BACKGROUND: Adverse childhood experiences (ACEs) include forms of abuse, neglect, and household stressors that are potentially early life traumatic experiences. A summed integer count of ACEs is often used to examine cumulative childhood adversity (CCA) but has limitations. OBJECTIVES: The current study tests two additional methods for measuring CCA using large samples of youth in low- and middle-income countries. PARTICIPANTS AND SETTING: Pooled data were analyzed from a multi-country, nationally representative sample of youth aged 18-24 years (N = 11,498) who completed the Violence Against Children and Youth Surveys (VACS) in Lesotho, Cote d'Ivoire, Kenya, Namibia, and Mozambique. METHODS: ACE exposures included: physical, sexual, and emotional violence; witnessing interparental violence; witnessing community violence; orphanhood. CCA was operationalized using an ACE score, ACE impact (standardized regression coefficients from outcome severity), and ACE exposure context (household; intimate partner; peer; community). Associations between CCA with mental distress (MD) were examined by sex using p ≤ 0.05 as the significance level. RESULTS: Exposure to ≥3 ACEs was associated with MD (p < 0.05) for both sexes. Among females, all contexts contributed to MD except peer ACEs (p < 0.05). Among males, household and community ACEs contributed to MD. High-impact ACEs were associated with MD both sexes. ACE context was the best-fitting model for these data. CONCLUSIONS: The challenges operationalizing CCA warrant continued research to ensure adversity type, severity, and context lead to validly assessing ACEs impact on child wellbeing.

BACKGROUND: Parental absence in childhood has been associated with multiple negative consequences, such as depression and anxiety in young adulthood. OBJECTIVE: To assess whether parental absence for six months or more in childhood is associated with poor mental health and substance use in young adulthood and whether parental absence accounts for additional variance beyond those explained by other adverse childhood experiences (ACEs) among youth in sub-Saharan Africa. PARTICIPANTS AND SETTINGS: We used combined Violence Against Children and Youth Survey (VACS) data from Cote d'Ivoire (2018), Lesotho (2018), Kenya (2019), Namibia (2019), and Mozambique (2019). Analyses were restricted to 18-24-year-olds (n(f) = 7699; n(m) = 2482). METHODS: We used logistic regression to examine sex-stratified relationships between parental absence in childhood (defined as biological mother or father being away for six months or more before age 18) and mental health problems and substance use and whether parental absence explained additional variance beyond those explained by other ACEs. RESULTS: In sub-Saharan Africa, parental absence in childhood was common (30.5 % in females and 25.1 % in males), significantly associated with poor mental health and substance use among females and males and accounted for additional variance beyond those explained by conventional ACEs. For example, after controlling for study covariates and other ACEs, females who experienced any parental absence had 1.52 (95 % CI = 1.02-2.26) higher odds of experiencing moderate/serious psychological distress compared with those who did not. CONCLUSION: The observed association between parental absence and poor mental health suggests that this experience has significant adverse consequences and merits consideration as an ACE.

Background: Adverse childhood experiences (ACEs) can have debilitating effects on child well-being, with consequences persisting into adulthood. Most ACE studies have been conducted in high-income countries and show a graded relationship between multiple ACE exposures and adverse health outcomes. Less is known about the types and burden of ACEs in sub-Saharan Africa (SSA). Objective: To estimate the pooled prevalence of six individual and cumulative ACE exposures (physical, sexual, and emotional violence; orphanhood; witnessing interparental and community violence) and assess their association with mental health outcomes, substance use, and violence perpetration among young adults in SSA. Participants and setting: Aggregate data from the Violence Against Children and Youth Survey (VACS) in Cote d'Ivoire 2018, Kenya 2019, Lesotho 2018, Mozambique 2019, and Namibia 2019 included a sample of 11,498 young adults aged 18–24 years. Methods: Cumulative ACEs were defined by an integer count of the total number of individual ACEs (0 to 6). Weighted prevalence and adjusted odds ratios were estimated. Result: ACEs prevalence ranged from 7.8 % (emotional violence) to 55.0 % (witnessing community violence). Strong graded relationships between cumulative ACE exposure and all study outcomes for both males and females were observed. Among females, witnessing interparental violence was the only individual ACE risk factor significantly associated with increased odds of substance use; among males, emotional violence was significantly associated with all outcomes. Conclusion: ACEs are associated with adverse mental health, substance use, and violence perpetration in SSA. Gender-specific and culturally sensitive intervention strategies are needed to effectively mitigate ACEs in this population. © 2023

