Publications by authors named "Joanna E Cohen"

176 Publications

Straw cigarette branding: misleading descriptors and a new Marlboro man.

Tob Control 2021 Nov 17. Epub 2021 Nov 17.

Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background: Straw cigarettes are hand-rolled tobacco in a corn straw, common in Brazil and believed to be less harmful by consumers. Traditionally consumed in rural areas and by men, a recent increase in use among young people in urban areas was observed. This study assessed marketing appeals of straw cigarette packaging in Brazil.

Methods: Following a systematic protocol, unique straw cigarette packs were purchased in 2013, 2016 and 2019 from three cities: Manaus, Salvador and São Paulo. Packs were double-coded for the absence/presence of marketing appeals (ie, luxury/quality, masculinity, classic/timeless, flavours and less harm).

Results: The number of unique straw cigarette packs purchased as part of the overall sample increased in the most recent collection: 2.3% (n=3), 1.3% (n=2) and 15.5% (n=27) in 2013, 2016 and 2019, respectively. Across the years, all packs presented luxury/quality elements (eg, images of crests); 93.8% (n=30) included the word 'artisanal'. Masculine appeal (eg, images of men) was present on 56.3% (n=18) of packs. Almost half had classic/timeless elements, including the words 'tradition'/'original'. In 2019, 59.3% (n=16) of the packs were flavoured compared with none in previous years. Over a quarter of all packs presented a less harm appeal (eg, 'smooth').

Conclusion: We identified an increase in availability of unique straw cigarette packs, strong branding and use of misleading descriptors on the packs. The adoption of plain packaging and the implementation of Brazil's additive ban could help to reduce the appeal of straw cigarettes and curb the current increase in use among youth.
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http://dx.doi.org/10.1136/tobaccocontrol-2021-056983DOI Listing
November 2021

Health Warning Label Compliance for Smokeless Tobacco Products and Bidis in Five Indian States.

Asian Pac J Cancer Prev 2021 Nov 1;22(S2):59-64. Epub 2021 Nov 1.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background: The burden of tobacco use In India is very high. To inform users of harm, India has a strong health warning label law that applies to all tobacco products. This study examines the extent of compliance of health warning labels on smokeless tobacco (SLT) and bidi products with the Indian law.

Methods: In 2017, a systematic protocol was used to collect unique SLT and bidi packages from five Indian states. To assess compliance, we used three indicators: location, label elements, and warning size.

Results: Only 1% of the 133 SLT products and none of the 32 bidi packs were compliant with all three compliance indicators. Other compliance-related issues included non-standardized packaging, incomplete health warning labels, poor printing quality, and old warning labels.

Conclusion: There is very poor compliance with the health warning label law on bidi and SLT products. India needs to regularly monitor and address implementation to ensure that warning labels are effective.
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http://dx.doi.org/10.31557/APJCP.2021.22.S2.59DOI Listing
November 2021

"It's all About the Colors:" How do Mexico City Youth Perceive Cigarette Pack Design.

Int J Public Health 2021 10;66:585434. Epub 2021 Mar 10.

Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.

Cigarette packs are relevant to branding strategies, designed to appeal to specific groups. There is little research on how pack features increase product appeal among key constituents such as youth in low- and middle-income countries. We conducted 10 focus group discussions (FGDs) with adolescents and 5 FGDs with young adult smokers in Mexico City, separated by age, gender, smoking, and socioeconomic status. Participants separated 23 cigarette packs into "appealing" and "unappealing" groups, and were asked to explain their decisions, describing the features that supported their views. FGDs were video-recorded, transcribed in Spanish, translated into English, and subjected to thematic analysis. Pack groupings did not differ greatly across FGDs; bold, contrasting colors and elements communicating flavor and promotion increased cigarette pack appeal and desire to try. Participants perceived packs with these features to be used by and designed for youth, like themselves. Our findings reinforce the importance of packaging design in attracting new consumers and maintaining current ones. Mexico should consider stronger tobacco advertising policies that include packaging color and depiction of flavor to reduce product appeal.
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http://dx.doi.org/10.3389/ijph.2021.585434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8565279PMC
November 2021

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda.

Int J Equity Health 2021 10 30;20(1):238. Epub 2021 Oct 30.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 2213 McElderry Street, Fourth Floor, Baltimore, MD, 21205, USA.

Background: Disparities in exposure to and density of tobacco advertising are well established; however, it is still unclear how e-cigarette and heated tobacco product (HTP) advertising vary by age, education, sex, gender identity, race/ethnicity, sexual orientation, socioeconomic status (SES), and/or urban/rural area. Through a scoping review, we sought to identify potential disparities in exposure to e-cigarette and HTP advertising and promotion across populations.

Methods: In January 2020, a systematic literature search was conducted in five databases: PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. The search was updated in October 2020. Articles reporting on exposure to e-cigarette and/or HTP advertising and promotion across age, education, sex, gender identity, race/ethnicity, sexual orientation, SES, and/or urban/rural areas were included for full-text review (n = 25). Of those, 15 were deemed relevant for data extraction.

Results: The majority of the studies were from the U.S. (n = 12) and cross-sectional (n = 14). Studies were published between 2014 and 2020 and focused on determining causal relationships that underlie disparities; only one study assessed HTP advertising and promotion. Exposure to e-cigarette and HTP advertising was assessed at the individual-level (e.g., recall seeing ads on television) and at the neighborhood-level (e.g., ad density at the point-of-sale). Studies addressed differences across age (n = 6), education (n = 2), sex (n = 6), gender identity and sexual orientation (n = 3), race/ethnicity (n = 11), SES (n = 5), and urban/rural (n = 2). The following populations were more likely to be exposed to e-cigarette advertising: youth, those with more than a high school diploma, males, sexual and gender minorities, Whites, and urban residents. At the neighborhood-level, e-cigarette advertisements were more prevalent in non-White neighborhoods.

