Faculty Bibliography

BACKGROUND: Little is known about electronic cigarette (e-cigarette) use among Chinese adolescents. We examined the prevalence of current (past 30-day) e-cigarette use and its associated factors in a large sample of adolescents in Hong Kong. METHODS: We analyzed data of the School-based Survey on Smoking among Students 2012/13 from a representative sample of 45,857 secondary school students (mean age: 14.8 +/- 1.9). We conducted chi-square tests and t-test to compare current e-cigarette use by covariates. We used multivariable logistic regression to examine the association between current e-cigarette use and demographic variables, parental smoking, peer smoking, knowledge about the harm of cigarette smoking, attitudes toward cigarette smoking, cigarette smoking status, use of other tobacco products, and alcohol consumption. RESULTS: Overall, 1.1% of students reported current e-cigarette use. Of e-cigarette users, 11.7% were never-cigarette smokers, 15.8% were experimental cigarette smokers, 39.3% were former cigarette smokers, and 33.2% were current cigarette smokers. Current e-cigarette use was associated with male sex, poor knowledge about the harm of smoking, cigarette smoking, use of other tobacco products, and alcohol consumption. CONCLUSIONS: Surveillance and intervention efforts should address a wide range of tobacco products, including e-cigarettes. Tobacco cessation programs should also address alcohol use collectively. Policies prohibiting e-cigarette sales to minors may help prevent e-cigarette uptake among adolescents.

OBJECTIVE: The goal of this study was to summarise the websites of electronic cigarette (e-cigarette) manufacturers in China and describe how they market their products. METHODS: From March to April 2013, we used two search keywords 'electronic cigarette' (Dian Zi Xiang Yan in Chinese) and 'manufacturer' (Sheng Chan Chang Jia in Chinese) to search e-cigarette manufacturers in China on Alibaba, an internet-based e-commerce business that covers business-to-business online marketplaces, retail and payment platforms, shopping search engine and data-centric cloud computing services. A total of 18 websites of 12 e-cigarette manufacturers in China were analysed by using a coding guide which includes 14 marketing claims. RESULTS: Health-related benefits were claimed most frequently (89%), followed by the claims of no secondhand smoke (SHS) exposure (78%), and utility for smoking cessation (67%). A wide variety of flavours, celebrity endorsements and e-cigarettes specifically for women were presented. None of the websites had any age restriction on access, references to government regulation or lawsuits. Instruction on how to use e-cigarettes was on 17% of the websites. CONCLUSIONS: Better regulation of e-cigarette marketing messages on manufacturers' websites is needed in China. The frequent claims of health benefits, smoking cessation, strategies appealing to youth and women are concerning, especially targeting women. Regulators should prohibit marketing claims of health benefits, no SHS exposure and value for smoking cessation in China until health-related, quality and safety issues have been adequately addressed. To avoid e-cigarette use for initiation to nicotine addiction, messages targeting youth and women should be prohibited.

INTRODUCTION: Electronic cigarettes (e-cigarettes) have gained popularity rapidly in the Western world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong. METHODS: Cross-sectional data were collected in 2014 from Chinese adults aged 15-65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status. RESULTS: 75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p=.03), younger adults (aged 15-29, 5.2%, p=.002), and current cigarette smokers (11.8%, p<.001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%). CONCLUSIONS: Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation.

