Blair N. Coleman

Intentions to Smoke Cigarettes Among Never-Smoking US Middle and High School Electronic Cigarette Users: National Youth Tobacco Survey, 2011–2013

INTRODUCTION Electronic cigarette (e-cigarette) use is increasing rapidly, and the impact on youth is unknown. We assessed associations between e-cigarette use and smoking intentions among US youth who had never smoked conventional cigarettes. METHODS We analyzed data from the nationally representative 2011, 2012, and 2013 National Youth Tobacco Surveys of students in grades 6-12. Youth reporting they would definitely not smoke in the next year or if offered a cigarette by a friend were defined as not having an intention to smoke; all others were classified as having positive intention to smoke conventional cigarettes. Demographics, pro-tobacco advertisement exposure, ever use of e-cigarettes, and ever use of other combustibles (cigars, hookah, bidis, kreteks, and pipes) and noncombustibles (chewing tobacco, snuff, dip, snus, and dissolvables) were included in multivariate analyses that assessed associations with smoking intentions among never-cigarette-smoking youth. RESULTS Between 2011 and 2013, the number of never-smoking youth who used e-cigarettes increased 3-fold, from 79,000 to more than 263,000. Intention to smoke conventional cigarettes was 43.9% among ever e-cigarette users and 21.5% among never users. Ever e-cigarette users had higher adjusted odds for having smoking intentions than never users (adjusted odds ratio = 1.70, 95% confidence interval = 1.24-2.32). Those who ever used other combustibles, ever used noncombustibles, or reported pro-tobacco advertisement exposure also had increased odds for smoking intentions. CONCLUSION In 2013, more than a quarter million never-smoking youth used e-cigarettes. E-cigarette use is associated with increased intentions to smoke cigarettes, and enhanced prevention efforts for youth are important for all forms of tobacco, including e-cigarettes.

Association Between Electronic Cigarette Use and Openness to Cigarette Smoking Among US Young Adults

INTRODUCTION Use of electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigarettes), is increasing. One concern is the appeal of these products to youth and young adults and the potential to influence perceptions and use of conventional cigarettes. METHODS Using data from the 2012-2013 National Adult Tobacco Survey, characteristics of adults aged 18-29 years who had never established cigarette smoking behavior were examined by ever use of e-cigarettes, demographics, and ever use of other tobacco products (smokeless tobacco, cigars, hookah, and cigarettes). Multivariate logistic regression was used to examine the relationship between e-cigarette use and openness to cigarette smoking among young adults, defined as the lack of a firm intention not to smoke soon or in the next year. RESULTS Among young adults who had never established cigarette smoking behavior (unweighted n = 4,310), 7.9% reported having ever tried e-cigarettes, and 14.6% of those who reported having ever tried e-cigarettes also reported current use of the product. Ever e-cigarette use was associated with being open to cigarette smoking (adjusted odds ratio = 2.4; 95% confidence interval = 1.7, 3.3), as was being male, aged 18-24 years, less educated, and having ever used hookah or experimented with conventional cigarettes. CONCLUSIONS Ever use of e-cigarettes and other tobacco products was associated with being open to cigarette smoking. This study does not allow us to assess the directionality of this association, so future longitudinal research is needed to illuminate tobacco use behaviors over time as well as provide additional insight on the relationship between ENDS use and conventional cigarette use among young adult populations.

“It's not smoke. It's not tar. It's not 4000 chemicals. Case closed”: Exploring attitudes, beliefs, and perceived social norms of e-cigarette use among adult users

BACKGROUND Electronic cigarette (e-cigarette) use is rapidly increasing among adults in the U.S. The purpose of this qualitative study was to explore consumer perceptions about e-cigarettes, including knowledge, attitudes, beliefs and perceived social norms. METHODS A total of 14 focus groups (N=116) were conducted with current adult e-cigarette users in five U.S. cities from March through May, 2014. Focus groups were segmented by age (young adults aged 18-29 and older adults aged 30 and older) as well as by e-cigarette use status (exclusive e-cigarette users and non-exclusive e-cigarette users). Focus group discussions lasted approximately 60-min and were audio-recorded and transcribed; data were analyzed using a phenomenological approach. RESULTS Participants expressed many positive attitudes towards e-cigarettes and simultaneously reported a lack of information and knowledge about the products. Focus group participants overwhelmingly felt as though the ingredients of e-cigarettes were likely less harmful than conventional cigarettes. Additionally, many described positive reactions from family and friends, especially when e-cigarettes were used in place of conventional cigarettes. CONCLUSIONS Findings from this qualitative study provide insight into consumer knowledge, attitudes and beliefs about e-cigarettes increasing our understanding of why and how they are being used. Such information will help provide insight into the potential public health impact of these emerging products.

Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014.

Background Electronic cigarette (e-cigarette) use in the USA is increasing. As such, it is critical to understand who uses e-cigarettes, how e-cigarettes are used and what types of products are prevalent. This study assesses patterns of current e-cigarette use among daily and non-daily adult users in the 2013–2014 Population Assessment of Tobacco and Health (PATH) Study. Methods We examined the proportion of current adult e-cigarette users (n=3642) reporting infrequent use (use on ‘some days’ and use on 0–2 of the past 30 days), moderate use (use on ‘some days’ and use on >2 of the past 30 days) and daily use. We examined demographic characteristics, use of other tobacco products and e-cigarette product characteristics overall and by use category. Adjusted prevalence ratios (aPRs) were calculated using Poisson regression to assess correlates of daily e-cigarette use. Results Among the 5.5% of adult current e-cigarette users in the PATH Study, 42.2% reported infrequent use, 36.5% reported moderate use and 21.3% reported daily use. Cigarette smokers who quit in the past year were more likely to report daily e-cigarette use, compared with current smokers (aPR=3.21, 95% CI=2.75 to 3.76). Those who reported using rechargeable or refillable devices were more likely to report daily use compared with those who did not use these devices (aPR=1.95, 95% CI=1.44 to 2.65 and aPR=2.10, 95% CI=1.75 to 2.52, respectively). Conclusions The majority of e-cigarette users in this study reported less than daily use. Compared with non-daily use, daily use was associated with being a former smoker; however, cross-sectional data limits our ability to establish the temporality or directionality of such associations.

Modeling the Potential Effects of New Tobacco Products and Policies. A Dynamic Population Model for Multiple Product Use and Harm

Background Recent declines in US cigarette smoking prevalence have coincided with increases in use of other tobacco products. Multiple product tobacco models can help assess the population health impacts associated with use of a wide range of tobacco products. Methods and Findings We present a multi-state, dynamical systems population structure model that can be used to assess the effects of tobacco product use behaviors on population health. The model incorporates transition behaviors, such as initiation, cessation, switching, and dual use, related to the use of multiple products. The model tracks product use prevalence and mortality attributable to tobacco use for the overall population and by sex and age group. The model can also be used to estimate differences in these outcomes between scenarios by varying input parameter values. We demonstrate model capabilities by projecting future cigarette smoking prevalence and smoking-attributable mortality and then simulating the effects of introduction of a hypothetical new lower-risk tobacco product under a variety of assumptions about product use. Sensitivity analyses were conducted to examine the range of population impacts that could occur due to differences in input values for product use and risk. We demonstrate that potential benefits from cigarette smokers switching to the lower-risk product can be offset over time through increased initiation of this product. Model results show that population health benefits are particularly sensitive to product risks and initiation, switching, and dual use behaviors. Conclusion Our model incorporates the variety of tobacco use behaviors and risks that occur with multiple products. As such, it can evaluate the population health impacts associated with the introduction of new tobacco products or policies that may result in product switching or dual use. Further model development will include refinement of data inputs for non-cigarette tobacco products and inclusion of health outcomes such as morbidity and disability.

