As policies legalizing adult cannabis use increase in the United States, understanding and characterizing the proportion of individuals consuming cannabis for medical and nonmedical purposes is important to inform targeted health education efforts. Data came from 7672 adults (> = 18 years) with past month cannabis use who responded to questions about reason for cannabis use on the 2018 Behavioral Risk Factor Surveillance System survey in 14 states. State and aggregated data were analyzed using weighted frequencies for descriptive analyses, and prevalence ratios were computed to identify demographic and substance use characteristics associated with medical only use or use for both medical and nonmedical reasons (vs. nonmedical use). Overall, 28.6% (95% CI: 26.7, 30.4) of adults who use cannabis reported using cannabis medically, 34.2% (95% CI: 32.3, 36.2) nonmedically, and 37.2% (95% CI: 35.2, 39.2) both medically and nonmedically. Characteristics associated with medical only use (compared with nonmedical only use) included being female; aged > 45 years; out of work, a homemaker, or unable to work; having daily or near daily cannabis use; having past month cigarette use; having no past month alcohol use; self-reporting poor health; and ever having been diagnosed with certain chronic diseases. Medical only use of cannabis is the least prevalent reason for use; use for both medical and nonmedical reasons is the most prevalent. Monitoring reasons for cannabis use can aid states in understanding differences between medical and nonmedical cannabis users, providing context to use patterns, and targeting health education messages to appropriate audiences.

BACKGROUND AND AIMS: Following emergency declarations related to COVID-19 in the United States, many states issued stay-at-home orders and designated essential business categories. Most states allowed medical and/or non-medical adult-use cannabis retailers to remain open. This study assesses changes in cannabis sales across Alaska, Colorado, Oregon, and Washington before and during the pandemic. METHODS: Pre-tax sales data from cannabis marketplaces in four states were analyzed to identify trends from January 2018-December 2020. Mean monthly sales and relative percent change in mean monthly sales were compared by state from April-December (coinciding with the pandemic) in 2018, 2019, and 2020. Differences were assessed using the nonparametric Mann-Whitney-U test. RESULTS: Mean monthly cannabis sales in all four states were higher during the pandemic period in 2020 compared to the same period in 2019. Sales reached a three-year peak in Washington in May 2020 and in Alaska, Colorado, and Oregon in July 2020. From April-December, the percent change in mean monthly sales from 2019 to 2020 was significantly higher than 2018-2019 in all four states, though Alaska saw similar increases between 2018-2019 and 2019-2020. CONCLUSION: To date, cannabis sales in Alaska, Colorado, Oregon, and Washington have increased more during the COVID-19 pandemic than in the previous two years. In light of these increases, data monitoring by states and CDC is warranted to understand how patterns of use are changing, which populations are demonstrating changes in use, and how such changes may affect substance use and related public health outcomes.

Introduction: Medical cannabis (marijuana) use is legal in 33 U.S. states and the District of Columbia. Clinicians can play an important role in helping patients access and weigh potential benefits and risks of medicinal cannabis. Accordingly, this study aimed to assess clinician beliefs and practices related to cannabis. Methods: Data are from 1506 family practice doctors, internists, nurse practitioners, and oncologists who responded to the 2018 DocStyles, a web-based panel survey of clinicians. Questions assessed medicinal uses for and practices related to cannabis and assessed clinicians' knowledge of cannabis legality in their state. Logistic regression was used to assess multivariable correlates of asking about, assessing, and recommending cannabis. Results: Over two-thirds (68.9%) of clinicians surveyed believe that cannabis has medicinal uses and just over a quarter (26.6%) had ever recommended cannabis to a patient. Clinicians who believed cannabis had medicinal uses had 5.9 times the adjusted odds (95% confidence interval 3.9-8.9) of recommending cannabis to patients. Beliefs about conditions for medical cannabis use did not necessarily align with the current scientific evidence. Nearly two-thirds (60.0%) of clinicians surveyed incorrectly reported the legal status of cannabis in their state. Discussion: Findings suggest that while clinicians believe that cannabis has medicinal uses, they may not have a full understanding of the scientific evidence and may not accurately understand their state-based policies for cannabis legalization and use. Given that clinicians are responsible for recommending medicinal cannabis in most states that have legalized it, ongoing education about the health effects of cannabis is warranted.

INTRODUCTION: As policies legalizing nonmedical marijuana have increased in states, understanding the implications of marijuana use among adolescents is increasingly important. This study uses nationally representative data to assess behavioral risk factors among students with different patterns of marijuana use. METHODS: Data from the 2015 and 2017 Youth Risk Behavior Surveys, cross-sectional surveys conducted among a nationally representative sample of students in Grades 9-12 (n=30,389), were used to examine the association between self-reported current marijuana use status and self-report of 30 risk behaviors across 3 domains: substance use, injury/violence, and sexual health. Among current marijuana users, authors assessed differences between established (≥100 lifetime uses) and nonestablished (<100 uses) users. Multivariable models were used to calculate adjusted prevalence ratios. Data were analyzed in 2019. RESULTS: Current marijuana users (regardless of use pattern) had a significantly greater likelihood of engaging in 27 of the 30 behaviors assessed across the 3 domains than the noncurrent users. Those with established use patterns (versus nonestablished) had a greater risk of lifetime use of most other substances (licit and illicit, including tobacco, alcohol, heroin, misuse of opioids), some injury/violence behaviors (including driving while using marijuana and suicide ideation and attempt), and sexual risk behaviors. CONCLUSIONS: Both established and nonestablished patterns of adolescent marijuana use are associated with a number of other risky behaviors. In addition to interventions focused on preventing youth initiation of marijuana, clinicians and public health professionals should consider interventions to help adolescents who have nonestablished use patterns to avoid continued, established use.

