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Introduction Cardiovascular disease (CVD) is a critical public health issue, with tobacco smoking the leading preventable cause. Perceptions of CVD risk in specific populations may differ by tobacco use status, potentially necessitating customized tobacco prevention measures. Methods Using data from the Youth Appalachian Tobacco Study (n=1104), CVD risk perceptions were defined by responses to three statements: ‘smoking causes heart disease’, ‘smoking causes strokes’ and ‘smoking causes high blood pressure’. Tobacco use status was characterized as never users, ever cigarette users, and ever non-cigarette users. Sociodemographic differences in CVD risk perceptions and tobacco use status were evaluated. Logistic regression analyses, adjusted for gender, race/ethnicity, and household tobacco use, were conducted. Results Among the sample, 24.1% were ever cigarette users and 10.1% were ever non-cigarette users. Compared to never users, ever cigarette users had higher odds of disagreeing that smoking causes heart disease (AOR=1.83; 95% CI: 1.23–2.73), stroke (AOR=1.54; 95% CI: 1.08–2.18) and hypertension (AOR=1.41; 95% CI: 1.00–1.99). White youth (vs racial/ethnic minorities) had fewer odds of disagreeing that smoking causes hypertension (AOR=0.44; 95% CI: 0.29– 0.68), and females (vs males) had fewer odds of disagreeing that smoking causes heart disease (AOR=0.69; 95% CI: 0.48–0.99). Conclusions Among Appalachian youth, CVD risk perceptions differed by tobacco use status and sociodemographic groups, such as race/ethnicity and gender. Findings from this study may be helpful in development of tobacco prevention efforts, such as health messaging for Appalachian youth.

Exposure to greenness has been studied through objective measures of remote visualization of greenspace; however, the link to how individuals interpret spaces as green is missing. We examined the associations between three objective greenspace measures with perceptions of greenness. We used a subsample (n = 175; 2018–2019) from an environmental cardiovascular risk cohort to investigate perceptions of residential greenness. Participants completed a 17-item survey electronically. Objective measurements of greenness within 300 m buffer around participants home included normalized difference vegetation index (NDVI), tree canopy and leaf area index. Principal component analysis reduced the perceived greenspaces to three dimensions reflecting natural vegetation, tree cover and built greenspace such as parks. Our results suggest significant positive associations between NDVI, tree canopy and leaf area and perceived greenness reflecting playgrounds; also, associations between tree canopy and perceived greenness reflecting tree cover. These findings indicate that the most used objective greenness measure, NDVI, as well as tree canopy and leaf area may most align with perceptions of parks, whereas tree canopy alone captures individuals’ perceptions of tree cover. This highlights the need for research to understand the complexity of green metrics and careful interpretation of data based on the use of subjective or objective measures of greenness.

Workplace culture has been studied for impact on health risk; however, connections with robust biologic markers of health remain to be established. We examined associations between the work environment and urinary levels of catecholamines and their metabolites as biomarkers of sympathetic nervous system activity, indicative of stress. We recruited participants (n = 219; 2018–2019) from a cardiovascular risk cohort to investigate workplace culture, well-being, and stress. Participants completed seven questionnaires. Urine samples were used to measure catecholamines and their metabolites by LC/MS/MS. Pearson correlation and linear regression models were used after adjusting for demographics and creatinine. Participants reporting higher well-being had lower urinary levels of dopamine, serotonin, and 3-methoxytyramine. Participants reporting a more engaged and more positive workplace had lower levels of dopamine and 3-methoxytyramine. Reported workplace isolation was correlated with higher levels of dopamine and 3-methoxytyramine. Given correlations between catecholamines, we used 3-methoxytyramine for linear regression. In fully adjusted models, in environments with a more positive culture, levels of 3-methoxytyramine remained lower (β = −0.065 ± 0.025, p = 0.01) and indicated a positive association between workplace isolation and 3-methoxytyramine (β = 0.064 ± 0.030, p = 0.04). These findings are consistent with an important relationship between workplace environment and sympathetic nervous system activity.

The early months of the COVID-19 pandemic saw significant increases in symptoms of anxiety and depression, particularly among college students. However, research has not examined how internalizing symptoms in this population have changed as the pandemic has continued into its second year. Further, there has yet to be an examination of potential changes in transdiagnostic vulnerability factors. Therefore, the purpose of the current repeated cross-sectional study was to examine differences by term in undergraduates' symptoms of depression, anxiety, worry, social anxiety, and anxiety sensitivity in the Spring 2020 (

