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.

Oral nicotine product marketing expenditures in the USA from 2016 to 2023: trends over time by brand and targeted media outlets.

BACKGROUND: Oral nicotine products (ONPs) are increasing in sales, availability and flavours. In April 2022, the US Food and Drug Administration (FDA) obtained regulatory authority over non-tobacco nicotine products, which include many ONPs. Advertising practices for ONPs need monitoring to understand marketing strategies and inform FDA marketing authorisation decisions. METHODS: ONP advertisement (ad) expenditure data (January 2016-June 2023) were purchased (print, TV, radio, online video, online display and mobile; N=125 236) and adjusted to 2023 dollars. Descriptive statistics examined expenditures by ONP brand and media outlet over time. RESULTS: Velo spent the most on ONP advertising (89.8%), followed by Zyn (5.7%) and Black Buffalo (1.2%). Velo encompassed the majority of TV (98.1%), radio (99.9%) and mobile ad spend (87.3%); Zyn was the leader for online display (46.2%) and online video (71.1%); and Black Buffalo accounted for 100% of print ads. In 2023, (January-June), Zyn accounted for 88.0% of ad expenditures and Velo spent $0, though the total amount spent by Zyn was far less than Velo in prior years. TV ads (98.1% Velo) aired primarily on prime time/late night or 09:00-17:00 on weekends. Radio ads (99.9% Velo) aired primarily from 06:00 to 10:00, 12:00 to 14:00 and 15:00 to 19:00 on weekdays. Overall, expenditures focused on reaching a national audience, though print ads indicated potential male-targeted marketing. CONCLUSIONS: Following FDA's regulatory authority over non-tobacco nicotine products, ad expenditures for Velo dropped to $0. Ongoing surveillance of ONP ad trends can inform FDA marketing authorisation decisions by revealing brand-specific marketing strategies that may be targeted toward populations at increased risk of tobacco use.

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.

"If You Just Tell Me You're 18, I'll Still Sell to You": A Qualitative Study of Underage Tobacco Product Purchasing Experiences in a Tobacco 21 Compliance Study.

BACKGROUND: Tens of thousands of underage tobacco buy attempts are conducted each year for research, compliance, and public health surveillance. However, little research has qualitatively examined the perceptions and experiences of underage buyers participating in these programs. We sought to understand underage buyers' experiences and gather recommendations for protocol improvements. METHODS: We conducted semi-structured interviews in the fall of 2022 to assess experiences with underage tobacco product purchasing. Participants (N = 19, 58% male, 42% White) were research assistants aged 18-20 in New Jersey, New York, or North Carolina. Interviews examined purchasing experiences in relation to store characteristics, clerk interactions, and buyer identities. We used deductive and inductive thematic coding to explore key themes related to buyer experiences. RESULTS: We identified four themes: (1) non-chain stores lacked consistency in verifying age; (2) female data collectors experienced uncomfortable situations more frequently than male data collectors; (3) not identifying with the store's typical demographics impacted purchase attempts; and (4) participants suggested improvements for inspections and research during training. DISCUSSION: Retailer education, widespread adoption of ID scanners, and enforcement could increase standardization of ID requests and verification. Male and female buyers can be trained on what they might expect based on their gender, as well as how to maneuver through unwanted situations. Consideration of shared identity is important for future waves of data collection and research. Efforts to improve training include more extensive mock purchase training with supervisors well-versed in this area. IMPLICATIONS: Electronic ID verification and promoting compliance at non-chain retailers could impact access to tobacco products for underage buyers. Training for underage buyers in research and compliance assessments should focus on ways to enhance data collectors' confidence when making a purchase attempt, which may improve the validity of the rate of sales to individuals under 21.

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.

US Physicians' Self-reported Discussions About Tobacco-Free Nicotine Pouches During Clinical Encounters With Patients in 2021.

This survey study assesses the extent to which physicians discussed tobacco-free nicotine pouches during clinical encounters with patients.

Indicators of Tobacco Dependence Among Youth: Findings From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study.

