Cigarette unit sales volume for brands using 'natural', 'organic' and 'tobacco and water' pack terms in the USA, 2018-2022.

BACKGROUND: Terms such as 'natural', 'organic' and 'tobacco and water' on cigarette packs may communicate misleading reduced harm messages to consumers. This study describes sales volume and price for brands that used these misleading descriptors in the USA by year, brand and state. METHODS: The data come from Information Resources Incorporated sales data collected in 44 US states from January 2018 to January 2023. Trained coders used Universal Product Codes, purchased packs and internet searches to identify cigarettes sold with 'natural', 'organic' and 'tobacco and water' on packs. We report cigarette pack unit sales counts (sales volume) and average price per pack by year, as well as per cent year-over-year change in sales volume and price and annual market share by descriptor terms. RESULTS: Overall, pack sales volume decreased year-over-year from 2019 to 2022. Sales volume for packs with 'natural', 'tobacco and water' and 'organic' decreased less than overall; in some cases, they increased. In 2022, packs with 'natural' accounted for the greatest share of cigarette unit sales (5.42% or 33 605 036 packs), followed by 'tobacco and water' (2.25% or 12 959 905 packs) and 'organic' (0.53% or 4 614 592 packs). Natural American Spirit (NAS) and Winston accounted for most sales with 'natural' and 'tobacco and water'; NAS accounted for nearly all sales with 'organic'. Packs with 'natural', 'tobacco and water' or 'organic' made up the largest portion of sales in western (Oregon, Idaho, California, Colorado and Washington) and northeastern (Vermont, Massachusetts and New Hampshire) US states. CONCLUSION: Brands using 'natural', 'tobacco and water' and 'organic' on packs increased their market share between 2019 and 2022; in some states, market share was over 10% in 2022. Our findings emphasise the importance of regulating these terms and continually monitoring their population impact.

"I Like the Vibes it Gives": Adolescent Perspectives on Cannabis Billboards and Print Advertising in Nevada.

An influx of laws permitting recreational cannabis sales in the US has allowed for increased advertising. The purpose of this study was to describe how adolescents perceive outdoor and print cannabis advertising and to identify aspects of advertising that are appealing or eye-catching, focusing on five themes: price promotion, sex appeal, wellness, party, and text-only. We recruited adolescents ages 11-17 to participate in seven focus groups (44 participants) from 2019 to 2020. Participants viewed cannabis advertisements and responses were summarized using deductive thematic analysis. The party-themed advertisements were the most salient to participants, who desired to emulate the behaviors shown. Participants favored ads featuring young people and containing multiple colors. Participants disliked advertisements perceived to portray misleading or contradictory messages, such as the promotion of physical activity or use of sex appeal, and ads perceived to lack authenticity. Identification of youth appealing features can help inform cannabis advertising regulations.

The Physical Abilities and Mobility Scale as a New Measure of Functional Progress in the PICU.

Assessing functional motor changes and their relationship to discharge needs in the pediatric intensive care unit (PICU) population is difficult given challenges quantifying small functional gains with current tools. Therefore, we compared the Physical Abilities and Mobility Scale (PAMS) to the Functional Status Scale (FSS) in PICU patients to assess correlation and differences and association with discharge needs. This study was a retrospective chart review of all patients (2-18 years old) admitted to the PICU and cardiac PICU for over 9 months who received early mobility services, including PAMS and FSS scoring. Correlation between scales, relationship of scores to disposition, and logistic regression model of changes in PAMS in relation to disposition were determined. Data were obtained for 122 patients. PAMS and FSS scores strongly negatively correlated (Spearman's ρ = - 0.85), but with a nonlinear relationship, as the PAMS more readily differentiated among patients with higher functional status. The median FSS at discharge was 12.5 for those recommended an inpatient rehabilitation facility (IRF) ( n = 24), versus 9 for those recommended discharge home ( n = 83, Δ 3.5, 95% confidence interval [CI]: 1-6, around one-tenth of FSS scale). The corresponding median PAMS were 42 and 66 (Δ 24, 95% CI: 10-30, one-fourth of PAMS scale). Although not statistically significant, a logistic regression model was consistent with patients who showed modest change in PAMS across hospitalization but persistent deficits (PAMS < 60) were more likely to be recommended an IRF. The PAMS correlates to the FSS, but appears more sensitive to small functional changes, especially in higher functioning patients. It may be useful in prognosticating discharge needs.