BACKGROUND: The objective of this study was to estimate the prevalence of current (past 30 days) marijuana use and its associations with demographic, other substance use, chronic disease, physical health and mental health measures among women of reproductive age (18-44 years) in 12 US states. METHODS: This analysis used 2016 Behavioral Risk Factor Surveillance System (BRFSS) data from 16,556 women of reproductive age in 12 US states. Women self-reported current marijuana use and covariates. Weighted χ(2) statistics and adjusted prevalence ratios (aPR) were calculated accounting for the complex survey design. RESULTS: Among women of reproductive age, 9.9 % reported current marijuana use. Current cigarette use (aPR: 2.0, 95 % CI: 1.6, 2.6), current e-cigarette use (aPR: 1.9, 95 % CI: 1.4, 2.6), binge drinking (aPR: 2.6, 95 % CI: 1.9, 3.6), ever having received a depression diagnosis (aPR: 1.6, 95 % CI: 1.2, 2.1), and ≥14 days of poor mental health in the past 30 days (aPR: 1.8, 95 % CI: 1.3, 2.4) were all associated with higher adjusted prevalence of current marijuana use. Reporting ≥14 days of poor physical health within the last 30 was associated with a 40 % lower adjusted prevalence of current marijuana use (aPR: 0.6, 95 % CI: 0.4, 0.8). CONCLUSION: Current marijuana use among women of reproductive age was associated with other substance use, poor mental health, and depression. As state laws concerning marijuana use continue to change, it is important to monitor usage patterns and to assess associated health risks in this population.

BACKGROUND: The prevalence of modes of marijuana use (e.g., smoked, vaped, eaten, dabbed, etc.), and of multi-modal use has not been assessed across multiple states, and can inform marijuana prevention and education work, given that certain modes of use are associated with specific public health risks. This study aimed to assess the prevalence of different modalities of reported marijuana use among adults in 12 states. METHODS: Data came from 6174 adult marijuana users age 18 and older who responded to questions about past month and mode of marijuana use on the 2016 BRFSS surveys in 12 states with varied state marijuana policies. We used weighted frequencies for descriptive analyses, and logistic regression to identify correlates of multi-modal use. RESULTS: The prevalence of past month (current) marijuana use among adults in these states was 9.1 % (males = 12.0 %, females= 6.3 %). Among current marijuana users, 33.7 % reported multiple methods of marijuana use, 90.1 % reported any marijuana smoking (e.g., joints, blunts, bongs, bowls), 58.3 % reported only smoking (no other modes of consumption), 24.5 % reported any edible use, 4.5 % reported using only edibles, 19.4 % reported any marijuana vaping, 2.1 % reported only vaping, 14.5 % reported any dabbing (flash vaporization/inhalation of highly concentrated marijuana), and 0.4 % reported only dabbing. Correlates of multimodal use are also examined. CONCLUSION: Multi-modal use of marijuana is common, and use of non-smoked marijuana (edibles, vaping, dabbing) often occurs in conjunction with other modes of marijuana use. Ongoing surveillance of marijuana modes of use and multi-modal use is warranted to inform public education and prevention.

BACKGROUND AND AIMS: Eleven U.S. states and the District of Columbia have legalized non-medical use of marijuana. Public marijuana smoking is generally prohibited, although some states have considered exemptions. This study assessed attitudes about public marijuana smoking, perceptions of harm from marijuana secondhand smoke (SHS), and self-reported marijuana SHS exposure. DESIGN: Internet panel survey fielded in June-July 2018. SETTING: USA PARTICIPANTS: U.S. adults aged >/=18 years (n=4,088). MEASUREMENTS: Current (past-30 day) tobacco product use, current marijuana use, opinions about public indoor marijuana smoking, perceptions of harm from marijuana SHS, and self-reported past-7 day exposure to marijuana SHS in public indoor or outdoor areas were assessed. Weighted prevalence estimates were computed and correlates were assessed using logistic and multinomial regression. FINDINGS: Overall, 27.4% (95% CI: 25.7, 29.1) of adults reported past-week marijuana SHS exposure in indoor and/or outdoor public areas; younger adults, blacks, Hispanics, those in the Northeast or West, and current marijuana and/or tobacco users were more commonly exposed (p<.0001). Over half of adults (52.4%; 95% CI: 50.7, 54.2) regarded marijuana SHS as harmful, and most (81.0%; 95% CI: 79.5, 82.4) opposed public marijuana smoking. Correlates of favoring public marijuana smoking included being male, younger (p<.01), black or Hispanic, past-month tobacco and/or marijuana users, and perceiving no/low harm from marijuana SHS (p<.0001). CONCLUSION: While one in four U.S. adults report recent marijuana secondhand smoke (SHS)exposure, a majority believe marijuana SHS is harmful and most oppose public marijuana smoking.

