Raymond S Niaura

Interim Chair of the Department of Epidemiology

Professor of Social and Behavioral Sciences

Professional overview

Dr. Raymond Niaura is a psychologist and an expert on tobacco dependence and treatment, as well as substance use and addiction to alcohol. Dr. Niaura researches the biobehavioral substrates of tobacco dependence, including factors that influence adolescent and early adult tobacco use trajectories. He also evaluates behavioral and pharmacological treatments for tobacco cessation, with a particular interest in cessation in disadvantaged population to address public health disparities in tobacco-related burdens of illness and disability.

For eight year, Dr. Niaura was the Director of Science and Training at the Schroeder Institute (SI) for Tobacco Research and Policy Studies at the Truth Initiative, where he also supervised the pre- and post-doctoral training programs. Dr. Niaura has previously taught and conducted research at Brown University, Johns Hopkins Bloomberg School of Public Health, the Georgetown Medical Center, and the School of Public Health at University of Maryland. He was also a former President of the Society for Research on Nicotine and Tobacco and is  a Deputy Editor of the Nicotine and Tobacco Research.

With grants from the National Institutes of Health, numerous foundations, and private industry, Dr. Niaura has published over 400 peer-reviewed articles, commentaries, and book chapters, including the book The Tobacco Dependence Treatment Handbook: A Guide to Best Practices.

Education

BA, Psychology (First Class Honors), McGill University, Montreal, Canada

MS, Psychology, Rutgers University, New Brunswick, NJ

PhD, Psychology, Rutgers University, New Brunswick, NJ

Honors and awards

Research Laureate, American Academy of Health Behavior (2009)

University Scholar Award, McGill University (1979)

Areas of research and study

Alcohol, Tobacco and Driving Policies

Evaluations

Health Disparities

Substance Abuse

Tobacco Control

Publications

Publications

A Cross-Sectional Analysis of the Nicotine Metabolite Ratio and Its Association with Sociodemographic and Smoking Characteristics among People with HIV Who Smoke in South Africa

Keke, C., Wilson, Z., Lebina, L., Motlhaoleng, K., Abrams, D., Variava, E., Gupte, N., Niaura, R., Martinson, N., Golub, J. E., & Elf, J. L. (n.d.).

Publication year

2023

Journal title

International journal of environmental research and public health

Volume

20

Issue

6

10.3390/ijerph20065090

Abstract

Abstract

The nicotine metabolite ratio (NMR) is associated with race/ethnicity but has not been evaluated among smokers in the African region. We conducted a cross-sectional analysis of baseline data from a large randomized, controlled trial for smoking cessation among people with HIV (PWH) in South Africa. Urine samples were analyzed for the NMR and evaluated as a binary variable using a cutoff value of the fourth quartile to determine the fastest metabolizers. The median NMR was 0.31 (IQR: 0.31, 0.32; range: 0.29, 0.57); the cut-point for fast metabolizers was ≥0.3174 ng/mL. A high NMR was not associated with the number of cigarettes per day (OR = 1.10, 95% CI: 0.71, 1.70, p = 0.66) but was associated with 40% lower odds of a quit attempt in the past year (OR = 0.69; 95% CI: 0.44, 1.07, p = 0.09) and alcohol use (OR = 0.59, 95% CI: 0.32, 1.06, p = 0.07). No association was seen with marijuana or HIV clinical characteristics. As we found only minimal variability in the NMR and minimal associations with intensity of smoking, NMR may be of limited clinical value in this population, although it may inform which individuals are less likely to make a quit attempt.

Author Response to E-cigarettes and Respiratory Disorder: The Broader Research Context

Sargent, J. D., Edwards, K. C., Emond, J., Tanski, S., Taylor, K. A., Pierce, J. P., Goniewicz, M. L., Niaura, R., Anic, G., Chen, Y., Callahan-Lyon, P., Gardner, L. D., Thekkudan, T., Borek, N., Kimmel, H. L., Michael Cummings, K., Hyland, A., & Brunette, M. (n.d.). In Nicotine and Tobacco Research (1–).

Publication year

2023

Volume

25

Issue

6

Page(s)

1217-1218

10.1093/ntr/ntad036

Changes in Tobacco Dependence and Association with Onset and Progression of Use by Product Type from Wave 1 to Wave 3 of the Population Assessment of Tobacco and Health (PATH) Study

Strong, D. R., Pierce, J. P., White, M., Stone, M. D., Abrams, D. B., Glasser, A. M., Wackowski, O. A., Cummings, K. M., Hyland, A., Taylor, K., Edwards, K. C., Silveira, M. L., Kimmel, H. L., Lambert, E. Y., Compton, W. M., Hull, L. C., & Niaura, R. (n.d.).

Publication year

2023

Journal title

Nicotine and Tobacco Research

Volume

25

Issue

3

Page(s)

571-579

10.1093/ntr/ntac167

Abstract

Abstract

Introduction: This study examined trajectories of tobacco dependence (TD) in relation to changes in tobacco product use and explored the effects of product-specific adding, switching, or discontinued use on dependence over time. Aims and Methods: Data were analyzed from the first three waves of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal study of adults and youth in the United States. Data included 9556 Wave 1 (2013/2014) adult current established tobacco users who completed all three interviews and had established use at ≥2 assessments. Groups included cigarettes-only users, e-cigarettes-only users, cigars-only users, hookah-only users, any smokeless-only users, cigarette + e-cigarette dual users, and multiple product users. A validated 16-item scale assessed TD across product users. Results: Wave 1 e-cigarette-only users' who maintained exclusive e-cigarette use increased levels of TD through Wave 3 as did those who added or switched to another product. Wave 1 multiple product users' TD decreased across waves. TD for all other Wave 1 user groups remained about the same. For Wave 1 cigarette-only smokers, switching to another product or moving to a pattern of no established use was associated with lower levels of TD than smokers whose use stayed the same. Movement to no established use of any tobacco product was consistently associated with lower TD for all other product users. Conclusions: Except for Wave 1 e-cigarette-only users, TD among US tobacco product users was stable over time, with daily users less likely to vary from baseline. Implications: The level of TD among most US tobacco users was stable over the first three waves of the PATH Study and trends in levels of TD were predominantly unrelated to changes in patterns of continued product use. Stable levels of TD suggest a population at persistent risk of health impacts from tobacco. Wave 1 e-cigarette users, including those maintaining exclusive e-cigarette use, experienced increasing levels of TD over time, perhaps because of increases in quantity or frequency of their e-cigarette product use or increasing efficiency of nicotine delivery over time.