Determinants of substance use among young people attending primary health centers in India.

Background: Substance use is a complex condition with multidimensional determinants. The present study aims to find the prevalence and determinants of substance use among young people attending primary healthcare centers in India. Methods: A multicentric cross-sectional study was conducted across 15 states in India on 1,630 young people (10-24 years) attending primary health centers. The Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) was used to capture data on substance use. The degree of substance involvement was assessed and multivariate regression analysis was conducted to determine the risk factors of substance use. Results: The prevalence of substance use was 32.8%, with a median substance initiation age of 18 years. Among the substance users, 75.5% began before completing adolescence. Tobacco (26.4%), alcohol (26.1%) and cannabis (9.5%) were commonly consumed. Sociodemographic determinants included higher age, male gender, urban residence, positive family history, northeastern state residence and lower socioeconomic class. Over 80% of users had moderate or high involvement. Conclusions: High substance use prevalence among young people in Indian healthcare centers underscores the urgency of targeted intervention. Insights on determinants guide effective prevention strategies for this complex public health issue.

Increasing lifetime and past 30-day marijuana use among middle school students regardless of recreational marijuana sales.

PURPOSE: This study investigated whether adult use marijuana sales were associated with changes in lifetime and past 30-day (P30D) marijuana use among middle school students in Nevada (NV), which had adult-use marijuana sales during the study period, compared to New Mexico (NM), which did not have adult-use marijuana sales during the study period. METHODS: Data were drawn from the middle school 2017 and 2019 NV Youth Risk Behavior and NM Youth Risk and Resiliency Surveys. Difference-in-difference analyses compare changes in lifetime and P30D marijuana use in NV (adult-use sales implemented July 2017) vs. NM (no adult-use sales during the study period). RESULTS: There was no difference in lifetime (aOR 1.11; 95% CI 0.91,1.36) and P30D (aOR 1.17; 95% CI 0.91,1.51) marijuana use by adult-use sales status. The odds of lifetime and P30D marijuana use increased in both states, particularly among students who were female, older, non-White, or attending a Title 1 school. DISCUSSION: Adult-use sales were not associated with an increase in lifetime or P30D marijuana use. State-level prevention efforts should focus on sub-populations with increasing lifetime and P30D use regardless of adult-use sales status.

Musculoskeletal physiotherapists' experiences of using remote consultations during the COVID-19 pandemic: A qualitative study.

BACKGROUND: The coronavirus (COVID-19) pandemic resulted in the rapid implementation of remote consultations to maintain musculoskeletal physiotherapy services. However, little is known about UK musculoskeletal physiotherapists' experiences of providing services during the COVID-19 pandemic. OBJECTIVES: To explore musculoskeletal physiotherapists' experiences of using remote consultations in one area of England during the COVID-19 pandemic. DESIGN: Qualitative study using hermeneutic phenomenology based on the approach of Gadamer. METHODS: Semi-structured interviews with twelve musculoskeletal physiotherapists were conducted online using Microsoft Teams. Data were analysed using frameworks based on the philosophical concepts of Gadamer's hermeneutics. FINDINGS: Musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic was framed by three concepts: therapeutic relationship, transformational change, and uncertainty. These concepts are underpinned by four main themes capturing their experiences: (1) Disconnection: Difficulties building a rapport and reduced non-verbal communication affected building an effective therapeutic relationship, (2) Necessity: Transformation of services to remote consultations was positive, although technology and connectivity issues had a negative impact, (3) Loss of control: Diagnostic uncertainty, being unprepared, and experience affected physiotherapists' clinical practice, (4) Protection: Peer support and the use of technology facilitated a feeling of protection for physiotherapists. CONCLUSION: The findings of this study contribute to a better understanding of musculoskeletal physiotherapists' experience of using remote consultations during the COVID-19 pandemic. Implications for practice include the need to provide training for all musculoskeletal physiotherapists and undergraduates to enable the effective delivery of remote physiotherapy. Furthermore, digital infrastructure should be optimised to support future delivery of remote musculoskeletal physiotherapy services.

Acute effects of charcoal filters and package color on cigarette perceptions and use behaviors: Results from a randomized pilot study examining Natural American Spirit "Sky".

