The prevalence of cigarette smoking among U.S. adults enrolled in Medicaid is higher than among adults with private insurance; more than one in five adults enrolled in Medicaid smokes cigarettes. Smoking cessation reduces the risk for smoking-related disease and death. Effective treatments for smoking cessation are available, and comprehensive, barrier-free insurance coverage of these treatments can increase cessation. However, Medicaid treatment coverage and treatment access barriers vary by state. The American Lung Association collected and analyzed state-level information regarding coverage for nine tobacco cessation treatments and seven access barriers for standard Medicaid enrollees. As of December 31, 2022, a total of 20 state Medicaid programs provided comprehensive coverage (all nine treatments), an increase from 15 as of December 31, 2018. Only three states had zero access barriers, an increase from two; all three also had comprehensive coverage. Although states continue to improve smoking cessation treatment coverage and decrease access barriers for standard Medicaid enrollees, coverage gaps and access barriers remain in many states. State Medicaid programs can improve the health of enrollees who smoke and potentially reduce health care expenditures by providing barrier-free coverage of all evidence-based cessation treatments and by promoting this coverage to enrollees and providers.

Background E-cigarettes are the most commonly used tobacco product among US youth and are regularly used on school grounds. We assessed school staff’s awareness of students’ e-cigarette use, response by schools, and resources needed to address use, and examined e-cigarettes confiscated by school staff in North Carolina to guide prevention and identify needed resources. methods In May 2019, staff from a random sample of 25 of 451 North Carolina public and charter high schools were invited to complete an online survey and semistructured interview; 12 schools consented to ≥ 1 component (survey, N = 514; interviews, N = 35). Staff knowledge and perceptions of students’ e-cigarette use and school tobacco policies were assessed, including school efforts to address e-cigarette use. E-cigarette products confiscated by nine schools from students during the 2018-2019 school year were collected. limitations Only 12 public high schools participated, and these schools might not be representative of all North Carolina high schools. Quantitative surveys were not collected from all staff at participating schools; however, the response rate was 62% and included different staff positions and both urban and rural schools. Finally, e-cigarette products collected by schools might not be representative of all devices used by students. Results Among surveyed staff, 33% observed students using e-cigarettes on school grounds; 86% believed e-cigarette use somewhat or largely contributes to learning disruptions. Overall, 94% of respondents knew their school’s policy prohibits student e-cigarette use on school grounds, and 57% were not confident their school has resources to help students quit. From 35 interviews, themes included concern that schools’ tobacco-free policies do not deter use and additional resources are needed to address e-cigarette use in schools. Of 336 collected devices, there were different e-cigarette types and most (65%) e-liquid bottles were flavored. conclusion Efforts are warranted to incorporate evidence-based curricula; educate staff, parents, and youth regarding health risks of ecigarette use; and help youth quit e-cigarettes. © 2023 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

E-cigarette products, related policies, and use patterns change rapidly. In the United States, the prevalence of e-cigarette use is markedly higher among youths and young adults than it is among adults overall. In 2021, 4.5% of all adults aged ≥18 years (an estimated 11.1 million) and 11.0% of young adults aged 18-24 years (an estimated 3.1 million) currently (≥1 day during the previous 30 days) used e-cigarettes; during 2022, 14.1% of high school students (an estimated 2.14 million) currently used e-cigarettes (1,2). E-cigarettes often contain high concentrations of nicotine. Nicotine is highly addictive and can harm the adolescent brain, which continues to develop through approximately age 25 years (3). Since 2020, the availability of e-cigarette products has changed in response to multiple factors, including local and state policies to address flavored e-cigarette sales, actions undertaken by the Food and Drug Administration (FDA), COVID-19-related closures, and global supply chain disruptions. To assess trends in unit sales of e-cigarettes in the United States, by product and flavor, and top-selling brands, the CDC Foundation, Truth Initiative,* and CDC analyzed retail scanner data during January 26, 2020-December 25, 2022, from Information Resources, Inc. (IRI), a U.S. data analytics and market research company. Overall, unit sales increased by 46.6% during the study period. The unit share of menthol-flavored product sales remained relatively stable during this period, whereas nonmenthol flavor unit shares changed. During January 26, 2020-December 25, 2022, unit shares of tobacco-flavored and mint-flavored products decreased (from 28.4% to 20.1% and from 10.1% to 5.9%, respectively), whereas shares of other flavor sales increased (from 29.2% to 41.3%). In addition, during January 2020-December 2022, unit shares of prefilled cartridges decreased from 75.2% to 48.0%, and disposable e-cigarette unit share increased from 24.7% to 51.8% of total unit sales. The five top-selling e-cigarette brands for the 4-week period ending December 25, 2022, were Vuse, JUUL, Elf Bar, NJOY, and Breeze Smoke. Analysis of information on e-cigarette retail sales can guide strategies to prevent youth access to and use of e-cigarettes, including restrictions on flavored tobacco products (4).