Changes in Tobacco Dependence and Association With Onset and Progression of Use by Product Type From Waves 1 to 3 of the Population Assessment of Tobacco and Health (PATH) Study

Strong, D. R., Pierce, J. P., White, M., Stone, M. D., Abrams, D. B., Glasser, A. M., Wackowski, O. A., Cummings, K. M., Hyland, A., Taylor, K., Edwards, K. C., Silveira, M. L., Kimmel, H. L., Compton, W. M., Hull, L. C., & Niaura, R. (n.d.).

Publication year

2023

Journal title

Nicotine and Tobacco Research

Volume

25

Issue

11

Page(s)

1781-1790

10.1093/ntr/ntad107

Abstract

Abstract

Introduction: This study examined trajectories of tobacco dependence (TD) in relationship to changes in tobacco product use, and explored the effects of product-specific adding, switching, or discontinued use on dependence over time. Aims and Methods: Data were analyzed from the first three waves from the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal study of adults and youth in the United States. Data included 9556 wave 1 (2013–2014) adult current established tobacco users aged 18 or older who completed all three interviews and had established use at ≥2 assessments. Mutually exclusive groups included: users of cigarettes only, e-cigarettes only, cigars only, hookah only, any smokeless only, cigarette + e-cigarette dual users, and other multiple product users. A validated 16-item scale assessed TD across product users. Results: People who used e-cigarettes exclusively at wave 1 had small increases in TD through wave 3. Wave 1 multiple product users’ TD decreased across waves. TD for all other wave 1 user groups remained about the same. For wave 1 cigarette only smokers, switching to another product was associated with lower levels of TD than smokers whose use stayed the same. Movement to no established use of any tobacco product was consistently associated with lower TD for all product users. Conclusions: Except for wave 1 e-cigarette only users (who experienced small increases in TD), TD among U.S. tobacco product users was stable over time, with daily users less likely to vary from baseline. Implications: The level of TD among most U.S. tobacco users was stable over the first three waves of the PATH Study and trends in levels of TD were predominantly unrelated to changes in patterns of continued product use. Stable levels of TD suggest a population at persistent risk of health impacts from tobacco. Wave 1 e-cigarette users experienced small increases in levels of TD over time, perhaps due to increases in quantity or frequency of their e-cigarette use or increasing efficiency of nicotine delivery over time.

Efficacy and safety of combination behavioral activation for smoking cessation and varenicline for treating tobacco dependence among individuals with current or past major depressive disorder: A 2 × 2 factorial, randomized, placebo-controlled trial

Hitsman, B., Papandonatos, G. D., Gollan, J. K., Huffman, M. D., Niaura, R., Mohr, D. C., Veluz-Wilkins, A. K., Lubitz, S. F., Hole, A., Leone, F. T., Khan, S. S., Fox, E. N., Bauer, A. M., Wileyto, E. P., Bastian, J., & Schnoll, R. A. (n.d.).

Publication year

2023

Journal title

Addiction

Volume

118

Issue

9

Page(s)

1710-1725

10.1111/add.16209

Abstract

Abstract

Background and Aims: Treatment of depression-related psychological factors related to smoking behavior may improve rates of cessation among adults with major depressive disorder (MDD). This study measured the efficacy and safety of 12 weeks of behavioral activation for smoking cessation (BASC), varenicline and their combination. Design, Setting, Participants: This study used a randomized, placebo-controlled, 2 × 2 factorial design comparing BASC versus standard behavioral treatment (ST) and varenicline versus placebo, taking place in research clinics at two urban universities in the United States. Participants comprised 300 hundred adult smokers with current or past MDD. Interventions: BASC integrated behavioral activation therapy and ST to increase engagement in rewarding activities by reducing avoidance, withdrawal and inactivity associated with depression. ST was based on the 2008 PHS Clinical Practice Guideline. Both treatments consisted of eight 45-min sessions delivered between weeks 1 and 12. Varenicline and placebo were administered for 12 weeks between weeks 2 and 14. Measurements: Primary outcomes were bioverified intent-to-treat (ITT) 7-day point-prevalence abstinence at 27 weeks and adverse events (AEs). Findings: No significant interaction was detected between behavioral treatment and pharmacotherapy at 27 weeks (χ2(1) = 0.19, P = 0.67). BASC and ST did not differ (χ2(1) = 0.43, P = 0.51). Significant differences in ITT abstinence rates (χ2(1) = 4.84, P = 0.03) emerged among pharmacotherapy arms (16.2% for varenicline, 7.5% for placebo), with results favoring varenicline over placebo (rate ratio = 2.16, 95% confidence interval = 1.08, 4.30). All significant differences in AE rates after start of medication were higher for placebo than varenicline. Conclusion: A randomized trial in smokers with major depressive disorder found that varenicline improved smoking abstinence versus placebo at 27 weeks without elevating rates of adverse events. Behavioral activation for smoking cessation did not outperform standard behavioral treatment, with or without adjunctive varenicline therapy.

Indicators of Tobacco Dependence Among Youth: Findings From Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health Study

Strong, D. R., Glasser, A. M., Leas, E. C., Pierce, J. P., Abrams, D. B., Hrywna, M., Hyland, A., Cummings, K. M., Hatsukami, D. K., Fong, G. T., Elton-Marshall, T., Sharma, E., Edwards, K. C., Stanton, C. A., Sawdey, M. D., Ramôa, C. P., Silveira, M. L., Kimmel, H. L., & Niaura, R. S. (n.d.).

Publication year

2023

Journal title

Nicotine and Tobacco Research

Volume

25

Issue

9

Page(s)

1565-1574

10.1093/ntr/ntad072

Abstract

Abstract

Background: Prior work established a measure of tobacco dependence (TD) among adults that can be used to compare TD across different tobacco products. We extend this approach to develop a common, cross-product metric for TD among youth. Methods: One thousand one hundred and forty-eight youth aged 12-17 who used a tobacco product in the past 30 days were identified from 13 651 youth respondents in Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study. Findings: Analyses confirmed a single primary latent construct underlying responses to TD indicators for all mutually exclusive tobacco product user groups. Differential Item Functioning analyses supported the use of 8 of 10 TD indicators for comparisons across groups. With TD levels anchored at 0.0 (standard deviation [SD] = 1.0) among cigarette only (n = 265) use group, mean TD scores were more than a full SD lower for e-cigarette only (n = 150) use group (mean = -1.09; SD = 0.64). Other single product use group (cigar, hookah, pipe, or smokeless; n = 262) on average had lower TD (mean = -0.60; SD = 0.84), and the group with the use of multiple tobacco products (n = 471) experienced similar levels of TD (mean = 0.14; SD = 0.78) as the cigarette only use group. Concurrent validity was established with product use frequency among all user groups. A subset of five TD items comprised a common metric permitting comparisons between youth and adults. Conclusion: The PATH Study Youth Wave 1 Interview provided psychometrically valid measures of TD that enable future regulatory investigations of TD across tobacco products and comparisons between youth and adult tobacco product use group. Implications: A measure of tobacco dependence (TD) has been established previously among adults to compare TD across tobacco products. This study established the validity of a similar, cross-product measure of TD among youth. Findings suggest a single latent TD construct underlying this measure, concurrent validity of the scale with product use frequency across different types of tobacco users, and a subset of common items that can be used to compare TD between youth and adults who use tobacco.

