Terry F. Pechacek

Changing Perceptions of Harm of E-Cigarettes Among U.S. Adults, 2012–2015

INTRODUCTION Although the impact of long-term use of electronic cigarettes (e-cigarettes) on health is still unknown, current scientific evidence indicates that e-cigarettes are less harmful than combustible cigarettes. The study examined whether perceived relative harm of e-cigarettes and perceived addictiveness have changed during 2012-2015 among U.S. adults. METHODS Data were from Tobacco Products and Risk Perceptions surveys of probability samples representative of U.S. adults in 2012, 2014, and 2015. Changes over time in perceived harmfulness of e-cigarettes were examined using pairwise comparisons of proportions and multinomial logistic regression analysis. Analyses were conducted in January 2016. RESULTS Whereas 11.5% and 1.3% of adults perceived e-cigarettes to have about the same level of harm and to be more harmful than cigarettes, respectively, in 2012, 35.7% and 4.1% did so in 2015. The proportion of adults who thought e-cigarettes were addictive more than doubled during 2012-2015 (32.0% in 2012 vs 67.6% in 2015). Compared with 2012, the odds of perceiving e-cigarettes to be equally or more harmful (than to be less harmful) doubled (95% CI=1.64, 2.41) in 2014, and tripled (95% CI=2.60, 3.81) in 2015. CONCLUSIONS There is an increase in the proportion of U.S. adults who misperceive the harm of e-cigarettes and consider them to be as harmful as combustible cigarettes. The study highlights the need to design public health messages that accurately interpret the scientific data on the potential harm of e-cigarettes and clearly differentiate the absolute from the relative harm of e-cigarettes.

The Potential That Electronic Nicotine Delivery Systems Can be a Disruptive Technology: Results From a National Survey

Introduction: This study evaluates the reasons for use and acceptance of Electronic Nicotine Delivery Systems (ENDS) among current and former cigarette smokers to assess if ENDS may become a satisfying alternative to cigarettes. Methods: Data are from a national probability sample of 5717 US adults, surveyed June–November 2014. The survey contained questions on awareness, usage, and reasons for use of traditional and novel tobacco products. The analytic sample was current and former smokers who ever used ENDS (n = 729) and was divided into four mutually exclusive categories. Among the 585 current smokers, 337 were no longer using ENDS (“E-Cig Rejecters”), and 248 were continuing to use both ENDS and cigarettes (“E-Cig Dual Users”). Among 144 former cigarette smokers, 101 were non-recent users of ENDS (“Quit All Products”), and 43 were continuing to use ENDS exclusively (“Switchers”). Results: Former smokers (the “Switchers”) report finding ENDS a satisfying alternative to regular cigarettes, with only 15.8% (95% confidence interval [CI] 4.4–27.1) rating ENDS as less enjoyable than regular cigarettes. However, greater than fivefold more current smokers did not find them satisfying and stopped using them (77.3%; 95% CI 72.1–82.4 of “E-Cig Rejecters” rated ENDS as less enjoyable). Being less harmful was the most highly rated reason for continuing to use ENDS among “Switchers.” Most (80.9%) “Switchers” reported that ENDS helped them quit cigarettes. Conclusion: Since many current smokers who have tried ENDS reject them as a satisfying alternative to regular cigarettes, ENDS will not replace regular cigarettes unless they improve. Implications: Since about one-half of recent former smokers are trying ENDS with about one-fourth continuing to use them, and many reporting that these products have helped them quit regular cigarettes, the potential impact of ENDS on population quit rates deserves continued surveillance. However, since most current smokers who have tried ENDS reject them as a satisfying alternative to regular cigarettes, the potential of ENDS becoming a disruptive technology replacing regular cigarettes remains uncertain. ENDS need to improve as a satisfying alternative or the attractiveness and appeal of the regular cigarette must be degraded to increase the potential of ENDS replacing regular cigarettes.

Flavored e-cigarette use: Characterizing youth, young adult, and adult users.