Despite significant declines in the use of cigarettes, a significant proportion of adults smoke. This study explores the association between smoking and health-related quality of life (HRQoL) by age. The 2016 Behavioral Risk Factor Surveillance System survey was administered to adults in 50 states and District of Columbia (n = 437,195). Physically unhealthy days (PUDs) and mentally unhealthy days (MUDs)) were regressed on age strata (18-24, 25-34, 35-44, 45-54, 55-64, ≥ 65 years) and smoking status (never, former, someday, and everyday) using negative binomial regression models with adjustment for sociodemographic covariates. For each age group, everyday smoking highly predicted PUDs and MUDs. Predicted PUDs increased with age; predicted MUDs decreased with age. Among adults aged 45-54 and 55-64 years, 3-day difference in PUDs was observed between never smokers and everyday smokers. Among young adults (18-24 years), a 4.3-day difference in MUDs was observed between everyday and never smokers. The discrepancies were nonlinear with age. The observed relationship between smoking and HRQoL provides novel information about the need to consider age when designing community-based interventions. Additional research can provide needed depth to understanding the relationship between smoking and HRQoL in specific age groups.

CONTEXT: Tobacco smoking is the leading cause of preventable morbidity and mortality in the United States, and smoking cessation has multiple health benefits. OBJECTIVE: The purpose of this study was to assess cigarette smokers' perceived importance toward characteristics of tobacco cessation medications using a willingness-to-pay approach. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of data from the 2008 HealthStyles survey, a mail-based probability sample of 5399 adults aged 18 years and older.Point estimates and 95% confidence intervals were calculated overall and by sociodemographic and smoking behavior characteristics. Multivariate Probit regression analysis was used to evaluate smokers' willingness to pay in relation to perceived importance of 3 cessation medication characteristics: convenience of use, over-the-counter availability, and efficiency to help quit. All models controlled for sociodemographic characteristics, smoking behavior characteristics, and US regional fixed effects. A total of 914 current cigarette smokers. MAIN OUTCOME MEASURES: Interest in quitting, interest in using cessation medications, and willingness to pay for 6 types of cessation medications. RESULTS: Approximately 68.4% of current cigarette smokers were interested in quitting. Among these individuals, 45.6% indicated that they were interested in using cessation medications, and of these, 47.3% indicated that they were willing to pay $150 or more out-of-pocket for these medications. Convenience of use and the effectiveness of these medications to help quit were positively associated with current smokers' willingness to pay for $300 or more (P < .05); however, no association was observed for over-the-counter availability. Self-reported exposure to telephone quitline advertisements was also positively associated with the willingness to pay. CONCLUSIONS: Approximately 68% of current smokers are interested in quitting, and about half of those smokers interested in quitting are also interested in using cessation medications. Convenience of use and the medication's effectiveness are important characteristics of cessation medication for smokers with quit intentions. Understanding preferences for these cessation medication characteristics may help inform smoking cessation efforts.

OBJECTIVE: The primary objective of this study was to estimate current smoking among workers in the health care and social assistance sector. METHODS: We analyzed the 2008 to 2012 National Health Interview Survey data for adults (age 18 years or more) working in health care and social assistance sector who reported current cigarette smoking. RESULTS: Of the approximately 18.9 million health care and social assistance workers, 16.0% were current cigarette smokers. Smoking prevalence was highest in women (16.9%) and among workers: age 25 to 44 years (17.7%); with a high school education or less (24.4%); with income less than $35,000 (19.5%); with no health insurance (28.5%); in the nursing and residential care facilities (26.9%) industry; and in the material recording, scheduling, dispatching, and distributing (34.7%) occupations. CONCLUSIONS: These findings suggest that specific group of workers in the health care and social assistance sector might particularly benefit from cessation programs and incentives to quit smoking.

PURPOSE: Youth are exposed to many types of protobacco influences, including smoking in movies, which has been shown to cause initiation. This study investigates associations between different channels of protobacco media and susceptibility to smoking cigarettes, cigarette experimentation, and current tobacco use among US middle and high school students. METHODS: By using data from the 2012 National Youth Tobacco Survey, structural equation modeling was performed in 2013. The analyses examined exposure to tobacco use in different channels of protobacco media on smoking susceptibility, experimentation, and current tobacco use, accounting for perceived peer tobacco use. RESULTS: In 2012, 27.9% of respondents were never-smokers who reported being susceptible to trying cigarette smoking. Cigarette experimentation increased from 6.3% in 6th grade to 37.1% in 12th grade. Likewise, current tobacco use increased from 5.2% in 6th grade to 33.2% in 12th grade. Structural equation modeling supported a model in which current tobacco use is associated with exposure to static advertising through perception of peer use, and by exposure to tobacco use depicted on TV and in movies, both directly and through perception of peer use. Exposure to static advertising appears to directly increase smoking susceptibility but indirectly (through increased perceptions of peer use) to increase cigarette experimentation. Models that explicitly incorporate peer use as a mediator can better discern the direct and indirect effects of exposure to static advertising on youth tobacco use initiation. CONCLUSIONS: These findings underscore the importance of reducing youth exposure to smoking in TV, movies, and static advertising.

