Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study

Nicotine-Free E-Cigarettes Might Promote Tobacco Smoking Reduction Better Than Nicotine Delivery Devices: Results of a Double-Blind Randomized Controlled Trial at 1 Year

The purpose of the present study was to determine whether the use of e-cigarettes to aid in quitting contributed to the increase in the pulmonary health of chronic smokers. The efficacy of e-cigarettes to support a successful smoking cessation attempt was also investigated. A total of 210 smokers (78 women) were enrolled in a screening program for the early detection of lung cancer and distributed in three arms: nicotine e-cigarette plus support, nicotine-free e-cigarette plus support, and support. Results showed that participants in the nicotine e-cigarette arm had a significant and fast decrease in daily cigarettes, but that later they resume smoking more than the other two groups. Conversely, participants in the other two arms showed similar daily consumption at the two evaluation points. Among abstinent participants, only 12.5% reported cough, while 48% of current smokers had pulmonary symptoms. Our study suggests that, in the long run, the use of a nicotine-free liquid may favor reducing smoking and could be considered a good option in a clinical setting.

Health impact of e-cigarettes and heated tobacco products in chronic obstructive pulmonary disease: current and emerging evidence

INTRODUCTION

Quitting is the only proven method to attenuate the progression of chronic obstructive pulmonary disease (COPD). However, most COPD smokers do not seem to respond to smoking cessation interventions and may benefit by lessening the negative health effects of long-term cigarette smoke exposure by switching to non-combustible nicotine delivery alternatives, such as heated tobacco products (HTPs) and e-cigarettes (ECs).

AREAS COVERED

Compared with conventional cigarettes, HTPs and ECs offer substantial reduction in exposure to toxic chemicals and have the potential to reduce harm from cigarette smoke when used as tobacco cigarette substitutes. In this review, we examine the available clinical studies and population surveys on the respiratory health effects of ECs and HTPs in COPD patients.

EXPERT OPINION

The current research on the impact of ECs and HTPs on COPD patients' health is limited, and more high-quality studies are needed to draw definitive conclusions. However, this review provides a comprehensive overview of the available literature for health professionals looking to advise COPD patients on the use of these products. While ECs and HTPs may offer some benefits in reducing harm from cigarette smoke, their long-term effects on COPD patients' health are still unclear.

Chronic E-Cigarette Use Impairs Endothelial Function on the Physiological and Cellular Levels

BACKGROUND

The harmful vascular effects of smoking are well established, but the effects of chronic use of electronic cigarettes (e-cigarettes) on endothelial function are less understood. We hypothesized that e-cigarette use causes changes in blood milieu that impair endothelial function.

METHODS

Endothelial function was measured in chronic e-cigarette users, chronic cigarette smokers, and nonusers. We measured effects of participants' sera, or e-cigarette aerosol condensate, on NO and H2O2 release and cell permeability in cultured endothelial cells (ECs).

RESULTS

E-cigarette users and smokers had lower flow-mediated dilation (FMD) than nonusers. Sera from e-cigarette users and smokers reduced VEGF (vascular endothelial growth factor)-induced NO secretion by ECs relative to nonuser sera, without significant reduction in endothelial NO synthase mRNA or protein levels. E-cigarette user sera caused increased endothelial release of H2O2, and more permeability than nonuser sera. E-cigarette users and smokers exhibited changes in circulating biomarkers of inflammation, thrombosis, and cell adhesion relative to nonusers, but with distinct profiles. E-cigarette user sera had higher concentrations of the receptor for advanced glycation end products (RAGE) ligands S100A8 and HMGB1 (high mobility group box 1) than smoker and nonuser sera, and receptor for advanced glycation end product inhibition reduced permeability induced by e-cigarette user sera but did not affect NO production.

CONCLUSIONS

Chronic vaping and smoking both impair FMD and cause changes in the blood that inhibit endothelial NO release. Vaping, but not smoking, causes changes in the blood that increase microvascular endothelial permeability and may have a vaping-specific effect on intracellular oxidative state. Our results suggest a role for RAGE in e-cigarette-induced changes in endothelial function.

Factors that influence cannabis vaping habits of college students: A qualitative study

Objective: The purpose of this study is to examine the attitudes and perceptions of college undergraduates regarding cannabis vaping. Participants: Twenty-one, predominantly male (71.4%; Mage = 22, SD = 2.09), undergraduate college students who reported vaping cannabis in the past 30 days. Methods: Participants were interviewed to determine their attitudes and perceptions regarding cannabis vaping. Findings: Thematic analysis uncovered six primary themes and eighteen subthemes. Main themes included (1) Convenience, (2) Discreetness, (3) Mood-Altering Experience, (4) Social Acceptability, (5) Health and Safety, and (6) COVID-19 Pandemic Impact. Conclusion: College students who use cannabis tend to both vape and use combustible methods, depending upon social and physical environment. This population tends to vaporize cannabis for its perceived mood-altering properties. Additional research is needed to further examine the behaviors and attitudes surrounding cannabis vaping among college undergraduates, as well as the development of interventions specific to this demographic.

A systematic review of the effects of e-cigarette use on lung function

Given the increasing use of e-cigarettes and uncertainty surrounding their safety, we conducted a systematic review to determine the effects of e-cigarettes on measures of lung function. We systematically searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 until July 2021, identifying 8856 potentially eligible studies. A total of eight studies (seven studying immediate effects and one long-term effects, 273 total participants) were included. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) and Cochrane risk of bias tools. These studies suggest that vaping increases airway resistance but does not appear to impact forced expiratory volume in one second (FEV₁₎, forced vital capacity (FVC), or FEV₁/FVC ratio. However, given the limited size and follow-up duration of these studies, larger, long-term studies are required to further determine the effects of e-cigarettes on lung function.

The Health Effects of Real-World Dual Use of Electronic and Conventional Cigarettes versus the Health Effects of Exclusive Smoking of Conventional Cigarettes: A Systematic Review

BACKGROUND

A high prevalence of dual use of e-cigarettes and conventional cigarettes has been reported across the world.

METHODS

A systematic search was carried out. We included original articles on any topic relevant to health, excluding mental health, in all languages. The PRISMA guidelines were followed. Both reviewers independently screened and read all publications. We compared dual use with exclusive smoking of conventional cigarettes (ESCC).

RESULTS

Fifty-two publications (49 studies) were included. Thirteen papers/10 studies were prospective. There was great heterogeneity across studies. Many methodological weaknesses, such as inaccurate exposure measurement, lack of adjustment for former tobacco consumption, and lack of significance testing were identified. Most prospective studies found dual use to be at least as harmful as ESCC. The longest follow-up was six years. Most of the best available cross-sectional studies found dual use associated with the same and, in several studies, significantly higher risk of self-reported symptoms/disease than in ESCC. The intensity of cigarette smoking seems associated with worse health.

CONCLUSION

Existing studies indicate that dual use is at least as, or probably even more, harmful than ESCC. Due to the predominance of cross-sectional studies and the methodological weaknesses we judged the overall certainty of the evidence as "low certainty".

Electronic cigarettes versus nicotine-replacement therapy for smoking cessation: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Nicotine-replacement therapy (NRT) and electronic cigarettes (e-cigarettes) have been frequently used for smoking cessation. The aim of this review is to investigate the effectiveness and safety of e-cigarettes versus NRT for smoking cessation.

METHODS

We searched PubMed, EMBASE, the Cochrane Library from inception to 10 October 2021. We included randomized controlled trials (RCTs) comparing e-cigarettes versus NRT for smoking cessation. Two authors independently screened titles, abstracts and full texts for eligibility. Paired authors extracted data, assessed risk of bias, and used GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) to rate the certainty of evidence.

