigarette authorization messages may impact some beliefs about product harm. More research is needed to track potential impacts on product use. IMPLICATIONS: This study provides new data about the potential impact of messages about FDA authorization of e-cigarette products (presented as ad claims or a news story) on authorized product perceptions, interest and susceptibility among adults who smoke cigarettes and youth. Our results suggest that FDA e-cigarette authorization messages may impact harm-related beliefs among adults who smoke and product susceptibility among youth who have ever used e-cigarettes before, though real-world effects are likely to be impacted by message type and format, and perceived message source and credibility. Authorization messages are likely to be misinterpreted as "FDA approval" by some; therefore, providing clarifications about authorization meaning and standards are relevant where possible.

Measuring disability among U.S. adolescents and young adults: A survey measurement experiment.

Objective: Disability is identified in surveys using various question sets, with little understanding of reliability across these measures, nor how these estimates may vary across age groups, including adolescents and young adults (AYA). The purpose of this study was to assess AYA prevalence of disability using two disability question sets and reliability of these measures. Methods: AYA participants in the Policy and Communication Evaluation (PACE) Vermont Study completed a single-item disability question used in the National Survey on Health and Disability (NSHD) and Urban Institute's Health Reform Monitoring Survey (HRMS) and a six-item set on functioning (Washington Group-Short Set, WG-SS) from the National Health Interview Survey (NHIS) and National Survey on Drug Use and Health (NSDUH) in 2021. Prevalence was estimated for any disability and each disability domain in adolescents (ages 12-17) and young adults (ages 18-25) and compared with U.S. national estimates in NHIS and NSDUH. Results: Using the WG-SS, the prevalence of any disability was 17.0 % in PACE Vermont adolescents and 22.0 % in young adults, consistent with the national prevalence of adolescents in NSDUH (17.9 %) but higher than estimates of young adults in NHIS (3.9 %) and NSDUH (12.9 %). The single-item question provided lower estimates of disability (adolescents: 6.9 %; young adults: 18.5 %) than the WG-SS, with low positive agreement between measures. Discussion: The prevalence of disability in AYAs varies depending on measures used. To improve disability surveillance, it may be necessary to validate new disability questions, including among AYAs, to capture a broader range of disability domains.

The Impact of New Jersey's 2020 E-Cigarette Flavor Ban on E-Cigarette, Cigarette, and Cigar Sales in NJ.

INTRODUCTION: On April 20, 2020, New Jersey (NJ) implemented a comprehensive ban on the sale of flavored e-cigarettes. This study compares sales of e-cigarettes, cigarettes, and cigars before and after the law. METHODS: Data were biweekly retailer scanner sales in NJ convenience stores for e-cigarettes, cigarettes, and cigars between August 2019 and December 2020. We used Joinpoint regression to assess sales trends for cigarettes (non-menthol, menthol), cigars (unflavored, flavored), and e-cigarettes (unflavored, fruit/sweet/concept flavor, menthol flavor) in the 36 weeks before and 36 weeks after a statewide ban on flavored e-cigarettes. RESULTS: Flavored e-cigarette sales, not including menthol, significantly decreased over the study period while menthol e-cigarette sales significantly increased until the e-cigarette flavor ban took effect, after which these sales rapidly declined through May 2020, then slowed. Unflavored e-cigarette sales declined through September 2019, then grew modestly until the flavored e-cigarette ban, after which sales significantly increased. Flavored cigar sales increased between March and May 2020, then declined; non-flavored cigar sales increased between mid-February and early July 2020, then declined. Cigarette sales were decreasing before the flavored e-cigarette ban but after, significantly increased until June 2020. Overall, there was no significant trend in the average biweekly percent change for cigarette sales. CONCLUSIONS: Flavored e-cigarette sales were declining prior to the ban but the pace of the decline accelerated following federal and state restrictions on flavored e-cigarette sales, then slowed by the second half of 2020, with a brief period of increased cigarette and cigar sales immediately following the ban. IMPLICATIONS: New Jersey's 2020 statewide e-cigarette flavor ban offered the opportunity to observe how sales of e-cigarette, cigarette, and cigar products shifted after the change. The effect of the state law, at least in the short-term, was decreased sales of flavored e-cigarettes and increased sales of unflavored e-cigarettes. Research on long term policy effects is needed.