Prevalence and Correlates of Cardiovascular, Pulmonary, Cancer, and Mental Health Comorbidities Among Adults With HIV Who Smoke

Elf, J. L., Horn, K., Abroms, L., Stanton, C. A., Cohn, A. M., Spielberg, F., Gray, T., Harvey, E., Debnam, C., Kierstead, L., Levy, M. E., Castel, A., Monroe, A., & Niaura, R. (n.d.).

Publication year

2023

Journal title

Journal of the Association of Nurses in AIDS Care

Volume

34

Issue

4

Page(s)

363-375

10.1097/JNC.0000000000000416

Abstract

Abstract

Using data from the D.C. Cohort Longitudinal HIV Study, we examined (a) diagnosed mental health and (b) cardiovascular, pulmonary, or cancer (CPC) comorbidity among adults with HIV who smoked. Among 8,581 adults, 4,273 (50%) smoked; 49% of smokers had mental health, and 13% of smokers had a CPC comorbidity. Among smokers, non-Hispanic Black participants had a lower risk for mental health (prevalence ratio [PR]: 0.69; 95% confidence interval [CI] [0.62-0.76]) but a higher risk for CPC (PR: 1.17; 95% CI [0.84-1.62]) comorbidity. Male participants had a lower risk for mental health (PR: 0.88; 95% CI [0.81-0.94]) and CPC (PR: 0.68; 95% CI [0.57-0.81]) comorbidity. All metrics of socioeconomic status were associated with a mental health comorbidity, but only housing status was associated with a CPC comorbidity. We did not find any association with substance use. Gender, socioeconomic factors, and race/ethnicity should inform clinical care and the development of smoking cessation strategies for this population.

Tutorial on Causal Mediation Analysis With Binary Variables: An Application to Health Psychology Research

Xu, S., Coffman, D. L., Luta, G., & Niaura, R. S. (n.d.).

Publication year

2023

Journal title

Health Psychology

10.1037/hea0001299

Abstract

Abstract

Mediation analysis has been widely applied to explain why and assess the extent to which an exposure or treatment has an impact on the outcome in health psychology studies. Identifying a mediator or assessing the impact of a mediator has been the focus of many scientific investigations. This tutorial aims to introduce causal mediation analysis with binary exposure, mediator, and outcome variables, with a focus on the resampling and weighting methods, under the potential outcomes framework for estimating natural direct and indirect effects.We emphasize the importance of the temporal order of the study variables and the elimination of confounding. We define the causal effects in a hypothesized causal mediation chain in the context of one exposure, one mediator, and one outcome variable, all of which are binary variables. Two commonly used and actively maintained R packages, mediation and medflex, were used to analyze a motivating example. R code examples for implementing these methods are provided.

Use of electronic nicotine delivery system (ENDS) devices among U.S. Youth and adults: Findings from the Population Assessment of Tobacco and Health Study Waves 1–5

Jiang, N., Xu, S., Li, L., Cleland, C. M., & Niaura, R. S. (n.d.).

Publication year

2023

Journal title

Addictive Behaviors

Volume

139

10.1016/j.addbeh.2022.107588

Abstract

Abstract

Introduction: Electronic nicotine delivery system (ENDS) devices evolve rapidly and impact nicotine dependence. This study described the type of ENDS devices used most frequently by U.S. youth and adults from 2013/14 to 2018/19. Methods: We analyzed Waves 1–5 data of the Population Assessment of Tobacco and Health Study. Among current ENDS users, descriptive statistics summarized the most frequently used ENDS devices (i.e., disposable cigalike, refillable cartridge, nonrefillable cartridge, tank, mod, prefilled pod, disposable pod) among youth (12–17 years), young adults (18–34 years), and older adults (≥35 years) for each wave. Results: The proportion of current ENDS users who reported they most frequently used disposable cigalikes and cartridge-based devices declined over time across all age groups. At Waves 1–4, tank was generally the most popular type for all ages and an increasing proportion of ENDS users reported they most frequently used tanks. The primary use of mods decreased among youth, and fluctuated among young and older adults. At Wave 5, prefilled pods became the dominant type (youth: 55.0%; young adults: 44.7%; older adults: 42.7%), and 4.2–10.0% of ENDS users reported using disposable pods most often. The popularity of tanks, mods, and prefilled pods was more evident in youth and young adults, and primary use of disposable pods was more common in older adults. Conclusions: The primary use of ENDS devices changed over the years and varied by age. More research is warranted to continuously monitor the characteristics of ENDS devices in youth and adults to inform product regulations and intervention efforts.

Validating Wave 1 (2014) Urinary Cotinine and TNE-2 Cut-points for Differentiating Wave 4 (2017) Cigarette Use from Non-use in the United States Using Data from the PATH Study

Edwards, K. C., Khan, A., Sharma, E., Wang, L., Feng, J., Blount, B. C., Sosnoff, C. S., Smith, D. M., Goniewicz, M. L., Pearson, J., Villanti, A. C., Delnevo, C. D., Bover-Manderski, M. T., Hatsukami, D. K., Niaura, R., Everard, C., Kimmel, H. L., Duffy, K., Rostron, B. L., … Hyland, A. (n.d.).

