Dynamic treatment regimes with interference

Background and AimsDispensing of prescription stimulants to adults has risen dramatically over the past decade. Examining trends in nonprescribed use of prescription stimulants can inform public health responses. Most studies in the United States (U.S.) have faced challenges in assessing trends over time due to changes in survey methodologies and variation in populations assessed. We examined data from the Population Assessment of Tobacco and Health (PATH) Study to assess changes in nonprescribed use of prescription stimulants in the U.S. from 2013 to 2022.DesignThe PATH Study is an ongoing longitudinal study of U.S. youth and adults, representative of the civilian noninstitutionalized population. Repeated cross‐sectional estimates at each wave were used (8 total waves). Trends from Wave (W) 1 (September 2013–December 2014) to W7 (January 2022–April 2023) were assessed. Full‐sample and replicate weights were used; joinpoint analyses and wave‐to‐wave comparisons were applied to test trends.SettingCivilian noninstitutionalized U.S. youth and adults.Participants/CasesYouth aged 12–17 and adults aged 18 + were assessed, with a total of 45 727 participants at wave 1 (Ns vary by wave).MeasurementsPast 12‐month (P12M) prevalence of nonprescribed use of Ritalin or Adderall was assessed. Nonprescribed use of stimulants was assessed across subgroups according to age (12–17, 18–24, 25–39, ≥40) and sex (male, female).FindingsWhile wave‐to‐wave comparisons showed fluctuations across certain waves, overall, there were no statistically significant changes in P12M prevalence of Ritalin or Adderall nonprescribed use (1.3% at W1 and 1.5% at W7) across the study period. However, statistically significant differences in trends existed across age groups. Among 12–17 year‐olds, nonprescribed use prevalence remained stable (1.4% in W1 and 1.5% in W7). Nonprescribed use prevalence also remained stable for 18–24‐year‐olds from W1 to W3, but then significantly declined (p = 0.016) from W3 (5.3%) to W7 (2.6%). There were no significant changes in nonprescribed use prevalence among 25–39‐year‐olds (1.7% in W1 and 2.4% in W7) and those aged ≥40 (0.3% in W1 and 0.9% in W7). Across most waves, young adults aged 18–24 had a statistically significantly higher prevalence of nonprescribed use. Neither sex had significant trends in P12M nonprescribed use prevalence.ConclusionsDespite an increase in dispensing of prescription stimulant medications in the United States, the prevalence of nonprescribed Ritalin or Adderall use does not appear to have increased, as assessed in the nationally representative Population Assessment of Tobacco and Health (PATH) Study. The prevalence of nonprescribed Ritalin or Adderall use among young adults aged 18–24, the age group with the highest nonprescribed use prevalence, declined 2013 to 2022.

1. United States Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, Food and Drug Administration, Center for Tobacco Products. Population Assessment of Tobacco and Health (PATH) Study [United States] Restricted-Use Files (ICPSR 36231). In: Population Assessment of Tobacco and Health (PATH) Study Series. Published June 3, 2019. Accessed December 1, 2019. doi:10.3886/ICPSR36231.v19 CrossRef Google Scholar

OBJECTIVES/GOALS: Wheezing has been shown to be associated with use of cigarettes, and more recently, electronic nicotine delivery systems (ENDS). This study assessed the association of poly use of tobacco products with wheezing among a national representative sample of US adult current tobacco users. METHODS/STUDY POPULATION: Data from the Population Assessment of Tobacco and Health (PATH) Study Wave 3 (W3) were used. Weighted prevalences of self-reported wheezing and related respiratory symptoms for non-users compared to users of cigarettes, ENDS, cigars, and any combination of these products (poly use of tobacco products) were presented for 28,082 adults. The cross-sectional association of tobacco use with self-reported wheezing and other related respiratory symptoms was assessed using weighted multivariable and ordinal logistic regression with consideration of complex sampling design. RESULTS/ANTICIPATED RESULTS: Most adults who reported on wheezing symptoms did not currently use cigarettes, ENDS or cigars (79%), 15% used cigarettes, 3% used a combination of cigarettes, ENDS and cigars, 1% used ENDS, and 1% used cigars. Significantly higher odds of ever had wheezing or whistling in chest at any time in the past was observed among current cigarette (adjusted OR: 2.62, 95%CI: 2.35, 2.91), ENDS (1.49, 95%CI: 1.14, 1.95), and poly users (2.67, 95%CI: 2.26, 3.16) compared to non-users. No differences were seen for cigar use. Polytobacco use was associated with a higher odds of ever wheezing when compared to ENDS (1.61, 95%CI: 1.19, 2.17) and cigar use (2.87, 95%CI: 1.93, 4.26), but not cigarettes. DISCUSSION/SIGNIFICANCE OF IMPACT: Wheezing is associated with the use of cigarettes, ENDS, or any combination of cigarette, ENDS and cigars likely due to the inhalation of noxious chemicals and gases found in the smoke of cigarettes and ENDS that are likely to increase the odds of experiencing wheezing. CONFLICT OF INTEREST DESCRIPTION: MLG serves as a paid consultant for Johnson & Johnson and has received research grant from Pfizer, manufacturers of smoking cessation medications. The other authors have no conflicts to declare.

