Background Large health warning labels (HWLs) with pictures on tobacco packaging are an effective policy to communicate the harms of tobacco use and discourage consumption. The tobacco industry also uses packaging as a key communication tool, altering its design to appeal and attract specific groups. Few studies have assessed compliance of HWLs noting ways that the tobacco industry exploits packaging and labeling regulation loopholes. This study assessed compliance with HWL requirements on cigarette packs from Mexico. Methods The analysis included cigarette packs purchased in October and November 2021 using the Tobacco Pack Surveillance System (TPackSS) protocol in 12 low, middle, and high socioeconomic areas in each of five cities: Mexico City, Guadalajara, León, Durango, and Mérida. In total, 191 unique cigarette packs, with Mexican HWLs that were current at the time of data collection, were assessed for compliance based on HWL location, size, label elements (ie, text and background colors), and use of exact images as published by the government. Compliance with HWL size was examined by pack shape and type. Results All the cigarette packs that were assessed were compliant with HWL location and the majority (98%) complied with label elements; 85% complied with HWL size. Beveled edge packs were less likely to be compliant in terms of warning size than packs without them ( P < 0.05). Only 27% of packs had the image appearing exactly as specified by the Mexican government, obscuring the intended visual composition and diverting attention away from the focal point—thus, diminishing the image’s impact. Conclusions Countries, including Mexico, implementing new or revising current HWL policies should establish enforcement procedures to ensure correct implementation of HWLs and prevent loopholes that can be exploited by the tobacco industry. Part of this would be to consider standardized tobacco pack shape to allow for better HWL implementation and effectiveness.

Introduction:This study aimed to assess the association between tobacco use patterns and cigarette smoking cessation in a representative cohort of adults who smoked combustible cigarettes in the U.S. Methods:Study included current cigarette smoking adults in Wave 4 of the Population Assessment of Health and Tobacco study (N=5,669). Patterns of use were exclusive cigarette smoking, dual cigar and cigarette smoking, dual ENDS use, and multiple product use (poly use). Abstinence status (cessation) was obtained from Population Assessment of Health and Tobacco study Wave 5 and defined as abstinent ≥3 months. Weighted multivariable logistic regression analyses were performed. Analyses were completed in June 2024. Results:Exclusive cigarette smoking was 82.0%, and dual cigar smoking and dual ENDS use constituted 3.7% and 4.4%, respectively. Of adults who smoked cigarettes, 25.7% were abstinent ≥3 months at follow-up. Adults with dual cigar smoking (20.8%) were more likely to be abstinent ≥3 months than those who smoked cigarettes exclusively (10.0%). Adults reporting dual cigar smoking had higher odds of being 3-month abstinent than those reporting exclusive cigarette smoking (OR=2.60, 95% CI=1.60, 4.21). Conclusions:Dual cigar smoking is positively associated with smoking abstinence in adults 1 year later. A deeper understanding of the dynamics and characteristics of dual cigar smoking that rendered cigarette smoking cessation more likely is needed. The data did not offer supporting evidence for dual ENDS use as a cessation aid. The majority of smoking cessation was achieved without the use of assistance.

Background Tobacco product litter may be a form of postconsumption marketing if the littered items are branded. We conducted an observational study in India to assess the presence of tobacco product litter and determine the proportion that included branding. Methods During November–December 2022, we identified tobacco product litter (cigarette/bidi butts and packaging; smokeless tobacco packaging) in nine Indian cities: Bengaluru, Bhubaneswar, Chennai, Delhi, Guwahati, Hyderabad, Lucknow, Mumbai and Patna. In each city, we conducted observations along 15 different routes, each approximately 250 m in distance, for a total of 135 observational routes. Data collectors classified each piece of tobacco litter (product/packaging) and recorded if the litter had visible branding, such as brand names and/or logos. Results The study identified 17 261 pieces of tobacco product litter; SLT packaging comprised the largest proportion of the sample (62%), followed by cigarette butts (26%), bidi butts (8%), cigarette packaging (3%) and bidi packaging (1%). Across the sample, 81% (n=13 924) of the litter was branded. A brand was visible on most packaging for cigarettes (98%), bidis (97%) and SLT (86%), and present on 82% of cigarette butts and 26% of bidi butts. Conclusion This study found that the majority of tobacco product litter in India is branded, which could function as a form of postconsumption marketing. Plain and standardised packaging and banning branding features on filters would reduce tobacco litter branding.