Receptivity to Tobacco Advertising and Susceptibility to Tobacco Products

This study examines receptivity to advertising for multiple tobacco products and its relationship to susceptibility to cigarette smoking among a representative sample of US adolescents. BACKGROUND AND OBJECTIVES: Non–cigarette tobacco marketing is less regulated and may promote cigarette smoking among adolescents. We quantified receptivity to advertising for multiple tobacco products and hypothesized associations with susceptibility to cigarette smoking. METHODS: Wave 1 of the nationally representative PATH (Population Assessment of Tobacco and Health) study interviewed 10 751 adolescents who had never used tobacco. A stratified random selection of 5 advertisements for each of cigarettes, e-cigarettes, smokeless products, and cigars were shown from 959 recent tobacco advertisements. Aided recall was classified as low receptivity, and image-liking or favorite ad as higher receptivity. The main dependent variable was susceptibility to cigarette smoking. RESULTS: Among US youth, 41% of 12 to 13 year olds and half of older adolescents were receptive to at least 1 tobacco advertisement. Across each age group, receptivity to advertising was highest for e-cigarettes (28%–33%) followed by cigarettes (22%–25%), smokeless tobacco (15%–21%), and cigars (8%–13%). E-cigarette ads shown on television had the highest recall. Among cigarette-susceptible adolescents, receptivity to e-cigarette advertising (39.7%; 95% confidence interval [CI]: 37.9%–41.6%) was higher than for cigarette advertising (31.7%; 95% CI: 29.9%–33.6%). Receptivity to advertising for each tobacco product was associated with increased susceptibility to cigarette smoking, with no significant difference across products (similar odds for both cigarette and e-cigarette advertising; adjusted odds ratio = 1.22; 95% CI: 1.09–1.37). CONCLUSIONS: A large proportion of US adolescent never tobacco users are receptive to tobacco advertising, with television advertising for e-cigarettes having the highest recall. Receptivity to advertising for each non–cigarette tobacco product was associated with susceptibility to smoke cigarettes.

Susceptibility to tobacco product use among youth in wave 1 of the population Assessment of tobacco and health (PATH) study.

The purpose of this study was to investigate susceptibility and ever use of tobacco products among adolescents and young adults in the US. Cross-sectional analysis of Wave 1(2013-2014) adolescent (12-17year-olds; n=13,651) and young adult (18-24year-olds; n=9112) data from the nationally-representative Population Assessment of Tobacco and Health (PATH) Study was conducted. At 12years, 5% were ever tobacco users and 36% were susceptible to use. Seventy percent were susceptible at age 17years, and the same proportion were ever users at age 22years. Susceptibility levels were comparable for cigarettes and e-cigarette (28.6% and 27.4%, respectively), followed by hookah (22.0%), pipes (17.5%), cigars (15.2%), and smokeless tobacco (9.7%). Non-Hispanic (NH) Black (Adjusted Odds Ratio [ORadj]=1.36; 95% Confidence Limit [CL], 1.18-1.56) and Hispanic (ORadj=1.34: 95% CL,1.19-1.49) adolescent never- users were more likely to be susceptible to future use of a tobacco product than NH Whites. Susceptibility was higher with age (15-17yrs. vs 12-14yrs.: ORadj=1.69; 95% CL, 1.55-1.85) and parental education (college graduates vs less than HS education: ORadj=1.22, 95% CL, 1.08-1.39). Compared to exclusive users of hookah, cigars, or smokeless products, larger proportions of exclusive e-cigarette ever users were also susceptible to cigarette use. Among adolescents, lower levels of ever use of tobacco products are often counterbalanced by higher levels of susceptibility for future use, which may suggest delayed initiation in some groups. Ever users of a given tobacco product were more susceptible to use other tobacco products, putting them at risk for future multiple tobacco product use.

E-cigarette and Smokeless Tobacco Use and Switching Among Smokers: Findings From the National Adult Tobacco Survey

