RESEARCH PAPER
 
KEYWORDS
TOPICS
ABSTRACT
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.

ACKNOWLEDGEMENTS
We thank Clara Sears, Alex Lee, Allison Siu, and Courteney Smith for help with questionnaire distribution and Shesh Rai for analysis assistance. We also thank the University of Louisville's research computing group and the Cardinal Research Cluster, whose resources aided in facets of this work.
CONFLICTS OF INTEREST
The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. J. L. Hart and K. Walker report grants from the National Institutes of Health during the conduct of the study.
FUNDING
Research reported in this publication was supported, in part, by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) and FDA Center for Tobacco Products under Award Numbers P50HL120163 and U54HL120163. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH, the Food and Drug Administration, or the American Heart Association. The funding sponsors had no role in study design; data collection, analyses, or interpretation; manuscript preparation; or the decision to publish the results.
PROVENANCE AND PEER REVIEW
Not commissioned; externally peer reviewed.
 
REFERENCES (31)
1.
U.S. Department of Health and Human Services. The Health Consequences of Smoking: 50 Years of Progress. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. https://www.ncbi.nlm.nih.gov/b.... Accessed July 7, 2020.
 
2.
U.S. Department of Health and Human Services. E-Cigarette Use Among Youth and Young Adults. A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2016. https://www.ncbi.nlm.nih.gov/b.... Accessed July 7, 2020.
 
3.
Wang TW, Gentzke AS, Creamer MR, et al. Tobacco product use and associated factors among middle and high school students - United States, 2019. MMWR Surveill Summ. 2019;68(12):1-22. doi:10.15585/mmwr.ss6812a1
 
4.
Chaffee BW, Watkins SL, Glantz SA. Electronic cigarette use and progression from experimentation to established smoking. Pediatrics. 2018;141(4):e20173594. doi:10.1542/peds.2017-3594
 
5.
Berry KM, Fetterman JL, Benjamin EJ, et al. Association of electronic cigarette use with subsequent initiation of tobacco cigarettes in US youths. JAMA Netw Open. 2019;2(2):e187794. doi:10.1001/jamanetworkopen.2018.7794
 
6.
Bold KW, Kong G, Camenga DR, Simon P, Cavallo DA, Morean ME, Krishnan-Sarin S. Trajectories of e-cigarette and conventional cigarette use among youth. Pediatrics. 2018;141(1):e20171832. doi:10.1542/peds.2017-1832
 
7.
National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018. doi:10.17226/24952
 
8.
Soneji S, Barrington-Trimis JL, Wills TA, et al. Association between initial use of e-cigarettes and subsequent cigarette smoking among adolescents and young adults: A systematic review and meta-analysis. JAMA Pediatr. 2017;171(8):788-797. doi:10.1001/jamapediatrics.2017.1488
 
9.
Johnston LD, Miech RA, O’Malley PM, Bachman JG, Schulenberg JE, Patrick ME. Monitoring the Future national survey results on drug use 1975-2018: Overview, key findings on adolescent drug use. Ann Arbor: Institute for Social Research, University of Michigan; 2019. doi:10.3998/2027.42/150621
 
10.
Marynak K, Gentzke A, Wang TW, Neff L, King BA. Exposure to electronic cigarette advertising among middle and high school students - United States, 2014-2016. MMWR Morb Mortal Wkly Rep. 2018;67(10):294-299. doi:10.15585/mmwr.mm6710a3
 
11.
Park E, Kwon M, Gaughan MR, Livingston JA, Chang YP. Listening to adolescents: Their perceptions and information sources about e-cigarettes. J Pediatr Nurs. 2019;48:82-91. doi:10.1016/j.pedn.2019.07.010
 
12.
Freeman B. New media and tobacco control. Tob Control. 2012;21(2):139-144. doi:10.1136/tobaccocontrol-2011-050193
 
13.
DiFranza JR, Wellman RJ, Sargent JD, et al. Tobacco promotion and the initiation of tobacco use: Assessing the evidence for causality. Pediatrics. 2006;117(6):e1237-1248. doi:10.1542/peds.2005-1817
 
14.
Mantey DS, Cooper MR, Clendennen SL, Pasch KE, Perry CL. E-cigarette marketing exposure is associated with e-cigarette use among US youth. J Adolesc Health. 2016;58(6):686-690. doi:10.1016/j.jadohealth.2016.03.003
 
