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: 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: 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.