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Evaluation of Risk Perception of Smoking after the Implementation of California’s Tobacco 21 Law

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Decreasing smoking initiation remains a public health priority. In 2016, California, in the United States, enacted the Tobacco 21 law, which raised the minimum age for the purchase of tobacco products from age 18 to age 21. This paper evaluates whether the enactment and implementation of the Tobacco 21 law changed how young adults perceive the risk(s) of smoking. Data were drawn from a cohort of emerging adults (n = 575) in California who were non-daily smokers at enrollment and followed quarterly for 3 years. Data were collected during 2015–2019. Piecewise multilevel regression models were used to test for changes in smoking status and perceived risks of cigarettes after Tobacco 21 enforcement began. Findings indicated that the prevalence of current smoking and perceived risks of smoking both declined following Tobacco 21 implementation (ps < 0.001). Post-hoc analyses suggested that post-implementation changes in perceived risk occurred primarily among ongoing smokers. Findings suggest that Tobacco 21 and associated public health measures have been effective, but additional research is needed to disentangle the effects of specific components. Understanding the impact and efficacy of tobacco laws provides great social value to research and implement policies that create intervention(s) on reducing tobacco use initiation.
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Int. J. Environ. Res. Public Health 2022, 19, 16971. https://doi.org/10.3390/ijerph192416971 www.mdpi.com/journal/ijerph
Article
Evaluation of Risk Perception of Smoking after the
Implementation of California’s Tobacco 21 Law
Joanna K. Sax
1,
* and Neal Doran
2
1
California Western School of Law, 225 Cedar St., San Diego, CA 92101, USA
2
Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
* Correspondence: jsax@cwsl.edu, Tel.: +1-619-515-1555
Abstract: Decreasing smoking initiation remains a public health priority. In 2016, California, in the
United States, enacted the Tobacco 21 law, which raised the minimum age for the purchase of to-
bacco products from age 18 to age 21. This paper evaluates whether the enactment and implemen-
tation of the Tobacco 21 law changed how young adults perceive the risk(s) of smoking. Data were
drawn from a cohort of emerging adults (n = 575) in California who were non-daily smokers at
enrollment and followed quarterly for 3 years. Data were collected during 2015–2019. Piecewise
multilevel regression models were used to test for changes in smoking status and perceived risks of
cigarettes after Tobacco 21 enforcement began. Findings indicated that the prevalence of current
smoking and perceived risks of smoking both declined following Tobacco 21 implementation (ps <
0.001). Post-hoc analyses suggested that post-implementation changes in perceived risk occurred
primarily among ongoing smokers. Findings suggest that Tobacco 21 and associated public health
measures have been effective, but additional research is needed to disentangle the effects of specific
components. Understanding the impact and efficacy of tobacco laws provides great social value to
research and implement policies that create intervention(s) on reducing tobacco use initiation.
Keywords: Tobacco 21 law; smoking; risk perception; intervention; public policy; young adults
1. Introduction
In 2016, California, in the United States, enacted Senate Bill No. 7 (known as “Tobacco
21”), which raised the minimum age for sales of tobacco products from age 18 to 21 [1].
The purpose of this Tobacco 21 law was to make it more difficult for individuals under
the age of 21 to obtain cigarettes and other tobacco and nicotine-containing products [2,3].
Previous research indicates that individuals are more likely to become addicted to smok-
ing the earlier they begin [2]. Historically, the initiation of smoking primarily occurred
during adolescence, but recent data suggest that initiation is shifting to young adulthood
[4]. Thus, the Tobacco 21 law raised the minimum age for retailers to sell nicotine and
tobacco products to individuals. In conjunction with the minimum age increase, Califor-
nia launched a public awareness campaign to educate the public, support the minimum
age change in the Tobacco 21 law, and inform retailers about the change [5].
Previous studies indicate that Tobacco 21 laws can be an effective means of reducing
smoking prevalence, particularly among youth and emerging adults [6,7]. Evidence indi-
cates that such restrictions decrease the ability of individuals under 21 to purchase tobacco
products, potentially delaying or even preventing the initiation of tobacco use [8]. It has
been demonstrated that California retailers were highly aware of the law and generally
compliant with its requirements [5].
While the Tobacco 21 law appears to decrease access to tobacco products at the point
of sale for individuals under 21, it is less clear whether it impacted how young adults
perceive the risk(s) of smoking. This is an important question, given that the perceived
Citation: Sax, J.K.; Doran, N.