Introduction Youth are at risk for tobacco use, and previous research has pointed to increased vulnerabilities associated with sexual minority identity. For example, LGB youth have increased odds for using tobacco than their heterosexual peers, and bisexual youth have higher odds of smoking than other sexual identity groups. As new tobacco products proliferate and health risks from dual/poly use grow, increased understanding of tobacco use patterns by sexual minority youth is needed. Methods For 3117 youth, aged 13-18 years, who completed an online questionnaire in 2017 and identified their sexual orientation [minority (e.g. lesbian/gay, bisexual, or pansexual) vs majority (heterosexual)] and gender, we classified current tobacco use into four categories: e-cigarette only, other product only (such as cigarette, cigar, or smokeless tobacco; not an e-cigarette), dual/poly use, and no use. Analyses were conducted separately for male and female participants. Multinomial logistic regression was employed. Results Female sexual minority youth had nearly twofold odds of dual/ poly tobacco use (OR=1.95; 95% CI: 1.12-3.40), compared to their heterosexual counterparts. For male youth, sexual minority identification was not significantly associated with dual/poly use. No significant differences were found in sexual minority and heterosexual youth e-cigarette only or other tobacco only use groups. Tobacco use patterns also significantly differed by age, race, place of residence, and parental education level. Conclusions Study findings reveal greater odds of dual/poly tobacco use for female sexual minority youth. Tailored tobacco prevention and cessation programs or interventions are needed for sexual minority youth most at risk of tobacco use, especially multiple product use.

E-cigarette use among youth remains a public health concern. Although extant literature has examined the perceived harms of cigarette use and secondhand smoke, perceptions of harms associated with secondhand e-cigarette aerosol (SHA) are not well understood. Therefore, we used data from the 2020 U.S. National Youth Tobacco Survey (n = 13,292) in which participants indicated whether SHA caused no harm, little harm, some harm, or a lot of harm. We dichotomized SHA harm perceptions as harmless vs harmful. We included sociodemographics (i.e., age, sex, race/ethnicity, sexual orientation, urbanicity), e-cigarette use characteristics, and SHA exposure as covariates and estimated associations between SHA harm perceptions and each covariate using adjusted logistic regression. Most youth perceived SHA as harmful (87.9 %) compared to harmless (12.1 %). Older youth (vs younger youth) had higher odds of perceiving SHA as harmless, whereas male (vs female) youth had 49 % higher odds (95 % CI: 1.29-1.72) of perceiving SHA as harmless. As the number of days of e-cigarette use in the past 30 days increased (vs non-users), odds of perceiving SHA as harmless increased. Youth exposed to SHA (vs no exposure) in the past 30 days had 35 % higher odds of perceiving SHA as harmless (95 % CI: 1.16-1.57). To conclude, youth SHA harm perceptions varied overall and by sociodemographic characteristics, e-cigarette use, and SHA exposure. Educational campaigns to inform youth of the health risks associated with e-cigarettes and SHA are needed to reduce overall nicotine intake and disparities in nicotine exposure.

The majority of sewer systems in the United States and other countries, are operated by public utilities. In the absence of any regulation, public perception of monitoring wastewater for population health biomarkers is an important consideration for a public utility commission when allocating resources for this purpose. In August 2021, we conducted a survey as part of an ongoing COVID-19 community prevalence study in Louisville/Jefferson County, KY. The survey comprised of seven questions about awareness of and privacy concerns and was sent to 32,000 households randomly distributed within the county. A total of 1,220 sampled adults participated in the probability sample, and 981 were used in analysis. A total of 2,444 adults additionally responded in the convenience sample, and 1,751 were used in analysis. The samples were weighted to produce estimates representative of all adults in the county. Public awareness of tracking COVID-19 virus in the sewers was low. Opinions about how data from this activity are shared strongly supported public disclosure of monitoring results. Responses showed more support for measuring the largest areas (>30,000 to 50,000 households) typically representing population levels found in a community or regional wastewater treatment plant. Those who had a history of COVID-19 infection were more likely to support highly localized monitoring. Understanding wastewater surveillance strategies and thresholds of privacy concerns requires in-depth, comprehensive analysis of public opinion for continued success and efficacy of public health monitoring.Graphic for Table of Contents (TOC)/Abstract Art

Introduction Sleep deficiency is associated with health risks, and time outdoors is related to health benefits. This study assessed time outdoors and its association with sleep normality. Methods As part of a health study in Louisville, Kentucky, 735 participants completed questionnaires on their health status, behaviors, neighborhoods, and demographics in 2018–2019. The measures included information on sleep, time outdoors, and mental and physical health. Participant characteristics were assessed by dichotomized sleep normality (N=728), and logistic regression (N=709) examined potential associations between time outdoors and sleep. Results As time spent outdoors increased from ≤4 hours to >4 – ≤8 hours (OR=1.04; 95% CI: 0.65–1.64) and >8 – ≤12 hours (OR=1.17; 95% CI: 0.63–2.17), odds of normal sleep increased; however, those who spent >12 – ≤16 hours (OR=0.63; 95% CI: 0.31–1.27) or >16 hours (OR=0.83; 95% CI: 0.45–1.53) outdoors had a lower likelihood of normal sleep. No associations between time outdoors and sleep were significant. There was a significant trend of less bodily pain associated with normal sleep (p

