Promoting Health Equity in Tobacco Outcomes: Examining Support for Endgame Policies Among Sample of U.S Adults

Promoting Health Equity in Tobacco Outcomes: Examining Support for Endgame Policies Among Sample of U.S Adults | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Promoting Health Equity in Tobacco Outcomes: Examining Support for Endgame Policies Among Sample of U.S Adults Julia M. Alber, Adrienne B. Lent, Pamela Estrada, Elmer Hernandez Gomez, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7511760/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Tobacco remains the leading cause of preventable death in the U.S. Endgame policies focus on addressing the causes of inequities in tobacco outcomes. While potentially impactful, public support in the U.S. is understudied. This study examined the public's support for comprehensive Endgame policies. A cross-sectional online survey of U.S. adults (N = 506) measured support for 36 Endgame policies. Participants also indicated preferred levels of government tobacco regulation and researchers examined factors associated with support. Support varied by policy category, from highest to lowest: Pricing/Nicotine, Packaging, Smoke-Free Housing, Retail Density, Sales Restrictions, and Eliminating Underage Penalties. Regulation preference varied, with some supporting national uniformity and others expressing distrust in specific government levels. Smoking status and Republican identification related to lower policy support. Support for Endgame policies varied in the sample. More research is needed to understand additional factors associated with policy support and strategies to promote support. advocacy public policy support tobacco prevention Endgame policies government control INTRODUCTION Tobacco use remains the leading cause of preventable death in the U.S. and globally [ 1 ]. Tobacco-related diseases and deaths are more likely to affect marginalized groups, [ 2 ] largely in part due to decades of targeted tobacco industry efforts. For example, black adults are more likely to die from smoking-related diseases compared to white adults [ 3 ]. Researchers likely attribute this to higher rates of menthol cigarette use, which are specifically marketed to these communities [ 4 ]. Despite efforts to provide education and implement strategies to reduce the burden of tobacco, inequities in tobacco use and tobacco-related deaths persist in the U.S. Refocusing and expanding on the type of tobacco control policies implemented is needed to make significant progress in reducing inequities in tobacco-related outcomes. Comprehensive tobacco control policies have shown to decrease tobacco availability and use [ 5 ]. Endgame policies provide a new outlook on tobacco control by promoting policies that address factors that led to inequities and provide a roadmap for the eventual end of commercial tobacco sales [ 6 ]. These policies address a variety of factors related to access, pricing, nicotine, and smoking cessation. Some previous studies have examined support for Endgame policies globally. A recent meta-analysis of Endgame policy support found high support for some of these policies worldwide [ 5 ]. However, studies that have examined support for a comprehensive number of Endgame policies have been conducted in countries outside the U.S., such as Ireland and the UK [ 7 ]. The existing U.S. studies have included a limited number of Endgame policies and do not provide a comprehensive analysis of Endgame support. For example, one study found support for a majority of federal tobacco regulations, such as banning certain flavors, among a sample of U.S. adults [ 8 ]. This support varied by individual factors such as demographics, education level, and exposure to tobacco control campaigns [ 8 ]. Another study of U.S. adults examined support for banning the sale of cigarettes and found that non-smokers were willing to support banning cigarette sales while former and current smokers did not [ 9 ]. Researchers limited these studies in the scope of Endgame policies and do not provide advocates with a comprehensive understanding of which type of policies are most likely to be supported in the U.S. Other research within the U.S. has been specific to a state or local jurisdiction and has focused on stakeholders rather than the public. For example, one California-based study examined support for Endgame policies among stakeholders (e.g., legislative members, advocacy groups/organizations)[ 10 ]. While support for Endgame policies was mixed, advocacy leaders and groups were more familiar with Endgame policies than legislative leaders. A similar study interviewed California policymakers to measure their reactions toward Endgame policies (e.g., banning tobacco sales and registering smokers) [ 11 ]. Most participants opposed tobacco sales bans but proposed or supported retailer reduction and prohibiting tobacco sales to individuals born after a certain year. Furthermore, some participants also agreed that more support for Endgame policies would come from state legislatures if similar enforcement was applied on the local level first [ 11 ]. These studies provide background on stakeholder support, however, public pressure is needed to ensure that stakeholders will be motivated to implement these policies [ 12 ]. Providing a more comprehensive assessment of Endgame policies support across the U.S. will provide a better understanding of which types of policies are more likely to be supported by the public in the short-term and which policies may need to be further promoted long-term. Additionally, understanding the role of demographic, political, and tobacco use factors related to support may inform advocacy efforts and research efforts. As such, the purpose of this mixed methods study was to examine: 1) support for a comprehensive list of Endgame policies, 2) factors associated with support for Endgame policies, and 3) explore individual perceptions towards which level of government should regulate tobacco policies among a sample of U.S. adults. Based on previous research, it was hypothesized that identifying as republican or independent, living in a rural location, and previous or current tobacco use would be related to lower support for policies overall. Additionally, it was hypothesized that policies that related to youth or schools, increasing prices, and limiting prices would receive higher support than policies related to smokefree, multiunit housing, and direct sales. METHODS This study received approval from the California Polytechnic State University Institutional Review Board (#2023 − 229) prior to data collection. This protocol was conducted in accordance with the relevant guidelines and regulations including the Declaration of Helsinki. All participants completed an online consent form prior to completing the survey. Sample and Procedures In February and March 2024, the research team used a Qualtrics Panel to recruit and conduct a cross-sectional survey. Qualtrics Panel is a survey panel company that recruits participants who are registered with the company from across the U.S. Participants were invited to complete a 15-minute online survey administered through Qualtrics Survey Software. Eligibility criteria included: 1) currently living in the U.S. and 2) aged 18 or older. Quota sampling was used to ensure representation of sex, age, and race/ethnicity similar to that of the U.S. based on census data. Sample size was based on available budget given parameters of the study (e.g., quota sampling, length of survey). Measures Demographic factors included age, sex, location (rural/urban), highest level of education, annual household income, and employment status and were measured using existing survey items [ 13 , 14 ]. Additionally, political party affiliations were accessed by participants' own identification as Democrat, Republican, Independent, or Other [ 15 ]. Participants also reported on their smoking and e-cigarette use in two separate questions by indicating if they currently smoked or used e-cigarettes 1) not all at, 2) some days, or 3) every day [ 16 ]. Some demographics and smoking-related items were re-coded for analysis including education 0) high school or below, 1) some college or above), employment 0) other values, 1) self-employed or employed for wages), political affiliation 0) Democrat, 1) Republican or Independent), income 0) less than $ 75,000 and below, 1) less than $ 100,000 and above), daily smoking habits 0) not at all, 1) some days or every day), current e-cigarette use 0) not at all, 1) some days or every day), and current tobacco use 0) not at all, 1) some days or every day). Support for specific tobacco control policies was measured across 6 categories including 1) Direct Sales Restrictions, 2) Retailer Focused and Density Policies, 3) Product Placement and Packaging Policies, 4) Pricing and Nicotine Level Policies, 5) Smokefree and Multiunit Housing Policies, and 6) Eliminating Penalties for Underage Use. To assess participants' support of each policy, a Likert scale was used ranging from 1) strongly opposed to 6) strongly supported. A list of items for each policy category can be found in the supplementary file for this article. Policies were based on Public Health Law Center’s Endgame Policy Platform Version 4 [ 17 ]. Participants were also asked “Which level of government do you believe should be regulating and implementing policies related to tobacco products?” with response options of local government, state government, and federal government. A textbox was then provided where participants could explain their answer. Participant zip codes were reported in a text box. The zip codes were then used to classify if they lived in a rural or urban area. The 2023 Rural-Urban Continuum Codes (RUCC) were specifically used to code each zip code using the nine classifications developed by the U.S. Department of Agriculture, Economic Research Service (18). The nine classifications were then recoded as either urban (1–3 RUCC) or nonmetro (4–9 RUCC) for analysis. Statistical Analysis Frequency and central tendency statistics were generated using IBM SPSS 24 (IBM, Armonk, NY, USA) to examine the demographic characteristics of the sample, including mean and standard deviation calculations for each category. An exploratory factor analysis was performed to group the policies into categories. A mean was then calculated across each category to create a composite score for each policy category. Linear regressions were run to examine the relationships between independent variables (i.e., demographic characteristics, political party preference, tobacco use, e-cigarette use, smoking frequency) and each policy category score. Listwise deletion was used to handle missing data. Researchers conducted Chi-squared tests to determine whether an individual’s political party, residence in a rural or urban environment, e-cigarette use frequency, smoking frequency, education level, sex, or racial identity (specifically identifying as Black African American or Latinx) were associated with their opinion on the level of government they believe should be involved in regulating and implementing policies related to tobacco products. Qualitative Analysis The qualitative response that allowed participants to explain why they believe a certain level of government should regulate tobacco policies was analyzed using a thematic analysis [ 19 ]. First, two trained coders developed open codes using 10% of the data. Next, the open codes were combined and defined. The codes were then pilot tested until intercoder reliability (Kappa value of .70 or above) was achieved [ 20 ]. The codes were then grouped into overarching themes. RESULTS Participants Characteristics Table 1 displays the participants' characteristics (n = 506). The mean age was 48.6 (SD = 17.26) with approximately half of participants identified as male (n = 243, 48%). The majority of participants identified as White (77.0%, n = 394) and 20.2% were Hispanic and/or Latino (n = 102). A similar number participated as identified as a Democrat (39.5%, n = 200), Independent (31.6%, n = 160), and Republican (26.9%, n = 136). Many of the participants were non-smokers (71.1%, n = 363). Table 1 Participant Characteristics Variable Study Participants Age (years), mean (SD) 61.1 (15.20) Sex, n (%) Female 261 (51.60) Male 243 (48.00) Other 2 (0.40) Ethnicity, n (%) Hispanic or Latino 102 (20.20) non-Hispanic or Latino 404 (79.80) Race, n (%) American Indian or Alaska Native 11 (2.20) Another Race 15 (3.00) Asian 32 (6.30) Black or African American 65 (12.80) Native Hawaiian or Other Pacific Islander 2 (0.20) White or European American 394 (77.90) Income, n (%) 75,000 and below 347 (68.60) 100,000 and above 149 (29.40) Education, n (%) Some college above 390 (77.10) High School or below 116 (22.90) Employment, n (% ) Employed for wages 208 (41.20) Retired 125 (24.70) Self-Employed 52 (10.30) Other 120 (23.80) Political Affiliation, n (%) Democrat 200 (39.50) Independent 160 (31.60) Republican 136 (26.90) Other 10 (2.00) Do you now smoke?, n (%) Everyday 87 (17.20) Some days 56 (11.10) Not at all 363 (71.10) Do you currently use e-cigarettes?, n (%) Everyday 38 (7.50) Some days 68 (13.40) Not at all 400 (79.10) Do you currently use any tobacco