Evaluating the Role of Nicotine Stereoisomer on Nicotine Pouch Abuse Liability: A Randomized Crossover Trial.

INTRODUCTION: Many oral nicotine pouch (ONP) brands use synthetic nicotine, which typically contains a racemic (50:50) mixture of nicotine's two stereoisomers: S-nicotine and R-nicotine. Because tobacco-derived nicotine contains more than 99% S-nicotine, the effects of R-nicotine in humans are not well known. We compared systemic nicotine exposure and product appeal of ONPs containing more than 99% S-nicotine versus racemic nicotine. AIMS AND METHODS: N = 18 adult smokers (Mage = 45 years, 66.7% male, 77.8% White) enrolled in a three-visit single-blind, randomized crossover study. During each visit, participants used one wintergreen-flavored, 3 mg nicotine ONP for 30 min following at least12 h nicotine abstinence. Study ONP #1 contained more than 99% S-nicotine and the other two study ONPs contained racemic nicotine (collapsed for analyses). Plasma nicotine assessments and measures of withdrawal relief occurred at t = 0, 5, 15, 30, 60, and 90 min; measures of product appeal were assessed following ONP use. RESULTS: Using the ONP with more than 99% S-nicotine resulted in greater plasma nicotine concentration from 15 to 90 min (p < .0001) and greater maximum plasma nicotine concentration than the ONPs with racemic nicotine (M = 9.9 ng/mL [SD = 2.5] vs. M = 5.7 ng/mL [SD = 2.8], respectively; p < .0001). Product liking and withdrawal relief were similar across ONPs, although participants reported more "bad effects" when using the ONP with more than 99% S-nicotine. CONCLUSIONS: Participants reported few subjective differences in ONPs according to nicotine stereoisomer, but plasma nicotine concentration was greater for ONPs using more than 99% S-nicotine. ONPs with more than 99% S-nicotine (vs. racemic nicotine) might be better substitutes for cigarettes, but research into other ONP characteristics (eg flavors, freebase nicotine) is needed to inform regulation. IMPLICATIONS: Little is known about the effects of racemic (vs. S-) nicotine in humans. In a sample of adults who smoke cigarettes, we identified that oral nicotine pouches containing racemic nicotine exposed participants to less nicotine than oral nicotine pouches containing only S-nicotine, but both types of oral nicotine pouches held similar, moderate appeal. Additional research evaluating the roles that flavorings, total nicotine concentration, and freebase nicotine play in the abuse liability of oral nicotine pouches would inform comprehensive product regulations to support public health.

An observational human laboratory assessment of nicotine delivery, vaping topography and subjective effects of usual brand electronic cigarette use among young adults.

AIMS: To measure nicotine delivery, vaping topography and subjective effects of current generations of disposable, cartridge-based and other types of electronic cigarettes (e-cigarettes) among young adults. DESIGN, SETTING, PARTICIPANTS: Observational, human laboratory assessment of e-cigarette use in Columbus, Ohio, USA (July 2020 to June 2021). Participants (n = 96, 60.4% female, age mean = 21.7 [standard deviation = 1.7] years, 82.4% white race) were identified via their participation in a cohort study or other convenience sampling and were 18 to 25 years old, vaped ≥4 days/week for ≥4 weeks and used other tobacco products for ≤5 days of past 30 days. Participants completed a pre-vaping questionnaire, vaped their usual brand of e-cigarette ad libitum for 30 min and completed a post-vaping questionnaire. MEASUREMENTS: Outcome variables included pre- and post-vaping measures of plasma nicotine (t = 0 and t = 30, respectively) and craving and withdrawal symptoms, as well as vaping topography (e.g. flow rate and inter-puff interval), pre-vaping expectancies and post-vaping product appeal. Variables used to characterize the sample included demographics, e-cigarette and other tobacco use history, e-cigarette dependence and e-cigarette device characteristics (e.g. device type, flavor and nicotine form). FINDINGS: Participants reported moderate nicotine dependence on average via the E-Cigarette Dependence Scale (mean = 6.9 [standard deviation = 4.0]). Following 30 min of ad libitum vaping, participants achieved substantial plasma nicotine boost (mean = 18.8 [standard deviation = 14.5] ng/mL), corresponding with statistically significant decreases in withdrawal symptoms measured via the Minnesota Nicotine Withdrawal Scale (pre-vaping mean = 9.0 [standard deviation = 5.1], post-vaping mean = 4.3 [standard deviation = 3.9]; P-value <0.0001). Pre-vaping, participants reported moderate vaping expectancies (e.g. mean = 2.5 [standard deviation = 1.0] on a scale from 0 to 4 for smell and taste expectancies); post-vaping, participants reported high satisfaction (mean = 4.6 [standard deviation = 1.2] on a scale from 1 to 7) and moderate reward (mean = 2.9 [standard deviation = 1.2]) and respiratory sensations (mean = 3.7 [standard deviation = 1.6]). Nearly half of participants (47.9%) used disposable e-cigarettes, and most used a mint/menthol or fruit flavored (99.0%) and nicotine salt (98.9%) e-liquid. CONCLUSIONS: Among young adults in the United States, the latest generations of e-cigarettes appear to deliver large quantities of nicotine (similar to cigarettes) and significantly relieve withdrawal symptoms, and they are appealing.

