Brian Rostron

Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014.

Article Tables Supplemental Content References Most tobacco use begins during youth and young adulthood.1 Recent declines in prevalence of cigarette smoking among youth have coincided with increased use of e-cigarettes and hookahs.2 Although flavors other than menthol are prohibited in cigarettes in the United States,3 flavored noncigarette tobacco products are widely available and may appeal to youth. We examined flavored tobacco use among a nationally representative sample of US youth.

Estimation of Cigarette Smoking-Attributable Morbidity in the United States

IMPORTANCE Cigarette smoking has been found to harm nearly every bodily organ and is a leading cause of preventable disease, but current estimates of smoking-attributable morbidity by condition for the United States are generally unavailable. OBJECTIVE To estimate the burden of major medical conditions attributable to cigarette smoking in the United States. DESIGN, SETTING, AND PARTICIPANTS The disease burden of smoking was estimated using population-attributable risk calculations, taking into account the uncertainty of estimates. Population estimates came from 2009 US Census Bureau data and smoking prevalence, disease prevalence, and disease relative risk estimates came from National Health Interview Survey data for surveyed adults from 2006 through 2012. National Health and Nutrition Examination Survey spirometry data obtained from medical examination of surveyed adults from 2007 through 2010 was used to adjust for underreporting of chronic obstructive pulmonary disease. EXPOSURES Smoking status was assessed from self-reported National Health Interview Survey data. MAIN OUTCOMES AND MEASURES The number of adults 35 years and older who had had a major smoking-attributable disease by sex and condition and the total number of these conditions were estimated for the United States in 2009. RESULTS Using National Health Interview Survey data, we estimated that 6.9 million (95% CI, 6.5-7.4 million) US adults had had a combined 10.9 million (95% CI, 10.3-11.5 million) self-reported smoking-attributable medical conditions. Using chronic obstructive pulmonary disease prevalence estimates obtained from National Health and Nutrition Examination Survey self-reported and spirometry data, we estimated that US adults had had a combined 14.0 million (95% CI, 12.9-15.1 million) smoking-attributable conditions in 2009. CONCLUSIONS AND RELEVANCE We estimate that US adults have had approximately 14 million major medical conditions that were attributable to smoking. This figure is generally conservative owing to the existence of other diseases and medical events that were not included in these estimates. Cigarette smoking remains a leading cause of preventable disease in the United States, underscoring the need for continuing and vigorous smoking-prevention efforts.

Systematic review of cigar smoking and all cause and smoking related mortality

BackgroundCigars are a growing public health concern, given the changes in cigar use patterns in the US and elsewhere since the 1960s. We conducted a systematic review of published studies on current cigar smoking and all-cause and cause-specific mortality risks to inform potential regulatory approaches and future research that would strengthen the body of evidence.MethodsUsing 3 different databases and handsearching, we identified epidemiological studies published prior to June 2014 that examined the association between cigar smoking and all-cause mortality and smoking-related mortality. Detailed study characteristics as well as association-level characteristics, including effect estimates and 95% confidence intervals, were abstracted or calculated from each selected study.ResultsA total of 22 studies from 16 different prospective cohorts were identified. Primary cigar smoking (current, exclusive cigar smoking with no history of previous cigarette or pipe smoking) was associated with all cause-mortality, oral cancer, esophageal cancer, pancreatic cancer, laryngeal cancer, lung cancer, coronary heart disease (CHD), and aortic aneurysm. Strong dose trends by cigars per day and inhalation level for primary cigar smoking were observed for oral, esophageal, laryngeal, and lung cancers. Among primary cigar smokers reporting no inhalation, relative mortality risk was still highly elevated for oral, esophageal, and laryngeal cancers.ConclusionsIn summary, cigar smoking carries many of the same health risks as cigarette smoking. Mortality risks from cigar smoking vary by level of exposure as measured by cigars per day and inhalation level and can be as high as or exceed those of cigarette smoking. The body of evidence would be strengthened by future studies that focus on the health effects of primary cigar smoking and incorporate more contemporary and diverse study populations to better reflect the current patterns of cigar use in the US. Ideally, these studies would also collect detailed information on cigar type, exposure level, and biomarkers of exposure and potential harm.

Smoking-attributable mortality by cause in the United States: revising the CDC's data and estimates.

INTRODUCTION Smoking is the leading cause of preventable mortality in the United States, but the methods and data used in the Centers for Disease Control and Preventions (CDC) published estimates of adult smoking-attributable mortality have not been substantially revised since their introduction in the 1980s. METHODS We employed the CDCs general methodology for estimating smoking-attributable mortality but produced improved estimates by using recent, nationally representative relative risk data from the National Health Interview Survey-Linked Mortality Files and adjusting for confounding risk factors. We also produced estimates by smoking status and over time. RESULTS Our use of more recent and nationally representative relative risks tended to decrease estimates of smoking deaths for men and increased estimates for women compared with the CDCs estimates. Adjustment for confounding factors further refined the estimates, particularly by smoking status. We estimated 200,000 smoking-attributable deaths for men and 180,000 smoking-attributable deaths for women in the United States in 2004. Estimated smoking-attributable mortality has finally begun to decline for both U.S. men and women. CONCLUSIONS Our approach offers several substantive improvements in the estimation of smoking-attributable mortality by cause for the United States. Cigarette smoking remains a leading cause of preventable mortality in the United States, but we estimate that the number of smoking-attributable deaths has begun to decline.

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.