RESULTS

The study included five RCTs with 1748 participants. The meta-analysis suggested the e-cigarettes versus NRT increased the ≥6 months continuous abstinence rate (RR=1.67; 95% CI: 1.21-2.28; 55 more per 1000 participants, low certainty), and 7-day point abstinence rate at ≥6 months follow-up (RR=1.43; 95% CI: 1.19-1.72; 84 more per 1000, low certainty). However, we found no evidence that e-cigarettes versus NRT increased 3-6 months continuous abstinence rate (RR=1.07; 95% CI: 0.73-1.57; 10 more per 1000, very low certainty) and <3 months continuous abstinence rate (RR=1.20; 95% CI: 0.90-1.60; 54 more per 1000, low certainty); similar results were found at <3 months follow-up (RR=1.19; 95% CI: 0.92-1.54; 55 more per 1000, very low certainty) and 3-6 months follow-up in 7-day point abstinence rate (RR=1.01; 95% CI: 0.70-1.44; 2 more per 1000, very low certainty). The adverse events were not significant between e-cigarettes and NRT other than throat irritation (RR=1.27; 95% CI: 1.13-1.42; 118 more per 1000, low certainty).

CONCLUSIONS

E-cigarettes appeared to be superior to NRT in ≥6 months continuous abstinence rate and 7-day point abstinence rate. At short-term duration, we found no evidence that e-cigarettes compared to NRT increased the <6 months continuous abstinence rate and 7-day point abstinence rate.

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

INTRODUCTION

We examined the relationship between current tobacco use and functionally important respiratory symptoms.

METHODS

Longitudinal cohort study of 16 295 US adults without COPD in Waves 2-3 (W2-3, 2014-2016) of the Population Assessment of Tobacco and Health Study. Exposure-Ten mutually exclusive categories of tobacco use including single product, multiple product, former, and never use (reference). Outcome-Seven questions assessing wheezing/cough were summed to create a respiratory symptom index; cutoffs of ≥2 and ≥3 were associated with functional limitations and poorer health. Multivariable regressions examined both cutoffs cross-sectionally and change over approximately 12 months, adjusting for confounders.

RESULTS

All tobacco use categories featuring cigarettes (>2/3's of users) were associated with higher risk (vs. never users) for functionally important respiratory symptoms at W2, for example, at symptom severity ≥ 3, risk ratio for exclusive cigarette use was 2.34 [95% CI, 1.92, 2.85] and for worsening symptoms at W3 was 2.80 [2.08, 3.76]. There was largely no increased symptom risk for exclusive use of cigars, smokeless tobacco, hookah, or e-cigarettes (adjustment for pack-years and marijuana attenuated the cross-sectional e-cigarette association from 1.53(95% CI 0.98, 2.40) to 1.05 (0.67, 1.63); RRs for these products were also significantly lower compared to exclusive use of cigarettes. The longitudinal e-cigarette-respiratory symptom association was sensitive to the respiratory index cutoff level; exclusive e-cigarette use was associated with worsening symptoms at an index cutoff ≥ 2 (RR = 1.63 [1.02, 2.59]) and with symptom improvement at an index cutoff of ≥ 3 (RR = 1.64 [1.04, 2.58]).

CONCLUSIONS

Past and current cigarette smoking drove functionally important respiratory symptoms, while exclusive use of other tobacco products was largely not associated. However, the relationship between e-cigarette use and symptoms was sensitive to adjustment for pack-years and symptom severity.

IMPLICATIONS

How noncigarette tobacco products affect respiratory symptoms is not clear; some studies implicate e-cigarettes. We examined functionally important respiratory symptoms (wheezing/nighttime cough) among US adults without COPD. The majority of adult tobacco users smoke cigarettes and have higher risk of respiratory symptoms and worsening of symptoms, regardless of other products used with them. Exclusive use of other tobacco products (e-cigarettes, cigars, smokeless, hookah) was largely not associated with functionally important respiratory symptoms and risks associated with their use was significantly lower than for cigarettes. The association for e-cigarettes was greatly attenuated by adjustment for cigarette pack-years and sensitive to how symptoms were defined.

Chronic health effects associated with electronic cigarette use: A systematic review

Introduction

Over the last decade, e-cigarette use has been on the rise but with growing health concerns. The objective of this systematic review was to update findings for chronic health outcomes associated with e-cigarette use from the 2018 National Academies of Sciences, Engineering, and Medicine (NASEM) report.

Methods

Three bibliographic databases were searched to identify studies comparing the chronic health effects of e-cigarette users (ECU) to non-smokers (NS), smokers, and/or dual users indexed between 31 August 2017 and 29 January 2021. Two independent reviewers screened abstracts and full texts. Data were extracted by one reviewer and verified by a second one. Outcomes were synthesized in a narrative manner using counts and based on statistical significance and direction of the association stratified by study design and exposure type. Risk of bias and certainty of evidence was assessed. The protocol was prospectively registered on Open Science Framework https://osf.io/u9btp.

Results

A total of 180 articles were eligible. This review focused on 93 studies for the 11 most frequently reported outcomes and from which 59 reported on daily e-cigarette use. The certainty of evidence for all outcomes was very low because of study design (84% cross-sectional) and exposure type (27% reported on exclusive ECU, i.e., never smoked traditional cigarettes). Overall, the summary of results for nearly all outcomes, including inflammation, immune response, periodontal and peri-implant clinical parameters, lung function, respiratory symptoms, and cardiovascular disease, suggested either non-significant or mixed results when daily ECU was compared to NS. This was also observed when comparing exclusive ECU to NS. The only notable exception was related to oral health where most (11/14) studies reported significantly higher inflammation among daily ECU vs. NS. Compared to the smokers, the exclusive-ECUs had no statistically significant differences in inflammation orperiodontal clinical parameters but had mixed findings for peri-implant clinical parameters.

Conclusions

This review provides an update to the 2018 NASEM report on chronic health effects of e-cigarette use. While the number of studies has grown, the certainty of evidence remains very low largely because of cross-sectional designs and lack of reporting on exclusive e-cigarette exposure. There remains a need for higher quality intervention and prospective studies to assess causality, with a focus on exclusive e-cigarette use.

Why do smokers use e-cigarettes? A study on reasons among dual users

Objective

There is minimal research that has measured motivations behind e-cigarette use and the relationship to cigarette and e-cigarette use. The aim of this study was to (1) examine extent to which motivations to use e-cigarettes varies among dual users and (2) examine whether e-cigarette motivations are related to e-cigarette and cigarette consumption among dual users.

Methods

Adults residing in California were recruited through social media (n = 1762, 68.9 % males, 62.9 % White) to complete an online survey. Participants self-identified as using combustible cigarettes and e-cigarettes (dual users) and reported their motivations for using an e-cigarette device, nicotine consumption, and nicotine dependence with both combustible cigarettes and e-cigarettes.

Results

A greater proportion of people reported using e-cigarettes for enjoyment purposes than other motivations (34.2 %). Motivations to use e-cigarettes to quit were positively related to monthly cigarette consumption (IRR = 1.17, 95 % CI [1.08, 1.26]). Motivations to use e-cigarettes to quit smoking were also related to smoking the first cigarette within 30 min (IRR = 1.46, 95 % CI [1.05, 2.02]) and first e-cigarette within 30 min (b = 0.28, 95 % CI [0.19, 0.37]).

Conclusions

Compared to those who use e-cigarettes for enjoyment, smokers who are motivated to use e-cigarettes for cessation purposes are more likely to have greater nicotine dependence, cigarette consumption, and e-cigarette consumption. Future research needs to acknowledge that not all e-cigarette users are the same; motivations and use differ and are related to both consumption and dependence.