Evaluation of Risk Perception of
Smoking after the Implementation of
California’s Tobacco 21 Law. Int. J.
Environ. Res. Public Health 2022, 19,
16971. https://doi.org/10.3390/
ijerph192416971
Academic Editor: Paul B.
Tchounwou
Received: 28 October 2022
Accepted: 15 December 2022
Published: 17 December 2022
Publisher’s Note: MDPI stays neu-
tral with regard to jurisdictional
claims in published maps and institu-
tional affiliations.
Copyright: © 2022 by the authors. Li-
censee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and con-
ditions of the Creative Commons At-
tribution (CC BY) license (https://cre-
ativecommons.org/licenses/by/4.0/).
Int. J. Environ. Res. Public Health 2022, 19, 16971 2 of 8
risk of smoking is inversely associated with the likelihood of initiation [9,10]. That is, if
Tobacco 21 laws increase the perceived risk in addition to reducing tobacco access for 18–
20-year-olds, they may be more likely to prevent rather than merely delay initiation. To
our knowledge, the present study is the first to examine changes in perceived risks from
smoking among young adults following the implementation of the Tobacco 21 law.
The primary goal of this study was to test two hypotheses in a sample of young adults
who had been non-daily smokers at enrollment. First, we expected that the likelihood of
current cigarette smoking would decline following Tobacco 21 implementation. Second,
we predicted that perceived risks of smoking would increase following the implementa-
tion of Tobacco 21. Secondary analyses examined associations with smoking status.
2. Materials and Methods
2.1. Participants
Participants (n = 575) were young adults enrolled in a longitudinal study of non-daily
cigarette smoking. Eligibility requirements included being aged 18–24 at baseline, smok-
ing cigarettes at least monthly for the past 6 months or more, never having been a daily
smoker, and being a California resident at the time of enrollment. A total of 52% of percent
of participants identified as male, 44% as non-Hispanic White, 18% as Asian American,
and 22% as Hispanic/Latinx. The average age at baseline was 20.4 years (SD = 1.7).
2.2. Procedure
Candidates were recruited via paid Facebook posts. If interested, they completed a
brief online eligibility screener. Eligible respondents completed a baseline assessment and
then quarterly assessments for the next 3 years, yielding a total of 13 waves of assessment.
All assessments occurred online. At annual assessment points (baseline and 1, 2, and 3
years later; hereafter annual waves), all measures were completed on a single day, and
participants were compensated with $25 gift cards. At each of the 9 waves between these
annual assessments (hereafter quarterly waves), participants completed brief daily assess-
ments for 9 consecutive days and were compensated up to $40 per wave. Data were col-
lected during 2015–2019. The study was approved by the Institutional Review Board at
the University of California, San Diego.
2.3. Measures
Demographics evaluated at baseline included self-identified sex, racial/ethnic identity,
and age. Due to small cell sizes for some groups, race/ethnicity was collapsed into 4
groups: non-Hispanic White (n = 254), Asian American (n = 102), Latinx (n = 122), and
multiple or other backgrounds (n = 96).
Cigarette use was assessed at each wave. At annual waves, a Timeline Followback
procedure [11] was used to evaluate the number of cigarettes smoked in each of the past
14 days. At quarterly waves, participants reported the number of cigarettes smoked in the
past 24 h on each of 9 consecutive days. From these raw data, we calculated a cigarette days
variable, which reflected the number of days on which cigarettes were smoked at each
wave, and a binary smoking status variable, indicating whether participants had smoked
at each wave (coded as 0 = no cigarette days, 1 = 1 or more cigarette days). Because the
maximum number of smoking days differed for annual and quarterly assessments, we
also calculated days assessed, reflecting the number of days at each wave that smoking was
assessed, for use as a covariate.
Risk perceptions were measured using the Negative Consequences subscale from the
short form of the Smoking Consequences Questionnaire [12,13], which has been validated
for use in young adult samples. The subscale includes 4 items on which participants rate
perceived health risks from cigarette smoking on a 10-point scale. The subscale had good
internal consistency in the present sample (α = 0.85). Risk perceptions were evaluated at
each annual wave and on day 9 of each quarterly wave.
Int. J. Environ. Res. Public Health 2022, 19, 16971 3 of 8
2.4. Analytic Plan
Two primary models were fit. First, a longitudinal logistic regression model using
the generalized estimating equations (GEE) approach [14] was used to evaluate post-im-
plementation change in smoking status. Second, a mixed effects longitudinal regression
model was used to evaluate post-implementation change in the perceived risk of smoking.