Evaluating the effects of nicotine concentration on the appeal and nicotine delivery of oral nicotine pouches among rural and Appalachian adults who smoke cigarettes: A randomized cross-over study.

BACKGROUND AND AIMS: Oral nicotine pouches (ONPs) probably offer reduced harm compared with cigarettes, but independent data concerning their misuse liability are lacking. We compared nicotine delivery and craving relief from ONPs with different nicotine concentrations to cigarettes. DESIGN: This was a single-blind, three-visit (≥ 48-hour washout), randomized-cross-over study. Participants were encouraged to complete all study visits in less than 1 month. SETTING: The study took place in Rural/Appalachian Ohio. PARTICIPANTS: Participants comprised 30 adults who smoke cigarettes. Participants (meanage = 34.5) were 60% men and 90% White. INTERVENTION: Participants who were ≥ 12-hour tobacco-abstinent used: (1) a 3-mg nicotine concentration ONP, (2) a 6-mg nicotine concentration ONP and (3) usual brand cigarette in separate visits. ONPs (wintergreen Zyn) were used for 30 minutes; cigarettes were puffed every 30 sec for 5 minutes. MEASUREMENTS: Plasma nicotine and self-reported craving were assessed at t = 0, 5, 15, 30, 60 and 90 minutes. The primary outcome was plasma nicotine concentration at t = 30 minutes. A secondary outcome was craving relief at t = 5 minutes. FINDINGS: At t = 30, mean [95% confidence interval (CI)] plasma nicotine was 9.5 ng/ml (95% CI = 7.1, 11.9 ng/ml) for the 3 mg nicotine ONP, 17.5 ng/ml (95% CI = 13.7, 21.3) for the 6 mg nicotine ONP and 11.4 ng/ml (95% CI = 9.2, 13.6 ng/ml) for the cigarette. Mean plasma nicotine at t = 30 minutes differed between the 3- and 6-mg nicotine ONPs (P = 0.001) and between the 6-mg nicotine ONP and cigarette (P = 0.002). Mean (95% CI) craving at t = 5 minutes was lower for the cigarette (mean = 1.00, 95% CI = 0.61, 1.39) than either the 3 mg (mean = 2.25, 95% CI = 1.68, 2.82; P < 0.0001) or 6 mg nicotine (mean = 2.19, 95% CI = 1.60, 2.79; P < 0.0001) ONP. CONCLUSIONS: Among adult smokers, using 6-mg nicotine concentration oral nicotine pouches (ONPs) was associated with greater plasma nicotine delivery at 30 minutes than 3-mg ONPs or cigarettes, but neither ONP relieved craving symptoms at 5 minutes as strongly as a cigarette. Accelerating the speed of nicotine delivery in ONPs might increase their misuse liability relative to cigarettes.

