Background: Electronic cigarette (e-cigarette) use among adolescents is a growing public health concern, particularly in low-income and Black communities. However, little is known about how social determinants of health shape e-cigarette perceptions in this population. Aims: This study examined social determinants associated with perceptions of e-cigarette safety among Baltimore high school students. Methods: A cross-sectional survey (CEASE Youth: School Survey) was conducted with 604 Baltimore high school students aged 14–20. Participants completed a questionnaire assessing perceptions of e-cigarette safety, as well as parental education, race/ethnicity, parental employment, household composition, and community tobacco use. Results: Higher parental education was associated with lower perceived e-cigarette safety among students. Students in higher grades also reported lower perceived e-cigarette safety. In contrast, male students—particularly those in upper grades—were more likely to perceive e-cigarettes as safe. Race/ethnicity, household composition, parental employment, and community tobacco exposure were not associated with perceived e-cigarette safety. Conclusion: Higher parental education, female gender, and being in higher grades were associated with perceiving e-cigarettes as unsafe. These findings highlight the need for targeted interventions to address vaping perceptions among youth in urban settings.

Background: Tobacco control policies nationwide have contributed to a substantial decline in cigarette and tobacco use, with particularly sharp reductions observed in states such as California that have implemented restrictive bans, strong prevention measures, and high excise taxes. While these policies have led to overall decreases in tobacco use, progress has not necessarily been distributed equally across racial groups. Understanding long-term trends by race is critical for addressing equity gaps in tobacco prevention and control. Evidence suggests that some racialized groups may experience slower or delayed declines, raising concerns about equity in public health gains. Methods: We analyzed data from the California Health Interview Survey (CHIS) spanning 2003–2023. Trends in current smoking were examined separately for non-Latino Black and non-Latino White adults. We also assessed current use of flavored tobacco products, given California’s statewide ban enacted in 2021. Changes were evaluated in both absolute terms (percentage point declines) and relative terms (percent reduction from baseline). Results: Smoking prevalence declined from 17.2% in 2003 to 5.2% in 2023 among White adults and from 19.9% to 9.0% among Black adults. This represents a 12.0 percentage point (69.8%) decline for Whites compared with a 10.9 percentage point (54.8%) decline for Blacks. For flavored tobacco use, prevalence decreased from 8.0% to 4.7% among White adults but only from 11.9% to 10.8% among Black adults. This corresponds to a 3.3 percentage point (41.3%) decline for Whites compared with a 1.1 percentage point (9.2%) decline for Blacks. Conclusions: Although both Black and White adults in California experienced reductions in smoking over the past two decades, White adults showed larger declines in both absolute and relative terms. Disparities were even more pronounced for flavored tobacco use, where declines were minimal among Black adults despite the statewide ban. These findings suggest that Black populations in California may have been left behind by tobacco control progress, especially regarding flavored products. Given the history of targeted marketing by the tobacco industry, the role of flavors in increasing dependence, and reduced access to cessation resources in Black communities, targeted policies and culturally tailored interventions are needed to ensure equitable reductions in tobacco use. Greater attention to flavored tobacco in Black communities may help narrow these disparities and advance California’s tobacco endgame goals.

Background: Tobacco endgame, defined as elimination of commercial tobacco sales The U.S. tobacco control landscape is a complex, adaptive system shaped by diverse stakeholders, evolving products and regulations, shifting social norms, and the strategic countermeasures of a powerful industry. Managing such complexity requires more than isolated interventions—it demands a coordinated, enterprise-wide approach that accounts for dynamic interactions, feedback loops, and emergent risks. Objective: Drawing on complex systems thinking, Zachman enterprise architecture model, and public health best practices, we conceptualize tobacco control as an evolving enterprise progressing through six interconnected phases: (1) Conception & Initiation, (2) Policy & System Design, (3) Implementation & Operation, (4) Evaluation & Adaptation, (5) Consolidation & Endgame Transition, and (6) Sustainment or Sunset. Each phase incorporates governance structures, performance benchmarks, and transition criteria designed to manage interdependence and reduce systemic vulnerabilities. Results: The lifecycle framing emphasizes how tobacco control in the U.S. can evolve as a complex, adaptive enterprise—integrating public health objectives with legal, operational, and cultural change processes. This model supports strategic sequencing, cross-sector alignment, and risk mitigation against emergent industry tactics, enabling a resilient and measurable pathway to the endgame. Conclusions: Seeing tobacco control as a complex enterprise that operates under a lifecycle model may offer a roadmap for achieving and sustaining the tobacco endgame. Using this approach may enhance policy coherence, resource efficiency, and adaptability, ensuring tobacco endgame is achieved.