Publication year

2023

Journal title

Cancer Epidemiology Biomarkers and Prevention

Volume

32

Issue

9

Page(s)

1233-1241

10.1158/1055-9965.EPI-22-1228

Abstract

Abstract

Background: Sex and racial/ethnic identity-specific cut-points for validating tobacco use using Wave 1 (W1) of the Population Assessment of Tobacco and Health (PATH) Study were published in 2020. The current study establishes predictive validity of the W1 (2014) urinary cotinine and total nicotine equivalents- 2 (TNE-2) cut-points on estimating Wave 4 (W4; 2017) tobacco use. Methods: For exclusive and polytobacco cigarette use, weighted prevalence estimates based on W4 self-report alone and with exceeding the W1 cut-point were calculated to identify the percentage missed without biochemical verification. Sensitivity and specificity of W1 cut-points on W4 self-reported tobacco use status were examined.ROCcurves were used to determine the optimalW4 cut-points to distinguish past 30-day users from non-users, and evaluate whether the cut-points significantly differed from W1. Results: Agreement betweenW4self-reported use and exceeding the W1 cut-points was high overall and when stratified by demographic subgroups (0.7%-4.4% of use was missed if relying on selfreport alone). The predictive validity of using the W1 cut-points to classify exclusive cigarette and polytobacco cigarette use at W4 was high (>90% sensitivity and specificity, except among polytobacco Hispanic smokers). Cut-points derived using W4 data did not significantly differ from the W1-derived cut-points [e.g., W1 exclusive =40.5 ng/mL cotinine (95% confidence interval, CI: 26.1-62.8), W4 exclusive = 29.9 ng/mL cotinine (95% CI: 13.5-66.4)], among most demographic subgroups. Conclusions: The W1 cut-points remain valid for biochemical verification of self-reported tobacco use in W4.

A Randomized Trial of Telephone-Based Smoking Cessation Treatment in the Lung Cancer Screening Setting

Taylor, K. L., Williams, R. M., Li, T., Luta, G., Smith, L., Davis, K. M., Stanton, C. A., Niaura, R., Abrams, D., Lobo, T., Mandelblatt, J., Jayasekera, J., Meza, R., Jeon, J., Cao, P., & Anderson, E. D. (n.d.).

Publication year

2022

Journal title

Journal of the National Cancer Institute

Volume

114

Issue

10

Page(s)

1410-1419

10.1093/jnci/djac127

Abstract

Abstract

Background: Lung cancer mortality is reduced via low-dose computed tomography screening and treatment of early-stage disease. Evidence-based smoking cessation treatment in the lung screening setting can further reduce mortality. We report the results of a cessation trial from the National Cancer Institute's Smoking Cessation at Lung Examination collaboration. Methods: Eligible patients (n = 818) aged 50-80 years were randomly assigned (May 2017-January 2021) to the intensive vs minimal arms (8 vs 3 phone sessions plus 8 vs 2 weeks of nicotine patches, respectively). Bio-verified (primary) and self-reported 7-day abstinence rates were assessed at 3, 6, and 12 months post random assignment. Logistic regression analyses evaluated the effects of study arm. All statistical tests were 2-sided. Results: Participants reported 48.0 (SD = 17.2) pack-years, and 51.6% were not ready to quit in less than 30 days. Self-reported 3-month quit rates were statistically significantly higher in the intensive vs minimal arm (14.3% vs 7.9%; odds ratio [OR] = 2.00, 95% confidence interval [CI] = 1.26 to 3.18). Bio-verified abstinence was lower but with similar relative differences between arms (9.1% vs 3.9%; OR = 2.70, 95% CI = 1.44 to 5.08). Compared with the minimal arm, the intensive arm was more effective among those with greater nicotine dependence (OR = 3.47, 95% CI = 1.55 to 7.76), normal screening results (OR = 2.58, 95% CI = 1.32 to 5.03), high engagement in counseling (OR = 3.03, 95% CI = 1.50 to 6.14), and patch use (OR = 2.81, 95% CI = 1.39 to 5.68). Abstinence rates did not differ statistically significantly between arms at 6 months (OR = 1.2, 95% CI = 0.68 to 2.11) or 12 months (OR = 1.4, 95% CI = 0.82 to 2.42). Conclusions: Delivering intensive telephone counseling and nicotine replacement with lung screening is an effective strategy to increase short-term smoking cessation. Methods to maintain short-term effects are needed. Even with modest quit rates, integrating cessation treatment into lung screening programs may have a large impact on tobacco-related mortality.

A scoping review of studies on the health impact of electronic nicotine delivery systems

Hajat, C., Stein, E., Shantikumar, S., Niaura, R., Ferrara, P., & Polosa, R. (n.d.).

Publication year

2022

Journal title

Internal and Emergency Medicine

Volume

17

Issue

1

Page(s)

241-268

10.1007/s11739-021-02835-4

Abstract

Abstract

We conducted a scoping review of studies on health outcomes from electronic nicotine delivery systems (ENDS). The objective was to identify, narratively synthesize, assess the strength and quality of evidence and critically appraise studies that have reported disease end points associated with the use of ENDS. We included published literature on the health impact of ENDS from 01/01/2015 until 01/02/2020 following the PRISMA guidelines using PubMed, Embase, Scopus and Google Scholar. The database search identified 755 studies, and other sources 265; 37 studies met final eligibility criteria. Levels of evidence included 24(65%) cross-sectional, one (2.7%) case–control and six (16%) case studies, four (11%) cohort studies, one (2.7%) randomized controlled trial (RCT) and one (2.7%) meta-analysis; 27(73%) studies reported only on harms, eight (22%) reported on benefits, two (2%) on benefits and harms. Quality ratings were poor in 20 (54%), fair in 9(24%) and good in 8(22%) of studies. In our review, ENDS was not shown to be causative for harmful cardiovascular disease (CVD) outcomes and shown to be beneficial for hypertensive patients. Switching from cigarettes to e-cigarettes resulted in reduced exacerbations of chronic obstructive pulmonary disease (COPD), with no evidence of long-term deterioration in lung function. Mental Health, cancer and mortality were not adequately studied to form any consensus. Our review has not demonstrated ENDS to be causative of harmful CVD outcomes; furthermore switching from cigarettes to e-cigarettes was associated with improved hypertensive control and reduced exacerbations of COPD, with no evidence of increased asthma risk or long-term respiratory harm. Mental health, cancer and mortality outcomes have not been adequately studied to form a conclusion. Overall, the findings of our review did not provide evidence to counter the consensus held by many that ENDS use is safer than the risks posed from smoking cigarettes.

Association of tobacco product use with chronic obstructive pulmonary disease (COPD) prevalence and incidence in Waves 1 through 5 (2013–2019) of the Population Assessment of Tobacco and Health (PATH) Study

Paulin, L. M., Halenar, M. J., Edwards, K. C., Lauten, K., Stanton, C. A., Taylor, K., Hatsukami, D., Hyland, A., MacKenzie, T., Mahoney, M. C., Niaura, R., Trinidad, D., Blanco, C., Compton, W. M., Gardner, L. D., Kimmel, H. L., Lauterstein, D., Marshall, D., & Sargent, J. D. (n.d.).