INTRODUCTION: Charcoal-filtered cigarettes have been available for decades but have never held a major share of the U.S. cigarette market. This pilot study gathered initial behavioral data characterizing how "Sky"-a recently introduced charcoal-filtered cigarette variety that uses potentially misleading marketing features-is used and what impact its packaging color has on consumer perceptions. METHODS: Forty adult daily non-menthol cigarettes users (52.5% male, 75.0% White, mean age = 46.1, 14.3 mean cigarettes/day) completed a single-session deception study utilizing a 2 ×2 mixed factorial design to manipulate cigarette filter condition (charcoal vs. non-charcoal) and pack color (light vs. dark). Participants smoked two cigarettes identical in appearance and packaging but differing in filter type (blinded and order counterbalanced) and completed pre- and post-cigarette CO samples and post-cigarette questionnaires. RESULTS: Participants endorsed more favorable subjective ratings, puffed less of, held more correct beliefs about risks, and expressed greater intentions to use the charcoal (vs. non-charcoal)-filtered cigarette (p's <0.05). Pack color had few effects on outcomes; however, cigarettes in light vs. dark colored packs were rated as cleaner tasting (p <0.01). Neither filter condition nor pack color affected CO boost. There were no interaction effects on any outcomes. CONCLUSIONS: Under blinded conditions, Sky charcoal-filtered cigarettes are initially appealing independent of their packaging color. Findings warrant further study of these effects on perceptions, behavior, and harm exposure after longer, open-label use periods. Findings may inform regulatory decisions regarding cigarette packaging and filter composition.

Organic, Earth-Friendly Tobacco With a Charcoal Filter and Smooth Taste: A Randomized Experiment Testing Effects of Natural American Spirit's "Sky" Cigarette Advertising on Consumer Perceptions.

INTRODUCTION: The Natural American Spirit (NAS) brand has a history of marketing tactics that may convey reduced harm. While no longer allowed to use "additive-free" or natural descriptors (except in the brand name), it continues promoting potentially misleading attributes. This study examined perceptions of NAS's newer "Sky" style, promoted as organic tobacco with a charcoal filter. AIMS AND METHODS: In an online experiment, we randomized 1927 adult past 30-day tobacco or nicotine product users to one of six conditions showing Sky ads with different descriptors: (1) charcoal filter, (2) charcoal + organic, (3) charcoal + earth-friendly, (4) charcoal + smooth taste, (5) charcoal + all other descriptors, and (6) no-descriptor control (Sky ads without target descriptors). Product perceptions were compared by condition. Participants also reported perceived benefits of charcoal filters. RESULTS: Overall, 28% of participants indicated Sky is less harmful and 38% believed it exposes users to fewer chemicals. Participants in the "charcoal + organic," "charcoal + earth-friendly," and the all-descriptor conditions had higher odds of believing Sky reduces chemical exposure (respectively, 43%, 40%, and 42%), relative to the no-descriptor control. Fewer control participants endorsed beliefs that Sky has a "better filter" and is "more environmentally friendly". Many believed cigarettes with charcoal filters could confer benefits relative to other cigarettes, such as reducing chemical exposure, or being cleaner, purer or safer (though research on relative safety of charcoal filters in cigarettes is inconclusive). CONCLUSIONS: Sky marketing may promote misperceptions about product safety and composition, and ads using both charcoal and organic text may particularly reinforce them. IMPLICATIONS: This study examined the impact of new cigarette advertising promoting the use of charcoal filters and organic tobacco along with other suggestive claims ("environmentally friendly," "smooth taste") on tobacco users' perceptions of the advertised product-NAS Sky cigarettes. Our study provides new data about positive consumer perceptions of charcoal-filtered cigarettes, and results suggest that combinations of these marketing terms evoke perceptions about reduced harm and reduced exposure to harmful chemicals that may be misleading to the public. Our findings underscore a need for additional regulatory action regarding tobacco marketing that makes use of natural-themed marketing.

The clinical spectrum of MELAS and associated disorders across ages: a retrospective cohort study.