Perceptions of oral nicotine pouches & their marketing among Ohio Appalachia smokers and smokeless tobacco users.

BACKGROUND: Oral nicotine pouches (ONPs) are novel products, gaining popularity and marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (SLT), but their public health impact is unknown. This study qualitatively examined ONP appeal and perceptions among cigarette smokers and SLT users from Ohio Appalachia. METHODS: In 2022, we conducted 10 virtual focus groups with smokers (n = 19) and smokeless tobacco users (n = 18) from Appalachia Ohio aged ≥21 to examine perceptions of risks and benefits, substitutability for cigarettes and SLT, and ONP marketing. We transcribed focus groups verbatim, thematically coded transcripts, and analyzed coded data for prominent themes. RESULTS: Participants perceived ONPs to have similar or less risk than cigarettes/SLT but prominently discussed gastrointestinal and cardiovascular risks. Addiction risk was thought to be comparable to cigarettes/SLT, citing "nicotine is nicotine." Participants viewed ONPs to be situational rather than complete substitutes for cigarettes/SLT, viewing them as "cleaner," more socially acceptable, and discrete. Despite appealing features of ONP marketing, participants surmised ads would appeal to youth, new users, tobacco users seeking to cut down/quit, or to "high class," "white-collar" demographics. CONCLUSIONS: Participants' perceptions of ONPs and their marketing suggest ONPs are more likely to be used as situational versus complete substitutes for cigarettes and SLT. While situational substitution could exacerbate disparities in Appalachia by facilitating more frequent tobacco/nicotine use, complete substitution could reduce disparities. Research is needed to understand how perceptions, the appeal of ONP marketing, and novel product features translate to patterns of use to understand ONPs' potential impact.

Sexual orientation and gender identity differences in perceptions and product appeal in response to e-cigarette advertising.

INTRODUCTION: E-cigarette use is disparately high among sexual minoritized populations. As e-cigarette advertising may influence product appeal, this study tested sexual orientation- and gender-based differences in response to e-cigarette advertisement exposure on advertisement perceptions and product appeal. METHODS: We recruited 497 adults (mean age=31.9 years, 45.1% women, 54.3% heterosexual, 71.2% Non-Hispanic White) living in the United States via the crowdsourcing platform Prolific. Participants viewed two randomly selected e-cigarette advertisements (from n=173 advertisements). Post-exposure, participants rated the perceived advertisement effectiveness, relevance, and product use intention. Associations between sexual orientation and outcomes were estimated using multivariable linear mixed-effects models. We tested interaction effects between sexual orientation, gender, and advertisement feature (e.g. presence of humans, flavors, and product packaging), and ran Tukey post hoc tests for pairwise comparisons. RESULTS: Post-exposure, heterosexual women, sexual minoritized men, and sexual minoritized women (reference group: heterosexual men) rated perceived advertisement effectiveness and relevance lower after viewing advertisements featuring flavors (vs no flavors; all p<0.001). Sexual minoritized men and sexual minoritized women rated perceived advertisement relevance lower after viewing advertisements featuring humans (all p<0.001) or fruit (all p<0.001). Heterosexual women, sexual minoritized men, and sexual minoritized women reported lower product use intention after viewing advertisements featuring an e-liquid bottle (vs no e-liquid bottle; all p<0.05). CONCLUSIONS: Sexual minoritized women and men reported lower e-cigarette advertisement appeal and product use intentions than heterosexual men. More evidence is needed to understand advertisement perceptions and product appeal in this group to inform e-cigarette advertising regulations and anti-tobacco messaging campaigns that aim to reduce tobacco-related health inequities.

Untargeted Metabolomics and Body Mass in Adolescents: A Cross-Sectional and Longitudinal Analysis.