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12–17 years old), young adults (18–29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014–2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and “usual” e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Cigarettes smoked per day among high school students in the U.S., 1991-2009.

BACKGROUND Recent declines in current cigarette smoking among youth are encouraging, but less is known about the trends in the number of cigarettes smoked per day among youth. PURPOSE This study examined trends in the number of cigarettes smoked per day among U.S. high school students during 1991-2009. METHODS Nationally representative data from the 1991-2009 national Youth Risk Behavior Surveys (YRBS) were analyzed in 2010. The YRBS is a biennial, school-based survey representative of 9th- through 12th-grade students in the U.S. Each survey year, students completed anonymous, self-administered questionnaires that included identically worded questions about cigarette use. The number of cigarettes smoked per day on smoking days was categorized as light smoking (<1-5 cigarettes per day); moderate smoking (6-10 cigarettes per day); and heavy smoking (≥11 cigarettes per day). Sample sizes ranged from 10,904 to 16,410. Overall response rates ranged from 60% to 71%. RESULTS During 1991-2009, among current cigarette users overall, light smoking increased from 67.2% to 79.4% and heavy smoking decreased from 18.0% to 7.8%. These trends were found among female and male students overall and white students. Among Hispanic students, light smoking remained stable, but heavy smoking significantly increased from 3.1% in 1991 to 6.4% in 2009. The prevalence of light, moderate, and heavy smoking did not change during 1991-2009 among black students. CONCLUSIONS The finding that during 1991-2009 light smoking increased and heavy smoking decreased among current cigarette users is encouraging; however, even light smoking is detrimental to health and efforts to reduce all cigarette use should continue.

Electronic nicotine delivery system dual use and intention to quit smoking: Will the socioeconomic gap in smoking get greater?

INTRODUCTION Electronic nicotine delivery systems (ENDS) are popular among cigarette smokers; however, it is not known whether the use of ENDS assists or delays quitting cigarettes, especially among certain priority populations. We examined predictors of intention to quit smoking and patterns of dual use of ENDS and traditional cigarettes among priority populations. METHODS This study used data from a 2014 survey of a national probability sample of 5717 USA adults. Descriptive statistics were used to examine differences in intention to quit cigarette use among current cigarette smokers (n=1014) and dual users of cigarettes and ENDS (n=248). Multivariable logistic regression analysis was conducted on the overall sample and the subsample of dual users to determine whether dual use (versus cigarette only use) and demographic characteristics predict self-reported intention to quit and having attempted to quit in the past year. Significance was set at p<0.05. RESULTS Compared to cigarette smokers, dual users were slightly more educated (p<0.05), more likely to intend to quit smoking (adjusted odds ratio [AOR]=1.8, p=0.001), and more likely to have attempted to quit smoking in the past year (AOR=1.7, p=0.003). Blacks reported higher intention to quit than Whites (AOR=1.8, p=0.003). Compared with high school education or less, dual users with some college (AOR=1.5, p=0.007) or a college degree (AOR=2.5, p≤0.0001) had high intention to quit. CONCLUSIONS Dual users of ENDS and traditional cigarettes are more likely to intend to quit smoking and have recently made quit attempts. If using ENDS contributes to increased smoking cessation among more educated individuals, disparity in smoking by level of education will increase.

The African American Youth Smoking Experience: An Overview.

