Adolescents' Perceptions of Health Risks, Social Risks, and Benefits Differ Across Tobacco Products

Examining the Association Between Physical Activity, Sedentary Behavior and Sport Participation With E-Cigarette Use and Smoking Status in a Large Sample of Canadian Youth

INTRODUCTION

Youth e-cigarette use is common worldwide, but the profile of e-cigarette users compared with tobacco users is unclear. This study examines how sport participation and activity levels among youth differ between e-cigarette users and smokers.

METHODS

Using Canadian data from 38977 grade 9 to 12 students who participated in Year 3 (2014-15) of the COMPASS study, logistic regression models were used to examine the likelihood of sport participation and activity level based on e-cigarette use and smoking status. Pearson's chi-square tests were used to examine subgroup differences by gender.

RESULTS

E-cigarette users are more likely to participate in intramural, competitive, and team sports compared to non-users. Current and former smokers are less likely to participate in those sports than non-smokers. Youth e-cigarette users are more likely than non-users to meet the physical activity guidelines. Current smokers are more likely than non-smokers to undertake physical activity at least 60 min daily but less likely than non-smokers to tone at least 3 times per week. Youth e-cigarette users are less likely than non-users to be sedentary less than 2 h daily. Gender differences among males and females show that male e-cigarettes users drive the general relationship.

CONCLUSION

Results suggest that e-cigarette users are more likely to engage in physical activity compared to non e-cigarette users. Youth e-cigarette users are more likely to be physically active while the opposite is true for smokers. Although e-cigarettes may be less harmful to health compared to cigarette smoking, the increased uptake among youth of differing profiles should be considered in prevention efforts.

IMPLICATIONS

These results highlight the importance of addressing e-cigarette use in youth who undertake health promoting behaviors. Prevention efforts should not focus only on youth who may undertake riskier health habits; e-cigarette prevention programs should go beyond the domain of tobacco control.

Hookah Use Among US Youth: A Systematic Review of the Literature From 2009 to 2017

INTRODUCTION

Given the US Food and Drug Administration (FDA)'s authority to regulate hookah, more research is needed to inform regulations intended to prevent youth from using hookah. This systematic review summarizes and assesses the literature related to hookah use among adolescents (11 to ≤18 years of age) in the United States from 2009 to 2017.

METHODS

Database searches yielded 867 peer-reviewed articles. After duplicates were removed, authors reviewed 461 articles for inclusion. Included articles (n = 55) were coded for study themes, study quality, and their relevance to FDA's research priorities. A qualitative synthesis is presented.

RESULTS

The following themes were identified: (1) prevalence of hookah use (n = 42), (2) tobacco use transitions (n = 7), (3) sociodemographic correlates (n = 35), (4) psychosocial risk factors (n = 21), (5) concurrent use of other tobacco products (n = 31), (6) concurrent use of other substances (n = 9), and (7) other (n = 15)-which includes low prevalence themes. The qualitative synthesis showed increasing rates of hookah use. Older age, male gender, positive social normative beliefs, higher peer use, as well as lower perceived risk were associated with hookah use. Longitudinal studies of youth hookah use showed bidirectional relationships between use of hookah and other tobacco products. All articles fell within FDA's research priority related to "behavior," and three priorities ("impact analysis," "health effects," and "toxicity") have not been explored for hookah use among US youth since 2009.

CONCLUSIONS

The prevalence of hookah use among youth in the United States is increasing, thus more research is needed to inform policies targeted to protect this vulnerable population.

IMPLICATIONS

This study represents a novel contribution to our understanding of hookah use among youth in the United States from 2009-the year that the Family Smoking Prevention and Tobacco Control Act was passed-to 2017. In recent years, hookah has become a more popular tobacco product among US youth; however, to date, no systematic reviews of hookah use among this population exist. Results highlight implications for future US FDA regulatory policy and identify gaps in research to be addressed in future studies.

Past 30-day co-use of tobacco and marijuana products among adolescents and young adults in California

BACKGROUND

Limited research among adolescents and young adults (AYA) has assessed tobacco and marijuana co-use in light of specific products. We examined the patterns of past 30-day co-use of tobacco and marijuana products, and the product-specific associations among past 30-day use of these substances.

METHODS

Data from three school-based convenience samples of California AYA (aged 15-22) (Sample 1 = 3008; Sample 2 = 1419; Sample 3 = 466) were collected during 2016-2017. Proportions of past 30-day co-use of tobacco (e-cigarettes, cigarettes, hookah, cigars) and marijuana (combustible, vaporized, edible, blunt) were estimated. Multivariable logistic regression analyses examined associations between use of each tobacco and marijuana product for individual samples, then the pooled analysis calculated combined ORs.

RESULTS

In the three samples, 7.3-11.3% of participants reported past 30-day co-use. Combinations of e-cigarettes or cigarettes and combustible marijuana were the most common co-use patterns. Past 30-day use of e-cigarettes or cigarettes (vs. non-use) increased the odds of past 30-day use of all marijuana products [e-cigarettes: ORs (95%CI) ranging from 2.5 (1.7, 3.2) for edible marijuana to 4.0 (2.8, 5.2) for combustible marijuana; cigarettes: from 3.2 (2.1, 4.2) for vaporized marijuana to 5.5 (3.8, 7.3) for combustible marijuana]. Past 30-day use of hookah or cigars was positively associated with past 30-day use of three of four marijuana products, except for hookah and vaporized marijuana, and for cigars and combustible marijuana.

CONCLUSIONS

Given various co-use patterns and significant associations among tobacco and marijuana products, interventions targeting AYA should address co-use across the full spectrum of specific products for both substances.

Health Care Utilization and Expenditures Attributable to Smokeless Tobacco Use Among US Adults

Introduction

This study estimated the health care utilization and expenditures attributable to the use of smokeless tobacco (ST) which includes chewing tobacco, snuff, dip, snus, and dissolvable tobacco among US adults aged 18 and older.

Methods

We used data from the 2012-2015 National Health Interview Surveys (n = 139451 adults) to estimate a zero-inflated Poisson (ZIP) regression model on four health care utilization measures among US adults (hospital nights, emergency room [ER] visits, doctor visits, and home care visits) specified as a function of tobacco use status, and other covariates. Tobacco use status was classified into four categories: current ST users, former ST users, non-ST tobacco users, and never tobacco users. ST-attributable utilization was calculated based on the estimated ZIP model using an "excess utilization" approach. It was then multiplied by the unit cost estimated from the 2014 Medical Expenditures Panel Survey data to derive ST-attributable health care expenditures.

Results

During 2012-2015, 2.1% of adults were current ST users and 7.7% were former ST users. ST-attributable health care utilization amounted to 681000 hospital nights, 624000 ER visits, and 4.6 million doctor visits per year (home care visits results were not significant). This resulted in annual excess expenditures of $1.8 billion for hospitalizations, $0.7 billion for ER visits, and $0.9 billion for doctor visits, totaling over $3.4 billion (in 2014 dollars).

Conclusion

Comprehensive tobacco control policies and interventions are needed to reduce ST use and the associated health care burden.

Implications

This is the first study to assess the impact of ST use on health care burden in the United States. Findings indicate that excess annual health care expenditures attributable to ST use for US adults were $3.4 billion in 2014 dollars.

Predictors of intentions to use cigarettes and electronic-cigarettes among high school students

Purpose

Tobacco is the second most commonly used drug by Spanish high school students and e-cigarette use has increased over the last three years among this population. Students who reported smoking tobacco and/or e-cigarette use often have friends and family that also consume these substances. The aims of the present study were to: determine the prevalence of tobacco and electronic cigarette consumption among young adolescents, the age of initiation and the intention to consume both of these substances in the future; study the relationships between their current tobacco and e-cigarette consumption status, intentions to consume these substances in the future and the consumption of these substances by family members living in their home and friend’s consumption status; investigate the relationship between their current tobacco and e-cigarette consumption status, friends’ consumption status and their intention to consume each substance in the future; analyse the relationship between current consumption status, intentions to consume in the future and perceived risk; identify the main predictors of intentions to use these substances in the future.