INTRODUCTION: Physicians and health care providers play an important role in educating their patients about the health risks of tobacco use and in providing effective cessation interventions. Little is known about these practices in hospital outpatient settings. The objective of the study was to assess the prevalence, correlates, and trends of tobacco use screening and cessation assistance offered to US adults during their hospital outpatient clinic visits. METHODS: Data for aggregated hospital outpatient visits among patients aged 18 years or older (N = 148,727) from the 2005-2010 National Hospital Ambulatory Medical Care Survey were analyzed. Tobacco use screening was defined as documentation of screening for either current tobacco use (cigarettes, cigars, snuff, or chewing tobacco) or no current use on the patient record form. Tobacco cessation assistance was defined as documentation of either tobacco counseling or cessation medications. RESULTS: Tobacco use screening was reported for 63.0% (estimated 271 million visits) of hospital outpatient visits, and cessation assistance was reported for 24.5% (estimated 17.1 million visits) of visits among current tobacco users. From 2005 through 2010, tobacco use screening (P for trend = .06) and cessation assistance (P for trend = .17) did not change significantly. CONCLUSION: From 2005 through 2010, more than one-third of hospital outpatient visits had no screening for tobacco use, and among current tobacco users, only 1 in 4 received any cessation assistance. Health care providers should consistently identify and document their patients' tobacco use status and provide them with appropriate tobacco cessation assistance. Opportunities also exist to expand the coverage for tobacco cessation.

INTRODUCTION: Smoking-related disparities continue to be a public health problem among American Indian/Alaska Native (AI/AN) population groups and data documenting the health burden of smoking in this population are sparse. The purpose of this study was to assess mortality attributable to cigarette smoking among AI/AN adults relative to non-Hispanic white adults (whites) by calculating and comparing smoking-attributable fractions and mortality. METHODS: Smoking-attributable fractions and mortality among AI/ANs (n=1.63 million AI/ANs) and whites were calculated for people living in 637 Indian Health Service Contract Health Service Delivery Area counties in the U.S., from mortality data collected during 2001-2009. Differences in smoking-attributable mortality between AI/ANs and whites for five major causes of smoking-related deaths were examined. All data analyses were carried out in 2013-2014. RESULTS: Overall, from 2001 to 2009, age-adjusted death rates, smoking-attributable fractions, and smoking-attributable mortality for all-cause mortality were higher among AI/ANs than among whites for adult men and women aged ≥35 years. Smoking caused 21% of ischemic heart disease, 15% of other heart disease, and 17% of stroke deaths in AI/AN men, compared with 15%, 10%, and 9%, respectively, for white men. Among AI/AN women, smoking caused 18% of ischemic heart disease deaths, 13% of other heart diseases deaths, and 20% of stroke deaths, compared with 9%, 7%, and 10%, respectively, among white women. CONCLUSIONS: These findings underscore the need for comprehensive tobacco control and prevention efforts that can effectively reach and impact the AI/AN population to prevent and reduce smoking.

Prevalence of smoking is particularly high among individuals with low socioeconomic status and who may be receiving Medicaid benefits. This study evaluates the public health and economic impact of providing coverage for nicotine replacement therapy with no out-of-pocket cost to the adult Medicaid population in Alabama, Georgia, and Maine, in 2012. We estimated the increase in the number of quitters and the savings in Medicaid medical expenditures associated with expanding Medicaid coverage of nicotine replacement therapy to the entire adult Medicaid population in the 3 states. With an expansion of Medicaid coverage of nicotine replacement therapy from only pregnant women to all adult Medicaid enrollees, the state of Alabama might expect 1873 to 2810 additional quitters ($526,203 and $789,305 in savings of annual Medicaid expenditures from both federal and state funds), Georgia 2911 to 4367 additional quits ($1,455,606 and $2,183,409 savings), and Maine 1511 to 2267 additional quits in ($431,709 and $647,564 savings). The expansion of coverage for smoking cessation therapy with no out-of-pocket cost could reduce Medicaid expenditures in all 3 states.

