Young adults' favorable perceptions of snus, dissolvable tobacco products, and electronic cigarettes: findings from a focus group study

Exploring the Predictive Validity of the Susceptibility to Smoking Construct for Tobacco Cigarettes, Alternative Tobacco Products, and E-Cigarettes

INTRODUCTION

Within tobacco prevention programming, it is useful to identify youth that are at risk for experimenting with various tobacco products and e-cigarettes. The susceptibility to smoking construct is a simple method to identify never-smoking students that are less committed to remaining smoke-free. However, the predictive validity of this construct has not been tested within the Canadian context or for the use of other tobacco products and e-cigarettes.

METHODS

This study used a large, longitudinal sample of secondary school students that reported never using tobacco cigarettes and noncurrent use of alternative tobacco products or e-cigarettes at baseline in Ontario, Canada. The sensitivity, specificity, and positive and negative predictive values of the susceptibility construct for predicting tobacco cigarette, e-cigarette, cigarillo or little cigar, cigar, hookah, and smokeless tobacco use 1 and 2 years after baseline measurement were calculated.

RESULTS

At baseline, 29.4% of the sample was susceptible to future tobacco product or e-cigarette use. The sensitivity of the construct ranged from 43.2% (smokeless tobacco) to 59.5% (tobacco cigarettes), the specificity ranged from 70.9% (smokeless tobacco) to 75.9% (tobacco cigarettes), and the positive predictive value ranged from 2.6% (smokeless tobacco) to 32.2% (tobacco cigarettes). Similar values were calculated for each measure of the susceptibility construct.

CONCLUSIONS

A significant number of youth that did not currently use tobacco products or e-cigarettes at baseline reported using tobacco products and e-cigarettes over a 2-year follow-up period. The predictive validity of the susceptibility construct was high and the construct can be used to predict other tobacco product and e-cigarette use among youth.

IMPLICATIONS

This study presents the predictive validity of the susceptibility construct for the use of tobacco cigarettes among secondary school students in Ontario, Canada. It also presents a novel use of the susceptibility construct for predicting the use of e-cigarettes, cigarillos or little cigars, cigars, hookah, and smokeless tobacco among secondary school students in Ontario, Canada.

Cigarettes vs. E-Cigarettes: Policy Implications from a Focus Group Study

Background: Rates of electronic cigarettes (e-cigarette) use (vaping) have increased among college students over the past decade. Objectives: The current study sought to provide an in-depth examination of college students' beliefs about and attitudes toward cigarettes and e-cigarettes that may influence support/non-support of tobacco-free policies on college campuses and within their communities. Methods: Between August and December 2015, five focus groups (n = 22) were conducted at a large Southern University. Focus group discussions addressed social acceptance and areas where students commonly smoked/vaped on campus. Sessions were transcribed verbatim. Two researchers independently coded the transcripts and identified themes. A third researcher independently reviewed the coding and thematic analysis process (triangulation of researchers). Results: Participants expressed positive attitudes toward smoke-free policies that did not target college students, especially those that protected vulnerable populations (e.g., children). However, some were skeptical of tobacco-free policies that included e-cigarettes. Participants believed the campus tobacco-free policy had moved smokers' behavior off campus, but many reported seeing people vape in locations where smoking was not allowed (i.e., library, dorm rooms). Most perceived smoking to be less acceptable than vaping; smoking was described as 'dirty', while vaping was glamorized as a cultural trend. Conclusions/Importance: Findings from our qualitative study suggest that college students are supportive of smoke-free policies, but they are less supportive of comprehensive tobacco-free policies that include e-cigarettes. College campuses and surrounding communities should plan for education about policy protection via communication channels viewed frequently by students when including vaping devices in their comprehensive tobacco-free policies/ordinances.

The use of e-cigarettes among university students in Malaysia

INTRODUCTION

E-cigarette use is an emerging phenomenon with increasing recognition and acceptance globally. This study aims to create a profile of e-cigarette users among university students in Malaysia.

METHODS

The study was conducted using a cross-sectional research involving six universities in Malaysia. A semi-structured questionnaire was distributed to 1302 randomly selected students, who either smoked cigarettes and/or e-cigarettes. The 2011 version of Global Adult Tobacco Surveys (GATS) tool was used to record the respondents' sociodemographic data.

RESULTS

The study revealed that 74.9% of the respondents smoked e-cigarettes; 40.3% used both cigarettes and e-cigarettes (dual users), and 34.5% were exclusive e-cigarette users. The exclusive use of e-cigarettes was related to gender (OR=0.18, 95% CI: 0.09-0.39). Also, male respondents were the majority users (95%). Of the respondents, 75.2 % were Malays, 98.0% single and most believed they have no health problems (92.1%). Further findings revealed the occurrence of adverse effects, dizziness 14.4%, cough 14.1%, and headaches 12.4%. Overall, 57.8% of the respondents used e-cigarettes as a smoking cessation tool, while others consider e-cigarettes a self-image enhancing tool or as part of social activities.