An International Systematic Review of Prevalence, Risk, and Protective Factors Associated with Young People's E-Cigarette Use

While the prevalence of young people's conventional cigarette use has decreased in many countries, the use of e-cigarettes has risen. To effectively counteract the growing popularity of e-cigarettes among young people internationally, researchers should know the exact prevalence as well as the protective and risk factors associated with vaping. Based on five eligibility criteria, 53 articles were chosen and analyzed by general characteristics, prevalence, sample characteristics, gender difference, protective factors, and risk factors. In this study, the international pooled prevalence of young people's lifetime e-cigarette use was 15.3%, the current use was 7.7%, and dual use was 4.0%. While the highest lifetime, current, and dual prevalence were found in Sweden, Canada, and the United Kingdom, respectively, the lowest prevalence was found in Germany, followed by South Korea and Sweden. Some protective and risk factors include perceived cost and danger of vaping, parental monitoring, internal developmental assets, cigarette use, family and peer smoking, exposure to online advertisements, and the presence of nearby retail stores. Based on this review, researchers and practitioners can develop different intervention programs and strategies for young smokers.

Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies

OBJECTIVES

This umbrella review aims to summarise the evidence about electronic nicotine delivery systems' (ENDS) risk and safety health profile to inform ENDS health communication strategies.

DATA SOURCES AND STUDY SELECTION

Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4.

DATA EXTRACTION

Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine's Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive.

DATA SYNTHESIS

We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes.

CONCLUSIONS

As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided.

PROSPERO REGISTRATION NUMBER

CRD42021241630.

Assessment of formal tobacco treatment and smoking cessation in dual users of cigarettes and e-cigarettes

BACKGROUND

The utility of electronic cigarettes ('e-cigarettes') as a smoking cessation adjunct remains unclear. Similarly, it is unclear if formal tobacco treatment (pharmacotherapy and/or behavioural support) augments smoking cessation in individuals who use both cigarettes and e-cigarettes.

METHODS

We performed a longitudinal cohort study of adult outpatients evaluated in our tertiary care medical centre (6/2018-6/2020). E-cigarette use, smoking status and formal tobacco treatment (deterrent pharmacotherapy and/or behavioural support) were assessed in 6-month blocks (eg, cohort 1 (C1)=6/2018-12/2018, C2=1/2019-6/2019 and so on) using our electronic health record. We assessed the relationship between e-cigarette use (either with or without formal tobacco treatment) and point prevalence of smoking cessation at 6 and 12 months.

RESULTS

111 823 unique patients were included in the study. The prevalence of dual use of cigarettes and e-cigarettes increased significantly over the study period (C1=0.8%; C2=1.1%; C3=1.8%; C4=2.3%; p<0.001). The prevalence of smoking cessation at 12 months was higher among e-cigarette users (20.8%) compared with non-users (16.8%) (risk difference, 4.0% (95% CI 2.5% to 5.5%); adjusted relative risk (aRR) 1.354, 95% CI 1.252 to 1.464, p<0.0001). Further, among dual users of cigarettes and e-cigarettes, the prevalence of smoking cessation at 12 months was higher among individuals who received tobacco treatment (29.1%) compared with individuals who did not receive tobacco treatment (19.6%) (risk difference, 9.5% (95% CI, 4.6% to 14.4%); aRR 1.238, 95% CI 1.071 to 1.432, p=0.004).

INTERPRETATION

These results suggest that dual users of cigarettes and e-cigarettes benefit from formal tobacco treatment. Clinicians should consider offering formal tobacco treatment to such patients, though future trials are needed.

Impact of vaping on respiratory health

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

HEATED TOBACCO PRODUCTS: WE STILL NEED TO KNOW A BIT MORE

OBJECTIVE

The aim: This research aims to analyze the challenges we came across due to the rapid spread among the population (including young people) of tobacco heating devices.

PATIENTS AND METHODS

Materials and methods: Analysis of 20 literature sources containing information about tobacco heating systems was performed. The search for literary sources was carried out in two main scientific databases: Scopus and PubMed. The review included original articles, research, and official recommendations from medical associations.

CONCLUSION

Conclusions: Tobacco heaters reduce harmful substances in the inhaled air compared to conventional tobacco cigarettes, but these new devices provide effective nicotine absorption, which prolongs a person's nicotine dependence and prevents smoking cessation. The main problem we face due to the rapid spreading of these devices - potentially tobacco heating systems can pose health risks and further research on such risks, especially long - term, are needed. Tobacco heating devices, regardless of their manufacturer and design, should be subject to restrictions similar to traditional cigarettes.

Association of Electronic Cigarette Use with Respiratory Symptom Development among U.S. Young Adults

Rationale: Electronic cigarette (e-cigarette) use is highly prevalent among young adults. However, longitudinal data assessing the association between e-cigarette use and respiratory symptoms are lacking. Objectives: To determine whether e-cigarette use is associated with the development of respiratory symptoms in young adults. Methods: Data are derived from the PATH (Population Assessment of Tobacco and Health) study waves 2 (2014-2015), 3 (2015-2016), 4 (2016-2018), and 5 (2018-2019). Young adults aged 18-24 years at baseline with no prevalent respiratory disease or symptoms were included in the analyses. Binary logistic regression models with a generalized estimating equation were used to estimate time-varying and time-lagged associations of e-cigarette use during waves 2-4, with respiratory symptom development approximately 12 months later at waves 3-5. Measurements and Main Results: The per-wave prevalence of former and current e-cigarette use was 15.2% and 5.6%, respectively. Former e-cigarette use was associated with higher odds of developing any respiratory symptom (adjusted odds ratio [aOR], 1.20; 95% confidence interval [CI], 1.04-1.39) and wheezing in the chest (aOR, 1.41; 95% CI, 1.08-1.83) in multivariable adjusted models. Current e-cigarette use was associated with higher odds for any respiratory symptom (aOR, 1.32; 95% CI, 1.06-1.65) and wheezing in the chest (aOR, 1.51; 95% CI, 1.06-2.14). Associations persisted among participants who never smoked combustible cigarettes. Conclusions: In this nationally representative cohort of young adults, former and current e-cigarette use was associated with higher odds of developing wheezing-related respiratory symptoms, after accounting for cigarette smoking and other combustible tobacco product use.

Association between e-cigarette use initiated after cigarette smoking and smoking abstinence: a cross-sectional study among adolescent established smokers in the USA

BACKGROUND

Recent years have seen a rapid increase in the popularity of electronic cigarettes (e-cigarettes) among adolescents in the USA. Evidence on their role in the continuation of or abstinence from cigarette smoking among young smokers remains scarce.

OBJECTIVE

To examine the relationship between e-cigarette use initiated after cigarette smoking and abstinence from cigarette smoking among US adolescent established smokers.

METHODS

The data were drawn from the 2015-2018 National Youth Tobacco Survey-a nationally representative survey of US middle and high school students. Multivariable logistic regression was used to assess the association between ever e-cigarette use and past 30-day abstinence from cigarette smoking. The analytical sample comprised ever established cigarette smokers with or without a history of e-cigarette use after smoking initiation.

RESULTS

Neither experimental (adjusted OR 0.67, 95% CI 0.39-1.14) nor prior established (adjusted OR 1.56, 95% CI 0.96-2.56) nor current established (adjusted OR 0.65, 95% CI 0.41-1.03) e-cigarette use was statistically significantly associated with subsequent abstinence from cigarette smoking among adolescent ever established smokers. These findings were largely consistent across sensitivity analyses using alternative key definitions, although experimental and current established e-cigarette use was significantly negatively associated with past 6-month abstinence.

CONCLUSIONS

We found no evidence that e-cigarette use among US adolescents already smoking cigarettes is associated with subsequent abstinence from cigarette smoking; there was some evidence of an inverse association among experimental and current established e-cigarette users. These findings could inform future regulatory and public health efforts regarding youth e-cigarette use and the reduction of youth cigarette smoking in the USA.

