Olivia A. Wackowski

Examining market trends in the United States smokeless tobacco use: 2005–2011

Background While cigarette consumption in the USA continues to decline, promotion for and consumption of smokeless tobacco (SLT) is growing. However, little research has explored what product features are driving SLT growth, despite awareness that product-level factors may be important in SLT use. This study analyses national sales data to better understand the impact of product features on SLT sales. Methods Data on sales of SLT in US convenience stores from 2005 to 2011 were obtained from Nielsen Research Company. Each listed product was coded for attributes such as type, brand, flavouring and form to calculate their respective total sales, market share and contribution to overall SLT growth. Results Sales of moist snuff products (including snus) increased by 65.6% between 2005 and 2011. Sales of pouched and flavoured forms of moist snuff increased by 333.8% and 72.1%, respectively, and contributed to 28% and 59.4% of the total growth in the moist snuff category, respectively. Value/discount brands accounted for 42% of moist snuff sales in 2011 among the top 10 selling brands, largely driven by Grizzly. After 2 years on the national market, Camel Snus was also one of the top 10 selling moist snuff brands. Conclusions Sales of moist snuff, both overall and for particular styles, are increasing. Growing pouch use may be attributed to new SLT users, which may include cigarette smokers using them as starter SLT products. Increased sales of flavoured and discounted snuff raise concerns about use and appeal to youth. Continued surveillance of SLT sales trends is warranted.

Exploring the relationship between race/ethnicity, menthol smoking, and cessation, in a nationally representative sample of adults.

OBJECTIVE To explore the relationship between race/ethnicity, menthol smoking, and cessation in a nationally representative sample of adults. METHODS Data from the 2005 U.S. National Health Interview Survey was analyzed. Our analyses were restricted to 7815 white, black, and Hispanic current and former cigarette smokers who indicated that they do not currently use other tobacco products and have made a quit attempt. We used multiple logistic regressions to test the relationship of menthol smoking and cessation controlling for various factors. RESULTS Significant interaction effects were found indicating that the association between menthol smoking and cessation differs between whites and blacks, and whites and Hispanics. When blacks and Hispanics are collapsed as non-white, we found that non-white menthol smokers were significantly less likely to have quit smoking (adjusted odds ratio=0.55, p<0.01) compared to their non-menthol smoking counterparts. In contrast, among whites, menthol smokers were more likely to be former smokers than nonmenthol smokers (adjusted odds ratio=1.17, p<0.05). CONCLUSION Our findings provide some support for the hypothesis that menthol smoking can lead to poorer cessation outcomes, but only for non-white smokers.

Young Adults’ Risk Perceptions of Various Tobacco Products Relative to Cigarettes: Results From the National Young Adult Health Survey

Objectives. Tobacco product risk perceptions may influence whether individuals use those products instead of or in addition to regular cigarettes. This study aimed to explore risk perceptions of various tobacco products relative to traditional cigarettes with young adults, a group with higher rates of tobacco use. Method. We examined risk perception responses among a nationally representative sample of young adults (age 18-34 years; n = 2,871, including tobacco and non–tobacco users) from the 2011 National Young Adult Health Survey. Results. Most (57.8%) respondents believed that e-cigarettes were less risky than cigarettes. Respondents were more likely to rate combustible products hookah (24.5%) and cigars (13.9%) as being less risky compared to noncombustible snus (10%) and other smokeless tobacco (SLT) products (7.1%) relative to cigarettes. Few (2.5%) rated menthol cigarettes as less risky. For e-cigarettes, hookah, and SLT, less risky beliefs were significantly higher among ever or current versus never product users. Between 22% and 33% of all respondents believed that SLT, snus, menthol cigarettes, and cigars were more risky than cigarettes, but differences in this belief between current and nonusers of these products were small and insignificant. Younger young adults were more likely to rate e-cigarettes and hookah as being “less risky” and rate cigars and SLT as being “more risky” than older young adults. Conclusion. The public’s views of comparative tobacco risk perceptions vary widely by tobacco product type and age-group. While “less risky” perceptions may be associated with product use, perceptions that products are “more risky” than cigarettes may not necessarily dissuade people from their use.