Obesity in children and adolescents has increased globally. Increased body mass index (BMI) during adolescence carries significant long-term adverse health outcomes, including chronic diseases such as cardiovascular disease, stroke, diabetes, and cancer. Little is known about the metabolic consequences of changes in BMI in adolescents outside of typical clinical parameters. Here, we used untargeted metabolomics to assess changing BMI in male adolescents. Untargeted metabolomic profiling was performed on urine samples from 360 adolescents using UPLC-QTOF-MS. The study includes a baseline of 235 subjects in a discovery set and 125 subjects in a validation set. Of them, a follow-up of 81 subjects (1 year later) as a replication set was studied. Linear regression analysis models were used to estimate the associations of metabolic features with BMI z-score in the discovery and validation sets, after adjusting for age, race, and total energy intake (kcal) at false-discovery-rate correction (FDR) ≤ 0.1. We identified 221 and 16 significant metabolic features in the discovery and in the validation set, respectively. The metabolites associated with BMI z-score in validation sets are glycylproline, citrulline, 4-vinylsyringol, 3'-sialyllactose, estrone sulfate, carnosine, formiminoglutamic acid, 4-hydroxyproline, hydroxyprolyl-asparagine, 2-hexenoylcarnitine, L-glutamine, inosine, N-(2-Hydroxyphenyl) acetamide glucuronide, and galactosylhydroxylysine. Of those 16 features, 9 significant metabolic features were associated with a positive change in BMI in the replication set 1 year later. Histidine and arginine metabolism were the most affected metabolic pathways. Our findings suggest that obesity and its metabolic outcomes in the urine metabolome of children are linked to altered amino acids, lipid, and carbohydrate metabolism. These identified metabolites may serve as biomarkers and aid in the investigation of obesity's underlying pathological mechanisms. Whether these features are associated with the development of obesity, or a consequence of changing BMI, requires further study.

Awareness of alcohol as a breast cancer risk factor and intentions to reduce alcohol consumption among U.S. young adult women.

Alcohol consumption is prevalent in young adult women and linked with breast cancer risk. Research to inform interventions targeting alcohol consumption as a breast cancer prevention strategy is limited. We examined young women's awareness of alcohol use as a breast cancer risk factor, identified correlates of awareness, and determined how awareness and conceptual predictors relate to intentions to reduce drinking. Women aged 18-25 years who drank alcohol in the past month (N = 493) completed a cross-sectional survey. Measures captured sociodemographics, breast cancer risk factors, awareness of alcohol use as a breast cancer risk factor, intentions to reduce drinking, and conceptual predictors. Analyses examined correlates of awareness and associations between awareness, conceptual predictors, and intentions to reduce drinking. Awareness was low (28%) and intentions to reduce drinking were moderate (M = 2.60, SD = 0.73, range 1-4). In multivariable analyses, awareness was associated with greater worry about cancer, beliefs that there's not much one can do to reduce cancer risk and everything causes cancer, higher perceived breast cancer risk, and stronger beliefs that reducing drinking reduces breast cancer risk. Awareness was not associated with intentions to reduce drinking. Younger age, older age of alcohol initiation, negative attitudes towards alcohol, fewer friends consuming alcohol, and stronger self-efficacy were associated with intentions to reduce drinking. Few young women recognize alcohol consumption as a breast cancer risk factor. Researchers and policymakers can apply our findings to design new or refine existing interventions to optimize their impact on awareness and alcohol consumption in young women.

Alcohol use is common among young adult women and is linked to an increased risk of breast cancer later in life. This study aimed to identify factors linked to young women's awareness of alcohol as a breast cancer risk factor and factors linked to intentions to reduce drinking. We surveyed 493 women aged 18­25 who resided in Ohio and reported drinking alcohol in the past month. Only 28% of the women were aware that alcohol use increases breast cancer risk, and intentions to reduce drinking were moderate. Factors associated with awareness of alcohol use as a breast cancer risk factor included cancer worry, believing there's not much you can do to lower your risk of cancer, believing everything causes cancer, higher perceived risk of breast cancer, and stronger beliefs that drinking less reduces breast cancer risk. Factors linked to intentions to reduce drinking included younger age, older age at first drinking, more negative attitudes about alcohol, believing fewer friends drink, and higher confidence to reduce drinking. The findings can help researchers and policymakers create new interventions to educate young women about the link between alcohol consumption and breast cancer risk and reduce alcohol use as a breast cancer prevention strategy.