CONCLUSIONS

Further research on the use of e-cigarettes should be conducted on a large number of respondents in other settings to augment the findings of this study, and also guide policy making on and prevention practice of e-cigarette use, among the general student population in Malaysia.

Advertisement of electronic cigarettes in Italy: characteristics of online videos and the most popular promotional messages

Given the increasing popularity of electronic cigarettes (ECs) and a lack of regulation of EC advertising, this study aimed to analyse online videos promoting ECs to assess the main marketing messages that could influence consumers' perceptions of associated risks and benefits. A web search of EC advertising videos was performed on YouTube by using keywords related to EC promotion. An evaluation grid was used to analyse promotional messages contained in each video. The most frequent promotional messages were related to health benefits (67.7%) and to the possibility of quitting smoking (57.4%). Messages that could also be appealing to adolescents and young adults, such as those promoting the multiple flavors available and the technological improvement of ECs, were present in 41.2% and 42.7% of the videos respectively. ECs similar to traditional cigarettes in appearance were included in 52.9% of the videos. EC promotional videos address messages not only to smokers who want to quit or decrease tobacco consumption but also to nonsmokers, especially young people. The use of ECs similar to traditional cigarettes may be a gateway to tobacco cigarette use. Since EC use may represent an important public health concern, regulatory policies on EC advertising should be established.

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.

Flavored E-cigarette Use and Cigarette Smoking Reduction and Cessation-A Large National Study among Young Adult Smokers

BACKGROUND

E-cigarette use prevalence has increased drastically among young adult cigarette smokers in recent years.

OBJECTIVES

This study seeks to understand which e-cigarette flavors-sweet and fruity or tobacco and menthol/mint-are more likely to be associated with smoking reduction and cessation among young adults.

METHODS

Longitudinal data (waves 1 and 2) of the Population Assessment of Tobacco and Health (PATH) Study from young adult (aged 18-34) cigarette smokers (n = 4,645) at wave 1 and current e-cigarette users (n = 844) at wave 2 were used. Univariate and multivariate regressions were conducted to examine the associations between past-year smoking reduction and cessation and current e-cigarette flavor use at wave 2.

RESULTS

At wave 2, 25.9% of respondents either reduced or quit smoking, and 6.7%, 5.2%, and 6.3% of them reported currently using e-cigarettes with tobacco/menthol (TM) flavors, one non-tobacco/non-menthol (NTM) flavor, and multiple NTM flavors, respectively. E-cigarette users with one (AOR = 2.5, p < 0.001) and multiple NTM flavors (AOR = 3.0, p < 0.001) were more likely to have reduced or quit smoking over the past year compared to non-e-cigarette users. NTM flavor use was positively associated with e-cigarette use of a higher frequency and larger amount.

CONCLUSIONS

The positive association between past-year smoking reduction and cessation and current NTM flavored e-cigarette use may be explained by young adults' escalated e-cigarette use with NTM flavors. Public health professionals should prevent and reduce multiple tobacco use through enhanced education about the harm of vaping NTM flavors and by advising young adult smokers to quit tobacco altogether using evidence-based methods.

[E-cigarettes: Perceived harmfulness and use for smoking cessation]

BACKGROUND

The perception that e‑cigarettes are less harmful than traditional tobacco products can influence the consumption of e‑cigarettes.

OBJECTIVES

Three questions were examined: (1) How do different population groups perceive health risks of e‑cigarettes? (2) Do sociodemographic variables explain differences in the risk assessment of e‑cigarettes? (3) Does the perception of health risks predict the use of e‑cigarettes for smoking cessation?

METHODS

Data came from the 2015 Epidemiological Survey of Substance Abuse (ESA) with a sample size of n = 9204 participants, aged 18 to 64 years (response rate 52.2%). Data were collected by telephone, online, or by written questionnaires. Assessments of risk perception of e‑cigarettes and conventional cigarettes (more harmful, just as harmful, less harmful, do not know) were compared. Descriptive statistics and logistic regressions were performed.

RESULTS

Individuals with lower education rated e‑cigarettes as more harmful. Older people and women perceived e‑cigarettes as just as harmful. Smokers considered e‑cigarettes to be more harmful than or just as harmful as conventional tobacco products. The likelihood of using e‑cigarettes for smoking cessation was higher if people thought they were less harmful than conventional cigarettes.

CONCLUSIONS

Only one-third of the population knows that e‑cigarettes are less harmful to health than conventional cigarettes. The perception of health risks is related to the usage of e‑cigarettes for smoking cessation.

Prospective predictors of flavored e-cigarette use: A one-year longitudinal study of young adults in the U.S

INTRODUCTION

E-cigarettes with fruit and candy flavors are appealing among young adults. This study examined the prospective predictors of young adults' flavored e-cigarette use to inform regulation and prevention efforts.

METHODS

We used the wave 1 (2013-2014) and wave 2 (2014-2015) data of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study of U.S. youth and adults. We analyzed a sample of young adults aged 18-34 (n = 12,383) to identify wave 1 prospective predictors (i.e., socio-demographic characteristics, mental health symptoms, marijuana use, tobacco use, and e-cigarette harm perceptions) of wave 2 flavored e-cigarette use.