Bupropion/zonisamide combination to assist smokers to switch from combustible cigarettes to electronic nicotine delivery systems (ENDS)

INTRODUCTION

Electronic nicotine delivery systems (ENDS) may offer a much less harmful alternative to combustible cigarettes (CC) for adult smokers unwilling or unable to relinquish nicotine. However, dual use of CC and ENDS undermines potential harm reduction, and progress needs to be made to assist smokers to switch to ENDS. This study explored the promise of a novel treatment combination of the smoking cessation medication bupropion and an FDA-approved anti-seizure medication, zonisamide, to facilitate switching from CC to ENDS. Both medications have been found to reduce craving for CC and possibly offset each other's side effects.

METHODS

Twenty-four smokers participated in a 13-week treatment during which they were provided with ENDS, bupropion and zonisamide. Assessments included CC and ENDS use, expired air carbon monoxide (CO), smoking withdrawal symptoms, reward ratings and tolerability/side effects.

RESULTS

33% of participants achieved biochemically confirmed, complete CC abstinence by the end of treatment. Those who did not achieve complete abstinence nonetheless showed a 44% reduction in expired air CO. Craving and other withdrawal symptoms were minimal, and CC smoking satisfaction declined markedly, while satisfaction ratings for ENDS increased over time to overtake those of CC. Side effects were generally mild, and adherence to the medication use was excellent.

CONCLUSIONS

The use of combination bupropion/zonisamide to facilitate switching from CC to ENDS is a promising approach that merits follow-up randomized controlled trials. Combining short-term medication approaches with long-term nicotine substitution using ENDS may be a promising strategy to help smokers sustain smoking abstinence in the long term.

Gender Differences in Reasons for Using E-Cigarettes: A Systematic Review

INTRODUCTION

Differential reasons for e-cigarette use for men and women have seldom been examined, and there is no systematic overview of this research literature. The aim for this review is to conduct a systematic review of the literature to identify gender differences in the reasons for e-cigarette use.

METHODS

Systematic searches covered in three databases found 866 unique articles: Web of Science, Pubmed and PsycInfo. Twenty six studies met the inclusion criteria and were reviewed. Reasons for e-cigarette use were sorted into 17 distinct categories.

RESULTS AND CONCLUSIONS

Fifteen studies identified statistically significant differences in reasons between men and women. Frequently assessed reasons for e-cigarette use across studies included Health/Smoking Cessation, Experimentation/Curiosity, Enjoyment/Pleasure, Use in Specific Locations, Acceptable to Others, and Cost. Of those that identified statistically significant differences in reasons between men and women, the findings varied considerably, and some reasons for e-cigarette use were found to be significant in only one or two studies. Most of the reasons identified were only measured in a small number of studies, complicating our ability to make intervention recommendations based on gender. Additionally, we limited our literature search to peer-reviewed studies. Of the reason categories that did find significant differences between gender, such as reasons related to Health/Smoking Cessation, the outcomes were not consistent across studies. Future studies are needed to identify potentially important differences in the reasons for e-cigarette use among men and women.

IMPLICATION

This systematic review aims to uncover gender differences in e-cigarette use to understand important differences in motivation for use that may help us better understand strategies for prevention and treatment of tobacco use disorder. This review is the first on this topic and could provide further insight on patterns of e-cigarette use across gender.

Global youth vaping and respiratory health: epidemiology, interventions, and policies

E-cigarette usage (also known as e-cigarettes or vaping products) has increasingly been recognized as a global public health problem. One challenge in particular involves their marketing to minors (teenagers and children) and the rising prevalence of use in this population. E-cigarettes unnecessarily expose minors to health risks, these include respiratory health problems, such as exacerbations of asthma, bronchitis, and respiratory-tract irritation. Nicotine, commonly found in e-cigarettes, is also associated with cognitive impairment and neurodevelopmental problems. E-cigarettes are also risk factors for downstream substance use, including cigarettes and cannabis initiation (the gateway hypothesis), which compounds health risks in dual users. Current public health preventative and intervention studies are limited, and there is a clear need for more interventions that may prevent usage and assist with cessation in this vulnerable population. Physician education and screening uptake should also be enhanced. Stricter public health policy and protection measures are also needed on a global scale to limit e-cigarette exposure in minors.

Electronic Cigarette Use and the Risk of Cardiovascular Diseases

Electronic cigarettes or e-cigarettes are the most frequently used tobacco product among adolescents. Despite the widespread use of e-cigarettes and the known detrimental cardiac consequences of nicotine, the effects of e-cigarettes on the cardiovascular system are not well-known. Several in vitro and in vivo studies delineating the mechanisms of the impact of e-cigarettes on the cardiovascular system have been published. These include mechanisms associated with nicotine or other components of the aerosol or thermal degradation products of e-cigarettes. The increased hyperlipidemia, sympathetic dominance, endothelial dysfunction, DNA damage, and macrophage activation are prominent effects of e-cigarettes. Additionally, oxidative stress and inflammation are unifying mechanisms at many levels of the cardiovascular impairment induced by e-cigarette exposure. This review outlines the contribution of e-cigarettes in the development of cardiovascular diseases and their molecular underpinnings.

Examining Metal Contents in Primary and Secondhand Aerosols Released by Electronic Cigarettes

The usage of electronic cigarettes (ECs) has surged since their invention two decades ago. However, to date, the health effects of EC aerosol exposure are still not well understood because of insufficient data on the chemical composition of EC aerosols and the corresponding evidence of health risks upon exposure. Herein, we quantified the metals in primary and secondhand aerosols generated by three brands of ECs. By combining aerosol filter sampling and inductively coupled plasma mass spectrometry (ICP-MS), we assessed the mass of metals as a function of EC flavoring, nicotine concentration, device power, puff duration, and aging of the devices. The masses of Cr, Cu, Mn, Ni, Cu, and Zn were consistently high across all brands in the primary and secondhand aerosols, some of which were above the regulated maximum daily intake amount, especially for Cr and Ni with mass (nanograms per 10 puffs) emitted at 117 ± 54 and 50 ± 24 (JUUL), 125 ± 77 and 219 ± 203 (VOOPOO), and 33 ± 10 and 27 ± 2 (Vapor4Life). Our analysis indicates that the metals are predominantly released from the EC liquid, potentially through mechanisms such as bubble bursting or the vaporization of metal-organic compounds. High metal contents were also observed in simulated secondhand aerosols, generally 80-90% of those in primary aerosols. Our findings provide a more detailed understanding of the metal emission characteristics of EC for assessing its health effects and policymaking.

Documento de posicionamiento de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) ante las estrategias de reducción del daño del tabaco

In the last decade, the appearance of electronic cigarettes and new tobacco products (heated tobacco or smokeless tobacco) has generated a growing interest in harm reduction methods that are defined as mechanisms that seek to reduce the harmful consequences of tobacco without give up the pleasant effects of it by replacing it with these new electronic devices. However, these products are addictive and not safe as they contain nicotine. Harm reduction is a false solution as it represents a commercial strategy of the tobacco industry to increase its sales, making it difficult to control smoking, since it keeps smokers from consuming tobacco and prevents them from making serious attempts to quit. In addition, these products are a gateway to adolescents in tobacco.

Harm reduction in tobacco control: where do we draw the line?

With substance abuse, harm reduction refers to reducing or replacing use of a harmful product with a less risky agent. But many advertised "non-pharmaceutical" harm reduction alternatives for tobacco smoking are problematic. Studies have revealed inconclusive results using agents including chewing tobacco and e-cigarettes to quit smoking and have demonstrated continued use of these agents. Many smoking harm reduction agents pose other health risks not found in traditional tobacco smoking. Given these limitations, efforts should focus on promoting nicotine replacement therapy, and other pharmacologic agents with a better chance of producing sustained smoking cessation. To address the harmful nature of many tobacco replacement products, public health should focus on regulating these alternatives with the same stringency as tobacco, and social marketing efforts should target evidence-based and safer pharmaceutical grade or behavioural alternatives.