BACKGROUND: The negative health effects of cigarette smoking and HIV infection are synergistic. OBJECTIVE: To compare the prevalence of current cigarette smoking and smoking cessation between adults with HIV receiving medical care and adults in the general population. DESIGN: Nationally representative cross-sectional surveys. SETTING: United States. PATIENTS: 4217 adults with HIV who participated in the Medical Monitoring Project and 27 731 U.S. adults who participated in the National Health Interview Survey in 2009. MEASUREMENTS: The main exposure was cigarette smoking. The outcome measures were weighted prevalence of cigarette smoking and quit ratio (ratio of former smokers to the sum of former and current smokers). RESULTS: Of the estimated 419 945 adults with HIV receiving medical care, 42.4% (95% CI, 39.7% to 45.1%) were current cigarette smokers, 20.3% (CI, 18.6% to 22.1%) were former smokers, and 37.3% (CI, 34.9% to 39.6%) had never smoked. Compared with the U.S. adult population, in which an estimated 20.6% of adults smoked cigarettes in 2009, adults with HIV were nearly twice as likely to smoke (adjusted prevalence difference, 17.0 percentage points [CI, 14.0 to 20.1 percentage points]) but were less likely to quit smoking (quit ratio, 32.4% vs. 51.7%). Among adults with HIV, factors independently associated with greater smoking prevalence were older age, non-Hispanic white or non-Hispanic black race, lower educational level, poverty, homelessness, incarceration, substance use, binge alcohol use, depression, and not achieving a suppressed HIV viral load. LIMITATION: Cross-sectional design with some generalizability limitations. CONCLUSION: Adults with HIV were more likely to smoke and less likely to quit smoking than the general adult population. Tobacco screening and cessation strategies are important considerations as part of routine HIV care.

Comprehensive tobacco prevention and control efforts that include implementing smoke-free air laws, increasing tobacco prices, conducting hard-hitting mass media campaigns, and making evidence-based cessation treatments available are effective in reducing tobacco use in the general population. However, if these interventions are not implemented in an equitable manner, certain population groups may be left out causing or exacerbating disparities in tobacco use. Disparities in tobacco use have, in part, stemmed from inequities in the way tobacco control policies and programs have been adopted and implemented to reach and impact the most vulnerable segments of the population that have the highest rates of smoking; e.g., those with lower education and incomes. Education and income are the two main social determinants of health that negatively impact health, however, there are other related social determinants of health that must be considered for tobacco control policies to be effective in reducing tobacco-related disparities. This paper will provide an overview of how tobacco control policies and programs can address key social determinants of health in order to achieve equity and eliminate disparities in tobacco prevention and control.

INTRODUCTION: Electronic cigarette (e-cigarettes) marketing has increased considerably since the product entered the U.S. market in 2007, thereby warranting additional surveillance to monitor recent trends in population-level awareness and utilization. We assessed the prevalence, characteristics, and trends in e-cigarette awareness and use among nationally representative samples of U.S. adults during 2010-2013. METHODS: Data came from the 2010-2013 HealthStyles survey, an annual consumer-based web survey of U.S. adults aged ≥18 years. Sample size ranged from 2,505 (2010) to 4,170 (2012). Descriptive statistics were used to assess e-cigarette awareness, ever use, and current use (use within the past 30 days), overall and by sex, age, race/ethnicity, education, income, U.S. region, and cigarette smoking status. Trends were assessed using logistic regression. RESULTS: During 2010-2013, increases (p<0.05) were observed for e-cigarette awareness (40.9% to 79.7%), ever use (3.3% to 8.5%), and current use (1.0% to 2.6%). Awareness increased among all sociodemographic subpopulations during 2010-2013 (p<0.05); an increase in ever use of e-cigarettes occurred among all sociodemographic groups except those aged 18-24 years, Hispanics and non-Hispanic 'other' adults, and those living in the Midwest (p<0.05). During 2010-2013, ever use increased among current (9.8% to 36.5%) and former (2.5% to 9.6%) cigarette smokers (p<0.05), but remained unchanged among never smokers (1.3% to 1.2%). CONCLUSIONS: Awareness and use of e-cigarettes increased considerably among U.S. adults during 2010-2013. In 2013, over one-third of current cigarette smokers reported having ever used e-cigarettes. Given the uncertain public health impact of e-cigarettes, continued surveillance of emerging utilization patterns is critical for public health planning.

Tobacco use continues to be the leading cause of preventable disease and death in the United States. Cigarette smoking accounts for approximately 480,000 premature deaths annually and approximately $130 billion in direct medical expenses and $150 billion in lost productivity in the United States each year. Approximately 88% of adults who smoke daily began smoking by the age of 18 years. Although tobacco cessation is beneficial at any age, intervening as early as possible is important to maximize potential health benefits. After years of steady progress in decreasing smoking prevalence, decreases in smoking among youths and young adults have slowed in recent years. In 2011, a total of 18.1% of U.S. high school students in the United States were current cigarette smokers, and 49.9% of these smokers had tried to quit in the past 12 months. The proportion of youth cigarette smokers who tried to quit smoking in the past year decreased from 57.4% in 2001 to 49.9% in 2011.

Trauma survivors’ beliefs are important toward a new social response to trauma-a response that reduces help-seeking barriers and invites and supports healing. This exploratory, mixed-methods study examined trauma survivors' perspectives about key elements of trauma healing. An online and paper-and-pencil survey (n= 82) asked participants to describe what hindered and what helped regarding how people in their lives, including mental health providers, responded to their abuse. Five central themes emerged: what hurt, what helped or would have helped, experience with the mental health system, recommendations to the mental health system, and what participants need in the mental health system. The majority of participants reported that they never or rarely received help or protection at the time of their abuse, and most were first abused early in childhood. This study supports the notion that trauma survivors’ insights should be central in the development of community-based healing models.

