Bachelor of Arts, Florida International University (1998)
Master of Public Health, Florida International University (2011)
Doctor of Philosophy, Florida International University (2014)
YOUTH USE OF DIFFERENT BRANDS OF POD-TYPE E-CIGARETTES POPULARIZED BY JUUL: HOW AND WHY THEY ARE USING
ELSEVIER SCIENCE INC. 2020: S32
View details for Web of Science ID 000506637300060
PMI's heated tobacco products marketing claims of reduced risk and reduced exposure may entice youth to try and continue using these products.
Philip Morris International (PMI) is seeking Food and Drug Administration's (FDA) authorisation to market IQOS as a modified risk tobacco product and to make marketing claims of reduced risk and reduced exposure. Such claims may be misunderstood by youth, thereby increasing their risk for tobacco initiation.To assess youth (mean age 19.3, SD=1.7) understanding and perceptions of PMI's proposed consumer marketing claims of reduced risk and reduced exposure, we embedded a randomised controlled experiment into a survey of 450 California youth (April to August 2018). Participants were randomised to see 'reduced exposure', 'reduced risk' or neither claim. Perceptions of IQOS-related health risks and general harm and understanding of the term 'switching completely' as used in PMI's proposed claims were compared.Mean expectancies to experience specific health risks did not differ by claim exposure. The reduced exposure group's perceptions of general harm did not differ from those of controls nor from the reduced risk group. The reduced risk group had the largest proportion who perceived IQOS as moderately/less harmful (n=78, 52%); controls the largest proportion perceiving IQOS as quite/extremely harmful (n=91, 63%). While 71% of the sample understood the term 'switch completely' correctly as used in the reduced risk (n=194, 71%) and reduced exposure (n=206, 72%) claims, more than 1 in 4 did not.FDA and other regulators must use caution when considering allowing claims of reduced risk or reduced exposure to appear on retail tobacco packaging. Youth misunderstand such claims, and misperceptions of harm are known to lead to tobacco-use initiation.
View details for DOI 10.1136/tobaccocontrol-2019-055318
View details for PubMedID 32029537
How and Why California Young Adults Are Using Different Brands of Pod-Type Electronic Cigarettes in 2019: Implications for Researchers and Regulators.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
The aim of the study was to describe young adult use and perceptions of different brands of pod-based electronic cigarettes (e-cigarettes) and compare with earlier types of non-pod-based e-cigarettes (e.g., mods and tanks).Data were collected from January to March 2019 and derive from the final wave of a cohort study recruited in 2013-2014 using a convenience sample from 10 large California high schools with racially/ethnically and socioeconomically diverse populations. A total of 445 participants completed an online survey (mean age = 20.1 years [SD = 1.66], 64.8% female [n = 278], 38.8% white [n = 161], 23.9% each for Asian and "more than one race" [n = 99], 13.5% other [n = 56], and 36.9% Hispanic [n = 160]). The main outcomes were description of and reasons to use pods, perceived nicotine content, and use patterns.Although <25% of participants reported smoking cigarettes and using non-pod-based e-cigarettes, >25% reported ever use of JUUL. Similarly, <33% of cigarette smokers and non-pod-based e-cigarette users reported use in the past 30 days, and >50% of JUUL ever users did. The most agreed upon reason (58%) for using pods was because they are "easy to hide." About half of pod users "do not know" if they mix brands of e-juice and pods, the nicotine concentration in their e-juice cartridges, nor time to finish a cartridge. Of the 50% of participants who shared their pod, 23 (15%) did "sometimes," 20 (13%) "always," and 16 (11% each) "about half the time" or "often." There was no consensus about how to refer to different brands of pods.Our findings indicate young adults harbor confusion about pod-based e-cigarettes, including nicotine content, usage patterns, and labeling, and that pod use is largely because of the ease with which they can "stealth" vape. The findings suggest needed regulation and education about these products.
View details for DOI 10.1016/j.jadohealth.2020.01.017
View details for PubMedID 32192827
Measuring waterpipe tobacco smoking in survey research.
