Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015

Introduction: Changes to the U.S. smokeless tobacco landscape in recent years include a change to health warnings on packages, the implementation of bans in some stadiums, and the launch of a federal youth pre- vention campaign. It is unclear whether such changes have impacted consumer beliefs about smokeless tobacco. This study examines relative harm perceptions of smokeless tobacco compared to cigarettes among adults and assesses changes in smokeless tobacco harm perceptions over time. Methods: We analyzed data from three cycles (2012, 2014, 2015) of the Health Information National Trends Survey (HINTS). Using 2015 data, we assessed bivariate associations between smokeless tobacco harm per- ceptions and tobacco use, beliefs, information seeking, and demographics. Using 2012, 2014, and 2015 data, we assessed whether smokeless tobacco harm perceptions changed over time within demographic groups using chi- square tests. We then used a weighted multinomial logistic regression to assess the association between smo- keless tobacco perceptions and survey year, adjusting for covariates. Results: When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of re- spondents across cycles said “no.” The percent of respondents who selected this response option decreased over time. Findings showed significant differences in relative harm perceptions of smokeless tobacco versus cigarettes for specific demographic subgroups. Among subgroups, these shifts did not occur with a discernible pattern. Conclusions: Understanding factors associated with perceptions of smokeless tobacco can inform tobacco control efforts. Additional monitoring of these trends may provide researchers with a deeper understanding of how and why smokeless tobacco harm perceptions change

Impact of Tobacco-Related Health Warning Labels across Socioeconomic, Race and Ethnic Groups: Results from a Randomized Web-Based Experiment

Background: The U.S. Family Smoking Prevention and Tobacco Control Act of 2009 requires updating of the existing text-only health warning labels on tobacco packaging with nine new warning statements accompanied by pictorial images. Survey and experimental research in the U.S. and other countries supports the effectiveness of pictorial health warning labels compared with text-only warnings for informing smokers about the risks of smoking and encouraging cessation. Yet very little research has examined differences in reactions to warning labels by race/ethnicity, education or income despite evidence that population subgroups may differ in their ability to process health information. The purpose of the present study was to evaluate the potential impact of pictorial warning labels compared with text-only labels among U.S. adult smokers from diverse racial/ethnic and socioeconomic subgroups. Methods/Findings: Participants were adult smokers recruited from two online research panels (n = 3,371) into a web-based experimental study to view either the new pictorial warnings or text-only warnings. Participants viewed the labels and reported their reactions. Adjusted regression models demonstrated significantly stronger reactions for the pictorial condition for each outcome salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41, 95% CI = 1.22−1.62), and intention to quit (OR = 1.30, 95% CI = 1.10−1.53). No significant results were found for interactions between condition and race/ethnicity, education, or income. The only exception concerned the intention to quit outcome, where the condition-by-education interaction was nearly significant (p = 0.057). Conclusions: Findings suggest that the greater impact of the pictorial warning label compared to the text-only warning is consistent across diverse racial/ethnic and socioeconomic populations. Given their great reach, pictorial health warning labels may be one of the few tobacco control policies that have the potential to reduce communication inequalities across groups. Policies that establish strong pictorial warning labels on tobacco packaging may be instrumental in reducing the toll of the tobacco epidemic, particularly within vulnerable communities

Examining the role of menthol cigarettes in progression to established T smoking among youth

Background: Menthol, a flavoring compound added to cigarettes, makes cigarettes more appealing to youth and inexperienced smokers and increases cigarettes\u27 abuse liability. However, limited studies are available on menthol\u27s role in smoking progression. Methods: To assess the association between menthol in cigarettes and progression to established smoking, we used five waves of data from the Evaluation of Public Education Campaign on Teen Tobacco Cohort Study, a nationally representative longitudinal survey of U.S. youth conducted as part of “The Real Cost” evaluation. We used discrete time survival analysis to model the occurrence of two event outcomes—progression to established, current smoking and progression to established, frequent smoking—using a logit model with a menthol use indicator as the key explanatory variable. Based on this framework, we estimated the effect of prior menthol use on the odds of smoking progression. Results: In the progression to established, current smoking model, prior menthol use was significantly associated with progression [adjusted odds ratio (aOR) = 1.80, p \u3c .05, confidence interval (CI) = (1.03–3.16)]. While results were in a similar direction for the model of progression to established, frequent smoking, the association between prior menthol use and this progression model did not reach significance [aOR=1.56, CI = (0.80–3.03)]. Conclusion: The results suggest a relationship between using menthol cigarettes and progression from experi- mental to established, current smoking among youth. This study adds to a growing literature base that supports that menthol cigarettes, compared to nonmenthol cigarettes, put youth at increased risk for regular cigarette use

Monitoring harm perceptions of smokeless tobacco products among U.S. adults: Health Information National Trends Survey 2012, 2014, 2015