Methods

A cross-sectional survey was conducted in 2017. The sample consisted of 468 school students in the first cycle of secondary education in Catalonia, Spain. The participants who were aged between 11 and 15 years old, with 49.4% being female.

Results

A stepwise binary logistic regression showed that the best predictors of the intention to smoke tobacco in the future were: having tried tobacco, being a current consumer, having a family member smoking at home and having a low perceived risk of smoking. The best predictors of the intention to use electronic cigarettes in the future were: having tried tobacco, being a current consumer and having friends who smoke or use electronic cigarettes.

Conclusion

Smoking prevention programs must consider the social network surrounding teenagers, particularly close friends and family. Intervention strategies for delaying the onset of tobacco or e-cigarette consumption are greatly needed.

Nicotine vaping product use, harm perception and policy support among pharmacy customers in Brisbane, Australia

INTRODUCTION AND AIMS

Despite regulatory barriers for accessing nicotine liquid, use of nicotine vaping products (NVPs) has increased rapidly in Australia. Legal use of NVPs to aid smoking cessation requires a prescription, and pharmacies report receiving enquiries about the use of and access to NVPs. In this study, we assessed vaping product use, harm perception and policy support among community pharmacy customers.

DESIGN AND METHODS

A cross-sectional survey was conducted among customers (n = 470) from a large community pharmacy chain in Brisbane, Australia. Multivariable logistic regression was used to examine perception of NVPs as less harmful than combustible cigarettes and regulatory recommendations in relation to demographics, smoking status and NVP use.

RESULTS

Almost one-third of the sample (31%) had either tried NVPs in the past (16%) or were current vapers (15%), the majority of them being current smokers (67%) who are trying to quit (31%) or substitute smoking (41%). Vapers primarily depended on family/friends as a source of information (76%). Current smokers and vapers were more likely to perceive NVPs as less harmful than cigarettes than non-smokers and non-vapers. Perceiving NVPs as safer than cigarettes was correlated with a recommendation to regulate as a tobacco product.

DISCUSSION AND CONCLUSIONS

There was widespread misperception about relative risk of nicotine-containing products, with 37% of respondents perceiving nicotine-containing NVPs to be as harmful as combustible cigarettes. Community pharmacies represent an ideal setting for educating smokers about smoking and vaping. Thus, pharmacy staff needs educational support to ensure that they are equipped to provide current evidence-based information to customers.

The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects

BACKGROUND

Electronic cigarettes (e-cigarettes) were first introduced in the U.S. market in 2006, with the more recent evolution of "pod-mod" e-cigarettes such as JUUL introduced in 2015. Although marketed as a smoking cessation tool, e-cigarettes are rarely used for this purpose in youth. This review aims to synthesize the literature regarding e-cigarette use among youth, and provides a resource for clinicians, educators, and families that helps answer commonly asked questions about e-cigarettes.

METHODS

PubMed, Scopus, and PsycINFO search was performed using search terms "Electronic Nicotine Delivery Systems," "e cigarettes," "e-cigarettes," "electronic cigarettes," "vaping," "JUUL," "e-cigs," and "vape pens." Search results were filtered to only include those related to adolescents and young adults.

RESULTS

E-cigarette use among youth is common, with rates of use increasing from 1.5% in 2011 to 20.8% in 2018. Pod mod devices such as JUUL have gained favor among youth for their sleek design, user-friendly function, desirable flavors, and ability to be used discreetly in places where smoking is forbidden. Adolescents are often uninformed about the constituents of e-cigarettes, and little is known about the long-term effects of e-cigarettes. Studies have suggested a "gateway" effect for combustible cigarettes and cannabis use.

CONCLUSIONS

E-cigarette use is becoming increasingly common among youth, leading to a myriad of questions and concerns from providers, educators, and family members. More research is needed to determine the ultimate public health impact of e-cigarette use. The authors provide a summary table of frequently asked questions in order to help clarify these common concerns.

Risk Factors for the Initiation of Smoking Behavior in Primary School Age Children in Karawang, Indonesia

Increases in smoking behavior among people in the community can cause health problems. Current smoking behavior changes in the younger generation and spreads to children. This condition is a concern for elementary school-age children. The purpose of this study was to determine the relationships between risk factors for smoking behavior in primary school-aged children in Karawang. Descriptive research method with cross-sectional design was used; a random sampling technique obtained a sample of 356 respondents aged 9-12 years in Karawang. This study used a smoking behavior questionnaire with validity (0.469-0.872) and reliability (0.92). Data were analyzed using linear correlation and multiple linear regression. The results of study show a relationship between age risk factors for the first-time smoking, family of smokers, and following trends and wanting to be cool with smoking behavior of primary school-age children. Multivariate analysis of multiple linear regression showed that the most dominant factor related to smoking behavior was sex (R square = 0.159). Risk factors for smoking and sex affect smoking behavior in primary school-aged children in Karawang Regency. The findings of this study indicate the need to control risk factors that influence school-age children to start smoking.

"Cloud chasers" and "substitutes": e-cigarettes, vaping subcultures and vaper identities

The use of e-cigarettes is increasing, a practice denoted as vaping. We explore user motives, self-identity as vapers and involvement in vaping subcultures, drawing on sociological theory of stigma, subcultures and symbolic boundaries. Based on analyses of semi-structured interviews with 30 Norwegian vapers, we find that there is a vaping subculture in Norway. We identify two dominant vaper identities. The first is labelled cloud chasers. These were dedicated vapers who identified with symbols and values in the subculture. Many were politically engaged in improving vaping regulation regimes and felt a sense of belonging to a vaping community. The second group is labelled substitutes. These were former daily smokers who used e-cigarettes for smoking cessation in a more pragmatic and defensive manner, to avoid health risks, to escape the stigma of smoking and to manage nicotine addiction. In this group, self-identity as a vaper was generally lacking. Vaping was often symbolically linked to the stigmatised smoker identity they wanted to escape, and was restricted to private contexts. The perceived symbolic meaning of e-cigarettes varies: for some, they are a symbol of pleasure and community. For others, they connote the stigmatised status of the addicted smoker seeking an alternative to cigarettes.

Harm perceptions and tobacco use initiation among youth in Wave 1 and 2 of the Population Assessment of Tobacco and Health (PATH) Study

In the US, youth attribute higher levels of harm and addictiveness to cigarettes relative to other tobacco products. Monitoring harm perceptions across a range of tobacco products is important when forecasting risk for experimentation. This study examined data from US youth (N = 10,081) ages 12-17 from the Population Assessment of Tobacco and Health (PATH) Study who completed both Wave 1 (2013-2014) and Wave 2 (2014-2015) interviews. Analyses assessed: (1) trends in perceived harm and addictiveness of products over time, (2) whether perceived harm and addictiveness of a product at Wave 1 predicted trying that product for the first time by Wave 2, and (3) whether trying a product between Waves 1 and 2 predicted a decrease in one's perceived harm and addictiveness of that product. Levels of perceived harmfulness and addictiveness significantly increased between Wave 1 and Wave 2 for all products (χ² (range): 7.8-109.2; p's ≤ 0.02). Compared to those with "high" perceived harmfulness of a tobacco product at Wave 1, those with "low" and "medium" perceived harmfulness had a significantly increased probability of use of that product at Wave 2. For all products, Wave 1 youth never tobacco users who tried a product (vs. did not) at Wave 2 had a significantly higher probability of being in the "low" category of perceived harmfulness at Wave 2. Among US youth, there is a bidirectional relationship between harm perceptions and product use. Understanding how changes in perceptions translate to changes in tobacco use could inform efforts to prevent tobacco initiation in youth.