INTRODUCTION: Light and intermittent smoking (LITS) has become increasingly common. Alcohol drinkers are more likely to smoke. We examined the association of smokefree law and bar law coverage and alcohol use with current smoking, LITS, and smoking quit attempts among US adults and alcohol drinkers. METHODS: Cross-sectional analyses among a population-based sample of US adults (n = 27,731) using restricted data from 2009 National Health Interview Survey and 2009 American Nonsmokers' Rights Foundation United States Tobacco Control Database. Multivariate logistic regression models examined the relationship of smokefree law coverage and drinking frequency (1) with current smoking among all adults; (2) with 4 LITS patterns among current smokers; and (3) with smoking quit attempts among 6 smoking subgroups. Same multivariate analyses were conducted but substituted smokefree bar law coverage for smokefree law coverage to investigate the association between smokefree bar laws and the outcomes. Finally we ran the above analyses among alcohol drinkers (n = 16,961) to examine the relationship of smokefree law (and bar law) coverage and binge drinking with the outcomes. All models controlled for demographics and average cigarette price per pack. The interactions of smokefree law (and bar law) coverage and drinking status was examined. RESULTS: Stronger smokefree law (and bar law) coverage was associated with lower odds of current smoking among all adults and among drinkers, and had the same effect across all drinking and binge drinking subgroups. Increased drinking frequency and binge drinking were related to higher odds of current smoking. Smokefree law (and bar law) coverage and drinking status were not associated with any LITS measures or smoking quit attempts. CONCLUSIONS: Stronger smokefree laws and bar laws are associated with lower smoking rates across all drinking subgroups, which provides further support for these policies. More strict tobacco control measures might help reduce cigarette consumption and increase quit attempts.

BACKGROUND: Electronic cigarettes (e-cigarettes) are being increasingly used. We examined the correlates associated with e-cigarette awareness, use and perceived effectiveness in smoking cessation among Chinese daily smokers in Hong Kong. METHODS: Daily smokers (N = 1,307) were recruited to a community-based randomised controlled trial ('Quit to Win') in 2014. Socio-demographic characteristics, conventional cigarette smoking status, nicotine addiction level, quit attempts, quit intention, e-cigarette awareness, use and perceived effectiveness on quitting were reported at baseline and 1-week follow-up. Multivariate logistic regression was used to identify factors associated with e-cigarette awareness, use and perceived effectiveness in quitting. RESULTS: Most smokers (82.6%, 95% CI 80.2%-84.9%) had heard about e-cigarettes, and 13.3% (11.3%-15.5%) ever used e-cigarettes. Most users (74.1%) and non-users (91.2%) did not perceive e-cigarettes as effective in quitting. Being younger and having a larger family income were associated with e-cigarette awareness. Being younger, a tertiary education and a stronger addiction to nicotine were associated with e-cigarette use, which was itself associated with lower levels of intention to quit and had no association with attempts to quit (P for trend 0.45). E-cigarette use, the last quit attempt being a month earlier, having made a quit attempt lasting 24 hours or longer and perceiving quitting as important were all associated with the perceived effectiveness of e-cigarettes in quitting (all P <0.05). CONCLUSIONS: Among community-recruited smokers who intended to quit, awareness of e-cigarettes was high, but most did not perceive e-cigarettes as effective in quitting. Correlates concerning e-cigarette perceptions and use will help to inform prospective studies, public education and policy on controlling e-cigarettes.

OBJECTIVE: Young adults frequently report social smoking. This study examined the relationship between different social smoking definitions and the co-use of cigarettes and alcohol, tobacco-related attitudes, and quitting efforts. METHOD: Cross-sectional data were collected at bars using randomized time location sampling among young adults aged 21-26 in San Diego, California from 2010 to 2011 (73% response rate). Multivariable logistic regression examined if current smoking and quit attempts were associated with tobacco-related attitudes, and whether social smoking self-identification or behavior was associated with cigarette-and-alcohol co-use, tobacco-related attitudes, quit attempts, or quitline use. RESULTS: Among 537 current smokers, 80% self-identified and 49% behaved as social smokers. Social smoking self-identification was positively associated with cigarette-and-alcohol co-use, and quit attempts. Social smoking behavior was negatively associated with tobacco marketing receptivity, quit attempts, and quitline use. Tobacco-related attitudes were associated with smoking but did not generally differ by social smoking status. CONCLUSION: Identification and behavior as a social smoker have opposing associations with co-use of cigarettes and alcohol and quit attempts. Tobacco cessation programs for self-identified social smokers should address co-use. Interventions denormalizing the tobacco industry or emphasizing the health effects of temporary smoking and secondhand smoke may address smoking among young adult bar patrons regardless of social smoking status.

