Linda A. Alexander

Workplace and home smoking restrictions and racial/ethnic variation in the prevalence and intensity of current cigarette smoking among women by poverty status, TUS-CPS 1998-1999 and 2001-2002.

Study objective: Recognition of the health consequences of exposure to environmental tobacco smoke has led government agencies and many employers to establish policies that restrict cigarette smoking in public and workplaces. This cross sectional study examines the association of workplace smoking policies and home smoking restrictions with current smoking among women. Design: Participants were employed US women ages 18–64 who were self respondents to the 1998–1999 or 2000–2001 tobacco use supplement to the current population survey supplements. Cross tabulations and multivariate logistic regression analyses examine the association of selected demographic characteristics, occupation, income, workplace and home smoking policies/restrictions with current smoking, consumption patterns, and quit attempts among women by poverty level for five race/ethnic groups. Main results: The prevalence of either having an official workplace or home smoking policy that completely banned smoking increased with increased distance from the poverty level threshold. A complete ban on home smoking was more frequently reported by African American and Hispanic women although Hispanic women less frequently reported an official workplace smoking policy. In general, policies that permitted smoking in the work area or at home were associated with a higher prevalence of current smoking but this varied by poverty level and race/ethnicity. Home smoking policies that permitted smoking were associated with lower adjusted odds of having a least one quit attempt for nearly all poverty level categories but there was no association between having one quit attempt and workplace policies. Conclusion: Home smoking policies were more consistently associated with a lower prevalence of current smoking irrespective of poverty status or race/ethnicity than workplace policies. These findings underscore the importance of examining tobacco control policies in multiple domains (work and home) as well as by race/ethnicity and socioeconomic position.

Health profile differences for menthol and non-menthol smokers: findings from the national health interview survey

AIMS Although the adverse effects of smoking are well known, limited information exists about the overall health profiles of menthol smokers when compared to their non-menthol smoking counterparts. Using a well-known nationally representative survey, this study examines differences between self-reported health characteristics for menthol and non-menthol smokers. DESIGN Cross-sectional data from the 2005 National Health Interview Survey and its cancer control supplement were used to analyze responses for current and former smokers (n = 12,004) independently. All analyses were conducted using SAS version 9.2 and SAS callable SUDAAN version 9.0.3. Multiple logistic regression analysis was used to model menthol smoking. FINDINGS After controlling for sex, age and race, we found that in current smokers the mean number of cigarettes smoked per day is significantly lower for menthol smokers when compared to non-menthol smokers [odds ratio (OR): 0.99; 95% confidence interval (CI): 0.98, 1.00]. Also, we found that former menthol smokers had higher body mass indices (BMIs) (OR: 1.01; 95% CI: 1.00, 1.02) and were more likely to have visited the emergency room due to asthma (OR: 2.30, 95% CI: 1.04, 5.09). CONCLUSIONS Overall, current menthol and non-menthol smokers have similar health profiles. However, menthol smokers reported smoking fewer cigarettes per day than their non-menthol counterparts. While these findings are supportive of other published data, future studies may need to tease out the health-related significance of smoking fewer menthol cigarettes per day but having similar health outcomes to those who smoke more non-menthol cigarettes per day. Additionally, our findings suggest that there may be some differences between the former menthol and non-menthol smoker.

Why We Must Continue to Investigate Menthol's Role in the African American Smoking Paradox.

BACKGROUND The disproportionate burden of tobacco use among African Americans is largely unexplained. The unexplained disparities, referred to as the African American smoking paradox, includes several phenomena. Despite their social disadvantage, African American youth have lower smoking prevalence rates, initiate smoking at older ages, and during adulthood, smoking rates are comparable to whites. Smoking frequency and intensity among African American youth and adults are lower compared to whites and American Indian and Alaska Natives, but tobacco-caused morbidity and mortality rates are disproportionately higher. Disease prediction models have not explained disease causal pathways in African Americans. It has been hypothesized that menthol cigarette smoking, which is disproportionately high among African Americans, may help to explain several components of the African American smoking paradox. PURPOSE This article provides an overview of the potential role that menthol plays in the African American smoking paradox. We also discuss the research needed to better understand this unresolved puzzle. METHODS We examined prior synthesis reports and reviewed the literature in PubMed on the menthol compound and menthol cigarette smoking in African Americans. RESULTS The pharmacological and physiological effects of menthol and their interaction with biological and genetic factors may indirectly contribute to the disproportionate burden of cigarette use and diseases among African Americans. CONCLUSIONS Future studies that examine taste sensitivity, the menthol compound, and their effects on smoking and chronic disease would provide valuable information on how to reduce the tobacco burden among African Americans. IMPLICATIONS Our study highlights four counterintuitive observations related to the smoking risk profiles and chronic disease outcomes among African Americans. The extant literature provides strong evidence of their existence and shows that long-standing paradoxes have been largely unaffected by changes in the social environment. African Americans smoke menthols disproportionately, and menthols role in the African American smoking paradox has not been thoroughly explored. We propose discrete hypotheses that will help to explain the phenomena and encourage researchers to empirically test menthols role in smoking initiation, transitions to regular smoking and chronic disease outcomes in African Americans.

