Background

Cross-sectional data suggests that adolescents' receptivity to the advertising of smokeless tobacco is correlated with use of chewing tobacco or snuff. Lack of longitudinal data has precluded determination of whether advertising receptivity precedes or follows initiation of smokeless tobacco.

Objectives

The objective of this study was to test for the association between advertising receptivity and subsequent initiation of smokeless tobacco among adolescent males.

Methods

Adolescent males from the 1993-1999 Teen Longitudinal California Tobacco Survey were selected at the baseline survey for never having used smokeless tobacco. Separate longitudinal analyses corresponded to two dependent variables, ever use of smokeless tobacco (1993-1996; N = 1,388) and use on 20 or more occasions (1993-1999; N = 1,014). Models were adjusted for demographic variables, risk factors for smokeless tobacco use, and exposure to users of smokeless tobacco.

Results

Advertising receptivity at baseline was predictive of ever use by late adolescence (RR(95% CI) = 2.0 (1.5, 2.8)) and regular use by young adulthood (RR(95% CI) = 3.7 (2.1, 6.7)) in models that were adjusted for covariates. Conclusions/ Importance: The findings challenge the tobacco industry's assertion that tobacco marketing does not impact youth initiation. This is particularly relevant to tobacco control in the United States because the 2009 Tobacco Control Act places fewer restrictions on smokeless tobacco products compared to cigarettes.

Some tobacco researchers have argued that the European Union should remove its ban on a form of low-nitrosamine smokeless tobacco referred to as Swedish 'snus'. This argument has developed in to an international debate over the use of smokeless tobacco as a measure of harm reduction for smokers. Leading authorities in the USA have firmly stated that there is no safe tobacco - a message which does not allow for any discussion of comparative tobacco risks. This commentary is intended to review the origin of the controversy over Swedish 'snus', to examine briefly the meta-analysis on cancer risks by Peter Lee and Jan Hamling (published in July in BMC Medicine) and to discuss the anticipated direction of the debate on tobacco-harm reduction in the USA. We anticipate that much of the debate will shift from the discussion of epidemiologic data to the discussion of the marketing, health communication and economics of smokeless tobacco. While the Food and Drug Administration's newly approved authority over tobacco will undoubtedly affect the smokeless products, it may not be the sole determinant of harm reduction's fate in the USA.

In August 2006, U.S. District Court Judge Gladys Kessler ordered four tobacco companies to disseminate court-approved corrective statements on five topics pertaining to health hazards of cigarette smoking. Based on the 2018 Health Information National Trends Survey (HINTS), approximately 50% of U.S. smokers viewed at least one corrective statement via television or newspaper during the first six months of the airings/publications (November 2017-April 2018). Using televised gross rating points (GRPs) and cross-sectional data from the 2018 HINTS (n = 3484) and 2019 HINTS (n = 3331), the current study extends previous ones by estimating broadcast reach/frequency and the moderating effect of survey year on smokers' exposure to a corrective statement. The weighted percentage of participants who viewed a corrective statement was significantly greater in the 2019 versus 2018 HINTS for smokers (64.3% vs. 50.5%, χ2 1df = 5.85, p = .01), but not for non-smokers (39% in 2018/2019, χ2 1df = 0.02; p = .88); this differential effect was evidenced by a significant interaction term (OR = 2.0(1.2, 3.2), p < .001). This study also revealed that the televised reach of the corrective statements to the U.S. population (43.5 GRPs/43.5%) was comparable to the published estimate from the 2018 HINTS (40.6%). The frequency of exposure to any corrective statement in the first six months of televised airings was only 0.68 exposures/month, an estimate that does not meet CDC Best Practices. Yet, as evidenced by the significant interaction with survey year, it is likely that the addition of messages to tobacco company websites and cigarette package onserts may have contributed to smokers' greater exposure to a corrective statement.