RESULTS

At wave 2, 8.0% of young adults used e-cigarettes, and 2.5% and 5.5% used tobacco and menthol (TM) and non-tobacco and non-menthol flavors (NTM) flavors, respectively. In the multivariable model, significant prospective predictors (wave 1) of NTM flavored e-cigarette use compared to TM flavored e-cigarette use (wave 2) were younger age (18-24 years) (AOR = 1.82, p < 0.001), female gender (AOR=1.81, p < 0.001), education attainment of high school graduate and higher (AOR=1.60, p = 0.024), marijuana use (AOR=1.96, p < 0.001), ever but non-past-month cigarette smoking (AOR=2.75, p < 0.001), never cigarette smoking (AOR=5.08, p = 0.016), and lower harm perception of e-cigarettes (AOR=1.59, p = 0.005).

CONCLUSION

This study highlights high rates of NTM flavor use and specific predictors of NTM flavored e-cigarettes use among young adults in the U.S. Regulation and prevention efforts for curbing flavored e-cigarette use among young adults should focus on these risk factors and high-risk groups (e.g., 18-24 years, female, and never cigarette smokers).

Using the Ecological Model to understand influences on college student vaping

Objective The Ecological Model was used to examine the social and environmental influences of the college environment on e-cigarette use (vaping) among college students.

PARTICIPANTS

Undergraduate college student e-cigarette users (vapers) across three large college campuses in the southwest US from Jan 2015- Aug 2016.

METHODS

Thirty-three interviews were conducted. Transcribed interviews were coded then analyzed for themes.

RESULTS

College student vapers report multiple levels of influence on their vaping beyond personal beliefs and peer influences, including parents, explicit campus and community messaging, community member requests, and respect for others. College student vapers also describe constant associations with smokers in allowable public places to vape.

CONCLUSIONS

Parents, community members, campus policy, and the physical environment all influence where and when college students vape. Health communication messages to prevent college student vaping should incorporate alternative messages that are important to college students, such as respect for others and social image.

Understanding Users' Vaping Experiences from Social Media: Initial Study Using Sentiment Opinion Summarization Techniques

Background

E-liquid is one of the main components in electronic nicotine delivery systems (ENDS). ENDS review comments could serve as an early warning on use patterns and even function to serve as an indicator of problems or adverse events pertaining to the use of specific e-liquids—much like types of responses tracked by the Food and Drug Administration (FDA) regarding medications.

Objective

This study aimed to understand users’ “vaping” experience using sentiment opinion summarization techniques, which can help characterize how consumers think about specific e-liquids and their characteristics (eg, flavor, throat hit, and vapor production).

Methods

We collected e-liquid reviews on JuiceDB from June 27, 2013 to December 31, 2017 using its public application programming interface. The dataset contains 27,070 reviews for 8058 e-liquid products. Each review is accompanied by an overall rating and a set of 4 aspect ratings of an e-liquid, each on a scale of 1-5: flavor accuracy, throat hit, value, and cloud production. An iterative dichotomiser 3 (ID3)-based influential aspect analysis model was adopted to learn the key elements that impact e-liquid use. Then, fine-grained sentiment analysis was employed to mine opinions on various aspects of vaping experience related to e-liquids.

Results

We found that flavor accuracy and value were the two most important aspects that affected users’ sentiments toward e-liquids. Of reviews in JuiceDB, 67.83% (18,362/27,070) were positive, while 12.67% (3430/27,070) were negative. This indicates that users generally hold positive attitudes toward e-liquids. Among the 9 flavors, fruity and sweet were the two most popular. Great and sweet tastes, reasonable value, and strong throat hit made users satisfied with fruity and sweet flavors, whereas “strange” tastes made users dislike those flavors. Meanwhile, users complained about some e-liquids’ steep or expensive prices, bad quality, and harsh throat hit. There were 2342 fruity e-liquids and 2049 sweet e-liquids. There were 55.81% (1307/2342) and 59.83% (1226/2049) positive sentiments and 13.62% (319/2342) and 12.88% (264/2049) negative sentiments toward fruity e-liquids and sweet e-liquids, respectively. Great flavors and good vapors contributed to positive reviews of fruity and sweet products. However, bad tastes such as “sour” or “bitter” resulted in negative reviews. These findings can help businesses and policy makers to further improve product quality and formulate effective policy.

Conclusions

This study provides an effective mechanism for analyzing users’ ENDS vaping experience based on sentiment opinion summarization techniques. Sentiment opinions on aspect and products can be found using our method, which is of great importance to monitor e-liquid products and improve work efficiency.