In light of previous reports of smoking differences between demographic groups, ra-
cial/ethnic background and gender were included as covariates in hypothesis tests [15].
Similarly, we included total cigarettes smoked in the past 2 weeks at baseline as a covari-
ate. Our primary interest was in the extent to which smoking status and the perceived risk
from cigarette smoking changed over time and in relation to the implementation of To-
bacco 21 in California.
Both models utilized a piecewise or segmented multilevel longitudinal regression
approach, which has been recommended [16] for the evaluation of policy changes. This
piecewise approach included segments for the periods before and after Tobacco 21 imple-
mentation, allowing us to compare outcomes between the two periods, as well as change
over time following implementation. Models included a binary, time-varying Tobacco 21
variable that indicated whether each measurement of perceived risk occurred before or
after implementation in June 2016. We also created a post-implementation slope variable to
evaluate change over time after implementation; for each participant, post-implementation
slope was coded as 0 for all visits prior to June 2016, 1 for the first visit after implementa-
tion, 2 for the second, and so on. Finally, we created a binary, time-varying age21 variable
that reflected whether participants were 21 years old at the time of their participation in
each wave. All analyses were conducted using Stata 15.0 (StataCorp LLP, College Station,
TX, USA) with alpha = 0.05. Analyses utilized an intent-to-treat approach, retaining par-
ticipants who were lost to follow-up without imputing missing values [17].
3. Results
3.1. Preliminary Analyses
Participants completed a total of 6032 assessments of cigarette use and risk percep-
tions; 74% of these occurred after Tobacco 21 implementation. At the participant level,
90% had at least one assessment prior to implementation, 79% had at least two, 57% had
at least three, 37% had at least four, and 8% had five. In other words, for almost all partic-
ipants, the key variables were evaluated at least once prior to implementation, and the
majority of participants reported cigarette use and perceived risk at three or more waves
prior to implementation. Attrition increased gradually over the 3-year study period, from
2% at the first baseline wave to 11% at year 1, 23% at year 2, and 37% at year 3 regarding
missing smoking status and/or risk perception data. Baseline demographic and cigarette
use characteristics are shown in Table 1.
Table 1. Demographic and clinical characteristics.
Variable M (SD), Range or Proportion
Age at baseline 20.4 (1.7), 18–24
Aged 21+ at baseline 33.9%, n = 195
Aged 21+ at year 1 63.5%, n = 365
Aged 21+ at year 2 87.2%, n = 501
% identifying as female 51.7%, n = 297
% identifying as non-Hispanic White 48.7%, n = 280
Total cigarettes, past 14 days at baseline 12.4 (17.7), 0–209
Perceived risk of smoking at baseline 19.6 (5.8), 4–28
Int. J. Environ. Res. Public Health 2022, 19, 16971 4 of 8
3.2. Hypothesis Tests: Post-Implementation Changes
The piecewise GEE model of smoking status is shown in Table 2. The time term was
not significant, indicating that smoking status was stable prior to implementation. How-
ever, the tobacco 21 (z = 2.16, p = 0.031) and post-implementation slope (z = 3.20, p = 0.001)
were both significant, and both indicated an inverse association with smoking status. That
is, current smoking was less likely after the implementation of Tobacco 21 and became
increasingly unlikely during the post-implementation period. Smoking status was not as-
sociated with sex, race/ethnicity, or whether participants were 21 or older.
Table 2. Piecewise longitudinal GEE model of smoking status overall and after Tobacco 21 imple-
mentation.
Predictor Coefficient Std Err z-Score p-Value
Days assessed 0.05 0.01 11.91 <0.001
Gender a 0.03 0.03 1.17 0.240
Racial/ethnic identity b 0.02 0.02 0.99 0.323
Total cigarettes at baseline 0.01 0.01 3.67 <0.001
Time 0.01 0.01 0.93 0.352
Age 21 c 0.04 0.03 1.23 0.217
Tobacco 21 d 0.08 0.04 2.16 0.031
Post-implementation slope 0.03 0.01 3.20 0.001
Note: a 0 = male, 1 = female; b 0 = non-Hispanic White, 1 = Hispanic or Latino, 2 = Asian American, 3
= other or multiple backgrounds; c 0 = participant was aged 18–20 at the time of assessment, 1 =
participant was aged 21 or older at the time of assessment; d 0 = assessment occurred prior to To-
bacco 21 implementation; 1 = assessment occurred after Tobacco 21 implementation.
