John P. Pierce

Background Tobacco use among United States (US) youth and young adults has declined from historic levels, but cannabis use has not. The importance of cannabis use as a risk factor for tobacco initiation is not known. Methods The association between past 12-month cannabis use in 2017 (study exposure; wave 4) and new-onset regular tobacco use in 2021 (study outcome; wave 6) was examined in a prospective representative US cohort aged 12–24 years who had never regularly used tobacco. Exposed respondents were propensity score matched to unexposed controls on demographics, tobacco use history, perceived harmfulness of cigarettes, mental health symptoms and other measures. Results Among these US youths aged 12–17 years who used cannabis, 32.7% (95% CI: 28.9% to 36.7%) progressed to regular tobacco use in 2021, an increase of 15.6 percentage points (pp) (95% CI: 11.1 pp to 20.2 pp) compared with their matched controls. Among the young adults aged 18–24 years, 14.0% (95% CI: 11.9% to 16.5%) of cannabis users reported regular tobacco use at follow-up, an increase of 5.4 pp (95% CI: 2.6 pp to 8.2 pp) over their matched controls. The matching analysis attributed 13.0% of total new regular tobacco use in the US to cannabis (the population attributable fraction), and estimated that in the absence of cannabis, 509 800 fewer US youth and young adults would have progressed to regular tobacco use in 2021. Conclusion Among US youth and young adults who had never regularly used tobacco, cannabis use in 2017 was associated with a large increase in current regular tobacco use in 2021.

Objective To investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000–2019 decline in cigarette smoking among US 18–24 year-olds. Methods Smoking behaviour was assessed in the 24 most populous US states using the 1992–2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011. Results Between 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018–2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean. Conclusion National programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

Objective To compare trends in cigarette smoking and nicotine vaping among US population aged 17–18 years and 18–24 years. Methods Regression analyses identified trends in ever and current use of cigarettes and e-cigarettes, using three US representative surveys from 1992 to 2022. Results From 1997 to 2020, cigarette smoking prevalence among those aged 18–24 years decreased from 29.1% (95% CI 27.4% to 30.7%) to 5.4% (95% CI 3.9% to 6.9%). The decline was highly correlated with a decline in past 30-day smoking among those aged 17–18 years (1997: 36.8% (95% CI 35.6% to 37.9%; 2022: 3.0% (95% CI 1.8% to 4.1%). From 2017 to 2019, both ever-vaping and past 30-day nicotine vaping (11.0% to 25.5%) surged among those 17–18 years, however there was no increase among those aged 18–24 years. Regression models demonstrated that the surge in vaping was independent of the decline in cigarette smoking. In the 24 most populous US states, exclusive vaping did increase among those aged 18–24 years, from 1.7% to 4.0% to equivalent to 40% of the decline in cigarette smoking between 2014–15 and 2018–19. Across these US states, the correlation between the changes in vaping and smoking prevalence was low (r=0.11). In the two US states with >US$1/fluid mL tax on e-cigarettes in 2017, cigarette smoking declined faster than the US average. Conclusions Since 1997, a large decline in cigarette smoking occurred in the US population under age 24 years, that was independent of the 2017–19 adolescent surge in past 30-day e-cigarette vaping. Further research is needed to assess whether the 2014–15 to 2018–19 increase in exclusive vaping in those aged 18–24 years is a cohort effect from earlier dependence on e-cigarette vaping as adolescents.

Living alone, particularly for individuals with poor physical health, can increase the likelihood of mortality. This study aimed to explore the individual and joint associations of living alone and physical health with overall mortality among breast cancer survivors in the Women’s Healthy Eating and Living (WHEL). We collected baseline, 12-month and 48-month data among 2869 women enrolled in the WHEL cohort. Living alone was assessed as a binary variable (Yes, No), while scores of physical health were measured using the RAND Short Form–36 survey (SF-36), which include four domains (physical function, role limitation, bodily pain, and general health perceptions) and an overall summary score of physical health. Cox proportional hazard models were used to evaluate associations. No significant association between living alone and mortality was observed. However, several physical health measures showed significant associations with mortality (p-values < 0.05). For physical function, the multivariable model showed a hazard ratio (HR) of 2.1 (95% CI = 1.02–4.23). Furthermore, the study examined the joint impact of living alone and physical health measures on overall mortality. Among women with better physical function, those living alone had a 3.6-fold higher risk of death (95% CI = 1.01–12.89) compared to those not living alone. Similar trends were observed for pain. However, regarding role limitation, the pattern differed. Breast cancer survivors living alone with worse role limitations had the highest mortality compared to those not living alone but with better role limitations (HR = 2.6, 95% CI = 1.11–5.95). Similar trends were observed for general health perceptions. Our findings highlight that living alone amplifies the risk of mortality among breast cancer survivors within specific health groups.

Introduction: This study examined trajectories of tobacco dependence (TD) in relationship to changes in tobacco product use, and explored the effects of product-specific adding, switching, or discontinued use on dependence over time. Aims and Methods: Data were analyzed from the first three waves from the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal study of adults and youth in the United States. Data included 9556 wave 1 (2013–2014) adult current established tobacco users aged 18 or older who completed all three interviews and had established use at ≥2 assessments. Mutually exclusive groups included: users of cigarettes only, e-cigarettes only, cigars only, hookah only, any smokeless only, cigarette + e-cigarette dual users, and other multiple product users. A validated 16-item scale assessed TD across product users. Results: People who used e-cigarettes exclusively at wave 1 had small increases in TD through wave 3. Wave 1 multiple product users’ TD decreased across waves. TD for all other wave 1 user groups remained about the same. For wave 1 cigarette only smokers, switching to another product was associated with lower levels of TD than smokers whose use stayed the same. Movement to no established use of any tobacco product was consistently associated with lower TD for all product users. Conclusions: Except for wave 1 e-cigarette only users (who experienced small increases in TD), TD among U.S. tobacco product users was stable over time, with daily users less likely to vary from baseline. Implications: The level of TD among most U.S. tobacco users was stable over the first three waves of the PATH Study and trends in levels of TD were predominantly unrelated to changes in patterns of continued product use. Stable levels of TD suggest a population at persistent risk of health impacts from tobacco. Wave 1 e-cigarette users experienced small increases in levels of TD over time, perhaps due to increases in quantity or frequency of their e-cigarette use or increasing efficiency of nicotine delivery over time.

Background: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth. Methods: One thousand one hundred and forty-eight youth aged 12–17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Findings: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = −1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = −0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults. Conclusion: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group. Implications: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco.

James D Sargent, MD, Kathryn C Edwards, PhD, Jennifer Emond, PhD, Susanne Tanski, MD, Kristie A Taylor, PhD, John P Pierce, PhD, Maciej L Goniewicz, PhD PharmD,

Thomson et al reported that there were almost 75 000 deaths by the end of 2019 among 551 338 respondents to the US National Health Interview Survey from 1997 to