INTRODUCTION Beginning in the late 1970s, a very sharp decline in cigarette smoking prevalence was observed among African American (AA) high school seniors compared with a more modest decline among whites. This historic decline resulted in a lower prevalence of cigarette smoking among AA youth that has persisted for several decades. METHODS We synthesized information contained in the research literature and tobacco industry documents to provide an account of past influences on cigarette smoking behavior among AA youth to help understand the reasons for these historically lower rates of cigarette smoking. RESULTS While a number of protective factors including cigarette price increases, religiosity, parental opposition, sports participation, body image, and negative attitudes towards cigarette smoking may have all played a role in maintaining lower rates of cigarette smoking among AA youth as compared to white youth, the efforts of the tobacco industry seem to have prevented the effectiveness of these factors from carrying over into adulthood. CONCLUSION Continuing public health efforts that prevent cigarette smoking initiation and maintain lower cigarette smoking rates among AA youth throughout adulthood have the potential to help reduce the negative health consequences of smoking in this population. IMPLICATIONS While AA youth continue to have a lower prevalence of cigarette smoking than white youth, they are still at risk of increasing their smoking behavior due to aggressive targeted marketing by the tobacco industry. Because AAs suffer disproportionately from tobacco-related disease, and have higher incidence and mortality rates from lung cancer, efforts to prevent smoking initiation and maintain lower cigarette smoking rates among AA youth have the potential to significantly lower lung cancer death rates among AA adults.

Reassessing the importance of ‘lost pleasure’ associated with smoking cessation: implications for social welfare and policy

Introduction Benefit–cost analyses of tobacco regulations include estimates of the informed choice of smokers to continue smoking. Few studies have focused on subjective feelings associated with continued smoking. This study estimates how smoker discontent and regret relate to risk perceptions and health concerns. Methods We analysed data from a 2015 nationally representative, online survey of 1284 US adult current smokers. Information was collected on regret, intention to quit, perceived addiction, risk perceptions and health concerns. Multivariate logistic regression adjusting for sociodemographics and health status was used to examine factors associated with smoker discontent. Results More than 80% of current smokers report high (22.5%) or very high (59.8%) discontent due to inability to quit, perceived addiction and regret about having started to smoke. Higher levels of discontent did not vary significantly by sex, age, race/ethnicity, education or income (adjusted odds ratios (AORs) 0.5–1.2). Compared with the smokers expressing low (5.9%) or very low (3.6%) discontent, those expressing higher levels of discontent perceived their health status as fair/poor (AOR=2.3), worried most of the time about lung cancer (AOR=4.6) and felt they were more likely to develop lung cancer in the future (AOR=5.1). Conclusion The proportion of smokers who might be characterised as having a preference to continue smoking are greatly outnumbered by addicted, discontent and concerned smokers who want to quit and regret ever having started to smoke. These discontent smokers could have a substantial net welfare gain if new regulations helped them escape their concerns about the health effects from continuing smoking.

Are electronic nicotine delivery systems helping cigarette smokers quit? Evidence from a prospective cohort study of U.S. adult smokers, 2015–2016

Background The potential of electronic nicotine delivery systems (ENDS) to reduce the cardiovascular and other disease risks of smoking is of great interest. While many smokers report using ENDS for cessation, their impact under real-world use patterns and conditions on adult smokers’ quitting behavior is uncertain. The objective of this study was to generate more recent and comprehensive evidence on the effect of “real world” ENDS use on the population quit rates of adult smokers while taking account of frequency and duration of use, device type, e-liquid flavor, and reasons for use. Methods and findings We conducted a population-based, prospective cohort study of a random probability sample of 1284 U.S. adult smokers recruited in August/September 2015 and re-contacted one-year later (September 2016) from GfK’s KnowledgePanel, a national, probability-based web-panel designed to be representative of non-institutionalized U.S. adults. Among the 1081 baseline smokers who remained members of KnowledgePanel, 858 completed the follow-up survey. The primary outcome was smoking abstinence for at least 30 days prior to follow-up. Secondary outcomes were making a quit attempt during the 12-month study period and number of cigarettes smoked per day at follow-up. The adjusted odds of quitting smoking were lower for those that used ENDS at baseline (9.4%, 95% CI = 5.22%-16.38%; AOR = 0.30, 95% CI = 0.13–0.72) compared to smokers who did not use at ENDS (18.9%, 95% CI = 14.24%-24.68%). Smokers who used ENDS daily at some point during the study period were also less likely to quit smoking than nonusers (AOR = 0.17; 95% CI = 0.04–0.82). Limited ability to draw causal inferences from the observational design and a lack of biochemical verification of quitting smoking or ENDS use are limitations of this study. Conclusions We found no evidence that ENDS use, within context of the 2015–2016 US regulatory and tobacco/vaping market landscape, helped adult smokers quit at rates higher than smokers who did not use these products. Absent any meaningful changes, ENDS use among adult smokers is unlikely to be a sufficient solution to obtaining a meaningful increase in population quit rates. Additional research is needed to reconcile the divergent literature and monitor the impact of ENDS in an environment of rapidly evolving markets and regulatory policies.