The piecewise mixed regression model of risk perceptions is shown in Table 3. Time
was inversely associated with perceived risk from smoking (z = 3.90, p < 0.001), indicating
that perceived risk was declining during the period prior to Tobacco 21 implementation.
However, both the tobacco 21 (z = 2.80, p = 0.005) and post-implementation slope (z = 3.95,
p < 0.001) terms were positively associated with perceived risk. This indicates that partic-
ipants reported greater perceived risk from cigarette smoking after Tobacco 21 implemen-
tation compared with before and that the strength of this association was increasing over
time. Risk perceptions did not differ by race or whether participants were age 21 but were
higher among participants who identified as female, who reported heavier cigarette use
at baseline, and who smoked cigarettes more frequently.
Table 3. Piecewise longitudinal multilevel model of risk perceptions overall and after Tobacco 21
implementation.
Predictor Coefficient Std Err z-Score p-Value
Days assessed 0.11 0.03 3.95 <0.001
Gender a 0.88 0.15 5.67 <0.001
Racial/ethnic identity b 0.02 0.09 0.27 0.789
Total cigarettes at baseline 0.04 0.01 8.02 <0.001
Time 0.23 0.06 3.90 <0.001
Age 21 c 0.25 0.19 1.31 0.189
Cigarette days 0.16 0.03 6.10 <0.001
Tobacco 21 d 0.69 0.25 2.80 0.005
Post-implementation slope 0.24 0.06 3.95 <0.001
Note: a 0 = male, 1 = female; b 0 = non-Hispanic White, 1 = Hispanic or Latino, 2 = Asian American, 3
= other or multiple backgrounds; c 0 = participant was aged 18–20 at the time of assessment, 1 =
participant was aged 21 or older at the time of assessment; d 0 = assessment occurred prior to To-
bacco 21 implementation; 1 = assessment occurred after Tobacco 21 implementation.
Int. J. Environ. Res. Public Health 2022, 19, 16971 5 of 8
To better understand this finding, post hoc analyses examined change in perceived
risk over time during the post-implementation period as a function of smoking status (i.e.,
whether participants reported any smoking days at each individual post-implementation
wave; see Figure 1). These analyses excluded pre-implementation waves and utilized lon-
gitudinal mixed effects regression, with time-varying risk perceptions as the outcome var-
iable. For non-smokers, the perceived risk did not change over time after implementation
(z = 0.50, p = 0.615). In contrast, for those who reported continued smoking, perceived
risks from smoking increased over the course of the post-implementation waves (z = 3.48,
p = 0.001).
Figure 1. Risk perceptions over time by smoking status after Tobacco 21 implementation.
4. Discussion
This study investigated smoking status and perceived risk of cigarette smoking
among young adults before and after the statewide implementation of Tobacco 21 in Cal-
ifornia, United States. As hypothesized, we found that likelihood of smoking decreased,
and risk perception increased after the implementation of the Tobacco 21 law. We also
found that the increased perception of risk was associated with smoking status, increasing
among those who were current smokers but not those who were not.
At the time of enactment, California was among the minority of states in the United
States that adopted a Tobacco 21 law. Other states and countries have a strong interest in
preventing young adults from initiating tobacco use due to the individual health and pub-
lic health issues related to smoking. Given the experience with state-initiated Tobacco 21
laws, the United States federal government enacted its own Tobacco 21 law [18]. Under-
standing not only the efficacy of a Tobacco 21 law but the possible underlying reason(s)
for its efficacy provides great social value in engaging in effective legal interventions to
address public health issues, both as it relates to tobacco use and possibly more broadly
to address other public health issues.
Studies analyzing risk perception suggest that the more heavily regulated an indus-
try is, the higher individuals perceive the risk of that industry [19]. Thus, one possible
reason that the Tobacco 21 law was associated with an increased perception of risk is be-
cause it represented increased regulation of tobacco products. In addition, the public
awareness campaign may also have contributed to perceptions of risk.
17
17.5
18
18.5
19
19.5
20
20.5
21
21.5
22
012345678910111213
Mean Perceived Risk
Post-Implementation Wave
Non-Smokers Smokers
Int. J. Environ. Res. Public Health 2022, 19, 16971 6 of 8
Additional studies are needed to increase our understanding of factors that directly
impact perceived risk to enable the optimization of public health messaging. For example,
risk information may be perceived differently depending on the perceived authority of
the source (e.g., television news versus social media) [20]. Initial work examining message
content also suggests that because the harms of combustible tobacco are well-understood,
messages that focus on emotional content framed around loss may be more effective than
messages that focus on providing information [21].