INTRODUCTION: Electronic cigarette (e-cigarette) use is increasing rapidly and their impact on youth is unknown. We assessed associations between e-cigarette use and smoking intentions among U.S. youth who had never smoked conventional cigarettes. METHODS: We analyzed data from the nationally representative 2011, 2012, and 2013 National Youth Tobacco Surveys of students in grades 6-12. Youth reporting they would definitely not smoke in the next year or if offered a cigarette by a friend were defined as not having an intention to smoke, while all others were classified as having positive intention to smoke conventional cigarettes. Demographics, pro-tobacco advertisement exposure, ever use of e-cigarettes, and ever use of other combustibles (cigars, hookah, bidis, kreteks, and pipes) and non-combustibles (chewing tobacco, snuff, dip, snus, and dissolvables) were included in multivariate analyses assessing associations with smoking intentions among never-cigarette-smoking youth. RESULTS: Between 2011-2013, the number of never-smoking youth who used e-cigarettes increased three-fold, from 79,000 to over 263,000. Intention to smoke conventional cigarettes was 43.9% among ever e-cigarette users and 21.5% among never users. Ever e-cigarette users had higher adjusted odds of having smoking intentions than never users (Adjusted Odds Ratio: 1.70, 95% Confidence Interval: 1.24-2.32). Those who ever used other combustibles, ever used non-combustibles, or reported pro-tobacco advertisement exposure also had increased odds of smoking intentions. CONCLUSION: In 2013, over a quarter million never-smoking youth had used e-cigarettes. E-cigarette use was associated with increased intentions to smoke cigarettes. Enhanced prevention efforts for youth are important for all forms of tobacco, including e-cigarettes.

BACKGROUND: Cigarette smoking remains a leading cause of morbidity and mortality. Although gender differences in cigarette smoking in the U.S. population have been documented, information on these differences among working adults is limited. PURPOSE: To describe the current smoking prevalence by gender among working U.S. adults and examine gender differences in smoking by occupation. METHODS: The 2004-2011 National Health Interview Survey data for adults aged ≥18 years that were working in the week prior to the interview (N=132,215) were analyzed in 2013. Current cigarette smokers were those who smoked at least 100 cigarettes in their lifetime and currently smoke every day or some days. RESULTS: During 2004-2011, an estimated 22.8% of men workers and 18.3% of women workers were current smokers. Of the current smokers, women workers had higher odds of being an everyday smoker (prevalence OR [POR]=1.17, 95% CI=1.09, 1.26); having poor self-rated emotional health (POR=1.28, 95% CI=1.15, 1.41); and having chronic obstructive pulmonary disease (POR=2.45, 95% CI=2.14, 2.80), heart disease (POR=1.27, 95% CI=1.12, 1.45), and current asthma (POR=2.21, 95% CI=1.96, 2.49) compared with men workers. Women in "supervisors, construction, and extraction" (38.9%) occupations and men in "extraction" (40.5%) occupations had the highest smoking prevalence. CONCLUSION: Among working adults, women had lower prevalence of smoking than men, yet women who smoke were more likely than men to have adverse health outcomes, including self-rated poorer physical and emotional health.

BACKGROUND: Among U.S. youth overall, cigars are the most commonly used tobacco product after cigarettes. However, youth who identify their products by brand names, not general terms like "cigar," may underreport use. PURPOSE: To examine changes in reported cigar (cigar, cigarillo, or little cigar) smoking among students following inclusion of cigar brand examples on the National Youth Tobacco Survey (NYTS). METHODS: Data from the 2011 and 2012 NYTS and National Survey on Drug Use and Health (NSDUH) were analyzed in 2013 to estimate ever and current cigar smoking, overall and by race/ethnicity. The 2012 NYTS included cigar brand examples (Black and Mild, Swisher Sweets, Dutch Masters, White Owl, Phillies Blunt) in the survey instructions and ever use question, but the 2011 NYTS and 2011 and 2012 NSDUH did not. RESULTS: NYTS ever cigar smoking was higher in 2012 (27.8%) than 2011 (19.5%) among black students overall. Current cigar smoking was 60%-70% higher among black females and students aged ≥17 years, in 2012 than 2011. For black females, current cigar smoking (11.5%) was two times greater than that of white females (4.3%) in 2012, whereas the prevalence among these subgroups was comparable in 2011. Similar changes were not observed among these subgroups in the 2011-2012 NSDUH. CONCLUSIONS: This study highlights the high burden of cigar use among U.S. youth and suggests that NYTS ascertainment of cigar smoking may have improved by including brands. Disparities in cigar smoking need to be addressed to prevent and reduce all youth tobacco use.