BACKGROUND: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth. METHODS: One thousand one hundred and forty-eight youth aged 12-17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. FINDINGS: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = -1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = -0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults. CONCLUSION: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group. IMPLICATIONS: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco.

Assessing the Effectiveness of Tobacco 21 Laws to Reduce Underage Access to Tobacco: Protocol for a Repeated Multi-Site Study.

Prior to the federal law passed in December 2019, many states passed an increased age of sale law prohibiting youth under age 21 (or Tobacco 21) from purchasing tobacco products, including e-cigarettes. Although previous research has documented tobacco retail sale violations, fewer studies have examined age verification and illegal tobacco sales in the context of Tobacco 21 or repeated purchase attempts in various settings. In this study conducted between 2019 and 2022, buyers aged 18 to 20 years made repeated unsupervised purchase attempts of cigarettes, cigars, e-cigarettes, tobacco-free nicotine pouches, and smokeless tobacco at over 180 tobacco or e-cigarette retailers in New Jersey, New York City, and Pitt County (North Carolina). Buyers documented whether they were asked for identification and whether they were able to successfully purchase a tobacco or nicotine product at each visit. The primary outcome will be the percent of retailers that checked the buyers' identification at store visits and the percent of visits that resulted in a successful underage tobacco product purchase. We will compare the results across time periods, study sites, products, and buyer characteristics (i.e., gender, minoritized racial/ethnic identity) while controlling for repeated visits. These results will inform improvements to current compliance check inspection programs as well as interventions that reduce youth access to tobacco.

Tobacco-Derived Nicotine Pouch Brands and Marketing Messages on Internet and Traditional Media: Content Analysis.

BACKGROUND: Nicotine pouches and lozenges are increasingly available in the United States, and sales are growing. The brands of nicotine pouch products with the largest market share are produced by tobacco companies. OBJECTIVE: The aim of this study is to examine the marketing of 5 oral nicotine products sold by tobacco companies. METHODS: Internet, radio, television, print, and web-based display advertisements between January 2019 and March 2020 for 6 brands of nicotine pouches and lozenges were identified through commercially available marketing surveillance systems supplemented by a manual search of trade press and a review of brand websites. A total of 711 advertisements (122 unique) were analyzed to identify characteristics, themes, marketing strategies, and target audiences, and qualitatively compared by brand. All 5 brand websites were also analyzed. Coders examined the entirety of each advertisement or website for products, marketing claims, and features and recorded the presence or absence of 27 marketing claims and lifestyle elements. RESULTS: All 6 brands of nicotine pouch products spent a total of US $11.2 million on advertising in 2019, with the most (US $10.7 million) spent by the brand Velo, and 86.1% (n=105) of the unique advertisements were web-based. Of the 711 total nicotine pouch advertisements run in 2019, the 2 brands Velo (n=407, 57%) and ZYN (n=303, 42%) dominated. These brands also made the greatest number of advertising claims in general. These claims focused on novelty, modernity, and use in a variety of contexts, including urban contexts, workplaces, transportation, and leisure activities. Of the 122 unique advertisements, ZYN's most common claims were to be "tobacco-free," featuring many flavors or varieties, and modern. Velo was the only brand to include urban contexts (n=14, 38.9% of advertisements) or freedom (n=8, 22.2%); Velo advertisements portrayed use in the workplace (n=15, 41.7%), bars or clubs (n=5, 13.9%), leisure activities (n=4, 11.1%), transportation (n=4, 11.1%), sports (n=3, 8.3%), cooking (n=2, 5.6%), and with alcohol (n=1, 2.8%). Velo and ZYN also included most of the images of people, including women and people of color. The 36 Velo ads included people in advertising in 77.8% (n=28) of advertisements, and of those advertisements with identifiable people, 40% (n=4) were young adults and 50% (n=5) were middle-aged. About one-third (n=11, 35.5%) of the 31 unique ZYN advertisements included people, and most identifiable models appeared to be young adults. Brands such as Rogue, Revel, Dryft, and on! focused mainly on product features. All nicotine pouch products made either tobacco-free, smoke-free, spit-free, or vape-free claims. The most common claim overall was "tobacco-free," found in advertisements from Rogue (1/1, 100%), ZYN (30/31, 96.8%), Velo (19/36, 52.8%), and Dryft (1/3, 33.3%), but not Revel. CONCLUSIONS: Nicotine pouches and lozenges may expand the nicotine market as tobacco-free claims alleviate concerns about health harms and advertising features a greater diversity of people and contexts than typical smokeless tobacco advertising. The market leaders and highest-spending brands, ZYN and Velo, included more lifestyle claims. Surveillance of nicotine pouch marketing and uptake, including influence on tobacco use behaviors, is necessary.