This study suggests that the impact of restrictions may go beyond logistical barriers
by impacting attitudes toward products or activities that are regulated. This is important
because it suggests that interventions that impact the perceived risks of tobacco products
can contribute to alleviating the public health consequences of tobacco use. Clinical impli-
cations of decreasing the initiation and prevalence of smoking among young adults in-
clude a decrease in mortality and morbidity [2]. These clinical implications are not just for
the individual but also for maternal/fetal and infant outcomes if tobacco use is lowered
among young adults [2].
Legal interventions do not always obtain the desired result and/or may have trade-
offs [22]. The results of this study suggest that the Tobacco 21 law may have led to in-
creased risk perception among emerging adults who were using tobacco products. This is
potentially important for multiple reasons. First, previous studies have indicated that
greater perceived risk is associated with a lower likelihood of smoking uptake and a
greater likelihood of cessation [9,10]. Second, evidence indicates that the perceived risk of
smoking cigarettes has been declining in recent years [23], which raises concern that prev-
alence may increase. Our data suggest that Tobacco 21 laws may be an effective way to
address this issue. In addition, these findings provide insight into the potential for legal
policy interventions to align an individual’s perception of risk with the evidence-based
assessment of risk.
To our knowledge, this is the first study to demonstrate that the Tobacco 21 law ap-
pears to change risk perception. Previous studies, for example, analyzed retailer compli-
ance and point of sale to young adults, which focus on the efficacy of restricting access to
young adults [5,8]. This study goes beyond compliance to suggest that this legal policy
intervention changed attitudes toward tobacco use. Put differently, the Tobacco 21 law
appears effective not just because it made it more difficult for young adults to purchase
tobacco products but because it also changed underlying attitudes towards the risk of
smoking.
This study has several limitations. First, we did not directly evaluate factors that may
have impacted risk perceptions over time. It could be that the messaging in the public
media campaign impacted risk perception. Alternatively, other components of Tobacco
21 implementation (e.g., restricted access at the point of sale) may have been significant.
Second, all participants were young adults with a history of non-daily cigarette smoking
who were California residents at the time of enrollment. It is possible that findings are not
generalizable to other groups.
The impact of the Tobacco 21 law on the risk perception of young adults is important
both as an intervention for reducing tobacco use initiation and could have wider applica-
tion and insight in other areas in which aligning individual perception of risk with the
evidence-based assessment of risk provides great social value, such as vaccines, food, and
other public health issues.
5. Conclusions
Smoking among young adults continues despite several public health measures to
curtail smoking initiation. These data suggest that the enactment of the Tobacco 21 law
effectively and significantly changed the perception of risk among young adults, espe-
cially those who were current smokers. Despite this significant change, young adults con-
tinue to smoke; thus, future studies that aim to understand why risk perception changed
Int. J. Environ. Res. Public Health 2022, 19, 16971 7 of 8
may inform future interventions to increase the extent to which they effectively reduce
cigarette consumption.
Author Contributions: Conceptualization, J.K.S. and N.D.; methodology, N.D.; formal analysis,
N.D.; writing—original draft preparation, J.K.S. and N.D.; writing—review and editing, J.K.S. and
N.D.; funding acquisition, N.D. All authors have read and agreed to the published version of the
manuscript.
Funding: This study was funded by research grant R01 DA 037217 (ND) from the National Institutes
of Health.
Institutional Review Board Statement: The study was conducted in accordance with the Declara-
tion of Helsinki and approved by the Institutional Review Board of the University of California San
Diego (protocol code 140271; original approval on 7 July 2014; most recent approval on 4 March
2022).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study.
Data Availability Statement: The dataset is available upon request from the second author at
nmdoran@health.ucsd.edu.
Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the
design of the study; in the collection, analyses, or interpretation of data; in the writing of the manu-
script; or in the decision to publish the results.