Publication year

2022

Journal title

Respiratory Research

Volume

23

Issue

1

10.1186/s12931-022-02197-1

Abstract

Abstract

Background: We examined the association of non-cigarette tobacco use on chronic obstructive pulmonary disease (COPD) risk in the Population Assessment of Tobacco and Health (PATH) Study. Methods: There were 13,752 participants ≥ 40 years with Wave 1 (W1) data for prevalence analyses, including 6945 adults without COPD for incidence analyses; W1–5 (2013–2019) data were analyzed. W1 tobacco use was modeled as 12 mutually-exclusive categories of past 30-day (P30D) single and polyuse, with two reference categories (current exclusive cigarette and never tobacco). Prevalence and incidence ratios of self-reported physician-diagnosed COPD were estimated using weighted multivariable Poisson regression. Results: W1 mean (SE) age was 58.1(0.1) years; mean cigarette pack-years was similar for all categories involving cigarettes and exclusive use of e-cigarettes (all > 20), greater than exclusive cigar users (< 10); and COPD prevalence was 7.7%. Compared to P30D cigarette use, never tobacco, former tobacco, and cigar use were associated with lower COPD prevalence (RR = 0.33, (95% confidence interval—CI) [0.26, 0.42]; RR = 0.57, CI [0.47, 0.70]; RR = 0.46, CI [0.28, 0.76], respectively); compared to never tobacco use, all categories except cigar and smokeless tobacco use were associated with higher COPD prevalence (RR former = 1.72, CI [1.33, 2.23]; RR cigarette = 3.00, CI [2.37, 3.80]; RR e-cigarette = 2.22, CI [1.44, 3.42]; RR cigarette + e-cigarette = 3.10, CI [2.39, 4.02]; RR polycombusted = 3.37, CI [2.44, 4.65]; RR polycombusted plus noncombusted = 2.75, CI]1.99, 3.81]). COPD incidence from W2-5 was 5.8%. Never and former tobacco users had lower COPD risk compared to current cigarette smokers (RR = 0.52, CI [0.35, 0.77]; RR = 0.47, CI [0.32, 0.70], respectively). Compared to never use, cigarette, smokeless, cigarette plus e-cigarette, and polycombusted tobacco use were associated with higher COPD incidence (RR = 1.92, CI [1.29, 2.86]; RR = 2.08, CI [1.07, 4.03]; RR = 1.99, CI [1.29, 3.07]; RR = 2.59, CI [1.60, 4.21], respectively); exclusive use of e-cigarettes was not (RR = 1.36, CI [0.55, 3.39]). Conclusions: E-cigarettes and all use categories involving cigarettes were associated with higher COPD prevalence compared to never use, reflecting, in part, the high burden of cigarette exposure in these groups. Cigarette—but not exclusive e-cigarette—use was also strongly associated with higher COPD incidence. Compared to cigarette use, only quitting tobacco was protective against COPD development.

Balfour et al. Respond

Balfour, D. J., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R. (n.d.). In American journal of public health (1–).

Publication year

2022

Volume

112

Issue

1

Page(s)

E2-E3

10.2105/AJPH.2021.306555

Balfour et al. Respond

Balfour, D. J., Benowitz, N. L., Colby, S. M., Hatsukami, D. K., Lando, H. A., Leischow, S. J., Lerman, C., Mermelstein, R. J., Niaura, R., Perkins, K. A., Pomerleau, O. F., Rigotti, N. A., Swan, G. E., Warner, K. E., & West, R. (n.d.). In American journal of public health (1–).

Publication year

2022

Volume

112

Issue

1

Page(s)

E5-E6

10.2105/AJPH.2021.306570

Cardiovascular Outcomes among Combustible-Tobacco and Electronic Nicotine Delivery System (ENDS) Users in Waves 1 through 5 of the Population Assessment of Tobacco and Health (PATH) Study, 2013–2019

Mahoney, M. C., Rivard, C., Kimmel, H. L., Hammad, H. T., Sharma, E., Halenar, M. J., Sargent, J., Cummings, K. M., Niaura, R., Goniewicz, M. L., Bansal-Travers, M., Hatsukami, D., Gaalema, D., Fong, G., Gravely, S., Christensen, C. H., Haskins, R., Silveira, M. L., Blanco, C., … Hyland, A. (n.d.).

Publication year

2022

Journal title

International journal of environmental research and public health

Volume

19

Issue

7

10.3390/ijerph19074137

Abstract

Abstract

Background: Prior studies have not clearly established risk of cardiovascular disease (CVD) among smokers who switch to exclusive use of electronic nicotine delivery systems (ENDS). We compared cardiovascular disease incidence in combustible-tobacco users, those who transitioned to ENDS use, and those who quit tobacco with never tobacco users. Methods: This prospective cohort study analyzes five waves of Population Assessment of Tobacco and Health (PATH) Study data, Wave 1 (2013–2014) through Wave 5 (2018–2019). Cardiovascular disease (CVD) incidence was captured over three intervals (Waves 1 to 3, Waves 2 to 4, and Waves 3 to 5). Participants were adults (40+ years old) without a history of CVD for the first two waves of any interval. Change in tobacco use status, from exclusive past 30 day use of any combustible-tobacco product to either exclusive past 30 day ENDS use, dual past 30 day use of ENDS and combustible-tobacco, or no past 30 day use of any tobacco, between the first two waves of an interval was used to predict onset of CVD between the second and third waves in the interval. CVD incidence was defined as a new self-report of being told by a health professional that they had congestive heart failure, stroke, or a myocardial infarction. Generalized estimating equation (GEE) analyses combined 10,548 observations across intervals from 7820 eligible respondents. Results: Overall, there were 191 observations of CVD among 10,548 total observations (1.7%, standard error (SE) = 0.2), with 40 among 3014 never users of tobacco (1.5%, SE = 0.3). In multivariable models, CVD incidence was not significantly different for any tobacco user groups compared to never users. There were 126 observations of CVD among 6263 continuing exclusive combustible-tobacco users (adjusted odds ratio [AOR] = 1.44; 95% confidence interval (CI) 0.87–2.39), 15 observations of CVD among 565 who transitioned to dual use (AOR = 1.85; 0.78–4.37), and 10 observations of CVD among 654 who quit using tobacco (AOR = 1.18; 0.33–4.26). There were no observations of CVD among 53 who transitioned to exclusive ENDS use. Conclusions: This study found no difference in CVD incidence by tobacco status over three 3 year intervals, even for tobacco quitters. It is possible that additional waves of PATH Study data, combined with information from other large longitudinal cohorts with careful tracking of ENDS use patterns may help to further clarify this relationship.