product?, n (%) Everyday 90 (17.80) Some days 65 (12.80) Not at all 351 (69.40) Overall Policy Support Table 2 summarizes specific support for Endgame policy categories. On average, the mean scores for the 6 policy categories ranged from 2.61 to 4.27 with a higher score relating to higher policy support. Support towards Eliminating Penalties for Underage Use (mean = 2.61, SD = 1.48) received the lowest average across categories while Pricing Policies and Nicotine Level Policies (mean = 4.27, SD = 1.39) had the highest overall average. Some notable individual policies with the highest average support included: 1) Requiring anyone selling tobacco to have a license which can be removed if they sell to underage individuals (mean = 5.00, SD = 1.20) and 2) Banning tobacco products in dining/service areas (mean = 4.92, SD = 1.40). The policies with the lowest average support included: 1) Eliminating all policies that penalize an underaged person for tobacco use (mean = 2.61, SD = 1.48) and 2) Banning cigarette filter sales (mean = 3.24, SD = 1.6). Table 2 Summary of Average Support by Endgame Policy Category Endgame Policy Category No. of Items Mean Std. Deviation Direct Sales Restrictions 6 3.55 1.44 Eliminating Penalties for Underage Use 1 2.61 1.48 Pricing Policies and Nicotine Level Policies 7 4.27 1.39 Product Placement and Packaging Policies 8 4.14 1.25 Retailer Focused Location and Density 6 3.86 1.29 Smokefree and Multiunit Housing Policies 8 4.12 1.19 Factors Associated with Policy Support Table 3 summarizes the results from the linear regressions for the associations between the demographic factors, smoking behaviors, and policy category average support. Older age was negatively associated with support for Penalties for Underage Use Policy (β = -0.12, p < 0.05). Republican or Independent political party affiliation was negatively associated with all tobacco control policies when compared to Democrat affiliation. The strongest effects were observed for Pricing Policies and Nicotine Level Policies (β = -0.15, p < 0.001) and Retailer Focused Location and Density Policies (β = -0.16, p < 0.001). Current smokers of any tobacco product were less likely to support several policies, most notably Retailer Focused Location and Density Policies (β = -0.23, p < 0.001). Individuals who currently used e-cigarettes showed lower support for Direct Sales Restriction (β = -0.12, p < 0.05) compared to those who did not report using e-cigarettes. Individuals employed for wages or self-employed demonstrated lower support for Penalties for Underage Use Policy compared to other non-employed individuals (β = -0.15, p = 0.046). Higher smoking frequency showed negative associations with multiple policies, with the strongest effects on Smokefree and Multiunit Housing Policies (β = -0.27, p < 0.001) and Pricing Policies and Nicotine Level Policies (β = -0.22, p < 0.001), indicating that more frequent smokers were less supportive than less frequent smokers. Individuals residing in urban areas demonstrated higher support for Product Placement and Packaging Policies (β = 0.13, p < 0.05), Pricing Policies and Nicotine Level Policies (β = 0.09, p < 0.05), and Retailer Focused Location and Density Policies (β = 0.14, p < 0.001) compared to people residing in rural areas. Individuals who identified as Black/African American showed lower support for Pricing Policies and Nicotine Level Policies (β = 0.09, p < 0.05) compared to those who were white. In regards to government regulations, most participants (56.5%, n = 286) favored federal regulation of tobacco policies, followed by state (31.0%, n = 157) and local (12.5%, n = 63) governments. Of the eight variables tested, three showed statistically significant associations: e-cigarette use frequency (p = 0.009), political party (p = 0.018), and smoking frequency (p = 0.013). Chi-squared tests revealed that Republicans and Independents were more likely to support state government regulating and implementing tobacco policies, χ² (2, N = 296) = 8.085, p < 0.05 whereas Democrats were more likely to support the federal government, χ² (2, N = 200) = 8.085, p < 0.05. Individuals using e-cigarettes daily were significantly more likely to support local governments regulating and implementing tobacco product-related policies χ² (2, N = 106) = 8.085, p < 0.05. Similarly, those who smoked some days or everyday preferred local governments (n = 27, 42.9%) regulating tobacco product-related policies, whereas those who do not smoke were more likely to select the federal government to regulate tobacco products, χ² (2, N = 143) = 8.085, p < 0.05. Qualitative Findings The qualitative findings highlighted 7 themes including: 1) Levels of Government, 2) Consistency, 3) Limited Control, 4) Government Authority and Responsibility, 5) Tobacco Beliefs, 6) Skeptical or distrustful, and 7) Unsure. The themes ranged from participants describing a specific level of government and its involvement in tobacco control, lack of confidence in government, a desire for uniformity in policies, as well as overall beliefs on tobacco. Table 4 highlights the codes and supportive quotes within each theme. Table 4 Linear Regressions Examining Factors Related to Endgame Policy Category Average Support Direct Sales Restrictions Product Placement and Packaging Policies Pricing Policies and Nicotine Level Policies Smokefree and Multiunit Housing Policies Retailer Focused Location and Density Policies Penalties for Underage Use Policy Age .08 .07 .09 .04 .05 − .12* Education a − .02 − .03 .02 .02 − .03 .08 Employment b − .02 − .01 .00 .00 .02 − .15** Income c − .01 − .01 .02 .01 − .01 − .07 Sex d − .07 − .04 − .07 − .07 − .06 − .01 Political Party e − .12** − .14** − .15** − .11* − .16** − .07 Urban f .04 .11* .09* .06 .14** .08 Current Smoker of Any Tobacco Product g − .19* − .12 − .17* − .14 − .23** .03 Current E-cigarette User g − .12* − .01 − .09 − .05 − .03 .04 Smoking Frequency g − .13 − .16* − .22** − .27** − .12 − .04 Black/African American .19 − .03 − .09* − .04 − .05 − .04 Latino or Hispanic .17 .03 .03 .04 .02 − .02 R 2 .20 .13 .26 .22 .19 .04 Note : All reported estimates are standardized regression coefficients. N = 506 a Referent group is high school or below b Referent group is all other values besides employed for wages or self employed; missing data (n = 1) c Referent group is less than $ 75,000 and below; missing data (n = 10) d Referent group is female, non-binary, or not-listed e Referent group is democrat; missing data (n = 10) f Referent group is nonmetro; missing data (n = 8) g Referent group is not at all Table 4 Supportive quotes of perspectives on tobacco product regulations among 506 participants, by theme and codes Themes Codes Supportive Quotes Levels of Government Local control preferred “The local government is most equipped to deal with the problem.” State control preferred “I prefer and trust in my state to regulate and implement policies to my liking rather than the federal government.” Federal control preferred “The federal government is the one with the authority to curb the tobacco industry menace.” No Government Involvement “No government should be regulating.” Case by Case “I think the substances should be regulated on a smaller case by case basis.” Multiple levels “It should be a joint process.” Consistency Consistency in policy “I believe that it's important to have a consistent policy that protects the health of all Americans.” Limited Control Limited federal control preferred “The federal government [control over regulations] should be more limited.” Limited state control preferred “This is because most likely these laws should be federal, not a decision by the individual state.” Limited local control preferred “It should be decisions taken for the whole country and not regional.” Government Authority & Responsibility Governmental protections “I just want there to be more restrictions on tobacco products, more specifically where they’re advertised, and who they’re being advertised to.” Rights “It’s not like we have a choice.” Tobacco illegal “I believe tobacco should be illegal.” Tobacco Beliefs Dangers of tobacco “I do believe it tends to be more or less dangerous depending on your location.” Perception of tobacco “I don’t ever want to try tobacco or vape products.” Skeptical or Distrustful Too complex “I think policies related to tobacco products are too big of an issue for local governments to handle.” Lack of trust “I do not trust the federal government to handle this issue.” Ineffective “Seems to be the way that it is, and we don’t have a real choice.” Of the 506 participants, 375 (74%) supported a preference for a specific level of government involvement (theme 1) (i.e., federal, state, or local) when creating, regulating, and enforcing tobacco-related policies. In contrast, 66 (13%) participants advocated for limited government control over tobacco regulation (theme 3). A desire for consistency (theme 2) was voiced by 81 (16%) participants who emphasized the need for uniformity across jurisdictions, noting that variability in policies can be “too confusing.” While 40 (8%) participants described that it was the government’s obligation to protect and/or enforce policies related to tobacco control (theme 4), 6 (1%) participants described distrust in the government (theme 6), and 17 (3%) participants were uncertain regarding the level of control the government should have (theme 7). Beyond views on governmental authority, 37 (7%) participants shared their opinions and beliefs related to tobacco (theme 5), acknowledging the potential harmful effects of tobacco. DISCUSSION This study provides insights into support and associated factors (e.g., demographic, political, tobacco behavior) for comprehensive endgame policies in the US. Findings indicate that the highest support was for policies within the Pricing Policies and Nicotine Level Policies category. On the other end, support was lowest for the category of Eliminating Penalties for Underage Use. Similar to previous research on tobacco control policy support, age, employment, political party, tobacco product smoking status, e-cigarette use, smoking frequency, and identifying as Black/African American were all associated with support for at least one Endgame policy category. One of the main findings of this research was that one category, Pricing Policies and Nicotine Level Policies, had the highest level of support among the study sample. Similarly, other studies have found high U.S. support for increasing prices and reducing nicotine levels in tobacco products. In terms of pricing, another study of U.S. adults conducted by the Truth Initiative found that the majority of Americans support increasing prices on cigarettes and banning coupons and multi-pack discounts [ 20 ]. Other researchers support the effectiveness of raising prices and eliminating discounts to reduce tobacco use [ 21 , 22 , 23 ]. While there is generally higher public support for pricing policies, the pricing overall in the U.S. still does not meet recommendations. The U.S. Surgeon General recommends a price tag of ten dollars or more per cigarette pack, yet the average retail price per pack was nine dollars as of July 2024 [ 24 , 25 ]. A total of 34 states had an average retail price per pack below ten dollars and 28 states had not increased cigarette taxes in the last ten years. Given the wide support for such policies and the ability of states to regulate cigarette taxes, public health advocates should consider promoting policies that increase the price of cigarettes, especially in the 34 states that have not increased taxes over the last ten years. In terms of nicotine-specific policies, another nationally representative study of U.S. adults found that more than 70% of Americans support reducing nicotine levels in cigarettes [ 8 ]. Research supports reducing nicotine to make cigarettes less addictive, support cessation, and reduce use [ 8 , 26 , 27 ]. The Food and Drug Administration (FDA) announced plans to set a maximum nicotine level in cigarettes and other combustible tobacco products in June 2022 [ 1 ]. The FDA was still working on a proposal for reducing nicotine levels as of 2024, and it is expected that such regulation could take years to approve [ 28 ]. Legal experts have argued that states have the power to regulate nicotine levels in cigarettes on their own and do not need to wait for the FDA [ 29 ]. Given strong public support and state authority to regulate nicotine levels, public health advocates should consider prioritizing the promotion of policies that limit the sale of cigarettes and limit nicotine levels. One policy clearly stood out as the lowest rated policy, eliminating penalties for underage tobacco use. Policies that restrict access to tobacco products, including penalties for underage use, have historically been widely supported in the U.S [ 30 ]. This study also found that support for policy that eliminates penalties for underage youth decreased with age and employment. Other research has found that support for youth-focused tobacco control policies are highest among older adults and those working in healthcare organizations [ 12 , 31 , 32 ]. Most U.S. states have laws penalizing underage tobacco use, some of which are classified as criminal offenses [ 33 ]. However, these laws are unlikely to reduce youth smoking at a population level [ 34 ]. Furthermore, they disproportionately affect youth from underrepresented and high risk groups. One U.S. study found that Black or African American and Latinx youth were cited at higher rates compared to their white peers even after adjusting for smoking behaviors [ 35 ]. Reversing laws that penalize underage use of tobacco products may be a challenge since older Americans support policies that restrict youth tobacco access and make up large portions of lawmakers in the US [ 36 ]. Given that the tobacco industry heavily advertises to youth, ineffective policies that penalize youth tobacco use should be replaced with policies that prohibit or limit the marketing of tobacco products. In 2019, the majority (over 90%) of tobacco company marketing expenditures included price discounts to reduce cigarette pack prices, promotional allowances for product stocking, shelving, and displaying, and promotions (e.g., rebates) [ 37 ]. It may be more feasible to promote policies focused on product placement (e.g., prohibiting retailers from displaying tobacco products and paraphernalia near schools) and pricing versus eliminating penalties for underage use as a way to address underage tobacco use in the near future given this study’s findings of wide support for Pricing Policies and Nicotine Level Policies and Product Placement and Packaging Policies. Given that policies that penalize youth tobacco use are prevalent in the U.S. and have wide public support despite their efficacy and resulting disparities, there is a need to advocate for the removal of such policies, especially with older lawmakers, to ensure health equity and reduce youth tobacco use. This study found that Endgame policy support varied across demographics and political party affiliation in particular. Political party affiliation appeared to be associated with five out of the six Endgame policy categories, with Republicans and Independents reporting lower support compared to Democrats overall. Similarly, another study of U.S. adults found that liberals were more likely to support several tobacco control policies compared to conservatives, such as removing tobacco products from customers’ views and removing tobacco advertisements from windows and registers [ 38 ]. While Republican support for tobacco control policies may be low, it’s important to note that smoking rates are higher in Republican states versus Democratic states [ 39 ]. Given the issue of racial disparities in tobacco use and related morbidity and mortality, Endgame policies are important for addressing health equity. However, several polls of U.S. adults from 2020 found that a substantial number of Democrats viewed racial inequality as a top priority while this was not a concern among Republicans [ 40 ]. Tobacco control advocacy groups may need to tailor messaging to Republican lawmakers and focus on the negative health effects of tobacco use on their constituents to support non-partisan legislation and passage of Endgame policies. Results from the linear regression analysis also found that Endgame policy support varied by tobacco use, race, and rural-urban residence. Current tobacco users and those who identified as Black/African American were less likely to support certain Endgame policies while those living in urban areas were more likely to indicate support. Results from other U.S. studies show similar results. Support for tobacco control policies is consistently lower among current versus non-smokers [ 41 ]. Black and African Americans have reported high support for tobacco control policies, including Pricing Policies and Nicotine Policies [ 42 , 43 ]. Individuals living in urban areas are more likely to support tobacco control policies compared to those in rural areas [ 44 ]. Rural counties with higher tobacco production are less likely to support policies aimed at reducing tobacco use [ 45 ]. While the dangers of tobacco have been well documented and established, Americans living in rural areas report lower trust in government and science [ 46 ]. Given higher rates of tobacco use in rural versus urban areas [ 44 ], more research and advocacy are needed in rural areas to reduce the burden of tobacco. In addition to current tobacco users, efforts and communications may need to be tailored to gain support from Black and African American and rural communities for Endgame policies to reduce disparities within these groups. While our study offers valuable insights into the support for specific Endgame policies among a sample of US adults, it is important to acknowledge its limitations. The use of a survey panel, while efficient for data collection, may limit the generalizability of our findings, as the sample may not fully represent the diversity of the U.S. adult population. While we employed quota sampling for certain demographics, not all demographic groups were equally represented, introducing potential biases. Additionally, the cross-sectional design restricts our ability to establish causal relationships between demographic variables and policy support. We also cannot make a direct connection between support and voting action. Our study included more policies than previously published work, however, there may be other policies that could be seen as Endgame policies that were not included. Moreover, the limited variables outside of policy support included in our analysis restrict our ability to investigate other potential influencing factors. Finally, the reliance on self-reported data for assessing support for 36 different policies may be subject to social desirability bias, as participants may provide responses that align with perceived societal norms. Despite these limitations, our findings expand our understanding of public support toward Endgame policies and provide a foundation for further investigation into strategies for promoting their adoption and implementation. CONCLUSION As tobacco continues to be the leading cause of preventable death in the U.S., Endgame policies are needed to better address the tobacco-related health inequities that exist. To promote the adoption of these types of policies, it is critical to understand which types of policies are more likely to be supported by the public now and which policies may need strategies to promote them. This study provided a much more comprehensive summary of different types of Endgame policy support in the U.S. than previously published work. This study found that Endgame policies varied in support by the type of policy with more support related to setting pricing and nicotine levels, where products can be placed, and the packaging that can be used. Additionally, this study echoed previous studies in finding that smokers and political affiliation may play a significant role in how the public perceives these types of policies. Results suggest that tailored strategies to incorporate these characteristics may be needed to increase support for Endgame policies. Future research is needed to examine the best approaches for increasing support for Endgame policies. Declarations Funding: This research was supported by the William and Linda Frost Fund in the Cal Poly Bailey College of Science and Mathematics and the Cal Poly Learning Aligned Employment Program (LEAP). Human Ethics and Consent to Participate: This was a cross-sectional study completed with the purpose of describing public support for tobacco Endgame policies. This study received approval from the California Polytechnic State University Institutional Review Board (#2023-229) prior to data collection in accordance with the National Research Act - 45 CFR 46 subpart A and the Belmont Report. The protocol was performed in accordance with the relevant guidelines and regulations [Declaration of Helsinki]. Electronic informed consent was received prior to proceeding with the study. Only those who agreed to participate completed the study. Participants were informed of their right to withdraw from the study or skip any question at time during the survey. All data collected was anonymous. Competing Interests: On behalf of all authors, the corresponding author states that there is no conflict of interest. Consent to publish: Not applicable. Clinical trial number: Not applicable. References U.S. Food and Drug Administration. FDA Announces Plans for Proposed Rule to Reduce Addictiveness of Cigarettes and Other Combusted Tobacco Products | FDA. 2022. https://web.archive.org/web/20221214010506/https://www.fda.gov/news-events/press-announcements/fda-announces-plans-proposed-rule-reduce-addictiveness-cigarettes-and-other-combusted-tobacco. Accessed 25 Sep 2024 American Lung Association. Top 10 Communities Disproportionately Affected by Cigarette Smoking and Tobacco Use.https://www.lung.org/research/sotc/by-the-numbers/top-10-populations-affected. Accessed 25 Sep 2024 CDC. Tobacco - Health Equity. 2024. African American Communities Experience a Health Burden From Commercial Tobacco. https://www.cdc.gov/tobacco-health-equity/collection/african-american-health-burden.html. Accessed 25 Sep 2024 Cheng YJ. Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999–2018. Prev Chronic Dis. 2024;21. https://www.cdc.gov/pcd/issues/2024/23_0291.htm. Accessed 25 Sep 2024 Kim H, Gartner C, Edwards R, Puljević C, Morphett K, Kim DH, et al. Public Support for Tobacco Endgame Policies: A Systematic Review and Meta-analysis. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2024 Jun 19;ntae149. Puljević C, Morphett K, Hefler M, Edwards R, Walker N, Thomas DP, et al. Closing the gaps in tobacco endgame evidence: a scoping review. Tob Control. 2022 Mar;31(2):365–75. Cosgrave EJ, Blake M, Murphy E, Sheridan A, Doyle F, Kavanagh P. Is the public ready for a tobacco-free Ireland? A national survey of public knowledge and attitudes to tobacco endgame in Ireland. Tob Control. 2023 May 26;tc-2023-057958. Schmidt AM, Kowitt SD, Myers AE, Goldstein AO. Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults. Int J Environ Res Public Health. 2018 Jan 5;15(1):72. Avisha A, Ribisl KM, Sheeran P. Realizing the Tobacco Endgame: Understanding and mobilizing public support for banning combustible cigarette sales in the United States - ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S0277953623002964. Accessed 1 Oct 2024 Smith EA, McDaniel PA, Malone RE. Leadership Perceptions of Endgame Strategies for Tobacco Control in California. J Public Health Manag Pract JPHMP. 2019;25(6):554–61. McDaniel P, Smith E, Malone RE. California policymakers’ perspectives on tobacco endgame approaches. 2018. https://www.tobaccoinduceddiseases.org/California-policymakers-perspectives-on-tobacco-endgame-approaches,83794,0,2.html. Accessed 25 Sep 2024 Winickoff JP, McMillen R, Tanski S, Wilson K, Gottlieb M, Crane R. Public support for raising the age of sale for tobacco to 21 in the United States. Tob Control. 2016;25(3):284–8. CDC. National Health Interview Survey. 2024 https://www.cdc.gov/nchs/nhis/2022nhis.htm. Accessed 1 Oct 2024 Alber JM, Glanz K. Does the Screening Status of Message Characters Affect Message Effects? Health Educ Behav Off Publ Soc Public Health Educ. 2018 Feb;45(1):14–9. Political Independents: Who They Are, What They Think. Pew Research Center. 2019. https://www.pewresearch.org/politics/2019/03/14/political-independents-who-they-are-what-they-think/. Accessed 1 Oct 2024 CDC. Behavioral Risk Factor Surveillance System Survey Questionnaire. 2024. https://www.cdc.gov/brfss/questionnaires/index.htm. Accessed 1 Oct 2024 Tobacco-Related Disease Research Program. California Endgame Resources. Endgame Policy Platform -Version 4. https://www.trdrp.org/about/ca-endgame-resources.html. Accessed 1 Oct 2024 U.S. Department of Agriculture, Economics Research Service. Rural-Urban Continuum Codes. 2024. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx. Accessed 4 Oct 2024 Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. Burla L, Knierim B, Barth J, Liewald K, Duetz M, Abel T. From Text to Codings: Intercoder Reliability Assessment in Qualitative Content Analysis. Nurs Res. 2008 Apr;57(2):113. Truth Initiative: inspiring lives free from smoking, vaping, and nicotine. https://truthinitiative.org/. Accessed 27 Sep 2024 Marynak KL, Xu X, Wang X, Holmes CB, Tynan MA, Pechacek T. Estimating the Impact of Raising Prices and Eliminating Discounts on Cigarette Smoking Prevalence in the United States. Public Health Rep Wash DC 1974. 2016;131(4):536–43. McLaughlin I, Pearson A, Laird-Metke E, Ribisl K. Reducing tobacco use and access through strengthened minimum price laws. Am J Public Health. 2014 Oct;104(10):1844–50. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Centers for Disease Control and Prevention (US); 2014 . (Reports of the Surgeon General). http://www.ncbi.nlm.nih.gov/books/NBK179276/. Accessed 27 Sep 2024 Campaign for Tobacco-Free Kids. Campaign for Tobacco Free Kids. Available from: https://www.tobaccofreekids.org/. Accessed 27 Sep 2024 Benowitz NL, Henningfield JE. Reducing the nicotine content to make cigarettes less addictive. Tob Control. 