Sara M. Kennedy

Characteristics of Electronic Cigarette Use Among Middle and High School Students - United States, 2015.

Electronic cigarettes (e-cigarettes) are now the most commonly used tobacco product among U.S. youths (1,2); in 2015, 5.3% of middle school students and 16.0% of high school students reported using e-cigarettes in the past 30 days (1). However, limited information exists on the e-cigarette product types and brands used and the substances used in these products by youths. CDC and the Food and Drug Administration (FDA) analyzed data from the 2015 National Youth Tobacco Survey (NYTS) to examine the characteristics of e-cigarette use among U.S. middle (grades 6-8) and high (grades 9-12) school students in 2015, including types of products used, brands of products used, and whether substances other than nicotine were used with the products. Among respondents reporting ever having used an e-cigarette, 14.5% used only disposable e-cigarettes, 53.4% used only rechargeable/refillable e-cigarettes, and 32.1% used both types. Two of the most commonly used e-cigarette brands were blu (26.4%, 1.65 million youths) and VUSE (12.2%, 760,000 youths); half of students (50.7%, 3.18 million) did not know the brand of e-cigarette they used. One third (32.5%) of those who reported ever using an e-cigarette also reported having used e-cigarettes for substances other than nicotine. Preventing youths from beginning use of any tobacco product, including e-cigarettes, is critical to tobacco use prevention and control strategies in the United States (3). Monitoring the characteristics of e-cigarette use among youths, including product types, brands, and ingredients, is important to inform strategies to prevent and reduce e-cigarette use among youths.

Clinical interventions to reduce secondhand smoke exposure among pregnant women: a systematic review

Objective To conduct a systematic review of clinical interventions to reduce secondhand smoke (SHS) exposure among non-smoking pregnant women. Data sources We searched 16 databases for publications from 1990 to January 2013, with no language restrictions. Study selection Papers were included if they met the following criteria: (1) the study population included non-smoking pregnant women exposed to SHS, (2) the clinical interventions were intended to reduce SHS exposure at home, (3) the study included a control group and (4) outcomes included either reduced SHS exposure of non-smoking pregnant women at home or quit rates among smoking partners during the pregnancy of the woman. Data extraction Two coders independently reviewed each abstract or full text to identify eligible papers. Two abstractors independently coded papers based on US Preventive Services Task Force criteria for study quality (good, fair, poor), and studies without biochemically-verified outcome measures were considered poor quality. Data synthesis From 4670 papers, we identified five studies that met our inclusion criteria: four focused on reducing SHS exposure among non-smoking pregnant women, and one focused on providing cessation support for smoking partners of pregnant women. All were randomised controlled trials, and all reported positive findings. Three studies were judged poor quality because outcome measures were not biochemically-verified, and two were considered fair quality. Conclusions Clinical interventions delivered in prenatal care settings appear to reduce SHS exposure, but study weaknesses limit our ability to draw firm conclusions. More rigorous studies, using biochemical validation, are needed to identify strategies for reducing SHS exposure in pregnant women.

Smoke-free policies in U.S. prisons and jails: A review of the literature

INTRODUCTION Despite progress in limiting exposure to secondhand smoke (SHS) in the United States, little is known about the impact of smoke-free polices in prisons and jails. SHS exposure in this setting may be great, as smoking prevalence among inmates is more than three times higher than among non-incarcerated adults. To inform the implementation of smoke-free policies, this article reviews the literature on the extent, nature, and impact of smoke-free policies in U.S. prisons and jails. METHODS We systematically searched PubMed, Embase, EconLit, and Social Services Abstracts databases. We examined studies published prior to January 2014 that described policies prohibiting smoking tobacco in adult U.S. correctional facilities. RESULTS Twenty-seven studies met inclusion criteria. Smoke-free policies in prisons were rare in the 1980s but, by 2007, 87% prohibited smoking indoors. Policies reduced SHS exposure and a small body of evidence suggests they are associated with health benefits. We did not identify any studies documenting economic outcomes. Non-compliance with policies was documented in a small number of prisons and jails, with 20%-76% of inmates reporting smoking in violation of a policy. Despite barriers, policies were implemented successfully when access to contraband tobacco was limited and penalties were enforced. CONCLUSION Smoke-free policies have become increasingly common in prisons and jails, but evidence suggests they are not consistently implemented. Future studies should examine the health and economic outcomes of smoke-free policies in prisons and jails. By implementing smoke-free policies, prisons and jails have an opportunity to improve the health of staff and inmates.