Association of Alternative Tobacco Product Initiation With Ownership of Tobacco Promotional Materials Among Adolescents and Young Adults

IMPORTANCE

Use of alternative tobacco products (ATPs) such as electronic cigarettes, chewing tobacco, pipes, cigars, cigarillos, little cigars, and hookah is rapidly increasing. Although marketing restrictions exist for cigarettes, marketing of ATPs is not yet fully regulated, and studies have not assessed the association between ownership of ATP promotional materials and subsequent ATP or cigarette initiation among adolescents and young adults.

OBJECTIVE

To estimate the association between marketing receptivity measured at baseline and ATP and any tobacco initiation 1 year later, including cigarettes, among adolescents and young adults.

DESIGN, SETTING, AND PARTICIPANTS

Longitudinal cohort study of adolescents and young adults aged 13 to 19 years recruited at high schools in California from July 2014 to October 2015, with follow-up 1 year later. Data were analyzed from January to March 2018.

EXPOSURES

Ownership of ATP-specific promotional material and ownership of any tobacco promotional materials (eg, samples, coupons, branded caps, t-shirts, or posters) assessed in wave 1.

MAIN OUTCOMES AND MEASURES

Outcomes were (1) ATP initiation and (2) either ATP or cigarette initiation in wave 2.

RESULTS

Of 757 participants (mean [SD] age at wave 1, 16.1 [1.1] years; 481 [63.5%] female; 166 [21.9%] Asian or Pacific Islander, 202 [26.7%] white, and 276 [36.4%] Latino), 129 (17.0%) initiated ATP use and 141 (18.6%) initiated ATP or cigarette use 1 year later. In unadjusted models, wave 2 ATP initiation was found to be significantly associated with wave 1 ownership of ATP promotional materials (odds ratio, 2.23; 95% CI, 1.26-3.97). After adjustment for wave 1 demographic covariates, the association between ownership of ATP promotional material and ATP initiation 1 year later yielded similar results (odds ratio, 2.13; 95% CI, 1.16-3.91). Results of models assessing a combined outcome variable of either ATP or cigarette ever use were not statistically significant.

CONCLUSIONS AND RELEVANCE

Ownership of ATP promotional materials was associated with subsequent initiation of ATPs. The results of this study are consistent with the suggestion that current marketing restrictions for cigarettes, including restrictions of the distribution of samples, coupons, and other promotional material, should extend to ATPs.

Harm Perceptions of Alternative Tobacco Products among US Adolescents

OBJECTIVES

In this study, we identified groups of adolescents who share similar awareness and perceptions of harm regarding e-cigarettes, cigars, hookah, and smokeless tobacco.

METHODS

We used latent class analyses (LCA) with the data from Wave 1 (2013-14) of the Population Assessment of Tobacco and Health youth and parent survey (PATH; N = 13,650) to address the research goal. Multinomial logistic regression analysis assessed the associations between identified classes with demographic characteristics and tobacco use.

RESULTS

LCA identified 5 classes: (1) perceived harm across all alternative tobacco products (36.6%); (2) perceived harm for e-cigarettes and smokeless tobacco but never heard of cigars and hookah (48.2%); (3) never heard of alternative tobacco products (8.6%); (4) mix of no harm and harm across alternative tobacco products (5.2%); and (5) "don't know" the harm across alternative tobacco products (1.4%). Relative to the class who perceived harm across all alternative tobacco products, classes of adolescents who were unaware of the products or did not know the harms were more likely to be non-white, younger, have lower parental education, and less likely to have tried an alternative tobacco product.

CONCLUSIONS

Tobacco prevention should target vulnerable youth, such as adolescents who are non-white, young, and have low parental education.

Youth perception of harm and addictiveness of tobacco products: Findings from the Population Assessment of Tobacco and Health Study (Wave 1)

PURPOSE

We provide a US national assessment of youth perceptions of the harm and addictiveness of six separate tobacco products, identifying a continuum of perceived harm associated with a range of products in relation to patterns of current use, former use, and susceptibility to use tobacco products.

METHODS

We evaluated youth respondents (N = 13,651) ages 12-17 from Wave 1 (2013-2014) of the Population Assessment of Tobacco and Health (PATH) Study. Analyses (2015-2016) focused on refining measures of perceived harm for each product and delineating youth characteristics (demographic, tobacco use status) associated with beliefs about the harmfulness and addictiveness of tobacco products.

RESULTS

Cigars, hookah and e-cigarettes were each perceived as having significantly lower harm (p's < 0.05) than smokeless products, with the lowest ratings of harmfulness and addictiveness observed for hookah and e-cigarettes (p's < 0.001). Incrementally lower levels of harm and addictiveness perceptions were observed among youth at increasing risk for tobacco use (p's < 0.05).

CONCLUSIONS

Among U.S. youth, lower perceptions of harm and addictiveness of tobacco products were associated with susceptibility to use tobacco and patterns of tobacco product use. Future longitudinal assessments from the PATH Study can provide key information on youth development of perceptions of harm and addictiveness and influences on patterns of tobacco use.

Youth say ads for flavored e-liquids are for them

INTRODUCTION

E-cigarettes are the most popular tobacco product among adolescents and young adults ("AYA") and are available in many flavors. The e-cigarette industry argues that flavors are not meant to appeal to youth, yet no study has asked youth what age group they think ads for flavored e-liquids are targeting. We asked AYA which age group they thought ads for flavored e-liquids targeted.

METHODS

In 2016 as part of a larger survey, a random sample of 255 youth from across California (62.4% female, mean age = 17.5, SD = 1.7) viewed eight ads, presented in randomized order, for fruit-, dessert-, alcohol-, and coffee-flavored e-liquids and indicated the age group they thought the ads targeted: younger, same age, a little older, or much older than them. Population means and 95% confidence intervals were estimated using bootstrapping (100,000 replicate samples).

RESULTS

Most participants (93.7%) indicated the cupcake man flavor ad targeted an audience of people younger than they. Over half felt ads for smoothy (68.2%), cherry (63.9%), vanilla cupcake (58%), and caramel cappuccino (50.4%) targeted their age and for no flavor ad did most feel the primary target age group was much older.

CONCLUSIONS

Youth believe ads for flavored e-liquids target individuals about their age, not older adults. Findings support the need to regulate flavored e-liquids and associated ads to reduce youth appeal, which ultimately could reduce youth use of e-cigarettes.

E-Cigarette Social Norms and Risk Perceptions Among Susceptible Adolescents in a Country That Bans E-Cigarettes

BACKGROUND

This study examined how risk perceptions and social norms around e-cigarettes are associated with susceptibility (i.e., openness to using the product in the next 12 months) of e-cigarettes and smoking among adolescents.

METHODS

We analyzed data from a 2016 representative survey of 8,718 middle school students in Mexico. The study sample was restricted to students who had tried neither e-cigarettes nor cigarettes, ( N = 4471). Students reported on the risks of e-cigarettes compared with those of cigarettes, and product-specific norms were measured by assessing current use by family members, at least one close friend, and, for e-cigarettes, by perceived societal acceptability of use (i.e., acceptability among people in general). Adjusted prevalence ratios (APR) were estimated using generalized estimating equation models that regressed e-cigarette societal acceptability on study variables. Adjusted generalized estimating equation models also regressed susceptibility for each product on study variables.

RESULTS

Susceptibility to both e-cigarettes and smoking was higher among students who reported that their family and friends used only cigarettes or both products when compared with students whose family and friends did not use either of these products. Friend use of e-cigarettes was associated with e-cigarette susceptibility (APR = 1.33) but not smoking susceptibility. Students who perceived that e-cigarettes were less risky than smoking were more susceptible to e-cigarette use (APR = 1.45). The association between e-cigarette susceptibility and friend or family use was not mediated by societal acceptability.

CONCLUSIONS

E-cigarette use among family and peers appears associated with susceptibility to use e-cigarettes in a way that is similar to the patterns found for cigarettes. However, the influences appear somewhat specific to the type of product that network members use.