Respiratory symptoms and outcomes among cigar smokers: findings from the Population Assessment of Tobacco and Health (PATH) study waves 2-5 (2014-2019).

BACKGROUND: The mechanisms by which cigarette smoking increases the risk of respiratory disease have been studied. However, less is known about risks of respiratory symptoms and outcomes associated with smoking cigars, and risks by cigar types have not been previously explored. The aim of this study was to examine associations between cigar use, including traditional cigars, cigarillos, filtered cigars, and dual cigar and cigarette use, and functionally important respiratory symptoms (FIRS), lifetime asthma diagnosis, uncontrolled asthma, and new cases of FIRS. METHODS: Data from Waves 2-5 (2014-19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal study, were analyzed in two ways. For cross-sectional analysis, the analytic sample included adults 18 and older at each wave, resulting in 44,040 observations. Separately, longitudinal analyses were assessed among adults 18 and older at Wave 2, resulting in 7,930 individuals. Both analyses excluded adults with chronic obstructive pulmonary disease (COPD) or non-asthma respiratory disease. RESULTS: Current established cigarillo smokers had higher odds of having FIRS (Adjusted odds ratio (AOR): 1.72; 95% CI: 1.08, 2.74) compared to never smokers of cigarillos and cigarettes, after adjusting for covariates. Current established filtered cigar smokers had higher odds of asthma diagnosis (AOR: 1.35; 95% CI: 1.10, 1.66) while current established dual smokers of filtered cigars and cigarettes had higher odds of uncontrolled asthma (AOR: 5.13; 95% CI: 1.75, 15.02) compared to never smokers of filtered cigars or cigarettes. Both current established cigar smokers and current established dual smokers of cigarettes and cigars had higher odds of new FIRS compared to never cigar or cigarette smokers (AORs: 1.62; 95% CI: 1.02, 2.60 for exclusive cigars and 2.55; 95% CI 1.57, 4.14 for dual smokers). CONCLUSIONS: This study provides evidence that cigar smokers or dual smokers of cigars and cigarettes have greater odds of FIRS, asthma, and uncontrolled asthma and that new incidence of FIRS is higher among any cigar smokers compared to never cigar or cigarette smokers. Understanding health impacts associated with cigar use provides information for supporting policy development, as well as for designing clinical interventions focused on smoking cessation for cigars.

National Trends in Sales and Price for Commercial Tobacco and Nicotine Products, 2018-2022.

This cross-sectional study explores recent trends in sales and price of tobacco and nicotine products in the US.

Patterns of blunt and cigar use in the United States, 2015-2019.

Background: The use of cigars for blunts (i.e., cannabis rolled in cigar paper) is well-documented; proportions of cigar and blunt use and associated characteristics are less studied. Methods: Pooled data from the 2015-2019 National Survey on Drug Use and Health (NSDUH) were analyzed in 2023. Respondents aged 12+ who reported past 30-day cigar use were categorized into three mutually exclusive use categories: (1) exclusively cigars, (2) exclusively blunts, and (3) both cigars and blunts. We examined associations between cigar-blunt use category and sociodemographic characteristics. Results: Among people 12 and older who reported past 30-day cigar use, 48.6% (95% CI=47.6-49.6) reported exclusive cigar use; 44.3% (95% CI=43.3-45.3) reported exclusive blunt use; and 7.2% (95% CI=6.8-7.6) reported cigars and blunts. The prevalence differed by age, with exclusively blunts most prevalent among youth (72.5% [95% CI=70.7-74.3]) and young adults (62.4% [95% CI=61.4-63.5]), and exclusively cigars most prevalent among adults 26+ (61.2% [95% CI=59.8-62.5]). Exclusive blunt users smoked more days in the past month (17.5; 95% CI=16.8-18.2), compared to 13.8 days (95% CI=13.2-14.4) for cigar and blunt users, and 7.7 days (95% CI=7.5-8.0) for exclusive cigar users. There were significant differences in characteristics, with exclusive blunt use more prevalent among female (41.6%; 95% CI=40.3-42.9) and Hispanic (18.2%; 95% CI=17.3-19.2) participants. Conclusions: Exclusive blunt use was the most prevalent pattern of past-30-day cigar use among youth and young adults. Those who use cigars as blunts smoke more cigars per month, suggesting this may be an important group for additional education and policy efforts.