Introduction E-cigarettes are the most popular tobacco product among youth. Although harm perceptions have been linked to youth e-cigarette use, little research focuses on vulnerable populations, such as Appalachian youth. This study examines associations between e-cigarette harm perceptions and tobacco use among a sample of Appalachian youth. Methods Using data from the 2014–2016 Youth Appalachian Tobacco Study (n=1074), distributions of six e-cigarette harm perceptions by tobacco use (never, ever non-e-cigarette, ever e-cigarette) were examined, and multivariable multinomial logistic regression was used. Results Nearly one-fourth (23.4%) of the sample were ever e-cigarette users. More e-cigarette users were male (53.4%) and in high school (57.0%). Fewer e-cigarette users strongly agreed that e-cigarettes cause health problems (15.1%), breathing problems (20.3%), and oral health problems (18.7%) and that e-cigarettes are addictive (25.1%), compared to never and non-e-cigarette users. More e-cigarette users strongly agreed (32.3%) that e-cigarettes are healthier alternatives to cigarettes compared to never (24.1%) and non-e-cigarette (25.7%) users. Regression models indicate that e-cigarette users had greater odds of strongly disagreeing with e-cigarettes being harmful or addictive, compared to never users. E-cigarette users had approximately six-fold odds of strongly disagreeing with e-cigarettes causing health problems (OR=6.12; 95% CI: 3.16–11.90) and two times greater odds of disagreeing with e-cigarettes being addictive (OR=2.09; 95% CI: 1.07–4.08) compared to never users. Conclusions Appalachian youth ever e-cigarette users perceive e-cigarettes as less harmful and less addictive compared to never users. Better informing youth, especially youth tobacco users, of the harms associated with e-cigarettes is vital.

Introduction Use of electronic nicotine delivery systems (ENDS) has increased markedly. We examined how current ENDS users differ in perceptions of tobacco and ENDS-related health risks as a function of cigarette smoking status. Methods We classified 1329 current ENDS users completing a national online survey based on cigarette smoking status, and employed linear and logistic regression to assess group differences in perceptions of tobacco-related health risks. Results The sample consisted of 38% Current Cigarette Smokers, 40% Former Cigarette Smokers, and 22% Non-Smokers. Our targeted recruitment strategy yielded a balance of key descriptive variables across participants. Significant differences were observed in race, employment and marital status across cigarette smoking status, but not in gender, education, income, or sexual orientation. Participants reported considerable perceived knowledge about health risks associated with tobacco use, but less regarding ENDS use. Current Smokers rated ENDS use as riskier than Non-Smokers, and considered cigarette use less risky for both users and bystanders. Current Smokers were more likely to perceive cardiovascular diseases, diabetes and cancer as the health risks associated with ENDS use. Former Smokers were more likely to perceive such risks with traditional tobacco use. Further, regardless of smoking status, perceived knowledge about the health risks of tobacco or ENDS use was positively associated with perceived likelihood of high risks of cardiovascular diseases and cancer. Conclusions Among current ENDS users, there were significant differences in perceived health risks based on cigarette smoking history. Improved health messaging can be achieved when cigarette smoking status is taken into account.

E-cigarettes are commonly used tobacco products among youth populations, including Appalachian youth. However, knowledge of the extent to which tobacco use status relates to temptation to try e-cigarettes is limited. Data from the Youth Appalachian Tobacco Study (n = 1047) were used. Temptation to try e-cigarettes was derived from a 12-item situational inventory. Tobacco use status was defined as never, ever non-e-cigarette, and ever e-cigarette use. A factorial ANOVA was used to estimate the adjusted association between tobacco use status and the e-cigarette use temptation scale. Two-way interaction terms between tobacco use status and gender, and tobacco use status and race/ethnicity, were plotted to depict effect modification. Approximately 10% of youth were ever non-e-cigarette users and 24% were ever e-cigarette users. Never and ever non-e-cigarette user middle schoolers had higher temptation to try e-cigarettes than their high school counterparts. The same relationship was found among never and ever e-cigarette users living in households with tobacco users. The ANOVA results suggest a positive, monotonic relationship between tobacco use status and temptation to try e-cigarettes, and that the adjusted group means differ by gender and race/ethnicity. The findings can inform tobacco prevention interventions for youth at higher risk for e-cigarette use, especially youth who have not yet tried e-cigarettes.