INTRODUCTION: Despite progress in adoption of smoke-free policies, smoking in casinos is allowed in some US states, including Nevada. In 2020, for the first time, a resort-style casino in Las Vegas prohibited smoking voluntarily. This study is the first to assess air quality in this casino and compare results with similar casinos that allow smoking. METHODS: A real-time personal aerosol monitor evaluated particulate matter with a diameter <2.5 µm (PM2.5), a surrogate for secondhand smoke (SHS). PM2.5 was measured at eight Las Vegas casinos, including the smoke-free casino. Each casino was visited twice, and PM2.5 was assessed in smoking-permitted gaming areas and areas where smoking is otherwise prohibited. RESULTS: Average PM2.5 levels were significantly higher in casinos that allow smoking, for both casino gaming areas and areas where smoking is otherwise prohibited (p<0.05). Mean PM2.5 in gaming areas was 164.9 µg/m(3) in casinos that allow smoking and 30.5 µg/m(3) in the smoke-free casino. Mean PM2.5 in areas where smoking is otherwise prohibited was 83.2 µg/m(3) in casinos which allowed smoking in gaming areas, and 48.1 µg/m(3) in the smoke-free casino. CONCLUSION: Despite robust evidence about the harms of SHS, tens of thousands of casino employees and tens of millions of tourists are exposed to high levels of SHS in Las Vegas casinos annually, with PM2.5 levels 5.4 times higher in gaming areas when compared with a smoke-free casino. The only way to protect people from SHS exposure is to prohibit smoking in all indoor areas.

INTRODUCTION: In 2019, an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) occurred in the US. We used Nielsen retail sales data to assess trends in sales of e-cigarettes, cigarettes, and nicotine replacement therapy (NRT) products before, during, and after the EVALI outbreak. METHODS: Monthly unit sales of e-cigarettes, cigarettes, and NRT products overall and by product type were assessed during January 2019 through June 2020 by using an interrupted time series model. Two time points were specified at the period ending July 13, 2019, and the period ending February 22, 2020, to partition before, during, and after the outbreak period. Sales trends by aggregated state-level EVALI case prevalence (low, medium, and high) were assessed to investigate interstate variations in changes of sales coinciding with the EVALI outbreak. RESULTS: Monthly e-cigarette sales increased 3.5% (P < .001) before the outbreak and decreased 3.1% (P < .001) during the outbreak, with no significant changes after the outbreak. Monthly cigarette sales increased 1.6% (P < .001) before the outbreak, decreased 1.8% (P < .001) during the outbreak, and increased 2.7% (P < .001) after the outbreak. NRT sales did not change significantly before or during the outbreak but decreased (2.8%, P = .01) after the outbreak. Sales trends by state-level EVALI case prevalence were similar to national-level sales trends. CONCLUSION: Cigarette and e-cigarette sales decreased during the EVALI outbreak, but no changes in overall NRT sales were observed until after the outbreak. Continued monitoring of tobacco sales data can provide insight into potential changes in use patterns and inform tobacco prevention and control efforts.

INTRODUCTION: Secondhand smoke and secondhand aerosol exposure are important public health concerns. This is the first study to present separate estimates of public indoor and outdoor secondhand smoke and secondhand aerosol exposure among U.S. youth. METHODS: Data came from the 2020 National Youth Tobacco Survey, an annual cross-sectional survey of U.S. students in Grades 6-12. Self-reported past 30-day indoor and outdoor secondhand smoke and secondhand aerosol exposures were assessed separately. Weighted prevalence and adjusted prevalence ratios for each outcome were assessed among students overall and stratified by sex, school level, race/ethnicity, sexual orientation, and current tobacco product use; prevalence also was calculated among those who did not currently use tobacco. RESULTS: Exposure to secondhand smoke and secondhand aerosol was reported by 60.6% (95% CI=58.7, 62.4) and 44.5% (95% CI=42.1, 46.9) of U.S. youth, respectively. Among all students, 37.6% (95% CI=36.0, 39.2) and 53.3% (95% CI=51.4, 55.2) reported indoor and outdoor secondhand smoke exposure, respectively; 34.9% (95% CI=32.9, 37.4) and 36.8% (95% CI=34.6, 38.9) reported indoor and outdoor secondhand aerosol exposure, respectively. After adjustment, female versus male students (adjusted prevalence ratio=1.15-1.30) and those who currently use versus do not use combustible tobacco products (adjusted prevalence ratio=1.15-1.36) were more likely to report exposure to all outcomes. CONCLUSIONS: Approximately 1 in 2 students overall reported outdoor secondhand smoke exposure, and 1 in 3 students reported exposures to each indoor secondhand smoke, indoor secondhand aerosol, and outdoor secondhand aerosol. Separate estimates of indoor and outdoor secondhand smoke and secondhand aerosol exposure, along with data on correlates of exposure, provide information to support comprehensive indoor and outdoor smoke-free policies.