INTRODUCTION:ENDS can benefit those who use combustible tobacco if they transition completely to ENDS. ENDS can also result in nicotine addiction among nicotine-naïve people. METHODS:ENDS-related tobacco-use transitions were assessed among U.S. youth and adults using weighted Population Assessment of Tobacco and Health Study Waves 4 (2016-2017) and 5 (2018-2019) adult and youth data. A beneficial transition was defined as those who used combustible tobacco and transitioned exclusively to ENDS use or quit with the help of ENDS. A harmful transition was defined as (1) nonusers of any tobacco product who initiated ENDS (with or without combustible tobacco co-use) or (2) those who exclusively used ENDS and then added or transitioned to combustible tobacco use. Sensitivity analyses were conducted to examine modified definitions of beneficial and harmful transitions based on different assumptions. The analyses were conducted between August 2024 and November 2024. RESULTS:Total sample size (N=31,733) represented ∼256 million people. For those using a combustible tobacco product in Wave 4, 2.1 million (∼4.6%) transitioned to exclusive ENDS use or to ENDS-assisted cessation of a combustible tobacco product (benefit). In addition, 4.6 million (∼%2.2) transitioned from nonuse to ENDS or, among people who use ENDS exclusively in Wave 4, added combustible or transitioned to combustible tobacco use in Wave 5 (harm). CONCLUSIONS:For every 1 beneficial transition, ENDS use was associated with 2.15 harmful transitions; this ratio ranged from 0.75 to 2.77 in sensitivity analyses. With effective restrictions on ENDS access and marketing for tobacco-naïve people, the population benefits of ENDS could outweigh population harms.

The likelihood of smoking cessation success, sustained cigarette abstinence, varies by demographics, e.g. age, and other factors which shape quality of life, like stress and comorbidities. The recent emergence of newer tobacco products, like cigars and electronic nicotine delivery systems and in turn newer patterns of tobacco use, like exclusive smoking, dual, or poly use, complicates the picture of cessation process. To fill this gap and inform treatment, this study aimed to assess the role of patterns of tobacco use and perceived change in quality of life in cessation (abstinence ≥ 3 months) and examine the effect of age on those relationships in younger (18-44 years) and middle aged/older (45+) adults in the United States who smoke cigarettes. Methods: This study included (N=5,669) participants, in a longitudinal cohort study, Population Assessment of Tobacco and Health Study, with self-reported patterns of tobacco use (wave 4) and valid information on cessation at follow-up (wave 5). Patterns of use included exclusive smoking, dual cigarette/cigar, dual cigarette/ENDS, and poly use. Perceived change in quality of life—perception of quality of life now compared with 12 months ago—included worse, about the same, and better. Cessation at follow-up, included sustained abstinence of ≥3m and current smoking/short-term abstinence. Weighted descriptive analyses and logistic regressions were conducted with sustained abstinence as outcome and patterns of use and change in quality of life as predictors, adjusting for sex, race, education, income, BMI, and tobacco dependence. Analyses were stratified by age groups. Results: Overall, 25.7% reported sustained abstinence at follow-up. In both age groups, dual cigarette/cigar compared to exclusive smoking (45+ year adults OR 3.33, 95% CI: 1.26-8.79) and better quality of life (compared to about the same) were associated with higher odds of sustained abstinence. In both groups, lower odds were associated with being black and higher tobacco dependence. Of interest, only in 45+ year adults, worse change quality of life had OR 1.95 (95% CI: 1.02-3.74). Conclusion: Findings indicate that patterns of tobacco use, improved quality of life, race, and tobacco dependence influence likelihood of cessation in all ages, but worse change in life may produce cessation only in older adults. Improving quality of life may hold a great potential to achieve successful smoking cessation.

Background:Tobacco usage and obesity remain critical public health issues in the United States. This study examined the relationship between smoking behaviors, specifically-cigarettes per day (CPD) and motivations to smoke-and body mass index (BMI). We hypothesized that motivations related to food or stress, as well as a higher CPD, will be positively associated with BMI. Methodology:We analyzed the electronic medical records of 204 patients from the Johns Hopkins' Tobacco Treatment and Cancer Screening Clinic (TTCSC) between January and April 2022. Demographic information, smoking behavior, CPD, and motivations to smoke were recorded. Multiple linear regression analysis was performed. Results:We found no statistical significance between motivations to smoke, CPD, and BMI. However, the age at a patient's first visit to the TTCSC was negatively associated with BMI (B = -0.152, P < 0.001). Conclusions:Smoking behaviors were not significantly related to BMI in our sample. It is advisable for clinicians working in tobacco cessation clinics to consider the BMI of individuals who present for cessation services, especially for younger individuals who smoke. They may be more likely to have an elevated BMI at presentation.