Conclusions: Exposure to e-cigarette/HTP advertising varies based on sociodemographic characteristics, although the literature is limited especially regarding HTPs. Higher exposure among youth might increase tobacco-related disparities since it can lead to nicotine/tobacco use. Research should incorporate and apply a health equity lens from its inception to obtain data to inform the elimination of those disparities.
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http://dx.doi.org/10.1186/s12939-021-01576-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8557615PMC
October 2021

Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data.

Tob Control 2021 Sep 15. Epub 2021 Sep 15.

Department of Health, Behavior and Society, Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.

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. χ, 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.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056448DOI Listing
September 2021

Feminine Appeals on Cigarette Packs Sold in 14 Countries.

Int J Public Health 2021 14;66:1604027. Epub 2021 Jun 14.

Department of Health, Behavior, and Society, Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.

Limited research has examined feminine marketing appeals on cigarette packs in low-and middle-income countries (LMICs). We reviewed a systematically collected sample of cigarette packs sold across 14 LMICs in 2013 (Wave 1) and 2015-2017 (Wave 2). Packs in Wave 1 ( = 3,240) and Wave 2 ( = 2,336) were coded for feminine imagery and descriptors (flowers, fashion, women/girls, color "pink"). We examined trends in feminine appeals over time, including co-occurrence with other pack features (slim or lipstick shape, flavor, reduced harm, and reduced odor claims). The proportion of unique feminine cigarette packs significantly decreased from 8.6% ( = 278) in Wave 1 to 5.9% ( = 137) in Wave 2 ( < 0.001). Among all feminine packs, flower-and fashion-related features were most common; a substantial proportion also used flavor and reduced odor appeals. While there was a notable presence of feminine packs, the decline observed may reflect global trends toward marketing gender-neutral cigarettes to women and a general contempt for using traditional femininity to market products directly to women. Plain packaging standards may reduce the influence of branding on smoking among women.
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http://dx.doi.org/10.3389/ijph.2021.1604027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8406490PMC
September 2021

Claims of reduced odor on tobacco packs in low- and middle-income countries.

Nicotine Tob Res 2021 Sep 2. Epub 2021 Sep 2.

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, McElderry Street, Baltimore, MD.

Introduction: Cigarettes designed to have less smoke smell were developed by the tobacco industry to supposedly reduce negative qualities. Cigarettes with marketing claims communicating these designs have been sold in high-income countries and marketing of "less smoke smell" terms on cigarette packaging can promote cigarette use. It is unclear to what extent they have been marketed in low- and middle-income countries (LMICs).

Methods: The Tobacco Pack Surveillance System (TPackSS) systemically collected tobacco packs available in 14 LMICs with high tobacco use between 2013-2017. We coded 4,354 packs for marketing appeals, including claims related to smoke smell. We describe "less smoke smell" and similar claims found on these packs and compare across country and tobacco manufacturers.

Results: Phrases communicating less smoke smell were present on packs purchased in nine of 14 LMICs, including Bangladesh, Brazil, China, India, Mexico, Philippines, Russia, Ukraine, and Vietnam. The most commonly (74.1%) used terminology was "less smoke smell", "LSS" or a combination of the two. Packs from Russia had the most prevalent use (11.8%) of such claims. Companies using these terms across 21 brands included Japan Tobacco International (JTI), British American Tobacco (BAT), Philip Morris International (PMI) and other smaller companies. JTI accounted for 70.9% of packs with such terms.

Conclusion: Some of the world's largest tobacco companies are communicating less smoke smell on packs in LMICs. Less smoke smell and similar phrases on packaging should be prohibited because they can enhance the appeal of cigarettes.

Implications: Tobacco companies are using "less smoke smell" and similar phrases on cigarette packs in LMICs. These claims have the potential to increase the appeal of smoking and promote cigarette use. Countries should consider policies to restrict attractive labeling claims, in accordance with the WHO Framework Convention on Tobacco Control (FCTC) Article 13 guidelines, which recommends restrictions on attractive design elements on tobacco packaging.
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http://dx.doi.org/10.1093/ntr/ntab177DOI Listing
September 2021

Tobacco control policies and smoking cessation treatment utilization: A moderated mediation analysis.

PLoS One 2021 30;16(8):e0241512. Epub 2021 Aug 30.

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States of America.

Background: Tobacco policies, including clean indoor air laws and cigarette taxes, increase smoking cessation in part by stimulating the use of cessation treatments. We explored whether the associations between tobacco policies and treatment use varies across sociodemographic groups.

Methods: We used data from 62,165 U.S. adult participants in the 2003 and 2010/11 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who reported smoking cigarettes during the past-year. We built on prior structural equation models used to quantify the degree to which smoking cessation treatment use (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet resources) mediated the association between clean indoor air laws, cigarette excise taxes, and recent smoking cessation. In the current study, we added selected moderators to each model to investigate whether associations between tobacco polices and smoking cessation treatment use varied by sex, race/ethnicity, education, income, and health insurance status.

Results: Associations between clean indoor air laws and the use of prescription medication and nicotine replacement therapies varied significantly between racial/ethnic, age, and education groups in 2003. However, none of these moderation effects remained significant in 2010/11. Higher cigarette excise taxes in 2010/2011 were associated with higher odds of using counseling among older adults and higher odds of using prescription medications among younger adults. No other moderator reached statistical significance. Smoking cessation treatments did not mediate the effect of taxes on smoking cessation in 2003 and were not included in these analyses.