This study examined the association between the current co-use of cannabis and cigarettes in the past 30 days and subsequent cigarette discontinuation (past 30-day point-prevalence abstinence) among U.S. adults with established cigarette use in the Population Assessment of Tobacco and Health (PATH) Study. Additionally, we investigated the impact of co-use on the subsequent discontinuation of all combustible tobacco products. A total of 26 381 observations contributed by 8218 adults with established cigarette use (ie, smoked ≥100 cigarettes in their lifetime, and currently smoking cigarettes every day or some days) from waves 1-5 of the PATH Study were included in the analysis. Weighted generalized estimating equations (GEE) models were used to evaluate the association between current co-use at baseline (waves 1-4) with the outcomes assessed at the subsequent wave (cigarette and combustible tobacco discontinuation at waves 2-5). Final models included: Demographic characteristics (age, sex, race and ethnicity, and educational attainment), behavior characteristics (intention to quit, internalizing symptoms, externalizing symptoms, and substance use problems), and wave-pair. Over one-third (35.91%) of the adults currently smoking cigarettes self-reported co-use during the study period. Cannabis use among adults with established cigarette use increased over time. Co-use was associated with decreased odds of cigarette smoking discontinuation at follow-up, after adjusting for covariates (aOR: 0.81; 95% CI: 0.72, 0.93; p = .0018). Similar effect sizes were observed for the discontinuation of all combustible tobacco products (aOR: 0.75; 95% CI: 0.65, 0.86; p < .0001). Cannabis use among adults with established cigarette use was inversely related to subsequent cigarette discontinuation, suggesting that co-use may reduce the likelihood of successful tobacco cessation. Findings demonstrate that cannabis use may lead to lower odds of discontinuation among adults with established cigarette use; therefore, individuals who co-use cigarettes and cannabis may need additional tobacco cessation support. Notably, this study observed an increase in the co-use of cigarettes and cannabis, emphasizing the need for researchers and public health programs to shift their focus toward understanding and addressing concurrent substance use among adults who smoke cigarettes.

Flavored combustible tobacco product initiation in two longitudinal youth cohorts in the US Population Assessment of Tobacco and Health Study: 2013–2016 and 2016–2019

Tobacco use is a well-established risk factor for multiple adverse oral conditions. Few nationally representative oral health data sets encompass the current diversity of tobacco and nicotine products. This investigation examines the validity of oral health measures in the Population Assessment of Tobacco and Health (PATH) Study to assess relationships between tobacco use and oral health. Cross-sectional data from PATH Study wave 4 (N = 33,643 US adults, collected 2016–2018) were used to obtain estimates for 6 self-reported oral conditions (e.g., bone loss around teeth, tooth extractions) and compared with analogous estimates from the National Health and Nutrition Examination Survey (NHANES) cycle 2017–2018 (N = 5,856). Within the PATH Study, associations were calculated between tobacco use status and lifetime and past 12-mo experience of adverse oral conditions using survey-weighted multivariable logistic regression. Nationally representative estimates of oral conditions between the PATH Study and NHANES were similar (e.g., ever-experience of bone loss around teeth: PATH Study 15.2%, 95% CI, 14.4%–15.9%; NHANES 16.6%, 95% CI, 14.9%–18.4%). In the PATH Study, combustible tobacco smoking was consistently associated with lifetime and past 12-mo experience of adverse oral health (e.g., exclusive cigarette smoking vs. never tobacco use, adjusted odds ratio [AOR] for loose teeth in past 12 mo: 2.02; 95% CI, 1.52–2.69). Exclusive smokeless tobacco use was associated with greater odds of loose teeth (AOR, 1.93; 95% CI, 1.15–3.26) and lifetime precancerous lesions (AOR, 3.85; 95% CI, 1.73–8.57). Use of other noncigarette products (e.g., pipes) was inconsistently associated with oral health outcomes. PATH Study oral health measures closely align with self-reported measures from NHANES and are internally concurrent. Observed associations with tobacco use and the ability to examine emerging tobacco products support application of PATH Study data in dental research, particularly to examine potential oral health effects of novel tobacco products and longitudinal changes in tobacco use behaviors.