Smokers’ attitudes and support for e-cigarette policies and regulation in the USA

Background In April 2014, the Food and Drug Administration (FDA) proposed a rule to extend its tobacco regulatory authority to e-cigarettes, which have been unregulated and growing in use since their 2006–2007 US introduction. The FDA will issue a final rule based on comments and data received from researchers, tobacco companies and the public. We aimed to present data about current smokers’ awareness of and attitudes towards potential e-cigarette regulation and various policies in the USA. Methods We conducted a cross-sectional online e-cigarette focused survey of 519 adult current smokers in April 2014, before the FDAs proposed rule was announced. Participants were recruited from a private research panel (GFKs Knowledge Networks) designed to be representative of the US population. Results The majority of respondents (62.5%) did not know that e-cigarettes are unregulated by the FDA but agreed that e-cigarettes should be regulated by the FDA for safety and quality (83.5%), carry warning labels about their potential risks (86.6%) and have the same legal age of sale as other tobacco (87.7%). Support was similarly high among current e-cigarette users. Support was substantial though lower overall for policies to restrict e-cigarette indoor use (41.2%), flavouring (44.3%) and advertising (55.5%), and was negatively associated with current e-cigarette use. Conclusions Support for many e-cigarette regulatory policies is strong among smokers, including for policies that the FDA has recently proposed and potential future regulations. States considering indoor e-cigarette restrictions should know that a substantial number of current smokers support such regulations.

Smokers’ and E-Cigarette Users’ Perceptions about E-Cigarette Warning Statements

Cigarette warning labels are important sources of risk information, but warning research for other tobacco products is limited. This study aimed to gauge perceptions about warnings that may be used for e-cigarettes. We conducted six small focus groups in late 2014/early 2015 with adult current e-cigarette users and cigarette-only smokers. Participants rated and discussed their perceptions of six e-cigarette warning statements, and warnings in two existing Vuse and MarkTen e-cigarette ads. Participants were open to e-cigarette warnings and provided the strongest reactions to statements warning that e-liquid/e-vapor or e-cigarettes can be poisonous, contain toxins, or are “not a safe alternative to smoking”. However, many also noted that these statements were exaggerated, potentially misleading, and could scare smokers away from reducing their harm by switching to e-cigarettes. Opinions on the Food and Drug Administration’s proposed nicotine addiction warning and warnings that e-cigarettes had not been approved for smoking cessation or had unknown health effects were mixed. Participants perceived MarkTen’s advertisement warning to be stronger and more noticeable than Vuse’s. Care should be taken in developing e-cigarette warnings given their relative recentness and potential for harm reduction compared to other tobacco products. Additional research, including with varied audiences, would be instructive.

A Content Analysis of Smokeless Tobacco Coverage in U.S. Newspapers and News Wires

INTRODUCTION Research attention on smokeless tobacco (SLT) has focused on SLT use, health risks, harm-reduction potential, and risk perceptions, but few studies have examined mediated communications about SLT. This study aims to contribute to the literature by providing the first description of SLT coverage in the news, an important communication channel given its ability to educate and shape public opinion about tobacco issues. METHODS A content analysis was conducted on SLT-related news and opinion articles between 2006 and 2010 from top circulating national and state newspapers and select news wires. Articles were coded for the main SLT topic, SLT risk references, and slant of opinion articles. RESULTS SLT was discussed in news/feature articles (n = 677) in terms of business (28%), new products, product regulation and harm reduction (19%), prevention/cessation (11.4%), taxation (10.2%), profiles/trends in use (9%), bans (8.1%), and tobacco industry promotional activities (4.9%). Health risk references (i.e., addictiveness, carcinogenicity, and specific health effects including oral cancer) were found in 40% of articles, though frequency differed by article topic. Although the majority of opinion articles (n = 176) conveyed an anti-SLT slant (64%), 25.6% were pro-SLT. CONCLUSIONS SLT topics of both national and local importance are covered in the news. Public health professionals can participate in SLT coverage by sending in press releases about new study findings, events, or resources and by submitting opinion pieces to share views or respond to previous coverage. Research on SLT news should continue given its potential to shape the publics SLT knowledge and opinions.