Effects of e-Cigarette Advertisements on Adolescents' Perceptions of Cigarettes

This study examined the effect of exposure to "cigalike" (products resembling cigarettes) e-cigarette advertisements on adolescents' perceptions of cigarettes. A nationally representative sample of 802 adolescents (13-17 years old) was randomly assigned to watch three e-cigarette or three control advertisements. Never-smokers who saw the e-cigarette advertisements (n = 352) reported significantly lower perceived risks of smoking than those in the control condition (n = 320). Ever-smokers (n = 130) did not show significant differences across the conditions. In subgroup analyses, current smokers (reported smoking in the past 30 days, n = 31) in the e-cigarette condition reported significantly lower perceived benefits of smoking than those in the control condition. E-cigarette advertisements can affect adolescents' perceptions of cigarettes. Many advertisements, especially the ones promoting "cigalikes," depict e-cigarettes as being similar to cigarettes (e.g., look, flavor) but also as a solution for cigarettes' shortcomings (e.g., bad smell). While the advertisements include messages about problems posed by cigarettes, proposing e-cigarettes as a solution may decrease the perceived risks of smoking among never-smokers. It may also not be clear to adolescents whether advertisements are for cigarettes or e-cigarettes. Regulating e-cigarette advertisements to minimize adolescents' exposure may prevent potential harmful effects on never-smokers' perception of smoking.

Youth's Perceptions of E-cigarette Advertisements with Cessation Claims

Objectives

E-cigarettes are not FDA-approved smoking cessation aids. Nevertheless, content analyses have shown that e-cigarette companies make claims about cessation efficacy. Some advertisements are explicit (directly mentioning their product can help smokers quit or stop smoking), while others are implicit (not containing cessation-related language, but implying cessation efficacy through subtle wording and imagery). This is the first study to examine directly how adolescents and young adults (AYAs) perceived these ads, and specifically whether they identify the cessation claims in e-cigarette advertisements.

Methods

248 AYAs in California viewed 4 e-cigarette advertisements with cessation claims, then selected claims made by each advertisement. Descriptive statistics and multi-level logistic regression models were used to examine the relationship between the type of claims and perception.

Results

The claim "helps me quit smoking" was most frequently selected after viewing advertisements with explicit cessation claims, but not after viewing implicit claims. No significant effect of tobacco use and age on claim selection was observed.

Conclusions

E-cigarette manufacturers make claims about cessation efficacy, and AYAs can identify such claims in advertisements, especially the explicit ones. FDA should regulate these advertisements as making therapeutic claims.

The Messages Presented in Electronic Cigarette-Related Social Media Promotions and Discussion: Scoping Review

Background

There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long-term health consequences. As smoking rates continue to drop or plateau in many well-developed countries, transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence indicates e-cigarettes are being marketed on social media as a harm reduction alternative, with retailers and manufacturers utilizing marketing techniques historically used by the tobacco industry.

Objective

This study aimed to identify and describe the messages presented in e-cigarette–related social media (Twitter, YouTube, Instagram, and Pinterest) promotions and discussions and identify future directions for research, surveillance, and regulation.

Methods

Data sources included MEDLINE, Scopus, ProQuest, Informit, the Journal of Medical Internet Research, and Google Scholar. Included studies were published in English between 2007 and 2017, analyzed content captured from e-cigarette–related social media promotions or discussions, and reported results for e-cigarettes separately from other forms of tobacco and nicotine delivery. Database search ceased in October 2017. Initial searches identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full-text articles to determine eligibility and identified 25 studies for inclusion. This process was undertaken with the assistance of the Web-based screening and data extraction tool—Covidence. The review was registered with the Joanna Briggs Institute (JBI) Systematic Reviews database and followed the methodology for JBI Scoping Reviews.

Results

Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavoring and highlighting the public performance of vaping. Discussion and promotion of these devices appear to be predominantly occurring among the general public and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media.

Conclusions

The social media landscape is dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly, real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals.

Adolescents have unfavorable opinions of adolescents who use e-cigarettes

Introduction

While evidence suggests positive opinions of smokers are associated with tobacco use, research exploring adolescents’ opinions of e-cigarette users is nascent. We hypothesized that adolescents harbor positive opinions of e-cigarette users, and that these opinions will be more positive among adolescents willing to try or who have used e-cigarettes.

Methods

Participants were 578 U.S. adolescents (ages 14 to 20) recruited from ten California schools. An online survey assessed their attitudes toward and opinions of adolescents who use e-cigarettes in 2015–2016. Analyses examined whether these variables were associated with willingness to try and use (ever vs. never) of e-cigarettes.

Results

The majority (61%) of participants had negative overall opinions toward adolescent e-cigarette users. Few participants ascribed positive traits (i.e., sexy, cool, clean, smart, and healthy) to e-cigarette users. Participants who were willing to try or had used e-cigarettes endorsed positive traits more than those unwilling to try and never-users (all p < .01). Participants sometimes endorsed negative traits (i.e., unattractive, trashy, immature, disgusting, and inconsiderate) to describe e-cigarette users. Unwilling and never-users viewed negative traits as more descriptive of e-cigarette users than willing or ever-users (all p < .01).

Conclusions

Adolescents generally had somewhat negative opinions of other adolescents who use e-cigarettes. Building on adolescents’ negativity toward adolescent e-cigarette users may be a productive direction for prevention efforts, and clinicians can play an important role by keeping apprised of the products their adolescent patients are using and providing information on health effects to support negative opinions or dissuade formation of more positive ones.

Heated tobacco products likely appeal to adolescents and young adults

BACKGROUND

Beginning in the 1960s in the USA and globally since 1998, tobacco companies have beenaggressively promoting heated tobacco products (HTP). In 2016, Philip Morris International (PMI) applied to the US Food and Drug Administration (FDA) seeking authorisation to market their IQOS HTP system and flavoured 'HeatSticks' in the USA as a modified-risk tobacco product (MRTP).

METHODS

We systematically evaluated the publicly available data PMI submitted to FDA in its MRTP application to determine whether PMI's IQOS product meets the US Tobacco Control Act's standard for MRTP claims. We examined whether PMI provided sufficient data showing tobacco users will not initiate with IQOS, that youth will not misperceive the MRTP-related claims being made concerning IQOS, and how youth perceive health risks associated with IQOS.

RESULTS

PMI's own studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS and will not perceive these products as risk-free. Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.

CONCLUSION

PMI's own data and available evidence from scientific studies conducted independent of the tobacco industry regarding how novel tobacco products are currently being marketed suggest that introduction of IQOS will result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.

Adolescents' and Young Adults' Use and Perceptions of Pod-Based Electronic Cigarettes

IMPORTANCE

Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among adolescents and young adults, and the new pod-based e-cigarette devices may put adolescents and young adults at increased risk for polytobacco use and nicotine dependence.

OBJECTIVE

To build an evidence base for perceptions of risk from and use of pod-based e-cigarettes among adolescents and young adults.

DESIGN, SETTING, AND PARTICIPANTS

In a survey study, a cross-sectional analysis was performed of data collected from April 6 to June 20, 2018, from 445 California adolescents and young adults as part of an ongoing prospective cohort study designed to measure the use and perceptions of tobacco products.

EXPOSURES

Use of pod-based e-cigarettes, e-cigarettes, and cigarettes.

MAIN OUTCOMES AND MEASURES

Ever use, past 7-day use, and past 30-day use and co-use of pod-based e-cigarettes, e-cigarettes, and cigarettes; use of flavors and nicotine in pod-based e-cigarettes and e-cigarettes; and associated perceptions of risks, benefits, and nicotine dependence.