Conclusions: Sociodemographic differences in associations between clean indoor air laws and smoking cessation treatment use have decreased from 2003 to 2010/11. In most cases, policies appear to stimulate smoking cessation treatment use similarly across varied sociodemographic groups.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241512PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8405013PMC
November 2021

Perceived effectiveness of four different cigarette health warning label themes among a sample of urban smokers and non-smokers in China.

Tob Control 2021 Aug 16. Epub 2021 Aug 16.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Objective: This study, conducted in China, evaluated the effectiveness of four different themes of health warning labels (HWLs) that used both text and pictures: (1) self-harm from using cigarettes, (2) harming family or children with secondhand smoke, (3) reinforcing compliance with existing smoke-free policies and (4) anticigarette gift giving practices.

Methods: A cross-sectional randomised experimental survey was conducted among 3247 adult (aged 18+ years) participants in Beijing, Shanghai and Shenzhen in 2017, using quotas for age group, gender and smoking status. Participants were randomly assigned to one of the four HWL themes. Each participant viewed eight HWLs and rated how effective these themed-labels were in terms of credibility, raising awareness of health harms of smoking on family and children, improving compliance with public smoking bans, stopping the practice of gifting cigarettes, thinking about quitting and preventing smoking using a 10-point scale, with 10 being most effective. Analysis of variance and independent t-tests were used to analyse these data.

Findings: All four HWL themes performed well for each outcome with average ratings >6.5. Harming family or children with secondhand smoke was the theme that received the highest ratings for each outcome, with credibility (8.0, 95% CI 7.86 to 8.09) and prevention of smoking (8.8, 95% CI 8.63 to 8.91) outcomes being significantly higher (p<0.05). Overall, analysis of ratings by gender, income and education did not impact outcomes.

Conclusion: All four HWL themes tested could be effective in China; the theme of secondhand smoke harming family or children may be a particularly credible/effective theme.
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http://dx.doi.org/10.1136/tobaccocontrol-2021-056703DOI Listing
August 2021

The Market for Bidis, Smokeless Tobacco, and Cigarettes in India: Evidence From Semi-Urban and Rural Areas in Five States.

Int J Public Health 2021 12;66:1604005. Epub 2021 May 12.

Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States.

Compare the brand availability, pricing and presence of illicit products in semi-urban and rural areas in India across product types and states. In late 2017, 382 unique tobacco products were purchased from localities with populations under 50,000 in the states of Assam, Karnataka, Maharashtra, Rajasthan, and Uttar Pradesh. Brand, printed maximum retail price, price paid, tax, and health warning labels (HWLs) were used to compare the market for bidis, smokeless tobacco (SLT), and cigarettes. Brand availability and pricing of SLT products was similar to cigarettes. Brand availability and pricing of bidis was consistent with having many small producers. Bidis and single serving SLT with spice mixtures were more affordable than cigarettes and SLT sold alone. 2% of SLT and 10% of cigarettes did not feature an India HWL. The elimination of single serving SLT packets and the removal of tax exemptions for small producers, often exploited by bidi producers, could reduce their respective affordability. State differences in illegal and illicit products could indicate a greater need for enforcement in some states.
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http://dx.doi.org/10.3389/ijph.2021.1604005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284861PMC
August 2021

Smoking cessation strategies used by former menthol cigarette smokers after a menthol ban.

Addict Behav 2021 12 13;123:107046. Epub 2021 Jul 13.

Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.

Introduction: Menthol cigarettes were banned in Ontario, Canada on January 1st, 2017. We used concept mapping, a mixed-method approach, to describe how menthol cigarette smokers quit smoking after the Ontario menthol ban.

Methods: Pre-ban daily and non-daily menthol cigarette smokers who reported smoking abstinence 24 months after the ban (n = 62; 53.2% women; mean age = 43.6, SD = 12.5) generated statements describing reasons and strategies for smoking cessation/reduction after the menthol ban. Participants sorted a final list of 57 statements into groups of similar content and rated statements on how true each statement was for them and multidimensional scaling analysis identified thematic clusters.

Results: Six clusters were identified: Mental and Environment Changes, Direct Ban Impacts, Health Reasons, Cues to Action, Family and Friends, and Cessation Strategies. The highest rated statements (i.e., most true) suggested many participants were motivated to quit smoking before or after the ban and 30.7% of participants believed the menthol ban helped with smoking cessation. Some of the lowest rated statements included using nicotine replacement therapy products, medication (i.e., Champix), or other tobacco products suggesting these strategies were less common. Statement ratings suggested many smokers quit without using replacement products or medication, but modifying cognitions and avoiding smoking cues were common.

Conclusions: The menthol ban aided some menthol smokers to quit, while others reported the ban did not play a role in smoking cessation. These data suggest the menthol ban had direct and indirect effects on smoking reduction behavior. Campaigns supporting similar bans that target both types of effects will likely be most effective for smoking reduction.
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http://dx.doi.org/10.1016/j.addbeh.2021.107046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419147PMC
December 2021

Association of cigarette production and tobacco retailer density on secondhand smoke exposure in urban China.

Tob Control 2021 Jul 6. Epub 2021 Jul 6.

Stomatology Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.

The primary aims of this study are to examine the associations between two key environmental factors-regional cigarette tobacco production and tobacco retail outlet density-and secondhand smoke (SHS) exposure in urban China and to explore the possible mechanisms that explain this association.

Methods: A cross-sectional multistage sampling design was used to collect individual information in 21 cities in China. Environmental variables were retrieved from national databases. Multilevel logistic regression analysis was conducted to examine the associations between regional cigarette tobacco production, tobacco retail outlet density and SHS exposure. Structural equation modelling was employed to determine possible mechanisms.