Introduction Given that Appalachian youth tobacco use rates are higher than the US national average, it is important to understand whether sex differences shape associations between receiving and sharing product information and using tobacco. Methods Middle and high school students in rural Appalachia (n=1038) were surveyed about tobacco-related perceptions and behaviors, including ways youth receive and share conventional tobacco-related and e-cigarette-related information. Youth were characterized as tobacco users (i.e. ever or current users of cigarettes, smokeless tobacco, or e-cigarettes) or never users. Descriptive characteristics were compared by tobacco use and sex. Adjusted logistic regression models evaluated associations between communication channels and tobacco use. Models were stratified by sex to examine effect modification. Results Approximately one-third of Appalachian youth (33.8%) were tobacco users and use varied by sex (males: 54.4%; females: 45.6%). Male (OR=1.75; 95% CI: 1.18–2.60) and female (OR=2.30; 95% CI: 1.53–3.47) youth who received e-cigarette-related information through friends and family (FF) had higher odds of tobacco use. Additionally, females who received e-cigarette-related information through public displays and digital media had nearly two-fold increased odds of tobacco use. Although sharing conventional tobacco-related and e-cigarette-related information through FF was associated with increased odds of tobacco use among both sexes, these relationships were stronger among females. Conclusions Although specific communication channels were associated with tobacco use, associations involving receiving and sharing e-cigarette information were more pronounced in female tobacco users. Consideration of sex differences in how youth receive and share tobacco-related information may benefit tobacco prevention interventions.

Introduction Despite decreases in the overall US smoking rate, tobacco use remains more common in some areas and by some groups. Deeper understanding of group differences is needed in order to tailor public health campaigns to the interests, perceptions and experiences of targeted audiences. Although some differences have been identified across African American and Caucasian smokers in the United States, additional insight is needed regarding factors that differentiate these groups. This study examined tobacco-related perceptions and practices, with an emphasis on identifying differences across African American and Caucasian smokers. Toward this goal, we examined key demographic variables of race and age, and tobacco use characteristics. Methods The sample consisted of 284 people from the Jackson, Mississippi area who participated in focus groups and completed surveys addressing a variety of tobacco-related topics, including knowledge and perceptions of products as well as use and health information seeking behavior. The selection criteria and recruitment approach ensured a balance across race (black, white), age (18-34, >35 years), sex, and cigarette smoking status (current, former, never). Statistical analyses were performed using SAS (v.9.4). Results Differences were observed across demographic subgroups regarding type and pattern of tobacco products used (e.g. mentholated, markers of nicotine dependence, hookah). Differences in preferred sources of health information based on age as well as perceptions of risk as a function of age, smoking status and race were also noted. Exposure to secondhand smoke and perceptions of its risks, quitting efforts and cessation methods differed by race. Conclusions Study findings suggest key differences across important subgroups. Knowledge of such differences has the potential to improve strategic public health messaging, allowing health campaigns to more effectively prevent tobacco product uptake as well as promote interest in quitting tobacco.

Introduction: Comprehensive studies regarding clinical symptoms related to electronic nicotine delivery systems (ENDS) usage are sparse. Methods: The sample included 1,432 current ENDS users, ages 18-64, drawn from a national online survey conducted in 2016. A quota sampling method was used for key demographic characteristics such as age, gender, and race/ethnicity. ENDS use included types of devices, flavors, and knowledge of e-liquid used. Outcomes included any E-cigarette or Vaping use-Associated Lung Injury (EVALI)-like symptoms (e.g., cough, shortness of breath, nausea) and any clinical symptoms (see Table footnotes). Results: Of the sample, 50% were female, 23% non-Hispanic (NH) White, 23% NH Black, 54% Hispanic, 18% aged 18-24, 17% LGBTQ, 41% with Conclusions: ENDS use was significantly associated with the odds of having clinical symptoms, including EVALI-like symptoms.

Highlights • ENDS were the tobacco products most likely to be tried first. • Fruit was the favorite flavor, followed by menthol/mint/wintergreen. • Preference for flavor varied by age, sex and racial/ethnic background. • Those who preferred fruit flavor were twice as likely to have tried ENDS first. • Those who preferred menthol/mint/wintergreen were less likely to have tried ENDS first., Among youth who use electronic nicotine delivery systems (ENDS), e-cigarettes are often the first tobacco product tried. Flavor is a common reason for experimentation with e-cigarettes. This study assessed flavor preferences and the choice of ENDS as an initial product among youth by selected demographic characteristics. The analysis sample included 1549 participants who had ever tried ENDS, drawn from a national online survey of youth aged 13–18 in 2017. Fruit was the most common favorite flavor among ENDS users, followed by menthol/mint/wintergreen. Preference for flavor varied by age, sex and racial/ethnic background. ENDS were the tobacco products most likely to be tried first, particularly among participants under age 17. Those who preferred fruit flavor were twice as likely to have tried ENDS first, compared to those with other flavor preferences, while those who preferred menthol/mint/wintergreen flavor were half as likely to have tried ENDS first. Our findings support an association between flavor and ENDS use. Our research supports previous findings indicating that: 1) flavor is one of the primary reasons for experimentation with ENDS among youth; 2) fruit flavor is strongly associated with use of ENDS as the first tobacco product; and 3) preference of fruit flavor varies by age, sex and racial/ethnic background. These findings have relevance for developing targeted messages for specific youth audiences and implications for tobacco regulatory policies. In addition to January 2020 federal regulations, the authors recommend tighter restrictions, specifically that the marketing and sale of all e-cigarette flavors other than tobacco be eliminated.