2013 May;22 Suppl 1(Suppl 1):i14-17. Apelberg BJ, Feirman SP, Salazar E, Corey CG, Ambrose BK, Paredes A, et al. Potential Public Health Effects of Reducing Nicotine Levels in Cigarettes in the United States. N Engl J Med. 2018 May 3;378(18):1725–33. King B. A Year in Review: FDA’s Progress on Tobacco Product Regulation in 2023. FDA. 2024 Aug 9. https://www.fda.gov/tobacco-products/ctp-newsroom/year-review-fdas-progress-tobacco-product-regulation-2023. Accessed 25 Sep 2024 Twinamatsiko A. States Don’t Need to Wait for FDA to Adopt Nicotine Reduction Endgame Strategies: Lessons from Flavored Tobacco Litigation. 2023 https://papers.ssrn.com/abstract=4761319. Accessed 4 Oct 2024 Bailey WJ, Crowe JW. A national survey of public support for restrictions on youth access to tobacco. J Sch Health. 1994 Oct;64(8):314–7. Gentzke AS, Glover-Kudon R, Tynan M, Jamal A. Adults’ attitudes toward raising the minimum age of sale for tobacco products to 21 years, United States, 2014-2017. Prev Med. 2020 Feb 3;133:106012. Howard KA, Rogers T, Howard-Pitney B, Flora JA, Norman GJ, Ribisl KM. Opinion leaders’ support for tobacco control policies and participation in tobacco control activities. Am J Public Health. 2000 Aug;90(8):1283–7. Bonnie RJ, Stratton K, Kwan LY, Products C on the PHI of R the MA for PT, Practice B on PH and PH, Medicine I of. Restrictions on Youth Access to Tobacco Products. In: Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. National Academies Press (US). 2015 https://www.ncbi.nlm.nih.gov/books/NBK310404/. Accessed 25 Sep 2024 Wakefield M, Giovino G. Teen penalties for tobacco possession, use, and purchase: evidence and issues. Tob Control. 2003 Jun;12 Suppl 1(Suppl 1):i6-13. Gottlieb NH, Loukas A, Corrao M, McAlister A, Snell C, Huang PP. Minors’ tobacco possession law violations and intentions to smoke: implications for tobacco control. Tob Control. 2004 Sep;13(3):237–43. Curry JM, Haydon MR. Lawmaker Age, Issue Salience, and Senior Representation in Congress. Am Polit Res. 2018 Jul 1;46(4):567–95. United States. Federal Trade Commission. Federal Trade Commission: Cigarette Report for 2001. Federal Trade Commission; 2003. Accessed 1 Oct 2024 Shete SS, Yu R, Shete S. Political Ideology and the Support or Opposition to United States Tobacco Control Policies. JAMA Netw Open. 2021 Sep 1;4(9):e2125385. Fox AM, Feng W, Yumkham R. State political ideology, policies and health behaviors: The case of tobacco. Soc Sci Med 1982. 2017 May;181:139–47. Smeltz D. Republican Views on Racial Inequality Starkly Contrast Those of Democrats. The Chicago Council on Global Affairs; 2020. https://globalaffairs.org/research/public-opinion-survey/republican-views-racial-inequality-starkly-contrast-those-democrats. Accessed 7 Oct 2024 Payán DD, Burke NJ, Persinger J, Martinez J, Barker LJ, Song AV. Public support for policies to regulate flavoured tobacco and e-cigarette products in rural California. Tob Control. 2023 Apr 1;32(e1):e125–9. King G, Mallett RK, Kozlowski LT, Bendel RB. African Americans’ Attitudes Toward Cigarette Excise Taxes. Am J Public Health. 2003 May;93(5):828–34. Pearson JL, Abrams DB, Niaura RS, Richardson A, Vallone DM. Public support for mandated nicotine reduction in cigarettes. Am J Public Health. 2013 Mar;103(3):562–7. Rayens MK, Hahn EJ, Langley RE, Zhang M. Public Support for Smoke-Free Laws in Rural Communities. Am J Prev Med. 2008 Jun 1;34(6):519–22. Hahn EJ, Rayens MK, York N. Readiness for smoke-free policy and overall strength of tobacco control in rural tobacco-growing communities. Health Promot Pract. 2013 Mar;14(2):238–46. Krause NM. Placing “trust” in science: The urban-rural divide and Americans’ feelings of warmth toward scientists. Public Underst Sci Bristol Engl. 2023 Jul;32(5):596–604. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7511760","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":531929619,"identity":"e1e306a9-e204-48af-a1fb-beea3ae28799","order_by":0,"name":"Julia M. Alber","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYBACxgYGxsNAWo6BgbmBgaEAJJZAUAsDSIsxhGlAhBYQAGlJbCBaC/O0ww8OF1TcS+9vP9j24IPBYQZ+9hwD/A6bnWZweMaZ4twZZxLbDWcAtUj2vCGkJcHgMG9bQu4GhsQ2aR6gFoMbBG1J/3CY919CugH/Q4gWe8JacoC2NCQkGEjAbJEgrKXg8IxjCYYzbjwE+SWdR+LMswK8Wgxnp298XFCTIM/fn3zswYcKazn+9uQN+LU0INhsQNzMg1c5CMgjsUFa6gjqGAWjYBSMgpEHAKNiStyRyU8zAAAAAElFTkSuQmCC","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":true,"prefix":"","firstName":"Julia","middleName":"M.","lastName":"Alber","suffix":""},{"id":531929620,"identity":"85475005-1357-4567-b717-aa90f00e3f77","order_by":1,"name":"Adrienne B. Lent","email":"","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":false,"prefix":"","firstName":"Adrienne","middleName":"B.","lastName":"Lent","suffix":""},{"id":531929621,"identity":"771da1c2-00dd-47eb-a2ee-f906012c251e","order_by":2,"name":"Pamela Estrada","email":"","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":false,"prefix":"","firstName":"Pamela","middleName":"","lastName":"Estrada","suffix":""},{"id":531929623,"identity":"8790067c-0119-4cb5-8608-b46c7ded5b7a","order_by":3,"name":"Elmer Hernandez Gomez","email":"","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":false,"prefix":"","firstName":"Elmer","middleName":"Hernandez","lastName":"Gomez","suffix":""},{"id":531929627,"identity":"09ec3f15-641a-4ab2-8139-7587714469b8","order_by":4,"name":"Jenna Holman","email":"","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":false,"prefix":"","firstName":"Jenna","middleName":"","lastName":"Holman","suffix":""},{"id":531929629,"identity":"5933c4d9-44d8-4394-ab6c-e53b04216184","order_by":5,"name":"Katharine Santilena","email":"","orcid":"","institution":"California Polytechnic State University","correspondingAuthor":false,"prefix":"","firstName":"Katharine","middleName":"","lastName":"Santilena","suffix":""}],"badges":[],"createdAt":"2025-09-01 22:38:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7511760/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7511760/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93929854,"identity":"ce3d3cc6-9779-483c-9c54-fe00d403a767","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":43002,"visible":true,"origin":"","legend":"","description":"","filename":"DiscoverPublicHealthMainPaperRevised.docx","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/357d476af695a46eba7a7f89.docx"},{"id":93929853,"identity":"0d6dc990-223f-4e17-a06f-eac43f3fb4f7","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":24882,"visible":true,"origin":"","legend":"","description":"","filename":"DiscoverPublicHealthTables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/1d519f3bb7071fbe998602a0.docx"},{"id":93929852,"identity":"af14fa59-1724-4cdb-ae53-add077988133","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"json","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7000,"visible":true,"origin":"","legend":"","description":"","filename":"8ed6a40271014af7a259b06e348b7658.json","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/68ee1e370f61ab0202aaf3ce.json"},{"id":93929855,"identity":"d7fca6d2-6ce1-4efd-88b8-fb2e09f4bb9d","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":121197,"visible":true,"origin":"","legend":"","description":"","filename":"8ed6a40271014af7a259b06e348b76581enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/da366e0c7931c7dc88611dad.xml"},{"id":93929856,"identity":"c4daff1c-2d0d-4bf0-89c4-733d9d128e83","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"xml","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118020,"visible":true,"origin":"","legend":"","description":"","filename":"8ed6a40271014af7a259b06e348b76581structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/cc5ef074c5e0b5774090f816.xml"},{"id":93929857,"identity":"6fc3b09f-0d7a-44b8-afdb-6fd815d7fbbb","added_by":"auto","created_at":"2025-10-20 11:34:01","extension":"html","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":128168,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/a473d69d70bd872dca560712.html"},{"id":105363134,"identity":"75af5f69-c810-429b-ab1c-0fcccb050b8f","added_by":"auto","created_at":"2026-03-25 08:13:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1040554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7511760/v1/df9c558b-8f90-4650-aa17-05cdfd6f140e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Promoting Health Equity in Tobacco Outcomes: Examining Support for Endgame Policies Among Sample of U.S Adults","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTobacco use remains the leading cause of preventable death in the U.S. and globally [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Tobacco-related diseases and deaths are more likely to affect marginalized groups, [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] largely in part due to decades of targeted tobacco industry efforts. For example, black adults are more likely to die from smoking-related diseases compared to white adults [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Researchers likely attribute this to higher rates of menthol cigarette use, which are specifically marketed to these communities [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite efforts to provide education and implement strategies to reduce the burden of tobacco, inequities in tobacco use and tobacco-related deaths persist in the U.S. Refocusing and expanding on the type of tobacco control policies implemented is needed to make significant progress in reducing inequities in tobacco-related outcomes. Comprehensive tobacco control policies have shown to decrease tobacco availability and use [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Endgame policies provide a new outlook on tobacco control by promoting policies that address factors that led to inequities and provide a roadmap for the eventual end of commercial tobacco sales [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These policies address a variety of factors related to access, pricing, nicotine, and smoking cessation. Some previous studies have examined support for Endgame policies globally. A recent meta-analysis of Endgame policy support found high support for some of these policies worldwide [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, studies that have examined support for a comprehensive number of Endgame policies have been conducted in countries outside the U.S., such as Ireland and the UK [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The existing U.S. studies have included a limited number of Endgame policies and do not provide a comprehensive analysis of Endgame support. For example, one study found support for a majority of federal tobacco regulations, such as banning certain flavors, among a sample of U.S. adults [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This support varied by individual factors such as demographics, education level, and exposure to tobacco control campaigns [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another study of U.S. adults examined support for banning the sale of cigarettes and found that non-smokers were willing to support banning cigarette sales while former and current smokers did not [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Researchers limited these studies in the scope of Endgame policies and do not provide advocates with a comprehensive understanding of which type of policies are most likely to be supported in the U.S.\u003c/p\u003e\u003cp\u003eOther research within the U.S. has been specific to a state or local jurisdiction and has focused on stakeholders rather than the public. For example, one California-based study examined support for Endgame policies among stakeholders (e.g., legislative members, advocacy groups/organizations)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. While support for Endgame policies was mixed, advocacy leaders and groups were more familiar with Endgame policies than legislative leaders. A similar study interviewed California policymakers to measure their reactions toward Endgame policies (e.g., banning tobacco sales and registering smokers) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Most participants opposed tobacco sales bans but proposed or supported retailer reduction and prohibiting tobacco sales to individuals born after a certain year. Furthermore, some participants also agreed that more support for Endgame policies would come from state legislatures if similar enforcement was applied on the local level first [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These studies provide background on stakeholder support, however, public pressure is needed to ensure that stakeholders will be motivated to implement these policies [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eProviding a more comprehensive assessment of Endgame policies support across the U.S. will provide a better understanding of which types of policies are more likely to be supported by the public in the short-term and which policies may need to be further promoted long-term. Additionally, understanding the role of demographic, political, and tobacco use factors related to support may inform advocacy efforts and research efforts. As such, the purpose of this mixed methods study was to examine: 1) support for a comprehensive list of Endgame policies, 2) factors associated with support for Endgame policies, and 3) explore individual perceptions towards which level of government should regulate tobacco policies among a sample of U.S. adults. Based on previous research, it was hypothesized that identifying as republican or independent, living in a rural location, and previous or current tobacco use would be related to lower support for policies overall. Additionally, it was hypothesized that policies that related to youth or schools, increasing prices, and limiting prices would receive higher support than policies related to smokefree, multiunit housing, and direct sales.