Waterpipe tobacco (WT) smoking remains a significant public health problem. However, few validated measures exist, presenting challenges for obtaining accurate prevalence estimates and making comparisons across studies. We identified items used to measure several WT smoking behaviours in eight US national surveys of youth and adults and two international studies, including the National Youth Tobacco Survey, National Adult Tobacco Survey, Population Assessment of Tobacco and Health Adult and Youth Surveys, Monitoring the Future, National Health Interview Survey, Health Styles, Tobacco Use Supplement: Current Population Survey, Global Adult Tobacco Survey and Global Youth Tobacco Survey. We also identified WT survey items across the first 14 Food and Drug Administration-funded Tobacco Centers of Regulatory Science. Constructs included product description and terminology, ever and current use, quantity and frequency, use of flavours and reasons for use. There was little consistency in WT measurement, highlighting the need for validated measures.
View details for DOI 10.1136/tobaccocontrol-2019-055000
View details for PubMedID 31484801
Popular Flavors Used in Alternative Tobacco Products Among Young Adults.
The Journal of adolescent health : official publication of the Society for Adolescent Medicine
2019; 65 (2): 306–8
PURPOSE: The aim of the article was to examine flavors of alternative tobacco products most commonly used by young adults (YAs).METHODS: California YA (N= 365; mean age= 20.0years) were surveyed in 2018 about the first and usual flavors of alternative tobacco products used. Flavor categories were fruit, candy, menthol, mint, coffee, spice, alcohol, wintergreen, and tobacco.RESULTS: Fruit and mint were the most common flavors used (pod-based e-cigarettes: 35.4% and 29.3%; other e-cigarettes: 52.7% and 23.1%; hookah: 45.4% and 18.5%; cigars/cigarillos: 22.4% and 6.9%, respectively). For other e-cigarettes and hookah, candy was also popular (20.5% and 14.8%, respectively). For pod-based and other e-cigarettes, menthol was widely used (13.4% and 17.0%, respectively). Approximately half of the ever-flavor users reported they "usually" used the same flavors across products (menthol users: 52.2%; fruit users: 51.7%; mint users: 44.0%; and candy users: 43.8%).CONCLUSIONS: YA are clearly using flavors, specifically fruit, mint, candy, and menthol, in their tobacco products.
View details for DOI 10.1016/j.jadohealth.2019.05.004
View details for PubMedID 31331543
A cigarette pack by any other color: Youth perceptions mostly align with tobacco industry-ascribed meanings.
Preventive medicine reports
2019; 14: 100830
Youth interpret cigarette pack-colors in line with industry-intended associations.Product-packaging restrictions may be circumvented by use of colors that misrepresent product harms.43.2% of participants attributed extra strong to the black cigarette pack.35.6% of participants ascribed rich to gold.31.1% of participants ascribed menthol to green.
View details for PubMedID 30815339
- WHAT ABOUT THE GOOD STUFF?: VALIDATION OF MEASUREMENT SCALES FOR ADOLESCENT TOBACCO AND MARIJUANA-RELATED PERCEPTIONS OF SPECIFIC RISKS AND BENEFITS ELSEVIER SCIENCE INC. 2019: S80
From tobacco-endgame strategizing to Red Queen's race: The case of non-combustible tobacco products.
View details for PubMedID 30642577
Heated tobacco products likely appeal to adolescents and young adults.
2018; 27 (Suppl 1): s41–s47
BACKGROUND: Beginning in the 1960s in the USA and globally since 1998, tobacco companies have beenaggressively promoting heated tobacco products (HTP). In 2016, Philip Morris International (PMI) applied to the US Food and Drug Administration (FDA) seeking authorisation to market their IQOS HTP system and flavoured 'HeatSticks' in the USA as a modified-risk tobacco product (MRTP).METHODS: We systematically evaluated the publicly available data PMI submitted to FDA in its MRTP application to determine whether PMI's IQOS product meets the US Tobacco Control Act's standard for MRTP claims. We examined whether PMI provided sufficient data showing tobacco users will not initiate with IQOS, that youth will not misperceive the MRTP-related claims being made concerning IQOS, and how youth perceive health risks associated with IQOS.RESULTS: PMI's own studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS and will not perceive these products as risk-free. Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.CONCLUSION: PMI's own data and available evidence from scientific studies conducted independent of the tobacco industry regarding how novel tobacco products are currently being marketed suggest that introduction of IQOS will result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.