Introduction: Electronic vapor products (EVPs), including e-cigarettes, can be used to aerosolize many substances. Examination of substances used in EVPs by US adults has been limited; we assessed past-year use of EVPs to deliver various substances. Methods: Data came from the 2017 SummerStyles Survey, a web-based survey of US adults (N = 4107). Ever EVP users were asked if they had used nicotine, marijuana, flavors or “something else” in an EVP during the past year. Weighted estimates for any, exclusive, and combined EVP substance use were calculated among ever (n = 586) and current (past 30-day; n = 121) EVP users. Results: Past-year use of nicotine, flavors, and marijuana in EVPs was 30.7%, 23.6%, and 12.5% among ever EVP users, respectively; and 72.3%, 54.6%, and 17.8% among current EVP users. Among ever EVP users, the most commonly used substances were nicotine only (29.6%), nicotine plus flavors (27.2%), flavors only (16.4%), and marijuana only (14.9%). Among current EVP users, the most common substances used were nicotine plus flavors (39.1%), nicotine only (29.6%), and flavors only (11.2%). Among ever users, males and 18–29 year olds were more likely to report use of flavors than females and respondents ≥30 years. Conclusions: Approximately 7 in 10 current EVP users reported nicotine use, about 1 in 2 used flavors, and nearly 1 in 6 used marijuana. These findings suggest that EVPs are used to consume a variety of substances and could guide efforts to address tobacco and non-tobacco substance use.

From 1965 to 2017, the prevalence of cigarette smoking among U.S. adults aged >/=18 years decreased from 42.4% to 14.0%, in part because of increases in smoking cessation (1,2). Increasing smoking cessation can reduce smoking-related disease, death, and health care expenditures (3). Increases in cessation are driven in large part by increases in quit attempts (4). Healthy People 2020 objective 4.1 calls for increasing the proportion of U.S. adult cigarette smokers who made a past-year quit attempt to >/=80% (5). To assess state-specific trends in the prevalence of past-year quit attempts among adult cigarette smokers, CDC analyzed data from the 2011-2017 Behavioral Risk Factor Surveillance System (BRFSS) surveys for all 50 states, the District of Columbia (DC), Guam, and Puerto Rico. During 2011-2017, quit attempt prevalence increased in four states (Kansas, Louisiana, Virginia, and West Virginia), declined in two states (New York and Tennessee), and did not significantly change in the remaining 44 states, DC, and two territories. In 2017, the prevalence of past-year quit attempts ranged from 58.6% in Wisconsin to 72.3% in Guam, with a median of 65.4%. In 2017, older smokers were less likely than younger smokers to make a quit attempt in most states. Implementation of comprehensive state tobacco control programs and evidence-based tobacco control interventions, including barrier-free access to cessation treatments, can increase the number of smokers who make quit attempts and succeed in quitting (2,3).

OBJECTIVES: Assess use and reasons for use of electronic vapour products (EVPs) shaped like universal serial bus (USB) flash drives among adults in the USA. METHODS: Data came from SummerStyles, an internet survey of US adults aged >/=18 (N=4088) fielded in June to July 2018. Respondents were shown product images and asked about ever use, current (past 30 days) use and reasons for use. Weighted point estimates and adjusted ORs were assessed. RESULTS: In 2018, 7.9% of participants had ever used flash drive-shaped EVPs, including 25.7% of current cigarette smokers and 45.9% of current EVP users. Moreover, 2.0% reported current use, including 6.8% of cigarette smokers and 34.3% of EVP users. Leading reasons for ever use were 'to deliver nicotine' (30.7%) and 'friend or family member used them' (30.2%). CONCLUSIONS: About one in 13 US adults have ever used flash drive-shaped EVPs, with use being highest among current EVP users. Nicotine content and friend/family use are drivers of ever use. PUBLIC HEALTH IMPLICATIONS: Understanding use of emerging EVP types can inform strategies to maximise any potential benefits for adult cessation and minimise risks of youth initiation.

BACKGROUND: Approximately 70% of current (past 30-day) adult marijuana users are current tobacco users, which may complicate tobacco cessation. We assessed prevalence and trends in tobacco cessation among adult ever tobacco users, by marijuana use status. METHODS: Data came from the National Survey on Drug Use and Health, a cross-sectional, nationally representative, household survey of U.S. civilians. Analyses included current, former, and never marijuana users aged≥18 reporting ever tobacco use (cigarette, cigar, chew/snuff). We computed weighted estimates (2013-2014) of current tobacco use, recent tobacco cessation (quit 30days to 12months), and sustained tobacco cessation (quit>12months) and adjusted trends in tobacco use and cessation (2005-2014) by marijuana use status. We also assessed the association between marijuana and tobacco use status. RESULTS: In 2013-2014, among current adult marijuana users reporting ever tobacco use, 69.1% were current tobacco users (vs. 38.5% of former marijuana users, p<0.0001, and 28.2% of never marijuana users, p<0.0001); 9.1% reported recent tobacco cessation (vs. 8.4% of former marijuana users, p<0.01, and 6.3% of never marijuana users, p<0.001), and 21.8% reported sustained tobacco cessation (vs. 53.1% of former marijuana users, p<0.01, and 65.5% of never marijuana users, p<0.0001). Between 2005 and 2014, current tobacco use declined and sustained tobacco cessation increased among all marijuana use groups. CONCLUSIONS: Current marijuana users who ever used tobacco had double the prevalence (vs. never-marijuana users) of current tobacco use, and significantly lower sustained abstinence. Interventions addressing tobacco cessation in the context of use of marijuana and other substances may be warranted.