Exploring Physician Attitudes Regarding Electronic Documentation of E-cigarette Use: A Qualitative Study

Background:

In this article, we present qualitative work designed to explore physicians’ attitudes toward and knowledge of electronic cigarettes (or Electronic Nicotine Delivery Systems—ENDS), particularly focusing on personal attitudes held by physicians regarding ENDS use, physician beliefs regarding the relative safety of ENDS, attitudes regarding the efficacy of ENDS as a smoking cessation tool, and how physicians’ document ENDS use in the electronic health record (EHR).

Methods:

We completed a total of 17 semistructured qualitative interviews with physicians in 4 different outpatient clinic locations. Clinics were selected with the goal of reaching patient panels across a diversity of socioeconomic and local geographic locations.

Results:

The findings from our qualitative analysis suggest that physicians feel uninformed about the long-term health risks of ENDS and believe that they lack the critical medical knowledge required for discussing ENDS with their patients who smoke. Although physician responses did not endorse the view that ENDS use is a safer alternative to combustible tobacco use, approximately one-third of our physician sample did not hold strong objections to ENDS usage. Physicians placed varying degrees of importance on the issue of ENDS documentation practices.

Discussion:

Three overarching themes were revealed from our analysis. These themes included (1) physicians’ attitudes regarding the use of ENDS for smoking cessation, (2) physicians’ guidance and advisement to patients in the use of ENDS for smoking cessation, and (3) current practices of clinical documentation of ENDS use in an EHR. Our qualitative results indicate that physicians in our study rarely screen patients for ENDS use, even for those patients who are both documented smokers and recipients of physician-led tobacco cessation counseling. However, most physicians agreed that the prospect of creating a structured data field specifically for the documentation of ENDS use within the EHR would result in the likelihood of increased screening and documentation of ENDS use patterns.

Perceptions of Alternative Tobacco Products, Anti-tobacco Media, and Tobacco Regulation among Young Adults: A Qualitative Study

Objectives With increased alternative tobacco product (ATP) use and lagging public health action, we explored perceptions of ATPs, anti-tobacco messaging, and tobacco regulation among young adults. Methods Semi-structured interviews were conducted with 60 Georgia college students aged 18-25 using: (1) cigarettes, little cigars/cigarillos (LCCs), smokeless tobacco, or e-cigarettes ≥15 days of the past 30; or (2) hookah ≥10 of the past 30 days (due to lower frequency of use). Of 99 participants recruited, 80 consented, and 60 participated. Results Participants were on average 21.01 years old (SD = 2.07), 56.7% women, and 65.0% black; 56.7% reported current use of cigarettes, 43.3% LCCs, 26.7% smokeless tobacco, 45.0% e-cigarettes, and 41.7% hookah. Cigarettes were perceived as most harmful to health and most addictive. E-cigarettes and hookah were generally regarded as lowest risk. Many indicated that ATP risk information was limited or inaccessible and that most anti-tobacco campaigns were irrelevant to ATPs. Participants requested more research and dissemination of evidence regarding ATP risks and need for ATP regulation. Conclusions In light of low risk perceptions regarding ATPs among young adults, research, anti-tobacco campaigns, and regulation must address their known and potential risks.

Altered lung biology of healthy never smokers following acute inhalation of E-cigarettes

Background

Little is known about health risks associated with electronic cigarette (EC) use although EC are rising in popularity and have been advocated as a means to quit smoking cigarettes.

Methods

Ten never-smokers, without exposure history to tobacco products or EC, were assessed at baseline with questionnaire, chest X-ray, lung function, plasma levels of endothelial microparticles (EMP), and bronchoscopy to obtain small airway epithelium (SAE) and alveolar macrophages (AM). One week later, subjects inhaled 10 puffs of “Blu” brand EC, waited 30 min, then another 10 puff; n = 7 were randomized to EC with nicotine and n = 3 to EC without nicotine to assess biological responses in healthy, naive individuals.

Results

Two hr. post-EC exposure, subjects were again assessed as at baseline. No significant changes in clinical parameters were observed. Biological changes were observed compared to baseline, including altered transcriptomes of SAE and AM for all subjects and elevated plasma EMP levels following inhalation of EC with nicotine.

Conclusions

This study provides in vivo human data demonstrating that acute inhalation of EC aerosols dysregulates normal human lung homeostasis in a limited cohort of healthy naïve individuals. These observations have implications to new EC users, nonsmokers exposed to secondhand EC aerosols and cigarette smokers using EC to quit smoking.

Trial registration

ClinicalTrials.gov NCT01776398 (registered 10/12/12), NCT02188511 (registered 7/2/14).

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0778-z) contains supplementary material, which is available to authorized users.

The Association Between Smoking and Electronic Cigarette Use in a Cohort of Young People

PURPOSE

Electronic cigarette (e-cigarette) use is associated with smoking initiation among young people; however, it is also possible that smoking is associated with e-cigarette initiation. This study explores these associations among young people in Great Britain.

METHODS

A longitudinal survey of 1,152 11- to 18-year-olds was conducted with baseline in April 2016 and follow-up between August and October 2016. Logistic regression models and causal mediation analyses assessed whether (1) ever e-cigarette use and escalation were associated with smoking initiation (ever smoking at follow-up) among baseline never smokers (n = 923), and (2) ever smoking and escalation were associated with e-cigarette initiation (ever e-cigarette use at follow-up) among baseline never e-cigarette users (n = 1,020).