View details for PubMedID 30352843
- Adolescents' and Young Adults' Use and Perceptions of Pod-Based Electronic Cigarettes JAMA NETWORK OPEN 2018; 1 (6)
Conversation Within a Facebook Smoking Cessation Intervention Trial For Young Adults (Tobacco Status Project): Qualitative Analysis.
JMIR formative research
2018; 2 (2): e11138
BACKGROUND: Smoking cessation interventions delivered through social media have the potential to engage young people in behavior change.OBJECTIVE: The aim of this study was to describe participant-posted messages in a Facebook smoking cessation intervention for young adults to discern support for behavior change.METHODS: We qualitatively analyzed data from the treatment arm of a randomized trial testing the efficacy of the Tobacco Status Project Facebook intervention. Young adults (N=138) aged 18-25 years (female: 81/138, 58.7%; white: 101/138, 73.2%; mean age 21 years) were recruited using Facebook and placed into one of the 15 secret Facebook groups based on readiness-to-quit smoking. Messages posted to groups for 90 consecutive days were tailored to readiness-to-quit: Not Ready (46/138, 33.3%), Thinking (66/138, 47.8%), and Getting Ready (26/138, 18.8%). Groups were randomized to receive up to US $90 for posting or no incentive. Two independent coders conducted open coding of user posts. We considered content by readiness-to-quit group and incentive condition.RESULTS: There were 4 dominant themes across all groups: coping skills, friends and family, motivation to quit, and benefits of quitting. The dominant themes in Not Ready groups were friends and family (incentive) and motivation to quit (no incentive), whereas coping skills was the dominant theme in Thinking and Getting Ready groups. The expression of themes varied by readiness-to-quit group but not by incentive condition.CONCLUSIONS: Intervention messages tailored to readiness-to-quit appear useful in eliciting the desired responses from young adult smokers, with limited influence by monetary incentive.TRIAL REGISTRATION: ClinicalTrials.gov NCT02207036;https://clinicaltrials.gov/ct2/show/NCT02207036(Archived by WebCite athttp://www.webcitation.org/722XAEAAz).
View details for PubMedID 30684432
IQOS labelling will mislead consumers.
BACKGROUND: Philip Morris International (PMI) continually expands and diversifies their nicotine product portfolio, which includes IQOS, a heated tobacco product. In December 2016, PMI filed a modified risk tobacco product (MRTP) application with the US Food and Drug Administration (FDA), seeking authorisation to market IQOS in USA with three claims of reduced harm: 'switching completely from conventional cigarettes to the IQOS system' (1) 'can reduce the risks of tobacco-related diseases;' (2) 'significantly reduce[s] your body's exposure to harmful or potentially harmful chemicals;' and (3) 'presents less risk of harm than continuing to smoke cigarettes.' Consumers may misunderstand what is meant by 'switching completely'.METHODS: We critically reviewed study reports submitted to FDA by PMI in support of proposed marketing claims in its MRTP application for IQOS and focused on the statement that switching completely to IQOS reduces risk.RESULTS: We found deficiencies with evidence provided by PMI supporting their assertions that: current smokers will understand what is meant by the phrase 'switching completely'; the proposed claims will not decrease smokers' intentions to quit; and IQOS users will in fact 'switch completely' from smoking cigarettes to using IQOS. The studies and measurement instruments employed by PMI suffer from design flaws and their reporting of associated findings is misleading.CONCLUSION: Consumers will not understand the condition of the claims-that they must quit using cigarettes completely to achieve the inferred health benefits of IQOS. Rather, they are likely to misunderstand the unsupported claims of reduced risks to mean IQOS are harm-free.
View details for PubMedID 30158208
Youth say ads for flavored e-liquids are for them.
INTRODUCTION: E-cigarettes are the most popular tobacco product among adolescents and young adults ("AYA") and are available in many flavors. The e-cigarette industry argues that flavors are not meant to appeal to youth, yet no study has asked youth what age group they think ads for flavored e-liquids are targeting. We asked AYA which age group they thought ads for flavored e-liquids targeted.METHODS: In 2016 as part of a larger survey, a random sample of 255 youth from across California (62.4% female, mean age = 17.5, SD = 1.7) viewed eight ads, presented in randomized order, for fruit-, dessert-, alcohol-, and coffee-flavored e-liquids and indicated the age group they thought the ads targeted: younger, same age, a little older, or much older than them. Population means and 95% confidence intervals were estimated using bootstrapping (100,000 replicate samples).RESULTS: Most participants (93.7%) indicated the cupcake man flavor ad targeted an audience of people younger than they. Over half felt ads for smoothy (68.2%), cherry (63.9%), vanilla cupcake (58%), and caramel cappuccino (50.4%) targeted their age and for no flavor ad did most feel the primary target age group was much older.CONCLUSIONS: Youth believe ads for flavored e-liquids target individuals about their age, not older adults. Findings support the need to regulate flavored e-liquids and associated ads to reduce youth appeal, which ultimately could reduce youth use of e-cigarettes.