Absolute and relative e-cigarette harm perceptions among young adult lesbian and bisexual women and nonbinary people assigned female at birth.

PURPOSE: Young adult lesbian and bisexual women report considerable e-cigarette disparities, which may be attributed to low harm perceptions. No studies have assessed differences in e-cigarette harm perceptions in this group, nor which factors might be intervention targets to influence harm perceptions. MATERIALS AND METHODS: We investigated differences in and modifiable correlates of e-cigarette harm perceptions among young adult lesbian and bisexual women and non-binary people assigned female at birth. Young adult women and non-binary people assigned female at birth, aged 18-30 years old, and who self-identified as lesbian or bisexual (N = 471) reported absolute and relative harm perceptions of e-cigarettes to health in an online survey. We modeled associations between harm perceptions and individual, interpersonal, and contextual factors. RESULTS: Bisexual (vs. lesbian) participants perceived higher absolute harm of e-cigarettes (Mean (M) = 7.61 vs M = 7.09, p = .03). Participants rated e-cigarettes as slightly less harmful than cigarettes, and there was no statistically significant difference by sexual orientation (Bisexual: M = 4.84 vs Lesbian: M = 4.36). In multivariable models, bisexual (vs. lesbian) participants and Hispanic/Latinx and Other race (vs. non-Hispanic White) participants reported higher absolute and relative e-cigarette harm perceptions. Greater sexual identify affirmation and greater perceived stress were associated with higher absolute and relative e-cigarette harm perceptions. CONCLUSIONS: E-cigarette harm perceptions vary vis-à-vis individual-level factors. Self-identification as bisexual or minoritized race/ethnicity, greater sexual identity affirmation, and greater perceived stress was associated with increased harm perceptions. Understanding variations may inform targeted health communications to reduce e-cigarette use disparities.

Effects of "Tobacco Free" Language in Warning Labels on Perceptions of Electronic Cigarettes and Nicotine Pouches among Young Adult Men: A Randomized Trial.

Background: Manufacturers of Puff Bar electronic cigarettes (e-cigarettes) and Fre nicotine pouches claim that their products contain synthetic nicotine. The packages for Puff Bar and Fre have modified versions of the warning labels required by the Food and Drug Administration (FDA) for tobacco products, which specify that Puff Bar and Fre products contain "tobacco free" or "non-tobacco" nicotine, respectively. We evaluated whether exposure to these "tobacco free" warning labels was associated with differing perceptions about the products. Method: N = 239 young adult men who were enrolled in a cohort study completed a short online experiment. Participants were randomly assigned to view either packages of Puff Bar and Fre nicotine pouches with the standard FDA warning or packages with the standard FDA warning + the tobacco free descriptor. We compared harm and addictiveness perceptions and products' perceived substitutability for cigarettes and smokeless tobacco (SLT) by exposure to a "tobacco free" warning. Results: Viewing a Puff Bar package with a "tobacco free" warning label was associated with increased perceived substitutability of the product for cigarettes and smokeless tobacco (p's<.05). Viewing a Fre package with a "non-tobacco" warning label was associated with thinking the product was less harmful than SLT (p<.01). Conclusions: "Tobacco free" descriptors in warning labels for e-cigarettes and nicotine pouches affect young adults' perceptions of the products. To date, it is unclear whether the FDA will continue to permit "tobacco free" descriptors in warning labels. As e-cigarettes and nicotine pouches are increasingly marketed with "tobacco free" language, urgent action is needed.

E-Cigarette Use among Sexual Minoritized Women and Nonbinary People Assigned Female at Birth: Assessing the Roles of Discrimination, Perceived Stress, and Social Support.