Nicotine pouch product awareness, interest and ever use among US adults who smoke, 2021.

BACKGROUND: Tobacco-free nicotine pouches are one of the fastest growing tobacco product categories in the US market. However, data on awareness, appeal or ever use of these products in the USA are limited. METHODS: We surveyed a population-based sample of US adults who smoked (n=1018) between January and February 2021 about awareness, ever use of or interest in nicotine pouches. Multivariable logistic regression models explored the relationship between nicotine pouch variables and demographic and tobacco use characteristics. RESULTS: In early 2021, 29.2% of adults who smoked had ever seen or heard of nicotine pouches, 5.6% had ever tried pouches and 16.8% reported interest in using pouches in the next 6 months. Adults who smoked aged 18-44 years and those who had ever used smokeless tobacco (SLT) were more likely to be aware of nicotine pouches. Interest in using nicotine pouches was more prevalent among adult smokers who planned to quit within 6 months, attempted to quit before using counselling or another tobacco product and had ever used pouches. Among adults who smoked, those with more education had lower odds of ever using nicotine pouches while those who had attempted to quit before using traditional methods or ever used SLT had higher odds of ever use. CONCLUSION: Levels of awareness, appeal and trial of nicotine pouches among US adults who smoke were modest, with variation by age, education, quit plans and quit attempt methods. Continued surveillance is warranted, including among naïve users and users of other tobacco and nicotine products.

Neighborhood distribution of availability of newer tobacco products: A US four-site study, 2021.

Audits of tobacco retailers can identify marketing patterns as newer tobacco products are introduced in the US. Our study examined store and neighborhood correlates of availability of nicotine pouches and disposable e-cigarettes in four US sites. We conducted standardized store audits of n = 242 tobacco retailers in 2021 in different states: New Jersey, Kentucky, North Carolina, and New York. We geocoded stores linking them with census tract demographics. We conducted unadjusted and adjusted Poisson regression of availability of each product with correlates of the proportion of Non-Hispanic White residents, households under poverty, proximity to schools, site, and store type. Nicotine pouches and disposable e-cigarettes were each available in around half the stores overall, but availability differed across sites (range: 76 %-32 %). In adjusted analyses, nicotine pouches were less likely to be available in each store type vs chain convenience (IRR range 0.2-0.6) and more likely in stores in census tracts with a greater percentage of non-Hispanic White residents (IRR range 1.8-2.3). In contrast, disposable e-cigarettes were more likely to be available in tobacco/vape shops (IRR 1.9 (1.4-2.5) than convenience stores and less likely in non-specialty store types like groceries (IRR 0.2 (0.1-0.4). Newer tobacco products like nicotine pouches and disposable e-cigarettes were widely available in stores across sites, but retail marketing patterns appear to differ. As these product types become subject to increased regulation as they go through the FDA pre-market authorization process, understanding patterns and changes in the retail environment is critical to inform potential policies regulating their sale and marketing.

A Pilot Study to Examine Retailer Compliance Before and After Tobacco 21 in New Jersey.

Despite rapid diffusion of Tobacco 21 (T21) laws in the last several years, research examining T21 compliance remains limited. This pilot study examined retailer compliance with carding before and after T21 as well as sales violations after T21 in New Jersey. A 19-year-old buyer made alternating cigar and cigarette purchase attempts in 15 licensed tobacco retailers weekly for five weeks before and 10 weeks following the T21 effective date for a total of 222 visits. We analyzed carding pre and post T21 and sales violations post T21, by store and product type. Failure to card declined post T21 (81.3% to 69.4%), particularly for cigarettes, but not cigars. Overall, 63.3% of retailers sold tobacco to the underage buyer post T21. Following New Jersey's T21 law, compliance with carding improved, but underage sales persisted. Future research examining T21 compliance should consider using a familiarity protocol to mimic real word conditions.