View details for PubMedID 30314868
YOUTH SAY FLAVORED E-CIGARETTE ADS ARE FOR THEM
ELSEVIER SCIENCE INC. 2018: S136–S137
View details for Web of Science ID 000422677600273
YOUTH-ASCRIBED CIGARETTE PACK COLOR MEANING: CORRECT PERCEPTIONS OF GREEN MENTHOL FLAVOR COLOR, YET CONFUSION OVER OTHER COLORS
ELSEVIER SCIENCE INC. 2018: S137
View details for Web of Science ID 000422677600274
Adolescents' and Young Adults' Use and Perceptions of Pod-Based Electronic Cigarettes.
JAMA network open
2018; 1 (6): e183535
Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among adolescents and young adults, and the new pod-based e-cigarette devices may put adolescents and young adults at increased risk for polytobacco use and nicotine dependence.To build an evidence base for perceptions of risk from and use of pod-based e-cigarettes among adolescents and young adults.In a survey study, a cross-sectional analysis was performed of data collected from April 6 to June 20, 2018, from 445 California adolescents and young adults as part of an ongoing prospective cohort study designed to measure the use and perceptions of tobacco products.Use of pod-based e-cigarettes, e-cigarettes, and cigarettes.Ever use, past 7-day use, and past 30-day use and co-use of pod-based e-cigarettes, e-cigarettes, and cigarettes; use of flavors and nicotine in pod-based e-cigarettes and e-cigarettes; and associated perceptions of risks, benefits, and nicotine dependence.Among 445 adolescents and young adults (280 females, 140 males, 6 transgender individuals, and 19 missing data; mean [SD] age, 19.3 [1.7] years) who completed wave 6 of the ongoing prospective cohort study, ever use information was provided by 437 respondents, of which 68 (15.6%) reported use of pod-based e-cigarettes, 133 (30.4%) reported use of e-cigarettes, and 106 (24.3%) reported use of cigarettes. The mean (SD) number of days that pod-based e-cigarettes were used in the past 7 days was 1.5 (2.4) and in the past 30 days was 6.7 (10.0). The mean (SD) number of days that other e-cigarettes were used in the past 7 days was 0.8 (1.8) and in the past 30 days was 3.2 (7.4). The mean (SD) number of days that cigarettes were used in the past 7 days was 0.7 (1.8) and in the past 30 days was 3.0 (7.6). Among ever users of pod-based e-cigarettes, 18 (26.5%) reported their first e-liquid was flavored menthol or mint and 19 (27.9%) reported fruit (vs 13 [9.8%] and 50 [37.6%] for other e-cigarettes). The mean perceived chance of experiencing social risks and short-term and long-term health risks from the use of either pod-based e-cigarettes or other e-cigarettes was 40% and did not differ statistically by e-cigarette type. Among 34 adolescents and young adults reporting any loss of autonomy from nicotine, there was no difference in mean (SD) Hooked On Nicotine Checklist scores between those using pod-based e-cigarettes (2.59 [3.14]) and other e-cigarettes (2.32 [2.55]).Use by adolescents and young adults of newer types of e-cigarettes such as pod-based systems is increasing rapidly, and adolescents and young adults report corresponding misperceptions and lack of knowledge about these products. Rapid innovation by e-cigarette manufacturers suggests that public health and prevention efforts appear to be needed to include messages targeting components common to all current and emerging e-cigarette products to increase knowledge and decrease misperceptions, with the goal to try to ultimately reduce e-cigarette use among adolescents and young adults.
View details for PubMedID 30646249
View details for PubMedCentralID PMC6324423
Adolescents have unfavorable opinions of adolescents who use e-cigarettes.