Background: Young adult sexual minoritized women (SMW) are at disproportionate risk for e-cigarette use, which may in part be due to excess minority stress imposed by discrimination exposure. While discrimination exposure is associated with risk for combustible tobacco/nicotine use among SMW, similar associations have yet to be tested with e-cigarettes. Moreover, it is unknown if discrimination-related risk may be mitigated by protective factors such as social support. This study examined concurrent associations of discrimination, perceived stress, and social support with past 30-day e-cigarette use in a sample of young adult SMW during the COVID-19 pandemic. Methods: N = 501 SMW and nonbinary people assigned female at birth (AFAB) aged 18-30 completed an online survey. A series of logistic regressions examined associations of discrimination, perceived stress, and four forms of social support received during the COVID-19 pandemic with past-30-day e-cigarette use. Results: Among SMW, greater perceived stress (OR = 1.10, p = .03), but not discrimination exposure, was associated with e-cigarette use. Associations of discrimination with e-cigarette use were nonsignificant when most forms of social support (emotional, material/financial, and virtual) were accounted for. Associations of perceived stress with e-cigarette use were strongest among those who needed but did not receive material support. Conclusions: Perceived stress, but not discrimination exposure, was associated with risk for e-cigarette use among young SMW during the COVID-19 pandemic. Effects of nonspecific stress may be compounded by insufficient material/financial support.

Associations of Perceived Stress and Social Support on Health Behavior Changes in Sexual Minoritized Women During the COVID-19 Pandemic.

Purpose: We examined how perceived stress and social support were associated with changes in health behaviors during the COVID-19 pandemic among sexual minoritized women (SMW). Methods: In an online convenience sample of SMW (N = 501, M age = 23.6), we used multinomial logistic regression models to estimate associations of perceived stress and social support (emotional, material, virtual, in-person) with self-reported changes (increased or decreased vs. no change) in fruit and vegetable intake, physical activity, sleep, tobacco, alcohol, and substance use during the pandemic. We also tested whether social support modified associations between perceived stress and changes in health behaviors. Models controlled for sexual orientation, age, race and ethnicity, and income. Results: Perceived stress and social support were associated with changes in health and risk behaviors. Specifically, increased perceived stress was associated with decrease (odds ratio [OR] = 1.20, p = 0.01) and increase (OR = 1.12, p = 0.04) in fruit and vegetable intake, and increase in substance use (OR = 1.19, p = 0.04). Receiving in-person social support was associated with changes in decrease (OR = 10.10, p < 0.001) and increase (OR = 7.35, p < 0.01) in combustible tobacco use and increase in alcohol use (OR = 2.63, p = 0.01). Among SMW who never received material social support during the pandemic, increased perceived stress was associated with increased alcohol use (OR = 1.25, p < 0.01). Conclusions: Perceived stress and social support were associated with SMW's health behavior changes during the pandemic. Future research may explore interventions to mitigate the effects of perceived stress and appropriately increase social support to promote health equity among SMW.

Correlates of motivation to quit waterpipe tobacco smoking among US young adults: implications for cessation interventions.

Waterpipe tobacco smoking is a public health concern that poses many of the same health risks as cigarette smoking, especially among young adults-a subpopulation characterized by the highest prevalence of waterpipe tobacco smoking. Nevertheless, it remains understudied relative to other forms of tobacco use. We examined sociodemographic, behavioral and cognitive factors associated with young adults' motivation to quit waterpipe smoking using a theory-informed approach. We completed a secondary analysis of baseline data on waterpipe tobacco smoking beliefs and behavior collected from 349 US young adults aged 18-30 years. We analyzed sociodemographics, tobacco use and cessation behaviors and perceptions, and theory-related constructs associated with motivation to quit waterpipe tobacco smoking using linear regression. Overall, participants reported low motivation (mean = 2.68, SD = 1.56, scale range 1-7) and high self-efficacy (mean = 5.12, SD = 1.79) to quit waterpipe tobacco smoking. In multivariable analysis, prior quit attempts (ß = 1.10, P < 0.01), greater perceived risks of waterpipe tobacco smoking (ß = 0.42, P < 0.01) and increasingly negative attitudes toward waterpipe tobacco smoking (ß = 0.29, P < 0.01) were associated with higher motivation to quit. These findings highlight the importance of those factors as potential cessation determinants. These findings can help guide the development and refinement of interventions targeting young adult waterpipe tobacco smoking.