A comparison of nicotine dependence among exclusive E-cigarette and cigarette users in the PATH study.

BackgroundPerceptions of cigar products' harmfulness and addictiveness in youth are associated with subsequent cigar product initiation, but their association on the age of initiation of cigar product use is unknown.MethodsThe association of perceptions of harmfulness and addictiveness at youth's first wave of PATH participation (waves 1 or 2 in years 2013–2015) on the age of initiation of (i) ever. (ii) past 30-day, and (iii) fairly regular use of any cigar products (cigarillos, filtered cigars, or traditional cigars) during the followed-up in PATH waves 2–4 (2014–2017) was estimated using weighted interval-censored Cox proportional hazards models. Also, the association of the interaction between perceptions of harmfulness and addictiveness and the age of initiation of any cigar use are reported. Hazard ratios (HR) and 95% confidence intervals (CI) are reported.ResultsAmong youth who had ever heard of cigar products, youth who perceived cigars to be “low-medium harmfulness and low-medium addictiveness” had 60% (HR: 1.60, 95%CI: 1.36–1.89) higher hazard risk to initiate ever cigar product use at an earlier age, and had 46% (HR:1.46, 95%CI: 1.14–1.86) higher hazard risk to initiate past 30-day cigar product use at younger ages than those who perceived cigars to be “high harmfulness and high addictiveness.” Moreover, youth who perceived cigars to be “low-medium harmfulness and high addictiveness” had 33% (HR: 1.33, 95%CI: 1.15–1.53) higher hazard risk to initiate ever cigar product use at younger ages than those who perceived cigars to be “high harmfulness and high addictiveness.” Youth who reported “high harmfulness and low-medium addictiveness” (HR: 0.24, 95% CI: 0.07–0.83) had 76% lower hazard risk to initiate fairly regular use of cigar products at younger ages compared to youth who reported “high harmfulness and high addictiveness.”ConclusionsPrevention and awareness campaigns should reinforce the unique potential for harm and addiction of cigar products to curb cigar product initiation among US youth.

Factors associated with past-year attempts to quit e-cigarettes among current users: Findings from the Population Assessment of Tobacco and Health Wave 4 (2017–2018)

Aims: Electronic Nicotine Delivery System (ENDS) use is increasing among US adults. While existing research has demonstrated higher cigarette smoking rates among people with mental health conditions, there is sparse information on the association between ENDS use and mental health such as internalizing and externalizing problems. The aim of this study was to evaluate associations between internalizing and externalizing problems for cigarette only, ENDS only, and dual users, as well as changes in mental health among those groups. Method: We used the U.S. Population Assessment of Tobacco and Health (PATH) Study Wave 3 adult data. Internalizing and externalizing problems were self-reported and assessed via the Global Appraisal of Individual Needs-Short Screener; response options were dichotomized to reflect past 12 months and any lifetime problems. Self-reported changes in mental health over the past 12 months were also assessed. Participants’ tobacco use status was categorized as ENDS only use (n = 618), cigarette only use (n = 6,779), dual use (cigarettes and ENDS) (n = 681), and non-current use (n = 16,515). Results Lifetime and past 12 month internalizing problems were reported by 63.8% (n = 18,706) and 50.4% (n = 15,326), respectively, while lifetime and past 12 months externalizing problems were reported by 63.3% (n = 18,835) and 52.7% (n = 16,005), respectively. Six percent of participants reported worse mental health over the past 12 months. Compared to non-current use of any tobacco product, and adjusting for age, sex, race, education, and household income, those reporting ENDS use only had higher odds of ever (aOR = 1.52; 95%CI: 1.22–1.89) and past 12 months (aOR = 1.49; 95%CI: 1.22–1.84) internalizing, and externalizing problems (aOR = 1.32; 95%CI: 1.04–1.66 and aOR = 1.34; 95%CI: 1.07–1.67, respectively), and higher odds of reporting worse mental health over the past 12 months (aOR = 1.50; 95%CI: 1.05–2.12). Conclusion: Health care providers should be aware that internalizing and externalizing problems, and worsening mental health, are more common among adults who use ENDS, cigarettes, or both of these tobacco products.