Background: Nicotine pouches, gummies, and candies have emerged as popular alternatives to traditional tobacco products among U.S. adolescents. While parental educational attainment is generally associated with youth substance use, marginalization-related diminished returns (MDRs) suggest that this effect may be weaker in marginalized populations, including non-Latino White communities. In particular, place-based marginalization—such as neighborhood economic disadvantage and school-level poverty—may attenuate the benefits of parental education. This study examines MDRs in the relationship between parental educational attainment and nicotine pouch/gummy/candy use among non-Latino White 12th graders in the 2024 Monitoring the Future (MTF) study. Methods: This study analyzed nationally representative data from the 2024 MTF study, focusing on non-Latino White 12th graders who reported parental education levels and adolescents’ use of nicotine pouch/gummy/candy. Structural equation modeling (SEM) was used to estimate the effects of parental education on adolescents’ use of nicotine pouches, gummies, and candies, while adjusting for demographic covariates. Place-based marginalization was operationalized using rural vs urban /suburban residence. Interaction terms tested whether the effect of parental education varied based on place of residence. Results: Higher parental educational attainment was associated with lower use of nicotine pouches, gummies, and candies. However, this effect was significantly weaker in rural areas. Conclusion: Public health interventions should account for place-based disparities rather than assuming a uniform effect of SES factors. This study highlights the need for policy responses that address structural inequities beyond individual family SES.

Background: Electronic cigarette (e-cigarette) use and vaping tobacco have increased rapidly worldwide, raising concerns about their health effects, social acceptability, and regulatory challenges. In many countries, e-cigarettes are more commonly used by individuals from higher socioeconomic status (SES) backgrounds, who, in theory, should have greater knowledge about e-cigarettes and their associated risks. However, it remains unclear why a group with more knowledge about e-cigarette risks would also hold more positive attitudes toward vaping and exhibit higher usage rates — a phenomenon that may represent a knowledge-behavior paradox. Understanding this paradox, along with the complex relationships between e-cigarette knowledge, attitudes, and behaviors, is critical for informing effective public health interventions, campaigns, social media messaging, and regulatory policies. Objectives: This study aimed to evaluate the complex relationship between SES, e-cigarette knowledge, pro-vaping attitudes, and e-cigarette use. Methods: The SMOKES Study (Study of Measurement of Knowledge and Examination of Support for Tobacco Control Policies) used a multi-center, cross-sectional design, collecting data from 2,403 college and university students across 15 provinces in Iran (covering nearly half of the country's provinces). The survey measured family income, age, sex, ethnicity, e-cigarette use, knowledge, and attitudes. Structural Equation Modeling (SEM) was employed to examine the interrelations between SES, knowledge, attitudes, and behavior, while adjusting for age, sex, and ethnic minority status. Results: SEM analysis confirmed the hypothesized paradox. Although greater knowledge about e-cigarettes was linked to less favorable attitudes toward vaping and lower use, pro-vaping attitudes emerged as the strongest predictor of vaping behavior, while knowledge played a weaker protective role. Notably, individuals with higher SES simultaneously showed higher knowledge and, paradoxically, more pro-e-cigarette attitudes and greater usage. Female students and ethnic minority students reported higher correct knowledge and lower pro-vaping attitudes and use. Although age and higher family income were associated with more favorable attitudes, they did not directly predict vaping behavior. These results suggest that for higher SES individuals, poor knowledge is not the main driver of e-cigarette use; rather, their pro-e-cigarette attitudes, which seem to outweigh the influence of knowledge, play a key role. Conclusions: Although individuals from higher SES backgrounds report greater correct knowledge about e-cigarettes, this knowledge does not necessarily translate into reduced positive attitudes or lower usage. This study highlights the complexity of these paradoxical effects and suggests that public health strategies need to go beyond simple education and knowledge-based interventions. Targeted approaches should address industry messaging, challenge misconceptions, and strengthen regulatory efforts to reduce e-cigarette use among young adults, including those from higher SES backgrounds.

Background: Women have consistently shown lower quit rates in tobacco cessation programs compared to men. This gender disparity persists despite comprehensive interventions and access to cessation resources. While prior studies suggest that factors such as social support, chronic disease burden, and socioeconomic status may contribute to these differences, there is limited empirical evidence to confirm these mechanisms. Aims: This study aimed to investigate potential mechanisms underlying gender differences in quit rates in a tobacco cessation program, testing whether demographic, socioeconomic, health, or behavioral factors explain the observed disparities. Methods: Participants were assigned to one of three smoking cessation interventions: an in-person program (CEASE), a self-help approach, or an online/hybrid program. The main outcome measured was smoking abstinence, evaluated three months after the intervention. Secondary analyses explored whether demographic, socioeconomic, health, or tobacco use-related factors mediated the association between gender and quit rates. Results: Women had significantly lower quit rates than men (p < 0.01). This association remained significant after adjusting for demographic, socioeconomic, health, and addiction-related factors. While women reported higher social support and a higher prevalence of chronic cardiometabolic conditions, these factors did not explain the gender disparity in quit rates. Conclusions: Gender differences in quit rates persist despite controlling for known factors that could influence cessation success. Although women had higher social support, they had lower quit rate. Future research should explore unmeasured variables, such as psychological, biological, and structural influences, to develop more effective cessation strategies tailored for women.