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e This study received approval from the California Polytechnic State University Institutional Review Board (#2023\u0026thinsp;\u0026minus;\u0026thinsp;229) prior to data collection. This protocol was conducted in accordance with the relevant guidelines and regulations including the Declaration of Helsinki. All participants completed an online consent form prior to completing the survey.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSample and Procedures\u003c/h2\u003e\u003cp\u003eIn February and March 2024, the research team used a Qualtrics Panel to recruit and conduct a cross-sectional survey. Qualtrics Panel is a survey panel company that recruits participants who are registered with the company from across the U.S. Participants were invited to complete a 15-minute online survey administered through Qualtrics Survey Software. Eligibility criteria included: 1) currently living in the U.S. and 2) aged 18 or older. Quota sampling was used to ensure representation of sex, age, and race/ethnicity similar to that of the U.S. based on census data. Sample size was based on available budget given parameters of the study (e.g., quota sampling, length of survey).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eDemographic factors included age, sex, location (rural/urban), highest level of education, annual household income, and employment status and were measured using existing survey items [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Additionally, political party affiliations were accessed by participants' own identification as Democrat, Republican, Independent, or Other [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Participants also reported on their smoking and e-cigarette use in two separate questions by indicating if they currently smoked or used e-cigarettes 1) not all at, 2) some days, or 3) every day [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Some demographics and smoking-related items were re-coded for analysis including education 0) high school or below, 1) some college or above), employment 0) other values, 1) self-employed or employed for wages), political affiliation 0) Democrat, 1) Republican or Independent), income 0) less than \u003cspan\u003e$\u003c/span\u003e75,000 and below, 1) less than \u003cspan\u003e$\u003c/span\u003e100,000 and above), daily smoking habits 0) not at all, 1) some days or every day), current e-cigarette use 0) not at all, 1) some days or every day), and current tobacco use 0) not at all, 1) some days or every day).\u003c/p\u003e\u003cp\u003eSupport for specific tobacco control policies was measured across 6 categories including 1) Direct Sales Restrictions, 2) Retailer Focused and Density Policies, 3) Product Placement and Packaging Policies, 4) Pricing and Nicotine Level Policies, 5) Smokefree and Multiunit Housing Policies, and 6) Eliminating Penalties for Underage Use. To assess participants' support of each policy, a Likert scale was used ranging from 1) strongly opposed to 6) strongly supported. A list of items for each policy category can be found in the supplementary file for this article. Policies were based on Public Health Law Center\u0026rsquo;s Endgame Policy Platform Version 4 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eParticipants were also asked \u0026ldquo;Which level of government do you believe should be regulating and implementing policies related to tobacco products?\u0026rdquo; with response options of local government, state government, and federal government. A textbox was then provided where participants could explain their answer.\u003c/p\u003e\u003cp\u003e Participant zip codes were reported in a text box. The zip codes were then used to classify if they lived in a rural or urban area. The 2023 Rural-Urban Continuum Codes (RUCC) were specifically used to code each zip code using the nine classifications developed by the U.S. Department of Agriculture, Economic Research Service (18). The nine classifications were then recoded as either urban (1\u0026ndash;3 RUCC) or nonmetro (4\u0026ndash;9 RUCC) for analysis.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eFrequency and central tendency statistics were generated using IBM SPSS 24 (IBM, Armonk, NY, USA) to examine the demographic characteristics of the sample, including mean and standard deviation calculations for each category. An exploratory factor analysis was performed to group the policies into categories. A mean was then calculated across each category to create a composite score for each policy category. Linear regressions were run to examine the relationships between independent variables (i.e., demographic characteristics, political party preference, tobacco use, e-cigarette use, smoking frequency) and each policy category score. Listwise deletion was used to handle missing data.\u003c/p\u003e\u003cp\u003eResearchers conducted Chi-squared tests to determine whether an individual\u0026rsquo;s political party, residence in a rural or urban environment, e-cigarette use frequency, smoking frequency, education level, sex, or racial identity (specifically identifying as Black African American or Latinx) were associated with their opinion on the level of government they believe should be involved in regulating and implementing policies related to tobacco products.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQualitative Analysis\u003c/h3\u003e\n\u003cp\u003eThe qualitative response that allowed participants to explain why they believe a certain level of government should regulate tobacco policies was analyzed using a thematic analysis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. First, two trained coders developed open codes using 10% of the data. Next, the open codes were combined and defined. The codes were then pilot tested until intercoder reliability (Kappa value of .70 or above) was achieved [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The codes were then grouped into overarching themes.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eParticipants Characteristics\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays the participants' characteristics (n\u0026thinsp;=\u0026thinsp;506). The mean age was 48.6 (SD\u0026thinsp;=\u0026thinsp;17.26) with approximately half of participants identified as male (n\u0026thinsp;=\u0026thinsp;243, 48%). The majority of participants identified as White (77.0%, n\u0026thinsp;=\u0026thinsp;394) and 20.2% were Hispanic and/or Latino (n\u0026thinsp;=\u0026thinsp;102). A similar number participated as identified as a Democrat (39.5%, n\u0026thinsp;=\u0026thinsp;200), Independent (31.6%, n\u0026thinsp;=\u0026thinsp;160), and Republican (26.9%, n\u0026thinsp;=\u0026thinsp;136). Many of the participants were non-smokers (71.1%, n\u0026thinsp;=\u0026thinsp;363).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant Characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStudy Participants\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (years), mean (SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.1 (15.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e261 (51.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e243 (48.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic or Latino\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102 (20.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003enon-Hispanic or Latino 404 (79.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRace, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (2.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnother Race\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (3.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (6.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack or African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65 (12.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNative Hawaiian or Other Pacific Islander\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite or European American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e394 (77.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e75,000 and below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e347 (68.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e100,000 and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e149 (29.40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome college above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e390 (77.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh School or below\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e116 (22.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment, n (%\u003c/b\u003e\u003csup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed for wages\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e208 (41.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetired\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e125 (24.70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSelf-Employed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (10.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120 (23.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePolitical Affiliation, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemocrat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e200 (39.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndependent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160 (31.60)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRepublican\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e136 (26.90)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (2.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDo you now smoke?, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEveryday\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87 (17.20)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56 (11.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e363 (71.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDo you currently use e-cigarettes?, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEveryday\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (7.50)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68 (13.40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e400 (79.10)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDo you currently use any tobacco product?, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEveryday\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (17.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65 (12.80)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e351 (69.40)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOverall Policy Support\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes specific support for Endgame policy categories. On average, the mean scores for the 6 policy categories ranged from 2.61 to 4.27 with a higher score relating to higher policy support. Support towards Eliminating Penalties for Underage Use (mean\u0026thinsp;=\u0026thinsp;2.61, SD\u0026thinsp;=\u0026thinsp;1.48) received the lowest average across categories while Pricing Policies and Nicotine Level Policies (mean\u0026thinsp;=\u0026thinsp;4.27, SD\u0026thinsp;=\u0026thinsp;1.39) had the highest overall average. Some notable individual policies with the highest average support included: 1) Requiring anyone selling tobacco to have a license which can be removed if they sell to underage individuals (mean\u0026thinsp;=\u0026thinsp;5.00, SD\u0026thinsp;=\u0026thinsp;1.20) and 2) Banning tobacco products in dining/service areas (mean\u0026thinsp;=\u0026thinsp;4.92, SD\u0026thinsp;=\u0026thinsp;1.40). The policies with the lowest average support included: 1) Eliminating all policies that penalize an underaged person for tobacco use (mean\u0026thinsp;=\u0026thinsp;2.61, SD\u0026thinsp;=\u0026thinsp;1.48) and 2) Banning cigarette filter sales (mean\u0026thinsp;=\u0026thinsp;3.24, SD\u0026thinsp;=\u0026thinsp;1.6).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of Average Support by Endgame Policy Category\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndgame Policy Category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo. of Items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStd. Deviation\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDirect Sales Restrictions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEliminating Penalties for Underage Use\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.48\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePricing Policies and Nicotine Level Policies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProduct Placement and Packaging Policies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetailer Focused Location and Density\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.86\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmokefree and Multiunit Housing Policies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\n\u003ch3\u003eFactors Associated with Policy Support\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eTable\u0026nbsp;3\u003c/b\u003e summarizes the results from the linear regressions for the associations between the demographic factors, smoking behaviors, and policy category average support. Older age was negatively associated with support for Penalties for Underage Use Policy (β = -0.