INTRODUCTION Assessing the extent that cigarette smokers use or switch to e-cigarettes and smokeless tobacco can help inform the population health impact of these products. This study estimated the prevalence of e-cigarette and smokeless tobacco use and switching among current and recent former adult cigarette smokers. METHODS Data from the 2012-2013 (n=8,891) and 2013-2014 (n=11,379) National Adult Tobacco Survey were analyzed in 2016. Response rates for this telephone survey were 44.9% and 36.1%, respectively. Tobacco product use was assessed by smoking status. RESULTS Current e-cigarette use increased for all groups, with a greater increase among recent quitters, 9.1% (95% CI=7.1%, 11.1%) in 2012-2013 and 15.8% (95% CI=13.7%, 17.9%) in 2013-2014, than smokers with an unsuccessful quit attempt, 10.4% (95% CI=9.1%, 11.7%) in 2012-2013 and 14.8% (95% CI=13.5%, 16.1%) in 2013-2014, or smokers with no quit attempt, 5.9% (95% CI=4.8%, 6.9%) in 2012-2013 and 10.7% (95% CI=9.4%, 12.0%) in 2013-2014. Between 2012-2013 and 2013-2014, current use of smokeless tobacco remained steady for recent quitters (4.6% to 4.7%, p=0.92) and smokers with no quit attempt (4.0% to 4.3%, p=0.97), and decreased in smokers with an unsuccessful quit attempt (5.7% to 3.8%, p=0.004). More recent quitters completely switched to e-cigarettes in the past year (15.3% in 2012-2013, 25.7% in 2013-2014) than to smokeless tobacco (4.6% in 2012-2013, 4.5% in 2013-2014). CONCLUSIONS Current and recent former adult smokers are more likely to use e-cigarettes than smokeless tobacco. Current e-cigarette use was most prevalent among unsuccessful quitters and recent quitters, who were substantially more likely to report complete switching to e-cigarettes than smokeless tobacco.

Transitions in electronic cigarette use among adults in the Population Assessment of Tobacco and Health (PATH) Study, Waves 1 and 2 (2013–2015)

Introduction This study assessed patterns of e-cigarette and cigarette use from Wave 1 to Wave 2 among adult e-cigarette users at Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Methods We examined changes in e-cigarette use frequency at Wave 2 among adult e-cigarette users at Wave 1 (unweighted n=2835). Adjusted prevalence ratios (aPR) were calculated using a predicted marginal probability approach to assess correlates of e-cigarette discontinuance and smoking abstinence at Wave 2. Results Half (48.8%) of adult e-cigarette users at Wave 1 discontinued their use of e-cigarettes at Wave 2. Among dual users of e-cigarettes and cigarettes at Wave 1, 44.3% maintained dual use, 43.5% discontinued e-cigarette use and maintained cigarette smoking and 12.1% discontinued cigarette use at Wave 2, either by abstaining from cigarette smoking only (5.1%) or discontinuing both products (7.0%). Among dual users at Wave 1, daily e-cigarette users were more likely than non-daily users to report smoking abstinence at Wave 2 (aPR=1.40, 95% CI 1.02 to 1.91). Using a customisable device (rather than a non-customisable one) was not significantly related to smoking abstinence at Wave 2 (aPR=1.14, 95% CI 0.81 to 1.60). Conclusions This study suggests that e-cigarette use patterns are highly variable over a 1-year period. This analysis provides the first nationally representative estimates of transitions among US adult e-cigarette users. Future research, including additional waves of the PATH Study, can provide further insight into long-term patterns of e-cigarette use critical to understanding the net population health impact of e-cigarettes in USA.

Unpacking smokers' beliefs about addiction and nicotine: A qualitative study

Evidence suggests that consumers correctly identify nicotine as addictive; however, many may also harbor misconceptions about its harmfulness. The majority of this evidence is based on survey data, however, which may be prone to some limitations. In the current study, we employed qualitative methods to examine, in their own words, smokers’ beliefs about nicotine and addiction. Twelve 1-hr focus groups were conducted in 3 cities in the United States (Columbus, OH; New Orleans, LA; and Washington, DC) from October to November, 2014. Adult cigarette smokers (N = 108), defined as those who reported smoking cigarettes on every day or some days, were segmented by age group (18–25 years and ≥26 years) and tobacco-use behavior. Thematic, in-depth analysis of focus-group discussion transcripts was conducted. Participant demographic information was recorded. Results showed that smokers identify nicotine as a cause of addiction to cigarettes; however, they also attribute their addiction to other factors. When asked about nicotine’s effects on the body, immediate physiological effects of smoking (e.g., stimulation, relaxation) were top of mind. Opinions varied in terms of whether nicotine itself was harmful or harmless; many were unsure and/or had not considered this question. Discussions revealed heterogeneity in smokers’ beliefs as well as recognition of their own uncertainty and lack of knowledge. The current findings provide insight that smokers may not be as misinformed regarding the relative harms of nicotine and tobacco, as has been suggested by quantitative evidence. Implications for future research are discussed.