Background: The hippocampus plays a critical role in memory and decision-making processes, with its resting-state functional connectivity (rsFC) linked to various behavioral outcomes. This study investigates whether baseline brain-wide rsFC of the hippocampus mediates the relationship between impulsivity and subsequent substance use, specifically tobacco and marijuana use, in adolescents. Methods: Data were drawn from the baseline wave of the Adolescent Brain Cognitive Development (ABCD) study. Resting-state fMRI data were used to evaluate the functional connectivity of the hippocampus with key brain networks, including the cingulo-parietal network, visual network, sensory-motor network, and default mode network (DMN). Impulsivity was assessed using validated self-report measures, and substance use (tobacco and marijuana) was evaluated at follow-up. Mediation models were conducted to examine the extent to which hippocampal rsFC explains the association between impulsivity and substance use. Results: Baseline hippocampal rsFC with the cingulo-parietal network, visual network, sensory-motor network, and DMN showed marginal associations with future tobacco and marijuana use. Additionally, hippocampal rsFC was significantly associated with impulsivity, which, in turn, predicted higher substance use at follow-up. These findings suggest that hippocampal rsFC partially mediates the relationship between impulsivity and substance use behaviors. Conclusions: Hippocampal functional connectivity with brain networks may influence the pathway from impulsivity to future substance use in adolescence. These findings emphasize the importance of hippocampal connectivity in understanding the neural mechanisms underlying risk behaviors and may inform the development of targeted interventions to reduce substance use in this vulnerable population.

Background: Tobacco control policies are implemented globally to reduce tobacco-related morbidity and mortality. Emerging evidence suggests that individual tobacco use may influence the level of support for these policies. However, the extent to which personal use affects policy endorsement remains underexplored, particularly among young adults in academic settings. Aims: This study aimed to examine whether college students who use tobacco exhibit lower support for tobacco control policies compared to their non-user counterparts. Methods: We conducted a multi-center, cross-sectional study involving 2403 college students from various provinces in Iran. Tobacco use was ascertained based on self-reported consumption of cigarettes, electronic cigarettes, and hookah. Attitudes toward tobacco control policies were evaluated using a structured survey instrument, and comparative analyses were performed to assess differences in policy support between tobacco users and non-users. Results: The analysis revealed that tobacco users demonstrated significantly lower support for tobacco control policies compared to non-users. This association was consistently observed across users of cigarettes, electronic cigarettes, and hookah, suggesting a systematic pattern irrespective of the type of tobacco product used. Conclusion: These findings indicated a clear association between tobacco use and reduced endorsement of tobacco control policies among Iranian college students. These results have potential implications for public health policy, emphasizing the importance of addressing individual tobacco use behaviors in the development and implementation of tobacco control strategies. Further research is needed to elucidate the underlying mechanisms of this relationship.

Background: Tobacco use remains a major global health concern, and understanding the factors that influence tobacco-related knowledge and support for tobacco control policies is critical for effective development of tobacco control policies that are accepted by the public. Objectives: This study introduces the rationale, design, methodology, and participants of the SMOKES Study (Study of Measurement of Knowledge and Examination of Support for tobacco control policies), which is conducted to evaluate tobacco use, tobacco-related knowledge and attitude, as well as support for tobacco control policies among college and university students. Methods: The SMOKES Study was designed to address significant gaps in literature by focusing on college and university students in a non-Western context. A multi-center, cross-sectional design was employed to collect data from a diverse sample of college and university students across different geographical provinces in Iran. The survey instrument incorporated a range of measures covering socio-demographic characteristics, university-related variables, family tobacco use status, personal tobacco consumption behaviors (including detailed assessments of cigarette, hookah, and electronic cigarette use), and attitudinal as well as knowledge-based assessments related to vaping. Support for tobacco control policies is also measured. Data were collected using an online survey that included self-administered questionnaires, enabling access to a large diverse sample. This study may be used to determine the prevalence of ever and current use of cigarettes, electronic cigarettes, and hookah, as well as examining the correlates of single, dual, and poly-tobacco use. The study also aims to assess the role of social determinants, attitudes, and ethnic/geographic differences in shaping these outcomes. Results: The study sample consisted of 2403 college and university students, including undergraduates enrolled in different academic programs from all faculties and disciplines. Participants were drawn from universities across 15 provinces, and 11 ethnic groups, ensuring a heterogeneous sample with respect to socio-demographic background, ethnicity, and institutional affiliation. This diversity enhances the generalizability of the findings and allows for the exploration of subgroup differences in tobacco use patterns and policy support. Conclusions: The SMOKES Study offers a framework for examining tobacco-related knowledge and the acceptability of tobacco control policies among a key part of the population, being college and university students. By providing detailed insights into the prevalence and correlates of tobacco knowledge, attitude, use, as well as the tobacco control policy support, the study lays the groundwork for tailored public health interventions and more effective tobacco regulation strategies particularly for college campuses in a non-Western setting.