Examining Demand and Substitutability of Usual Brand Little Cigars/Cigarillos and Cigarettes in Young Adults Who Dual Use.

INTRODUCTION: Cigarette and little cigar/cigarillo (LCC) dual use is popular among young people and poses a substantial health risk. What remains unclear is the abuse liability of LCCs vs. cigarettes, LCCs' substitutability for cigarettes, and the influence of flavors on the abuse liability and substitutability of LCCs. METHODS: Sixty-five young adults (18-34 years) who dual use completed hypothetical purchase tasks to measure consumption of usual brand cigarettes and LCCs in 24h at increasing prices (demand), and LCC consumption at increasing cigarette prices (substitution). Three demand indices were calculated from raw data: breakpoint (price after which consumption reaches 0), Omax (maximum daily expenditure), and Pmax (price at maximum expenditure). Two indices were estimated using nonlinear mixed-effects modeling: intensity (consumption when free), and price-sensitivity (rate of decline in consumption as price increases). Substitution, and associations of flavored use with demand and substitution, were estimated using linear mixed models. RESULTS: Results indicated similar abuse liability for LCCs and cigarettes. Intensity was greater for cigarettes, but price-sensitivity was similar. Flavored LCC use was associated with lower price-sensitivity and greater intensity than unflavored. LCCs were significant substitutes for cigarettes, but the effect was small. Flavored use was not associated with substitution. CONCLUSIONS: Among young adults who dual use, LCCs and cigarettes had similar abuse liability, and those who used flavored had higher demand for their LCCs. A flavored cigar ban, as well as targeted prevention and cessation services for those who smoke flavored LCCs, may be important for reducing dual use in young adults. IMPLICATIONS: Cigarette and little cigar/cigarillo (LCC) dual use remains high among young adults. Using hypothetical purchase tasks with young adults who dual use, LCCs had abuse liability similar to cigarettes, but were only modest substitutes for cigarettes. Participants who used flavored LCCs reported greater abuse liability than those who used unflavored, but not greater substitution for cigarettes. Prevention and cessation services are needed to target LCCs in young people, particularly those smoking flavored products. A flavored cigar ban may help to reduce their demand.

Does noticing cigar warnings associate with cigar harm perceptions and smoking behaviors? Analysis from Wave 5 of the population assessment of tobacco and health study.

BACKGROUND: In the US, cigar warning label standards are less stringent than cigarette warning requirements and are not uniformly required; research is needed about warning efficacy in promoting cigar risk beliefs, discouraging use and supporting public health. METHODS: Using data from the PATH Study (Wave 5), we analyzed associations between noticing cigar warnings and perceived harm from cigar use, frequency of thinking about harms, and effects of warnings labels. RESULTS: Among adults who smoke cigars, respondents noticing warnings at least sometimes (vs. never/rarely) had higher odds of thinking about harms of their tobacco use often/very often (cigarillos 30% vs. 19%, p <.001, aOR 1.80 [1.27, 2.56]); filtered cigars: 43% vs. 16%, p <.001, aOR 3.81 [2.50, 5.82]) and of reporting that smoking cigars is very/extremely harmful (cigarillos: 59% vs. 46%, p =.001, aOR 1.45 [1.05, 1.99]). A substantial majority found cigar warnings to be very/extremely believable (cigarillos: 63%, filtered cigars: 59%, traditional cigars: 65%), with 16%, 24% and 12% respectively reporting past-30-day warning avoidance. Those noticing warnings at least sometimes (vs. rarely) had higher rates of reporting that warnings sometimes/often/very often stopped them from having a cigar in the past 30 days (cigarillos: 36% vs. 10%; filtered cigars: 50% versus 6%; traditional cigars: 30% versus 9%; p's < 0.001) and that warnings made them somewhat/a lot more likely to quit smoking (cigarillos: 55% versus 37%, p <.01; filtered cigars: 55% versus 26%, p <.001; traditional cigars: 39% vs. 24%, p <.05). CONCLUSIONS: Results support potential public health benefits of mandating the presence and increasing salience of cigar warning labels.

Cardiovascular disease outcomes among established cigar users 40 years and older: Findings from the population assessment of tobacco and health (PATH) study, waves 1-5 (2013-2019).