OBJECTIVE: Many states have implemented laws prohibiting tobacco smoking in indoor public places. However, private settings remain a major source of secondhand smoke (SHS) exposure for many people. We assessed the association between current asthma and SHS exposure in vehicles among adult never-smokers in Indiana, Kentucky, Louisiana and Mississippi. METHODS: Data came from the 2011 Behavioral Risk Factor Surveillance System, a state-based telephone survey of US adults aged ≥18 years. Analyses were restricted to states (n=4) that administered an optional SHS module. Prevalence of self-reported asthma and past 7-day SHS exposure in vehicles was calculated by demographics, voluntary smoke-free vehicle rules and SHS exposure in homes, public places and workplaces. Logistic regression was used to assess the adjusted association between asthma and SHS exposure in vehicles. RESULTS: Among 17 863 never-smoking adults, 7.4% reported having current asthma, whereas 12.3% reported past 7-day SHS exposure in vehicles. Among adults with asthma, SHS exposure in vehicles was lower among those with voluntary smoke-free rules compared with those without voluntary smoke-free rules (9.5% vs 56.7%, p<0.0001). Following adjustment, adults exposed to SHS in a vehicle had a higher odds of having current asthma compared with unexposed adults (OR=2.01, 95% CI 1.18 to 3.40). CONCLUSIONS: Never-smoking adults recently exposed to SHS in a vehicle had higher odds of having current asthma compared with unexposed adults. Efforts are warranted to warn about the dangers of SHS and to encourage voluntary smoke-free rules in vehicles, especially among adults with asthma.

INTRODUCTION: This study assessed the prevalence and correlates of secondhand smoke (SHS) exposure and attitudes toward smoke-free workplaces among employed U.S. adults. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a landline and cellular telephone survey of adults aged ≥18 years in the 50U.S. states and District of Columbia. National and state estimates of past 7-day workplace SHS exposure and attitudes toward indoor and outdoor smoke-free workplaces were assessed among employed adults. National estimates were calculated by sex, age, race/ethnicity, education, annual household income, sexual orientation, U.S. region, and smoking status. RESULTS: Among employed adults who did not smoke cigarettes, 20.4% reported past 7-day SHS exposure at their workplace (state range: 12.4% [Maine] to 30.8% [Nevada]). Nationally, prevalence of exposure was higher among males, those aged 18-44 years, non-Hispanic Blacks, Hispanics, and non-Hispanic American Indians/Alaska natives compared to non-Hispanic Whites, those with less education and income, those in the western United States, and those with no smoke-free workplace policy. Among all employed adults, 83.8% and 23.2% believed smoking should never be allowed in indoor and outdoor areas of workplaces, respectively. CONCLUSIONS: One-fifth of employed U.S. adult nonsmokers are exposed to SHS in the workplace and disparities in exposure exist across states and subpopulations. Most employed adults believe indoor areas of workplaces should be smoke free and nearly one-quarter believe outdoor areas should be smoke free. Efforts to protect employees from SHS exposure and to educate the public about the dangers of SHS and benefits of smoke-free workplaces could be beneficial.

Despite significant declines during the past 30 years, cigarette smoking among adults in the United States remains widespread, and year-to-year decreases in prevalence have been observed only intermittently in recent years. To assess progress made toward the Healthy People 2020 objective of reducing the proportion of U.S. adults who smoke cigarettes to ≤12% (objective TU-1.1),* this report provides the most recent national estimates of smoking prevalence among adults aged ≥18 years, based on data from the 2012 National Health Interview Survey (NHIS). The findings indicate that the proportion of U.S. adults who smoke cigarettes fell to 18.1% in 2012. Moreover, during 2005-2012, the percentage of ever smokers who quit increased significantly, from 50.7% to 55.0%, and the proportion of daily smokers who smoked ≥30 cigarettes per day (CPD) declined significantly, from 12.6% to 7.0%. Proven population-level interventions, including tobacco price increases, high-impact antitobacco mass media campaigns, comprehensive smoke-free laws, and barrier-free access to help quitting, are critical to decreasing cigarette smoking and reducing the health and economic burden of tobacco-related diseases in the United States.

PURPOSE: The purpose of this study was to assess patterns and trends of tobacco use among high school students to better understand which products are used individually or concurrently. METHODS: Data from the National Youth Tobacco Survey from 2000 through 2012 were used to assess patterns and trends of current tobacco use (cigarettes, cigars, smokeless tobacco, and other tobacco products) among U.S. high school students. We assessed use of products individually and concurrently. RESULTS: During 2000-2012, overall linear declines were observed in current use of any tobacco product from 33.6% to 20.4% (p < .05), current use of only 1 tobacco product, from 18.8% to 10.5% (p < .05), and current poly tobacco use, from 14.7% to 9.9% (p < .05), among high school students. Overall current use of only cigarettes had both a linear decline, from 14.0% to 4.7%, as well as a quadratic trend. CONCLUSIONS: During 2000-2012, the most significant overall decline observed was for students who reported smoking only cigarettes. The results suggest that more data on the use of multiple tobacco products, not just cigarettes, is needed to guide tobacco prevention and control policies and programs.