The influence of menthol, e-cigarettes and other tobacco products on young adults’ self-reported changes in past year smoking

Objective Progression to regular smoking often occurs during young adulthood. This study examines self-reported changes in past year smoking among young adults and the potential influence of tobacco products on these trajectories. Methods Respondents to the 2011 National Young Adult Health Survey who smoked 100 cigarettes in their lifetime (n=909) described smoking behaviour at the time of the survey and 1 year prior. Cigarette smoking trajectories were categorised as: no change, quit, decreased smoking or increased smoking. Participants were also asked about current use of menthol cigarettes and other tobacco products (ie, cigars, smokeless tobacco, hookah) and ever use of e-cigarettes. Results Most young adults (73.1%) reported stable cigarette smoking behaviours, while 8.2% reported having quit, 5.8% reported that they smoke on fewer days, 5% progressed from someday to daily smoking and 8% increased from not at all to current smoking. The youngest smokers (18–20) had significantly higher odds (adjusted OR (AOR) =2.6) of increasing cigarette use over the past year compared to those aged 30–34, as did blacks versus whites (AOR=2.35). Menthol cigarette use nearly doubled (AOR=1.87) the odds of increased smoking behaviour. E-cigarette and other tobacco product (OTP) use were not associated with increasing smoking but OTP use was negatively associated with remaining quit from cigarettes. Conclusions Young adulthood is a critical period for smoking interventions, particularly among those most vulnerable to increasing smoking behaviours (ie, black and younger young adults). Policy efforts to restrict menthol cigarettes may reduce young adult smoking progression.

Asian American, Native Hawaiian and Pacific Islander tobacco use patterns.

OBJECTIVES To provide a national depiction of Asian American (AA) and Native Hawaiian/Pacific Islander (NHPI) tobacco use and highlight considerations for targeted interventions. METHODS We analyzed data from the 2009-2010 National Adult Tobacco Survey for subgroup differences in prevalence and consumption of various tobacco products. RESULTS Use varies considerably by ethnic subgroups for cigarette smoking (including menthol) and other forms of tobacco. Despite being lighter, less frequent, and seemingly less dependent smokers, AANHPIs had similar quit ratios as non-AANHPIs. CONCLUSIONS AA and NHPI disparities in tobacco use may be due to underutilization of cessation resources, including those for non-cigarette tobacco products, and lack of availability of culturally-appropriate resources. Community-based and regulatory approaches should be employed to reduce use of all tobacco products, especially among high prevalence subgroups.

Banning Smoking in New Jersey Casinos—A Content Analysis of the Debate in Print Media

New Jerseys (NJs) 2006 statewide smoking ban controversially exempted Atlantic City casinos. This study presents a content analysis of 210 NJ newspaper articles printed between November 2005 and February 2007, and describes the different frames and supporting information used to argue for or against exempting casinos from the smoking ban. Those in favor of exempting casinos framed the issue in terms of economics and compromise, while those opposing it framed the issue in terms of equity and health. Implications for policy initiatives and media advocacy are discussed. This work was supported in part by funding from the NJ Department of Health & Senior Services.

Smokers' and e-cigarette users' perceptions of modified risk warnings for e-cigarettes

The 2009 Family Smoking Prevention and Tobacco Control Act opened the possibility for tobacco companies to apply to market their products as having “modified” or reduced risks. However, research on how to communicate comparative tobacco risks and how such messages are interpreted is limited. This study aimed to qualitatively examine perceptions of potential modified risk statements presented as warning labels for e-cigarettes. We conducted six focus groups between 2014 and 2015 with 27 adult e-cigarette users and cigarette-only smokers who provided comments on two versions of a modified risk warning for e-cigarettes: 1) “WARNING: No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes” (as proposed by two companies for their smokeless tobacco products) and 2) “WARNING: This product may be harmful to health, but is substantially less harmful than cigarettes” (an alternative developed by our team). Although most personally believed that e-cigarettes are safer than cigarettes and some thought the messages were true and accurate, many were skeptical and uncomfortable with the warnings because they did not “seem like a warning” and because use of the phrase “substantially lower risks” could be misleading and difficult to understand. Several thought the second warning was stronger (e.g., more active, more specific). Modified risk messages about e-cigarettes may impact perceptions and use of the product. More research is needed to identify the framing, wording and placement (e.g. within or in addition to a warning) that could potentially increase population-level benefits and minimize harms.