Prevalence and Factors Associated with Smokeless Tobacco Use, 2014-2016.

OBJECTIVES We aimed to determine whether the prevalence of current use of smokeless tobacco products (STPs) changed during 2014-2016 and examine factors associated with use among adults in the United States (US). METHODS Data were obtained from Tobacco Products and Risk Perceptions Surveys of probability samples representative of US adults in 2014, 2015, and 2016. Change over time in current (past 30 day) STP use was examined using pairwise comparisons of proportions and multivariable logistic regression. Associated factors were examined using Rao-Scott χ2 and multivariable logistic regression. RESULTS The prevalence of current STP use was higher in 2015 (3.6%) than in 2014 (2.3%, p < .001) and 2016 (2.7%, p = .018) among US adults. In 2016, current STP use was associated with being male, under age 60, currently using hookah or e-cigarettes, and having less than a college degree. Rates of use did not vary by cigarette smoking status, race/ethnicity, income, or metropolitan statistical area (MSA). CONCLUSIONS The prevalence of current STP use peaked in 2015. In 2016, current STP use was more prevalent among males and adults with lower education. Continuous monitoring of STP use is needed, particularly non-cigarette tobacco product users.

A National Comparison of Dual Users of Smokeless Tobacco and Cigarettes and Exclusive Cigarette Smokers, 2015–2016

Abstract Introduction While smoking rates have declined, use of smokeless tobacco (ST) has remained constant. ST is heavily marketed to cigarette smokers, and many ST users smoke cigarettes. This study provides updated comparisons of the characteristics, smoking behaviors, and perceptions of US adult dual ST and cigarette users and exclusive cigarette smokers in 2015–2016. Methods Data were from nationally representative, cross-sectional surveys from 2015 and 2016. Adult smokers reported past 30-day use of ST, current cigarette smoking, risk perceptions, smoking, and quitting behaviors. We estimated Rao–Scott χ2 and adjusted odds ratios (AORs) to compare dual users and exclusive smokers. Results Dual users were more likely to be younger, reside in nonmetropolitan statistical areas (MSA) and outside the Northeast United States. Adjusting for covariates, dual users did not differ significantly from exclusive smokers on most smoker characteristics, including number of past year quit attempts. Dual users were more likely to report past 30-day use of novel tobacco products (AORs 2.90 [little cigars and cigarillos] to 11.02 [hookah]). Dual users who reported at least 1 past year cigarette quit attempt were more likely than exclusive smokers to report using ST, traditional cigars, hookah, or heat-not-burn as a past year quit method (AOR: 9.54 [95% CI: 3.22 to 28.23]). Conclusions Smokers who use ST are more likely than exclusive smokers to attempt to quit smoking cigarettes using other tobacco products. These findings may be attributed to increasing use prevalence of novel products. We recommend further monitoring to assess polytobacco use and differences among these populations. Implications Many current ST users smoke cigarettes and ST promotions often target cigarette smokers. As the FDA considers ST regulations and implements a nicotine centered regulatory framework, it is imperative to evaluate how these policies and promotion of ST as potentially reduced risk products impact dual and polytobacco use. Our study found that many dual users engage in novel tobacco use in general and as a cessation method. Consideration of ST and polytobacco use among smokers may be helpful in the development of forthcoming FDA regulations, messaging, and interventions.