Objective: Mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) is a severe multisystemic disease, although some have a milder phenotype. We aimed to evaluate the clinical spectrum of this disease from MELAS patients to asymptomatic carriers and identify predictors of severity. Methods: We reviewed 81 patients, who had MELAS or had positive genetics without meeting clinical criteria. Patients who met criteria including lactic acidosis, encephalomyopathy, and stroke-like episodes (SLE) were categorized as MELAS, symptomatic non-MELAS, and asymptomatic. MELAS was further categorized as "standard-onset" if the first stroke-like episode (SLE) occurred before age 40 or "late-onset." Results: Eighty-one patients were included: 42 MELAS (13 late-onset), 30 symptomatic non-MELAS, and 9 asymptomatic. MELAS patients had lower BMI at onset (mean 18.6 vs. 25.1 asymptomatic and 22.0 symptomatic non-MELAS, p < 0.05). There was a trend toward higher serum heteroplasmy in MELAS compared to symptomatic non-MELAS and asymptomatic (means 39.3, 29.3, and 21.8% p = 0.09). Symptomatic non-MELAS had more sensorineural hearing loss as first presenting symptom (51.6% vs. 24.4%, p < 0.05). MELAS had higher prevalence of seizures (88.1% vs. 16.7%, p < 0.05) and shorter survival from onset to death (50% mortality at 25 years vs. 10%, p < 0.05). Late-onset MELAS had longer disease duration from first symptom to first SLE (mean 16.6 vs. 9.3 yrs) and also lived longer (mean age at death 62 vs. 30). Standard-onset MELAS had more neurologic involvement at onset than late-onset (51.7% vs. 15.4%). Late-onset patients had more prevalent diabetes (69.2% vs. 13.8%) and nephropathy (53.8% vs. 10.3%). Patients with late-onset MELAS also had more organ systems involved (mean 4.1 vs. 2.7, p < 0.05). There was a trend toward higher heteroplasmy levels in standard-onset (mean 44.8% vs. 25.3%, p = 0.18). Discussion: Our study highlights the spectrum of MELAS. The lower BMI in MELAS at presentation as well as higher rates of sensorineural hearing loss as initial symptom in symptomatic non-MELAS may be useful clinical markers. While many patients present before age 40 with SLE, some can present with SLE later in life. Standard onset MELAS is more likely to present with neurologic symptoms. Late-onset is more likely to suffer diabetes or nephropathy and have more organ systems involved.

Longitudinal relationship between relative harm perceptions, beliefs about organic and additive-free tobacco, and cigarette brand switching among Natural American Spirit, Camel and Marlboro cigarette smokers.

INTRODUCTION: While previous research has examined misperceptions related to Natural American Spirit (NAS), a premium cigarette brand using 'natural'-themed marketing, the longitudinal relationship between NAS-related harm beliefs and switching to NAS has not been established. METHODS: Using data from the PATH study, we modelled the longitudinal relationship between (1) brand switching and subsequent belief that one's own brand might be less harmful than other brands (Waves 1-5); (2) belief that organic and/or additive-free tobacco products are less harmful and subsequent brand switching (Waves 3-5); and (3) belief that some types of cigarettes are less harmful and subsequent brand switching (Waves 3-5) for NAS and two leading comparator brands (Camel and Marlboro). RESULTS: Among people who did not think their prior brand might be less harmful, switching to NAS or maintaining NAS preference increased the odds of believing one's own brand might be less harmful (aOR 19.4; 95% CI: 15.19, 24.8; aOR 6.1; 95% CI: 4.23, 8.67, respectively). Prior belief that organic and additive-free tobacco products were less harmful increased the odds of switching to (aOR 2.5; 95% CI: 1.68, 3.74) and decreased the odds of switching away (0.57; 955 CI: 0.36, 0.92) from NAS in the subsequent wave. Parallel analyses for Marlboro/Camel were largely null or in the opposite direction. CONCLUSIONS: NAS use may maintain or shape new beliefs that the brand may be less harmful than other brands; holding pre-existing beliefs about the relative harm of some tobacco products may increase risk for NAS use.

Validating Wave 1 (2014) Urinary Cotinine and TNE-2 Cut-points for Differentiating Wave 4 (2017) Cigarette Use from Non-use in the United States Using Data from the PATH Study.