Changes in Biomarkers of Tobacco Exposure among Cigarette Smokers Transitioning to ENDS Use: The Population Assessment of Tobacco and Health Study, 2013–2015

Anic, G. M., Rostron, B. L., Hammad, H. T., Van Bemmel, D. M., Valle-Pinero, A. Y., Christensen, C. H., Erives, G., Faulcon, L. M., Blount, B. C., Wang, Y., Wang, L., Bhandari, D., Calafat, A. M., Kimmel, H. L., Everard, C. D., Compton, W. M., Edwards, K. C., Goniewicz, M. L., Wei, B., … Chang, C. M. (n.d.).

Publication year

2022

Journal title

International journal of environmental research and public health

Volume

19

Issue

3

10.3390/ijerph19031462

Abstract

Abstract

Limited data are available for how biomarkers of tobacco exposure (BOE) change when cigarette smokers transition to using electronic nicotine delivery systems (ENDS). Using biomarker data from Waves 1 (2013–2014) and 2 (2014–2015) of the PATH Study, we examined how mean BOE concentrations, including metabolites of nicotine, tobacco-specific nitrosamines (TSNA), polycyclic aromatic hydrocarbons (PAH), and volatile organic compounds (VOCM) and metals, changed when 2475 adult smokers transitioned to using ENDS or quit tobacco products. Exclusive smokers who transitioned to dual use had a significant decrease in NNAL (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol), but not nicotine metabolites, most PAHs, metals, or VOCMs. Exclusive smokers who became dual users had significant reductions in total nicotine equivalents, NNAL, and 2CyEMA (acrylonitrile metabolite), but only in those who reduced cigarettes per day (CPD) by >=50%. Smokers who transitioned to exclusive ENDS use had significant reductions in most TSNAs, PAHs, and VOCMs; however, nicotine metabolites did not decrease in dual users who became exclusive ENDS users. Smokers who quit tobacco use had significant decreases in nicotine metabolites, all TSNAs, most PAHs, and most VOCMs. Cigarette smokers who became dual users did not experience significant reductions in most BOEs. Reductions were impacted by changes in CPD. However, transitioning from smoking to no tobacco or exclusive ENDS use was associated with reduced exposure to most BOEs measured. Future analyses could incorporate additional waves of PATH data and examine changes in biomarker exposure by ENDS device type and CPD.

Correlates of tobacco product initiation among youth and young adults between waves 1–4 of the population assessment of tobacco and Health (PATH) study (2013–2018)

Cooper, M., Day, H. R., Ren, C., Oniyide, O., Corey, C. G., Ambrose, B. K., Michael Cummings, K., Sargent, J., Niaura, R., Pierce, J. P., Kaufman, A., Choi, K., Goniewicz, M. L., Stanton, C. A., Villanti, A., Kasza, K., Bansal-Travers, M., Silveira, M. L., Kimmel, H. L., … Hyland, A. J. (n.d.).

Publication year

2022

Journal title

Addictive Behaviors

Volume

134

10.1016/j.addbeh.2022.107396

Abstract

Abstract

Introduction: While risk factors for cigarette smoking among youth and young adults are well-documented, less is known about the correlates of initiation of other tobacco products. This study aims to provide estimates and correlates of initiation among U.S. youth and young adults. Methods: Data on youth aged 12–17 (n = 10,072) and young adults aged 18–24 (N = 5,727) who provided information on cigarettes, electronic nicotine delivery systems (ENDS), cigars, pipe, hookah and smokeless tobacco use in Wave 1 (W1: 2013–2014)-Wave 4 (W4: 2016–2018) of the nationally-representative PATH Study were used to calculate ever use initiation and correlates of initiation by W4. Results: Nearly 6 million youth and 2.5 million young adults used tobacco for the first time between W1-W4. Approximately one quarter of youth and young adult ENDS never users initiated ENDS between W1-W4 of the PATH Study. Among youth, use of other tobacco products, ever substance use, and high externalizing problems were associated with initiation of most products. Among young adults, use of other tobacco products and ever substance use were associated with initiation of most products. In both youth and young adults, Hispanics were more likely to initiate hookah use than their non-Hispanic White counterparts. While male sex was a risk factor for most tobacco product initiation across both age groups, it was not associated with hookah initiation. Conclusions: Cigarette and non-cigarette products shared many correlates of initiation, although there are noteworthy demographic differences. Findings can help tailor product specific interventions to reach populations at risk during preliminary stages of use.

E-cigarette use and change in plans to quit cigarette smoking among adult smokers in the United States: Longitudinal findings from the PATH Study 2014–2019

Kasza, K. A., Edwards, K. C., Anesetti-Rothermel, A., Creamer, M. L. R., Cummings, K. M., Niaura, R. S., Sharma, A., Pitts, S. R., Head, S. K., Everard, C. D., Hatsukami, D. K., & Hyland, A. (n.d.).

Publication year

2022

Journal title

Addictive Behaviors

Volume

124

10.1016/j.addbeh.2021.107124

Abstract

Abstract

Introduction: Much of the population-based e-cigarette use and cigarette cessation literature is restricted to smokers who have expressed intention to quit smoking, though experimental studies suggest e-cigarette use might motivate some smokers to change their quit intentions. We used U.S. nationally representative data to evaluate whether e-cigarette use by smokers initially not planning to ever quit is associated with change in plans to quit. Methods: Longitudinal Population Assessment of Tobacco and Health (PATH) Study data collected between 2014 and 2019 were analyzed. Main analyses were conducted among adult daily cigarette smokers not currently using e-cigarettes with no plans to ever quit smoking (n = 2366 observations from n = 1532 individuals). Generalized estimating equations were used to evaluate the association between change in e-cigarette use and change in plans to quit smoking within the next six months, over three assessment pairs. Results: Daily cigarette smokers with no plans to quit had a higher rate of change to plan to quit if at follow-up they used e-cigarettes daily (41.4%, 95% CI: 27.1–57.3%) versus not at all (12.4%, 95% CI: 10.6–14.5%; aOR = 5.7, 95% CI: 2.9–11.2). Rate of change to plan to quit did not statistically differ between those who at follow-up used e-cigarettes some days versus not at all. Conclusions: Among adult daily cigarette smokers initially not planning to ever quit, subsequent daily e-cigarette use is associated with subsequent plans to quit smoking. Population-level research on e-cigarette use that is focused on smokers already motivated to quit may limit a complete evaluation of the smoker population.