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Although cigarette smoking has declined over the past several decades, a diverse landscape of combustible and noncombustible tobacco products has emerged in the United States (1-4). To assess recent national estimates of commercial tobacco product use among U.S. adults aged ≥18 years, CDC analyzed data from the 2020 National Health Interview Survey (NHIS). In 2020, an estimated 47.1 million U.S. adults (19.0%) reported currently using any commercial tobacco product, including cigarettes (12.5%), e-cigarettes (3.7%), cigars (3.5%), smokeless tobacco (2.3%), and pipes* (1.1%).† From 2019 to 2020, the prevalence of overall tobacco product use, combustible tobacco product use, cigarettes, e-cigarettes, and use of two or more tobacco products decreased. Among those who reported current tobacco product use, 79.6% reported using combustible products (e.g., cigarettes, cigars, or pipes), and 17.3% reported using two or more tobacco products.§ The prevalence of any current commercial tobacco product use was higher among the following groups: 1) men; 2) adults aged <65 years; 3) non-Hispanic American Indian or Alaska Native (AI/AN) adults and non-Hispanic adults categorized as of "Other" race¶; 4) adults in rural (nonmetropolitan) areas; 5) those whose highest level of educational attainment was a general educational development certificate (GED); 6) those with an annual household income <$35,000; 7) lesbian, gay, or bisexual adults; 8) uninsured adults or those with Medicaid; 9) adults living with a disability; and 10) those who regularly had feelings of anxiety or depression. Continued monitoring of tobacco product use and tailored strategies and policies that reduce the effects of inequitable conditions could aid in reducing disparities in tobacco use (1,4).
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Introduction Tobacco 21 (T21) policies have shown promise in reducing cigarette use among adolescents. This study examined whether local T21 policies affected adolescent use of a variety of tobacco products and whether results differed by grade level. Methods We used repeated cross-sectional data from eighth, ninth, and eleventh-grade respondents to the 2016 (n = 107 981) and 2019 (n = 102 196) Minnesota Student Surveys. Generalized estimating equations modeled eight adolescent tobacco use outcomes in 2019 (past 30-day use of any tobacco, cigarettes, cigars, e-cigarettes, hookah, chewing tobacco, flavored tobacco, and multiple products) by T21 exposure, defined as respondents’ attendance at a school within a jurisdiction with T21 policy implementation between the two surveys. Models controlled for demographic characteristics and product-specific baseline tobacco use at the school level in 2016 and were stratified by grade. Results After adjusting for baseline tobacco use and other demographics, T21-exposed eighth and ninth-grade students had significantly lower odds of tobacco use than unexposed peers in five of eight models, i.e. any tobacco (aOR = 0.80, 95% CI: 0.74, 0.87), cigarettes (aOR = 0.81, 95% CI: 0.67, 0.99), e-cigarettes (aOR = 0.78, 95% CI: 0.71, 0.85), flavored tobacco (aOR = 0.79, CI: 0.70, 0.89), and dual/poly tobacco (aOR = 0.77, 95% CI: 0.65, 0.92). T21-exposed eleventh-grade students did not differ significantly in their odds of any tobacco use outcomes relative to their unexposed peers. Conclusions T21 exposure is associated with lower odds of multiple forms of tobacco use, particularly among younger adolescent populations, supporting the implementation of T21 policies to reduce tobacco use in this population.
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Background The use of new and emerging tobacco products (NETPs) and conventional tobacco products (CTPs) has been linked to several alarming medical conditions among young adults (YAs). Considering that 96% of YAs own mobile phones, SMS text messaging may be an effective strategy for tobacco risk communication. Objective Project Debunk is a community-based randomized trial aiming to identify specific types of messages that effectively improve perceived NETP and CTP risk among YAs in community colleges. Methods With YAs recruited offline from 3 campuses at the Houston Community College (September 2016 to July 2017), we conducted a 6-month randomized trial with 8 arms based on the combination of 3 message categories: framing (gain-framed vs loss-framed), depth (simple vs complex), and appeal (emotional vs rational). Participants received fully automated web-based SMS text messages in two 30-day campaigns (2 messages per day). We conducted repeated-measures mixed-effect models stratified by message type received, predicting perceived CTP and NETP risks. Owing to multiple testing with 7 models, an association was deemed significant for P
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We examine how individuals seek information about e-cigarette risk and selectively expose themselves to media sources that may provide information consistent with their existing beliefs and behaviors related to e-cigarettes in application of the Reinforcing Spirals Model (Slater, 2007). Additionally, the associations among e-cigarette risk information-seeking, tobacco risk information exposure via media, and comparative risk assessment of e-cigarettes versus conventional cigarettes were identified. The results were compared among current users, former users, and those who had never used e-cigarettes (“never users”). A nationally representative data from the 2017 Health Information National Trends Surveys - FDA was employed. Our analyses suggest the presence of comparative risk perception among current users as assessing the health harm and addiction risk of e-cigarettes significantly lower than cigarettes. Current users did not avoid information about health effects of e-cigarettes; they were more likely to look for such information than former and never users. Current users’ e-cigarette risk information-seeking was negatively associated with the difference between perceived addiction risk of e-cigarettes and that of cigarettes. Current users’ tobacco risk information exposure via social media was related with a lower level of perceived risk of e-cigarettes, while such exposure via news media was related with a higher level of perceived risk of e-cigarettes. Our findings suggest the need for regulating and counteracting the prevalent e-cigarette information that discounts the relative risks of e-cigarettes as well as the potential of news media as influential sources helping current users scrutinize the risks.