RESULTS

At baseline, 19.8% were ever smokers and 11.4% were ever e-cigarette users. Respondents who were ever e-cigarette users (vs. never users, 53% vs. 8%, odds ratio [OR] = 11.89, 95% confidence interval [CI] = 3.56-39.72) and escalated their e-cigarette use (vs. did not, 41% vs. 8%, OR = 7.89, 95% CI = 3.06-20.38) were more likely to initiate smoking. Respondents who were ever smokers (vs. never smokers, 32% vs. 4%, OR = 3.54, 95% CI = 1.68-7.45) and escalated their smoking (vs. did not, 34% vs. 6%, OR = 5.79, 95% CI = 2.55-13.15) were more likely to initiate e-cigarette use. There was a direct effect of ever e-cigarette use on smoking initiation (OR = 1.34, 95% CI = 1.05-1.72), and ever smoking on e-cigarette initiation (OR = 1.08, 95% CI = 1.01-1.17); e-cigarette and smoking escalation, respectively, did not mediate these effects.

CONCLUSIONS

Among young people in Great Britain, ever e-cigarette use is associated with smoking initiation, and ever smoking is associated with e-cigarette initiation.

E-Cigarette Use Among Adolescents: An Overview of the Literature and Future Perspectives

Background

Electronic cigarettes (e-cigarettes) are rapidly emerging into a new trend among adolescents, signaling a new époque, that of vapers. E-cigarettes are battery-powered nicotine delivery devices that heat a typically flavoring liquid solution into an aerosol mist that users inhale, allowing them to imitate the act of conventional smoking. There are concerns about the impact of e-cigarettes at both individual and public health level.

Aim

To discuss the characteristics of the most vulnerable, to become e-cigarette users, group of adolescents and to further highlight their behaviors and characteristics.

Methods

An electronic search in PubMed, EMBASE, and Google Scholar databases was conducted, using combinations of the following keywords: adolescents, teenagers, e-cigarettes, vaping. The search included all types of articles written in English until August 2017. A total of 100 articles were found, and 25 were finally included in the present review.

Results

Older age, male gender, conventional smokers, peer influence, daily smoking, and heavier smoking are the most common characteristics of adolescent e-cigarette users.

Conclusion

E-cigarette use is common, especially between certain subgroups in the adolescent population. Since e-cigarette use is increasing and considering that the long term health effects are still under investigation, targeted interventions towards more susceptible individuals may be an effective prevention strategy.

Influence of Flavors on the Propagation of E-Cigarette-Related Information: Social Media Study

Background

Modeling the influence of e-cigarette flavors on information propagation could provide quantitative policy decision support concerning smoking initiation and contagion, as well as e-cigarette regulations.

Objective

The objective of this study was to characterize the influence of flavors on e-cigarette–related information propagation on social media.

Methods

We collected a comprehensive dataset of e-cigarette–related discussions from public Pages on Facebook. We identified 11 categories of flavors based on commonly used categorizations. Each post’s frequency of being shared served as a proxy measure of information propagation. We evaluated a set of regression models and chose the hurdle negative binomial model to characterize the influence of different flavors and nonflavor control variables on e-cigarette–related information propagation.

Results

We found that 5 flavors (sweet, dessert & bakery, fruits, herbs & spices, and tobacco) had significantly negative influences on e-cigarette–related information propagation, indicating the users’ tendency not to share posts related to these flavors. We did not find a positive significance of any flavors, which is contradictory to previous research. In addition, we found that a set of nonflavor–related factors were associated with information propagation.

Conclusions

Mentions of flavors in posts did not enhance the popularity of e-cigarette–related information. Certain flavors could even have reduced the popularity of information, indicating users’ lack of interest in flavors. Promoting e-cigarette–related information with mention of flavors is not an effective marketing approach. This study implies the potential concern of users about flavorings and suggests a need to regulate the use of flavorings in e-cigarettes.

A systematic review of consumer preference for e-cigarette attributes: Flavor, nicotine strength, and type

Objective

Systematic review of research examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type.

Method

A systematic search of peer-reviewed articles resulted in a pool of 12,933 articles. We included only articles that meet all the selection criteria: (1) peer-reviewed, (2) written in English, and (3) addressed consumer preference for one or more of the e-cigarette attributes including flavor, strength, and type.

Results

66 articles met the inclusion criteria for this review. Consumers preferred flavored e-cigarettes, and such preference varied with age groups and smoking status. We also found that several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception. In addition, some flavor chemicals and sweeteners used in e-cigarettes could be of toxicological concern. Finally, consumer preference for nicotine strength and types depended on smoking status, e-cigarette use history, and gender.