E-cigarette Use Among Young Adult Patients: The Opportunity to Intervene on Risky Lifestyle Behaviors to Reduce Cancer Risk

Use of e-cigarettes and other electronic nicotine delivery systems (ENDS) is on the rise. We administered a health needs survey via email to 804 adult primary care and oncology patients at a large urban academic medical center in 2019. We examined differences in e-cigarette use by smoking status, personal history of cancer, alcohol use, and second-hand tobacco smoke exposure. Of the 804 participants, 90 (11.2%) reported ever using e-cigarettes. E-cigarette use was more prevalent in young adults (risk ratio [RR] for 18-24 years: 4.58, 95% confidence interval [95% CI] 2.05, 10.26), current smoking (RR 4.64, 95% CI 1.94, 11.07), very often/often binge drinking (RR 3.04, 96% CI 1.38, 6.73), and ≥ 1 smokers in the home (RR 3.90, 95% CI 2.10, 7.23). Binge alcohol consumption and tobacco smoking are associated with increased risk cancer. Inquiries about e-cigarette use among adults 25-40 years present providers the opportunity to also counsel young adult about reducing cancer risk.

"When I Don't Have a Cigarette It's Helpful, but It Really Don't Satisfy:" Qualitative Study of Electronic Nicotine Delivery Systems (ENDS) Use among Low-Income Smokers

BACKGROUND

Little is known about the use of electronic nicotine delivery systems (ENDS) among low-income adult cigarette smokers, who experience severe tobacco-related health disparities.

METHODS

This study conducted interviews to examine experiences and perceptions associated with ENDS use among predominantly low-income adult smokers (n = 30; mean age 30.2 ± 12.9; 60% male, 46.7% African American, 30% white, 10% more than one race; 76.7% annual household income ≤USD 24,000). Interviews were transcribed verbatim and coded in NVivo 11.

RESULTS

Overall, participants reported complementing rather than substituting their smoking with ENDS use (e.g., using ENDS only when smoking is not allowed). Predominant reasons for vaping were convenience, smoking reduction/cessation, stress management, social acceptability, lower long-term costs than smoking, and appealing flavors. Common reasons for not switching to exclusive vaping were that ENDS did not satisfy cigarette cravings and concerns about ENDS health effects. Participants indicated higher likelihood of switching to exclusive ENDS use if the products were more affordable, perceived as substantially less harmful, tasted and felt more like smoking a cigarette, and more effective for reducing cravings.

CONCLUSIONS

Continued research is needed to maximize any harm reduction potential of ENDS and ensure that these products do not contribute to worsening health disparities.

Influence of Nicotine from Diverse Delivery Tools on the Autonomic Nervous and Hormonal Systems

Background: Through measurements of the heart rate variability (HRV) accompanied by the pertinent biomarker assays, the effects of nicotine and byproducts derived from alternative nicotine delivery systems (ANDS) on the autonomic nervous system (ANS) and hormonal system have been investigated. Methods: HRV was studied in a group of volunteers (17 people), involving non-smokers, i.e., who never smoked before (11), ex-smokers (4) and active smokers (2). ANDS and smoking simulators, including regular, nicotine-free and electronic cigarettes; tobacco heating systems; chewing gums and nicotine packs of oral fixation (nic-packs), were used. Blood pressure, levels of stress hormones in saliva and catecholamines in the blood were also monitored. Results: HRV analysis showed relatively small changes in HRV and in the other studied parameters with the systemic use of nic-packs with low and moderate nicotine contents (up to 6 mg) compared to other ANDS. Conclusions: The HRV method is proven to be a promising technique for evaluation of the risks associated with smoking, dual use of various ANDS and studying the biomedical aspects of smoking cessation. Nic-packs are shown to be leaders in biological safety among the studied ANDS. A sharp surge in the activity of the sympathetic division of the ANS within the first minutes of the use of nicotine packs implies that nicotine begins to act already at very low doses (before entering the blood physically in any significant amount) through fast signal transmission to the brain from the nicotinic and taste buds located in the mouth area.

E-Cigarette Toxicology

Since the spread of tobacco from the Americas hundreds of years ago, tobacco cigarettes and, more recently, alternative tobacco products have become global products of nicotine addiction. Within the evolving alternative tobacco product space, electronic cigarette (e-cigarette) vaping has surpassed conventional cigarette smoking among adolescents and young adults in the United States and beyond. This review describes the experimental and clinical evidence of e-cigarette toxicity and deleterious health effects. Adverse health effects related to e-cigarette aerosols are influenced by several factors, including e-liquid components, physical device factors, chemical changes related to heating, and health of the e-cigarette user (e.g., asthmatic). Federal, state, and local regulations have attempted to govern e-cigarette flavors, manufacturing, distribution, and availability, particularly to underaged youths. However, the evolving e-cigarette landscape continues to impede timely toxicological studies and hinder progress made toward our understanding of the long-term health consequence of e-cigarettes.

Negative Affect and Cigarette Cessation in Dual Users of Cigarettes and Electronic Nicotine Delivery Systems

Objectives: Dual use of cigarettes and electronic nicotine delivery systems (ENDS) is increasingly common in adult smokers, who often report using ENDS to quit smoking. Elevated negative affect is an established predictor of increased difficulty quitting smoking combustible cigarettes but has not yet been examined in the context of cigarette cessation for dual users. Method: This study examined whether mood-related factors predict cigarette smoking cessation among dual users (N = 364) over 12-months. Self-reported cigarette smoking at 12 months, with abstinence defined as no smoking for the past 7 days, was the primary outcome variable. Logistic regression included baseline levels of depression symptoms (CES-D), anxiety symptoms (MASQ), and negative affect expectancies for smoking, with baseline nicotine dependence for cigarettes (NDSS), motivation to quit, age, race/ethnicity, rate of cigarette smoking at baseline, and ENDS usage at baseline and 12 months as covariates. Interactions between CES-D, MASQ, and negative affect expectancies were examined. We predicted that negative affect, especially for smokers who had high negative affect expectancies for smoking, would be negatively associated with quitting. Results: Contrary to expectations, negative affect constructs did not predict quitting. Baseline nicotine dependence for cigarettes, gender, and race/ethnicity significantly predicted the likelihood of cigarette cessation. Higher rates of ENDS use, higher motivation, and lower negative affect smoking expectancies were significantly correlated with quitting cigarettes. Conclusion: In this non-treatment seeking sample of dual users, negative affect did not predict cigarette cessation over and above nicotine dependence for cigarettes, gender, and race/ethnicity.

Characterizing Vaping Industry Political Influence and Mobilization on Facebook: Social Network Analysis

Background

In response to recent policy efforts to regulate tobacco and vaping products, the vaping industry has been aggressive in mobilizing opposition by using a network of manufacturers, trade associations, and tobacco user communities, and by appealing to the general public. One strategy the alternative tobacco industry uses to mobilize political action is coordinating on social media platforms, such as the social networking site Facebook. However, few studies have specifically assessed how platforms such as Facebook are used to influence public sentiment and attitudes towards tobacco control policy.

Objective

This study used social network analysis to examine how the alternative tobacco industry uses Facebook to mobilize online users to influence tobacco control policy outcomes with a focus on the state of California.

Methods

Data were collected from local and national alternative tobacco Facebook groups that had affiliations with activities in the state of California. Network ties were constructed based on users’ reactions to posts (eg, “like” and “love”) and comments to characterize political mobilization networks.

Results

Findings show that alternative tobacco industry employees were more likely to engage within these networks and that these employees were also more likely to be influential members (ie, be more active) in the network. Comparisons between subnetworks show that communication within the local alternative tobacco advocacy group network was less dense and more centralized in contrast to a national advocacy group that had overall higher levels of engagement among members. A timeline analysis found that a higher number of influential posts that disseminated widely across networks occurred during e-cigarette–related legislative events, suggesting strategic online engagement and increased mobilization of online activity for the purposes of influencing policy outcomes.