IMPORTANCE: e-Cigarettes are the most commonly used tobacco product among US youths. Flavors are among the most cited reasons for use of e-cigarettes among youths, and therefore, some states have imposed restrictions on flavored e-cigarette sales. To our knowledge, no study has compared e-cigarette sales between states with statewide flavored e-cigarette restrictions and states without such restrictions while controlling for co-occurring events. OBJECTIVE: To assess whether implementation of statewide restrictions on flavored e-cigarette sales in Massachusetts, New York, Rhode Island, and Washington was associated with a reduction in total e-cigarette unit sales from 2014 to 2020. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study with difference-in-differences analysis used e-cigarette retail sales data from Massachusetts, Rhode Island, and Washington, which implemented restrictions on flavored e-cigarette sales in October 2019; New York, which implemented these restrictions in May 2020; and 35 states without these restrictions (control states). Sales were summed into 4-week periods from August 24, 2014, to December 27, 2020, for a total of 2988 state-period observations. MAIN OUTCOMES AND MEASURES: A difference-in-differences analysis was conducted to compare e-cigarette unit sales in the 4 states with flavor restrictions (before and after implementation) with those in the 35 control states. The model controlled for other population-based policies and emergent events (eg, the COVID-19 pandemic). Data on 4-week e-cigarette unit sales were sorted into 4 flavor categories (tobacco, menthol, mint, and other). Unit sales were standardized to reflect the most common package sizes for each product type. RESULTS: Statewide restrictions on non-tobacco-flavored e-cigarette sales were associated with the following reductions in mean 4-week total e-cigarette sales in intervention states compared with control states from October 2019 to December 2020: 30.65% (95% CI, 24.08%-36.66%) in New York, 31.26% (95% CI, 11.94%-46.34%) in Rhode Island, and 25.01% (95% CI, 18.43%-31.05%) in Washington. In Massachusetts, the comprehensive sales prohibition of all e-cigarette products was associated with a 94.38% (95% CI, 93.37%-95.23%) reduction in 4-week sales compared with control states. Except in Massachusetts, where all sales of flavored e-cigarettes decreased, reductions were found only for non-tobacco-flavored e-cigarette sales in the other states with restrictions. Among control states, mean sales decreased by 28.4% from August 2019 to February 2020 but then increased by 49.9% from February through December 2020. CONCLUSIONS AND RELEVANCE: In this cross-sectional study, statewide restrictions on the sale of flavored e-cigarettes in Massachusetts, New York, Rhode Island, and Washington were associated with a reduction in total e-cigarette sales. These findings suggest that not all e-cigarette users who purchased non-tobacco-flavored e-cigarettes switched to purchasing tobacco-flavored e-cigarettes after policy implementation.

INTRODUCTION: Cigar smoking has increased in recent decades as the cigar product landscape has diversified. This study assessed trends in U.S. cigar sales during 2016-2020. METHODS: Unit sales and average unit price for cigars were assessed during January 3, 2016-June 13, 2020, overall and by product and flavor type, for the 48 contiguous U.S. states and D.C. Assessed cigar types were large cigars, little cigars, and cigarillos; assessed flavor types were tobacco/unflavored, candy/sweets, fruit, menthol, alcohol, coffee, other flavors, and no flavor stated. A joinpoint regression model was used to assess the magnitude and significance of sales trends. RESULTS: During January 3, 2016-June 13, 2020, unit sales of cigarillos increased (average monthly percentage change (AMPC)=0.7%, p<0.001), while unit sales of large cigars (AMPC=-0.8%, p<0.001) and little cigars decreased (AMPC=-0.2%, p<0.001). The average price of cigarillos gradually decreased since mid-August 2017 (AMPC=-0.1%, p<0.001), and the average price of little cigars decreased from mid-June 2016 to mid-June 2019 (AMPC=-0.3%, p<0.001). In contrast, the average price of large cigars increased during the entire study period (AMPC=0.6%, p<0.001). Irrespective of cigar type, tobacco-flavored/unflavored products were the most commonly sold cigars during the assessed period; however, sales of other flavors varied by cigar type. CONCLUSIONS: Cigar sales and price vary by type over time in the U.S., including sales of cigarillos (94.2% of unit sales) increasing as their prices have decreased in recent years. Public health strategies are warranted to address the full scope of cigar types being used in the U.S. IMPLICATIONS: Surveillance of cigar sales data, including product characteristics, can provide a timely complement to self-reported survey data of cigar use. This study assessed trends in U.S. cigar sales during 2016-2020, including by product and flavor type. The findings indicate that sales of cigarillos, which comprise most cigar sales in the U.S. during the assessed period, increased as their prices decreased. Sales of certain flavors, such as candy/sweet cigarillos and coffee large cigars, increased significantly. These findings reinforce the importance of evidence-based strategies, including increasing price and restricting flavors, to reduce the affordability and consumption of cigars in the U.S.