RESULTS

Among 445 adolescents and young adults (280 females, 140 males, 6 transgender individuals, and 19 missing data; mean [SD] age, 19.3 [1.7] years) who completed wave 6 of the ongoing prospective cohort study, ever use information was provided by 437 respondents, of which 68 (15.6%) reported use of pod-based e-cigarettes, 133 (30.4%) reported use of e-cigarettes, and 106 (24.3%) reported use of cigarettes. The mean (SD) number of days that pod-based e-cigarettes were used in the past 7 days was 1.5 (2.4) and in the past 30 days was 6.7 (10.0). The mean (SD) number of days that other e-cigarettes were used in the past 7 days was 0.8 (1.8) and in the past 30 days was 3.2 (7.4). The mean (SD) number of days that cigarettes were used in the past 7 days was 0.7 (1.8) and in the past 30 days was 3.0 (7.6). Among ever users of pod-based e-cigarettes, 18 (26.5%) reported their first e-liquid was flavored menthol or mint and 19 (27.9%) reported fruit (vs 13 [9.8%] and 50 [37.6%] for other e-cigarettes). The mean perceived chance of experiencing social risks and short-term and long-term health risks from the use of either pod-based e-cigarettes or other e-cigarettes was 40% and did not differ statistically by e-cigarette type. Among 34 adolescents and young adults reporting any loss of autonomy from nicotine, there was no difference in mean (SD) Hooked On Nicotine Checklist scores between those using pod-based e-cigarettes (2.59 [3.14]) and other e-cigarettes (2.32 [2.55]).

CONCLUSIONS AND RELEVANCE

Use by adolescents and young adults of newer types of e-cigarettes such as pod-based systems is increasing rapidly, and adolescents and young adults report corresponding misperceptions and lack of knowledge about these products. Rapid innovation by e-cigarette manufacturers suggests that public health and prevention efforts appear to be needed to include messages targeting components common to all current and emerging e-cigarette products to increase knowledge and decrease misperceptions, with the goal to try to ultimately reduce e-cigarette use among adolescents and young adults.

Polytobacco Use Among a Nationally Representative Sample of Adolescent and Young Adult E-Cigarette Users

PURPOSE

Electronic nicotine delivery systems (ENDS) are adolescents' most commonly used tobacco product and young adults' second most used. Little is known about ENDS use alongside other tobacco products (polytobacco use) and whether exclusive ENDS users differ from polytobacco ENDS users.

METHODS

In spring 2016, we surveyed a nationally representative sample of 3,517 13-25-year olds (36.9% 13-17-year olds), and examined sociodemographic and relative risk perceptions between two groups of past 30-day ENDS users: exclusive (only ENDS) and polytobacco (ENDS and at least one other tobacco product).

RESULTS

4.5% of adolescents and 10% of young adults reported past 30-day ENDS use (n = 281; analytic sample). ENDS users were 38.8% female and 70.6% white. Over half (55.9%) were polytobacco ENDS users. The most common patterns of polytobacco ENDS use were ENDS and cigarettes (11.5%), ENDS and cigars (7.7%), and ENDS, cigars, and waterpipe (5.2%). Those who perceived ENDS to be less harmful than cigarettes were more likely to be exclusive ENDS users than those who perceived ENDS to be as or more harmful than cigarettes (adjusted odds ratio = 2.6, confidence interval = 1.2, 5.7). There were no differences between ENDS groups on age, race, sex, parental education, sexual orientation, or ENDS use frequency.

CONCLUSIONS

Just over half of ENDS users also used other tobacco products, increasing their risk for nicotine addiction and other health harms. The Food and Drug Administration is responsible for communicating product risk to consumers and should consider common patterns of use and relative risk perceptions in its ENDS public education efforts.

Perceived family relationship quality and use of poly-tobacco products during early and late adolescence

BACKGROUND

The role of family relationship in adolescent use of emerging tobacco products, which have become increasingly popular, is unknown. We examined the associations of perceived family relationship quality with current use of poly-tobacco products including cigarettes, electronic cigarettes (e-cigarettes), waterpipe and smokeless tobacco in adolescents.

METHODS

Data from a representative sample of 42,250 US grade 7-12 equivalent students (mean ± SD age 14.6 ± 1.9 years; 51.3% boys) from 75 randomly selected secondary schools in Hong Kong (2012-13) were analysed. Logistic regressions yielded adjusted odds ratios (AORs) for current (past 30-day) use of cigarettes, e-cigarettes, waterpipe, smokeless tobacco and poly-tobacco (≥2 products) in relation to perceived family relationship quality, adjusted for age, sex, perceived family affluence, parental education, family structure, parental and sibling smoking and secondhand smoke exposure at home. Subgroup analyses were conducted to compare the associations in early (aged ≤14 years) versus late (>14) adolescents.

RESULTS

The odds of current use increased with worse perceived family relationship quality with AORs (95% confidence interval) of up to 2.92 (2.32-3.68) for cigarettes, 7.28 (4.71-11.2) for e-cigarettes, 5.04 (3.44-7.40) for waterpipe, 8.09 (4.87-13.4) for smokeless tobacco and 5.25 (3.45-8.01) for poly-tobacco products use (all P for trend <.001). The associations for all tobacco use outcomes were stronger in early than late adolescents (all P for interaction <.001).

CONCLUSIONS

Dose-response relationships were found between negatively perceived family relationship quality and current poly- and individual tobacco product use by Hong Kong Chinese secondary students. The associations were stronger for alternative tobacco products and in early adolescents.

Examining Hookah as an Introduction to Nicotine Products among College Students

BACKGROUND

Limited data exist on what young adults report as their first-ever nicotine product; some evidence suggests that they report hookah as their first product smoked.

OBJECTIVES

This study reports on the first nicotine product used among undergraduates who had ever tried tobacco, and explores correlates of hookah as that first product.

METHODS

Participants included a convenience sample of undergraduate students (n = 1538) at four universities in upstate New York during fall 2013. Descriptive statistics assessed first nicotine product used and prevalence of current use. Logistic regression was used to examine correlates of hookah as the first nicotine product used.

RESULTS

Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. Among students who ever smoked cigarettes, most reported cigarettes as their introductory product. Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. Among ever nicotine users, current hookah smoking was common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. Never users of cigarettes, females, and non-Hispanic African Americans, had higher adjusted odds of reporting hookah as their introductory product.

CONCLUSIONS

The results of this study have implications for the identification of risk factors for tobacco initiation, the assessment of tobacco use patterns and behaviors, and the tailoring of tobacco prevention initiatives among youth. Our findings suggest that broadening prevention efforts beyond a focus on combustible cigarettes may be warranted.

Adolescent E-Cigarette, Hookah, and Conventional Cigarette Use and Subsequent Marijuana Use

: media-1vid110.1542/5799875103001PEDS-VA_2017-3616Video Abstract OBJECTIVES: Noncigarette tobacco products may confer a risk of marijuana use similar to combustible cigarettes. We examined whether adolescent electronic cigarette (e-cigarette), hookah, or combustible cigarette use is associated with initiating and currently using marijuana as well as using both tobacco and marijuana concurrently.

METHODS

Adolescents from 10 public schools in Los Angeles, California, completed in-classroom surveys at baseline (fall 2013, ninth grade) and at a 24-month follow-up (fall 2015, 11th grade). Among adolescents who never used marijuana at baseline (N = 2668), associations of baseline e-cigarette, hookah, or combustible cigarette use with ever marijuana use (initiation), current marijuana use (past 30 days), and current dual use of marijuana and these tobacco products at the 24-month follow-up were examined.

RESULTS

Baseline ever versus never e-cigarette use was associated with initiation (odds ratio [OR] 3.63; 95% confidence interval [CI] 2.69-4.90) and current (OR 3.67; 95% CI 2.51-5.36) marijuana use 24 months later. Ever versus never hookah use was associated with initiation (OR 3.55; 95% CI 2.49-5.08) and current (OR 4.10; 95% CI 2.69-6.25) marijuana use 24 months later. Similar associations were observed for combustible cigarette smoking and initiation (OR 4.30; 95% CI 2.79-6.63) and current use of marijuana (OR 1.97; 95% CI 1.05-3.68). Current use of any of these tobacco products at baseline was associated with current use of both tobacco and marijuana (OR 2.28; 95% CI 1.47-3.55) 24 months later.

