Meghan Elizabeth Morean

Perceptions of secondhand exposure may influence adolescent use of cigarettes, e-cigarettes, and cannabis. In Spring 2024, 4760 Connecticut high school students completed an online survey assessing perceived harms from secondhand exposure to cigarettes, e-cigarettes, and smoked or vaped cannabis. Compared to never use, low perceived harm of secondhand exposure to cigarettes, e-cigarettes, smoked and vaped cannabis were significantly associated with higher odds of current use of cigarettes, e-cigarettes, smoked and vaped cannabis, respectively (all p s < 0.05). Additionally, low perceived harm of secondhand exposure to smoked and vaped cannabis were associated with ever (vs never) smoked or vaped cannabis, respectively (all p s < 0.05). Low harm perceptions of secondhand exposure to cigarettes, e-cigarettes, or cannabis were associated with current use of these products. Public health interventions should provide evidence-based information about the potential risks of secondhand exposure to smoked and vaped nicotine and/or cannabis products and support informed perceptions of these risks among adolescents.

Background: This study examines how two competing policy approaches, tobacco-free pharmacies and pharmacy-only tobacco sales, could impact the number of tobacco retailers, retailer availability and neighbourhood disparities in the US. Methods: We compiled a list of tobacco retailers in 2023 and coded for primary store type in four US states: California, Connecticut, North Carolina and Ohio. We calculated the reduction in tobacco retailer availability defined as the number of tobacco retailers per 1000 people for each hypothetical policy. We used models fitted for count data and addressed overdispersion and possible spatial dependence to assess associations between the availability of pharmacies in census tracts and neighbourhood characteristics (rurality, age, poverty, race/ethnicity and vacant housing). Results: The hypothetical tobacco-free pharmacy policy showed a much smaller reduction in the number of tobacco retailers (California: 3.9%, Connecticut: 3.1%, North Carolina: 3.0% and Ohio: 4.7%) than a hypothetical pharmacy-only tobacco sales policy (California: 96.1%, Connecticut: 96.9%, North Carolina: 97.0% and Ohio: 95.3%). Regarding the potential impact of each policy on neighbourhood disparities, tobacco-free pharmacies would leave neighbourhood disparities largely unchanged or make them worse in some instances. Pharmacy-only tobacco sales policies would disproportionately locate the few remaining tobacco retailers in neighbourhoods with a greater percentage of people living under the poverty line. Conclusions: Competing pharmacy-based policies about tobacco sales could impact tobacco retailer availability in the US and have different implications for neighbourhood disparities in tobacco retailer availability.

Background Age-restricted location (ARL) policies are a novel tobacco control strategy that restrict in-person tobacco sales to locations that do not allow underage buyers on their premises, such as tobacco shops. This study aimed to examine how ARL policies might impact different US communities. Methods Preliminary work geocoded the locations of all tobacco retailers (collected 2023–2024) across four states (California, Connecticut, North Carolina and Ohio) and calculated tobacco retailer density (TRD) at the census tract level. We then simulated an ARL policy by removing all retailers that would no longer be allowed to sell tobacco. Finally, using statistical methods that accounted for varying spatial distributions over census tracts for each state, we conducted pre–post analyses to determine how an ARL policy would reduce TRD overall, and by neighbourhood characteristics (census tract-level poverty, race and ethnicity and rurality). Results The percentage reduction in tobacco retailers was highest for North Carolina (86.4% reduction in TRD), followed by Ohio (85.8%), California (74.4%) and Connecticut (62.4%). Results also indicated that an ARL policy would generally be equity-neutral, meaning that it would not exacerbate the current disparities that exist in TRD. And, in some cases, the policy would be equity-enhancing, such as in the case of reducing existing rural TRD disparities. Conclusions The degree of TRD reduction estimated by these simulation models for an ARL policy is more powerful than what has been found for other retailer-focused strategies (eg, prohibiting tobacco retailers close to schools). ARL policies could be a promising and potentially powerful strategy for reducing TRD in the USA.

Significance: Flavor accessories (e.g., flavor capsules), which are separate products that can be used with combustible tobacco products to alter their flavor, are on the market. These new products may bypass flavor restrictions and appeal to youth, yet no research has examined US youth awareness or use of flavor accessories. This study aimed to examine awareness and use of flavor accessories among a sample of youth in the US. Methods: A school-based survey of 4,760 Connecticut high school students (mean age = 15.9, SD = 1.2) was conducted in April-May 2024. All youth reported on awareness of flavor accessories (i.e., flavor capsules, sprays/drops, cards). Youth who had ever used combustible tobacco products (i.e., cigarettes, cigars, cigarillos) or cannabis blunts, which are all products that can be used with flavor accessories (N = 868), also reported on ever use of flavor accessories. Differences in awareness by ever product user type (i.e., exclusive combustible tobacco (n = 173), exclusive blunt (n = 461), dual tobacco and blunt (n = 234)) were assessed using Bonferroni-corrected chi-square tests. Results: Overall, 22.9% of youth were aware of at least one type of flavor accessory. Among ever users of combustible tobacco or blunts, awareness of at least one type of flavor accessory was 32.8%, with awareness most common for flavor capsules (19.6%), followed by sprays/drops (16.3%), and cards (9.5%). Among this group, more dual users of combustible tobacco and blunts were aware of at least one type of flavor accessory compared to exclusive users of combustible tobacco (44.1% vs 26.3%, p = 0.002) and compared to exclusive users of blunts (44.1% vs 30.8%, p = 0.005). Among ever users of combustible tobacco or blunts, ever use of any flavor accessory was 7.6%, ranging from 4.7% for flavor capsules, 3.5% for sprays/drops, and 2.7% for cards. Conclusions: Nearly one-quarter of a sample of Connecticut high school youth were aware of flavor accessories, with differences in awareness by product user groups, although ever use of these products was lower. Continued monitoring of flavor accessories is critical for informing regulatory actions and interventions.