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Introduction California’s law raising the minimum tobacco sales age to 21 went into effect on 9 June 2016. This law, known as ‘Tobacco 21’ or ‘T21’, also expanded the definition of tobacco to include electronic smoking devices. This paper describes the T21 evaluation plan and initial evaluation results. Methods An evaluation plan and logic model were created to evaluate T21. A tobacco retailer poll was conducted 7 months after the law went into effect to assess awareness, support and implementation; an online survey of California adults was fielded to provide data on tobacco use and attitudinal changes before and after T21 implementation; and tobacco purchase surveys were conducted to assess the retailer violation rate (RVR). Multivariate models estimated the odds of RVR and odds of being aware, agreeing with and observing advertisements related to T21. Results Seven months after the T21 effective date, 98.6% of retailers were aware of the law and 60.6% supported the law. Furthermore, 66.2% of retailers agreed that people who start smoking before 21 would become addicted to tobacco products. The RVR using youth decoys under age 18 statistically decreased from 10.3% before T21 to 5.7% after T21 (P=0.002). Furthermore, the RVR using young adult decoys ages 18–19 was 14.2% (95% CI 9.3% to 19.1%) for traditional tobacco and 13.1% (95% CI 10.2% to 16.1%) for electronic smoking devices. Conclusions Survey findings suggest that the high awareness and support for the law may have contributed to reducing illegal tobacco sales to youth under 18 and achieving widespread retailer conformity with the new law disallowing sales to young adults under 21.
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Introduction States and municipalities are increasingly restricting tobacco sales to those under age-21, in an effort to reduce youth and young adult smoking. However, the effectiveness of such policies remains unclear, particularly when implemented locally. Methods Analyses use 2011 - 2016 data from the Behavioral Risk Factor Surveillance System’s Selected Metropolitan/Micropolitan Area Risk Trends dataset. Difference-in-differences and triple-difference regressions estimate the relationship between local tobacco-21 policies and smoking among 18 to 20 year-olds living in MMSAs (metropolitan/micropolitan statistical areas). Results Current smoking rates fell from 16.5 percent in 2011 to 8.9 percent in 2016 among 18-20 year-olds in these data. Regressions indicate that a tobacco-21 policy covering one’s entire MMSA yields an approximately 3.1 percentage point reduction in 18 to 20 year-olds’ likelihoods of smoking [CI: -0.0548, -0.0063]. Accounting for partial policy exposure — tobacco-21 laws implemented in some but not all jurisdictions within an MMSA — this estimate implies that the average exposed 18 to 20 year-old experienced a 1.2 percentage point drop in their likelihood of being a smoker at interview relative to unexposed respondents of the same age, all else equal. Conclusions Local tobacco-21 policies yield a substantive reduction in smoking among 18 to 20 year-olds living in metropolitan and micropolitan statistical areas. This finding provides empirical support for efforts to raise the tobacco purchasing age to 21 as a means to reduce young adult smoking. Moreover, it suggests that state laws preempting local tobacco-21 policies may impede public health. Implications While states and municipalities are increasingly restricting tobacco sales to under-21-year-olds, such policies’ effectiveness remains unclear, particularly when implemented locally. Using quasi-experimental methods, this paper provides what may be the first evidence that sub-state tobacco-21 laws reduce smoking among 18 to 20 year-olds. Specifically, considering metropolitan and micropolitan areas from 2011 to 2016, the average 18 to 20 year-old who was exposed to these policies exhibited a 1.2 percentage point drop in their likelihood of being a current established smoker, relative to those who were unexposed. These findings validate local tobacco-21 laws as a means to reduce young adult smoking.