OBJECTIVES: Approximately 10% (40 000) of US quitline enrollees who smoke cigarettes report current use of electronic nicotine delivery systems (ENDS); however, little is known about callers' ENDS use. Our aim was to describe why and how quitline callers use ENDS, their beliefs about ENDS and the impact of ENDS use on callers' quit processes and use of FDA-approved cessation medications. DESIGN: Qualitative interviews conducted 1-month postregistration. Interviews were recorded, transcribed, double-coded and analysed to identify themes. SETTING: Oklahoma Tobacco Helpline. PARTICIPANTS: 40 callers aged ≥18 who were seeking help to quit smoking were using ENDS at registration and completed ≥1 programme calls. RESULTS: At 1-month postregistration interview, 80% of callers had smoked cigarettes in the last 7 days, almost two-thirds were using ENDS, and half were using cessation medications. Nearly all believed ENDS helped them quit or cut down on smoking; however, participants were split on whether they would recommend cessation medications, ENDS or both together for quitting. Confusion and misinformation about potential harms of ENDS and cessation medications were reported. Participants reported using ENDS in potentially adaptive ways (eg, using ENDS to cut down and nicotine replacement therapy to quit, and stepping down nicotine in ENDS to wean off ENDS after quitting) and maladaptive ways (eg, frequent automatic ENDS use, using ENDS in situations they did not previously smoke, cutting down on smoking using ENDS without a schedule or plan to quit), which could impact the likelihood of quitting smoking or continuing ENDS use. CONCLUSIONS: These qualitative findings suggest quitline callers who use ENDS experience confusion and misinformation about ENDS and FDA-approved cessation medications. Callers also use ENDS in ways that may not facilitate quitting smoking. Opportunities exist for quitlines to educate ENDS users and help them create a coordinated plan most likely to result in completely quitting combustible tobacco.

Background: Tobacco and marijuana use are related behaviors; therefore, it is important to identify how users consume marijuana, and how it varies with tobacco use status. We estimated the modes of ever marijuana use among current, former, and never adult tobacco users. Methods: Weighted data were analyzed for 4181 adults from 2014 Styles, an online consumer panel survey of US adults, to estimate proportions for modes of ever marijuana use. Differences in modes of ever marijuana use between categories of tobacco use status were assessed (p-value <0.05). Results: More than half of current (56.6%) and former tobacco users (50.9%) had ever used marijuana, whereas only 13.0% of never tobacco users had ever used marijuana. Among ever marijuana users, joint use was the most common mode of use among current (86.4%), former (92.5%), and never (79.8%) tobacco users. Similarly, other modes of marijuana use were significantly higher in current and former tobacco users compared to never tobacco users. Conclusions: Prevalence of all modes of ever marijuana use was higher in current and former tobacco users. These findings underscore the importance of considering the relationship between marijuana and tobacco use when developing programs and policies aimed at preventing and reducing marijuana use.

OBJECTIVE: Describe cigarette smoking abstinence among employer and health plan-sponsored quitline registrants who were not using Electronic Nicotine Delivery Systems (ENDS), were using ENDS to quit smoking or were using ENDS for other reasons at the time of quitline registration. METHODS: We examined 6029 quitline callers aged ≥18 years who smoked cigarettes at registration, and completed ≥1 counselling calls, baseline ENDS use questions and a 6-month follow-up survey (response rate: 52.4%). 30-day point prevalence smoking quit rates (PPQRs) were assessed at 6-month follow-up (ENDS-only users were considered quit). Data were weighted for non-response bias. Logistic regression analyses controlled for participant characteristics and programme engagement. RESULTS: At registration, 13.8% of respondents used ENDS (7.9% to quit smoking, 5.9% for other reasons). 30-day PPQRs were: 55.1% for callers using ENDS to quit, 43.1% for callers using ENDS for other reasons, and 50.8% for callers not using ENDS at registration. Callers using ENDS for other reasons were less likely to quit than other groups (adjusted ORs=0.65-0.77); quit rates did not significantly differ between non-ENDS users and those using ENDS to quit. Among callers using ENDS to quit at baseline, 40% used ENDS regularly at follow-up. CONCLUSIONS: ENDS users not using ENDS to quit smoking were less successful at quitting at 6-month follow-up compared with callers using ENDS to quit smoking and callers who did not use ENDS at programme registration. Incorporating reasons for ENDS use may be important for future studies examining the role of ENDS in tobacco cessation.