Introduction Electronic nicotine delivery systems (ENDS) are a relatively new type of nicotine-containing product that has risen greatly in use within the past decade, displacing conventional tobacco products as the dominant source of nicotine exposure by many groups. Among those impacted are large sections of US youth. Though health outcomes associated with ENDS use are still being assessed, several potential harms have been noted in the extant literature. The purpose of this study is to examine which US youth subpopulations are at greatest risk for ENDS ever use and how perceptions pertaining to nicotine-containing products relate to this risk. Methods A nationwide online survey was administered to US youth ENDS users and non-users aged 13-18 years. A total weighted sample of 2501 participants was obtained. Statistical analyses included binomial logistic regression and a likelihood ratio test. Results Of these youth, 1346 (53.8%) reported having ever used an ENDS product. Those most likely to have used ENDS were White males in their late teens. Those who reported ever using a conventional tobacco product were much more likely to have reported ever using ENDS (AOR= 19.96; 95% CI: 15.30-26.05). A number of perceptions related to nicotine-containing products, including product safety and health effects, were significantly associated with an increased likelihood of ENDS use. Conclusions Certain sections of the US youth population have elevated odds of being ENDS ever users. As increasing evidence supports the need to combat ENDS use by youth, effectively targeted education and prevention campaigns will be necessary.

Introduction Youth tobacco use rates in Appalachia exceed the US national average, and e-cigarette use has increased. Thus, further research is needed to understand how these youth receive and share product information. Methods Middle and high school students in rural Appalachia were surveyed (N=1103). The primary outcome, tobacco use, was categorized as: never users, cigarette-only users, smokeless-only users, e-cigarette-only users, and polytobacco users. Associations between receiving or sharing conventional tobacco-related or e-cigarette-related information via specific communication channels and tobacco use were assessed. Results Participants who received tobacco information from friends and family (FF) (OR=1.87; 95% CI: 1.35-2.57), public displays (PUB) (OR=1.49; 95% CI: 1.09-2.05), and digital media (DIG) (OR=1.95; 95% CI: 1.41-2.70) and e-cigarette information via the same communication channels, FF (OR=2.65; 95% CI: 1.93-3.65), PUB (OR=1.62; 95% CI: 1.17-2.26), and DIG (OR=2.24; 95% CI: 1.61-3.12), had greater odds of being polytobacco users, compared to never users. Participants who received e-cigarette-related information from FF (OR=2.42; 95% CI: 1.42-4.13) and PUB (OR=2.13; 95% CI: 1.25-3.65) had greater odds of being e-cigarette-only users compared to never users. Participants who shared e-cigarette-related information with FF had greater odds of being e-cigarette-only users (OR=3.16; 95% CI: 1.80-5.58) and polytobacco users (OR=4.48; 95% CI: 3.16-6.35) compared to never users. Conclusions Receiving and sharing tobacco-related and e-cigarette-related information via multiple communication channels is associated with e-cigarette and polytobacco use among Appalachian youth. Several channels may need to be utilized in health campaigns to influence youth.

Introduction Prior research has shown that tobacco companies target point-of-sale (POS) marketing to low-income communities. This research assessed the association between demographic characteristics and venue type with purchasing tobacco products in response to marketing. Methods Using Population Assessment of Tobacco and Health (PATH) Study Wave 1 Adult data, this analysis compared promotion awareness and purchase influence among current smokers. Results Tobacco promotions were more likely to be noticed at convenience stores, gas stations, or tobacco stores than at other outlets. Smokers who bought their cigarettes at these outlets were more likely to purchase a brand other than their usual brand because of marketing. Smokers below the poverty level had greater odds than others to have noticed tobacco ads and to indicate purchase influence. Conclusions Point-of-sale marketing is effective in garnering the attention of low-income populations and influencing their tobacco purchases. Enforcing retailers' adherence to regulations is vital.

Although college students represent a growing demographic of e-cigarette users, it is unclear how knowledgeable they are about the product they use. The lack of such knowledge could result in unsafe practices and greater health risks. Therefore, the purpose of the current study was to examine college student e-cigarette users’ knowledge about e-cigarette ingredients and health risks, how often they modify their devices, and whether they utilize reputable sources when searching for information regarding e-cigarettes. The participants were 183 undergraduate e-cigarette users (Mage = 19.98, SD = 1.98; 71.6% female; 85.8% White). Most participants correctly recognized that e-cigarettes increase the risk of cardiovascular disease and lung disease, but fewer than half recognized the increased risk of seizures and depression. Only one-third to one-half of participants correctly identified the toxic compounds commonly found in e-cigarettes, and most indicated that they would consult Google or a friend with questions about e-cigarettes. College student e-cigarette users are well-informed about many health risks associated with e-cigarettes. However, they are relatively unaware of the harmful substances in e-cigarettes and are seeking information from less reliable sources. Targeted public health campaigns educating college students about e-cigarettes, including where to seek reliable information, are needed.