This study uses retail scanner data to assess nicotine pouch sales in the US between 2016 and 2020.

PURPOSE: To examine the chemical composition of JUUL pods collected from a convenience sample of 16 high schools in California to identify possible consumer modification or counterfeit use. METHODS: Using Gas Chromatography-Mass Spectrometry, we quantitatively analyzed the nicotine, propylene glycol (PG), and vegetable glycerin (VG) in JUUL pods (n = 26) collected from California high schools and compared results to commercial 3% (n = 15) and 5% (n = 24) JUUL pods purchased online. RESULTS: Most of the collected JUUL pods (24/26 pods) had a nicotine concentration (43.3 mg/ml, 95% PI: 21.5-65.1) outside the prediction intervals (PI) of the 3% (33.5 mg/ml, 95% PI: 31.8-35.2) and 5% (55.0 mg/ml, 95% PI: 51.5-58.3) commercial JUUL pods. Most (73%) collected JUUL pods had VG concentrations (583.5 mg/ml, PI: 428.9-738.1) lower than the 3% (722.2 mg/ml, PI: 643.0-801.4) and 5% (710.5 mg/ml, PI: 653.1-767.8) commercial JUUL pods. CONCLUSIONS: Used JUUL products collected from high school students or found on school grounds were not chemically consistent with the manufacturer's stated formulations.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value<.05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio [aPR] = 0.57; 95% confidence intervals [CI] = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

E-cigarette, or vaping, products are electronic devices that produce an inhalable aerosol by heating an e-liquid that typically contains nicotine and other additives (1). Nicotine is highly addictive, can harm adolescent brain development, and can prime the brain for addiction to other drugs (1). In 2019, 27.5% of U.S. high school students currently used e-cigarettes (2), and 73.4% of high school students had observed e-cigarette use on school grounds (3). E-cigarette use among U.S. youths increased considerably during 2017–2019 (2). This rise coincided with the increased popularity of “pod mods,” which are products with a prefilled or refillable pod cartridge (pod) and a modifiable (mod) system. Pod mods typically use nicotine salts rather than the freebase nicotine used in most other e-cigarette, or vaping, products and conventional tobacco products (e.g., cigarettes).* Nicotine salts, which have a lower pH than freebase nicotine, allow particularly high levels of nicotine to be inhaled more easily and with less irritation to the throat than freebase nicotine.† The most commonly sold pod mod brand is JUUL, which accounted for 75% of all U.S. e-cigarettes sales by the end of 2018.§ A majority (59.1%) of U.S. high school student e-cigarette users report JUUL is their usual brand (2).

Since electronic cigarettes (e-cigarettes) entered the U.S. marketplace in 2007, the landscape has evolved to include different product types (e.g., prefilled cartridge-based and disposable products) and flavored e-liquids (e.g., fruit, candy, mint, menthol, and tobacco flavors), which have contributed to increases in youth use (1,2). E-cigarettes have been the most commonly used tobacco product among U.S. youths since 2014; in 2019, 27.5% of high school students reported current e-cigarette use (3). To assess trends in unit sales of e-cigarettes in the United States by product and flavor type, CDC, CDC Foundation, and Truth Initiative analyzed retail scanner data during September 14, 2014-May 17, 2020, from Information Resources, Inc. (IRI). During this period, total e-cigarette sales increased by 122.2%, from 7.7 million to 17.1 million units per 4-week interval. By product type, the proportion of total sales that was prefilled cartridge products increased during September 2014-August 2019 (47.5% to 89.4%). During August 2019-May 2020, the proportion of total sales that was disposable products increased from 10.3% to 19.8%, while the proportion that was prefilled cartridge products decreased (89.4% to 80.2%). Among prefilled cartridge sales, the proportion of mint sales increased during September 2014-August 2019 (<0.1% to 47.6%); during August 2019-May 2020, mint sales decreased (47.6% to 0.3%), as menthol sales increased (10.7% to 61.8%). Among disposable e-cigarette sales during September 2014-May 2020, the proportion of mint sales increased (<0.1% to 10.5%), although tobacco-flavored (52.2% to 17.2%) and menthol-flavored (30.3% to 10.2%) sales decreased; during the same period, sales of all other flavors combined increased (17.2% to 62.1%). E-cigarette sales increased during 2014-2020, but fluctuations occurred overall and by product and flavor type, which could be attributed to consumer preferences and accessibility. Continued monitoring of e-cigarette sales and use is critical to inform strategies at the national, state, and community levels to minimize the risks of e-cigarettes on individual- and population-level health. As part of a comprehensive approach to prevent and reduce youth e-cigarettes use, such strategies could include those that address youth-appealing product innovations and flavors.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to spread from person to person primarily by the respiratory route and mainly through close contact (1). Community mitigation strategies can lower the risk for disease transmission by limiting or preventing person-to-person interactions (2). U.S. states and territories began implementing various community mitigation policies in March 2020. One widely implemented strategy was the issuance of orders requiring persons to stay home, resulting in decreased population movement in some jurisdictions (3). Each state or territory has authority to enact its own laws and policies to protect the public's health, and jurisdictions varied widely in the type and timing of orders issued related to stay-at-home requirements. To identify the broader impact of these stay-at-home orders, using publicly accessible, anonymized location data from mobile devices, CDC and the Georgia Tech Research Institute analyzed changes in population movement relative to stay-at-home orders issued during March 1-May 31, 2020, by all 50 states, the District of Columbia, and five U.S. territories.* During this period, 42 states and territories issued mandatory stay-at-home orders. When counties subject to mandatory state- and territory-issued stay-at-home orders were stratified along rural-urban categories, movement decreased significantly relative to the preorder baseline in all strata. Mandatory stay-at-home orders can help reduce activities associated with the spread of COVID-19, including population movement and close person-to-person contact outside the household.

SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), is thought to be transmitted mainly by person-to-person contact (1). Implementation of nationwide public health orders to limit person-to-person interaction and of guidance on personal protective practices can slow transmission (2,3). Such strategies can include stay-at-home orders, business closures, prohibitions against mass gatherings, use of cloth face coverings, and maintenance of a physical distance between persons (2,3). To assess and understand public attitudes, behaviors, and beliefs related to this guidance and COVID-19, representative panel surveys were conducted among adults aged >/=18 years in New York City (NYC) and Los Angeles, and broadly across the United States during May 5-12, 2020. Most respondents in the three cohorts supported stay-at-home orders and nonessential business closures* (United States, 79.5%; New York City, 86.7%; and Los Angeles, 81.5%), reported always or often wearing cloth face coverings in public areas (United States, 74.1%, New York City, 89.6%; and Los Angeles 89.8%), and believed that their state's restrictions were the right balance or not restrictive enough (United States, 84.3%; New York City, 89.7%; and Los Angeles, 79.7%). Periodic assessments of public attitudes, behaviors, and beliefs can guide evidence-based public health decision-making and related prevention messaging about mitigation strategies needed as the COVID-19 pandemic evolves.

Raising the minimum legal sales age (MLSA) for tobacco products to 21 years (T21) is a strategy to help prevent and delay the initiation of tobacco product use (1). On December 20, 2019, Congress raised the federal MLSA for tobacco products from 18 to 21 years. Before enactment of the federal T21 law, localities, states, and territories were increasingly adopting their own T21 laws as part of a comprehensive approach to prevent youth initiation of tobacco products, particularly in response to recent increases in use of e-cigarettes among youths (2). Nearly all tobacco product use begins during adolescence, and minors have cited social sources such as older peers and siblings as a common source of access to tobacco products (1,3). State and territorial T21 laws vary widely and can include provisions that might not benefit the public's health, including penalties to youths for purchase, use, or possession of tobacco products; exemptions for military populations; phase-in periods; and preemption of local laws. To understand the landscape of U.S. state and territorial T21 laws before enactment of the federal law, CDC assessed state and territorial laws prohibiting sales of all tobacco products to persons aged <21 years. As of December 20, 2019, 19 states, the District of Columbia (DC), Guam, and Palau had enacted T21 laws, including 13 enacted in 2019. Compared with T21 laws enacted during 2013-2018, more laws enacted in 2019 have purchase, use, or possession penalties; military exemptions; phase-in periods of 1 year or more; and preemption of local laws related to tobacco product sales. T21 laws could help prevent and reduce youth tobacco product use when implemented as part of a comprehensive approach that includes evidence-based, population-based tobacco control strategies such as smoke-free laws and pricing strategies (1,4).

CONTEXT: Policy is an effective tool for reducing the health harms caused by tobacco use. State laws can establish baseline public health protections. Preemptive legislation at the state level, however, can prohibit localities from enacting laws that further protect their citizens from public health threats. APPROACH: Preemptive state tobacco control laws were assessed using the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System. Based on the assessments, the Centers for Disease Control and Prevention quantified the number of states with certain types of preemptive tobacco control laws in place. In addition, 4 different case examples were presented to highlight the experiences of 4 states with respect to preemption. DISCUSSION: Tracking and reporting on preemptive state tobacco control laws through the Centers for Disease Control and Prevention's State Tobacco Activities Tracking and Evaluation System provide an understanding of the number and scope of preemptive laws. Case examples from Hawaii, North Carolina, South Carolina, and Washington provide a detailed account of how preemption affects tobacco control governance at state and local levels within these 4 states.

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.