Retailer Compliance With Tobacco 21 in New Jersey, 2019-2020.

This cross-sectional study assesses retailer compliance with the Tobacco 21 law in New Jersey during 2019 and 2020.

A Pilot Feasibility Study of an Online Youth Tobacco Survey Administration among High School Students.

The COVID-19 pandemic restrictions forced many schools to shift to remote or hybrid learning, disrupting surveillance systems such as the New Jersey Youth Tobacco Survey, traditionally administered in schools by paper and pencil. In spring 2021, we conducted a feasibility study among a convenience sample of six public high schools to assess the use of an online survey to allow for remote participation. In each school, 4 to 6 classes were selected randomly, and all students within a sampled class were selected to participate in the survey. A total of 702 students completed surveys. School contacts were asked to provide qualitative feedback about the survey administration. Feedback was generally positive, with a few suggestions for improvement. Approximately 19% of students reported the ever use of e-cigarettes. Among current e-cigarette users, there was a shift in popularity from prefilled or refillable pods or cartridges (23.3%) to disposable e-cigarettes (53.5%). Less than 10% of current e-cigarette users reported using tobacco-flavored e-cigarettes, despite a statewide flavor ban on all other flavors.

Communication Between US Physicians and Patients Regarding Electronic Cigarette Use.

Importance: Physicians play a primary role in patient smoking cessation, yet their communication regarding e-cigarettes is not well understood. Objective: To assess physician-patient communication regarding e-cigarettes. Design, Setting, and Participants: A national cross-sectional survey in 2018 and 2019 was conducted. Participants were invited by mail; surveys were completed online. Respondents were 2058 board-certified physicians from family medicine, internal medicine, obstetrics and gynecology, cardiology, pulmonary, and oncology. Data were analyzed from August to September 2021. Exposures: Physician demographic characteristics, tobacco use, medical specialty, and harm-reduction beliefs (ie, not all tobacco products are equally harmful) applied within 2 hypothetical clinical scenarios. Main Outcomes and Measures: Physicians' self-reported e-cigarette communication (being asked about e-cigarettes by patients and recommending e-cigarettes to patients) and hypothetical e-cigarette communication in 2 clinical scenarios. Results: Among 2058 physicians, the mean (SD) age was 51.6 (10.5) years, and 1173 (58.5%) were male. More than 60% of physicians believed all tobacco products to be equally harmful. Overall, 69.8% of physicians reported ever being asked about e-cigarettes by their patients (35.9% in the past 30 days), and 21.7% reported ever recommending e-cigarettes to a patient (9.8% in the past 30 days). Pulmonologists (adjusted odds ratio [aOR], 2.14, 95% CI, 1.10-4.16) and cardiologists (aOR, 2.04; 95% CI, 1.03-4.05), as well as physicians who implemented the US Public Health Service Clinical Practice Guidelines (aOR, 1.77; 95% CI, 1.12-2.80), had greater odds of recommending e-cigarettes to patients. Physicians who endorsed a harm-reduction perspective (aOR, 3.04, 95% CI, 2.15-4.31) and had ever smoked cigarettes (aOR, 1.98; 95% CI, 1.27-3.08) were significantly more likely to recommend e-cigarettes. Physicians who reported being asked about e-cigarettes had greater odds of recommending e-cigarettes (aOR, 16.60; 95% CI, 10.33-26.68). In clinical scenarios, physicians were overall more likely to recommend e-cigarettes for cessation to an older heavy smoker with multiple unsuccessful quit attempts (49.3%; 95% CI, 47.1%-51.4%) than a younger light smoker with no prior cessation treatments (15.2%; 95% CI, 13.6%-16.7%) (P < .001). Conclusions and Relevance: In this survey study of physicians, findings suggest that physicians may recommend switching to e-cigarettes for some patients who smoke cigarettes under certain circumstances, presumably for cessation. The belief that all tobacco products are equally harmful was associated with lower rates of recommending e-cigarettes. As the evidence base grows for e-cigarette efficacy for smoking cessation, there is need for physician education regarding e-cigarette efficacy.