BACKGROUND:Few studies have evaluated Electronic Nicotine Delivery Systems (ENDS) in longitudinal studies, as a potential source of metals which may have carcinogenic, neurotoxic, and cardiotoxic effects. We evaluated metal body burden by ENDS use status in a longitudinal population-based national survey. METHODS:We used the Population Assessment of Tobacco and Health (PATH) Study wave 1 (2013-2014), wave 2 (2014-2015), and wave 3 (2015-2016) adult data to assess urinary concentrations of seven metals among (1) ENDS only users who never used any nonelectronic tobacco products (n = 50), (2) ENDS only users who were former users of any nonelectronic tobacco products (n = 123) and (3) Never users (n = 1501) of any tobacco product. RESULTS:Among ENDS only users who never used any nonelectronic tobacco products (n = 50), the geometric mean ratios (GMRs) of Cd and Pb were 1.25 (95%CI: 1.09-1.42) and 1.19 (95%CI: 1.05-1.34), respectively, compared to never users after adjustment for PATH Study wave, age, sex, race/ethnicity, education, region, secondhand smoke at home and work, and cannabis and other substance use. After the same adjustment, the corresponding GMRs were 1.48 (95%CI: 1.32-1.67) and 1.43 (95%CI: 1.28-1.60) for ENDS only users who were former users of any nonelectronic tobacco products (n = 123). No difference was observed in urinary concentrations of other metals comparing ENDS users to never users of any tobacco product. DISCUSSION:ENDS users show higher urinary levels of Cd and Pb, including lifetime exclusive ENDS users compared to never users of any tobacco product. These findings are limited by the small sample size and could be related to underreporting of past combustible tobacco use or other factors. Metals typical of ENDS such as nickel and chromium unfortunately are not available in PATH. Studies assessing metal exposure associated with long term lifetime exclusive ENDS use (≥5 years) with larger sample size are needed.

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

PURPOSE: Sexual and gender minoritized (SGM) people experience several health disparities and at higher risk of certain conditions, have less access to health care and worse health outcomes.The aim of this study is to compare asthma severity between SGM and straight people in a nationally representative longitudinal study between 2015-2019 in the US. METHODS:We used the Population Assessment of Tobacco and Health (PATH) Study waves 3 (2015Study waves 3 ( -2016Study waves 3 ( ), 4 (2016Study waves 3 ( -2017Study waves 3 ( ), and 5 (2018Study waves 3 ( -2019) ) adult (18+ years, nonpregnant) data.The following questions with dichotomized response options were assessed as asthma severity: in past 12 months, number of asthma attacks required steroid use (0:#1; 1:$2) or urgent care visit (0:0; 1:$1); in past 30 days, amount of time asthma kept from daily activity (0:None; 1:A little or more), shortness of breath in a week (0:#2; 1:$3), woke you up at night in a week (0:#2; 1:$3), required rescue inhaler use in a week (0:#1; 1:$2).The three datasets were merged and mixed effect logistic regression models were used with the adjustment for age, sex, race/ethnicity, education, tobacco use (1: Dual cigarette and e-cigarette users, 2: Cigarette only, 3: E-cigarette (e-cig) users who were former combustible user, 4: Lifetime exclusive e-cig users, 5: Never users of any tobacco products), body mass index, physical activity, asthma medication use. RESULTS:The sample of the study was consisted of 1.815 (9.4%) SGM and 12.879 (90.6%) straights.After the adjustment, the odds ratios (ORs) of keeping from daily activity and having shortness of breath among SGM were 1.33 (95%CI: 1.10-1.61)and 1.82 (95%CI: 1.32-2.51)compared to straights, respectively.Dual use for urgent care visit and lifetime exclusive e-cig use for waking up at nights were detected as interaction.The OR of urgent care visit among SGM who dual use was 3.89 (95%CI: 1.99-7.63)compared to straights who dual use, and the OR of waking up at nights among SGM who lifetime exclusive e-cig use was 7.81 (95%CI: 2.93-20.81)compared to straights who lifetime exclusive e-cig use.The same ORs were 0.74 (95%CI: 0.48-1.14)and 0.85 (95%CI: 0.64-1.12)among SGM and straight who never used any tobacco products, respectively.Steroid and rescue inhaler use were not associated with sexual orientation.CONCLUSIONS: An increased risk of asthma severity was observed among SGM, and this risk was augmented by dual cigarette and e-cig or exclusive e-cig use.CLINICAL IMPLICATIONS: Future research is needed to identify and develop culturally appropriate interventions for lung health risk reduction among SGM.