CONCLUSIONS

The association between tobacco use and subsequent marijuana use across adolescence extends to multiple tobacco products.

Attitudes and Risk Perceptions Toward Smoking Among Adolescents Who Modify Cigar Products

Objective

To examine high school youths' perceptions of health risks, and personal and parental attitudes toward cigarette, cigar, and marijuana use among youth who use or modify cigars.

Participants

The 2013 Cuyahoga County Youth Risk Behavior Survey used a two-stage cluster sample design to randomly sample public high schools and classrooms. Students in selected classrooms were eligible; 16,855 students completed the survey.

Main Outcome Measures

This study examines the association between risk perceptions of and youths' personal and parental attitudes toward smoking cigarettes, cigars, and marijuana with current use of cigars, cigarillos or little cigars (CCLCs) or modified CCLCs (ie, freaking or blunting).

Results

23.5% of youth reported current use of CCLCs in some way; 11.0% reported current freaking and 18.5% reported current blunt use. CCLC users tended to be male and Black. Perceiving all smoking behaviors as risky, wrong, or wrong by parents reduced odds of using CCLCs. After multivariate analysis, Blacks had increased odds of using CCLCs if they perceived smoking cigarettes as harmful, which was not found among other race/ethnicity categories. Having parents who believed that smoking CCLCs is wrong increased the odds of youth freaking or blunting among all CCLC users. Odds of blunting was greater for those who believed CCLCs were more risky among all CCLC users.

Conclusions

Findings suggest that CCLC users may think cigars are safer than cigarettes, and that modifiers may think their use is safer and more in line with their parents' views than non-modified CCLCs.

Cigarette and Smokeless Tobacco Perception Differences of Rural Male Youth

Objectives

Compare cigarette and smokeless tobacco (ST) perceptions within a youth population where ST use is common.

Methods

Male baseball players (N = 594) at 36 rural high schools in California rated separately 20 potential risks or benefits associated with cigarettes or ST, along with global harm ratings. Informed by principal components analysis, 3 composite categories were created: oral/rule-breaking risks (eg, mouth cancer, getting in trouble), systemic risks (eg, heart attack), and benefits (eg, relaxation). Standardized composite scores and harm ratings were compared by product and by tobacco use status.

Results

Cigarettes were perceived as likely to impart oral/rule-breaking risks and systemic risks, unlikely to cause benefits, and as very harmful overall. ST was perceived similarly as cigarettes regarding oral/rule-breaking risks, but less likely to cause systemic risks, and more beneficial. Most participants rated cigarettes as more harmful than ST. Similar patterns existed in all tobacco use groups, including non-users and dual-users.

Conclusions

In this population, cigarettes were perceived as very harmful. ST was perceived similarly to cigarettes only for some risks and as less harmful overall. Communication for rural adolescents should consider multifaceted aspects of ST risk.

Adolescents' perceptions of flavored tobacco products, including E-cigarettes: A qualitative study to inform FDA tobacco education efforts through videogames

INTRODUCTION

Flavored tobacco products have been shown to appeal to youth, however tobacco control strategies have traditionally not focused on these products. To inform the adaptation of an existing videogame to focus on the prevention of flavored tobacco product use, this study explored adolescents' perceptions, beliefs, and social norms surrounding these products, including flavored e-cigarettes.

METHODS

We conducted and analyzed transcripts from seven focus groups with 11-17-year-old adolescents (n = 33) from after-school programs in CT and CA in 2016. Participants discussed flavored tobacco product beliefs and experiences, and how these compared to traditional cigarettes.

RESULTS

Thematic analysis of transcripts revealed that participants could name flavors in tobacco products, even though few discussed first-hand experience with the products. Most groups perceived that flavored tobacco product and flavored e-cigarette use facilitated peer approval and acceptance. All groups discussed how youth could easily access flavored tobacco products, including e-cigarettes. Flavoring was a salient aspect of e-cigarette advertisements; however the groups did not recall exposure to other types of flavored tobacco product counter-marketing.

CONCLUSIONS

These data can help inform the development of tobacco control strategies, novel interventions (such as videogames), and future FDA efforts to prevent adolescent tobacco product use through education and risk communication.

A fMRI study on the impact of advertising for flavored e-cigarettes on susceptible young adults

BACKGROUND

E-cigarettes are sold in flavors such as "skittles," "strawberrylicious," and "juicy fruit," and no restrictions are in place on marketing e-cigarettes to youth. Sweets/fruits depicted in e-cigarette advertisements may increase their appeal to youth and interfere with health warnings. This study tested a brain biomarker of product preference for sweet/fruit versus tobacco flavor e-cigarettes, and whether advertising for flavors interfered with warning labels.

METHODS

Participants (N = 26) were college-age young adults who had tried an e-cigarette and were susceptible to future e-cigarette use. They viewed advertisements in fMRI for sweet/fruit and tobacco flavor e-cigarettes, menthol and regular cigarettes, and control images of sweets/fruits/mints with no tobacco product. Cue-reactivity was measured in the nucleus accumbens, a brain biomarker of product preference. Advertisements randomly contained warning labels, and recognition of health warnings was tested post-scan. Visual attention was measured using eye-tracking.

RESULTS

There was a significant effect of e-cigarette condition (sweet/tobacco/control) on nucleus accumbens activity, that was not found for cigarette condition (menthol/regular/control). Nucleus accumbens activity was greater for sweet/fruit versus tobacco flavor e-cigarette advertisements and did not differ compared with control images of sweets and fruits. Greater nucleus accumbens activity was correlated with poorer memory for health warnings.

CONCLUSIONS

These and exploratory eye-tracking findings suggest that advertising for sweet/fruit flavors may increase positive associations with e-cigarettes and/or override negative associations with tobacco, and interfere with health warnings, suggesting that one way to reduce the appeal of e-cigarettes to youth and educate youth about e-cigarette health risks is to regulate advertising for flavors.

A longitudinal study of risk perceptions and e-cigarette initiation among college students: Interactions with smoking status

BACKGROUND

Recent data suggest that lower perceived risks of e-cigarettes are associated with e-cigarette use in young adults; however, the temporality of this relationship is not well-understood. We explore how perceptions of harmfulness and addictiveness of e-cigarettes influence e-cigarette initiation, and specifically whether this association varies by cigarette smoking status, in a longitudinal study of tobacco use on college campuses.

METHODS

Data are from a 5-wave 24-college study in Texas. Only students who reported never using e-cigarettes at wave 1 were included (n = 2565). Multilevel discrete-time hazard models, accounting for school clustering, were used. The dependent variable, ever e-cigarette use, was assessed at each wave. Both time-varying (e-cigarette perceptions of harmfulness and addictiveness, age, use of cigarettes, use of other tobacco products, and use of other substances) and time-invariant demographic covariates were included. Two-way interactions between each e-cigarette perception variable and current conventional cigarette use were tested to determine if the hypothesized relationship differed among smokers and non-smokers.

RESULTS

21% of all never e-cigarette users at baseline had initiated e-cigarette ever use by wave 5. Significant two-way interactions qualified the relationship between risk perceptions and e-cigarette initiation. Specifically, perceptions of a lower degree of harmfulness (OR = 1.13, p = .047) and addictiveness (OR = 1.34, p < .001) of e-cigarettes predicted initiation among non-smokers, but not among current smokers.

CONCLUSION

Perceiving a lower degree of risk of e-cigarettes contributes to subsequent e-cigarette initiation among non-smokers, but not among current smokers.

FINDINGS

have implications for prevention campaigns focusing on the potential harm of e-cigarettes for non-smoking college students.

Decline of adolescent smoking in Ireland 1995-2015: trend analysis and associated factors

OBJECTIVES

The study examines trends in smoking among Irish adolescents aged 15-16 years between 1995 and 2015 and the factors associated with their smoking behaviours between 2007 and 2015.