BACKGROUND: Cigarette smoking is the predominant cause of COPD. Quitting can prevent development of and complications from COPD. The gold standard in clinician delivery of smoking cessation treatments is the 5As (ask, advise, assess, assist, arrange). This study assessed prevalence and correlates of self-reported receipt of the 5A strategies among adult smokers with and without COPD. METHODS: Data were analyzed from 20,021 adult past-year cigarette smokers in the 2009-2010 National Adult Tobacco Survey, a nationally representative telephone survey of US adults 18 years of age and older. Past-year receipt of the 5As was self-reported by participants who saw a clinician in the past year. Logistic regression was used to estimate the likelihood of receipt of each of the 5As by COPD status, adjusted for sociodemographic and smoking characteristics. RESULTS: Among smokers, those with COPD were more likely than those without COPD to report being asked about tobacco use (95.4% vs 85.8%), advised to quit (87.5% vs 59.4%), assessed for readiness to quit (63.8% vs 37.9%), offered any assistance to quit (58.6% vs 34.0%), and offered follow-up (14.9% vs 5.2%). In adjusted logistic regression models, those with COPD were significantly more likely than those without COPD to receive each of the 5As. CONCLUSIONS: Health professionals should continue to prioritize tobacco cessation counseling and treatment to smokers with COPD. Increased system-level changes and insurance coverage for cessation treatments could be used to improve the delivery of brief tobacco cessation counseling to all smokers, regardless of COPD status.

INTRODUCTION: Telephone-based tobacco quitlines are an evidence-based intervention, but little is known about how callers hear about quitlines and whether variations exist by demographics or state. This study assessed trends in "how-heard-abouts" (HHAs) in 38 states. METHODS: Data came from the Centers for Disease Control and Prevention's (CDC's) National Quitline Data Warehouse, which stores nonidentifiable data collected from individual callers at quitline registration and reported quarterly by states. Callers were asked how they heard about the quitline; responses were grouped into the following categories: media, health professional, family or friends, and "other." We examined trends from 2010 through 2013 (N = 1,564,437) using multivariable models that controlled for seasonality and the impact of CDC's national tobacco education campaign, Tips From Former Smokers (Tips). Using data from 2013 only, we assessed HHAs variation by demographics (sex, age, race/ethnicity, education) and state in a 38-state sample (n = 378,935 callers). RESULTS: From 2010 through 2013, the proportion of HHAs through media increased; however, this increase was not significant when we controlled for calendar quarters in which Tips aired. The proportion of HHAs through health professionals increased, whereas those through family or friends decreased. In 2013, HHAs occurred as follows: media, 45.1%; health professionals, 27.5%, family or friends, 17.0%, and other, 10.4%. Media was the predominant HHA among quitline callers of all demographic groups, followed by health professionals (except among people aged 18-24 years). Large variations in source of HHAs were observed by state. CONCLUSION: Most quitline callers in the 38-state sample heard about quitlines through the media or health care professionals. Variations in source of HHAs exist across states; implementation of best-practice quitline promotional strategies is critical to maximize reach.

Recent changes in policy and social norms related to marijuana use have increased its use and concern about how/where marijuana should be used. We aimed to characterize rules regarding marijuana and its use in homes. We recruited 1,567 US adults aged 18-34 years through Facebook advertisements to complete an online survey assessing marijuana use, social factors, perceptions of marijuana, and rules regarding marijuana and its use in the home, targeting tobacco and marijuana users to ensure the relevance of this topic. Overall, 648 (41.6%) were current marijuana users; 46.0% of participants reported that "marijuana of any type is not allowed in their home or on their property." Of those allowing marijuana on their property, 6.4% prohibited use of marijuana in their home. Of the remainder, 29.2% prohibited smoking marijuana, and 11.0% prohibited vaping, eating, or drinking marijuana. Correlates of more restrictive rules included younger age, being female, having <Bachelor's degree, not having parents or people living with them who use marijuana, perceiving use to be less socially acceptable and more harmful, and being a nonuser (p's <.05). Attitudes and subjective norms regarding marijuana are correlates of allowing marijuana in residential settings. Future work should examine areas of risk regarding household marijuana rules.

INTRODUCTION: To understand changes occurring in nondaily smoking (NDS), we assessed differences in demographics and trends in NDS, by smoking frequency and amount. METHODS: Participants were 13,966 adult nondaily cigarette smokers age 18 years and older responding to the 2000-2012 U.S. National Health Interview Survey, an annual, nationally-representative, cross-sectional, household interview survey. We created a nine-level smoking frequency-amount variable using tertile cut points from the number of days smoked in the past 30 (1-7, 8-14, 15-29 days) and number of cigarettes smoked per day (cpd) (1-2, 3-5, 6+). We computed weighted frequencies by low, moderate, high frequency use, by low, moderate, high cpd amount, and by demographics. We estimated temporal trends using weighted least squares regression, and the association between groups and past year quit attempts using logistic regression. RESULTS: Overall prevalence of NDS among adults remained stable between 2000-2012 (p=0.62). The most prevalent NDS frequency-amount groups were: smoking 15-29 days (in the past 30), 3-5 cpd (20.2%); 1-7 days, 1-2 cpd (19.7%); 15-29 days, 1-2 cpd (14.9%); and 15-29 days, 6+ cpd (12.1%). From 2000-2012, low cpd NDS (1-2 cpd) across moderate (8-14 days) and high (15-29 days) frequency groups increased (p<.01), while moderate frequency-moderate cpd (8-14 days, 3-5 cpd; p<.05) and high frequency-high cpd (15-29 days, 6+ cpd; p<.01) NDS declined. Adjusting for demographics and year, the lowest frequency-amount groups had the lowest odds of past year quit attempts. CONCLUSION: Changes occurred in NDS frequency and amount from 2000-2012, suggesting that more granular classifications may be important for monitoring NDS patterns.