Conclusions

Results from this study provide important insights into how tobacco industry–related advocacy groups leverage the Facebook platform to mobilize their online constituents in an effort to influence public perceptions and coordinate to defeat tobacco control efforts at the local, state, and federal level. Study results reveal one part of a vast network of socially enabled alternative tobacco industry actors and constituents that use Facebook as a mobilization point to support goals of the alternative tobacco industry.

Impact of electronic cigarette ever use on lung function in adults aged 45-85: a cross-sectional analysis from the Canadian Longitudinal Study on Aging

OBJECTIVE

To describe the sociodemographic characteristics associated with e-cigarette ever use and to examine the impact of e-cigarette ever use on lung function impairment in an ageing population.

DESIGN

A cross-sectional analysis of data from the Canadian Longitudinal Study on Aging.

SETTING

A national stratified sample of 44 817 adults living in Canadian provinces.

PARTICIPANTS

Respondents included participants aged 45-85 and residing in the community in Canadian provinces.

OUTCOME MEASURES

The Global Lung Function Initiative normative values for forced expiratory volume in the first second (FEV₁), forced vital capacity (FVC), forced expiratory ratio (FEV₁/FVC) appropriate for age, sex, height and ethnicity were used to interpret the severity of lung function impairment. Multinomial logistic regression analysis was used to examine the impact of e-cigarette ever use on obstructive and restrictive lung function impairment.

RESULTS

The prevalence of e-cigarette ever use was 6.5% and varied by sociodemographic factors including higher prevalence among individuals younger than 65 years, those with lower education attainment and those with lower annual household income. E-cigarette ever use was associated with 2.10 (95% CI 1.57 to 2.08) times higher odds of obstructive lung function impairment after adjusting for conventional cigarette smoking and other covariates. Individuals with exposure to e-cigarette ever use and 15 or more pack-years had 7.43 (95% CI 5.30 to 10.38) times higher odds for obstructive lung function impairment when compared with non-smokers and non-e-cigarette users after adjusting for covariates. Smokers with 15 or more pack-years had higher odds of restrictive lung function impairment irrespective of e-cigarette ever use.

CONCLUSIONS

Ever use of e-cigarettes was found to be associated with obstructive lung function impairment after adjusting for covariates, suggesting that e-cigarette use may be adding to the respiratory and other chronic disease burden in the population.

Electronic nicotine delivery systems (ENDS) cue reactivity in dual users: A combined analysis

BACKGROUND

Cigarette smokers report increases in smoking urge in response to exposure to electronic nicotine delivery systems (ENDS) and dual users, i.e. smokers who also vape ENDS, may exhibit greater cue reactivity than exclusive smokers. The current investigation examined reactivity to a variety of ENDS cues across a large sample of cigarette smokers and dual ENDS users.

METHODS

Young adult smokers (N = 345; >5 cigarettes per day) were recruited between 2013-2019 for participation in a series of within-subjects laboratory-based studies. Participants completed surveys before and after exposure to a confederate-delivered control cue (water) and an active cue, including cigarette or ENDS cues ranging from first generation "cigalikes" to a fourth generation "pod-mod". Main outcomes were post-cue changes in desire for combustible cigarettes and e-cigarettes, and smoking behavior as determined by the smoking latency portion of the Smoking Lapse Paradigm after cue exposure.

RESULTS

Relative to smokers who do not use ENDS, dual users demonstrated higher baseline desire for ENDS and greater ENDS cue reactivity (across product types) in terms of post-cue increases in smoking urge and shorter latency to smoking choice. In contrast, reactivity to the cigarette cue was similar across groups.

CONCLUSIONS

Dual users show heightened ENDS cue reactivity on smoking urge and behavior relative to never users of ENDS, regardless of the type of ENDS cue. Given their reactivity to both cigarette and ENDS cues, it may be difficult for dual users to transition to exclusive vaping or quit tobacco product use altogether.

Predictors of incident SARS-CoV-2 infections in an international prospective cohort study

OBJECTIVE

Until effective treatments and vaccines are made readily and widely available, preventative behavioural health measures will be central to the SARS-CoV-2 public health response. While current recommendations are grounded in general infectious disease prevention practices, it is still not entirely understood which particular behaviours or exposures meaningfully affect one's own risk of incident SARS-CoV-2 infection. Our objective is to identify individual-level factors associated with one's personal risk of contracting SARS-CoV-2.

DESIGN

Prospective cohort study of adult participants from 26 March 2020 to 8 October 2020.

SETTING

The COVID-19 Citizen Science Study, an international, community and mobile-based study collecting daily, weekly and monthly surveys in a prospective and time-updated manner.

PARTICIPANTS

All adult participants over the age of 18 years were eligible for enrolment.

PRIMARY OUTCOME MEASURE

The primary outcome was incident SARS-CoV-2 infection confirmed via PCR or antigen testing.

RESULTS

28 575 unique participants contributed 2 479 149 participant-days of data across 99 different countries. Of these participants without a history of SARS-CoV-2 infection at the time of enrolment, 112 developed an incident infection. Pooled logistic regression models showed that increased age was associated with lower risk (OR 0.98 per year, 95% CI 0.97 to 1.00, p=0.019), whereas increased number of non-household contacts (OR 1.10 per 10 contacts, 95% CI 1.01 to 1.20, p=0.024), attending events of at least 10 people (OR 1.26 per 10 events, 95% CI 1.07 to 1.50, p=0.007) and restaurant visits (OR 1.95 per 10 visits, 95% CI 1.42 to 2.68, p<0.001) were associated with significantly higher risk of incident SARS-CoV-2 infection.

CONCLUSIONS

Our study identified three modifiable health behaviours, namely the number of non-household contacts, attending large gatherings and restaurant visits, which may meaningfully influence individual-level risk of contracting SARS-CoV-2.

Prevalence of Flavored e-Cigarette Use Among Subpopulations of Adults in the United States

BACKGROUND

Evidence of US adult flavored e-cigarette use prevalence stratified by age, smoking status, and purpose for vaping (ie, quitting smoking, to use when or where smoking is not allowed) can inform policies that reduce the tobacco-related cancer burden.

METHODS

Current flavored e-cigarette use (use 1 or more nontobacco flavors) prevalence estimates were compared across subpopulation groups using 2-sided statistical significance tests in the July 2018 Current Population Survey Tobacco Use Supplement, a nationally representative cross-sectional adult survey (n = 46 759).

RESULTS

Current flavored e-cigarette use was reported by 1.6% (95% confidence interval [CI] = 1.47% to 1.69%) of all respondents. Among current vapers, the percentage of those who used flavored e-cigarettes was higher for adults aged 18-24 years (89.6%), 25-34 years (86.7%), and 35-44 years (76.0%) than for adults aged 45 years and older (60.4%, Ps < .001); was higher in never smokers (89.8%) than current (72.9%), long-term former (73.9%), and recent former (80.4%) smokers (Ps ≤ .009); was higher in smokers who reportedly did (78.9%) vs did not (71.1%) use e-cigarettes to vape where or when smoking is not allowed (P = .005); and did not differ between smokers who reportedly did (75.0%) vs did not (73.9%) vape to quit smoking (P = .71). Individuals who vaped to quit smoking and currently used flavored e-cigarettes constituted 0.9% (95% CI = 0.82% to 0.99%) of all adults (weighted N = 2 251 000, 95% CI = 2 046 000 to 2 476 000) and 57.2% of current flavored e-cigarette users.

CONCLUSIONS

Flavored e-cigarette use prevalence was low among US adults overall but common for current vapers. Flavored e-cigarette use was disproportionately prevalent among never smokers and other subpopulations that might experience harm from vaping.

Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data

BACKGROUND

Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication.

METHOD

Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. 'Cessation' was defined as being a former cigarette smoker in wave 4. χ², logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used.

RESULTS

Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes.

CONCLUSION

No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.

Association between e-cigarette use and asthma: a systematic review and meta-analysis

OBJECTIVE

Increasing e-cigarette use combined with emerging evidence of their respiratory effects raises concerns about their potential impact on asthma prevalence. This review evaluates the most recent available evidence on the association of e-cigarette use and asthma world-wide.

METHODS

A literature search was performed in PubMed, Scopus, CINAHL, Cochrane Library, Web of Science and ProQuest in March 2021. This study was conducted in accordance with the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) registered with PROSPERO (registration number: CRD42020211812).

STUDY SELECTIONS

Cross-sectional and cohort studies assessing the association between e-cigarette use and asthma were eligible for inclusion. Studies examining exacerbations in asthma symptoms and severity were excluded. The quality of the included studies was assessed using the Appraisal tool for Cross-Sectional Studies (AXIS).

RESULTS

Thirteen cross-sectional studies with the sample size of 1,039,203 met the eligibility criteria. Odds ratios were pooled using a random effects model. Pooled analysis found a significant association between current e-cigarette use and asthma (pOR = 1.36, 95% CI 1.21-1.52) and ever e-cigarette use and asthma (pOR = 1.24 95% CI 1.13-1.36).

CONCLUSION

Our review found that e-cigarette use and ever e-cigarette use are correlated with asthma. However, heterogeneity and inconsistencies between covariates limited the interpretation of the results. This warrants further studies to investigate any potential causal association between e-cigarette use and asthma. No funding was received for this systematic review.

Co-creating opportunities to incorporate cessation for electronic nicotine delivery systems in family medicine - a qualitative program evaluation

BACKGROUND

The number of Americans who use tobacco has decreased in the twenty-first century, but electronic nicotine delivery systems (ENDS) have increased the complexity of treating tobacco dependence. The experiences of 18 family medicine practices were explored and opportunities to improve ENDS cessation were co-created in this study.

METHODS

Eighteen family medicine practices were enrolled into an implementation project to incorporate ENDS cessation into their practice. The participants' experiences were explored throughout the project using an iterative qualitative approach. The research team provided technical assistance. Semi-structured group interviews and focus groups were held with participants at the beginning, middle, and end of the project to explore participants' experiences. The collective knowledge and experiences of participants, expert consultants and the research team were fused together to co-create opportunities to improve ENDS cessation.

RESULTS

Nine opportunities to improve ENDS cessation were identified in three larger categories. The first category was leading change. This included: creating a vision for change to establish buy-in from key stakeholders and educate health care professionals to improve their confidence to address ENDS. The second category was creating processes. This included: establishing criteria for screening and quality improvement for ENDS cessation; being specific when asking about ENDS; creating electronic health record systems to support incorporating ENDS cessation; using chart audits if electronic health records cannot support incorporating ENDS into tobacco cessation; and assigning roles and responsibilities to members of the clinical care team. The third category was assisting patients who use ENDS. This included: educating patients and their parents/caregivers about ENDS and their potential harms, avoiding dual use, and developing a plan to quit.

CONCLUSIONS

This study highlights challenges and opportunities for incorporating ENDS cessation into family medicine. The opportunities outlined here provide a practical approach which is rooted in the experiences of family physicians and their clinical care teams working to improve how they address ENDS and based on peer reviewed literature and expert input. Improving how ENDS are addressed in family medicine will require more than clinical expertise. It will also require leadership skills and the ability to create process improvements.

TRIAL REGISTRATION

Not applicable.

Harms of Electronic Cigarettes: What the Healthcare Provider Needs to Know

Electronic cigarettes (e-cigarettes) reached the market without either extensive preclinical toxicology testing or long-term safety trials that would be required of conventional therapeutics or medical devices. E-cigarettes are considered a tobacco product and as such have no manufacturing quality or safety standards. A growing body of evidence documents severe harms from e-cigarette use, including injuries from product explosions, nicotine poisoning, and severe lung diseases. Commonly used e-cigarette components have significant inhalation toxicity. Emerging evidence from laboratory studies suggests substantial reason for concern for long-term harms, including risk for cardiovascular disease, chronic obstructive lung disease, and cancer. Rather than helping people stop smoking, e-cigarette use is associated with reduced rates of smoking cessation among current smokers and an increased risk of relapse to smoking among former smokers. The World Health Organization advises, "Unlike the tried and tested nicotine and non-nicotine pharmacotherapies that are known to help people quit tobacco use, WHO does not endorse e-cigarettes as cessation aids." Careful evaluation of all the available research justifies a strong recommendation that healthcare providers should neither prescribe nor recommend e-cigarettes for persons who are tobacco dependent. If a patient is dependent on e-cigarettes, the healthcare provider should provide counseling and treatment (of nicotine dependence) to help the patient to stop their e-cigarette use.

Characterizing alternative and emerging tobacco product transition of use behavior on Twitter

OBJECTIVE

The objective of this study was to develop an inductive coding approach specific to characterizing user-generated social media conversations about transition of use of different tobacco and alternative and emerging tobacco products (ATPs).

RESULTS

A total of 40,206 tweets were collected from the Twitter public API stream that were geocoded from 2018 to 2019. Using data mining approaches, these tweets were then filtered for keywords associated with tobacco and ATP use behavior. This resulted in a subset of 5718 tweets, with 657 manually annotated and identified as associated with user-generated conversations about tobacco and ATP use behavior. The 657 tweets were coded into 9 parent codes: inquiry, interaction, observation, opinion, promote, reply, share knowledge, use characteristics, and transition of use behavior. The highest number of observations occurred under transition of use (43.38%, n = 285), followed by current use (39.27%, n = 258), opinions about use (0.07%, n = 46), and product promotion (0.06%, n = 37). Other codes had less than ten tweets that discussed these themes. Results provide early insights into how social media users discuss topics related to transition of use and their experiences with different and emerging tobacco product use behavior.

Impact of tobacco and/or nicotine products on health and functioning: a scoping review and findings from the preparatory phase of the development of a new self-report measure

BACKGROUND

Measuring self-reported experience of health and functioning is important for understanding the changes in the health status of individuals switching from cigarettes to less harmful tobacco and/or nicotine products (TNP) or reduced-risk products (RRP) and for supporting tobacco harm reduction strategies.

METHODS

This paper presents insights from three research activities from the preparatory phase of the development of a new self-report health and functioning measure. A scoping literature review was conducted to identify the positive and negative impact of TNP use on health and functioning. Focus groups (n = 29) on risk perception and individual interviews (n = 40) on perceived dependence in people who use TNPs were reanalyzed in the context of health and functioning, and expert opinion was gathered from five key opinion leaders and five technical consultants.

RESULTS

Triangulating the findings of the review of 97 articles, qualitative input from people who use TNPs, and expert feedback helped generate a preliminary conceptual framework including health and functioning and conceptually-related domains impacted by TNP use. Domains related to the future health and functioning measurement model include physical health signs and symptoms, general physical appearance, functioning (physical, sexual, cognitive, emotional, and social), and general health perceptions.

CONCLUSIONS

This preliminary conceptual framework can inform future research on development and validation of new measures for assessment of overall health and functioning impact of TNPs from the consumers' perspective.

Electronic Cigarettes and Asthma: What Do We Know So Far?