BACKGROUND: Sex and racial/ethnic identity-specific cut-points for validating tobacco use using Wave 1 (W1) of the Population Assessment of Tobacco and Health (PATH) Study were published in 2020. The current study establishes predictive validity of the W1 (2014) urinary cotinine and total nicotine equivalents-2 (TNE-2) cut-points on estimating Wave 4 (W4; 2017) tobacco use. METHODS: For exclusive and polytobacco cigarette use, weighted prevalence estimates based on W4 self-report alone and with exceeding the W1 cut-point were calculated to identify the percentage missed without biochemical verification. Sensitivity and specificity of W1 cut-points on W4 self-reported tobacco use status were examined. ROC curves were used to determine the optimal W4 cut-points to distinguish past 30-day users from non-users, and evaluate whether the cut-points significantly differed from W1. RESULTS: Agreement between W4 self-reported use and exceeding the W1 cut-points was high overall and when stratified by demographic subgroups (0.7%-4.4% of use was missed if relying on self-report alone). The predictive validity of using the W1 cut-points to classify exclusive cigarette and polytobacco cigarette use at W4 was high (>90% sensitivity and specificity, except among polytobacco Hispanic smokers). Cut-points derived using W4 data did not significantly differ from the W1-derived cut-points [e.g., W1 exclusive = 40.5 ng/mL cotinine (95% confidence interval, CI: 26.1-62.8), W4 exclusive = 29.9 ng/mL cotinine (95% CI: 13.5-66.4)], among most demographic subgroups. CONCLUSIONS: The W1 cut-points remain valid for biochemical verification of self-reported tobacco use in W4. IMPACT: Findings from can be used in clinical and epidemiologic studies to reduce misclassification of cigarette smoking status.

The impact of freezing and multiple freeze-thaw cycles on Brix refractometry estimates of immunoglobulin concentration in beef cattle colostrum.

Evaluation of immunoglobulin G (IgG) concentration in colostrum is important to guide on-farm management. Studies have shown that digital Brix refractometry accurately estimates colostrum IgG concentration in both dairy and beef cattle colostrum. Colostrum is often frozen in both clinical and research settings. The implications of this freezing on the accuracy of Brix refractometry measurements are largely unknown. The first objective of this study was to evaluate the agreement between digital Brix percentage measurements of IgG in beef cattle colostrum taken before and after different durations of freezing. The second objective was to evaluate the effects of multiple freeze-thaw (FT) cycles on Brix percentage measurements of IgG in beef cattle colostrum. There was good agreement between Brix percentages in fresh colostrum and after short (2 to 8 d), medium (4 to 7 mo), and long (3 y) periods of freezing (concordance correlation coefficient: 0.95, 0.96, and 0.96, respectively). Although there was no significant change in mean Brix percentages over 2 FT cycles (P > 0.05), mean Brix percentages decreased with 3 FT cycles (P = 0.017). Samples from the fourth and fifth FT cycles were observably coagulated, and these measurements were therefore deemed inaccurate. Data from this study indicate that freezing had minimal impact on digital Brix refractometer estimates of IgG concentration in beef cattle colostrum, but that samples stored for future testing should not undergo more than 2 FT cycles.

L'évaluation de la concentration d'immunoglobuline G (IgG) dans le colostrum est importante pour guider la gestion à la ferme. Des études ont montré que la réfractométrie Brix numérique estime avec précision la concentration d'IgG du colostrum dans le colostrum des bovins laitiers et de boucherie. Le colostrum est souvent congelé dans les milieux cliniques et de recherche. Les implications de cette congélation sur la précision des mesures de réfractométrie Brix sont largement inconnues. Le premier objectif de cette étude était d'évaluer la concordance entre les mesures numériques du pourcentage de Brix d'IgG dans le colostrum de bovins de boucherie prises avant et après différentes durées de congélation. Le deuxième objectif était d'évaluer les effets de plusieurs cycles de congélation-décongélation (FT) sur les mesures du pourcentage Brix d'IgG dans le colostrum de bovins de boucherie. Il y avait un bon accord entre les pourcentages de Brix dans le colostrum frais et après des périodes de congélation courtes (2 à 8 jours), moyennes (4 à 7 mois) et longues (3 ans) (coefficient de corrélation de concordance : 0,95, 0,96 et 0,96, respectivement). Bien qu'il n'y ait pas eu de changement significatif dans les pourcentages moyens de Brix sur deux cycles FT (P > 0,05), les pourcentages moyens de Brix ont diminué avec trois cycles FT (P = 0,017). Les échantillons des quatrième et cinquième cycles FT étaient coagulés de manière observable, et ces mesures ont donc été jugées inexactes. Les données de cette étude indiquent que la congélation a eu un impact minimal sur les estimations du réfractomètre numérique Brix de la concentration d'IgG dans le colostrum de les bovins de boucherie, mais que les échantillons stockés pour les tests futurs ne doivent pas subir plus de deux cycles FT.(Traduit par Docteur Serge Messier).