INTRODUCTION: Quitting smoking at any age confers health benefits. However, studies have suggested that quitting by age 35 years leads to mortality rates similar to never smokers. This study assessed whether the mean and median ages of past-year quitting and prevalence of past-year quit attempts and successful quitting by age group changed over time. METHODS: Data came from 113,599 adult cigarette smokers participating in the 1997-2012 National Health Interview Survey, an annual, cross-sectional household survey of U.S. adults aged ≥18 years. Mean and median ages of past-year successful abstinence (quit 6-12 months) were computed. Orthogonal polynomial logistic regression models tested for trends in quit attempts and successful quitting. Data were analyzed in 2014. RESULTS: The average age of quitting (40.0 years in 1997-1998, 39.5 years in 2011-2012, p=0.80) and median age of quitting (35.9 years in 1997-1998, 36.9 years in 2011-2012, p=0.62) did not change over time. During 1997-2012, the percentage of smokers making a past-year quit attempt increased among those aged 25-34, 35-44, and 45-64 years; the percentage of smokers who reported quitting successfully increased among those aged 25-34 and 35-44 years (p<0.001). CONCLUSIONS: Although the average age of quitting did not change over time, increases in past-year quit attempts and successful quitting occurred among adults aged 25-44 years. Proven population-level interventions-including price increases, mass media campaigns, comprehensive smoke-free policies, and health systems interventions-should be continued to further increase cessation, particularly among younger adults.

OBJECTIVES: To examine abstinence outcomes among tobacco users with and without a reported mental health condition (MHC) who enrolled in state tobacco quitline programs. METHODS: Data were analyzed from a 7-month follow-up survey (response rate: 41% [3,132/7,459]) of three state-funded telephone quitline programs in the United States that assessed seven self-reported MHCs at quitline registration. We examined 30-day point prevalence tobacco quit rates for callers with any MHC versus none. Data were weighted to adjust for response bias and oversampling. Multivariable logistic regression was used to examine cessation outcomes. RESULTS: Overall, 45.8% of respondents reported ≥1 MHC; 57.4% of those reporting a MHC reported ≥2 MHCs. The unadjusted quit rate for callers with any MHC was lower than for callers with no MHC (22.0% versus 31.0%, P < 0.001). After adjusting for demographics, nicotine dependence, and program engagement, callers reporting ≥1 MHC were less likely to be abstinent at follow-up (adjusted OR = 0.63, 95% CI = 0.51-0.78, P < 0.001). CONCLUSIONS: More intensive or tailored quitline programs may need to be developed among callers with MHCs as their quit rates appear to be lower than callers without MHCs.

INTRODUCTION: Policies legalizing marijuana for medical and recreational use have been increasing in the U.S. Considering the potential impact of these policies, important knowledge gaps exist, including information about the prevalence of various modes of marijuana use (e.g., smoked in joints, bowls, bongs; consumed in edibles or drinks) and about medical versus recreational use. Accordingly, this study assessed (1) prevalence and correlates of modes of current and ever marijuana use and (2) prevalence of medicinal and recreational marijuana use in U.S. adults. METHODS: Data came from Summer Styles (n=4,269), a nationally representative consumer panel survey of adults aged ≥18 years, collected in 2014. The survey asked about past 30-day (current) and ever mode of marijuana use and current reason for use (medicinal, recreational, both). Weighted prevalence estimates were computed and correlates were assessed in 2014 using logistic regression. RESULTS: Overall, 7.2% of respondents reported current marijuana use; 34.5% reported ever use. Among current users, 10.5% reported medicinal-only use, 53.4% reported recreational-only use, and 36.1% reported both. Use of bowl or pipe (49.5%) and joint (49.2%) predominated among current marijuana users, with lesser use of bong, water pipe, or hookah (21.7%); blunts (20.3%); edibles/drinks (16.1%); and vaporizers (7.6%); 92.1% of the sample reported combusted-only marijuana use. CONCLUSION: Combusted modes of marijuana use are most prevalent among U.S. adults, with a majority using marijuana for recreation. In light of changing policies and patterns of use, improved marijuana surveillance is critical for public health planning.

INTRODUCTION: It is unclear how use of other tobacco products impacts cigarette-smoking cessation. We assessed differences in past year cigarette smoking quit attempts and use of counseling and medication among current cigarette-only users, cigarette and cigar users, and cigarette and smokeless tobacco (SLT) users. METHODS: Data came from 24,448 current cigarette-only, 1,064 cigarette and cigar only, and 508 cigarette and SLT only users who responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey. Demographic, smoking, and cessation characteristics were computed by group. Bivariate and multivariable logistic regression models assessed the relationship of tobacco use group to making a past year quit attempt, and use of counseling or medication during the last quit attempt. RESULTS: Dual users of cigarettes and cigars or SLT had similar interest in quitting and prevalence of reported past year quit attempts compared to cigarette-only users. In unadjusted analyses, cigarette and SLT users had higher odds of trying to quit in the past year compared to cigarette-only users (OR=1.31, 95% CI: 1.05, 1.64); no differences were found for cigarette and cigar users. However, adjusting for demographic and cigarette smoking variables, both groups of dual users had similar odds as cigarette-only users for having made a past year cigarette smoking quit attempt, and to have used counseling or medication during the last quit attempt. CONCLUSION: Dual tobacco use was not associated with decreased attempts to quit smoking cigarettes; however, use of evidence-based treatment was sub-optimal among cigarette-only and dual users and should be increased.