Purpose: Nicotine and cannabis are commonly co-used among adolescents and young adults (AYAs). Same session co-use has more negative effects than co-use that does not overlap. Little is known about how or why these products are used within the same session. Enhanced understanding of this behavior pattern can be leveraged to reduce co-use in this population. Methods: Connecticut AYAs (15–20 years old) who self-reported past-month nicotine and cannabis vaping participated in 1-hour focus groups examining of nicotine and cannabis use. Six focus groups were conducted in Spring 2023 (N = 29, mean group size n = 5). Data was analyzed with a two-stage deductive and inductive approach. Results: Participants reported deliberate same session use in various modes (e.g., smoking, vaping). Same session use was most commonly reported to enhance positive psychoactive effects of cannabis (e.g., improve/enhance the high). Other common reasons were to reduce negative cannabis effects, such as vaping nicotine to reduce throat irritation or mask taste (e.g., vaping flavored nicotine product to mask cannabis taste). Some reported vaping nicotine so frequently that it unintentionally overlapped with cannabis use. Finally, other participants reported avoiding same session use as the combined psychoactive effects of nicotine and cannabis were too strong. Conclusion: AYAs reported same session use primarily to enhance cannabis use experience (e.g., improving high or taste, reducing negative effects). Our findings indicate a complementary role of nicotine and cannabis, and suggest that prevention and cessation efforts for either substance need to address co-use behaviors.

Introduction: Historically, cannabis blunts were made using tobacco products like cigars, but tobacco-free blunt wraps (TFBWs) made from sources like hemp and palm leaves are gaining popularity. While marketed for cannabis, it is unknown what substances adolescents put in TFBWs. Here, we focused on using tobacco in TFBWs. Aims and Methods: From April to May 2024, 4760 Connecticut high school students completed school-wide, anonymous, online surveys. The analytic sample comprised 489 adolescents (44.6% male, 28.2% non-Hispanic White, mean age 16.20 [1.27] years) with lifetime cannabis blunt use who answered questions about TFBW awareness and use, including with tobacco. We examined demographic-, tobacco-, and cannabis-related associations with using tobacco in TFBWs. Results: Of students reporting lifetime cannabis blunt use, 49.7% were aware of TFBWs and 24.7% reported use. Among adolescents using TFBWs, 12.4% reported putting tobacco in TFBWs, and 8.7% reported usually doing so. In bivariate analyses, putting tobacco in TFBWs was associated with using blunts at an earlier age; using other tobacco products; using a greater total number of tobacco products in one’s lifetime; and greater dependence on e-cigarettes, cigarettes, and cannabis (p-values <.05). Conclusions: Few students who use cannabis blunts reported putting tobacco in TFBWs. Yet, using tobacco in TFBWs was associated with negative outcomes like nicotine and cannabis dependence, requiring future investigation. Unlike cigarette rolling papers and tobacco blunt wraps, TFBWs are not regulated by the US Food and Drug Administration as tobacco products. However, surveillance in nationally representative samples may support the need for regulatory action if tobacco use in TFBWs continues. Implications: Although some brands of TFBWs specifically note that their products are not intended for tobacco use, blunts are user-rolled. Results demonstrate that among adolescents who use cannabis blunts and endorse TFBW use, 12.4% have added tobacco to a TFBW and 8.7% regularly do so. If findings are replicated in future national survey studies of adolescents and adults, this would support the United States Food and Drug Administration in regulating TFBWs as tobacco products.

Oral nicotine pouches may have potential for smoking cessation, but scientific evidence on the effects of pouches and their constituents on smoking behaviour is limited.Design: This study was a 4-week, open-label, randomised pilot trial of nicotine pouches in 3 mg (low) or 6 mg (high) nicotine strength.Subjects: US outpatient research clinic with non-treatment seeking adults who smoke cigarettes (N=30).Interventions: Participants selected two flavours and were instructed to switch to using nicotine pouches in place of cigarettes.Main outcome measures: We compared groups on cigarettes smoked per day, pouch use and urinary levels of a tobacco-specific carcinogen (NNAL) over 4 weeks, biochemically verified 7-day point prevalence smoking abstinence at week 4, and willingness to continue pouch use.Results: Nearly all participants completed the trial (29/30). Participants in both groups significantly reduced their cigarettes smoked per day (log-transformed) over time (F_{3, 74.4}=3.8, p=0.01). The 6 mg group reported numerically greater, but non-significant, reductions in smoking than the 3 mg group (least-square mean difference (LSMD) at week 1=0.008; 95% CI −0.42–0.44; LSMD at week 4=0.38; 95% CI −0.06–0.81). The 6 mg group also reported numerically higher, but non-significant, likelihood of complete smoking abstinence (13% vs 0%) and willingness to continue pouch use (67% vs 40%). There were no differences by group or time for NNAL.Conclusions: Results provide preliminary support for nicotine pouches for cigarette substitution. Compared with lower nicotine strength pouches, higher nicotine strength pouches may have a greater impact on smoking behaviour and adults who smoke may be more willing to use them.Trial registration number: NCT04250727.