This study examined associations between established cigar use and prevalence and incidence of cardiovascular diseases (CVD; congestive heart failure, stroke, or heart attack/needed bypass surgery) among U.S. adults, 40 years or older. Using Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health (PATH) Study, incidence (Nindividuals (Nind) = 6,692; Nobservations (Nobs) = 23,738) and prevalence (Nind = 7,819; Nobs = 33,952) of CVD outcomes were examined using weighted generalized estimating equations (WGEEs) among adults who were exclusive current/former established cigar smokers (ever cigar smokers who have smoked fairly regularly), exclusive current/former established cigarette smokers (lifetime smokers of 100 or more cigarettes), dual current/former established cigarette and cigar smokers compared with never smokers of cigars or cigarettes, adjusting for covariates. The population-averaged incidence of CVD from one wave to next among exclusive current/former established cigar smokers during a six-year period based on WGEEs was low (overall average rate of 3.0 %; 95 % CI: 1.2, 7.0). Compared with never users, exclusive current/former established cigar smokers (OR = 1.67, 95 % CI: 1.11, 2.51) and exclusive current/former established cigarette smokers (OR = 2.12, 95 % CI: 1.45, 3.09) were more likely to have any CVD outcome in unadjusted analyses. When adjusted for covariates, only exclusive current/former established cigarette use was associated with CVD outcomes (AOR = 1.60, CI: 1.07, 2.40). Results suggest that exclusive established use of cigars or duration of exclusive cigar use was not associated with lifetime CVD prevalence compared with never cigar or cigarette smokers, which is important in understanding health outcomes in cigar users.

The Impact of Modest Price Increases and Single Cigar Restrictions on Youth Cigar Use.

INTRODUCTION: In 2011, Boston restricted cigar sales to packages of at least 4 cigars unless sold at a minimum of $2.50 per cigar. Nearly 200 localities in Massachusetts have since adopted policies establishing minimum pack quantities of 2-5 or minimum prices of $2.50-5.00 per cigar. The objective of this study was to examine the impact of these policies on youth cigar use. METHODS: Biennial data from 1999 to 2019 were obtained from the Massachusetts Youth Risk Behavior Survey and analyzed in 2023. Final analytic samples included 15,674 youth for the Boston analyses and 35,674 youth for the statewide analyses. For Boston, change in use was examined from prepolicy (1999-2011) to postpolicy (2012-2019). For statewide analyses, the percentage of the state covered by a policy was estimated. Multivariable logistic regressions examined the impact of cigar policies on cigar and cigarette use. Analyses were adjusted for sociodemographic characteristics and stratified by sex and race. RESULTS: Policy enactment was associated with significant decreases in the odds of cigar use in Boston (AOR: 0.28; 95% CI: 0.17-0.47) and statewide (AOR: 0.98; 95% CI: 0.98-0.99), with similar findings for cigarette use. Results were consistent among males and females statewide but only among males in Boston. By race statewide and in Boston, odds of cigar use decreased significantly among White, Black, and Hispanic youth, but not youth of other races. CONCLUSIONS: These findings indicate small increases in the quantity and price of cigar packs could discourage young people from purchasing and using cigars, providing significant benefits for local tobacco control efforts.

Communicating the benefits of quitting smoking on mental health increases motivation to quit in people with anxiety and/or depression.

BACKGROUND: Although smoking rates have declined over time, this decline has not been observed among those with mental health concerns. It is therefore important to develop effective messaging to support quitting in this population. METHODS: We conducted an online experiment with 419 adults who smoke cigarettes daily. Participants with, or without a lifetime history of anxiety and/or depression were randomized to view a message focused on the benefits of quitting smoking on mental or physical health. Participants then reported motivation to quit smoking, mental health concerns about quitting, and perceived effectiveness of the message. RESULTS: Participants with a lifetime history of anxiety and/or depression who saw the message focused on the benefits of quitting smoking on mental health reported greater motivation to quit than when they saw a message focused on the benefits to physical health. This was not replicated when examining current symptoms instead of lifetime history. Pre-existing beliefs that smoking improves one's mood were greater in those experiencing current symptoms and in those with a lifetime history of anxiety and/or depression. There was no main or interaction (message type X mental health status) effect of message type received on mental health related concerns about quitting. CONCLUSIONS: This study is one of the first to evaluate a smoking cessation message with content specifically targeted to those with mental health concerns about quitting smoking. Additional work is needed to determine how to best target those with mental health concerns with messages focused on the benefits of quitting on mental health.