A Qualitative Approach to Increasing HIV Prevention in Primary Care Settings for Older Adults Perspectives From Primary Care Providers

The purpose of this research was to explore primary care providers’ willingness and ability to increase HIV prevention efforts among older adults and to gain recommendations for improving HIV prevention in primary care settings. Data were collected through 24 semistructured interviews with primary care providers. The results of the study reveal that the majority of providers find it necessary to increase HIV prevention efforts in primary care settings and are willing to do so; however, they cannot do so without assistance. Providers suggested strategies to increase HIV prevention in primary care, for instance, expanding the use of electronic reminders to include HIV prevention and increasing collaboration among providers of different specialties. As a result of the interviews, additional recommendations for increasing HIV prevention have been identified. These findings will aid in improving the quality of care provided to individuals older than 50 in primary care settings.

Sugar and Aldehyde Content in Flavored Electronic Cigarette Liquids

Introduction Sugars are major constituents and additives in traditional tobacco products, but little is known about their content or related toxins (formaldehyde, acetaldehyde, and acrolein) in electronic cigarette (e-cigarette) liquids. This study quantified levels of sugars and aldehydes in e-cigarette liquids across brands, flavors, and nicotine concentrations (n = 66). Methods Unheated e-cigarette liquids were analyzed using liquid chromatography mass spectrometry and enzymatic test kits. Generalized linear models, Fishers exact test, and Pearsons correlation coefficient assessed sugar, aldehyde, and nicotine concentration associations. Results Glucose, fructose and sucrose levels exceeded the limits of quantification in 22%, 53% and 53% of the samples. Sucrose levels were significantly higher than glucose [χ2(1) = 85.9, p < .0001] and fructose [χ2(1) = 10.6, p = .001] levels. Formaldehyde, acetaldehyde, and acrolein levels exceeded the limits of quantification in 72%, 84%, and 75% of the samples. Acetaldehyde levels were significantly higher than formaldehyde [χ2(1) = 11.7, p = .0006] and acrolein [χ2(1) = 119.5, p < .0001] levels. Differences between nicotine-based and zero-nicotine labeled e-cigarette liquids were not statistically significant for sugars or aldehydes. We found significant correlations between formaldehyde and fructose (-0.22, p = .004) and sucrose (-0.25, p = .002) and acrolein and fructose (-0.26, p = .0006) and sucrose (-0.21, p = .0006). There were no significant correlations between acetaldehyde and any of the sugars or any of the aldehydes and glucose. Conclusions Sugars and related aldehydes were identified in unheated e-cigarette liquids and their composition may influence experimentation in naïve users and their potential toxicity. Implications The data can inform the regulation of specific flavor constituents in tobacco products as a strategy to protect young people from using e-cigarettes, while balancing FDAs interest in how these emerging products could potentially benefit adult smokers who are seeking to safely quit cigarette smoking. The data can also be used to educate consumers about ingredients in products that may contain nicotine and inform future FDA regulatory policies related to product standards and accurate and comprehensible labeling of e-cigarette liquids.