Introduction The electronic nicotine delivery systems (ENDS) market is highly heterogeneous and changing rapidly in the United States, making classification of devices complicated, especially for surveys. We assessed the percentage of concordant responses between self-reported device type and device type reported by manufacturer/retailer sites for three ENDS brands. Aims and Methods Population Assessment of Tobacco and Health Study wave 5 (2018-2019) asked adult ENDS users about their ENDS device type with the following multiple-choice question: "What kind of electronic nicotine product [is/was] it?" with response options: (1) A disposable device, (2) A device that uses replaceable prefilled cartridges, (3) A device with a tank that you refill with liquids (4) A mod system, and (5) Something else. Participants using only one ENDS device and reporting brands of JUUL (n = 579), Markten (n = 30), or Vuse (n = 47) were included. Responses were dichotomized as "concordant=1" (prefilled cartridge for these three brands) and "discordant = 0" (other responses) to assess the concordance. Results The overall concordance between self-reports and manufacturer/retail sites was 81.8% (n = 537). This percentage was 82.7% (n = 37) among Vuse users, 82.6% (n = 479) among JUUL users, and 69.1% (n = 21) among Markten users. Almost one in three people who use Markten did not indicate that their device uses replaceable prefilled cartridges. Conclusions While at least 70% concordance could be acceptable, collecting more information about device type (eg, liquid container (pod/cartridge/tank), refillability; and submitting pictures) may improve the accuracy of the information. Implications This study is particularly relevant for researchers analyzing smaller samples for example when examining disparities. Monitoring the characteristics of ENDS accurately in population-based studies is critical for regulatory authorities to understand ENDS toxicity, addiction, health effects, and use behaviors at the population level. There is evidence that higher concordance can be achieved with other questions- and methods. Adjusting survey questions about ENDS device type (eg, more descriptive response options, inclusion of separate questions asking about tank, pod, cartridge) and potentially including photos of participants' devices may help to classify ENDS device types more accurately.

INTRODUCTION The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12–17 years), young adults (aged 18–24 years), and older adults (aged ≥25 years) between 2014 and 2019. METHODS Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014–2015), Wave 3 (2015–2016), Wave 4 (2016–2017), and Wave 5 (2018–2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed. RESULTS The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58–7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves. CONCLUSIONS Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

Introduction: The combination of electronic nicotine delivery systems (ENDS) device and liquid characteristics affect user nicotine and toxicant exposure, however population-level national survey studies have not reported device and liquid features jointly nor in detail. We examined combinations of characteristics of devices and liquids used by adult ENDS users.Methods: U.S. adults (21+) using ENDS at least five days/week (n = 1,179) completed an online survey in 2020 and uploaded photos of their most used device and liquid. Device/liquid combinations were analyzed to determine and describe the most common pairings. Data were weighted to the U.S. population of adult daily ENDS users.Results: Five device/liquid combinations accounted for 87 % of those reported. The most prevalent combination, reported by 36.2 %, was re-useable devices with adjustable settings and a tank refilled with a free-base nicotine liquid with a median nicotine concentration of 5.2 mg/mL. The second most frequent combination - re-usable devices with no adjustable settings and a nicotine salt liquid in a disposable pod or cartridge - was reported by 22.8 % and the median nicotine concentration was 49.4 mg/mL. Wattage, voltage and resistance varied across device/liquid combination. Overall, 66.5 % refilled their device's tank or pod and 64.2 % had the ability to manipulate device characteristics (power, airflow, and/or coil).Conclusions: Analyzing ENDS device/liquid combinations rather than each separately can allow researchers to better evaluate relationships between use and key outcomes, such as quitting cigarettes and abuse liability. Additional research may reveal whether certain combinations are more effective at helping smokers quit and which device/liquid combinations should remain on the market.