Purpose: The purpose of this study was to explore an association between e-cigarette use and Quality of Life (QOL) among college students. Methods: During February 2016, 1,132 students completed an online survey that included measures of tobacco use and the WHOQOL-BREF instrument. Differences were tested using Chi-square, Fisher’s exact test, and ANOVA, and regression was used to assess possible relationships. Results: E-cigarettes were used by 6.97% of the participants, either solo or along with traditional cigarettes. Bivariate analyses suggest that male college students are more likely than females to use e-cigarettes, either solo or in combination with traditional cigarettes (χ2 =19.4, P < .01). Lesbian, gay, and bisexual students are more likely than heterosexual students to use traditional cigarettes, either solo or in combination with e-cigarettes (χ2 = 32.9, P < .01). Multivariate models suggest that for every 10-unit increase in overall QOL, psychological well-being, social relations or environmental health the adjusted odds of being a sole cigarette user were significantly lower (all, P < .01), respectively. For every 10-unit increase in psychological well-being the adjusted odds of being a dual user was significantly lower (OR = .83, P = .026). Conclusions: Findings indicate that lower quality of life appears to be connected to tobacco use.

There is little research examining the social patterning of electronic nicotine delivery system (ENDS) use. This study investigated the association between socioeconomic status (SES) (education, income, and employment status) and current and former ENDS use. Data were collected from 2561 participants from the American Heart Association Tobacco Regulatory and Addiction Center (A-TRAC) online survey. Participants were 18–64 years old and reported demographic, SES, and ENDS use. Poisson regression was used to estimate prevalence ratios (PR 95% confidence interval-CI) of participants’ current and former (vs. never) ENDS use. Models were adjusted for age, sex, sexual orientation, race/ethnicity, marital status, and reasons for ENDS use. In the unadjusted analysis, ENDS use was primarily patterned by education and employment status. College educated persons (versus those with less than a high school diploma) had a 37% greater prevalence of current ENDS use (PR 1.37, 95% CI 1.20–1.55), and a 16% greater prevalence of former ENDS use (PR 1.16, 95% CI 1.06–1.28) in the fully-adjusted model. Persons with household incomes above $90K (versus less than $20,000) had a greater prevalence of current (PR 1.30, 95% CI 1.19–1.41) and former (PR 1.17, 95% CI 1.05–1.30) ENDS use. Those who were employed (versus not employed) had a 13% greater prevalence of current ENDS use (PR: 1.13, 95% CI 1.07–1.19) after full adjustment. Higher SES (versus lower SES) persons were more likely to use ENDS.

Highlights • Clinical symptoms were common in healthy/asymptomatic e-cigarette users. • Over 1/2 reported any clinical and nearly 1/3 reported any EVALI-like symptom. • Product modifications or use of flavored e-liquids increased likelihood of symptoms. • Altering ENDS products or using flavors may increase risk., Studies reporting clinical symptoms related to electronic nicotine delivery systems (ENDS) usage, especially types of devices and e-liquids, are sparse. The sample included 1,432 current ENDS users, ages 18–64, from a nationwide online survey conducted in 2016. ENDS use included device types, nicotine content, flavors, and e-liquid used. Outcomes included any e-cigarette, or vaping, product use-associated lung injury (EVALI)-like symptoms (e.g., cough, shortness of breath, nausea) as well as any clinical symptoms. Of the sample, 50% were female, 23% non-Hispanic (NH) White, 23% NH Black, 54% Hispanic, 18% aged 18–24, 17% LGBTQ, 41% with

Research about e-cigarette use is emerging and there is no clear evidence about the effectiveness of their use in smoking cessation. The purpose of this study was to explore the knowledge and attitudes of primary care nurse practitioners (NPs) toward e-cigarettes. A nonexperimental, descriptive study was conducted with primary care NPs (N = 93). Thirty-five percent of NPs believed that e-cigarettes were healthier than traditional cigarettes; 60% endorsed using them for cessation and 19% thought they were as effective as nicotine replacement therapies. Given NPs' varying opinions regarding the use of e-cigarettes, more education regarding evidence on e-cigarette health risks and limited cessation efficacy is necessary.