Prioritizing common terminology and measures to advance research on oral nicotine product use.

This commentary calls for consistent measurement of oral nicotine product use by the scientific community, recommends specific measures where possible, and emphasizes areas in need of further research. We hope to expedite the use of consistent measures of oral nicotine product use so that this area of tobacco research can advance quickly.

Dramatic Reductions in Cigarette Smoking Prevalence among High School Youth from 1991 to 2022 Unlikely to Have Been Undermined by E-Cigarettes.

There is concern that youth e-cigarette use could lead youth to initiate cigarette smoking. This study identifies epochs of cigarette smoking among U.S. high school students in three commonly utilized national school-based surveys over three decades without a priori assumptions. We examined trends in ever and current cigarette smoking among high school youth from 1991 to 2022 in three datasets: Monitoring the Future (MTF), the National Youth Risk Behavior Survey (NYRBS) and the National Youth Tobacco Survey (NYTS) via Joinpoint regression. High stable rates of ever smoking were noted from 1991 to 1999 (NYRBS and MTF) and then significantly declined from 1999 to 2013; declines accelerated through to 2022. In the NYTS, ever cigarette smoking significantly declined from 1999 to 2018 and then declines accelerated to 2022. Current cigarette smoking reached its peak in 1997, and then significantly declined from 1997 to 2013 in the NYRBS and MTF and similarly in the NYTS from 1999 to 2018. Declines in current smoking then accelerated in all surveys through to 2022. These findings suggest dramatic successes in reducing youth smoking since the late 1990s, with more rapid declines in prevalence in the past decade.

Effects of pictorial warning labels depicting lesser-known and well-known risks of smoking on viewing patterns, recall, and knowledge of smoking harms.

BACKGROUND: In 2019, the Food and Drug Administration introduced 11 pictorial warning labels (PWLs) for inclusion on cigarette packages, created in compliance with court recommendations and tailored to increase knowledge of smoking harms. Several highlighted lesser-known risks of smoking. No behavioral studies have yet evaluated how risk content in PWLs impacts viewing patterns, recall, and knowledge of smoking harms. METHODS: Seventy adults who reported smoking cigarettes daily (62.9% male, 57.1% African American, mean age = 50.3, mean cigarettes per day = 14.4) completed a single-session laboratory study. They were randomized to view a set of four PWLs depicting either lesser-known or well-known risks of smoking while having eye movements recorded, then completed post-exposure recall and knowledge measures. RESULTS: Participants exposed to PWLs depicting lesser-known smoking risks viewed the text of the warning sooner and for longer than the image (p's <0.05); those exposed to PWLs depicting well-known risks viewed the image longer than text (p <0.001). PWL condition did not affect recall of text or image (p's >0.1). Those viewing lesser-known (vs. well-known) risks had greater knowledge of smoking causing lesser-known risks of bladder cancer, blindness, bloody urine, cataracts, diabetes, and head and neck cancer (p's <0.001). CONCLUSIONS: Individuals viewing PWLs depicting lesser-known (vs. well-known) smoking risks visually engaged with the PWL text more than image, had similarly high recall of PWL content, and had greater knowledge of lesser-known risks of smoking. Findings suggest including lesser-known risk information on PWLs improves overall knowledge of smoking health risks.

Longitudinal analysis of cigar use patterns among US youth and adults, 2013-2019.