BACKGROUND: Bars and nightclubs are key public venues where young adults congregate and use both tobacco and alcohol, and young adult bar patrons are at high risk for substance use. This study examined the association between cigarette smoking and alcohol use among a random sample of young adult bar patrons from three different cities in the USA. METHODS: Cross-sectional data was collected from a random sample of young adult bar patrons aged 18-29 in San Diego, CA (N = 1,150), Portland, ME (N = 1,019), and Tulsa, OK (N = 1,106) from 2007-2010 (response rate 88%) using randomized time location sampling. Respondents reported the number of days they smoked cigarettes, drank alcohol, and binge drank in the past 30 days. Multinomial logistic regression was used to analyze the association between smoking (nonsmoker, occasional smoker, and regular smoker) and drinking and binge drinking for each city controlling for age, gender, race/ethnicity, and education. Predicted probabilities of each smoking category were calculated by drinking and binge drinking status. The association between smoking and drinking and binge drinking among combined samples was also analyzed, controlling for demographic variables and city. RESULTS: Respondents reported high current smoking rates, ranging from 51% in Portland to 58% in Tulsa. Respondents in Tulsa were more likely to report regular smoking than those in San Diego and Portland, with demographic variables being controlled. Young adult bar patrons also exhibited a strong association between smoking and drinking. In general, as the frequency of drinking and binge drinking increased, the predicted probability of being a smoker, especially a regular smoker, increased in each city. CONCLUSIONS: Young adult bar patrons consistently reported a high smoking rate and a strong relationship between smoking and drinking, regardless of the different bar cultures and tobacco control contexts in each of the three cities. While smoke-free bar policies were negatively associated with regular smoking, these policies alone may not be enough to influence the association between smoking and drinking, particularly if tobacco marketing continues in these venues, or in the absence of programs specifically addressing the co-use of tobacco and alcohol.

AIMS: The tobacco and alcohol industries share common policy goals when facing regulation, opposing policies such as tax increases and advertising restrictions. The collaboration between these two industries in the tobacco policy arena is unknown. This study explored if tobacco and alcohol companies built alliances to influence tobacco legislation and, if so, how those alliances worked. METHODS: Analysis of previously secret tobacco industry documents. FINDINGS: In the early 1980s, tobacco companies started efforts to build coalitions with alcohol and other industries to oppose cigarette excise taxes, clean indoor air policies and tobacco advertising and promotion constraints. Alcohol companies were often identified as a key partner and source of financial support for the coalitions. These coalitions had variable success interfering with tobacco control policy-making. CONCLUSIONS: The combined resources of tobacco and alcohol companies may have affected tobacco control legislation. These alliances helped to create the perception that there is a broader base of opposition to tobacco control. Advocates should be aware of the covert alliances between tobacco, alcohol and other industries and expose them to correct this misperception.

OBJECTIVES: We examined cigarette smoking and quit attempts in the context of alcohol use and bar attendance among young adult bar patrons with different smoking patterns. Methods. We used randomized time location sampling to collect data among adult bar patrons aged 21 to 26 years in San Diego, California (n = 1235; response rate = 73%). We used multinomial and multivariate logistic regression models to analyze the association between smoking and quit attempts and both drinking and binge drinking among occasional, regular, very light, and heavier smokers, controlling for age, gender, race/ethnicity, and education. RESULTS: Young adult bar patrons reported high rates of smoking and co-use of cigarettes and alcohol. Binge drinking predicted smoking status, especially occasional and very light smoking. All types of smokers reported alcohol use, and bar attendance made it harder to quit. Alcohol use was negatively associated with quit attempts for very light smokers, but positively associated with quitting among heavier smokers. CONCLUSIONS: Smoking and co-use of cigarettes and alcohol are common among young adult bar patrons, but there are important differences by smoking patterns. Tobacco interventions for young adults should prioritize bars and address alcohol use.

OBJECTIVES: We investigated tobacco companies' knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities. METHODS: We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results. RESULTS: Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use. CONCLUSIONS: Tobacco companies' numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.