BACKGROUND: Most tobacco use begins during youth. Thus, this study assessed the prevalence, trends, and correlates of pro-tobacco advertising among United States students in grades 6-12 during 2000-2012. METHODS: Data from the 2000-2012 National Youth Tobacco Survey were analyzed to assess self-reported exposure to pro-tobacco advertisements through three media: over the Internet, in newspapers/magazines, and at retail stores. Trends during 2000-2012 were assessed in a binary logistic regression model (P<0.05). RESULTS: Among all middle and high school students, the overall prevalence of exposure to Internet pro-tobacco advertisements increased from 22.3% to 43.0% during 2000-2012 (P<0.001 for linear trend). During the same period, declines were observed in the overall prevalence of exposure to pro-tobacco advertisements in newspapers/magazines (65.0% to 36.9%) and at retail stores (87.8% to 76.2%) (P<0.001 for all linear trends). CONCLUSION: Exposure to pro-tobacco advertisements over the Internet increased significantly during 2000-2012 among United States middle and high school students, while a decline in exposure to advertisements in newspapers or magazines, and at retail stores occurred during the same period. However, over two-thirds of students still reported retail store exposure to pro-tobacco advertisements in 2012. Enhanced and sustained efforts would be beneficial to reduce even more exposure to all forms of pro-tobacco advertisements among youths.

Cigarette smoking is the leading cause of preventable disease and death in the United States, resulting in approximately 443,000 deaths and $193 billion in direct health-care expenditures and productivity losses each year. Declines in smoking prevalence would significantly impact the health-care and economic costs of smoking. Efforts to accelerate the decline in cigarette smoking include reducing cigarette smoking disparities among specific population groups. Findings from the previous report on cigarette use in the first CDC Health Disparities and Inequalities Report (CHDIR) indicated that progress has been achieved in reducing disparities in cigarette smoking among certain racial/ethnic groups. However, little progress has been made in reducing disparities in cigarette smoking among persons of low socioeconomic status (SES) and low educational attainment.

PURPOSE: Flavors can mask the harshness and taste of tobacco, making flavored tobacco products appealing to youth. We assessed the prevalence and correlates of flavored-little-cigar and flavored-cigarette use among U.S. middle and high school students in 2011. METHODS: Data were obtained from the 2011 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6-12. National estimates of current flavored-little-cigar use, flavored-cigarette use, and combined use of either product were calculated overall and among current smokers by respondent characteristics, including sex, race/ethnicity, school level, and grade. Additionally, intention to quit tobacco and smoking frequency were assessed by flavored product use. RESULTS: The overall prevalence of current use was 4.2% for flavored cigarettes, 3.3% for flavored little cigars, and 6.3% for either product. Among current cigar smokers, 35.9% reported using flavored little cigars, and among current cigarette smokers, 35.4% reported using flavored cigarettes. Among current cigar or cigarette smokers, 42.4% reported using flavored little cigars or flavored cigarettes. Flavored product use among current smokers was higher among non-Hispanic whites than among blacks and Hispanics, higher among high school students than middle school students, and increased with grade. Among cigar smokers, prevalence of no intention to quit tobacco was higher among flavored-little-cigar users (59.7%) than nonusers (49.3%). CONCLUSIONS: More than two fifths of U.S. middle and high school smokers report using flavored little cigars or flavored cigarettes, and disparities in the use of these products exist across subpopulations. Efforts are needed to reduce flavored tobacco product use among youth.

OBJECTIVE: To determine the prevalence and characteristics of current cigarette smokers who report receiving health care provider interventions ('5A's': ask, advise, assess, assist, arrange) for smoking cessation. METHODS: Data came from the 2009-2010 National Adult Tobacco Survey, a telephone survey of United States adults aged ≥18years. Among current cigarette smokers who reported visiting a health professional in the past year (n=16,542), estimates were calculated overall and by sex, age, race/ethnicity, education, income, health insurance coverage, and sexual orientation. RESULTS: Among smokers who visited a health professional (75.2%), 87.9% were asked if they used tobacco, 65.8% were advised to quit, and 42.6% were asked if they wanted to quit. Among those wanting to quit, 78.2% were offered assistance and 17.5% had follow-up arranged. Receipt of the 'ask' component was lower among males and uninsured individuals. Receipt of the 'advise' and 'assess' components was lower among those aged 18-24 and uninsured individuals. Receipt of the 'assist' component was lower among non-Hispanic blacks. No differences were observed for the 'arrange' component. CONCLUSIONS: Many current smokers report receiving health care provider interventions for smoking cessation. Continued efforts to educate, encourage, and support all health professionals to provide effective, comprehensive tobacco cessation interventions to their patients may be beneficial.