Concurrent use of tobacco cigarettes and e-cigarettes ("dual use") is common among tobacco users. Little is known about differences in demographics and toxicant exposure among subsets of dual users. We analyzed data from adult dual users (current every/some day users of tobacco cigarettes and e-cigarettes, n = 792) included in the PATH Study Wave 1 (2013-2014) and provided urine samples. Samples were analyzed for biomarkers of exposure to nicotine and selected toxicants (tobacco-specific nitrosamine NNK [NNAL], lead, cadmium, naphthalene [2-naphthol], pyrene [1-hydroxypyrene], acrylonitrile [CYMA], acrolein [CEMA], and acrylamide [AAMA]). Subsets of dual users were compared on demographic, behavioral, and biomarker measures to exclusive cigarette smokers (n = 2411) and exclusive e-cigarette users (n = 247). Most dual users were predominant cigarette smokers (70%), followed by daily dual users (13%), non-daily concurrent dual users (10%), and predominant vapers (7%). Dual users who smoked daily showed significantly higher biomarker concentrations compared with those who did not smoke daily. Patterns of e-cigarette use had little effect on toxicant exposure. Dual users with high toxicant exposure were generally older, female, and smoked more cigarettes per day. Dual users who had low levels of biomarkers of exposure were generally younger, male, and smoked non-daily. In 2013-2014, most dual users smoked cigarettes daily and used e-cigarettes occasionally. Cigarette smoking appears to be the primary driver of toxicant exposure among dual users, with little-to-no effect of e-cigarette use on biomarker levels. Results reinforce the need for dual users to stop smoking tobacco cigarettes to reduce toxicant exposure. With considerable dual use of tobacco cigarettes and e-cigarettes in the United States, it is important to understand differences in toxicant exposure among subsets of dual users, and how these differences align with user demographics. Findings suggest most dual users smoke daily and use e-cigarettes intermittently. Low exposure to toxicants was most common among younger users, males, and intermittent smokers; high exposure to toxicants was most common among older users, females, and heavier cigarette smokers. Results underscore the heterogeneity occurring within dual users, and the need to quit smoking cigarettes completely in order to reduce toxicant exposure.

IntroductionThis study assessed the association of exclusive and concurrent use of cigarettes, electronic nicotine delivery systems (ENDS), and cigars with ever and past 12-month wheezing symptoms among a nationally representative sample of US adult current tobacco users.MethodsCross-sectional data from the Population Assessment of Tobacco and Health (PATH) Study Wave 3 (W3) were used. The weighted prevalence of self-reported ever and past 12-month wheezing symptoms for noncurrent users compared with users of cigarettes, ENDS, cigars, and any combination of these products (polytobacco use of these tobacco products) were presented for 28 082 adults. The cross-sectional association of tobacco use with self-reported wheezing symptoms was assessed using weighted multivariable and ordinal logistic regression with consideration of complex sampling design.ResultsSignificantly higher odds of ever had wheezing or whistling in the chest at any time in the past were observed among current cigarette (adjusted odds ratio: 2.62, 95% confidence intervals [CI]: 2.35, 2.91), ENDS (1.49, 95% CI: 1.14, 1.95), and polytobacco users (2.67, 95% CI: 2.26, 3.16) compared with noncurrent users. No associations were seen for cigar use. Polytobacco use was associated with a higher odds of ever wheezing when compared with exclusive ENDS (1.61, 95% CI: 1.19, 2.17) and exclusive cigar use (2.87, 95% CI: 1.93, 4.26), but not exclusive use of cigarettes.ConclusionsEver wheezing is associated with the use of cigarettes, ENDS, and polytobacco use of cigarettes, ENDS, and/or cigars, but not cigar use. The association of polytobacco use and wheezing appears to be driven by cigarette use.ImplicationsCross-sectional associations with ever and past 12-month wheezing symptoms were found to be the strongest among cigarette users, exclusively or in combination. Future longitudinal research is needed to better understand how cigarette use interacts with other tobacco and nicotine products and contributes to respiratory symptoms.