METHODS

Data were obtained from the European School Survey Project on Alcohol and Other Drugs Ireland between 1995 and 2015. To examine the gender gap, two-sample proportion tests were used. Multivariate logistic regression was performed to examine the factors associated with smoking behaviours. Dependent variable is whether a respondent is a smoker in last 30 days. Independent variables include gender, survey years, perceived ease of access to cigarettes, perceived risk of smoking, perceived relative wealth, parental monitoring, maternal relationship, family structure, truancy and peer smoking.

RESULTS

Smoking prevalence has dropped from 41% in 1995 to 13% in 2015. The prevalence was much higher among girls than boys in 1995. The gender gap was closed by 2015. Multivariate regression results show that peer smoking, perceived access to cigarettes, perceived risks of smoking, parental monitoring, truancy, maternal relationship, perceived relative wealth and family structure were all significantly associated with adolescent smoking, and some of the factors had different effects for female and male students.

CONCLUSION

Ireland has successfully achieved a considerable decrease of adolescent smoking from 1995 to 2015, during which various tobacco control policies have been implemented. In addition, the gender gap on adolescent smoking has been closed during the period. Adolescent smoking could be further improved through strengthening enforcement on adolescent access to cigarettes and maintaining a high-intensity tobacco control media campaign targeting adolescents. Parents could also contribute by enhancing monitoring.

Measuring perceptions related to e-cigarettes: Important principles and next steps to enhance study validity

Measuring perceptions associated with e-cigarette use can provide valuable information to help explain why youth and adults initiate and continue to use e-cigarettes. However, given the complexity of e-cigarette devices and their continuing evolution, measures of perceptions of this product have varied greatly. Our goal, as members of the working group on e-cigarette measurement within the Tobacco Centers of Regulatory Science (TCORS) network, is to provide guidance to researchers developing surveys concerning e-cigarette perceptions. We surveyed the 14 TCORS sites and received and reviewed 371 e-cigarette perception items from seven sites. We categorized the items based on types of perceptions asked, and identified measurement approaches that could enhance data validity and approaches that researchers may consider avoiding. The committee provides suggestions in four areas: (1) perceptions of benefits, (2) harm perceptions, (3) addiction perceptions, and (4) perceptions of social norms. Across these 4 areas, the most appropriate way to assess e-cigarette perceptions depends largely on study aims. The type and number of items used to examine e-cigarette perceptions will also vary depending on respondents' e-cigarette experience (i.e., user vs. non-user), level of experience (e.g., experimental vs. established), type of e-cigarette device (e.g., cig-a-like, mod), and age. Continuous formative work is critical to adequately capture perceptions in response to the rapidly changing e-cigarette landscape. Most important, it is imperative to consider the unique perceptual aspects of e-cigarettes, building on the conventional cigarette literature as appropriate, but not relying on existing conventional cigarette perception items without adjustment.

E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications

Since e-cigarettes appeared in the mid-2000s, some practitioners, researchers, and policy makers have embraced them as a safer alternative to conventional cigarettes and an effective way to stop smoking. While e-cigarettes deliver lower levels of carcinogens than do conventional cigarettes, they still expose users to high levels of ultrafine particles and other toxins that may substantially increase cardiovascular and noncancer lung disease risks, which account for more than half of all smoking-caused deaths, at rates similar to conventional cigarettes. Moreover, rather than stimulating smokers to switch from conventional cigarettes to less dangerous e-cigarettes or quitting altogether, e-cigarettes are reducing smoking cessation rates and expanding the nicotine market by attracting youth.

Association of Noncigarette Tobacco Product Use With Future Cigarette Smoking Among Youth in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015

IMPORTANCE

Approximately 90% of adult smokers first tried a cigarette by 18 years of age, and even infrequent smoking in adolescence is associated with established adult smoking. Noncigarette tobacco use is increasing and could stimulate subsequent conventional cigarette smoking in youths.

OBJECTIVE

To estimate the longitudinal association between noncigarette tobacco use and subsequent cigarette smoking initiation among US youth.

DESIGN, SETTING, AND PARTICIPANTS

In this prospective cohort study of the Population Assessment of Tobacco and Health (PATH) waves 1 (September 12, 2013, to December 14, 2014) and 2 (October 23, 2014, to October 30, 2015), a nationally representative sample of youths who never smoked a conventional cigarette at baseline and completed wave 2 follow-up (N = 10 384) was studied. PATH retention at follow-up was 87.9%.

EXPOSURES

Ever use and past 30-day use of electronic cigarettes (e-cigarettes), hookah, noncigarette combustible tobacco, or smokeless tobacco at baseline.

MAIN OUTCOMES AND MEASURES

Ever use and past 30-day use of cigarettes at follow-up.

RESULTS

The present analysis was based on the 10 384 PATH youth respondents who reported never having smoked a cigarette in wave 1 and whose cigarette ever or past 30-day use was reported in wave 2 (mean [SD] age, 14.3 [1.7] years; age range, 12-17 years; 5087 [49.1%] female; 4829 [52.5%] white). At 1-year follow-up, 469 (4.6%) of all baseline never-smoking youths had tried a cigarette and 219 (2.1%) had smoked a cigarette within the past 30 days. Cigarette ever use at follow-up was higher among youths who had ever used e-cigarettes (78 [19.1%]), hookah (60 [18.3%]), noncigarette combustible tobacco (45 [19.2%]), or smokeless tobacco (29 [18.8%]) at baseline. After adjusting for sociodemographic, environmental, and behavioral smoking risk factors and for baseline ever use of other tobacco products, the odds of past 30-day cigarette use at follow-up were approximately twice as high among baseline ever users of e-cigarettes (odds ratio [OR], 1.87; 95% CI, 1.15-3.05), hookah (OR, 1.92; 95% CI, 1.17-3.17), noncigarette combustible tobacco (OR, 1.78; 95% CI, 1.00-3.19), and smokeless tobacco (OR, 2.07; 95% CI, 1.10-3.87). Youths who had tried more than 1 type of tobacco product at baseline had 3.81 (95% CI, 2.22-6.54) greater adjusted odds of past 30-day cigarette smoking at follow-up than did baseline never tobacco users.

CONCLUSIONS AND RELEVANCE

Any use of e-cigarettes, hookah, noncigarette combustible tobacco, or smokeless tobacco was independently associated with cigarette smoking 1 year later. Use of more than 1 product increased the odds of progressing to cigarette use.

Smokeless Tobacco Decision-Making Among Rural Adolescent Males in California

Smokeless tobacco (ST) use among US high school males living in rural areas exceeds national levels. Subgroups at heightened risk of ST use have been identified, but less is known regarding ST decision-making within high-risk groups. The study objective was to describe rural adolescent males' perceived ST acceptability, health risks, and social implications and how those perceptions differ between ST users and never-users. Semi-structured individual interviews were conducted with a purposeful sample of 55 male students (32 ST ever-users) at three rural California high schools. Interviews were audio recorded and professionally transcribed. Investigators collaboratively developed a codebook based on thematic content and then independently coded transcripts, reconvening frequently to achieve consensus. Coded text was systematically organized into themes following a general inductive approach. ST users and non-users shared multiple ST-related perceptions, including: that ST is a common, normative way of life in rural "country" culture among certain groups; that ST use conveys oral health risks; and that the decision to use (or not to use) is rooted in personal choice. ST users' and never-users' perceptions differed regarding the immediacy, severity, and inevitability of health risks, particularly relative to cigarette smoking. Other differences included perceived parental permissiveness and the expected social benefits of ST use, such as peer acceptance and conveying maturity. Within this population of rural male adolescents, ST users emphasized the social benefits of ST use, while acknowledging but discounting health risks. Differences and similarities in tobacco perceptions among adolescents living in similar environments may inform effective health communication.