Tobacco and Marijuana Initiation Among African American and White Young Adults.

INTRODUCTION African American youth use marijuana at similar rates and tobacco at lower rates compared with white youth; however, in adulthood, tobacco use is similar. Tobacco and marijuana use are closely associated; differing initiation patterns may contribute to observed racial differences in tobacco prevalence by age. Therefore, it is important to assess tobacco and marijuana initiation patterns by race. METHODS Data were obtained from 56,555 adults aged 18-25 who completed the 2005-2012 National Survey on Drug Use and Health. The analysis was restricted to those who reported ever use of marijuana and combustible tobacco (cigarettes and/or cigars). Three mutually exclusive categories of initiation patterns were evaluated: use of marijuana before tobacco; marijuana and tobacco at the same age; and tobacco before marijuana. Multivariable regression models were used to assess changes over time and compare these outcomes by race while controlling for sociodemographics, risk perceptions, and current substance use. RESULTS In 2005, 26.6% of African American and 14.3% of white young adults used marijuana before tobacco, compared with 41.5% of African American and 24.0% of white young adults in 2012 (P < .001). Overall, African American young adults had greater odds of using marijuana before tobacco (AOR = 1.79; 95% CI: 1.67, 1.91) compared with whites. CONCLUSION African American young adults were more likely than whites to use marijuana before tobacco and both groups were increasingly likely to use marijuana before tobacco over time. A greater understanding of how marijuana initiation interacts with tobacco initiation could inform more effective tobacco and marijuana use prevention efforts. IMPLICATIONS Among ever users of combustible tobacco and marijuana, greater proportions of African American young adults used marijuana before tobacco or at the same age than their white counterparts. Moreover, both African Americans and whites were more likely to use marijuana before tobacco in 2012 compared with 2005. Tobacco control policy may benefit from a broader understanding of the patterns of initiation to tobacco and marijuana use. Some public health interventions aimed at preventing and reducing combustible tobacco use among African American young adults may be strengthened by considering marijuana use.

Cigarette, Cigar, and Marijuana Use Among High School Students - United States, 1997-2013.

What is already known on this topic? Since 2010, the proportion of U.S. 12th grade students who reported using marijuana during the preceding 30 days (21.4%) has surpassed the proportion reporting use of cigarettes during the preceding 30 days (19.2%).What is added by this report? During 1997–2013, the proportion of white, black, and Hispanic high school students overall who were exclusive cigarette or cigar users decreased 64%, from 20.5% to 7.4%. The proportion of white, black, and Hispanic students who were exclusive marijuana users more than doubled from 4.2% to 10.2%, and among cigarette or cigar users, marijuana use increased, with considerable increases identified among black and Hispanic students toward the end of the study period.What are the implications for public health practice? Despite significant declines since 1997, approximately 30% of white, black, and Hispanic U.S. high school students were current users of cigarettes, cigars, or marijuana in 2013. Policy and programmatic efforts might benefit from integrated approaches that focus on reducing the use of tobacco and marijuana among youths.