Results: SHS exposure prevalence defined as daily exposure to SHS for at least 15 min/day at the time of the survey was found to be 28.1% among non-smokers (95% CI 27.1 to 29.0) across the 21 cities. The multilevel logistic regressions showed that province-level per capital cigarette production (OR: 2.72 (95% CI 1.56 to 4.76)and per GDP cigarette production(OR:1.69(95% CI 1,42,2.01), and city-level tobacco retail outlet density (OR: 2.66 (95% CI 1.63 to 4.38)) were significantly associated with SHS exposure. Moreover, results showed that these associations may be explained by the level of tobacco advertisement, which influences social norms, including attitudes and behaviours toward SHS exposure.

Conclusions: Findings shed light on the role of cigarette manufacturers and retailers in producing environmental SHS pollution. To address the health and economic burden associated with SHS in China, it will be critical for the Chinese government to enact tobacco control measures consistent with the Framework Convention for Tobacco Control. Efforts should also focus on restricting the permitted density of tobacco retail outlets, and tobacco production in China.
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http://dx.doi.org/10.1136/tobaccocontrol-2021-056655DOI Listing
July 2021

Machine-assessed tar yield marketing on cigarette packages from two cities in South Korea.

Tob Induc Dis 2021 25;19:54. Epub 2021 Jun 25.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States.

Introduction: South Koreans continue to smoke at high rates. Tobacco manufacturers have a history of branding cigarettes with misleading descriptors including the introduction of low or ultra-low tar brand variants. The government bans traditional misleading descriptors (low, mild) but requires the presence of machine-assessed tar yields on cigarette packages. Literature suggests the presence of quantitative constituents can be misleading for smokers. We analyzed the machine-assessed tar value branding and the presence of additional branding that highlight tar levels on South Korean cigarette packs.

Methods: In August 2018, we analyzed 178 unique cigarette packs purchased in Seoul and Busan, South Korea using a systematic protocol. Cigarette packs were coded for tar levels and classified as ultra-low, low, mid, and high tar. The presence of misleading descriptors and any additional branding relating to tar or potentially indicating strength were also coded.

Results: Machine-assessed tar yields ranged from 0.1 to 8 mg. Cigarettes with a 1 mg machine-assessed tar yield accounted for 38% of all packs purchased. A majority (80%) of packs with tar values <3 mg had additional marketing present on the pack that highlighted tar yields, compared to 45% for packs with tar values 3 mg or greater. Many (85%) of the 1 mg packs and all of the 0.1 and 0.5 mg packs had additional marketing present that referenced tar levels.

Conclusions: These findings suggest that tobacco manufacturers are highlighting and reinforcing the tar yields of lower tar cigarettes by the deliberate use of tar level branding. These actions have the potential to mislead South Korean consumers that some cigarettes are less harmful than others. Strengthening of tobacco packaging regulations to prohibit references to tar yields on packs are needed to further protect consumers.
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http://dx.doi.org/10.18332/tid/136421DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8231860PMC
June 2021

Association between e-cigarette use and parents' report of attention deficit hyperactivity disorder among US youth.

Tob Induc Dis 2021 4;19:44. Epub 2021 Jun 4.

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States.

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.
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http://dx.doi.org/10.18332/tid/136031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8176894PMC
June 2021

Association of cigarette and electronic nicotine delivery systems use with internalizing and externalizing problems among US adults: Findings from wave 3 (2015-2016) of the PATH study.

PLoS One 2021 15;16(6):e0253061. Epub 2021 Jun 15.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Aims: Electronic Nicotine Delivery System (ENDS) use is increasing among US adults. While existing research has demonstrated higher cigarette smoking rates among people with mental health conditions, there is sparse information on the association between ENDS use and mental health such as internalizing and externalizing problems. The aim of this study was to evaluate associations between internalizing and externalizing problems for cigarette only, ENDS only, and dual users, as well as changes in mental health among those groups.

Method: We used the U.S. Population Assessment of Tobacco and Health (PATH) Study Wave 3 adult data. Internalizing and externalizing problems were self-reported and assessed via the Global Appraisal of Individual Needs-Short Screener; response options were dichotomized to reflect past 12 months and any lifetime problems. Self-reported changes in mental health over the past 12 months were also assessed. Participants' tobacco use status was categorized as ENDS only use (n = 618), cigarette only use (n = 6,779), dual use (cigarettes and ENDS) (n = 681), and non-current use (n = 16,515).

Results: Lifetime and past 12 month internalizing problems were reported by 63.8% (n = 18,706) and 50.4% (n = 15,326), respectively, while lifetime and past 12 months externalizing problems were reported by 63.3% (n = 18,835) and 52.7% (n = 16,005), respectively. Six percent of participants reported worse mental health over the past 12 months. Compared to non-current use of any tobacco product, and adjusting for age, sex, race, education, and household income, those reporting ENDS use only had higher odds of ever (aOR = 1.52; 95%CI: 1.22-1.89) and past 12 months (aOR = 1.49; 95%CI: 1.22-1.84) internalizing, and externalizing problems (aOR = 1.32; 95%CI: 1.04-1.66 and aOR = 1.34; 95%CI: 1.07-1.67, respectively), and higher odds of reporting worse mental health over the past 12 months (aOR = 1.50; 95%CI: 1.05-2.12).

Conclusion: Health care providers should be aware that internalizing and externalizing problems, and worsening mental health, are more common among adults who use ENDS, cigarettes, or both of these tobacco products.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0253061PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8205124PMC
November 2021

Exploring the relationship between the alcohol policy environment and nondiscrimination laws: Implications for binge drinking disparities among LGB adults in the United States.