Optimising management of complex regional pain syndrome to improve clinical outcomes throughout the therapy care pathway in England: Protocol for a qualitative interview and observational study with patients and clinicians.

INTRODUCTION: Complex Regional Pain Syndrome (CRPS) is a disabling and distressing chronic pain condition characterised by a range of sensory, motor, autonomic and trophic symptoms. Guidelines recommend early referral for therapies that promote movement of the painful limb. However, evidence suggests a lack of defined therapy pathways for CRPS. AIMS: The current study aims to explore CRPS therapy management in centres of excellence in England, and outside of these settings, to understand what facilitates and hinders best practice. The overall aim is to develop a draft stratified package of care to expedite patient access to optimal CRPS therapy across the management pathway. METHODS AND ANALYSIS: Semi-structured interviews will be conducted with therapists working in CRPS centres of excellence and with therapists in other settings. Observations of therapy interventions in CRPS centres of excellence and interviews with patients who have received this care, will also help to identify potential key care package components. Interview data will be analysed using thematic analysis, mapped to the Theoretical Domains Framework (TDF), and Intervention Mapping Adapt (IMA) framework. Observations will be described and documented using the TDF headings. CONCLUSION: A triangulation protocol for qualitative health research will be used to integrate all data. Online stakeholder events will be held using consensus methods to agree a draft package of care for future implementation following further refinement, testing and evaluation. CLINICAL TRIAL REGISTRATION: The trial was registered with ISRCTN registry on 24 February 2022 (ISRCTN16917807).

Nationally representative surveys on cannabis use lack product details relevant to public health.

Objectives: Many annual, nationally representative US surveys that assess cannabis use do not collect information on product characteristics despite varying health risks and benefits. Capitalizing on a rich dataset of primarily medical users, the purpose of this study was to describe the degree of potential misclassification in clinically relevant cannabis use measures when primary mode of use is recorded but not product type. Methods: Analyses consider user-level data from the Releaf App™ database on product types, consumption modes, and potencies in a non-nationally representative sample of 26,322 cannabis administration sessions occurring in 2018, across 3,258 users. Proportions, means, and 95% confidence intervals were calculated and compared across products and modes. Results: Primary consumption modes were smoking (47.1%), vaping (36.5%), and eating/drinking (10.4%), with 22.7% of users reporting multiple modes of use. Moreover, mode of use did not signify a single product type: users reported vaping both flower (41.3%) and concentrates (68.7%). Of those who smoked cannabis, 8.1% reported smoking concentrates. Concentrates averaged 3.4 times higher tetrahydrocannabinol (THC) potency and 3.1 times higher cannabidiol (CBD) potency than flower. Conclusions: Cannabis consumers employ multiple consumption modes, and product type cannot be inferred from mode of use. With THC potencies markedly higher in concentrates, these findings underscore the importance of including information on cannabis product types and mode of use in surveillance surveys. Clinicians and policymakers need these data to inform treatment decisions and assess cannabis policies' implications for population health.

Multilevel Risk and Protective Factors for Frequent and Nonfrequent Past-30-Day Marijuana Use: Findings From a Representative Sample of High School Youth.

OBJECTIVE: Research has identified many factors associated with past-30-day (P30D) marijuana use among youth but has not assessed factors that may differentiate youth who use frequently from youth who do not. We took a multilevel approach to identify and compare risk and protective factors associated with frequent and nonfrequent P30D marijuana use among high school students. METHOD: Individual-level data were obtained from the 2019 Nevada Youth Risk Behavior Survey (completed by 4,980 high school youth from 99 schools); school-level data were obtained from the state's Department of Education. A multinomial, multilevel model was used to estimate the association between risk and protective factors at the individual and school levels and a three-level frequency of use outcome: no P30D use (0 times), nonfrequent P30D use (1-19 times), and frequent P30D use (≥20 times). RESULTS: At the individual level, other P30D substance use, exposure to adverse childhood experiences (ACEs), perceived ease of access, and perceived risk were associated with both frequent and nonfrequent use, but the relationships were generally stronger for frequent use. P30D nonprescription drug use and school connectedness were associated with frequent use only. At the school level, number of students with individualized education programs, number of incidents involving possession of controlled substances, and school type were associated with frequent use only. CONCLUSIONS: Individual and school-based interventions designed to address the factors uniquely or strongly associated with frequent marijuana use may prevent escalation from occasional use to more frequent use among high school youth.