15.
Unger JB, Urman R, Cruz TB, et al. Talking about tobacco on Twitter is associated with tobacco product use. Prev Med. 2018;114:54-56. doi:10.1016/j.ypmed.2018.06.006
 
16.
Chu KH, Unger JB, Cruz TB, Soto DW. Electronic cigarettes on Twitter - spreading the appeal of flavors. Tob Regul Sci. 2015;1(1):36-41. doi:10.18001/TRS.1.1.4
 
17.
Hebert ET, Case KR, Kelder SH, Delk J, Perry CL, Harrell MB. Exposure and engagement with tobacco- and e-cigarette-related social media. J Adolesc Health. 2017;61(3):371-377. doi:10.1016/j.jadohealth.2017.04.003
 
18.
Tsai J, Walton K, Coleman BN, et al. Reasons for electronic cigarette use among middle and high school students - National Youth Tobacco Survey, United States, 2016. MMWR Morb Mortal Wkly Rep. 2018;67(6):196-200. doi:10.15585/mmwr.mm6706a5
 
19.
Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: Tobacco product use among middle and high school students - United States, 2011-2018. MMWR Morb Mortal Wkly Rep. 2019;68(6):157-164. doi:10.15585/mmwr.mm6806e1
 
20.
Altman DG, Levine DW, Coeytaux R, Slade J, Jaffe R. Tobacco promotion and susceptibility to tobacco use among adolescents aged 12 through 17 years in a nationally representative sample. Am J Public Health. 1996;86(11):1590-1593. doi:10.2105/ajph.86.11.1590
 
21.
Appalachian Regional Commission. Income and Poverty in Appalachia. In: The Appalachian Region: A data overview from the 2013-2017 American Community Survey. https://www.arc.gov/noindex/re.... Accessed February 28, 2020.
 
22.
Hart JL, Walker KL, Sears CG, et al. The 'state' of tobacco: Perceptions of tobacco among Appalachian youth in Kentucky. Tob Prev Cessat. 2018;4(January):1-5. doi:10.18332/tpc/81857
 
23.
Owusu D, Mamudu HM, Robertson C, et al. Intention to try tobacco among middle school students in a predominantly rural environment of Central Appalachia. Subst Use Misuse. 2019;54(3):449-458. doi:10.1080/10826084.2018.1504080
 
24.
Casetta B, Videla AJ, Bardach A, et al. Association between cigarette smoking prevalence and income level: A systematic review and meta-analysis. Nicotine Tob Res. 2017;19(12):1401-1407. doi:10.1093/ntr/ntw266
 
25.
Centers for Disease Control and Prevention. Map of Current Cigarette Use Among Youth. In: State Tobacco Activities Tracking and Evaluation (STATE) System, 2017. https://www.cdc.gov/statesyste.... Accessed January 31, 2020.
 
26.
Farrelly MC, Niederdeppe J, Yarsevich J. Youth tobacco prevention mass media campaigns: Past, present, and future directions. Tob Control. 2003;12(Suppl 1):i35-47. doi:10.1136/tc.12.suppl_1.i35
 
27.
Lee RG, Taylor VA, McGetrick R. Toward reducing youth exposure to tobacco messages: Examining the breadth of brand and nonbrand communications. J Health Commun. 2004;9(5):461-479. doi:10.1080/10810730490504288
 
28.
Kruger TM, Howell BM, Haney A, Davis RE, Fields N, Schoenberg NE. Perceptions of smoking cessation programs in rural Appalachia. Am J Health Behav. 2012;36(3):373-384. doi:10.5993/AJHB.36.3.8
 
29.
Soneji S, Yang J, Knutzen KE, et al. Online tobacco marketing and subsequent tobacco use. Pediatrics. 2018;141(2):e20172927. doi:10.1542/peds.2017-2927
 
30.
Owusu D, Mamudu HM, Collins C, et al. The usage and associated factors of alternative tobacco products among school-going youth in Central Appalachia. J Health Care Poor Underserved. 2019;30(1):249-264. doi:10.1353/hpu.2019.0019
 
31.
Owusu D, Aibangbee J, Collins C, et al. The use of e-cigarettes among school-going adolescents in a predominantly rural environment of Central Appalachia. Journal Community Health. 2017;42(3):624–631. doi:10.1007/s10900-016-0297-0
 
ISSN:2654-1459