BACKGROUND: Cigars are available in a range of pack quantities, which contrasts regulations requiring cigarettes to be sold in packs of 20 or greater. Smaller packages may be associated with increases in initiation while larger packs may lead consumers to smoke more. The purpose of this study was to inform pack quantity regulations by examining whether usual cigar pack quantity purchased was associated with use, initiation, and discontinuation among youth and adults for four cigar types: premium cigars, large cigars, cigarillos, and filtered cigars. METHODS: We analyzed waves 1-5 (2013-2019) of the adult and waves 2-5 (2014-2019) of the youth Population Assessment of Tobacco and Health (PATH) Study. Samples included those responding to the item on pack quantity and providing data at all waves (adults: premium cigars [N = 536], large cigars [N = 1,272], cigarillos [N = 3,504], filtered cigars [N = 1,281]; youth: premium cigars [N = 55], large cigars [N = 217], cigarillos [N = 1514], filtered cigars [N = 266]). Generalized estimating equation models examined the population-averaged effects of pack quantity on cigar use, initiation, and discontinuation. RESULTS: Adult pack quantity was positively associated with the days used per month for premium cigars (b: 0.23, 95% CI: 0.11, 0.34), large cigars (b: 0.17, 95% CI: 0.08, 0.25), cigarillos (b: 0.12, 95% CI: 0.003, 0.24), and filtered cigars (b: 0.07, 95% CI: 0.04, 0.10), and positively associated with amount smoked per day for all cigar types. Youth pack quantity was positively associated with days used per month for premium cigars (b: 0.88, 95% CI: 0.33, 1.43), large cigars (b: 0.79, 95% CI: 0.43, 1.15), and cigarillos (b: 0.17, 95% CI: 0.01, 0.34). Adult initiation was associated with pack quantity for filtered cigars (b: -2.22, 95% CI: -4.29, -0.13), as those who initiated purchased smaller pack quantities compared to those who did not initiate that wave. Pack quantity was not associated with discontinuation for adults or youth. CONCLUSIONS: Cigar use increased as usual pack quantity purchased increased across cigar types for youth and adults. Small increases in pack quantity (e.g., one additional cigar) are likely to result in consuming less than one additional day per month, though larger increases (e.g., 10 additional cigars per pack) may result in greater use.

Effects of reduced nicotine content cigarette advertising with warning labels and social media features on product perceptions among young adults.

This study sought to understand reactions to very low nicotine (VLN) cigarette advertising compared with conventional cigarette advertising with consideration of warning labels and social media context. The online experimental study recruited young adult cigarette smokers and nonsmokers (N = 1,608). Participants completed a discrete choice task with a 2 × 2 × 3 mixed design: brand, (VLN, Marlboro), context (Ad only, Ad on social media), and warning (Text-only, Well-known risk pictorial, or Lesser-known risk pictorial). Participants made choices about attention, appeal, harm, buying, and quitting intentions. Social media context increased attention and appeal. A well-known risk pictorial warning outperformed a text-only warning. Smokers had increased odds of quit intentions for VLN ads, yet nonsmokers had increased intentions to buy cigarettes on social media with a text-only warning. Results indicate differences in how young adults react to cigarette ads on social media, especially with the warnings they portray.

Evaluating Correlations Between Premium Cigar Smoking and Mental Health and Substance Use Dependence Conditions Among U.S. Adults, 2010-2019.

INTRODUCTION: Improved understanding of health conditions associated with premium cigar smoking can inform efforts to reduce cigar use. This paper extends findings commissioned for the National Academies of Science, Engineering, and Medicine report on premium cigars. AIMS AND METHODS: We pooled 2010-2019 National Survey on Drug Use and Health data to evaluate cross-sectional associations between premium cigar smoking and mental health and substance use conditions among U.S. adults. A series of logistic regression models adjusted for age, sex, race and ethnicity, cigarette smoking, and alcohol consumption compared odds of each condition associated with past-month premium cigar smoking relative to past-month nonpremium cigar smoking, never tobacco use, and current established cigarette smoking. RESULTS: Premium cigar smoking was associated with lower adjusted odds of past month serious psychological distress, past year major depressive episode, and cannabis and illicit drug dependence relative to nonpremium cigar and cigarette smoking; however, higher odds of alcohol and cannabis dependence were observed relative to never tobacco use, and lower odds of alcohol dependence were observed relative to current cigarette smoking but not current nonpremium cigar smoking. CONCLUSIONS: We observed considerable variation in both magnitude and direction of associations between premium cigar smoking and mental health and substance use indicators depending on the condition and reference group to which premium cigar smoking was compared. IMPLICATIONS: Premium cigar smoking frequently cooccurs with cigarette smoking and alcohol consumption, thus potential health correlates must be considered in appropriate context. We observed considerable variation in direction and magnitude of association depending on the health condition and reference population, as well as potential for reverse causality and residual confounding in this cross-sectional analysis. As the tobacco landscape continues to evolve, rigorous scientific studies that incorporate clear differentiation of cigar type, measures of cumulative use, and temporal data collection are necessary to fully evaluate the health effects of premium cigar smoking and effectively inform Food and Drug Administration regulation.