Introduction: Changes to the U.S. smokeless tobacco landscape in recent years include a change to health warnings on packages, the implementation of bans in some stadiums, and the launch of a federal youth pre- vention campaign. It is unclear whether such changes have impacted consumer beliefs about smokeless tobacco. This study examines relative harm perceptions of smokeless tobacco compared to cigarettes among adults and assesses changes in smokeless tobacco harm perceptions over time. Methods: We analyzed data from three cycles (2012, 2014, 2015) of the Health Information National Trends Survey (HINTS). Using 2015 data, we assessed bivariate associations between smokeless tobacco harm per- ceptions and tobacco use, beliefs, information seeking, and demographics. Using 2012, 2014, and 2015 data, we assessed whether smokeless tobacco harm perceptions changed over time within demographic groups using chi- square tests. We then used a weighted multinomial logistic regression to assess the association between smo- keless tobacco perceptions and survey year, adjusting for covariates. Results: When asked whether smokeless tobacco products are less harmful than cigarettes, the majority of re- spondents across cycles said “no.” The percent of respondents who selected this response option decreased over time. Findings showed significant differences in relative harm perceptions of smokeless tobacco versus cigarettes for specific demographic subgroups. Among subgroups, these shifts did not occur with a discernible pattern. Conclusions: Understanding factors associated with perceptions of smokeless tobacco can inform tobacco control efforts. Additional monitoring of these trends may provide researchers with a deeper understanding of how and why smokeless tobacco harm perceptions change

Examining the role of menthol cigarettes in progression to established T smoking among youth

Background: Menthol, a flavoring compound added to cigarettes, makes cigarettes more appealing to youth and inexperienced smokers and increases cigarettes\u27 abuse liability. However, limited studies are available on menthol\u27s role in smoking progression. Methods: To assess the association between menthol in cigarettes and progression to established smoking, we used five waves of data from the Evaluation of Public Education Campaign on Teen Tobacco Cohort Study, a nationally representative longitudinal survey of U.S. youth conducted as part of “The Real Cost” evaluation. We used discrete time survival analysis to model the occurrence of two event outcomes—progression to established, current smoking and progression to established, frequent smoking—using a logit model with a menthol use indicator as the key explanatory variable. Based on this framework, we estimated the effect of prior menthol use on the odds of smoking progression. Results: In the progression to established, current smoking model, prior menthol use was significantly associated with progression [adjusted odds ratio (aOR) = 1.80, p \u3c .05, confidence interval (CI) = (1.03–3.16)]. While results were in a similar direction for the model of progression to established, frequent smoking, the association between prior menthol use and this progression model did not reach significance [aOR=1.56, CI = (0.80–3.03)]. Conclusion: The results suggest a relationship between using menthol cigarettes and progression from experi- mental to established, current smoking among youth. This study adds to a growing literature base that supports that menthol cigarettes, compared to nonmenthol cigarettes, put youth at increased risk for regular cigarette use

Medical costs and quality-adjusted life years associated with smoking: a systematic review

Abstract Background Estimated medical costs (“T”) and QALYs (“Q”) associated with smoking are frequently used in cost-utility analyses of tobacco control interventions. The goal of this study was to understand how researchers have addressed the methodological challenges involved in estimating these parameters. Methods Data were collected as part of a systematic review of tobacco modeling studies. We searched five electronic databases on July 1, 2013 with no date restrictions and synthesized studies qualitatively. Studies were eligible for the current analysis if they were U.S.-based, provided an estimate for Q, and used a societal perspective and lifetime analytic horizon to estimate T. We identified common methods and frequently cited sources used to obtain these estimates. Results Across all 18 studies included in this review, 50 % cited a 1992 source to estimate the medical costs associated with smoking and 56 % cited a 1996 study to derive the estimate for QALYs saved by quitting or preventing smoking. Approaches for estimating T varied dramatically among the studies included in this review. T was valued as a positive number, negative number and $0; five studies did not include estimates for T in their analyses. The most commonly cited source for Q based its estimate on the Health Utilities Index (HUI). Several papers also cited sources that based their estimates for Q on the Quality of Well-Being Scale and the EuroQol five dimensions questionnaire (EQ-5D). Conclusions Current estimates of the lifetime medical care costs and the QALYs associated with smoking are dated and do not reflect the latest evidence on the health effects of smoking, nor the current costs and benefits of smoking cessation and prevention. Given these limitations, we recommend that researchers conducting economic evaluations of tobacco control interventions perform extensive sensitivity analyses around these parameter estimates

FDA-approved pictorial warning label images.

<p>This document includes images of the nine FDA-approved pictorial warning label images used in this study. Reprinted from <a href="http://www.fda.gov" target="_blank">http://www.fda.gov</a> under a CC BY license, with permission from the FDA, copyright 2012.</p

Percentage indicating intention to quit by education level.

<p>This figure shows the percentages reporting intention to quit in the next 30 days (yes/no) by exposure to the control or experimental condition for each level of education (high school or less/some college/college or more). In adjusted regression models, the interaction for experimental condition by education was marginally significant at p = .057. The figure indicates a stronger effect for the pictorial condition versus the text-only condition among individuals with moderate education compared with higher educated groups.</p