Drug Alcohol Depend 2021 08 21;225:108749. Epub 2021 May 21.

Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway Street, Baltimore, MD, 21205, United States. Electronic address:

Background: Alcohol policies reduce population-level binge drinking; however, they may not reduce binge drinking disparities between different populations. We examined the association between the alcohol policy environment and binge drinking among Lesbian, Gay and Bisexual (LGB) and heterosexual adults in the presence and absence of state laws protecting LGB people from discrimination.

Methods: The 2015-2018 Behavioral Risk Factor Surveillance System (BRFSS) provided information about individual-level binge drinking, sexual identity, and individual-level covariates. The Alcohol Policy Scale (APS) score measures the strength of the alcohol policy environment. Presence of state-level nondiscrimination protections based on sexual orientation came from the Movement Advancement Project. Logistic regression models were used to test whether nondiscrimination statutes modified the association between the alcohol policy environment and binge drinking and whether this interaction differed for LGB and heterosexual adults.

Results: Among women, a 10 percentage-point increase in APS score was significantly associated with 7% lower odds of binge drinking in states with inclusive nondiscrimination laws (aOR: 0.93 [95% CI: 0.89-0.97; p = 0.0003]) but was not associated with binge drinking in states without inclusive laws (aOR: 0.98 [95% CI: 0.93-1.03] p = 0.4781). Moreover, binge drinking disparities comparing lesbian/bisexual women with heterosexual women were narrower in states with inclusive nondiscrimination laws. No significant association was found among men.

Conclusions: Binge drinking disparities between lesbian and heterosexual women are negligible in states with inclusive laws and strong alcohol policy environments. Inclusive nondiscrimination laws are an indicator of less structural stigma directed at lesbian and bisexual women.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8282708PMC
August 2021

The battle to increase tobacco taxes: Lessons from Philippines and Ukraine.

Soc Sci Med 2021 06 7;279:114001. Epub 2021 May 7.

Johns Hopkins Bloomberg School of Public Health, Institute for Global Tobacco Control, 2213 McElderry Street, Fourth Floor, Baltimore, MD, 21205, USA.

Introduction: While increasing taxes on tobacco is one of the most effective tobacco control measures, its adoption has been slow compared to other tobacco control policies. Given this, there is an urgent need to better understand the political and economic dynamics that lead to its adoption despite immense tobacco industry opposition. The primary aim of this study is to explore the process, actors, and determinants that helped lead to the successful passage of the 2012 Sin Tax Reform Law in the Philippines and the 2017 seven-year plan for tobacco tax increases in Ukraine.

Method: Under the guidance of the Advocacy Coalition Framework, we used a case study approach gathering data from key informant interviews (n = 37) and documents (n = 56). Subsequently, cross-case analysis was undertaken to identify themes across the two cases.

Results: We found that external events in the Philippines and Ukraine triggered policy subsystem instability and tipped the scale in the favor of tobacco tax proponents. In the Philippines, elections brought forth a new leader in 2010 who was keen to achieve universal health care and improve tax collection efficiency. In Ukraine, the European Union Association Agreement came into force in 2017 and included the Tobacco Products Directive requiring Ukraine to synchronize its excise taxes to that of the European Union. Exploiting these key entry points, tobacco tax proponents formed a multi-sectoral coalition and used a multi-pronged approach. In both countries, respected economic groups and experts who could generate timely evidence were present and used local as well as international data to counter opponents who also used an array of strategies to water down the tax policies.

Conclusions: Findings are largely consistent with the Advocacy Coalition Framework and suggest the need for tobacco tax proponents to 1) form a multi-sectoral coalition, 2) include respected economic groups and experts who can generate timely evidence, 3) use both local data and international experiences, and 4) undertake a multi-pronged approach.
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http://dx.doi.org/10.1016/j.socscimed.2021.114001DOI Listing
June 2021

The Flavor Train: The Nature and Extent of Flavored Cigarettes in Low- and Middle-Income Countries.

Nicotine Tob Res 2021 10;23(11):1936-1941

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Introduction: Flavors and depictions of flavors are attractive and facilitate initiation and use of tobacco products. However, little is known about the types of flavored products on the market, particularly in low- and middle-income countries. We describe the nature and extent of flavored cigarettes sold in nine low- and middle-income countries from four of the six World Health Organization (WHO) regions.

Aims And Methods: We employed a systematic protocol to purchase unique cigarette packs in Bangladesh, Brazil, China, India, Indonesia, Philippines, Russia, Thailand, and Vietnam. Packs were double coded for flavor descriptors and imagery using a standard codebook. Frequencies and crosstabs were conducted to examine the proportion of packs with flavor descriptors and/or flavor imagery, and flavor capsules, by country and by major manufacturer.

Results: Overall, 15.4% of the country-unique cigarette packs had flavor descriptors and/or imagery, representing a variety of flavors: menthol or mint (8.2%), "concept" descriptors (3.5%) (eg, Fusion blast), fruit or citrus (3.3%), beverages (1.4%), and others (1.4%). Flavor was mostly communicated using descriptors (15.2%), with flavor imagery being less common (2.2%). Flavor capsules were prevalent (6.2%), with almost half having "concept" descriptors. All major tobacco companies produced cigarettes with flavors, and with capsules.

Conclusions: A range of flavored cigarettes remain on the market in the low- and middle-income countries with the greatest number of smokers. This finding is particularly concerning given the appeal of flavored cigarettes among youth and their potential to circumvent country bans on flavored tobacco products if those laws are not sufficiently comprehensive. Laws addressing flavored tobacco products need to account for flavor capsules and concept descriptors.