Electronic nicotine delivery systems: use, knowledge, and attitudes among diverse college students

Olonoff, M., Niaura, R. S., Ciecierski, C. C., Ciolino, J. D., & Hitsman, B. (n.d.).

Publication year

2022

Journal title

Journal of American College Health

Volume

70

Issue

7

Page(s)

2159-2167

10.1080/07448481.2020.1846044

Abstract

Abstract

Objective The purpose of this study was to examine Electronic Nicotine Delivery Systems (ENDS) use among nonusers in diverse college students. Participants: Participants were college students enrolled at a Hispanic-Serving University in Chicago, IL, USA in December 2017. Methods: An online survey was administered using questions about ENDS-use behaviors, device characteristics, and knowledge of their own device, and ENDS attitudes. ENDS attitudes included questions about health, susceptibility, and quit characteristics. Results: The prevalence rate of ENDS use was 7%, and 39% of ENDS users identified all device characteristics. Nonusers categorize ENDS as a healthier alternative to cigarettes and as quit devices. Finally, cigarette use, age, health factor, and social proximity are correlated with ENDS susceptibility. Conclusions: These ENDS users lack awareness of their devices and tobacco use plays a key role in ENDS susceptibility. Future studies should continue to study the role ENDS has in dependence and cigarette use.

Improved motivation and readiness to quit shortly after lung cancer screening: Evidence for a teachable moment

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Publication year

2022

Journal title

Cancer

Volume

128

Issue

10

Page(s)

1976-1986

10.1002/cncr.34133

Abstract

Abstract

Background: For patients at high risk for lung cancer, screening using low-dose computed tomography (lung cancer screening [LCS]) is recommended. The purpose of this study was to examine whether screening may serve as a teachable moment for smoking-related outcomes. Methods: In a smoking-cessation trial, participants (N = 843) completed 2 phone interviews before randomization: before LCS (T0) and after LCS (T1). By using logistic and linear regression, the authors examined teachable moment variables (perceived risk, lung cancer worry) and outcomes (readiness, motivation, and cigarettes per day [CPD]). Results: Participants were a mean ± SD age of 63.7 ± 5.9 years, had 47.8 ± 7.1 pack-years of smoking, 35.2% had a high school diploma or General Educational Development (high school equivalency) degree or less, and 42.3% were undergoing their first scan. Between T0 and T1, 25.7% of participants increased readiness to quit, 9.6% decreased readiness, and 64.7% reported no change (P <.001). Motivation to quit increased (P <.05) and CPD decreased between assessments (P <.001), but only 1.3% self-reported quitting. Compared with individuals who reported no lung cancer worry/little worry, extreme worry was associated with readiness to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.1-3.0) and with higher motivation (b = 0.83; P <.001) at T1. Individuals undergoing a baseline (vs annual) scan were more ready to quit in the next 30 days (odds ratio, 1.8; 95% CI, 1.3-2.5). Conclusions: During the brief window between registering for LCS and receiving the results, the authors observed that very few participants quit smoking, but a significant proportion improved on readiness and motivation to quit, particularly among individuals who were undergoing their first scan and those who were extremely worried about lung cancer. These results indicate that providing evidence-based tobacco treatment can build upon this teachable moment.

Maternal nicotine metabolism moderates the impact of maternal cigarette smoking on infant birth weight: A Collaborative Perinatal Project investigation

Stroud, L. R., Papandonatos, G. D., Jao, N. C., Niaura, R., Buka, S., & Benowitz, N. L. (n.d.).

Publication year

2022

Journal title

Drug and alcohol dependence

Volume

233

10.1016/j.drugalcdep.2022.109358

Abstract

Abstract

Background: Maternal cigarette smoking is an important modifiable risk factor for low birth weight in the US. We investigated the maternal nicotine metabolite ratio (NMR; trans-3’-hydroxycotinine/cotinine) – a genetically-informed biomarker of nicotine clearance – as a moderator of links between prenatal cigarette use and birth weight. We also explored the role of race in these associations. Methods: Participants were 454 pregnant women (Mage = 25 years; 11% Black) who smoked cigarettes and their 537 infants from the Collaborative Perinatal Project. Cigarettes smoked per day were assessed at each prenatal visit; maternal NMR was assayed from third trimester serum. Birth weight was obtained from medical records. Generalized estimating equations were used to evaluate associations between cigarette smoking, NMR, race, and birth weight. Results: NMR moderated continuous associations between cigarettes per day over pregnancy and infant birth weight (p = .025). Among women who smoked at moderate levels (<15 cigarettes per day), those with slower NMR showed ~50–100 g decrements in birth weight versus those with faster NMR., while there were no significant associations between NMR and birth weight among women who smoked 15+ cigarettes per day. Although effects of NMR on birthweight were similar for Black and white women, Black women showed significantly slower NMR (p < .001). Conclusions: This is the first demonstration that the maternal nicotine metabolism phenotype moderates associations between maternal smoking during pregnancy and birth weight. Infants of women with slower nicotine metabolism – including disproportionate representation of Black women – may be at heightened risk for morbidity from maternal smoking.

Relationships Between E-cigarette Use and Subsequent Cigarette Initiation Among Adolescents in the PATH Study: an Entropy Balancing Propensity Score Analysis

Xu, S., Coffman, D. L., Liu, B., Xu, Y., He, J., & Niaura, R. S. (n.d.).

Publication year

2022

Journal title

Prevention Science

Volume

23

Issue

4

Page(s)

608-617

10.1007/s11121-021-01326-4

Abstract

Abstract

This study aimed to examine the relationship between electronic cigarette use and subsequent combustible cigarette use, controlling for confounding by using a propensity score method approach. Data from the first three annual waves of the Population Assessment of Tobacco and Health study were analyzed (n = 6309). Participants were tobacco-naïve at Wave 1; used e-cigarettes exclusively (n = 414), used combustible cigarettes exclusively (n = 46), or not used any tobacco products (n = 5849) at Wave 2. We conducted entropy balancing propensity score analysis to examine the association between exclusive e-cigarette or cigarette initiation and subsequent cigarette use at Wave 3, adjusting for non-response bias, sampling bias, and confounding. Among tobacco-naïve youth, exclusive e-cigarette use was associated with greater risk for subsequent combustible cigarette smoking initiation (OR = 3.42, 95% CI = (1.99, 5.93)) and past 30-day combustible cigarette use (OR = 2.88, 95% CI = (1.22, 6.86)) in the following year. However, the latter risk was comparatively lower than the risk if youth started with a combustible cigarette (OR = 25.79, 95% CI = (9.68, 68.72)). Results of sensitivity analyses indicated that estimated effects were robust to unmeasured confounding. Use of e-cigarettes in tobacco-naïve youth is associated with increased risk of subsequent past 30-day combustible cigarette use but the risk is an order of magnitude higher if they start with a combustible cigarette.