The importance of cigarillo product characteristics among young adult cigarillo users: Differences by demographics, cigarillo use and other tobacco/substance use behaviors.

INTRODUCTION: Cigar products, including cigarillos, have increased in popularity in the U.S. and are disproportionately used by young adults. Cigarillo product characteristics can influence consumer perceptions and the appeal of these characteristics can vary by subgroup. The goal of this study was to examine a) product characteristics important to young adult cigarillo users and b) differences based on demographics and cigarillo and other tobacco/substance use behaviors. METHODS: In 2016, a convenience sample of 628 past-year cigarillo users rated the importance of the following cigarillo product characteristics when choosing a cigarillo to smoke tobacco: brand, tobacco filler quality, tobacco wrap quality, flavors, price, package graphic design, and number of cigars in the pack. Differences in mean importance by demographic, cigarillo use and other tobacco/substance use characteristics were analyzed using t-tests and ANOVA tests. RESULTS: The most important cigarillo product characteristics were price, quality of tobacco wrap, and flavors. The least important was graphic design of packaging. There were differences in importance by demographics and/or cigar and other tobacco/substance use behaviors for all product characteristics. In particular, pack size was rated as more important among current cigarillo users, users of foil pouches (2-3 cigarillos) or cardboard/paper boxes or other packaging styles, and current users of cigarettes, blunts and marijuana. Price was rated as more important among Hispanic/Latino and lower income smokers, and current cigarette and blunt smokers. CONCLUSIONS: Findings suggest cigarillo users prioritize different product characteristics depending on their demographics or smoking behavior. Further research is needed to examine whether various cigar-related policies, such as those that ban flavors or set minimum pack sizes, could impact sub-populations of cigarillo users differently.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study.

INTRODUCTION: Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time. METHODS: This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves. RESULTS: Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age. CONCLUSIONS: Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Can States Continue to Set the Agenda for Tobacco 21? Insights From US News Coverage Between 2012 and 2020.

INTRODUCTION: Existing research on media examining the news content related to Tobacco 21 (T21) predate the adoption of most T21 laws. This study examined the discussion of T21 laws in top-circulating print media sources in the United States between 2012 and 2020. AIMS AND METHODS: Systematic database searches using Access World News and Factiva identified T21-related news articles appearing in the top daily circulating newspapers in each state between January 2012 and December 2020 (n = 586 articles). Content analyses documented prevalence, types of articles and context related to framing of arguments for or against T21 laws. RESULTS: Newspaper coverage of T21 was highest in 2019 (42.8% of articles). The majority were news or features (75.4%) followed by editorials or opinions (24.6%) which largely supported T21. Most articles focused on state or local T21 action. Coverage of federal T21 increased in 2019. The most common argument supporting T21 included reducing youth tobacco prevalence (64.8%) while the most frequent objection was freedom infringement (25.1%). Tobacco and vape industries began voicing support for T21 in 2019. CONCLUSIONS: News coverage of state-level T21 in the United States began to increase in 2015 and peaked in 2019 with enactment of federal T21, a newsworthy event. As states adopt and amend T21 laws to align with federal law, advocates can use media to help shape the narrative and encourage strong T21 policies. IMPLICATIONS: This study described the volume and content of T21 print media coverage from 2012 to 2020, including common arguments used to support and oppose T21. Arguments in support of T21 included reducing youth tobacco use, particularly use of e-cigarettes, and related health effects while arguments against T21 focused on individual rights. Support for T21 reached a tipping point in 2019, including the tobacco industry's reversal in opposing such laws. States can and should continue to improve existing T21 laws and policies and increase public awareness about critical policy components such as inspection procedures and penalties.