Electronic cigarettes (EC) are a novel product, marketed as an alternative to tobacco cigarette. Its effects on human health have not been investigated widely yet, especially in specific populations such as patients with asthma. With this review, we use the existing literature in order to answer four crucial questions concerning: (1) ECs' role in the pathogenesis of asthma; (2) ECs' effects on lung function and airway inflammation in patients with asthma; (3) ECs' effects on asthma clinical characteristics in asthmatics who use it regularly; and (4) ECs' effectiveness as a smoking cessation tool in these patients. Evidence suggests that many EC compounds might contribute to the pathogenesis of asthma. Lung function seems to deteriorate by the use of EC in this population, while airway inflammation alters, with the aggravation of T-helper-type-2 (Th2) inflammation being the most prominent but not the exclusive effect. EC also seems to worsen asthma symptoms and the rate and severity of exacerbations in asthmatics who are current vapers, whilst evidence suggests that its effectiveness as a smoking cessation tool might be limited. Asthmatic patients should avoid using EC.

Correlates of e-cigarette use among adults initiating smoking cessation treatment

BACKGROUND

Little is known about the correlates of e-cigarette (EC) use among adults seeking smoking cessation treatment, and it is unclear how EC use affects smoking treatment outcomes.

METHODS

Participants were 649 adult smokers enrolled in smoking cessation treatment. Participants completed a baseline (pre-quit) assessment with follow-up at 4-, 12-, and 26-weeks after a scheduled combustible cigarette (CC) cessation date. EC use was described before and after the CC cessation date, and the impact of baseline EC use on CC cessation at follow-up was evaluated.

RESULTS

At baseline, 66.6 % of participants had ever-used ECs and 23.1 % reported past 30-day EC use. Past 30-day EC users were younger, more socioeconomically disadvantaged, more CC dependent, and less likely to report Black race compared to non-users. At the 4-, 12-, and 26-week follow-ups, 6.4 %, 7.4 %, and 8.1 % reported dual EC/CC use; and 2.7 %, 3.4 %, and 2.7 % had switched to exclusive EC use. Past 30-day EC use at baseline was not associated with CC cessation at any follow-up. However, among baseline past 30-day EC users (n = 150), using ECs ≥ once per week was associated with a lower likelihood of CC cessation at 26-week follow-up (adjusted OR 0.346, 95 % CI: 0.120, 0.997).

CONCLUSION

Findings indicated that dual users of CCs and ECs at baseline differed from CC-only users on sociodemographic and smoking characteristics. Baseline EC use did not impact smoking cessation overall. However, among past 30-day users, more frequent EC use at baseline adversely impacted longer-term cessation outcomes, perhaps due to greater baseline CC/nicotine dependence.

Tobacco Use Status and Temptation to Try E-Cigarettes among a Sample of Appalachian Youth

E-cigarettes are commonly used tobacco products among youth populations, including Appalachian youth. However, knowledge of the extent to which tobacco use status relates to temptation to try e-cigarettes is limited. Data from the Youth Appalachian Tobacco Study (n = 1047) were used. Temptation to try e-cigarettes was derived from a 12-item situational inventory. Tobacco use status was defined as never, ever non-e-cigarette, and ever e-cigarette use. A factorial ANOVA was used to estimate the adjusted association between tobacco use status and the e-cigarette use temptation scale. Two-way interaction terms between tobacco use status and gender, and tobacco use status and race/ethnicity, were plotted to depict effect modification. Approximately 10% of youth were ever non-e-cigarette users and 24% were ever e-cigarette users. Never and ever non-e-cigarette user middle schoolers had higher temptation to try e-cigarettes than their high school counterparts. The same relationship was found among never and ever e-cigarette users living in households with tobacco users. The ANOVA results suggest a positive, monotonic relationship between tobacco use status and temptation to try e-cigarettes, and that the adjusted group means differ by gender and race/ethnicity. The findings can inform tobacco prevention interventions for youth at higher risk for e-cigarette use, especially youth who have not yet tried e-cigarettes.

Changes in Biomarkers of Cigarette Smoke Exposure After 6 Days of Switching Exclusively or Partially to Use of the JUUL System with Two Nicotine Concentrations: A Randomized Controlled Confinement Study in Adult Smokers

Introduction

Evidence suggests that cigarette smokers who switch to electronic nicotine delivery systems (ENDS) reduce their exposure to harmful toxicants and carcinogens. It is unclear if dual-use is associated with decreases in exposure to toxicants.

Methods

This parallel-group confinement study assessed changes in biomarkers of exposure (BOEs) over six days among healthy adult smokers who were randomized into 1 of 11 study groups: eight JUUL-brand System (JUUL) groups (4 JUUL flavors [Virginia Tobacco, Menthol, Mint, Mango] × 2 nicotine concentrations [5.0% or 3.0% by weight]); Dual-Use group used preferred JUUL flavor (5.0% nicotine) and ≤50% usual brand (UB) cigarettes/day; UB Cigarette group and one group abstained from all tobacco/nicotine product use (Abstinence group). Urine and blood analysis assessed changes in primary BOE endpoints (NNAL, 3-HPMA, MHBMA, S-PMA COHb) and secondary BOE endpoints (NNN, HMPMA, CEMA, 1-OHP, O-toluidine, 2-NA, 4-ABP) among 279 adult smokers.

Results

In JUUL groups, median percent reductions in primary BOEs (Day 6–Baseline) were 90%–≥100% of Abstinence; there were no significant differences between JUUL groups and Abstinence. All reductions in JUUL groups were substantially and statistically significantly greater than reductions in the UB Cigarette group (ps < 0.025). Median reductions in primary BOEs in the Dual-Use group were 43%–55% of Abstinence. Similar results were observed for secondary BOEs.

Conclusion

This study suggests that the use of JUUL as a complete or partial substitute (i.e., dual-use with ≥50% reduction in cigarette consumption) for combustible cigarettes can substantially reduce exposure to multiple toxins associated with cigarette smoking.

Implications

This study adds to the growing body of evidence supporting the utility of ENDS products as potentially reduced-harm alternatives to cigarettes for adult smokers. Adult smokers who switched completely from cigarette smoking to use of the JUUL System (“JUUL”) in two nicotine concentrations (5.0% and 3.0%) and four flavors significantly reduced their exposure to multiple classes of cigarette-related toxicants. Additionally, smokers who used JUUL and continued smoking but reduced their daily cigarette consumption by ≥50% (dual users) also significantly reduced their toxicant exposure compared to cigarette smoking.

A Descriptive Analysis of Transitions from Smoking to Electronic Nicotine Delivery System (ENDS) Use: A Daily Diary Investigation

OBJECTIVES

We aimed to examine patterns in smoking and electronic nicotine delivery system (ENDS) use over an extended period of time (up to 20 weeks) in people who smoked and who had never previously made a successful quit attempt using an ENDS.

DESIGN AND SETTING

We conducted a longitudinal mixed-methods study in Dunedin, New Zealand, during 2018 and 2019.

PARTICIPANTS

Purposively selected participants (N = 45; age (≥18 years), gender, ethnicities, cigarettes/day) who wished to quit smoking.

INTERVENTIONS

Participants were provided with a second-generation ENDS device (vape pen or starter "tank" device) at the start of their quit attempt, and asked to complete smartphone-based daily diary surveys assessing smoking and ENDS use.

OUTCOME MEASURES

Sunburst plots and a sequence plot were used to describe weekly and daily patterns of smoking and ENDS use (smoking only, ENDS use only, dual use, abstinent).

RESULTS

The most frequently reported movements among participants, classified according to their study week behaviour, occurred between dual use and exclusive ENDS use (and vice versa). A smaller group reported moving from dual use to exclusive smoking (and often back to dual use), and a small number reported moving between abstinence and different ENDS and smoked tobacco usage behaviours. Data visualisations focussing on those participants who had provided data during each of weeks 9-12 indicate that only a minority reported sustained dual use; instead, most participants indicated varied smoked tobacco and ENDS use, which included periods of dual use.

CONCLUSIONS

The considerable variety observed within and between study participants suggests that high variability is typical rather than exceptional. Transitions from smoking to ENDS use may involve considerable periods of dual use, which is likely to be dynamic and potentially sustained over several months.