Tobacco Product Use and Functionally Important Respiratory Symptoms Among US Adolescents/Young Adults

Tanski, S., Halenar, M. J., Edwards, K. C., Emond, J., Woloshin, S., Brunette, M., Schwartz, L., Taylor, K. A., Goniewicz, M. L., Niaura, R., Anic, G., Chen, Y., Callahan-Lyon, P., Gardner, L. D., Thekkudan, T., Borek, N., Kimmel, H. L., Cummings, K. M., Hyland, A., & Sargent, J. (n.d.).

Publication year

2022

Journal title

Academic Pediatrics

Volume

22

Issue

6

Page(s)

1006-1016

10.1016/j.acap.2022.03.001

Abstract

Abstract

Objective: The relation between respiratory symptoms and the range of tobacco product use among US adolescents/young adults is not yet clear. This cross-sectional analysis examines tobacco product use and respiratory symptoms in a nationally representative sample of 21,057 adolescents/young adults aged 12–24 years from Wave 4 (2016–17) of the Population Assessment of Tobacco and Health Study. Methods: Presence of functionally important respiratory symptoms was defined by questions regarding wheezing and nighttime cough at a cutoff score associated with poorer functional health status. Past-30-day tobacco use was analyzed 2 ways: never-tobacco users (reference) versus combustible users, noncombustible-only users, and former users; or frequency of use of cigarettes and/or e-cigarettes. Weighted Poisson regression adjusted for past-30-day marijuana use, secondhand smoke exposure, and asthma. Results: Functionally important respiratory symptoms were present in 10.0% overall: 13.8% of combustible users, 9.0% of noncombustible users, 8.2% of noncurrent users and 9.7% of never users. Functionally important respiratory symptoms were associated with combustible tobacco use (relative risk [RR] = 1.52[95% CI 1.29, 1.80]), marijuana use (RR = 1.54[1.34, 1.77]) and secondhand smoke exposure (RR = 1.04[1.03, 1.05]). Higher cigarette smoking frequency was also associated with functionally important respiratory symptoms for frequency categories >14 days/month (eg, RR = 1.93[1.50, 2.49] for 15–29 days/month). Frequency of e-cigarette use was not associated with functionally important respiratory symptoms. Conclusions: During 2016–17, smoking cigarettes, marijuana use, and secondhand smoke exposure were cross-sectionally associated with functionally important respiratory symptoms in adolescents/young adults. Risk increased with increased frequency of cigarette use but not e-cigarette use. Given changes to contemporary e-cigarettes and use, findings may not generalize to newer products.

Tobacco Use and Respiratory Symptoms Among Adults: Findings From the Longitudinal Population Assessment of Tobacco and Health (PATH) Study 2014-2016

Sargent, J. D., Halenar, M. J., Edwards, K. C., Woloshin, S., Schwartz, L., Emond, J., Tanski, S., Taylor, K. A., Pierce, J. P., Liu, J., Goniewicz, M. L., Niaura, R., Anic, G., Chen, Y., Callahan-Lyon, P., Gardner, L. D., Thekkudan, T., Borek, N., Kimmel, H. L., … Brunette, M. (n.d.).

Publication year

2022

Journal title

Nicotine and Tobacco Research

Volume

24

Issue

10

Page(s)

1607-1618

10.1093/ntr/ntac080

Abstract

Abstract

Introduction: We examined the relationship between current tobacco use and functionally important respiratory symptoms. Methods: Longitudinal cohort study of 16 295 US adults without COPD in Waves 2-3 (W2-3, 2014-2016) of the Population Assessment of Tobacco and Health Study. Exposure - Ten mutually exclusive categories of tobacco use including single product, multiple product, former, and never use (reference). Outcome - Seven questions assessing wheezing/cough were summed to create a respiratory symptom index; cutoffs of ≥2 and ≥3 were associated with functional limitations and poorer health. Multivariable regressions examined both cutoffs cross-sectionally and change over approximately 12 months, adjusting for confounders. Results: All tobacco use categories featuring cigarettes (>2/3's of users) were associated with higher risk (vs. never users) for functionally important respiratory symptoms at W2, for example, at symptom severity ≥ 3, risk ratio for exclusive cigarette use was 2.34 [95% CI, 1.92, 2.85] and for worsening symptoms at W3 was 2.80 [2.08, 3.76]. There was largely no increased symptom risk for exclusive use of cigars, smokeless tobacco, hookah, or e-cigarettes (adjustment for pack-years and marijuana attenuated the cross-sectional e-cigarette association from 1.53(95% CI 0.98, 2.40) to 1.05 (0.67, 1.63); RRs for these products were also significantly lower compared to exclusive use of cigarettes. The longitudinal e-cigarette-respiratory symptom association was sensitive to the respiratory index cutoff level; exclusive e-cigarette use was associated with worsening symptoms at an index cutoff ≥ 2 (RR = 1.63 [1.02, 2.59]) and with symptom improvement at an index cutoff of ≥ 3 (RR = 1.64 [1.04, 2.58]). Conclusions: Past and current cigarette smoking drove functionally important respiratory symptoms, while exclusive use of other tobacco products was largely not associated. However, the relationship between e-cigarette use and symptoms was sensitive to adjustment for pack-years and symptom severity. Implications: How noncigarette tobacco products affect respiratory symptoms is not clear; some studies implicate e-cigarettes. We examined functionally important respiratory symptoms (wheezing/nighttime cough) among US adults without COPD. The majority of adult tobacco users smoke cigarettes and have higher risk of respiratory symptoms and worsening of symptoms, regardless of other products used with them. Exclusive use of other tobacco products (e-cigarettes, cigars, smokeless, hookah) was largely not associated with functionally important respiratory symptoms and risks associated with their use was significantly lower than for cigarettes. The association for e-cigarettes was greatly attenuated by adjustment for cigarette pack-years and sensitive to how symptoms were defined.