Patterns of E-cigarette Use Frequency—National Adult Tobacco Survey, 2012–2014

INTRODUCTION Accounting for occasional or intermittent e-cigarette use has yielded higher estimates of current use among U.S. adults. However, frequency of e-cigarette use by population subgroups is not well described. This study assessed e-cigarette use frequency by sociodemographic characteristics and other tobacco product use among U.S. adults. METHODS This study analyzed combined data from the 2012-2013 (n=60,192) and 2013-2014 (n=75,233) National Adult Tobacco Survey, a telephone-based survey of U.S. adults aged ≥18 years, to assess frequency of e-cigarette use (daily, some days, rarely) by sex, age, race/ethnicity, education, annual household income, U.S. region, marital status, sexual orientation, and cigarette smoking and other tobacco product use (cigars, cigarillos, little filtered cigars; traditional pipes; water pipes; and chewing tobacco, snuff, dip, snus, and dissolvable tobacco products). Analyses took place in 2016. RESULTS Among current e-cigarette users, 19.3% used daily, 29.3% used some days, and 51.4% used rarely. Daily use was lowest among younger adults, Hispanics, and those who were single, never married, or not living with a partner; and greatest among non-Hispanic Asians (p<0.0001). Among current e-cigarette users, 25.3% were cigarette-only smokers, 52.8% smoked cigarettes and used other tobacco products, 5.5% used other tobacco products only, 6.5% were former cigarette-only smokers, 6.7% were former users of cigarettes and other tobacco products, 1.3% were former other tobacco product users only, and 1.8% never used cigarettes or other tobacco products. CONCLUSIONS E-cigarette use frequency varies by sociodemographic characteristics and other tobacco use. Further surveillance, particularly related to frequency of e-cigarette use and its impact on cigarette cessation, could inform public health policy, planning, and practice.

Not Just Cigarettes: A More Comprehensive Look at Marijuana and Tobacco Use Among African American and White Youth and Young Adults

INTRODUCTION Cigarettes, cigars, and marijuana have generally been studied in isolation yet their use does not occur in isolation. Focus on cigarette smoking may overstate the observation that African American youth and young adults are less likely to smoke any combustible product compared with their white counterparts. Assessing cigarette, cigar, and marijuana use trends may help identify the extent of this difference. METHODS Data from the 2002-2012 National Survey on Drug Use and Health (N = 25 541 to N = 28 232) were used to investigate past 30-day cigarette, cigar, and marijuana use trends among African American and white youth (12-17) and young adults (18-25). Logistic regressions assessed trends in combustible tobacco (cigarettes and cigars) and marijuana use, alone and in combination. RESULTS From 2002-2012, the absolute difference in cigarette smoking prevalence between African American and white youth (9.6%-4.2%) and young adults (19.0%-10.5%) narrowed. Any combustible tobacco/marijuana use was significantly lower among African Americans than whites but, relative to cigarettes, the absolute difference was much smaller among youth (7.2%-2.2%) and young adults (15.8%-5.6%). Among any combustible tobacco/marijuana users, using two or more substances ranged from 31.4% to 40.3% among youth and 29.1% to 39.8% among young adults. CONCLUSION Any combustible tobacco/marijuana use trends suggest the smoking prevalence difference between African American and white youth and young adults is real, but less pronounced than when assessing cigarette smoking alone. Policies and programs addressing smoking behaviors may benefit from broadening focus to monitor and address cigar and marijuana use as well. IMPLICATIONS Trends in any use of cigarettes, cigars, and/or marijuana suggest the difference in smoking prevalence between African American and white youth and young adults is real, but less pronounced than when cigarette smoking is assessed alone. In 2012, more than 10% of African American and white youth, more than a third of African American young adults, and nearly half of white young adults reported past 30-day use of cigarette, cigars, and/or marijuana. Public health programs aimed at reducing these behaviors among youth and young adults could be informed by considering detailed, race-specific information regarding tobacco and marijuana use patterns.

Cigarette Smoking Among Inmates by Race/Ethnicity: Impact of Excluding African American Young Adult Men From National Prevalence Estimates.

INTRODUCTION Cigarette smoking prevalence is more than two times greater among incarcerated adults, a population usually excluded from national health surveys. African American young adult (18-25) men are less likely to smoke cigarettes than their white counterparts. However, they are two and a-half-times more likely to be incarcerated. This study estimated smoking prevalence with noninstitutionalized and incarcerated samples combined to determine if excluding incarcerated adults impacts smoking prevalence for certain populations. METHODS The Bureau of Justice Statistics last fielded the Survey of Inmates in State and Federal Correction Facilities in 2003-2004. We combined data from Survey of Inmates in State and Federal Correction Facilities (n = 17 910) and the 2003 and 2004 National Health Interview Survey (n = 61 470) to calculate combined cigarette smoking estimates by race/ethnicity, sex, and age. RESULTS Inmates represented the greatest proportion of smokers among African American men. Among African American young adult men, inmates represented 15.2% of all smokers in the combined population, compared to 2.0% among white young adult men. Cigarette smoking prevalence was 17.6% in the noninstitutionalized population of young adult African American men and 19.7% in the combined population. Among white young adult men, cigarette smoking prevalence was 29.8% in the noninstitutionalized population, and 30.2% in the combined population. There was little difference in estimates among women. CONCLUSIONS The exclusion of incarcerated African American young adult men may result in a small underestimation of cigarette smoking prevalence in this population. Increasing access to smoking cessation support among inmates may reduce smoking prevalence in disproportionately incarcerated segments of the US population. IMPLICATIONS The exclusion of incarcerated adults from national survey data should be considered when examining differences in cigarette smoking prevalence estimates between African American and white young adult men. Approximately one in six African American young adult men who smoke were incarcerated. Increasing access to smoking cessation support among inmates may reduce smoking prevalence among disproportionately incarcerated segments of the population.

