Elizabeth Lambert

Design and methods of the Population Assessment of Tobacco and Health (PATH) Study

Background This paper describes the methods and conceptual framework for Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study data collection. The National Institutes of Health, through the National Institute on Drug Abuse, is partnering with the Food and Drug Administrations (FDA) Center for Tobacco Products to conduct the PATH Study under a contract with Westat. Methods The PATH Study is a nationally representative, longitudinal cohort study of 45 971 adults and youth in the USA, aged 12 years and older. Wave 1 was conducted from 12 September 2013 to 15 December 2014 using Audio Computer-Assisted Self-Interviewing to collect information on tobacco-use patterns, risk perceptions and attitudes towards current and newly emerging tobacco products, tobacco initiation, cessation, relapse behaviours and health outcomes. The PATH Studys design allows for the longitudinal assessment of patterns of use of a spectrum of tobacco products, including initiation, cessation, relapse and transitions between products, as well as factors associated with use patterns. Additionally, the PATH Study collects biospecimens from consenting adults aged 18 years and older and measures biomarkers of exposure and potential harm related to tobacco use. Conclusions The cumulative, population-based data generated over time by the PATH Study will contribute to the evidence base to inform FDAs regulatory mission under the Family Smoking Prevention and Tobacco Control Act and efforts to reduce the Nations burden of tobacco-related death and disease.

Co-occurrence of tobacco product use, substance use, and mental health problems among adults: Findings from Wave 1 (2013–2014) of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND Although non-cigarette tobacco product use is increasing among U.S. adults, their associations with substance use and mental health problems are unclear. This study examined co-occurrence of tobacco use, substance use, and mental health problems, and its moderation by gender, among 32,202U.S. adults from Wave 1 (2013-2014) of the nationally representative longitudinal Population Assessment of Tobacco and Health (PATH) Study. METHODS Participants self-reported current cigarette, e-cigarette, traditional cigar, cigarillo, filtered cigar, hookah, smokeless tobacco and other tobacco product use; past year alcohol, marijuana, and other drug use; and past year substance use, internalizing and externalizing problems. RESULTS Compared to non-current tobacco users, current users were more likely to report alcohol or drug use (adjusted odds ratio (AOR)=2.6; 95% confidence interval (CI): 2.3, 2.9), with the strongest associations observed for cigarillo and hookah users. Across all tobacco product groups, users were more likely to report internalizing (AOR=1.9; 95% CI: 1.7, 2.1), externalizing (AOR=1.6; 95% CI: 1.5, 1.8), and substance use (AOR=3.4; 95% CI: 2.9, 4.1) problems than non-users. Gender moderated many of these associations and, of these, all non-cigarette tobacco product associations were stronger among females. CONCLUSIONS This nationally representative study of U.S. adults is the first to comprehensively document tobacco use, substance use, and mental health comorbidities across the range of currently available tobacco products, while also demonstrating that female tobacco users are at increased risk for substance use and mental health problems. These findings may point to gender differences in vulnerability and suggest that interventions incorporate gender-specific approaches.

Introduction: new dynamics of HIV risk among drug-using men who have sex with men.

On March 1–2, 2004, the National Institute on Drug Abuse (NIDA) sponsored a workshop on “New Dynamics of HIV Risk Among Drug-Using Men Who Have Sex With Men.” The workshop convened NIDA-funded researchers and experts from the Centers for Disease Control and Prevention to review scientific findings on the epidemiology and prevention of HIV/AIDS and other health and medical consequences of drug abuse among men who have sex with men (MSM). It had been 10 years or more since NIDA last hosted such a meeting, and it quickly became apparent that although much had changed, much had remained the same. The past decade of research has advanced our understanding of the behavioral, social, and environmental factors that influence HIV risk behaviors in this population and has informed the development of effective outreach and HIV prevention interventions for drug-using MSM. However, the steady progress made since the epidemic began in reducing risks and sustaining behavioral change among drug-using MSM appears to have slowed. Today, there are concerns that a resurgence of HIV/AIDS may be imminent, fueled in part by increasing indicators of high-risk behavior in this population. The CDC reported in 2003, for example, that after declining every year from 1990 to 2000, the rate of primary and secondary syphilis in the United States increased by 9.1% in 2001, and in 2002, by 12.4% over the increase seen in 2001. Most of this increase is among MSM. For example, from 1998 to 2000, MSM in Chicago accounted for just 15% of syphilis morbidity, but since 2001, MSM have represented nearly 60% of syphilis cases in the city. Moreover, a high rate of HIV co-infection has been reported among MSM involved in recent syphilis outbreaks, raising additional concerns about the magnitude and scope of new HIV infections. Whether the increases in syphilis cases are specific to drug-using MSM is to be determined. Drug use can interfere with the ability and desire to practice safer sex. Methamphetamine use, in particular, is considered highly prevalent among MSM and a cause of sexual risk taking within the gay male community. Over the 2-day workshop, participants discussed their research and findings and the implications for public health interventions to prevent and treat HIV/AIDS among drug-using MSM. Considerable time was devoted to what is known today about the risk behaviors of drug-using MSM, and how emerging patterns of drug

Indicators of dependence for different types of tobacco product users: Descriptive findings from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) study.