Perceptions of the Harm and Addictiveness of Conventional Cigarette Smoking Among Adolescent E-Cigarette Users

PURPOSE

Although existing evidence indicates that e-cigarette use is a risk factor for cigarette smoking initiation, mechanisms of this association are not yet known. E-cigarette users perceive e-cigarette use to be less harmful relative to conventional cigarettes, but their absolute perceptions of addictiveness of conventional cigarette smoking are unknown. This study examines how e-cigarette users compare with nonusers (non-e-cigarette users/nonconventional cigarette smokers), conventional cigarette smokers, and dual users on perceptions of harm and the addictiveness of conventional cigarette smoking and on other known predictors of cigarette smoking such as peer smoking, influence of antismoking ads, and risk-taking propensity.

METHODS

National samples of 8th- and 10th-grade students from 2014 and 2015 (N = 14,151) were obtained from the Monitoring the Future Study. Multivariate logistic regression models were used to examine relationships between adolescent smoking status and perceptions of harm and the addictiveness of conventional cigarette smoking while controlling for potential confounders.

RESULTS

E-cigarette users had lower perceptions of the addictiveness of conventional cigarette smoking compared with nonusers but higher than cigarette smokers and dual users. E-cigarette users reported lower influence by antismoking ads, more conventional cigarette-smoking peers, and greater risk-taking propensity than nonusers. E-cigarette users and cigarette smokers did not differ in their perceived harm of conventional cigarette smoking or in their risk-taking propensity.

CONCLUSIONS

E-cigarette users' attitudes and perceptions regarding conventional cigarette smoking may leave them vulnerable to becoming conventional cigarette smokers. Future studies should explore the prospective relationship between smoking-related perceptions of conventional cigarette smoking among e-cigarette users and the onset of cigarette smoking.

High-resolution Temporal Representations of Alcohol and Tobacco Behaviors from Social Media Data

Understanding tobacco- and alcohol-related behavioral patterns is critical for uncovering risk factors and potentially designing targeted social computing intervention systems. Given that we make choices multiple times per day, hourly and daily patterns are critical for better understanding behaviors. Here, we combine natural language processing, machine learning and time series analyses to assess Twitter activity specifically related to alcohol and tobacco consumption and their sub-daily, daily and weekly cycles. Twitter self-reports of alcohol and tobacco use are compared to other data streams available at similar temporal resolution. We assess if discussion of drinking by inferred underage versus legal age people or discussion of use of different types of tobacco products can be differentiated using these temporal patterns. We find that time and frequency domain representations of behaviors on social media can provide meaningful and unique insights, and we discuss the types of behaviors for which the approach may be most useful.

Access to Tobacco Among California High School Students: The Role of Family Members, Peers, and Retail Venues

PURPOSE

The purpose of the study was to determine from whom and where adolescents obtained tobacco, including cigarettes, e-cigarettes, and hookah.

METHODS

California adolescents (N = 772; 63.19% female; mean age = 16.13 years, SD = 1.61; 26.44% white, 22.12% Asian/Pacific Islander, 36.65% Hispanic, and 14.79% other) were surveyed about their access to different tobacco products.

RESULTS

Adolescents were significantly more likely to obtain tobacco from friends (54.9%) than family members or direct purchasing (p < .001). Smoke shops were the most common purchase location across products (44.3%), with adolescents significantly more likely to purchase hookah and e-cigarettes from smoke shops than gas stations, liquor stores, or drug stores (p < .02).

CONCLUSIONS

The effective characterization of tobacco access patterns is critical to the development of comprehensive tobacco control. By demonstrating peers and smoke shops as the primary social and retail outlets, this study identifies targets for the optimization of regulation and messaging aimed at reducing adolescents' access to tobacco.

Adolescent Cigarette Smoking Perceptions and Behavior: Tobacco Control Gains and Gaps Amidst the Rapidly Expanding Tobacco Products Market From 2001 to 2015

PURPOSE

The aim of the study was to determine whether adolescents' intentions to smoke, cigarette smoking behavior, and specific perceptions of cigarette smoking are different in 2015 versus 2001.

METHODS

Data from two California school-based studies (Xage = 14) were compared: one conducted in 2001-2002 ("2001"), N = 395; the second in 2014-2015 ("2015"); N = 282.

RESULTS

In 2015, more participants reported it was very unlikely they would smoke (94% vs. 65%) and that they never smoked (95% vs. 74%); they reported perceiving less likelihood of looking more mature (17% vs. 28%) and greater likelihood of getting into trouble (86% vs. 77%), having a heart attack (76% vs. 69%), and contracting lung cancer (85% vs. 78%) from smoking (p < .001). Perceptions of short-term health problems and addiction were similar in 2001 and 2015.

CONCLUSIONS

Findings suggest that adolescents in 2015 perceived greater risks compared to those in 2001 even amidst the rapidly changing tobacco product landscape. In addition to continuing messages of long-term health risks, prevention efforts should include messages about addiction and short-term health and social risks.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Adolescents' attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation

E-cigarette use has dramatically increased. While studies have examined adolescents' attitudes towards smoking, few have extended this research to adolescents' attitudes towards e-cigarettes. The goal of this study was to examine adolescents' attitudes regarding e-cigarette ingredients, safety, addictive properties, social norms, accessibility, price, and regulation; and determine whether attitudes differ by past cigarette/e-cigarette use. Participants were 786 9th and 12th graders from California (63.21% females; mean age=16.10years [SD=1.6]; 26.61% White, 21.98% Asian/Pacific Islander, 29.82% Hispanic, and 21.59% other). Results indicated that 19.05% of participants believed smoke from e-cigarettes is water; 23.03% believed e-cigarettes aren't a tobacco product; 40.36% considered e-cigarettes to be for cessation, and 43.13% felt they were safer than cigarettes. Participants felt it was more acceptable to use e-cigarettes indoors and outdoors compared to cigarettes (p<0.0001), 23.13% felt raising e-cigarette taxes is a bad idea, 63.95% thought e-cigarettes were easier to get than cigarettes, 54.42% felt e-cigarettes cost too much, 64.33% felt the age for buying e-cigarettes should be raised, and 64.37% favored e-cigarette regulation. Adolescents who used e-cigarettes and/or cigarettes had significantly more favorable e-cigarette attitudes than non-users. This study indicates that adolescents are aware of some of the risks of e-cigarettes, although many harbor misperceptions and hold more favorable attitudes towards e-cigarettes than cigarettes. Of concern is the relationship between favorable e-cigarette attitudes and use. Findings suggest the need to provide adolescents with correct information about e-cigarette ingredients, risks, and the insufficient evidence of their role in cigarette cessation.

Perceptions of social norms and exposure to pro-marijuana messages are associated with adolescent marijuana use

Despite consistent declines in rates of cigarette use among adolescents in the last five years, rates of marijuana use have remained constant, with marijuana being the most widely used illegal drug among adolescents. More work is needed to understand how social norms, perceived risks and benefits, and social media messaging impact use of marijuana. This study compared perceptions and social norms related to marijuana, blunts and cigarettes. Additionally, we assessed how perceptions related to social norms, risks and benefits, and exposure to pro- versus anti-marijuana messaging is related to use. Participants were 786 adolescents from Southern and Northern California (36.7% male, 63.21% females; mean age=16.1years; SD=1.6). Participants came from diverse ethnic backgrounds, with 207 (26.61%) White, 171 (21.98%) Asian/Pacific Islander, 232 (29.82%) Hispanic, and 168 (21.59%) other. Results indicated that marijuana and blunts were consistently perceived as more socially acceptable and less risky than cigarettes (p<0.01). Participants who reported that their friends used marijuana had a 27% greater odds of using marijuana themselves. Further, seeing messages about the good things or benefits of marijuana use was associated with a 6% greater odds of use [OR 1.06 (CI 1.00, 1.12)]. This study's findings offer a number of important public health implications, particularly as states move towards legalization of marijuana for recreational use. As this occurs, states need to take adolescents' perceptions of risks, benefits, social norms, and peer influences into account as they implement strategies to reduce youth use of marijuana and blunts.