Conclusion

Adolescents could consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults overall preferred sweet, menthol, and cherry flavors, while non-smokers in particular preferred coffee and menthol flavors. Adults in general also preferred sweet flavors (though smokers like tobacco flavor the most) and disliked flavors that elicit bitterness or harshness. In terms of whether flavored e-cigarettes assisted quitting smoking, we found inconclusive evidence. E-cigarette users likely initiated use with a cigarette like product and transitioned to an advanced system with more features. Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength.

Evaluating the mutual pathways among electronic cigarette use, conventional smoking and nicotine dependence

BACKGROUND AND AIMS

The implications of the rapid rise in electronic cigarette (e-cigarette) use remain unknown. We examined mutual associations between e-cigarette use, conventional cigarette use and nicotine dependence over time to (1) test the association between e-cigarette use and later conventional smoking (both direct and via nicotine dependence), (2) test the converse associations and (3) determine the strongest pathways predicting each product's use.

DESIGN

Data from four annual waves of a prospective cohort study were analyzed. Path analysis modeled the bidirectional, longitudinal relationships between past-month smoking frequency, past-month e-cigarette frequency and nicotine dependence.

SETTING

Chicago area, Illinois, USA.

PARTICIPANTS

A total of 1007 young adult smokers and non-smokers (ages 19-23 years).

MEASUREMENTS

Frequency of (1) cigarettes and (2) e-cigarettes was the number of days in the past 30 on which the product was used. The Nicotine Dependence Syndrome Scale measured nicotine dependence to cigarettes.

FINDINGS

E-cigarette use was not associated significantly with later conventional smoking, either directly (β = 0.021, P = 0.081) or through nicotine dependence (β = 0.005, P = 0.693). Conventional smoking was associated positively with later e-cigarette use, both directly (β = 0.118, P < 0.001) and through nicotine dependence (β = 0.139, P < 0.001). The strongest predictors of each product's use was prior use of the same product; this pathway was strong for conventional cigarettes (β = 0.604, P < 0.001) but weak for e-cigarettes (β = 0.120, P < 0.001). Nicotine dependence moderately strongly predicted later conventional smoking (β = 0.169, P < 0.001), but was a weak predictor of later e-cigarette use (β = 0.069, P = 0.039).

CONCLUSIONS

Nicotine dependence is not a significant mechanism for e-cigarettes' purported effect on heavier future conventional smoking among young adults. Nicotine dependence may be a mechanism for increases in e-cigarette use among heavier conventional smokers, consistent with e-cigarettes as a smoking reduction tool. Overall, conventional smoking and, to a lesser extent, its resulting nicotine dependence, are the strongest drivers or signals of later cigarette and e-cigarette use.

Second Generation Electronic Nicotine Delivery System Vape Pen Exposure Generalizes as a Smoking Cue

Introduction

Second generation electronic nicotine delivery systems (ENDS; also known as e-cigarettes, vaporizers or vape pens) are designed for a customized nicotine delivery experience and have less resemblance to regular cigarettes than first generation "cigalikes." The present study examined whether they generalize as a conditioned cue and evoke smoking urges or behavior in persons exposed to their use.

Methods

Data were analyzed in N = 108 young adult smokers (≥5 cigarettes per week) randomized to either a traditional combustible cigarette smoking cue or a second generation ENDS vaping cue in a controlled laboratory setting. Cigarette and e-cigarette urge and desire were assessed pre- and post-cue exposure. Smoking behavior was also explored in a subsample undergoing a smoking latency phase after cue exposure (N = 26).

Results

The ENDS vape pen cue evoked both urge and desire for a regular cigarette to a similar extent as that produced by the combustible cigarette cue. Both cues produced similar time to initiate smoking during the smoking latency phase. The ENDS vape pen cue elicited smoking urge and desire regardless of ENDS use history, that is, across ENDS naїve, lifetime or current users. Inclusion of past ENDS or cigarette use as covariates did not significantly alter the results.

Conclusions

These findings demonstrate that observation of vape pen ENDS use generalizes as a conditioned cue to produce smoking urge, desire, and behavior in young adult smokers. As the popularity of these devices may eventually overtake those of first generation ENDS cigalikes, exposure effects will be of increasing importance.

Implications

This study shows that passive exposure to a second generation ENDS vape pen cue evoked smoking urge, desire, and behavior across a range of daily and non-daily young adult smokers. Smoking urge and desire increases after vape pen exposure were similar to those produced by exposure to a first generation ENDS cigalike and a combustible cigarette, a known potent cue. Given the increasing popularity of ENDS tank system products, passive exposures to these devices will no doubt increase, and may contribute to tobacco use in young adult smokers.

Young adult waterpipe tobacco users' perceived addictiveness of waterpipe tobacco

INTRODUCTION

Young adults generally do not perceive waterpipe tobacco smoking (WTS) to be addictive. Underlying reasons for these false perceptions have received limited research attention and little is known about effective WTS prevention messaging. This study examined perceptions of the addictiveness of WTS among young adults and ascertained their feedback on WTS prevention message content.