Objectives: In 2018, approximately 4.9 million US middle and high school students reported past 30-day use of any tobacco product. This study describes how and where youth obtained tobacco products and whether refusal of sale occurred during 2016-2018. Methods: Data from 3 annual waves (2016-2018) of the National Youth Tobacco Survey, a school-based survey of US youth in grades 6-12, were analyzed among current (past 30-day) tobacco product users aged 9 to 17 years. Results: During 2016-2018, youth tobacco product users most commonly obtained tobacco products from social sources. Although the percentage of users who reported buying tobacco products significantly decreased from 2016 to 2018 (2016: 15.6%; 2018: 11.4%), no significant differences in the prevalence of being refused sale were observed (2016: 24.7%; 2018: 25.5%). Conclusions: Whereas the number of youth users who report buying tobacco products has declined, sales of tobacco products to youth remain a public health concern, as only one in 4 youth who attempted to buy were refused sale in 2018. Monitoring youth tobacco product purchases, retailer compliance check inspections, and retailer penalties for sales to minors remain important for reducing youth access at retail sources.

OBJECTIVES: To assess trends and behavioral patterns of marijuana and cigarette and/or cigar (ie, smoked tobacco) use among 18- to 22-year-old US young adults who were in or not in college. METHODS: Data were from the 2002-2016 National Survey on Drug Use and Health. Past-30-day and past-12-month use of marijuana and smoked tobacco were assessed by college enrollment status. chi(2) tests were used to examine within- and between-group differences. Trends were assessed by using logistic regression and relative percentage change (RPC). RESULTS: Among both college and noncollege individuals during 2002 to 2016, exclusive marijuana use increased (faster increase among college students; RPC = 166.6 vs 133.7), whereas exclusive smoked tobacco use decreased (faster decrease among college students; RPC = -47.4 vs -43.2). In 2016, 51.6% of noncollege and 46.8% of college individuals reported past-12-month usage of marijuana and/or smoked tobacco products (P < .05). Exclusive marijuana use was higher among college than noncollege individuals, both for past-30-day (11.5% vs 8.6%) and past-12-month use (14.6% vs 10.8%). Exclusive smoked tobacco use was higher among noncollege than college individuals, both for past-30-day (17.7% vs 10.4%) and past-12-month (17.4% vs 12.2%) use (P < .05). CONCLUSIONS: Exclusive marijuana use is increasing among young adults overall, whereas exclusive smoked tobacco use is decreasing: faster rates are seen among college students. Exclusive marijuana use is higher among college students, whereas exclusive smoked tobacco use is higher among noncollege individuals. Surveillance of tobacco and marijuana use among young people is important as the policy landscape for these products evolves.

The Surgeon General has concluded that there is a causal relationship between depictions of smoking in movies and initiation of smoking among young persons (1). Youths heavily exposed to onscreen smoking imagery are more likely to begin smoking than are those with minimal exposure (1,2). To assess tobacco-use imagery in top-grossing youth-rated movies (General Audiences [G], Parental Guidance [PG], and Parents Strongly Cautioned [PG-13]),* 2010-2018 data from the Breathe California Sacramento Region and University of California-San Francisco's Onscreen Tobacco Database were analyzed.(dagger) The percentage of all top-grossing movies with tobacco incidents remained stable from 2010 (45%) to 2018 (46%), including youth-rated movies (31% both years). However, total tobacco incidents increased 57% from 2010 to 2018, with a 120% increase in PG-13 movies. Tobacco incidents in PG-13 fictional movies declined 57% from 511 in 2010 to an all-time low of 221 in 2018. Although the number of PG-13 fictional movies with tobacco incidents declined 40% during 2010-2018, the number of PG-13 biographical dramas with tobacco incidents increased 233%. In 2018, biographical dramas accounted for most tobacco incidents, including 82% of incidents in PG-13 movies; 73% of characters who used tobacco in these biographical dramas were fictional. Continued efforts could help reduce tobacco incidents in top-grossing movies, particularly in PG-13 biographical dramas, to help prevent youth smoking initiation.

The 2009 Family Smoking Prevention and Tobacco Control Act prohibits the inclusion of characterizing flavors (e.g., candy or fruit) other than tobacco and menthol in cigarettes; however, characterizing flavors are not currently prohibited in other tobacco products at the federal level.* Flavored tobacco products can appeal to youths and young adults and influence initiation and establishment of tobacco-use patterns (1). The Food and Drug Administration (FDA) and CDC analyzed data from the 2014-2018 National Youth Tobacco Surveys (NYTS) to determine prevalence of current (past 30-day) use of flavored tobacco products, including electronic cigarettes (e-cigarettes), hookah tobacco, cigars, pipe tobacco, smokeless tobacco, bidis, and menthol cigarettes among U.S. middle school (grades 6-8) and high school (grades 9-12) students. In 2018, an estimated 3.15 million (64.1%) youth tobacco product users currently used one or more flavored tobacco products, compared with 3.26 million (70.0%) in 2014. Despite this overall decrease in use of flavored tobacco products, current use of flavored e-cigarettes increased among high school students during 2014-2018; among middle school students, current use of flavored e-cigarettes increased during 2015-2018, following a decrease during 2014-2015. During 2014-2018, current use of flavored hookah tobacco decreased among middle and high school students; current use of flavored smokeless tobacco, cigars, pipe tobacco, and menthol cigarettes decreased among high school students. Full implementation of comprehensive tobacco prevention and control strategies, coupled with regulation of tobacco products by FDA, can help prevent and reduce use of tobacco products, including flavored tobacco products, among U.S. youths (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.