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Republican or Independent political party affiliation was negatively associated with all tobacco control policies when compared to Democrat affiliation. The strongest effects were observed for Pricing Policies and Nicotine Level Policies (β = -0.15, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Retailer Focused Location and Density Policies (β = -0.16, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Current smokers of any tobacco product were less likely to support several policies, most notably Retailer Focused Location and Density Policies (β = -0.23, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Individuals who currently used e-cigarettes showed lower support for Direct Sales Restriction (β = -0.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to those who did not report using e-cigarettes. Individuals employed for wages or self-employed demonstrated lower support for Penalties for Underage Use Policy compared to other non-employed individuals (β = -0.15, p\u0026thinsp;=\u0026thinsp;0.046). Higher smoking frequency showed negative associations with multiple policies, with the strongest effects on Smokefree and Multiunit Housing Policies (β = -0.27, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and Pricing Policies and Nicotine Level Policies (β = -0.22, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating that more frequent smokers were less supportive than less frequent smokers. Individuals residing in urban areas demonstrated higher support for Product Placement and Packaging Policies (β\u0026thinsp;=\u0026thinsp;0.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), Pricing Policies and Nicotine Level Policies (β\u0026thinsp;=\u0026thinsp;0.09, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and Retailer Focused Location and Density Policies (β\u0026thinsp;=\u0026thinsp;0.14, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) compared to people residing in rural areas. Individuals who identified as Black/African American showed lower support for Pricing Policies and Nicotine Level Policies (β\u0026thinsp;=\u0026thinsp;0.09, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) compared to those who were white.\u003c/p\u003e\u003cp\u003eIn regards to government regulations, most participants (56.5%, n\u0026thinsp;=\u0026thinsp;286) favored federal regulation of tobacco policies, followed by state (31.0%, n\u0026thinsp;=\u0026thinsp;157) and local (12.5%, n\u0026thinsp;=\u0026thinsp;63) governments. Of the eight variables tested, three showed statistically significant associations: e-cigarette use frequency (p\u0026thinsp;=\u0026thinsp;0.009), political party (p\u0026thinsp;=\u0026thinsp;0.018), and smoking frequency (p\u0026thinsp;=\u0026thinsp;0.013). Chi-squared tests revealed that Republicans and Independents were more likely to support state government regulating and implementing tobacco policies, χ\u0026sup2; (2, N\u0026thinsp;=\u0026thinsp;296)\u0026thinsp;=\u0026thinsp;8.085, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 whereas Democrats were more likely to support the federal government, χ\u0026sup2; (2, N\u0026thinsp;=\u0026thinsp;200)\u0026thinsp;=\u0026thinsp;8.085, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Individuals using e-cigarettes daily were significantly more likely to support local governments regulating and implementing tobacco product-related policies χ\u0026sup2; (2, N\u0026thinsp;=\u0026thinsp;106)\u0026thinsp;=\u0026thinsp;8.085, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Similarly, those who smoked some days or everyday preferred local governments (n\u0026thinsp;=\u0026thinsp;27, 42.9%) regulating tobacco product-related policies, whereas those who do not smoke were more likely to select the federal government to regulate tobacco products, χ\u0026sup2; (2, N\u0026thinsp;=\u0026thinsp;143)\u0026thinsp;=\u0026thinsp;8.085, p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Findings\u003c/h2\u003e\u003cp\u003eThe qualitative findings highlighted 7 themes including: 1) Levels of Government, 2) Consistency, 3) Limited Control, 4) Government Authority and Responsibility, 5) Tobacco Beliefs, 6) Skeptical or distrustful, and 7) Unsure. The themes ranged from participants describing a specific level of government and its involvement in tobacco control, lack of confidence in government, a desire for uniformity in policies, as well as overall beliefs on tobacco. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e highlights the codes and supportive quotes within each theme.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eLinear Regressions Examining Factors Related to Endgame Policy Category Average Support\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDirect Sales Restrictions\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProduct Placement and Packaging Policies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePricing Policies and Nicotine Level Policies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSmokefree and Multiunit Housing Policies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRetailer Focused Location and Density Policies\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePenalties for Underage Use Policy\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducation\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.15**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIncome\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePolitical Party\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.14**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.15**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.11*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.16**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.07\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.11*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.09*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.14**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent Smoker of Any Tobacco Product\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.19*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.17*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.23**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCurrent E-cigarette User\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmoking Frequency\u003csup\u003eg\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.16*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.22**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.27**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack/African American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.09*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLatino or Hispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNote\u003c/em\u003e: All reported estimates are standardized regression coefficients. N\u0026thinsp;=\u0026thinsp;506\u003c/p\u003e\u003cp\u003e\u003csup\u003ea\u003c/sup\u003e Referent group is high school or below\u003c/p\u003e\u003cp\u003e\u003csup\u003eb\u003c/sup\u003e Referent group is all other values besides employed for wages or self employed; missing data (n\u0026thinsp;=\u0026thinsp;1)\u003c/p\u003e\u003cp\u003e\u003csup\u003ec\u003c/sup\u003e Referent group is less than \u003cspan\u003e$\u003c/span\u003e75,000 and below; missing data (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003cp\u003e\u003csup\u003ed\u003c/sup\u003e Referent group is female, non-binary, or not-listed\u003c/p\u003e\u003cp\u003e\u003csup\u003ee\u003c/sup\u003e Referent group is democrat; missing data (n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003cp\u003e\u003csup\u003ef\u003c/sup\u003e Referent group is nonmetro; missing data (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003cp\u003e\u003csup\u003eg\u003c/sup\u003e Referent group is not at all\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSupportive quotes of perspectives on tobacco product regulations among 506 participants, by theme and codes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThemes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCodes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSupportive Quotes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003eLevels of Government\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocal control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The local government is most equipped to deal with the problem.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eState control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I prefer and trust in my state to regulate and implement policies to my liking rather than the federal government.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFederal control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The federal government is the one with the authority to curb the tobacco industry menace.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo Government Involvement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;No government should be regulating.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCase by Case\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think the substances should be regulated on a smaller case by case basis.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMultiple levels\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It should be a joint process.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConsistency\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsistency in policy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I believe that it's important to have a consistent policy that protects the health of all Americans.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eLimited Control\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited federal control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;The federal government [control over regulations] should be more limited.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited state control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;This is because most likely these laws should be federal, not a decision by the individual state.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLimited local control preferred\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It should be decisions taken for the whole country and not regional.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eGovernment Authority \u0026amp; Responsibility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGovernmental protections\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I just want there to be more restrictions on tobacco products, more specifically where they\u0026rsquo;re advertised, and who they\u0026rsquo;re being advertised to.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRights\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s not like we have a choice.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTobacco illegal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I believe tobacco should be illegal.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003eTobacco Beliefs\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDangers of tobacco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I do believe it tends to be more or less dangerous depending on your location.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerception of tobacco\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I don\u0026rsquo;t ever want to try tobacco or vape products.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003eSkeptical or Distrustful\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eToo complex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I think policies related to tobacco products are too big of an issue for local governments to handle.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLack of trust\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I do not trust the federal government to handle this issue.\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIneffective\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Seems to be the way that it is, and we don\u0026rsquo;t have a real choice.\u0026rdquo; \u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOf the 506 participants, 375 (74%) supported a preference for a specific level of government involvement (theme 1) (i.e., federal, state, or local) when creating, regulating, and enforcing tobacco-related policies. In contrast, 66 (13%) participants advocated for limited government control over tobacco regulation (theme 3). A desire for consistency (theme 2) was voiced by 81 (16%) participants who emphasized the need for uniformity across jurisdictions, noting that variability in policies can be \u0026ldquo;too confusing.