Cigarette marketing contributes to initiation of cigarette smoking among young people, which has led to restrictions on use of cigarette advertising. However, little is known about other tobacco advertising and progression to tobacco use in youth and young adults. To investigate whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking. The Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10 989). Household interviews using audio computer-assisted self-interviews were conducted. Advertising for conventional cigarettes, electronic cigarettes (e-cigarettes), cigars, and smokeless tobacco products at wave 1. Progression to susceptibility or ever tobacco use at 1-year follow-up in wave 2. Of the 10 989 participants (5410 male [weighted percentage, 48.3%]; 5579 female [weighted percentage, 51.7%]), receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years (44.0%; 95% confidence limit [CL], 42.6%-45.4%) but highest for those aged 18 to 21 years (68.7%; 95% CL, 64.9%-72.2%). e-Cigarette advertising had the highest receptivity among all age groups. For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products. Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2 (conventional cigarettes: adjusted odds ratio [AOR], 1.43; 95% CL, 1.23-1.65; e-cigarettes: AOR, 1.62; 95% CL, 1.41-1.85; cigars: AOR, 2.01; 95% CL, 1.62-2.49; and smokeless [males only]: AOR, 1.42; 95% CL, 1.07-1.89) and with use of the product (conventional cigarettes: AOR, 1.54; 95% CL, 1.03-2.32; e-cigarettes: AOR, 1.45; 95% CL, 1.19-1.75; cigars: AOR, 2.07; 95% CL, 1.26-3.40). Compared with those not receptive to any product advertising, receptivity to e-cigarette advertising, but not to cigarette advertising, was independently associated with those aged 12 to 21 years having used a cigarette at wave 2 (AOR, 1.60; 95% CL, 1.08-2.38). Receptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.

Introduction Flavored tobacco restrictions provide an opportunity to reduce tobacco product initiation. However, this policy raises concerns about the decrease in cessation of combustible tobacco due to decreased transition to e-cigarettes. Methods We developed a Markov model using transition rates between inhaled tobacco product use states derived from the Population Assessment of Tobacco and Health (PATH) study to assess how a flavored tobacco restriction may impact current users and those at risk of starting tobacco products. This quasi-experimental cohort study assesses the potential impact of flavored restrictions on primary and secondary prevention strategies, providing a cohort and population assessment of flavored tobacco restrictions. Results The model predicts that for every million adolescents at risk of starting tobacco, a restrictive flavor policy will have 121,000 fewer people ever using tobacco, with a decrease in every use state. After 10 years of policy for every million people over 21 years old, the model predicts 25,200 fewer tobacco product users and 19,200 fewer combustible tobacco users. Discussion We demonstrated that a flavored tobacco restriction would see a short-term increase in combustible use from a substitution effect, before seeing a long-term downward trend in all tobacco product use is largely driven by a reduction in initiation among the youth cohort. Current users would see little to no long-term change in combustible use rates compared to a permissive flavor policy. Conclusion These findings support a restrictive flavor policy by showing that current combustible users face minimal to no harm, with significant improvements in tobacco use rates across the population leading to improved community health.

Research Article| May 01 2021 E-Cigarette and Other Tobacco Product Use Effect on Later Smoking AAP Grand Rounds (2021) 45 (5): 56. https://doi.org/10.1542/gr.45-5-56 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation E-Cigarette and Other Tobacco Product Use Effect on Later Smoking. AAP Grand Rounds May 2021; 45 (5): 56. https://doi.org/10.1542/gr.45-5-56 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search nav search search input Search input auto suggest search filter All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: electronic cigarettes, smoking, tobacco Source: Pierce JP, Chen R, Leas EC, et al. Use of e-cigarettes and other tobacco products and progression to daily cigarette smoking. Pediatrics. 2021;147(2):e2020025122; doi: https://doi.org/10.1542/peds.2020-025122Google Scholar Investigators from the University of California San Diego, La Jolla, CA, reviewed data from the US Population Assessment of Tobacco and Health (PATH) Study to identify predictors of becoming a daily cigarette smoker within a 4-year period among youths and young adults. The PATH Study is a longitudinal survey of individuals identified using a probability sampling methodology, so that nationally representative estimates can be derived. For the current study, investigators identified a cohort of individuals, 12-24 years old, who completed their first survey in 2013–2014, and responded to all subsequent annual surveys. On the initial survey, in addition to demographic information, participants were asked about any use, age of... You do not currently have access to this content.