Nicotine and Toxicant Exposure among U.S. Smokeless Tobacco Users: Results from 1999 to 2012 National Health and Nutrition Examination Survey Data

Background: It has been suggested that smokeless tobacco users have high nicotine and toxicant exposure, but studies with nationally representative data have been limited. Methods: We analyzed biomarkers of tobacco exposure for 23,684 adult participants from the National Health and Nutrition Examination Survey from 1999 to 2012. The biomarkers analyzed were serum cotinine, urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), blood lead, blood cadmium, blood mercury, urinary arsenic, and urinary N-acetyl-S-(2-cyanoethyl)-L-cysteine. We calculated geometric mean concentrations for each biomarker by tobacco use category and geometric mean ratios adjusting for demographic factors. Results: Exclusive smokeless tobacco users had higher geometric mean concentrations of serum cotinine [178.9 ng/mL, 95% confidence interval (CI), 145.5–220.0] and NNAL (583.0 pg/mg creatinine, 95% CI, 445.2–763.5) than exclusive cigarette smokers (130.6 ng/mL, 95% CI, 122.3–139.6 and 217.6 pg/mg creatinine, 95% CI, 193.0–245.2, respectively). Smokeless tobacco users also had higher concentrations of blood lead compared with nontobacco users (adjusted geometric mean ratio = 1.30, 95% CI, 1.21–1.38). Based on limited sample sizes, NNAL concentrations for smokeless tobacco users appear to have declined from 2007 to 2008 (geometric mean = 1013.7 pg/mg creatinine, 95% CI, 738.9–1390.8) to 2011 to 2012 (geometric mean = 325.7 pg/mg creatinine, 95% CI, 159.6–664.9). Conclusions: Exclusive smokeless tobacco users have higher observed levels of exposure to nicotine and carcinogenic tobacco-specific nitrosamines, as measured by cotinine and NNAL biomarker concentrations, than exclusive cigarette smokers. These patterns in NNAL levels for smokeless tobacco users may be changing over time. Impact: High exposure to harmful constituents among smokeless tobacco users is a continuing health issue. Cancer Epidemiol Biomarkers Prev; 24(12); 1829–37. ©2015 AACR.

Mortality and Economic Costs From Regular Cigar Use in the United States, 2010

OBJECTIVES We estimated annual mortality, years of potential life lost, and associated economic costs attributable to regular cigar smoking among US adults aged 35 years or older. METHODS We estimated cigar-attributable mortality for the United States in 2010 using the Centers for Disease Control and Preventions Smoking-Attributable Mortality, Morbidity, and Economic Costs methodology for smoking-related causes of death. We obtained cigar prevalence from the National Adult Tobacco Survey, relative risks from the Cancer Prevention Studies I and II, and annual US deaths from the National Vital Statistics System. We also estimated the economic cost of this premature mortality using the value of a statistical life-year. RESULTS Regular cigar smoking was responsible for approximately 9000 premature deaths and more than 140,000 years of potential life lost among US adults aged 35 years or older in 2010. These years of life had an economic value of approximately

A systematic review of transitions between cigarette and smokeless tobacco product use in the United States

23 billion. CONCLUSIONS . The health and economic burden of cigar smoking in the United States is large and may increase over time because of the increasing consumption of cigars in the United States.

Biomarkers of Exposure among U.S. Cigar Smokers: An Analysis of 1999–2012 National Health and Nutrition Examination Survey (NHANES) Data

BackgroundSmokeless tobacco use is becoming an increasingly important public health issue in the US and may influence cigarette smoking behavior. Systematic information on transitions between smokeless tobacco and cigarette use in the US is limited.MethodsWe conducted a systematic review of published literature on transitions between smokeless tobacco and cigarette use in the US. We searched PubMed, Web of Science and EbscoHost databases for all published articles from January 2000 to March 2014 that presented estimates of transitions in US youth and adult study populations over time between at least one of the following tobacco use states: exclusive cigarette smoking, exclusive smokeless tobacco use, dual use of both products, and use of neither product. We excluded non-English language studies, studies published before 2000, clinical trials, controlled cessation programs, and clinical studies or evaluations of smokeless tobacco cessation programs.ResultsThe review identified six studies on US populations published since 2000 with longitudinal data on some or all of the transitions that users can undergo between smokeless tobacco and cigarette use. There was considerable heterogeneity across studies in design and tobacco use definitions. Despite these differences, the existing data indicate that switching behaviors from exclusive smoking to exclusive smokeless tobacco use are limited (adults: 0%-1.4%, adolescents: 0.8%-3.8%) but may be more common from exclusive smokeless tobacco use to exclusive smoking (adults: 0.9%-26.6%, adolescents: 16.6%-25.5%). Among adults, exclusive cigarette smoking was generally stable and consistent (79.7% to 87.6%) over follow-up across studies but less stable in adolescents (46.8%-78.7%). Exclusive smokeless tobacco use was less stable than exclusive cigarette smoking over time (adults: 59.4%-76.6%, adolescents: 26.2%-44.8%).ConclusionThis review provides published estimates of the proportions of adults and adolescents transitioning between tobacco use categories from the most recently available studies on longitudinal transitions between smokeless tobacco and cigarettes in the US. These data can be used to track tobacco use behaviors and evaluate their effect on public health; however, the data for these studies were generally collected more than a decade ago. Additional research including nationally representative longitudinal estimates using consistent definitions and designs, would improve understanding of current tobacco transition behaviors.