Research shows that there is no risk-free level of exposure to secondhand smoke (SHS) and that eliminating smoking indoors fully protects nonsmokers from indoor SHS exposure. Casinos often allow smoking indoors and can be a source of involuntary SHS exposure for employees and visitors. We examined attitudes toward smoke-free casino policies among US adults. During June and July 2017, we used a web-based survey to ask a nationally representative sample of 4107 adults aged >/=18 about their attitudes toward smoke-free casinos. Among 4048 respondents aged >/=18, a weighted 75.0% favored smoke-free casino policies, including respondents who visited casinos about once per year (74.1%), several times per year (75.3%), and at least once per month (74.2%). Although the sociodemographic characteristics of respondents who favored smoke-free casino policies varied, the majority in each group, except current smokers (45.4%), supported smoke-free policies. Allowing smoking inside casinos involuntarily exposes casino employees and visitors to SHS, a known and preventable health risk. Further assessment of public knowledge and attitudes toward smoke-free casinos at state and local levels may help inform tobacco control policy, planning, and practice.

This Research Letter examines the prevalence of electronic cigarette use and association with cannabis use among US middle and high school students.

INTRODUCTION: Sales of electronic vapor products have increased in recent years. This increase in use may be related to manufacturer price promotions. This study assessed the use of price-related promotions among current electronic vapor product users. METHODS: Data from the 2015 and 2016 Summer Styles, an Internet survey of U.S. adults aged >/=18 years, were analyzed in 2017. Current electronic vapor product users (n=300) were those who reported past 30-day electronic vapor product use. Price-related promotion use was defined as reported use of coupons, rebates, discount codes, or other special price-related promotions when purchasing electronic vapor products (e.g., electronic cigarettes [e-cigarettes], electronic hookah [e-hookah], or vape pens). Associations between price-related promotion use and sex, age, race/ethnicity, educational attainment, U.S. region, cigarette smoking status, electronic vapor product use frequency, place electronic vapor products were obtained, and survey year were assessed using multivariable logistic regression. RESULTS: Among current electronic vapor product users, 15.0% reported using price-related promotions. The adjusted odds of using price-related promotions was significantly higher among respondents who obtained electronic vapor products from a gas station, grocery or drug store, or the Internet (AOR=2.65, 95% CI=1.22, 5.74) versus anywhere else (i.e., mall kiosks, vape shop, friends/family) and among those who used electronic vapor products >/=15 days in the past 30 days (AOR=2.57, 95% CI=1.18, 5.56) versus </=14 days. CONCLUSIONS: Nearly one in seven current U.S. adult electronic vapor product users reported using price promotions during 2015-2016, and variations in price promotion use existed by electronic vapor product use frequency and where electronic vapor products were obtained. Continued monitoring of the use of price-related promotions could help inform public health policy, planning, and practice.

Each year in the United States, cigarette smoking causes an estimated 480,000 deaths, including approximately 41,000 deaths from secondhand smoke exposure among nonsmoking adults (1). Smoke-free policies protect nonsmokers from secondhand smoke exposure, reduce the social acceptability of smoking, help in preventing youth and young adult smoking initiation, and increase smokers' efforts to quit smoking (1,2). Given that 99% of adult cigarette smokers first start smoking before age 26 years and many smokers transition to regular, daily use during young adulthood (2),* colleges and universities represent an important venue for protecting students, faculty, staff members, and guests from secondhand smoke exposure through tobacco control policies (3). To assess smoke-free and tobacco-free policies in U.S. colleges and universities, CDC and the American Nonsmokers' Rights Foundation (ANRF) determined the number of campuses nationwide that completely prohibit smoking (smoke-free) or both smoking and smokeless tobacco product use (tobacco-free) in all indoor and outdoor areas. As of November 2017, at least 2,082 U.S. college and university campuses had smoke-free policies. Among these campuses, 1,743 (83.7%) were tobacco-free; 1,658 (79.6%) specifically prohibited electronic cigarette (e-cigarette) use; and 854 (41.0%) specifically prohibited hookah smoking. Smoke-free and tobacco-free policies on college and university campuses can help reduce secondhand smoke exposure, tobacco use initiation, and the social acceptability of tobacco use (1-3).