BACKGROUND AND AIMS With no established standard for assessing tobacco dependence (TD) across tobacco products in surveys, the Population Assessment of Tobacco and Health (PATH) Study provides a unique platform for examining the psychometric properties and validity of multiple indicators of tobacco dependence across a range of tobacco products. PARTICIPANTS A U.S. nationally representative sample from the 32,320 adult Wave 1 interviews with analyses focused on 14,287 respondents who were current established users of tobacco products. FINDINGS This analysis confirms a single primary latent construct underlying responses to TD indicators for cigarettes, e-cigarettes, cigars, hookah, and smokeless tobacco products. Mutually exclusive past year tobacco-user groups included: cigarette only (n=8689), e-cigarette only (n=437), cigar only (traditional, cigarillo, or filtered) (n=706), hookah only (n=461), smokeless tobacco only (n=971), cigarette plus e-cigarette (n=709), and multiple tobacco product users (n=2314). Differential Item Functioning (DIF) analyses supported use of 16 of the 24 examined TD indicators for comparisons across tobacco users. With cigarette users as a reference (mean=0.0, SD=1.0), we observed a range of TD with hookah (mean=-1.71) and cigar (mean=-1.92) only users being the lowest, and cigarette plus e-cigarette product users being the highest (mean=0.35). Regression models including sociodemographic factors supported concurrent validity with increased product use frequency and TD among cigarette-only (p<0.001), e-cigarette only (p<0.002), cigar (p<0.001), hookah only (p<0.001), and smokeless tobacco users (p<0.001). CONCLUSION The PATH Study Adult Wave 1 Questionnaire provided psychometrically valid measures of TD that enables future regulatory investigations of nicotine dependence across tobacco products.

Understanding the dynamics of sexual transmission of HIV among drug-using populations: an integration of biological, behavioral, and environmental perspectives.

In October 2002, the Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA) of the National Institute on Drug Abuse (NIDA) sponsored a science meeting, HIV Acquisition and Transmission Among Drug-Using Populations: Future Research Strategies. The meeting, chaired by Dr. David Vlahov, Director of the Center for Urban Epidemiologic Studies at the New York Academy of Medicine, convened experts in HIV/AIDS and drug abuse research to examine the dynamics of HIV disease transmission among drug users and other at-risk populations, and to explore why new infections continue apace despite our best efforts at HIV prevention and control. This special issue of the Journal of Urban Health represents one step in the process of addressing new and emerging research gaps and unanswered questions that challenge our best efforts to prevent the continuing spread of HIV/AIDS. The particular focus of the issue is on identifying and understanding some of the dynamic factors involved in the sexual transmission of HIV among drug-using populations. It is hoped that, as we are challenged by yet another decade of HIV/AIDS, we will develop novel, more effective behavioral and biomedical strategies to reduce and prevent—and possibly even to eliminate—this disease. Since HIV/AIDS was first identified in the early 1980s, knowledge and understanding about the disease have grown exponentially. Today, we know more than we ever imagined possible about the natural history, epidemiology, virology, etiology, pathogenesis, prevention, and treatment of HIV/AIDS. Yet despite these gains, dynamic changes in the epidemic continue as new infections spread among drug users and their sexual partners both in the United States and around the world. In the United States today, the estimated annual rate of 40,000 new HIV infections continues, as it did throughout the 1990s. This persistent rate of new infections reminds us that, while we have made advances in the science of HIV prevention, there is much that we have yet to do to make HIV prevention efforts better, more far-reaching, and sustainable. The HIV/AIDS surveillance data from the US Centers for Disease Control and Prevention 1 reveal that, since the 1980s, there have been notable shifts in the demo

Prevention and treatment of HIV/AIDS among drug-using populations: a global perspective.

As the HIV/AIDS epidemic nears its fourth decade, there are signs that explosive spread of the virus may be subsiding, only to be replaced by outbreaks of HIV among vulnerable populations and in diverse locations that have, until now, been largely free of the disease. Yet today, just as in the earliest years, we have understood that containing the spread of HIV requires an ongoing commitment by scientists, clinicians, public health officials, and affected communities to HIV prevention and treatment among drug users. To this end, the National Institute on Drug Abuse (NIDA) and the International AIDS Society (IAS) convened a consultation meeting in January 2010 with leading national and international experts in the fields of HIV and substance abuse to renew our collective focus on the role of drug abuse in fuelling HIV transmission. Meeting participants reviewed the most current scientific evidence on HIV and substance abuse and worked to incorporate that evidence into new clinical recommendations for the prevention and treatment of HIV/AIDS among drug users. When the evidence was viewed as incomplete, new priorities were identified for future behavioral, clinical, and biomedical research.