The uneven diffusion of local and state laws restricting the use of electronic nicotine delivery systems (ENDS) in the United States may be a function of inconclusive scientific evidence and lack of guidance from the federal government. The objective of this study was to assess whether the rationale for amending clean indoor air acts (CIAAs) is being conflated by issues that are not directly relevant to protecting the health of ENDS non-users. Online sources were used in identifying bills (n = 25) that were presented in U.S. state legislatures from January 2009 to December 2015. The bills were categorized into one of three groups: 1) bills amending comprehensive CIAAs (n = 11), 2) bills prohibiting use of ENDS in places frequented by youth (n = 5), and 3) remaining bills that varied between the two categories (n = 9). Arguments presented in committee hearings were coded as scientific, public health, economic, enforcement, freedom, or regulatory. Arguments pertaining to amendment of clean indoor air acts spanned several categories, many of which were not directly relevant to the aims of the legislation. This finding could assist lawmakers and expert witnesses in making arguments that yield greater success in amending legislation. Alternatively, inconclusive scientific data on the hazards of ENDS aerosols might encourage lawmakers to propose legislation that prohibits ENDS use in places frequented by youths.

We used a systems science perspective to examine adolescents' personal networks, school networks, and neighborhoods as a system through which emotional support and peer influence flow, and we sought to determine whether these flows affected past-month smoking at 2 time points, 1994-1995 and 1996. To test relationships, we employed structural equation modeling and used public-use data from the National Longitudinal Study of Adolescent Health (n = 6504). Personal network properties affected past-month smoking at both time points via the flow of emotional support. We observed a feedback loop from personal network properties to emotional support and then to past-month smoking. Past-month smoking at time 1 fed back to positively affect in-degree centrality (i.e., popularity). Findings suggest that networks and neighborhoods in this system positively affected past-month smoking via flows of emotional support.

Introduction

The objective of this study was to assess whether the nascent, but rapidly growing e-liquid industry prohibits Internet sales to minors and employs safety measures to prevent accidental poisonings.

Methods

A stratified simple random sample (n = 120) was selected from the target population (N = 1107) of US online vendors of e-liquid in July 2015. The vendors were stratified and subsequently oversampled by trade association membership and vendor popularity. Three minors aged 16 to 17, who were supervised by adult research staff, attempted to purchase e-liquid from the 120 online vendors using debit cards issued in their names. Measures included vendors' use of age verification, warning labels on e-liquid bottles, and child-resistant packaging.

Results

Statistically significant differences were observed by vendor popularity, but not by membership in a trade association. The differences by vendor popularity, however, occurred for measures that were limited to an age warning and list of ingredients. The most striking finding was the scant vendors (n = 4) who successfully prevented the sale of e-liquid to the minors. In contrast, 87.5% and 53.9% of the bottles contained child-resistant packaging and a health warning label, respectively.

Conclusions

Irrespective of trade association membership or vendor popularity, online vendors of e-liquids are not taking the proper precautions in preventing sales to minors. The FDA's upcoming deeming rules on e-cigarette products should include explicit requirements for offline and online e-liquid vendors, particularly the use of effective age verification, warning labels, and child-resistant packaging.

Implications

This study demonstrates that, in the absence of any current FDA regulation of e-liquid products, self-regulation among vendors is not effective in preventing product acquisition by minors. Lax oversight of the e-liquid industry may draw consumers to bypass current tobacco control restrictions implemented in face-to-face sales settings. As a consequence, there may be an increase in online sales to minors. Further regulation of the industry may increase the already prevalent use of child-resistant packaging, leading to fewer cases of accidental nicotine poisoning.

Several cities, but only two U.S states, have passed a law banning the sales of flavored tobacco products. It has been suggested that framing tobacco control policy solely in terms of the youth could send the erroneous message that tobacco use is an acceptable behavior for adults. This study was intended to compare the framing of policy between California's Senate Bill (SB) 38 and 793. Seven audio files of hearings on SB-38 (N = 2) and SB-793 (N = 5), held between March 2019 and August 2020, were transcribed and coded for youth issues and the unprecedented events of 2020 that shaped society's views of health and racial/social justice. The Framework Method was used for organizing and analyzing content of the legislative hearings. Many of the same arguments pertaining to youth were presented in hearings on the two bills. The one notable difference was legislators' sense of obligation to younger constituents, which was expressed in hearings on SB-793, but not SB-38. The hearings on SB-793 also differed with respect to greater discussion about the relevance of a tobacco flavor ban to society as a whole. These discussions revolved around the COVID-19 pandemic and potential impact of a ban on communities of color. Discussions on SB-793 about the larger societal impact of flavored tobacco may be a more effective strategy than focusing exclusively on the youth. Thus, legislators from other U.S. states who are contemplating a statewide ban should consider reframing the issue according to California's SB-793.