In 2015, an estimated 18.8 million U.S. adults were military veterans (1). Although the prevalence of tobacco-attributable conditions is high among veterans (2), there is a paucity of data on use of tobacco products, other than cigarettes, in this population. To monitor tobacco product use among veterans, CDC analyzed self-reported current (i.e., past 30-day) use of five tobacco product types (cigarettes, cigars [big cigars, cigarillos, or little cigars], roll-your-own tobacco, pipes, and smokeless tobacco [chewing tobacco, snuff, dip, or snus]) from the National Survey on Drug Use and Health (NSDUH). Overall, 29.2% of veterans reported current use of any of the assessed tobacco products. Cigarettes were the most commonly used tobacco product (21.6%), followed by cigars (6.2%), smokeless tobacco (5.2%), roll-your-own tobacco (3.0%), and pipes (1.5%); 7.0% of veterans currently used two or more tobacco products. Within subgroups of veterans, current use of any of the assessed tobacco products was higher among persons aged 18-25 years (56.8%), Hispanics (34.0%), persons with less than a high school diploma (37.9%), those with annual family income <$20,000 (44.3%), living in poverty (53.7%), reporting serious psychological distress (48.2%), and with no health insurance (60.1%). By age and sex subgroups, use of any of the assessed tobacco products was significantly higher among all veteran groups than their nonveteran counterparts, except males aged >/=50 years. Expanding the reach of evidence-based tobacco control interventions among veterans could reduce tobacco use prevalence in this population.

Electronic cigarettes (e-cigarettes) are the most frequently used tobacco product among U.S. youths, and past 30-day e-cigarette use is more prevalent among high school students than among adults (1,2). E-cigarettes typically deliver nicotine, and the U.S. Surgeon General has concluded that nicotine exposure during adolescence can cause addiction and can harm the developing adolescent brain (2). Through authority granted by the Family Smoking Prevention and Tobacco Control Act, the Food and Drug Administration (FDA) prohibits e-cigarette sales to minors, free samples, and vending machine sales, except in adult-only facilities (3). States, localities, territories, and tribes maintain broad authority to adopt additional or more stringent requirements regarding tobacco product use, sales, marketing, and other topics (2,4). To understand the current e-cigarette policy landscape in the United States, CDC assessed state and territorial laws that 1) prohibit e-cigarette use and conventional tobacco smoking indoors in restaurants, bars, and worksites; 2) require a retail license to sell e-cigarettes; 3) prohibit e-cigarette self-service displays (e.g., requirement that products be kept behind the counter or in a locked box); 4) establish 21 years as the minimum age of purchase for all tobacco products, including e-cigarettes (tobacco-21); and 5) apply an excise tax to e-cigarettes. As of September 30, 2017, eight states, the District of Columbia (DC), and Puerto Rico prohibited indoor e-cigarette use and smoking in indoor areas of restaurants, bars, and worksites; 16 states, DC, and the U.S. Virgin Islands required a retail license to sell e-cigarettes; 26 states prohibited e-cigarette self-service displays; five states, DC, and Guam had tobacco-21 laws; and eight states, DC, Puerto Rico, and the U.S. Virgin Islands taxed e-cigarettes. Sixteen states had none of the assessed laws. A comprehensive approach that combines state-level strategies to reduce youths' initiation of e-cigarettes and population exposure to e-cigarette aerosol, coupled with federal regulation, could help reduce health risks posed by e-cigarettes among youths (2,5).

Policies prohibiting smokeless tobacco (SLT) use at sports venues have been enacted in California and nine U.S. cities. We measured opposition toward SLT use at all public sports venues and its correlates among U.S. adults. Data were from the 2016 SummerStyles, a web-based survey of U.S. adults aged ≥18years (n=4203). Weighted estimates of opposition ("strongly" or "somewhat") SLT use were computed overall and by selected characteristics. Multivariable Poisson regression analyses were performed to identify determinants of opposition toward SLT use overall and among current tobacco product users. Overall, 81.8% of U.S. adults opposed SLT use at all public sports venues. Opposition varied by tobacco product use status: 85.9%, 86.9% and 60.4% among never, former, and current tobacco product users, respectively. Among all adults, the likelihood of opposition was higher among females than males (Adjusted Prevalence Ratio [APR]=1.05; 95%CI=1.01-1.08) and increased with every 10-year increase in age (APR=1.01; 95%CI=1.00-1.02). Likelihood was lower among persons with a high school diploma (APR=0.92; 95%CI=0.88-0.96) than those with college degree or higher; persons widowed/divorced/separated (APR=0.92; 95%CI=0.87-0.97) than those married; and current tobacco product users (APR=0.70; 95%CI=0.65-0.76) than never users. Among current tobacco product users, likelihood was lower among persons living in the Midwest (APR=0.81; 95%CI=0.66-0.98) and South (APR=0.78; 95%CI=0.65-0.94) than the Northeast. Most U.S. adults, including three-fifths of current tobacco product users, oppose SLT use at all public sports venues. Complete tobacco-free policies for sports venues that prohibit all forms of tobacco product use can help reduce the social acceptability of SLT use.