METHODS

Young adult (n=44, Mean [M] age 25.3, SD 2.7, range 18-30) waterpipe tobacco users were recruited online for a cross-sectional survey. Closed-ended measures assessed demographics, waterpipe use, other tobacco consumption, and perceived addictiveness of WTS. Open-ended items assessed perceptions of WTS and ascertained feedback on WTS prevention message content. Quantitative data were analyzed descriptively. Open-ended data were coded to identify emerging themes.

RESULTS

Participants reported low perceived addictiveness of WTS (Mean 2.0, SD 0.9, range 1- not at all, 4 - very), perceived chances of becoming addicted (Mean 3.0, SD 1.6, range 1- no chance, 7- certain), and desire to quit (Mean 3.0, SD 1.8, range 1- not at all, 7- very). In open-ended responses, participants indicated social WTS does not lead to addiction and believe it is easy to quit. Some expressed concerns that WTS addiction may lead to health harms, social stigma, and financial costs. Participants indicated messages using vivid imagery and conveying negative health effects could motivate cessation.

CONCLUSIONS

Young adults view that WTS is not addictive, particularly related to use in social settings. Research can build from this study by developing and testing messages to motivate WTS cessation in young adults.

Assessing notions of denormalization and renormalization of smoking in light of e-cigarette regulation

The rationale for 'denormalization' of smoking in tobacco policies has been challenged by the emergence of e-cigarettes and the need to regulate e-cigarette use and promotion. Our aim is to assess the research status on e-cigarettes' contribution to 'renormalization' of smoking and to clarify how renormalization of smoking can be appraised at the conceptual and empirical level. Combining conceptual analysis and narrative review, the paper brings out three dimensions of denormalization/renormalization of smoking ('unacceptability/acceptability'; 'invisibility/visibility'; 'phasing out behaviour/maintaining behaviour') and an inherent duality of the e-cigarette as a smoking-like device and a smoking alternative. These analytical dimensions are applied qualitatively to consider the literature identified by searching the Web of Science database for 'e-cigarettes AND renormalization' (and variants thereof). Theoretically, normative changes in smoking acceptability, increased visibility of e-cigarettes and use, and observations of actual use (prevalence, dual use, gateway) can all be applied to illustrate processes of renormalization. However, only acceptability measures and user measures can be said to be empirical tests of renormalization effects. Visibility measures are only based on logical assumptions of a possible renormalization; they are not in themselves indicative of any "real" renormalization effects and can just as well be understood as possible consequences of normalization of e-cigarettes. Just as a downward trend in smoking prevalence is the litmus test of whether denormalization policy works, stagnating or rising smoking prevalence should be the main empirical indicator of renormalization.

Characteristics of Adults Who Switched From Cigarette Smoking to E-cigarettes

INTRODUCTION

Because of the rapidly increasing use of electronic cigarettes (e-cigarettes), this study aimed to investigate the individual characteristics and state-level prevalence of U.S. adults who have switched to e-cigarettes from traditional cigarettes.

METHODS

Data from the 2012-2013 and 2013-2014 National Adult Tobacco Surveys were analyzed in 2016. Relative percent change in switching was estimated, and the state-specific prevalence of adults who switched to e-cigarettes from traditional cigarettes was calculated and mapped. Multivariate logistic regression was conducted to examine how switching varied by sociodemographic subgroups and region.

RESULTS

Overall, the number of individuals who switched from traditional cigarettes to e-cigarettes increased by approximately 100% over the 1-year interval. Significant increases were found among a number of sociodemographics and regions. Multivariate logistic regression analyses showed that young adults and those living in the South and West were more likely to switch to e-cigarettes, compared to former smokers who did not switch. Compared with current dual users, those with higher education and those who were not single were more likely to switch to e-cigarettes. The state with the highest prevalence of switching was New Mexico (7.3%), whereas Connecticut had the lowest prevalence (0.8 %) among former smokers.

CONCLUSIONS

There is an increase in the progression from traditional cigarette use to e-cigarette use. Further research is warranted to determine whether this change continues and facilitates cigarette smoking cessation as a possible public health benefit and opportunity to save lives rather than constitutes a potential threat to public health.

Marketing activities of vape shops across racial/ethnic communities

INTRODUCTION

There has been a surge in the number of vape shops in the USA. Research on the marketing practices of e-cigarette manufacturers is scarce and even less known are the practices of vape shop retailers. Past research on tobacco marketing has shown differences in the amount and content of marketing material, based on a community’s demographic profile. This study examined marketing strategies in vape shops and explored differences among vape shops located in communities that differ by ethnic composition.

METHODS

Data was gathered in 2014 from a pilot-study on vape shops (n=77) in Los Angeles, which documented the characteristics of shops through employee interviews and in-store observations. Data were collected from shops located in communities that were predominantly, African-American (n=20), Hispanic (n=17), Korean (n=18), or non-Hispanic White (n=22).

RESULTS

Sixty-one percent of vape shops had advertisements (print ads and posters) for e-cigarettes and 84% offered discounts. Vape shops in Hispanic communities were more likely to have ethnic specific marketing material compared to shops in other communities. All the shops provided customers with free samples, however those in Korean and non-Hispanic White communities had a significantly higher prevalence of customer accessible free samples.