BACKGROUND: Increased knowledge of the harmful effects of SHS is an evidence-based key indicator for eliminating nonsmokers' exposure to SHS. This study assessed the prevalence and predictors of perceptions about the harm of secondhand smoke (SHS) exposure among U.S. middle and high school students. FINDINGS: Data were obtained from the 2012 National Youth Tobacco Survey, a nationally representative school-based survey of U.S. students in grades 6-12. Respondents who reported that they thought breathing smoke from other people's cigarettes or other tobacco products causes "some" or "a lot" of harm were considered to have the perception that SHS is harmful. Multivariate logistic regression was used to identify predictors of the perception that SHS is harmful. Predictors included sex, race/ethnicity, school grade level, current tobacco use, and whether the respondent currently lived with a tobacco user. Overall, 75.4% of students perceived SHS exposure as harmful. The adjusted odds of perceiving SHS exposure as harmful were higher among non-Hispanic Asians than among non-Hispanic whites, and among students in 10th-12th grades than among students in 8th grade. Adjusted odds were lower among boys than among girls, among non-Hispanic blacks than among non-Hispanic whites, among students living with a tobacco user than among those not, and among those who use combustible tobacco only or both combustible and non-combustible tobacco than among those who use no tobacco. CONCLUSIONS: Most middle and high school students perceive SHS exposure as harmful, but efforts are needed to increase the prevalence of this perception in certain subpopulations, particularly tobacco users.

INTRODUCTION: An increasing number of US states and localities have implemented comprehensive policies prohibiting tobacco smoking in all indoor areas of public places and worksites. However, private settings such as homes and vehicles remain a major source of exposure to secondhand smoke (SHS) for many people. This study assessed the prevalence and correlates of voluntary smoke-free rules and SHS exposure in homes and vehicles among US adults. METHODS: We obtained data from the 2009-2010 National Adult Tobacco Survey, a landline and cellular-telephone survey of adults aged 18 years or older residing in the 50 US states or the District of Columbia. We calculated national and state estimates of smoke-free rules and past-7-day SHS exposure in homes and vehicles and examined national estimates by sex, age, race/ethnicity, and education. RESULTS: The national prevalence of voluntary smoke-free home rules was 81.1% (state range, 67.9%-92.9%), and the prevalence of household smoke-free vehicle rules was 73.6% (state range, 58.6%-85.8%). Among nonsmokers, the prevalence of SHS exposure was 6.0% in homes (state range, 2.4%-13.0%) and 9.2% in vehicles (state range, 4.8%-13.7%). SHS exposure among nonsmokers was greatest among men, younger adults, non-Hispanic blacks, and those with a lower level of education. CONCLUSION: Most US adults report having voluntary smoke-free home and vehicle rules; however, millions of people remain exposed to SHS in these environments. Disparities in exposure also exist among certain states and subpopulations. Efforts are needed to warn about the dangers of SHS and to promote voluntary smoke-free home and vehicle rules.

PURPOSE: Smoking is a leading cause of cancer, and most smokers begin during adolescence. We examined the proportion of adolescents exposed to pro-tobacco advertising and assessed the association between this exposure and susceptibility to smoking. METHODS: Data from the 2011 National Youth Tobacco Survey were used to calculate the proportion of susceptible middle school (MS) and high school (HS) students exposed to pro-tobacco advertisements through stores, magazines, and the Internet. Following previous work, susceptibility to smoking cigarettes was defined as "never smoked but open to trying cigarettes." RESULTS: In 2011, 81.5% of MS students and 86.9% of HS students were exposed to tobacco advertisements in stores; 48.2% of MS students and 54.0% of HS students were exposed to such advertising in magazines. Exposure to tobacco advertisements on the Internet was similar for MS (40.8%) and HS students (40.2%). Of those surveyed, 22.5% of MS students and 24.2% of HS students were susceptible to trying cigarettes. Exposure to magazine advertising declined from 71.8% in 2000 to 46.1% in 2009 among susceptible MS students; however, exposure increased to 55.4% in 2011. Tobacco advertising seen through the Internet among susceptible HS students increased from 25.9% in 2000 to 44.7% in 2011. CONCLUSIONS: Adolescents continue to be exposed to pro-tobacco advertisements. Adolescents susceptible to smoking are more likely to report exposure to pro-tobacco advertisements. In addition to continued monitoring, more effective interventions to eliminate youth exposure to pro-tobacco marketing are needed.