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Aims: To estimate the impact of tobacco-21 laws on smoking among young adults who are likely to smoke, and consider potential social multiplier effects. Design Quasi-experimental, observational study using new 2016-17 survey data. Setting: United States. Participants/cases: A total of 1869 18-22-year-olds who have tried a combustible or electronic cigarette. Intervention and comparators: Tobacco-21 laws raise the minimum legal sales age of cigarettes to 21 years. Logistic regressions compared the association between tobacco-21 laws and smoking among 18-20-year-olds with that for 21-22-year-olds. The older age group served as a comparison group that was not bound by these restrictions, but could have been affected by correlated factors. Age 16 peer and parental tobacco use were considered as potential moderators. Measurements: Self-reported recent smoking (past 30-day smoking) and current established smoking (recent smoking and life-time consumption of at least 100 cigarettes). Findings: Exposure to tobacco-21 laws yielded a 39% reduction in the odds of both recent smoking [odds ratio (OR) = 0.61; 95% confidence interval (CI) = 0.42, 0.89] and current established smoking (OR = 0.61; 95% CI = 0.39, 0.97) among 18-20-year-olds who had ever tried cigarettes. This association exceeded the policy's relationship with smoking among 21-22-year-olds. For current established smoking, the tobacco-21 reduction was amplified among those whose closest friends at age 16 used cigarettes (OR = 0.50; 95% CI = 0.29, 0.87), consistent with peer effects moderating the policy's impact on young adult smoking. Conclusions: Tobacco-21 laws appear to reduce smoking among 18-20-year-olds who have ever tried cigarettes.
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Purpose: Historically, adolescence has been regarded as the time when most tobacco use initiation occurs. This study examines the initiation of tobacco product use, including cigarettes, e-cigarettes, cigar products, and hookah, among contemporary youth and young adults, to determine whether the developmental timing (youth vs. young adulthood) of initiation has changed. Methods: Three cohort studies were used to examine the onset of ever use and current (past 30 days) use of each tobacco product among never-using youth (11 to <17 years) and young adults (18-24 years) at baseline (2013-2015) to one-year follow-up (2015-2016). These studies include the national Population Assessment of Tobacco and Health Study, and two Texas cohort studies, the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS), and the Marketing and Promotions Across Colleges in Texas (M-PACT) project. Estimations of onset were computed using generalized linear mixed models for TATAMS and M-PACT. The rates of initiation in Population Assessment of Tobacco and Health Study were compared to standardized incidence rates from TATAMS to M-PACT. Results: Young adults had significantly higher incidence rates than youth to initiate ever and current use of each/all tobacco products for all comparisons. Conclusions: These findings extend prior research on the timing of the onset of tobacco use by using longitudinal analyses from three contemporary cohort studies to include not just cigarettes, but also e-cigarettes, cigar products, and hookah. Among those who were never-users of tobacco products, young adults began to ever and currently use all tobacco products more than youth in these samples, a marked departure from prior decades of research.
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Introduction: Perceived risk of smoking is associated with smoking status, interest in quitting, quit attempts, and sustained quitting. Tracking and reporting of risk perceptions is integral to inform regulation and education. However, no research describes temporal changes in perceived great risk of smoking in the U.S. using nationally representative data. Methods: Data came from the 2006-2015 National Survey on Drug Use and Health (NSDUH). Time trends were assessed for the population overall, stratified by smoking status and by sociodemographic characteristics. Linear time trends of perceived great risk (versus other risk) were assessed using logistic regression, with survey year as the predictor. Results: Perceived great risk of smoking declined significantly among the entire population between 2006 and 2015 (73.89% versus 72.89%). Perceived great risk also decreased among all smoking statuses: daily (51.16% versus 48.19%), non-daily (64.12% versus 58.44%, former (79.57% versus 77.12%), and non-smokers (79.32% versus 77.10%). The prevalence of perceived great risk declined between 2006 and 2015 among both males and females; the rate of decline was more rapid among females (aOR = 0.98, 95% CI = 0.97, 0.98 versus aOR = 0.99, 95% CI = 0.98, 0.99). Older age, African American and Hispanic race/ethnicity, educational attainment, and non-daily, former, and never smoking statuses were positively associated with perceived great risk of smoking. Discussion: Perceived risk of smoking has declined over a 10-year period in the U.S. Declines in perceived risk indicate the need for innovative interventions to reinforce the harms associated with smoking. Differential rates of decline among males and females indicate the need for sex-specific interventions.