Shifts in preference for Natural American Spirit and associated belief that one's own cigarette brand might be less harmful than other brands: results from Waves 1-4 of the Population Assessment of Tobacco and Health (PATH) Study (2013-2018).

INTRODUCTION: People believe that cigarettes using 'organic,' 'additive-free' or similar descriptors are less harmful than other cigarettes. Natural American Spirit (NAS) is the most popular US cigarette brand using these descriptors. This cohort study describes changes in US smokers' odds of preferring NAS and changes in NAS smokers' odds of believing their brand might be less harmful than other brands. METHODS: Data come from four waves (2013-2018) of the Population Assessment of Tobacco and Health (PATH) Study. Generalised estimating equations produced population-averaged estimates of relationships between (1) NAS brand preference and wave and (2) belief that one's own brand might be less harmful than other brands, wave and NAS brand preference. Models tested interactions by age group and sexual minority status. RESULTS: The odds that smokers preferred NAS increased by 60% in W4 relative to W1. Disproportionate preference by younger adult and sexual minority smokers was observed. The odds that NAS smokers believed their own brand might be less harmful decreased by 50% between W1 and W4, but this perception was still 16 times higher for NAS compared with non-NAS smokers. Given the increasing preference for NAS, there was no significant change in the absolute number of NAS smokers who believed their own brand might be less harmful (W1: 562 122 (95% CI 435 190 to 689 055) vs W4: 580 378 (95% CI 441 069 to 719 689)). CONCLUSIONS: Both brand popularity and concentration of brand-related harm perceptions are important for understanding population impact of changes in cigarette marketing.

Predictors of E-cigarette and Cigarette Use Trajectory Classes from Early Adolescence to Emerging Adulthood Across Four Years (2013-2017) of the PATH Study.

INTRODUCTION: This study examines predictors of trajectories of cigarette and e-cigarette use among a cohort of US adolescents transitioning into young adulthood. Comparing trajectories of each tobacco product is important to determine if different intervention targets are needed to prevent progression to daily use. METHODS: Latent trajectory class analyses identified cigarette and e-cigarette use (never, ever excluding past 12-month, past 12-month (excluding past 30-day (P30D)), P30D 1-5 days, P30D 6+ days) trajectory classes, separately, among US youth (12-17; N = 10,086) using the first 4 waves (2013-2017) of data from the nationally representative PATH Study. Weighted descriptive analyses described the class characteristics. Weighted multinomial logistic regression analyses examined demographic, psychosocial, and behavioral predictors of class membership. RESULTS: Younger adolescents 12-15 years had lower tobacco use compared to 16-17 year olds and less stable classes. In the 16-17 year group, there were five unique trajectories of cigarette smoking, including a Persistent High Frequency class. Four e-cigarette use trajectories were identified; but not a persistent use class. Shared predictors of class membership for cigarettes and e-cigarettes included mental health problems, other tobacco use, marijuana use, and poorer academic achievement. Male sex and household tobacco use were unique e-cigarette trajectory class predictors. CONCLUSIONS: There was no evidence that initiation with e-cigarettes as the first product tried was associated with cigarette progression (nor cigarettes as first product and e-cigarette progression). Interventions should focus on well-established risk factors such as mental health and other substance use to prevent progression of use for both tobacco products. IMPLICATIONS: Using nationally representative data and definitions of use that take into account frequency and recency of use, longitudinal 4-year trajectories of e-cigarette and cigarette use among US adolescents transitioning into young adulthood were identified. Results among 16-17-year olds revealed a class of persistent high frequency cigarette smoking that was not identified for e-cigarette use. Cigarette use progression was not associated with e-cigarettes as the first product tried. Risk factors for progression of use of both products included mental health and other substance use, which are important prevention targets for both tobacco products.