Implications: While a number of countries have restricted flavors in tobacco products to reduce their appeal and attractiveness, a range of flavors continue to be on the market in low- and middle-income countries, putting people in these countries at increased risk for tobacco use and subsequent tobacco-caused death and disease. The presence of capsules and concept descriptors is particularly concerning given their appeal among youth and their potential to circumvent country bans on flavored tobacco products if those laws are not sufficiently comprehensive.
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http://dx.doi.org/10.1093/ntr/ntab092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8496476PMC
October 2021

The youth e-cigarette epidemic: New estimates of JUUL Labs' revenue from youth users in the US.

Tob Induc Dis 2021 29;19:33. Epub 2021 Apr 29.

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States.

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.
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http://dx.doi.org/10.18332/tid/133874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8082675PMC
April 2021

Industry manipulation of pictorial health warning labels in Pakistan.

Tob Control 2021 Apr 16. Epub 2021 Apr 16.

Department of Health, Behavior & Society, Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1136/tobaccocontrol-2020-056433DOI Listing
April 2021

Philip Morris International used the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak to market IQOS heated tobacco.

Tob Control 2021 Apr 16. Epub 2021 Apr 16.

Institute for Global Tobacco Control, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1136/tobaccocontrol-2021-056661DOI Listing
April 2021

Analysis of wedding appeals on cigarette packs in China.

Tob Control 2021 Apr 9. Epub 2021 Apr 9.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Introduction: Exchanging or gifting cigarettes is a common practice in Chinese culture, often occurring during weddings to connote celebrations and happiness. We examined Chinese cigarette packs for wedding terminology and imagery to assess the extent to which packs are marketed for such occasions.

Methods: Cigarette packs were collected from Beijing, Guangzhou, Shanghai, Kunming and Chengdu in February 2017 using a systematic protocol designed to capture unique packs. Packs were coded by two independent coders for text and imagery of traditional Chinese wedding symbols, such as double happiness, dragon and phoenix, and other culturally specific phrases and images associated with weddings in China.

Results: From the sample of 738 unique cigarette packs, 68 (9.2%) contained either lexical and/or imagery appeals for wedding gifting. Of these 68 packs, 65 contained both lexical and imagery appeals, 1 pack had only a lexical appeal and 2 packs only included an imagery appeal. The most common appeal was 'double happiness' found on 56 packs (82.4%) for both lexical and imagery, followed by 'dragon and phoenix' found lexically on 12 packs (17.6%), and through imagery on 15 packs (22.1%).

Conclusions: Chinese tobacco manufacturers take full advantage of the cigarette gifting and sharing culture demonstrated by packs with imagery and terminology specific to weddings. With only a 35% text health warning label, manufacturers have much real estate to make packs attractive for gifting on such occasions. Implementing plain packaging policies may be effective in decreasing gifting attractiveness for cigarette packs.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056189DOI Listing
April 2021

The First 10 Years: Reflecting on Opportunities and Challenges of the Tobacco Products Scientific Advisory Committee of the United States Food and Drug Administration.

J Leg Med 2020 Jul-Dec;40(3-4):293-320

Tobacco control policies have helped to reduce the health, social, and economic burden of commercial tobacco use worldwide. Little is known about the long-term impact of regulatory policies and functioning bodies that make recommendations to inform policies. The Tobacco Products Scientific Advisory Committee (TPSAC) of the U.S. Food and Drug Administration (FDA) was formed in 2009 to evaluate the safety, health, and dependence of tobacco products and provide related advice and recommendations to the FDA and the Secretary of Health and Human Services. This article describes the first 10 years of the TPSAC activities and reflects on the impact of their service on regulatory actions. We reviewed public documents from the 2010-2019 TPSAC meetings to examine the purposes, TPSAC decisions, public health participation in meetings, and concordance of the TPSAC recommendations with regulatory actions. Meeting agendas, transcripts, public testimony, and presentations were reviewed to obtain this information. Since 2010, the TPSAC held 25 public meetings with 178 speakers who provided oral public testimony. Sixty-four percent of meetings were held from 2010 to 2012, when three congressionally mandated reports were due on the topics of menthol cigarettes, harmful and potentially harmful constituents in tobacco products, and dissolvable tobacco products. Forty-four percent of meetings focused on menthol cigarettes, 32% on modified risk tobacco products, 16% on harmful and potentially harmful constituents, 12% on dissolvable tobacco, and 4% on tobacco addiction/dependence. FDA regulatory actions were largely nonconcordant with voting decisions by TPSAC. The TPSAC has evaluated an enormous amount of science during the first 10 years, but their influence on regulatory policies has been limited. The TPSAC roles and functioning should be reevaluated to determine how TPSAC can better fulfill its mandate to inform the FDA's regulatory decision making, which could ultimately reduce the burden of tobacco use in the United States.
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http://dx.doi.org/10.1080/01947648.2020.1868938DOI Listing
October 2021

Prior Daily Menthol Smokers More Likely to Quit 2 Years After a Menthol Ban Than Non-menthol Smokers: A Population Cohort Study.

Nicotine Tob Res 2021 08;23(9):1584-1589

Department of Psychology, Virginia Commonwealth University, Richmond, VA.

Background And Aims: The province of Ontario, Canada, banned the use of menthol-flavored tobacco products as of January 1, 2017. This study aims to assess the longer-term impact of a menthol ban on smoking behavior at 2 years, which is unknown.

Methods: Population cohort study with baseline survey (n = 1821) conducted September-December 2016 and follow-up survey January-August 2019 among current smokers in Ontario (16+) prior to the menthol ban. Poisson regression was used to assess the probability of quitting smoking by pre-ban menthol status, controlling for differences in smoking and demographic characteristics, with multiple imputations used to address missing data.