\u0026rdquo; While 40 (8%) participants described that it was the government\u0026rsquo;s obligation to protect and/or enforce policies related to tobacco control (theme 4), 6 (1%) participants described distrust in the government (theme 6), and 17 (3%) participants were uncertain regarding the level of control the government should have (theme 7). Beyond views on governmental authority, 37 (7%) participants shared their opinions and beliefs related to tobacco (theme 5), acknowledging the potential harmful effects of tobacco.\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study provides insights into support and associated factors (e.g., demographic, political, tobacco behavior) for comprehensive endgame policies in the US. Findings indicate that the highest support was for policies within the Pricing Policies and Nicotine Level Policies category. On the other end, support was lowest for the category of Eliminating Penalties for Underage Use. Similar to previous research on tobacco control policy support, age, employment, political party, tobacco product smoking status, e-cigarette use, smoking frequency, and identifying as Black/African American were all associated with support for at least one Endgame policy category.\u003c/p\u003e\u003cp\u003eOne of the main findings of this research was that one category, Pricing Policies and Nicotine Level Policies, had the highest level of support among the study sample. Similarly, other studies have found high U.S. support for increasing prices and reducing nicotine levels in tobacco products. In terms of pricing, another study of U.S. adults conducted by the Truth Initiative found that the majority of Americans support increasing prices on cigarettes and banning coupons and multi-pack discounts [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Other researchers support the effectiveness of raising prices and eliminating discounts to reduce tobacco use [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. While there is generally higher public support for pricing policies, the pricing overall in the U.S. still does not meet recommendations. The U.S. Surgeon General recommends a price tag of ten dollars or more per cigarette pack, yet the average retail price per pack was nine dollars as of July 2024 [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A total of 34 states had an average retail price per pack below ten dollars and 28 states had not increased cigarette taxes in the last ten years. Given the wide support for such policies and the ability of states to regulate cigarette taxes, public health advocates should consider promoting policies that increase the price of cigarettes, especially in the 34 states that have not increased taxes over the last ten years. In terms of nicotine-specific policies, another nationally representative study of U.S. adults found that more than 70% of Americans support reducing nicotine levels in cigarettes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Research supports reducing nicotine to make cigarettes less addictive, support cessation, and reduce use [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The Food and Drug Administration (FDA) announced plans to set a maximum nicotine level in cigarettes and other combustible tobacco products in June 2022 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The FDA was still working on a proposal for reducing nicotine levels as of 2024, and it is expected that such regulation could take years to approve [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Legal experts have argued that states have the power to regulate nicotine levels in cigarettes on their own and do not need to wait for the FDA [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Given strong public support and state authority to regulate nicotine levels, public health advocates should consider prioritizing the promotion of policies that limit the sale of cigarettes and limit nicotine levels.\u003c/p\u003e\u003cp\u003eOne policy clearly stood out as the lowest rated policy, eliminating penalties for underage tobacco use. Policies that restrict access to tobacco products, including penalties for underage use, have historically been widely supported in the U.S [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. This study also found that support for policy that eliminates penalties for underage youth decreased with age and employment. Other research has found that support for youth-focused tobacco control policies are highest among older adults and those working in healthcare organizations [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Most U.S. states have laws penalizing underage tobacco use, some of which are classified as criminal offenses [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. However, these laws are unlikely to reduce youth smoking at a population level [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, they disproportionately affect youth from underrepresented and high risk groups. One U.S. study found that Black or African American and Latinx youth were cited at higher rates compared to their white peers even after adjusting for smoking behaviors [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Reversing laws that penalize underage use of tobacco products may be a challenge since older Americans support policies that restrict youth tobacco access and make up large portions of lawmakers in the US [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Given that the tobacco industry heavily advertises to youth, ineffective policies that penalize youth tobacco use should be replaced with policies that prohibit or limit the marketing of tobacco products. In 2019, the majority (over 90%) of tobacco company marketing expenditures included price discounts to reduce cigarette pack prices, promotional allowances for product stocking, shelving, and displaying, and promotions (e.g., rebates) [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. It may be more feasible to promote policies focused on product placement (e.g., prohibiting retailers from displaying tobacco products and paraphernalia near schools) and pricing versus eliminating penalties for underage use as a way to address underage tobacco use in the near future given this study\u0026rsquo;s findings of wide support for Pricing Policies and Nicotine Level Policies and Product Placement and Packaging Policies. Given that policies that penalize youth tobacco use are prevalent in the U.S. and have wide public support despite their efficacy and resulting disparities, there is a need to advocate for the removal of such policies, especially with older lawmakers, to ensure health equity and reduce youth tobacco use.\u003c/p\u003e\u003cp\u003eThis study found that Endgame policy support varied across demographics and political party affiliation in particular. Political party affiliation appeared to be associated with five out of the six Endgame policy categories, with Republicans and Independents reporting lower support compared to Democrats overall. Similarly, another study of U.S. adults found that liberals were more likely to support several tobacco control policies compared to conservatives, such as removing tobacco products from customers\u0026rsquo; views and removing tobacco advertisements from windows and registers [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. While Republican support for tobacco control policies may be low, it\u0026rsquo;s important to note that smoking rates are higher in Republican states versus Democratic states [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Given the issue of racial disparities in tobacco use and related morbidity and mortality, Endgame policies are important for addressing health equity. However, several polls of U.S. adults from 2020 found that a substantial number of Democrats viewed racial inequality as a top priority while this was not a concern among Republicans [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Tobacco control advocacy groups may need to tailor messaging to Republican lawmakers and focus on the negative health effects of tobacco use on their constituents to support non-partisan legislation and passage of Endgame policies.\u003c/p\u003e\u003cp\u003eResults from the linear regression analysis also found that Endgame policy support varied by tobacco use, race, and rural-urban residence. Current tobacco users and those who identified as Black/African American were less likely to support certain Endgame policies while those living in urban areas were more likely to indicate support. Results from other U.S. studies show similar results. Support for tobacco control policies is consistently lower among current versus non-smokers [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Black and African Americans have reported high support for tobacco control policies, including Pricing Policies and Nicotine Policies [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Individuals living in urban areas are more likely to support tobacco control policies compared to those in rural areas [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Rural counties with higher tobacco production are less likely to support policies aimed at reducing tobacco use [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. While the dangers of tobacco have been well documented and established, Americans living in rural areas report lower trust in government and science [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Given higher rates of tobacco use in rural versus urban areas [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], more research and advocacy are needed in rural areas to reduce the burden of tobacco. In addition to current tobacco users, efforts and communications may need to be tailored to gain support from Black and African American and rural communities for Endgame policies to reduce disparities within these groups.\u003c/p\u003e\u003cp\u003eWhile our study offers valuable insights into the support for specific Endgame policies among a sample of US adults, it is important to acknowledge its limitations. The use of a survey panel, while efficient for data collection, may limit the generalizability of our findings, as the sample may not fully represent the diversity of the U.S. adult population. While we employed quota sampling for certain demographics, not all demographic groups were equally represented, introducing potential biases. Additionally, the cross-sectional design restricts our ability to establish causal relationships between demographic variables and policy support. We also cannot make a direct connection between support and voting action. Our study included more policies than previously published work, however, there may be other policies that could be seen as Endgame policies that were not included. Moreover, the limited variables outside of policy support included in our analysis restrict our ability to investigate other potential influencing factors. Finally, the reliance on self-reported data for assessing support for 36 different policies may be subject to social desirability bias, as participants may provide responses that align with perceived societal norms. Despite these limitations, our findings expand our understanding of public support toward Endgame policies and provide a foundation for further investigation into strategies for promoting their adoption and implementation.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eAs tobacco continues to be the leading cause of preventable death in the U.S., Endgame policies are needed to better address the tobacco-related health inequities that exist. To promote the adoption of these types of policies, it is critical to understand which types of policies are more likely to be supported by the public now and which policies may need strategies to promote them. This study provided a much more comprehensive summary of different types of Endgame policy support in the U.S. than previously published work. This study found that Endgame policies varied in support by the type of policy with more support related to setting pricing and nicotine levels, where products can be placed, and the packaging that can be used. Additionally, this study echoed previous studies in finding that smokers and political affiliation may play a significant role in how the public perceives these types of policies. Results suggest that tailored strategies to incorporate these characteristics may be needed to increase support for Endgame policies. Future research is needed to examine the best approaches for increasing support for Endgame policies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research was supported by the William and Linda Frost Fund in the Cal Poly Bailey College of Science and Mathematics and the Cal Poly Learning Aligned Employment Program (LEAP).