Background. The prevalence of e-cigarette use among youth is rising and may be associated with perceptions of health risks for these products. We examined how demographic factors and socioeconomic status (SES) are correlated with the perceived health risks of e-cigarette product contents among youth. Method. Data were from a national online survey of youth aged 13 to 18 between August and October 2017, weighted to be representative of the overall U.S. population in age, sex, race/ethnicity, and region. Survey analysis procedures were used. Results. Of 1,549 e-cigarette users and 1,451 never-e-cigarette users, 20.9% were Hispanic, 13.7% Black, 21.7% LGBTQ (lesbian/gay/bisexual/transgender/queer), and 49.3% in low-income families. With adjustment for e-cigarette use status, perceived health risks of nicotine and toxins/chemicals in e-cigarettes significantly differed by gender, race, sexual orientation, and SES ( ps < .05). For example, adjusted odds of perceiving harm from nicotine were 60% higher in girls versus boys, 34% lower in non-Hispanic Blacks versus non-Hispanic Whites, 33% lower in urban versus suburban residents, 40% higher in LGBTQ versus straight-identifying individuals, and 28% lower in low-income versus high-income families. Lower parental education level also was associated with children’s lower health risk perception of e-cigarette product contents. Conclusions. For youth, the perceived health risks of e-cigarette product contents were associated with demographics, sexual orientation, and SES. The findings may have relevance for developing communication and education strategies addressing specific youth audiences, especially those in vulnerable groups. These strategies could improve awareness among youth concerning the health risks of e-cigarettes, helping to prevent or reduce e-cigarette uptake and continued use.

Improving health equity as well as overall community health rests in large part on partnerships, especially those between researchers and community members and groups. Employing the theory of relational dialectics, we analyze relationships in an interdisciplinary research project examining how community health is influenced by increases in neighborhood greening. Relational dialectics posits that opposing tensions, such as desires not only to be connected but also to remain independent, shape relationships and are evidenced and negotiated through communication. We provide examples of dialectical tensions in a community-rooted research project and lessons that we have learned from this work.

Introduction Historically, lesbian, gay and bisexual (LGB) individuals have higher rates of cigarette smoking, often attributed to targeted tobacco advertising, exposure to stressors, and psychological distress. Elevated use of electronic nicotine delivery systems (ENDS) among LGB individuals has been documented recently. However, the LGB groups are not homogeneous and differences may exist between the use of tobacco by men and women within the LGB groups. The purpose of this research was to examine cigarette smoking, ENDS use and dual use (cigarettes plus ENDS) among LGB subgroups. Methods We classified 2087 participants completing a national online survey based on tobacco-use status (i.e. cigarette only, ENDS only, dual use) and sexual orientation. Multinomial logistic regression was employed to assess group differences. Results After adjusting for demographics and socioeconomic status, bisexual women were 1.85 times (95% CI: 1.19-2.87) more likely to report current dual use, in contrast to cigarette only use, compared to heterosexual women. No significant differences were found between lesbian and heterosexual women, or between gay or bisexual men and their heterosexual counterparts. Conclusions This study describes significantly greater dual use by bisexual women and is one of the first reports of elevated dual use in this group compared to heterosexual women. These findings suggest that targeted health messages may be needed to raise awareness of risk in specific LGB groups and that future research with these populations is necessary to better understand differences in tobacco perceptions and use.

Background: The prevalence of e-cigarette use among youth is on the rise and may be associated with adolescents’ limited knowledge of the health effects of these products. We examined how demographics and socioeconomic status (SES) are correlated with the perceived health risks of e-cigarettes among youth. Methods: Data from a national online survey of youth aged 13-18 in 2017, weighted to be representative of the overall U.S. population in age, sex, race, ethnicity, and region were analyzed. Differences in perceived health risks of nicotine and other chemicals provided by vaping were addressed with respect to the demographics and SES of the participants, taking into account their e-cigarette use status. Results: Among 3,174 participants, 56.5% were female, 19.3% Hispanics and 14.7% non-Hispanic Blacks. Indicators of low SES [family receiving public assistance (PA) or participating in free school lunch program] were seen in 50.2%. With adjustment for e-cigarette use status in multivariable regression models, perceived health risks from the contents of e-cigarettes differed by gender, age, place of residence, and SES status. For example, the odds of perceiving harm from nicotine in e-cigarette products was 1.6 times higher in girls than in boys; the same odds was lower by 27% for those in families receiving government PA compared to those in families that did not. A parent’s education level also significantly influenced their child’s perception of the harm of the contents of e-cigarette products ( see Figure ). Conclusions: For youth, the perceived health risks of nicotine, toxins or chemicals in e-cigarette products were significantly different by age, gender, race/ethnicity, and SES. The findings may have relevance for developing communications and education strategies targeting specific youth audiences, especially those in vulnerable groups. These strategies could improve awareness among youth concerning the health effects of e-cigarettes, helping to prevent or reduce e-cigarette use.