Associations between observed neighborhood physical disorder and health behaviors, New Jersey behavioral risk factor Surveillance System 2011-2016.

This study tested associations between observed neighborhood physical disorder and tobacco use, alcohol binging, and sugar-sweetened beverage consumption among a large population-based sample from an urban area of the United States. Individual-level data of this cross-sectional study were from adult respondents of the New Jersey Behavioral Risk Factor Surveillance System, 2011-2016 (n = 62,476). Zip code tabulation area-level observed neighborhood physical disorder were from virtual audits of 23,276 locations. Tobacco use (current cigarette smoking or chewing tobacco, snuff, or snus use), monthly binge drinking occasions (5+/4+ drinks per occasion among males/females), and monthly sugar-sweetened beverages consumed were self-reported. Logistic and negative binomial regression models were used to generate odds ratios, prevalence rate ratios (PRR), 95 % confidence intervals (CI) by levels of physical disorder. Compared to the lowest quartile, residence in the second (PRR: 1.16; 95 % CI: 1.03, 1.13), third (PRR: 1.24; 95 % CI: 1.10, 1.40), and fourth (highest) quartile of physical disorder (PRR: 1.24; 95 % CI: 1.10, 1.40) was associated with higher monthly sugar-sweetened beverage consumption. Associations involving tobacco use and alcohol binging were mixed. Observed neighborhood disorder might be associated with unhealthy behaviors, especially sugar-sweetened beverage consumption.

The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions.

BACKGROUND: Oral nicotine pouches (ONPs) are novel products that are marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (ST). This study examined the effects of ONP packaging features on adult tobacco users' and non-users' product perceptions. MATERIALS AND METHODS: Adult tobacco users (cigarettes, ST, and dual cigarette/ST) and non-users (total N = 301) viewed ONP pack images in a 4 × 3 × 2 between-subject experiment testing the effects of the displayed flavor (cool mint, coffee, dark frost, and smooth), nicotine concentration (none displayed on the package, 3 mg, and 6 mg), and addiction warning label (yes or no). The outcomes were perceived substitutability of ONPs for cigarettes and ST and perceived risks. We modeled the effects of tobacco user status and the experimental factors on these outcomes. RESULTS: All tobacco user groups perceived ONPs to be significantly less harmful and less addictive than non-users. There were significant effects of nicotine concentration on perceived risks. Compared to packages that did not display nicotine concentration, packages displaying 6 mg nicotine concentration produced significantly lower perceived harm (ß = -0.23, 95% CI -0.44, -0.02), perceived addictiveness (ß = -0.28, 95% CI -0.51, -0.05), risk appraisals of harm (ß = -0.50, 95% CI -0.88, -0.12) and risk appraisals of addictiveness (ß = -0.53, 95% CI -0.95, -0.11). CONCLUSIONS: The study findings demonstrate that the nicotine concentration displayed on ONP packaging can affect adults' perceptions of ONPs. Further research on the effects of ONP packaging features emphasizing nicotine (e.g., "tobacco free" nicotine claims) on tobacco users and non-users is needed to assess their potential public health impact.

Tobacco 21's Impact Amid the E-Cigarette Surge.

OBJECTIVES: Nationwide implementation of Tobacco 21 (raising the legal sales age for all tobacco products to 21) is occurring against the backdrop of an electronic cigarette (e-cigarette) epidemic among young people, which makes Tobacco 21 evaluation difficult. To address this issue, we examined young adult use of e-cigarettes separately from use of other tobacco products. Our objective was to determine whether use changed after Tobacco 21 implementation and whether those changes differed by product. METHODS: In Columbus, Ohio, which began enforcing Tobacco 21 in 2017, we surveyed incoming first-year undergraduates at a large, public university in 2016 (Cohort 1; n = 529) and re-contacted them in 2018. We surveyed a new sample of incoming first-year students in 2018 (Cohort 2; n = 611). Survey items assessed tobacco use, sources for obtaining tobacco, and attitudes surrounding Tobacco 21. RESULTS: Both cross-sectional (Cohort 1 vs Cohort 2) and prospective (pre-post Tobacco 21 in Cohort 1) analyses indicated a slight decline in most tobacco use from 2016 to 2018, but e-cigarette use more than doubled during the same period. Students enrolled throughout the transition to Tobacco 21 (Cohort 1) perceived little effect of Tobacco 21 on peer use. The largest proportions (35.3%-43.5%) of combustible tobacco were obtained outside Columbus; 61.8% of e-cigarette users reported obtaining e-cigarettes through borrowing. CONCLUSIONS: Tobacco 21 was associated with reductions in combustible and smokeless tobacco use, but its impact was not sufficient to curb the surge in e-cigarette use. Tobacco 21 should be contextualized as part of a broader network of tobacco control efforts, including additional youth-access regulations, that may be needed to address e-cigarette use among young people.