Objective

Restricting tobacco marketing is a key element in the US Food and Drug Administration's (FDA) public health framework for regulating tobacco. Given the dearth of empirical data on direct marketing, the objective of this study was to assess the reach and impact of promotions on sales through snuff websites.

Methods

Nine brands of snuff, representing more than 90% of market share, were monitored for content of coupons, sweepstakes, contests, and other promotions on their respective websites. Monthly sales data and website traffic for the 9 brands, corresponding to the 48-month period of January 2011 through December 2014, were obtained from proprietary sources. A time-series analysis, based on the autoregressive, integrated, moving average (ARIMA) method, was employed for testing the relationships among sales, website visits, and promotions.

Results

Website traffic increased substantially during the promotion periods for most brands. Time-series analyses, however, revealed that promotion periods for 5 of 7 brands did not significantly correlate with monthly snuff sales.

Conclusions

The success in attracting tobacco consumers to website promotions demonstrates the marketing reach of snuff manufacturers. This form of direct marketing should be monitored by the FDA given evidence of adolescents' exposure to cigarette brand websites.

Abstract Background High levels of airborne particles from secondhand smoke have been reported in California Indian casinos. Yet, little is known regarding the smoking status of casino patrons, their avoidance of secondhand smoke while visiting, and their views on a hypothetical smoking ban. Methods Predictors of visiting an Indian casino were assessed among participants of the 2008 California Tobacco Survey (n = 10, 397). Exposure to and avoidance of secondhand smoke were subsequently analyzed among a subset of participants who had visited a casino in the year prior to the survey (n = 3, 361). Results Ethnic minorities, older individuals, current smokers and residents of sparsely populated regions of California were more likely than other demographic groups to visit a tribal casino. Avoidance of secondhand smoke was more frequent among the never smokers than former and current smokers, particularly those who last visited a casino lacking physical separation between non-smoking and smoking sections. The never smokers versus current smokers disproportionately expressed a willingness to extend their stay and visit again if smoking were prohibited. Conclusions If casinos became smoke free, then it is anticipated that they would be visited by a significantly larger number of Californians, including both patrons and those who otherwise would not have visited a casino.

Introduction

Recent studies have separately examined the content and demographic reach of the advertising of electronic nicotine delivery systems (ENDS). No study to our knowledge has linked the two in investigating whether racial/ethnic groups are differentially exposed to the comparative messages conveyed in online ENDS advertisements.

Methods

932 unique ENDS advertisements (6311 total), which were posted on 3435 websites between December, 2009 and October, 2015, were categorized as either comparative or non-comparative with respect to the traditional cigarette. The race/ethnicity of website visitors was obtained from a proprietary source and used in constructing variables for racial/ethnic viewership. The variables for advertising content and website racial/ethnic viewership were then linked yielding a final sample of 551 unique ENDS advertisements (2498 total) on 1206 websites. A two-level hierarchical generalized linear model, used in estimating website racial/ethnic viewership as a predictor of comparative advertising, accounted for the nesting of advertisements (level 1) within 152 ENDS brands (level 2).

Results

In contrast to racial/ethnic minorities, a greater proportion of non-Hispanic whites visited websites with ENDS advertisements than the overall proportion of nonHispanic white U.S. Internet users. Yet, it was the advertisements on websites that appealed to Hispanics that had greater odds of comparing ENDS to traditional cigarettes.

Conclusions

The lower exposure to ENDS advertising among racial/ethnic minorities versus non-Hispanic whites is consistent with survey data. Yet, the greater odds of comparative advertising of ENDS on websites that appeal to racial/ethnic minorities (ie, Hispanics) could impact the longterm health of minority smokers.

Implications

This study's findings have important implications for the uptake of ENDS among minority smokers. If the comparative advertising yields greater interest and eventual use of ENDS, then minority smokers could either benefit from smoking cessation because they switch to ENDS, or adopt dual tobacco use. The fate of comparative advertising of ENDS versus the traditional cigarette will depend on the Food and Drug Administration enforcement of its deeming rules and the ensuing changes in the ENDS marketplace.