Findings: Menthol smokers were more likely to report having quit smoking (12% [daily menthol] and 10% [occasional menthol] vs. 3% [non-menthol]; p < .001) than non-menthol smokers in the 2 years after a menthol ban. After adjustment for smoking and demographic characteristics, daily menthol smokers had higher likelihood of quitting smoking (adjusted relative risk [ARR] 2.08; 95% confidence interval [CI] 1.20-3.61) and reported more quit attempts (ARR 1.45; 95% CI 1.15-1.82). Among those who attempted to quit, menthol smoking was not associated with relapse (daily ARR = 0.96; 95% CI: 0.86, 1.07; occasional ARR = 0.99; 95% CI: 0.90, 1.08). However, there was a statistically significant interaction among menthol users who reported using other flavored tobacco products 1 year after the ban (ARR = 0.26 [95% CI: 0.08, 0.90]).

Conclusions: The study found increased probability of quitting among daily menthol smokers and more quit attempts among daily and occasional menthol smokers compared with non-menthol smokers in Ontario 2 years after the implementation of a menthol ban.

Implications: This study examines quitting behavior 2 years after a menthol ban in Ontario, Canada. Those who were daily menthol smokers prior to the ban were more likely to quit smoking and make more quit attempts in the 2 years after the ban. While there was no difference in the likelihood of relapse between menthol and non-menthol smokers among those who attempt to quit, there were indications that pre-ban daily menthol smokers who used other tobacco products after the ban were likely to quit.
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http://dx.doi.org/10.1093/ntr/ntab042DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8500186PMC
August 2021

'Menthol-Plus': a major category of cigarette found among 'concept' descriptor cigarettes from Mexico.

Tob Control 2021 Mar 9. Epub 2021 Mar 9.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA

Background: Tobacco companies are offering cigarettes with 'concept' descriptor names that suggest sensation and/or flavour properties (eg, Marlboro 'Velvet Fusion'). Little has been known about the identities and levels of flavour chemicals in such cigarettes.

Methods: Thirty-three filter cigarette variants from 27 packs (including two sampler packs with four variations each) from Canada and Mexico were analysed (rod + filter) for 177 flavour chemicals plus triacetin, a filter plasticiser and possible flavourant. Five brands of US mentholated filter cigarettes were also analysed.

Results: Twenty-seven of the 33 cigarettes (all were Mexican variants) were categorised as 'menthol-plus': significant menthol (3.0-11.9 mg/cigarette), plus varying amounts (0.32-3.4 mg/cigarette) of total other flavour chemicals (TOFCs) (excludes triacetin). For 10 of the 27, TOFCs >1.0 mg/cigarette. For 7 of the 27, the TOFCs profile was categorised as containing total fruit flavour compounds (TFFCs) >1.0 mg/cigarette. One Mexican variant was categorised as 'menthol-only' (TOFCs ≤0.15 mg/cigarette). All menthol-plus and menthol-only cigarettes contained one or two optional-crush capsules in their filters (crushed prior to analysis). All five Canadian brand variants were 'non-flavoured'. All five US brand variants were 'menthol-only'.

Conclusions: All but one of the 'concept' descriptor cigarettes from Mexico were 'menthol-plus'. While the Canadian cigarettes complied with Canada's flavour chemical ban, concept descriptors on the packs may increase appeal. Given the scale of the problem posed by menthol alone, health officials seeking to decrease the appeal of smoked tobacco should examine the extent to which 'concept descriptor' cigarettes using 'menthol-plus' flavour profiling together with artful descriptors are furthering the problem of smoked tobacco.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056173DOI Listing
March 2021

State-Level Alcohol Environments and Sexual Identity Disparities in Binge Drinking in the Behavioral Risk Factor Surveillance System.

LGBT Health 2021 04 4;8(3):190-200. Epub 2021 Feb 4.

Department of Health, Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

Binge drinking disparities by sexual identity are well documented. Stronger alcohol policy environments reduce binge drinking in the general population. We examined whether state-level alcohol policy environments have the same association with binge drinking among lesbian, gay, and bisexual (LGB) adults as among heterosexual adults. Binge drinking, sexual identity, and demographic characteristics were extracted from the 2015 to 2018 Behavioral Risk Factor Surveillance System. The strength of the alcohol policy environment was measured by using the Alcohol Policy Scale (APS) score. We estimated the association between APS score and binge drinking by using logistic regression and included an interaction term between APS score and sexual identity. The interaction between APS score and sexual identity was not significant, and findings differed between women and men. Among women, a higher APS score was associated with lower odds of binge drinking (adjusted odds ratio [aOR]: 0.96, 95% confidence interval [CI]: 0.94-0.99). Differences in binge drinking by sexual identity remained after adjusting for individual and state-level factors (e.g., the percentage of LGB adults in the state). Compared with heterosexual women, the odds of binge drinking were 43% higher (aOR: 1.43, 95% CI: 1.17-1.75) among lesbian women and 58% higher (aOR: 1.58, 95% CI: 1.40-1.79) among bisexual women. A higher APS score was not associated with binge drinking among men. Stronger state-level alcohol policy environments were associated with lower binge drinking among women. Lesbian and bisexual women were still more likely to engage in binge drinking compared with heterosexual women even in states with stronger alcohol policy environments.
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http://dx.doi.org/10.1089/lgbt.2020.0182DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8060877PMC
April 2021

Impact of cigarette package warnings on attitudes towards sharing and gifting cigarettes in China: a nationwide study of smokers and non-smokers.

Tob Control 2021 Jan 12. Epub 2021 Jan 12.