Adherence to COVID-19 Protective Measures in a Longitudinal Sample of Male Youth.

BACKGROUND: Adherence to COVID-19 protective measures is lowest for young people and males. The current study investigated characteristics associated with adherence to COVID-19 protective measures among male youth during the early months of the pandemic. METHOD: The study used data from a prospective cohort study among male youth with baseline assessment in 2015/2016 and follow-up measurements in 2019 and summer 2020. Attrition-weighted multivariable ordinal logistic and log-binomial regression models were used to assess factors associated with adherence to overall and specific adherence measures, respectively. RESULTS: Among 571 male youth (mean age 18.5), overall adherence was higher for those who were older (OR: 1.15; 95% CI: 1.03-1.30), non-White (OR: 1.96; 95% CI: 1.20-3.32), and residing in an urban area (OR: 2.06; 95% CI: 1.46-3.01). Overall adherence was lower for those who had a history of being drunk (OR: 0.65; 95% CI: 0.42-0.99). For outdoor mask-wearing, adherence was higher for youth with attention-deficit disorder or attention-deficit/hyperactivity disorder (RR: 1.58; 95% CI: 1.16-1.97) and lower for youth who currently used tobacco products (RR: 0.42; 95% CI: 0.21-0.70). Before a statewide mask mandate was issued, non-White youth were more likely to report wearing masks in outdoor spaces than their non-Hispanic White peers (RR: 2.34; 95% CI: 1.75-3.23). CONCLUSION: The study identified demographic, psychosocial, and behavioral factors associated with adherence to COVID-19 protective behaviors among male youth. The findings illustrate characteristics that could be leveraged for targeted preventive efforts during the ongoing pandemic and future outbreaks in a low-compliance group.

How Age and E-cigarette Use Status Interact to Influence E-cigarette Ad Perceptions.

Background: The prevalence of e-cigarette use among young people remains high. Young people are susceptible to e-cigarette advertising, although potential heterogeneity in perceptions of e-cigarette ads with respect to age and e-cigarette use history remains unexplored. We aimed to assess differences in perceptions of e-cigarette ads and product use intention, by age and e-cigarette use status. Methods: Participants from an online convenience sample (N = 497, Mage=31.9) viewed two randomly selected e-cigarette ads and reported their perceptions of the ads and product use intention. We used mixed effects linear regression models to estimate associations between age group (18-20 years, 21-25 years, 26+ years), e-cigarette use status (never, former, and current use), and their interaction effects, on outcomes related to perceptions of ads and use intention. Models controlled for demographics and other tobacco use. Results: Current e-cigarette users (vs. never users) and participants who were 26+ years old (vs. 18-20 years old) had greater liking of the ads, perceived ad relevance, and perceived ad effectiveness. Among current e-cigarette users, participants who were 26+ years old (vs. 18-20 years old) had lower use intention. Conclusion: The effect of e-cigarette ad exposures on perceptions of the ad and use intention is heterogeneous with respect to age group and e-cigarette use history. While ads appealed more to adults who were 26+ years old across e-cigarette use groups, current e-cigarette users who were 18-20 years old demonstrated high use intention following ad exposure, suggesting a need for marketing interventions to mitigate continued e-cigarette use among young people.