INTRODUCTION: Using nationally representative data, we assessed the prevalence and correlates of cigarette smokers who tried switching to smokeless tobacco (SLT) or to other combusted tobacco (OCT) products to quit. METHODS: Data came from 12,400 current or former adult smokers who made a quit attempt in the past year and responded to the 2010-2011 Tobacco Use Supplement to the Current Population Survey. Demographics and smoking characteristics were computed among those switching to SLT, switching to OCT, or trying to quit without using either strategy. Bivariate and multinomial logistic regression models identified correlates of using each strategy. RESULTS: Overall, 3.1% of smokers tried switching to SLT to quit, 2.2% tried switching to OCT, and 0.6% tried both strategies. Compared to those not using either switching strategy to try to quit, males were more likely than females to try switching to SLT or OCT; Blacks were less likely than Whites to try switching to SLT, but more likely to try switching to OCT; younger age groups were more likely to try switching to SLT or OCT; current someday smokers were more likely to have try switching to SLT (vs. everyday smokers), while recent former smokers were more likely to have tried switching to OCT. Both switching groups were more likely to have used cessation medication versus those not using switching strategies. CONCLUSION: Data suggest that switching to other tobacco products is a prevalent cessation approach; messages are needed to help clinicians encourage smokers who try to quit by switching to use evidence-based cessation approaches.

INTRODUCTION: Gradually reducing cigarette consumption is an approach used to quit smoking, but has not been widely studied at a population level. The purpose of this study was to assess the prevalence and demographic characteristics of U.S. adult smokers who tried to reduce to quit, and the relationship between reducing and successful quitting. METHODS: Data came from 12,571 adults in the 2010-2011 U.S. Tobacco Use Supplement to the Current Population Survey who tried to quit smoking in the past year. Frequencies and percentages were used to assess prevalence of reducing to quit; bivariate and multiple logistic regression models were used to assess correlates of reducing to quit and successful past year cessation. Analyses were conducted in SAS-callable SUDAAN. RESULTS: Among adults who tried to quit smoking in the past year, 43.0% (n=5,444) tried reducing to quit. Compared to those who tried to quit without reducing consumption, those reducing to quit had a significantly higher prevalence of using counseling or medication (40.2% vs. 25.0%). In adjusted multivariable models, females (vs. males), blacks (vs. whites), current some day smokers (vs. every day smokers), and those who used counseling had greater odds of trying to reduce to quit. Reducing to quit was negatively associated with successful past-year quitting (AOR=0.59, 95% CI: 0.48, 0.72). CONCLUSION: Reducing to quit is a common cessation strategy and, in these analyses, was associated with lower cessation success rates. More research on reducing to quit in a real-world setting is needed before widely recommending it as a cessation strategy.

BACKGROUND: Health care providers play an important role in promoting tobacco use abstinence among adolescents. This study aimed to provide nationally representative data on the prevalence of provider tobacco use screening and advice delivered to adolescents. Cessation behaviors and correlates of past year quit attempts among current smokers are also explored. METHODS: Data came from the 2011 National Youth Tobacco Survey, a nationally representative school-based survey of adolescents in grades 6 through 12 (n = 18 385). Provider screening and advice were assessed by smoking status and demographic characteristics. Logistic regression was used to assess the association between advice and past year quit attempt. RESULTS: The overall prevalence of current tobacco use was 16.6%; 10.8% were current cigarette smokers (3.6% were established smokers, 7.2% were nonestablished smokers); 17.3% were former smokers; and 71.9% were never smokers (22.6% high susceptibility, 77.4% low susceptibility). Among all respondents, the prevalence of being asked about tobacco use by a health care provider was 32.2%; the prevalence of being advised to quit or avoid tobacco was 31.4%. Established smokers were more likely than other groups to report provider assessment of tobacco use and advice. Receipt of advice was associated with a higher adjusted odds of having made a past year quit attempt (odds ratio: 1.47, 95% confidence interval: 1.18-1.82). CONCLUSIONS: Less than one-third of adolescents report being asked about tobacco use or being advised not to use tobacco. Increased tobacco use intervention by health care providers is needed to prevent initiation and increase cessation.