Institute for Global Tobacco Control, Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.

Background: Sharing and gifting cigarettes are common in China. These social practices promote cigarette consumption, and consequently may reduce quit rates in China. This study investigated sharing and gifting cigarettes, and the relationship of observing pictorial health warnings to attitudes towards sharing and gifting cigarettes in China.

Methods: We conducted an online nationwide cross-sectional study of 9818 adults in China. Experiences of sharing and gifting cigarettes, and attitudes towards sharing and gifting cigarettes before and after viewing text and pictorial health warnings on the packages were assessed, and compared between smokers and non-smokers.

Results: Most current smokers reported experiences of sharing (97%) and gifting (around 90%) cigarettes. Less than half of non-smokers reported sharing cigarettes and receiving gifted cigarettes, but over half (61.4%) gave cigarettes as a gift to others. More than half of non-smokers but less than 10% of smokers disagreed with sharing and gifting cigarettes. After observing both text and pictorial health warnings on the packages, disagreement with sharing and gifting cigarettes increased by more than 10 percentage points among both smokers and non-smokers.

Conclusion: Having pictorial health warnings on cigarette packages may reduce sharing and gifting cigarettes in China.
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http://dx.doi.org/10.1136/tobaccocontrol-2020-056160DOI Listing
January 2021

How Internet Contracts Impact Research: Content Analysis of Terms of Service on Consumer Product Websites.

JMIR Public Health Surveill 2020 12 2;6(4):e23579. Epub 2020 Dec 2.

Department of Health, Behavior & Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States.

Background: Companies use brand websites as a promotional tool to engage consumers on the web, which can increase product use. Given that some products are harmful to the health of consumers, it is important for marketing associated with these products to be subject to public health surveillance. However, terms of service (TOS) governing the use of brand website content may impede such important research.

Objective: The aim of this study is to explore the TOS for brand websites with public health significance to assess possible legal and ethical challenges for conducting research on consumer product websites.

Methods: Using Statista, we purposefully constructed a sample of 15 leading American tobacco, alcohol, psychiatric pharmaceutical, fast-food, and gun brands that have associated websites. We developed and implemented a structured coding system for the TOS on these websites and coded for the presence versus absence of different types of restriction that might impact the ability to conduct research.

Results: All TOS stated that by accessing the website, users agreed to abide by the TOS (15/15, 100%). A total of 11 out of 15 (73%) websites had age restrictions in their TOS. All alcohol brand websites (5/15, 33%) required users to enter their age or date of birth before viewing website content. Both websites for tobacco brands (2/15, 13%) further required that users register and verify their age and identity to access any website content and agree that they use tobacco products. Only one website (1/15, 7%) allowed users to display, download, copy, distribute, and translate the website content as long as it was for personal and not commercial use. A total of 33% (5/15) of TOS unconditionally prohibited or put substantial restrictions on all of these activities and/or failed to specify if they were allowed or prohibited. Moreover, 87% (13/15) of TOS indicated that website access could be restricted at any time. A total of 73% (11/15) of websites specified that violating TOS could result in deleting user content from the website, revoking access by having the user's Internet Protocol address blocked, terminating log-in credentials, or enforcing legal action resulting in civil or criminal penalties.

Conclusions: TOS create complications for public health surveillance related to e-marketing on brand websites. Recent court opinions have reduced the risk of federal criminal charges for violating TOS on public websites, but this risk remains unclear for private websites. The public health community needs to establish standards to guide and protect researchers from the possibility of legal repercussions related to such efforts.
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http://dx.doi.org/10.2196/23579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7744264PMC
December 2020

Plain packaging of tobacco products: Lessons for the next round of implementing countries.

Tob Induc Dis 2020 17;18:93. Epub 2020 Nov 17.

Centre for Global Health, School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland.

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http://dx.doi.org/10.18332/tid/130378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670849PMC
November 2020

E-cigarette use behaviors and device characteristics of daily exclusive e-cigarette users in Maryland: Implications for product toxicity.

Tob Induc Dis 2020 10;18:93. Epub 2020 Nov 10.

Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States.

Introduction: Few studies to date have characterized daily exclusive e-cigarette users, device characteristics, and use behaviors. This study describes daily e-cigarette user characteristics, and assesses the association between user behaviors and demographics.

Methods: From 2015-2017, 100 daily exclusive e-cigarette users and 50 non-users were recruited in Maryland, USA. Sociodemographic characteristics, health status, e-cigarette/tobacco use behaviors, device characteristics, and reasons for e-cigarette use were collected by interview. Chi-squared tests (categorical variables), Student's t-test (continuous variables), and linear regressions were used to assess relationships between variables.

Results: Most daily exclusive e-cigarette users were men, White, former smokers, used MODs/tanks, and vaped on average 365 puffs/day (SD: 720). A third of users first vaped within 5 minutes of waking in the morning, and 56% vaped throughout the day. E-liquid consumption ranged from 5-240 mL/week (median: 32.5), with nicotine concentration 0-24 mg/mL (median: 3). E-cigarette users were more likely to report wheezing/whistling and hypertension than controls, although the finding was not statistically significant after adjustment. Less than half planned to quit vaping.

Conclusions: Daily e-cigarette users between 2015-2017 most commonly vaped MOD/tank devices. Being male and of lower education was associated with higher usage. Daily users with no intention to quit may be at risk for increased exposure to emissions from e-cigarettes that include inorganic (metals) and organic (e.g. acrolein, formaldehyde) compounds with known toxic effects, particularly to the lung. Further research is needed to characterize the long-term health effects of daily e-cigarette use.
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http://dx.doi.org/10.18332/tid/128319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668279PMC
November 2020
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