Vaping is popular among adolescents. Previous research has explored sources of information and influence on youth vaping, including marketing, ads, family, peers, social media, and the internet. This research endeavors to expand understanding of peer influence. Our hypothesis is that friends’ influence on teen vapers’ first electronic nicotine delivery systems (ENDS) use varies by demographic variables and awareness of ENDS advertising. In August–October 2017, youth (n = 3174) aged 13–18 completed an online survey to quantify ENDS behaviors and attitudes and were invited to participate in follow-up online research in November-December 2017 to probe qualitative context around perceptions and motivations (n = 76). This analysis focused on the ENDS users, defined as having ever tried any ENDS product, from the survey (n = 1549) and the follow-up research (n = 39). Among survey respondents, friends were the most common source of vapers’ first ENDS product (60%). Most survey respondents tried their first ENDS product while “hanging out with friends” (54%). Among follow-up research participants, the theme of socializing was also prominent. ENDS advertising and marketing through social media had a strong association with friend networks, in fact, the odds of friends as source of the first vaping experience were 2 times higher for those who had seen ENDS ads on social media compared with other types of media. The influence of friends is particularly evident among non-Hispanic Whites, Hispanics/Latinos, those living in urban areas, those living in high-income households, those with higher self-esteem, and those who experiment with vaping. These findings support the premise that peer influence is a primary social influencer and reinforcer for vaping. Being included in a popular activity appears to be a strong driving force.

Highlights • Over one-third had tried tobacco and over one-fifth had tried two or more products. • Most participants recognized harms associated with conventional tobacco use. • E-cigarettes were perceived as less harmful than conventional tobacco products. • Smokers and polytobacco users had lower odds of indicating tobacco health risks. • E-cigarette users were less likely to perceive e-cigarettes as harmful or addictive., Appalachian youth tobacco use rates exceed the national average. Additional inquiry is needed to better understand youth product perceptions and use patterns. This study examined tobacco harm perceptions and their relationship with tobacco use among Appalachian youth. From 2014 to 2016, a survey of Appalachian middle and high school students (N = 1,136) was conducted. Tobacco harm perceptions were assessed by tobacco use status, categorized as never user, cigarette only user, smokeless only user, e-cigarette only user, or polytobacco user. Descriptive characteristics were compared by tobacco use status and harm perceptions. Adjusted multivariable logistic regression models assessed the relationship between tobacco use status and harm perceptions. Over one-third of participants were tobacco users (34.6%; 4.7% cigarette only users, 3.3% smokeless only users, 5.6% e-cigarette only users, and 21.0% polytobacco users). Approximately half agreed that e-cigarettes cause health problems (54.4%), and 64.7% agreed that e-cigarettes are addictive. Most participants (83.4–92.3%) agreed that smoking and smokeless tobacco cause health problems and are addictive. Tobacco users more often disagreed that tobacco products cause health problems than did never users. Compared to never users, e-cigarette only users were more likely to disagree that smoking (AOR: 2.99, 95% CI: 1.30–6.90) and e-cigarettes cause health problems (AOR: 2.79, 95% CI: 1.64–4.75) and that e-cigarettes cause addiction (AOR: 2.48, 95% CI: 1.48–4.16). Most youth were aware of health dangers associated with smoking, but perceptions were split on whether e-cigarettes were associated with health problems or addiction. The findings indicate the need for additional youth tobacco use prevention efforts.

Introduction As e-cigarette use increases, questions about individual and public health effects remain unanswered (e.g. cessation tool, addiction path). Despite increasing use, few studies have focused on vape shop patrons. This study examined whether vape shop patrons believe their health is affected by the use of e-cigs; more specifically, the aim was to evaluate the association between e-cig use, change in tobacco use, and perception of health. Methods A survey of e-cig users (N=78) was conducted in vape shops. Questions included e-cig and traditional tobacco use, health perceptions, and demographics. Descriptive techniques were used to characterize participants as either those who perceived e-cig use improved their health or those who perceived their health unaffected. Logistic regression assessed the association between change in tobacco use, e-cig use, and perception of health effects. Results Most reported daily e-cig (91%) and current (11.5%) or former (78.2%) combustible cigarette use. Approximately, three-fourths (76.9%) perceived better health; the remainder (23.1%) perceived unaffected health. Change in cigarette use was significantly associated with perceptions that health is better with e-cig use. Participants who decreased cigarette use by 2-3 cartons/month and more than 3 cartons/month were significantly more likely to indicate that e-cig use has improved their health compared to those who decreased tobacco use by 1.5 cartons or fewer per month (OR=4.35, 95% CI: 1.13-16.9; OR=25.67, 95% CI: 2.97-221.7, respectively). Conclusions The majority of e-cig users perceived better health. Our findings suggest that health campaign designers should carefully assess the scientific uncertainty surrounding the use of these devices and consider means to clearly convey this information. Given the lack of scientific agreement on the health effects of e-cigs and the important role that perceptions play in behavior, health campaign designers, health education practitioners, policy makers, and health care providers should err on the side of caution when advising individuals about e-cig use.