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis was a cross-sectional study completed with the purpose of describing public support for tobacco Endgame policies. This study received approval from the California Polytechnic State University Institutional Review Board (#2023-229) prior to data collection in accordance with the National Research Act - 45 CFR 46 subpart A and the Belmont Report. The protocol was performed in accordance with the relevant guidelines and regulations [Declaration of Helsinki]. Electronic informed consent was received prior to proceeding with the study. Only those who agreed to participate completed the study. Participants were informed of their right to withdraw from the study or skip any question at time during the survey. All data collected was anonymous.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e On behalf of all authors, the corresponding author states that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eU.S. Food and Drug Administration. FDA Announces Plans for Proposed Rule to Reduce Addictiveness of Cigarettes and Other Combusted Tobacco Products | FDA. 2022. https://web.archive.org/web/20221214010506/https://www.fda.gov/news-events/press-announcements/fda-announces-plans-proposed-rule-reduce-addictiveness-cigarettes-and-other-combusted-tobacco. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eAmerican Lung Association. Top 10 Communities Disproportionately Affected by Cigarette Smoking and Tobacco Use.https://www.lung.org/research/sotc/by-the-numbers/top-10-populations-affected. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eCDC. Tobacco - Health Equity. 2024. African American Communities Experience a Health Burden From Commercial Tobacco. https://www.cdc.gov/tobacco-health-equity/collection/african-american-health-burden.html. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eCheng YJ. Sociodemographic and Temporal Differences in Menthol Cigarette Use Among US Adults Who Smoke, 1999\u0026ndash;2018. Prev Chronic Dis. 2024;21. https://www.cdc.gov/pcd/issues/2024/23_0291.htm. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eKim H, Gartner C, Edwards R, Puljević C, Morphett K, Kim DH, et al. Public Support for Tobacco Endgame Policies: A Systematic Review and Meta-analysis. Nicotine Tob Res Off J Soc Res Nicotine Tob. 2024 Jun 19;ntae149.\u003c/li\u003e\n\u003cli\u003ePuljević C, Morphett K, Hefler M, Edwards R, Walker N, Thomas DP, et al. Closing the gaps in tobacco endgame evidence: a scoping review. Tob Control. 2022 Mar;31(2):365\u0026ndash;75.\u003c/li\u003e\n\u003cli\u003eCosgrave EJ, Blake M, Murphy E, Sheridan A, Doyle F, Kavanagh P. Is the public ready for a tobacco-free Ireland? A national survey of public knowledge and attitudes to tobacco endgame in Ireland. Tob Control. 2023 May 26;tc-2023-057958.\u003c/li\u003e\n\u003cli\u003eSchmidt AM, Kowitt SD, Myers AE, Goldstein AO. Attitudes towards Potential New Tobacco Control Regulations among U.S. Adults. Int J Environ Res Public Health. 2018 Jan 5;15(1):72.\u003c/li\u003e\n\u003cli\u003eAvisha A, Ribisl KM, Sheeran P. Realizing the Tobacco Endgame: Understanding and mobilizing public support for banning combustible cigarette sales in the United States - ScienceDirect. https://www.sciencedirect.com/science/article/abs/pii/S0277953623002964. Accessed 1 Oct 2024\u003c/li\u003e\n\u003cli\u003eSmith EA, McDaniel PA, Malone RE. Leadership Perceptions of Endgame Strategies for Tobacco Control in California. J Public Health Manag Pract JPHMP. 2019;25(6):554\u0026ndash;61.\u003c/li\u003e\n\u003cli\u003eMcDaniel P, Smith E, Malone RE. California policymakers\u0026rsquo; perspectives on tobacco endgame approaches. 2018. https://www.tobaccoinduceddiseases.org/California-policymakers-perspectives-on-tobacco-endgame-approaches,83794,0,2.html. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eWinickoff JP, McMillen R, Tanski S, Wilson K, Gottlieb M, Crane R. Public support for raising the age of sale for tobacco to 21 in the United States. Tob Control. 2016;25(3):284\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eCDC. National Health Interview Survey. 2024 https://www.cdc.gov/nchs/nhis/2022nhis.htm. Accessed 1 Oct 2024\u003c/li\u003e\n\u003cli\u003eAlber JM, Glanz K. Does the Screening Status of Message Characters Affect Message Effects? Health Educ Behav Off Publ Soc Public Health Educ. 2018 Feb;45(1):14\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003ePolitical Independents: Who They Are, What They Think. Pew Research Center. 2019. https://www.pewresearch.org/politics/2019/03/14/political-independents-who-they-are-what-they-think/. Accessed 1 Oct 2024\u003c/li\u003e\n\u003cli\u003eCDC. Behavioral Risk Factor Surveillance System Survey Questionnaire. 2024. https://www.cdc.gov/brfss/questionnaires/index.htm. Accessed 1 Oct 2024\u003c/li\u003e\n\u003cli\u003eTobacco-Related Disease Research Program. California Endgame Resources. Endgame Policy Platform -Version 4. https://www.trdrp.org/about/ca-endgame-resources.html. Accessed 1 Oct 2024\u003c/li\u003e\n\u003cli\u003eU.S. Department of Agriculture, Economics Research Service. Rural-Urban Continuum Codes. 2024. https://www.ers.usda.gov/data-products/rural-urban-continuum-codes.aspx. Accessed 4 Oct 2024\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77\u0026ndash;101.\u003c/li\u003e\n\u003cli\u003eBurla L, Knierim B, Barth J, Liewald K, Duetz M, Abel T. From Text to Codings: Intercoder Reliability Assessment in Qualitative Content Analysis. Nurs Res. 2008 Apr;57(2):113.\u003c/li\u003e\n\u003cli\u003eTruth Initiative: inspiring lives free from smoking, vaping, and nicotine. https://truthinitiative.org/. Accessed 27 Sep 2024\u003c/li\u003e\n\u003cli\u003eMarynak KL, Xu X, Wang X, Holmes CB, Tynan MA, Pechacek T. Estimating the Impact of Raising Prices and Eliminating Discounts on Cigarette Smoking Prevalence in the United States. Public Health Rep Wash DC 1974. 2016;131(4):536\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eMcLaughlin I, Pearson A, Laird-Metke E, Ribisl K. Reducing tobacco use and access through strengthened minimum price laws. Am J Public Health. 2014 Oct;104(10):1844\u0026ndash;50.\u003c/li\u003e\n\u003cli\u003eNational Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. The Health Consequences of Smoking\u0026mdash;50 Years of Progress: A Report of the Surgeon General. Centers for Disease Control and Prevention (US); 2014 . (Reports of the Surgeon General). http://www.ncbi.nlm.nih.gov/books/NBK179276/. Accessed 27 Sep 2024\u003c/li\u003e\n\u003cli\u003eCampaign for Tobacco-Free Kids. Campaign for Tobacco Free Kids. Available from: https://www.tobaccofreekids.org/. Accessed 27 Sep 2024\u003c/li\u003e\n\u003cli\u003eBenowitz NL, Henningfield JE. Reducing the nicotine content to make cigarettes less addictive. Tob Control. 2013 May;22 Suppl 1(Suppl 1):i14-17.\u003c/li\u003e\n\u003cli\u003eApelberg BJ, Feirman SP, Salazar E, Corey CG, Ambrose BK, Paredes A, et al. Potential Public Health Effects of Reducing Nicotine Levels in Cigarettes in the United States. N Engl J Med. 2018 May 3;378(18):1725\u0026ndash;33.\u003c/li\u003e\n\u003cli\u003eKing B. A Year in Review: FDA\u0026rsquo;s Progress on Tobacco Product Regulation in 2023. FDA. 2024 Aug 9. https://www.fda.gov/tobacco-products/ctp-newsroom/year-review-fdas-progress-tobacco-product-regulation-2023. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eTwinamatsiko A. States Don\u0026rsquo;t Need to Wait for FDA to Adopt Nicotine Reduction Endgame Strategies: Lessons from Flavored Tobacco Litigation. 2023 https://papers.ssrn.com/abstract=4761319. Accessed 4 Oct 2024\u003c/li\u003e\n\u003cli\u003eBailey WJ, Crowe JW. A national survey of public support for restrictions on youth access to tobacco. J Sch Health. 1994 Oct;64(8):314\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGentzke AS, Glover-Kudon R, Tynan M, Jamal A. Adults\u0026rsquo; attitudes toward raising the minimum age of sale for tobacco products to 21 years, United States, 2014-2017. Prev Med. 2020 Feb 3;133:106012.\u003c/li\u003e\n\u003cli\u003eHoward KA, Rogers T, Howard-Pitney B, Flora JA, Norman GJ, Ribisl KM. Opinion leaders\u0026rsquo; support for tobacco control policies and participation in tobacco control activities. Am J Public Health. 2000 Aug;90(8):1283\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eBonnie RJ, Stratton K, Kwan LY, Products C on the PHI of R the MA for PT, Practice B on PH and PH, Medicine I of. Restrictions on Youth Access to Tobacco Products. In: Public Health Implications of Raising the Minimum Age of Legal Access to Tobacco Products. National Academies Press (US). 2015 https://www.ncbi.nlm.nih.gov/books/NBK310404/. Accessed 25 Sep 2024\u003c/li\u003e\n\u003cli\u003eWakefield M, Giovino G. Teen penalties for tobacco possession, use, and purchase: evidence and issues. Tob Control. 2003 Jun;12 Suppl 1(Suppl 1):i6-13.\u003c/li\u003e\n\u003cli\u003eGottlieb NH, Loukas A, Corrao M, McAlister A, Snell C, Huang PP. Minors\u0026rsquo; tobacco possession law violations and intentions to smoke: implications for tobacco control. Tob Control. 2004 Sep;13(3):237\u0026ndash;43.\u003c/li\u003e\n\u003cli\u003eCurry JM, Haydon MR. Lawmaker Age, Issue Salience, and Senior Representation in Congress. Am Polit Res. 2018 Jul 1;46(4):567\u0026ndash;95.\u003c/li\u003e\n\u003cli\u003eUnited States. Federal Trade Commission. Federal Trade Commission: Cigarette Report for 2001. Federal Trade Commission; 2003. Accessed 1 Oct 2024 \u003c/li\u003e\n\u003cli\u003eShete SS, Yu R, Shete S. Political Ideology and the Support or Opposition to United States Tobacco Control Policies. JAMA Netw Open. 2021 Sep 1;4(9):e2125385.\u003c/li\u003e\n\u003cli\u003eFox AM, Feng W, Yumkham R. State political ideology, policies and health behaviors: The case of tobacco. Soc Sci Med 1982. 2017 May;181:139\u0026ndash;47.\u003c/li\u003e\n\u003cli\u003eSmeltz D. Republican Views on Racial Inequality Starkly Contrast Those of Democrats. The Chicago Council on Global Affairs; 2020. https://globalaffairs.org/research/public-opinion-survey/republican-views-racial-inequality-starkly-contrast-those-democrats. Accessed 7 Oct 2024\u003c/li\u003e\n\u003cli\u003ePay\u0026aacute;n DD, Burke NJ, Persinger J, Martinez J, Barker LJ, Song AV. Public support for policies to regulate flavoured tobacco and e-cigarette products in rural California. Tob Control. 2023 Apr 1;32(e1):e125\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eKing G, Mallett RK, Kozlowski LT, Bendel RB. African Americans\u0026rsquo; Attitudes Toward Cigarette Excise Taxes. Am J Public Health. 2003 May;93(5):828\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003ePearson JL, Abrams DB, Niaura RS, Richardson A, Vallone DM. Public support for mandated nicotine reduction in cigarettes. Am J Public Health. 2013 Mar;103(3):562\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eRayens MK, Hahn EJ, Langley RE, Zhang M. Public Support for Smoke-Free Laws in Rural Communities. Am J Prev Med. 2008 Jun 1;34(6):519\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eHahn EJ, Rayens MK, York N. Readiness for smoke-free policy and overall strength of tobacco control in rural tobacco-growing communities. Health Promot Pract. 2013 Mar;14(2):238\u0026ndash;46.\u003c/li\u003e\n\u003cli\u003eKrause NM. Placing \u0026ldquo;trust\u0026rdquo; in science: The urban-rural divide and Americans\u0026rsquo; feelings of warmth toward scientists. Public Underst Sci Bristol Engl. 2023 Jul;32(5):596\u0026ndash;604.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"advocacy, public policy support, tobacco prevention, Endgame policies, government control","lastPublishedDoi":"10.21203/rs.3.rs-7511760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7511760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTobacco remains the leading cause of preventable death in the U.S. Endgame policies focus on addressing the causes of inequities in tobacco outcomes. While potentially impactful, public support in the U.S. is understudied. This study examined the public's support for comprehensive Endgame policies. A cross-sectional online survey of U.S. adults (N\u0026thinsp;=\u0026thinsp;506) measured support for 36 Endgame policies. Participants also indicated preferred levels of government tobacco regulation and researchers examined factors associated with support. Support varied by policy category, from highest to lowest: Pricing/Nicotine, Packaging, Smoke-Free Housing, Retail Density, Sales Restrictions, and Eliminating Underage Penalties. Regulation preference varied, with some supporting national uniformity and others expressing distrust in specific government levels. Smoking status and Republican identification related to lower policy support. Support for Endgame policies varied in the sample. More research is needed to understand additional factors associated with policy support and strategies to promote support.\u003c/p\u003e","manuscriptTitle":"Promoting Health Equity in Tobacco Outcomes: Examining Support for Endgame Policies Among Sample of U.S Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-20 11:33:56","doi":"10.21203/rs.3.rs-7511760/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8c9d95fe-32da-4643-8029-adbabcadd9f0","owner":[],"postedDate":"October 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T08:12:27+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-20 11:33:56","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7511760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7511760","identity":"rs-7511760","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}