2018; 13 (11): e0206352
INTRODUCTION: While evidence suggests positive opinions of smokers are associated with tobacco use, research exploring adolescents' opinions of e-cigarette users is nascent. We hypothesized that adolescents harbor positive opinions of e-cigarette users, and that these opinions will be more positive among adolescents willing to try or who have used e-cigarettes.METHODS: Participants were 578 U.S. adolescents (ages 14 to 20) recruited from ten California schools. An online survey assessed their attitudes toward and opinions of adolescents who use e-cigarettes in 2015-2016. Analyses examined whether these variables were associated with willingness to try and use (ever vs. never) of e-cigarettes.RESULTS: The majority (61%) of participants had negative overall opinions toward adolescent e-cigarette users. Few participants ascribed positive traits (i.e., sexy, cool, clean, smart, and healthy) to e-cigarette users. Participants who were willing to try or had used e-cigarettes endorsed positive traits more than those unwilling to try and never-users (all p < .01). Participants sometimes endorsed negative traits (i.e., unattractive, trashy, immature, disgusting, and inconsiderate) to describe e-cigarette users. Unwilling and never-users viewed negative traits as more descriptive of e-cigarette users than willing or ever-users (all p < .01).CONCLUSIONS: Adolescents generally had somewhat negative opinions of other adolescents who use e-cigarettes. Building on adolescents' negativity toward adolescent e-cigarette users may be a productive direction for prevention efforts, and clinicians can play an important role by keeping apprised of the products their adolescent patients are using and providing information on health effects to support negative opinions or dissuade formation of more positive ones.
View details for PubMedID 30403731
Adolescent Cigarette Smoking Perceptions and Behavior: Tobacco Control Gains and Gaps Amidst the Rapidly Expanding Tobacco Products Market From 2001 to 2015.
journal of adolescent health
2017; 60 (2): 226-228
The aim of the study was to determine whether adolescents' intentions to smoke, cigarette smoking behavior, and specific perceptions of cigarette smoking are different in 2015 versus 2001.Data from two California school-based studies (Xage = 14) were compared: one conducted in 2001-2002 ("2001"), N = 395; the second in 2014-2015 ("2015"); N = 282.In 2015, more participants reported it was very unlikely they would smoke (94% vs. 65%) and that they never smoked (95% vs. 74%); they reported perceiving less likelihood of looking more mature (17% vs. 28%) and greater likelihood of getting into trouble (86% vs. 77%), having a heart attack (76% vs. 69%), and contracting lung cancer (85% vs. 78%) from smoking (p < .001). Perceptions of short-term health problems and addiction were similar in 2001 and 2015.Findings suggest that adolescents in 2015 perceived greater risks compared to those in 2001 even amidst the rapidly changing tobacco product landscape. In addition to continuing messages of long-term health risks, prevention efforts should include messages about addiction and short-term health and social risks.
View details for DOI 10.1016/j.jadohealth.2016.09.025
View details for PubMedID 27939880
View details for PubMedCentralID PMC5270372
Polydrug use among urban adolescent cigarette smokers
2017; 66: 145-150
View details for DOI 10.1016/j.addbeh.2016.11.017
Impact of quitting smoking and smoking cessation treatment on substance use outcomes: An updated and narrative review
2017; 65: 161-170
View details for DOI 10.1016/j.addbeh.2016.10.012
Implications and challenges for implementation of the FDA's final deeming rule for waterpipe tobacco
View details for DOI 10.1136/tobaccocontrol-2017-053634
- Sex and racial/ethnic differences in premature mortality due to HIV: Florida, 2000–2009 Public Health Reports 2015; 130 (5): 505-513
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- Determinants of waterpipe smoking initiation among school children in Irbid, Jordan: a 4-year longitudinal analysis Drug Alcohol Depend 2014; 142: 307-313
Determinants of cigarette smoking initiation in Jordanian schoolchildren: Longitudinal analysis
Nicotine Tob Res
2014; 17 (5): 552-558
View details for DOI 10.1093/ntr/ntu165
Time trends of cigarette and waterpipe smoking among a cohort of school children in Irbid, Jordan, 2008-11
Eur J Public Health
2013; 23 (5): 862-867
View details for DOI 10.1093/eurpub/ckt140