BACKGROUND:Transgender and Gender Diverse (TGD) populations have current cigarette/e-cigarette/cigar use rates ranging from 32.6% to 39.7%. Importantly, while some studies have reported tobacco use as significantly higher among TGD versus cisgender individuals in multivariate analyses, others have reported no significant differences. The present study used data from wave 4 of the Population Assessment of Tobacco and Health (PATH) study, a large, nationally representative U.S. study, to examine relationships among sociodemographic characteristics, internal and external factors, and tobacco use behaviors, with a focus on TGD individuals.METHODS:Data were from 33,628 adults from the PATH study's wave 4 (collected December 2016-January 2018). Multivariable logistic regression models examined differences in current tobacco use (cigarettes, electronic nicotine products, and cigars) between TGD and cisgender individuals through the replication of previous work using PATH data, as well as evaluating the role of other internal and external factors.RESULTS:TGD individuals were 2-3 times more likely than cisgender individuals to report current nicotine/tobacco use, even after adjustment for potential confounders. TGD individuals tended to have lower income and education and be more likely to endorse a sexual minority identity than their cisgender counterparts; meanwhile, lower income, less education, and lesbian/gay and bisexual identities were significant predictors of nicotine/tobacco use, independent of TGD identity.CONCLUSIONS:Present findings underscore the high rates of nicotine/tobacco use in the TGNC community and emphasize the necessity of TGD-focused research methods and measures, access to quality medical care, and policy aimed at minimizing marginalization and nicotine/tobacco use disparities experienced by TGD communities.

Introduction Past 30-day e-cigarette use increased by 78% among high school students from 2017 to 2018, an increase attributable to pod-style devices. JUUL Labs (JUUL) insists they do not market their product to teenagers. We created several scenarios to estimate the percentages of JUUL’s net revenue from adults and youth in the US in 2018. Methods We used the number of youth (aged 12–17 years) and adults (aged ≥18 years) who reported using JUUL in the nationally representative Population Assessment of Tobacco and Health (PATH) Study wave 4 (Dec 2016–Jan 2018) to estimate the youth proportion of JUUL users. As a sensitivity analysis, we also used data from the nationally representative Truth Longitudinal Cohort (TLC) study to estimate the youth proportion of JUUL users. Based on this percentage, we then applied several scenarios to estimate JUUL’s net revenue from youth in the US in 2018. Results From the PATH Study, 31% of JUUL users were youth (aged 12–17 years). In the TLC study, 30% of current JUUL users were aged 15–17 years. Given that JUUL’s net revenue was $1.3 billion in 2018, we calculated that JUUL made between $130 million and $650 million of its net revenue from youth, depending on consumption scenarios. Conclusions A substantial proportion of JUUL’s profits in 2018 were a result of use by youth. It could be required that all e-cigarette companies actively ensure that use by youth is below a pre-determined small fraction of their sales, requiring that a high penalty be paid by those that fail to do so.

Background Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication. Method Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. ‘Cessation’ was defined as being a former cigarette smoker in wave 4. χ2, logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used. Results Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes. Conclusion No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.

INTRODUCTION There is paucity of literature that evaluates e-cigarette use rates among the youth with attention deficit hyperactivity disorder (ADHD). The aim of this study is to compare the rates of cigarette only, e-cigarette only, dual use, and initiation age of regular use and trying to quit cigarettes or e-cigarettes among the youth with and without ADHD. METHODS We used Population Assessment of Tobacco and Health (PATH) study Wave 3 (2015-2016) youth data, a nationally representative cross-sectional study in the US. The main outcome was tobacco use status of youth and ADHD diagnosis was based on parent report. RESULTS The survey included 11801 youth (50%, 12-14 years; 49% female). Compared to youth without ADHD, the relative risk ratio (RRR) was 1.79 (95% CI: 1.02-3.21) for cigarette only use, 1.41 (95% CI: 1.01-2.21) for e-cigarette only use, 3.40 (95% CI: 1.69-6.84) for dual use, 1.75 (95% CI: 0.92-3.35) for cigarette and other product(s) use, 1.48 (95% CI: 0.58-3.77) for e-cigarette and other product(s) use, and 3.37 (95% CI: 1.88-6.17) for poly use among youth with ADHD, after adjusting for age group, sex, and race/ethnicity. CONCLUSIONS Cigarette only use, e-cigarette only use, dual use of cigarettes and e-cigarettes, and poly use of cigarettes, e-cigarettes, and other product(s) were significantly associated with parent report of an ADHD diagnosis. It is critical for healthcare providers to be screening youth for e-cigarette use, especially youth who are diagnosed with ADHD.