Sexual Acquisition and Transmission of HIV Cooperative Agreement Program (SATHCAP), July 2009: introduction.

In 2003, the National Institute on Drug Abuse (NIDA) of the National Institutes of Health invited collaborative research proposals on the sexual transmission of HIV and other infectious diseases among drug-using and non-drug-using populations. The outcome of this effort was the cooperative agreement program called the “Sexual Acquisition and Transmission of HIV Cooperative Agreement Program” or SATHCAP. SATHCAP was designed for multidisciplinary epidemiologic research on the behavioral, biological, and environmental processes involved in the sexual transmission of HIV and other sexually transmitted infections/diseases (STD) among drug users and to non-drug-using populations.

US Adult Cigar Smoking Patterns, Purchasing Behaviors, and Reasons for Use According to Cigar Type: Findings From the Population Assessment of Tobacco and Health (PATH) Study, 2013–2014

Introduction The US cigar market is diverse, yet until recently most research studies and tobacco surveillance systems have not reported behavioral and related outcomes by cigar type. Methods The 2013-2014 Population Assessment of Tobacco and Health Study collected data separately for filtered cigars (FCs), cigarillos, and traditional cigars, which were further distinguished as premium or nonpremium. Descriptive statistics for adult established current smokers of each cigar type and cigarettes were calculated for demographic characteristics, tobacco use patterns, purchasing behaviors and reasons for use. Adjusted prevalence ratios (APRs) using a marginal predictions approach with logistic regression assessed correlates of dual cigar and cigarette smoking. Results Age, sex, race/ethnicity, education level, and poverty status of smokers varied according to cigar type. Daily cigar smoking prevalence and number of cigars smoked per day were higher for FCs (37.3%; median: 1.6 cigars/day, respectively), than all other cigar types (6.7%-25.3%, all p < .01; 0.1-0.4 cigars/day, all p < .01, respectively); daily smoking and cigars per day were similar for nonpremium cigars and cigarillos (p = .11; p = .33, respectively). Cigarette smoking was twice as common among smokers of nonpremium cigars, cigarillos, and FCs (58.0%-66.0%) than among premium cigars (29.9%). Among current cigar smokers, FC smokers (APR = 1.23, 95% confidence interval [CI] = 1.09-1.39), other tobacco product users (APR = 1.27, 95% CI = 1.15-1.41), and those with a GED/high school diploma or less (APR = 1.20, 95% CI = 1.09-1.33) were more likely to also smoke cigarettes. Conclusion User characteristics, cigar smoking patterns, and dual smoking with cigarettes varied by cigar type highlighting the importance of adequately describing the cigar type studied and, where appropriate, differentiating results by cigar type. Implications Despite the diversity of the cigar market place, historically many research studies and tobacco surveillance systems have treated cigars as a single product type. This study describes similarities and differences in the user characteristics, tobacco use patterns, and purchasing behaviors of premium, nonpremium, cigarillo, and filtered cigar smokers. To enhance tobacco regulatory science, sufficient descriptions of the cigar type(s) studied and, where appropriate, differentiation of the particular cigar type(s) studied should be undertaken to improve the interpretation of study findings, understanding of cigar use patterns and related behaviors and future approaches to reducing cigar-attributable morbidity and mortality.

Longitudinal associations between youth tobacco and substance use in waves 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study

BACKGROUND While evidence suggests bidirectional associations between cigarette use and substance (alcohol or drug) use, how these associations are reflected across the range of currently available tobacco products is unknown. This study examined whether ever tobacco use predicted subsequent substance use, and ever substance use predicted subsequent tobacco use among 11,996 U.S. youth (12-17 years) from Waves 1 (2013-2014) and 2 (2014-2015) of the Population Assessment of Tobacco and Health (PATH) Study. METHODS Ever use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe, hookah, snus pouches, smokeless tobacco excluding snus pouches, dissolvable tobacco, bidis, kreteks, alcohol, marijuana, prescription drugs, and other drugs (cocaine and other stimulants, heroin, inhalants, solvents, and hallucinogens) was assessed at Wave 1 followed by past 12-month use assessments at Wave 2. The analyses included covariates (demographics, mental health, sensation seeking, prior use) to mitigate confounding. RESULTS Ever tobacco use predicted subsequent substance use. The magnitude of the associations was lowest for alcohol, higher for marijuana, and highest for other drugs. Ever substance use also predicted subsequent tobacco use. Specifically, ever alcohol, marijuana, and non-prescribed Ritalin/Adderall use predicted tobacco-product use. Ever e-cigarette and cigarette use exclusively and concurrently predicted subsequent any drug (including and excluding alcohol) use. E-cigarette and cigarette use associations in the opposite direction were also significant; the strongest associations were observed for exclusive cigarette use. CONCLUSION Tobacco and substance use prevention efforts may benefit from comprehensive screening and interventions across tobacco products, alcohol, and drugs, and targeting risk factors shared across substances.