Point-of-sale cigarette purchase patterns among U.S. adult smokers—National Adult Tobacco Survey, 2012–2014

Tobacco products are ubiquitous in most U.S. retail environments. Given that data on preferred point-of-sale purchase locations among U.S. adult tobacco users are limited, an enhanced understanding of tobacco purchase locations can help inform tobacco control policy, planning, and practice. We investigated prevalence and sociodemographic characteristics associated with cigarette purchase location among U.S. adult smokers. Pooled data came from the 2012-2013 (N=60,192) and 2013-2014 (N=75,233) National Adult Tobacco Surveys. Current cigarette smokers (n=18,005) aged ≥18 were asked if they purchased cigarettes within the previous 30days (n=15,182) and, if so, where they last purchased cigarettes. In 2016, logistic regression adjusted for sex, age, race/ethnicity, education level and annual household income was used to assess characteristics associated with purchase location. Among current smokers, 90.2% reported purchasing cigarettes in the past 30days. The most common purchase locations were convenience stores/gas stations (69.1%), tobacco discount stores (9.9%), drug stores (5.0%), supermarkets (4.9%), and liquor stores (3.6%). The odds of purchasing cigarettes at convenience stores/gas stations were higher among men (adjusted odds ratio (AOR)=1.4; 95% confidence interval (CI)=1.2-1.5) than women; and among adults aged 18-24 (AOR=3.1; 95% CI=2.4-3.9), 25-44 (AOR=3.1; 95% CI=2.7-3.7), and 45-64years (AOR=1.8 95% CI=1.6-2.1) than adults aged ≥65years. Over two-thirds of U.S. smokers last purchased cigarettes from convenience stores/gas stations. Understanding the relationship between purchase location and smoker characteristics may inform tobacco control strategies in the retail environment.

National Surveys and Tobacco Use Among African Americans: A Review of Critical Factors.

INTRODUCTION Beginning in the 1970s, US national surveys showed African American youth having a lower prevalence of cigarette smoking than white youth. Yet, during adulthood, African Americans have a smoking prevalence comparable to white adults. Data sources chosen can contribute in different ways to understanding tobacco use behaviors among African American youth and adults; this article is a review of national and/or state-based health surveys to examine their methodology, racial and ethnic classifications, and tobacco-use related measures. METHODS Eleven national and/or state based surveys were selected for review. Eight surveys were multitopic and included questions on tobacco use and three surveys were tobacco specific. Survey methods included telephone (4), household (3), and school (4). Three major characteristics examined for each survey were: (1) survey design and methods, (2) racial and ethnic background classification, and (3) selected tobacco smoking questions. Within these three characteristics, 15 factors considered to be important for examining tobacco use behaviors by African Americans were identified a priori using previously published reviews and studies. RESULTS Within survey design and methods, the majority of surveys (≥7) oversampled African Americans and did not use proxy respondents for tobacco questions. All surveys used Office of Management and Budget standard classification for race/ethnicity classification. The majority of surveys (≥7) captured five of the seven tobacco-related smoking questions. CONCLUSIONS Programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors. IMPLICATIONS This review of 11 national and state tobacco-related surveys shows that these surveys provide much needed estimates of tobacco use behaviors. However, as tobacco programs and researchers seek to examine tobacco use behaviors among African Americans, it is important to consider multiple surveys as each can contribute to informing the tobacco experience in African Americans. Most importantly, programmatic objectives and/or research questions should guide the selection of data sources for tobacco control programs and researchers examining African American tobacco use behaviors.