Menthol cigarette smoking and obesity in young adult daily smokers in Hawaii

This study investigates 1) the relationship between menthol cigarette smoking and obesity and 2) the association of body mass index with the nicotine metabolite ratio among menthol and non-menthol daily smokers aged 18–35 (n = 175). A brief survey on smoking and measures of height and weight, carbon monoxide, and saliva samples were collected from participants from May to December 2013 in Honolulu, Hawaii. Multiple regression was used to estimate differences in body mass index among menthol and non-menthol smokers and the association of menthol smoking with obesity. We calculated the log of the nicotine metabolite ratio to examine differences in the nicotine metabolite ratio among normal, overweight, and obese smokers. Sixty-eight percent of smokers used menthol cigarettes. Results showed that 62% of normal, 54% of overweight, and 91% of obese smokers used menthol cigarettes (p = .000). The mean body mass index was significantly higher among menthol compared with non-menthol smokers (29.4 versus 24.5, p = .000). After controlling for gender, marital status, educational attainment, employment status, and race/ethnicity, menthol smokers were more than 3 times as likely as non-menthol smokers to be obese (p = .04). The nicotine metabolite ratio was significantly lower for overweight menthol smokers compared with non-menthol smokers (.16 versus .26, p = .02) in the unadjusted model, but was not significant after adjusting for the covariates. Consistent with prior studies, our data show that menthol smokers are more likely to be obese compared with non-menthol smokers. Future studies are needed to determine how flavored tobacco products influence obesity among smokers.

Abstract IA47: Resolving the complex problem of tobacco-caused lung cancer disparities in the U.S

Existing data show that lung cancer disparities are not explained by cigarette smoking dose and duration alone. Data from the Multiethnic Cohort Study show that Native Hawaiians and African Americans who smoked 10 cigarettes per day have an elevated risk of lung cancer compared to Japanese American, White, and Latino smokers. Prior studies also suggest that African Americans have slower nicotine metabolism compared to Whites. It remains unclear why we consistently observe slower rates of nicotine metabolism among African Americans, but higher rates of lung cancer since studies suggest that smokers with low levels of CPY2A6 activity may be less efficient in bioactivating tobacco smoke pre-carcinogens to carcinogens. Little is known about nicotine metabolism among Native Hawaiians and Filipinos who have disproportionate and unexplained lung cancer rates like African Americans. This study compares biomarkers of tobacco smoke exposure in Native Hawaiian, Filipino, and White young adult daily smokers. We hypothesized that Native Hawaiians and Filipinos, like African Americans, would have slower nicotine metabolism compared to Whites. We collected data on sociodemographics, smoking history, and psychosocial risk factors among young adult daily smokers aged 18-35. We measured height, weight, and carbon monoxide levels among all smokers. A saliva sample was collected from each smoker using standard passive drool procedures. The geometric means were calculated for nicotine, cotinine, trans 39 hydroxycotinine, the nicotine metabolite ratio, and expired carbon monoxide and the data were compared among racial/ethnic groups. Two analysis of covariance models tested biomarker differences among racial/ethnic groups. Model 1, the unadjusted model, contained no covariates. Model 2 included gender, body mass index (BMI), menthol smoking status, Hispanic ethnicity, and the number of cigarettes smoked per day as covariates. The sample included 44% Native Hawaiians, 16% Filipinos, and 40% Whites (n=186). Twenty-four percent of young adults were of Hispanic origin, 48% were females, and smokers had a mean BMI of 28. Forty-one percent of Filipino smokers reported Hispanic ethnicity compared to 27% of Native Hawaiian and 15% of White smokers (p In the unadjusted and adjusted models, cotinine levels were higher among Native Hawaiians compared to Whites, but these differences were not significant among racial/ethnic groups. In the unadjusted model, the nicotine metabolic ratio was significantly lower in Native Hawaiian and Filipino smokers compared to White smokers (NMR: 0.17, 0.15, 0.27, p In summary, our data show that Native Hawaiian and Filipino daily smokers have slower nicotine metabolism than White daily smokers as indicated by the nicotine metabolite ratio. Studies show that the nicotine metabolite ratio is a reliable phenotypic marker for CYP2A6 activity. However, is it not clear whether the algorithm suggesting that slow nicotine metabolizers have reduced lung cancer risk applies to all racial/ethnic groups. Resolving the complex problem of lung cancer disparities requires further investigation of multiple biological pathways to determine which lung cancer risk algorithms apply to specific racial/ethnic groups. Such investigations will allow to us to improve community, clinical, and policy-based interventions to reduce disparities. Citation Format: Pebbles Fagan, Eric T. Moolchan, Pallav Pokhrel, Thaddeus Herzog, Kevin Cassel, Ian Pagano, Adrian Franke, Joseph Keawe9aimoku Kaholokula, Angela Sy, Linda A. Alexander, Dennis R. Trinidad, Kari-Lyn Sakuma, Carl Anderson Johnson, Alyssa M. Antonio, Dorothy Jorgensen, Tania Lynch, Crissy Kawamoto, Mark S. Clanton. Resolving the complex problem of tobacco-caused lung cancer disparities in the U.S. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr IA47.