BACKGROUND: Despite declining use of conventional tobacco products, youth use of non-cigarette tobacco has become prevalent; however, quitting behaviors remain largely unexplored. PURPOSE: To examine nationally representative data on quit intentions and past-year attempts to quit all tobacco use among current youth tobacco users. METHODS: In 2013, data were analyzed from the 2012 National Youth Tobacco Survey (NYTS). Weighted prevalence estimates of quit intentions and past-year quit attempts for current youth tobacco users are presented. RESULTS: Prevalence of quit intentions and past-year attempts to quit all tobacco use were 52.8% and 51.5%, respectively, among current youth tobacco users. Among non-mutually exclusive groups, current cigarette smokers had the highest prevalence of quit intentions (56.8%) and past-year quit attempts (52.5%), whereas current hookah users had the lowest prevalence of quit intentions (41.5%) and past-year quit attempts (43.7%). Quit intentions among black, non-Hispanics (65.0%) and Hispanics (60.4%) were significantly higher versus white, non-Hispanics (47.5%). Youth reporting parental advice against tobacco had significantly higher prevalence of quit intentions (56.7%) and past-year quit attempts (55.0%) than those not reporting parental advice. Youth who agreed all tobacco products are dangerous (58.5%) had significantly higher prevalence of quit intentions than those who disagreed (37.0%). CONCLUSIONS: Continued efforts are needed to better understand youth motivation for quitting all tobacco products. Public health messaging about the dangers of all tobacco and cessation efforts should be aimed at the full range of tobacco products, not just cigarettes, and tailored to meet the needs of youth polytobacco users.

INTRODUCTION: Cigarette smoking is a major cause of chronic obstructive pulmonary disease, (COPD) but many persons with COPD continue to smoke. Quitting can help prevent the development of and complications from COPD. This study examined whether smoking and cessation behaviors differed among adults with a) COPD, b) asthma, c) other chronic conditions only, or d) no chronic conditions. METHODS: Smoking and chronic disease status was obtained from 488,909 adults aged >18 years using the Behavioral Risk Factor Surveillance System; 9,476 current smokers and recent quitters in 5 states responded to additional questions about cessation. We computed age-adjusted prevalence of smoking and past-year quit attempts, and used bivariate and multivariable logistic regression to identify correlates of past-year quit attempts. RESULTS: Similar to the overall sample, in the 5-state sample, 47.3% of adults with COPD were current smokers versus 23.1% of those with asthma, 28.8% of adults with other chronic conditions, and 20.0% of those with no chronic conditions. Those with COPD did not differ significantly from those with asthma, other chronic diseases, or no chronic disease in having made a past-year quit attempt (59.7% versus 64.0%, 61.5%, and 53.9%, respectively). Smokers with COPD were significantly more likely than those with no chronic disease to have used cessation treatment resources, including a quitline, counseling, or medication (p <0.001). CONCLUSIONS: Adults with COPD were just as likely as those without COPD to make a past-year quit attempt; however, approximately 40% of smokers with COPD did not try to quit.

INTRODUCTION: Tobacco quitlines are evidence-based cessation resources but have been underutilized. The purpose of this study is to provide population-level data about quitline awareness and utilization in the United States and to assess correlates of awareness and utilization. METHODS: Data were from the 2009-2010 National Adult Tobacco Survey. Descriptive statistics were produced for national- and state-level quitline awareness and for national quitline utilization. Bivariate and multivariable logistic regressions were used to identify correlates of quitline awareness and utilization. RESULTS: Quitline awareness among the total sample was 33.9% (current smokers 53.9%, former smokers 34.0%, never-smokers 27.0%). Awareness varied by state (range: 35.8%-84.6% for current smokers). Among current smokers who tried to quit in the past year, correlates of lower awareness included being Black, non-Hispanic, and making <$50,000 annually; correlates of higher awareness included having seen a health professional, higher state tobacco program expenditures, and being female. Among smokers who made at least one quit attempt in the previous year and were aware of the quitline, quitline utilization was 7.8%. Higher state tobacco program expenditure, health professional advice, and being Black, non-Hispanic were correlated with higher utilization; older age was correlated with lower utilization. Awareness was significantly associated with use at the state level (r = .98, p < .01). CONCLUSION: Although the majority of smokers in the United States are aware of quitlines, only a small percentage of those trying to quit utilize them. State tobacco program expenditures and receipt of advice from a health professional were associated with both higher quitline awareness and higher utilization.

INTRODUCTION: Nondaily smoking in the United States is increasing. Although differences in smoking and cessation behaviors between daily and nondaily smokers have been documented, differences among nondaily smokers are poorly understood. This study provides updated national data on smoking and cessation characteristics among nondaily versus daily smokers and between subgroups of nondaily smokers. METHODS: Data were obtained from the 2009-2010 National Adult Tobacco Survey, a stratified, dual-frame telephone survey conducted in the United States. Participants were categorized into daily smokers, never-daily nondaily smokers (NDNS), recently converted (≤1 year) nondaily smokers (RCNS), and established-converted (>1 year) nondaily smokers (ECNS). Chi-square tests were used to assess differences across groups, and multivariable logistic regression was used to identify factors associated with past year quit attempts. RESULTS: Among nondaily smokers (17.8% of the total sample), 27.1% were NDNS, 37.4% were RCNS, and 35.4% were ECNS. RCNS were the most likely to report ever having tried to quit (p < .0001), having tried to quit in the past year (p < .0001), having used cessation treatment during their last quit attempt (p < .05), and wanting to quit smoking for good (p < .001). Compared with NDNS, RCNS had more than twice the odds of trying to quit in the past year after adjusting for demographics and smoking characteristics (adjusted odds ratio = 2.1, 95% CI 1.3-3.2). No significant differences existed between NDNS and ECNS. CONCLUSIONS: RCNS are potentially more interested in quitting and should be specifically targeted with cessation interventions to avoid relapse to daily or long-term nondaily smoking.