CONCLUSIONS

Vape shop marketing practices differed by ethnic community. A large majority of shops provided free samples to their customers, a practice which is now banned by the FDA. It will be important to monitor how vape shops will adjust their marketing strategy because of this ban. Future research should expand on the findings presented here to provide regulators with further crucial information.

The Use of Substances Other Than Nicotine in Electronic Cigarettes Among College Students

INTRODUCTION

Electronic cigarettes (e-cigarettes) have grown in popularity, especially among youth and young adults. Although e-cigarettes were originally intended to vaporize a liquid mixture containing nicotine, there appears to be an increasing trend in other substance use in e-cigarettes (OSUE).

MATERIALS AND METHODS

Cross-sectional data from 1542 undergraduate college student e-cigarette users from a large Midwestern university were collected via online survey to assess prevalence of e-cigarette use, reasons for use, perceived harm, and prevalence and predictors of OSUE.

RESULTS

Nearly 7% (6.94%) reported using an e-cigarette to vaporize and inhale a substance other than nicotine. Current tobacco cigarette smokers were significantly more likely to report OSUE (51.0%) as compared with never (33.7%) and former (15.4%) smokers. Among respondents reporting OSUE, the primary reason for e-cigarette use was "safer than cigarettes" (21.7%), followed by "experimentation" (18.9%) and "friends use" (17.0%). Most (77.9%) reported using cannabis or some derivative of cannabis in an e-cigarette. Binomial logistic regression found that women were less likely to report OSUE by a factor of 0.60, former tobacco cigarette smokers as compared with never smokers were more likely to report OSUE by a factor of 1.87, and e-cigarette users who reported using e-cigarettes for "cool or trendy" reasons were more likely to report OSUE by a factor of 2.89.

DISCUSSION

Little is known regarding the health effects of cannabis and cannabis derivatives delivered through e-cigarettes. Concern may also be warranted regarding the potential dangers of this young population using substances more dangerous than cannabis in e-cigarettes. Knowledge is limited regarding the public health impact of vaping cannabis or other illicit substances among college student populations. This study stresses the need for continued research regarding the vaping of cannabis and other illicit substances among college students.

Evidentiary Support in Public Comments to the FDA's Center for Tobacco Products

Electronic Nicotine Delivery Systems (ENDS) were introduced into the US market in 2007, and until recently these devices were unregulated at the federal level. In 2014, the US Food and Drug Administration (FDA) published a Notice of Proposed Rulemaking asserting its intention to regulate ENDS and requesting public comments on numerous related issues, including potential limits on the sale of flavored ENDS. This article analyzes key comments submitted to the FDA on the issue of flavor regulation in ENDS and examines the weight and credibility of the evidence presented by both supporters and opponents of regulation. It also describes the final deeming rule, published in May 2016, and the FDA's response to the evidence submitted. This is the first study to examine public comments submitted to the FDA's Center for Tobacco Products, and it concludes that opponents of regulation were more likely to rely on sources that were not peer reviewed and that were affected by conflicts of interest. In light of these findings, the FDA and the research community should develop processes to carefully and critically analyze public comments submitted to the FDA on issues of tobacco regulation.

Mining online e-liquid reviews for opinion polarities about e-liquid features

BACKGROUND

In recent years, the emerging electronic cigarette (e-cigarette) marketplace has developed prosperously all over the world. By analyzing online e-liquid reviews, we seek to identify the features attracting users.

METHODS

We collected e-liquid reviews from one of the largest online e-liquid review websites and extracted the e-liquid features by keywords. Then we used sentiment analysis to classify the features into two polarities: positive and negative. The positive sentiment ratio of a feature reflects the e-cigarette users' preference on this feature.

RESULTS

The popularity and preference of e-liquid features are not correlated. Nuts and cream are the favorite flavor categories, while fruit and cream are the most popular categories. The top mixed flavors are preferable to single flavors. Fruit and cream categories are most frequently mixed with other flavors. E-cigarette users are satisfied with cloud production, but not satisfied with the ingredients and throat hit.

CONCLUSIONS

We identified the flavors that e-cigarette users were satisfied with, and we found the users liked e-cigarette cloud production. Therefore, flavors and cloud production are potential factors attracting new users.

Effect of e-cigarette advertisements and antismoking messages on explicit and implicit attitudes towards tobacco and e-cigarette smoking in 18-65-year-olds: a randomised controlled study protocol

INTRODUCTION

Since the advent of e-cigarettes, e-cigarette advertising has escalated and companies are able to use marketing strategies that are not permissible for tobacco products. Research into the effect of e-cigarette advertising on attitudes towards tobacco and e-cigarettes is in its infancy. To date, no research has compared indirect (implicit) measures of attitude towards e-cigarettes with direct (explicit) measures. Furthermore, little consideration has been given to how viewing online advertisements may have an effect on attitudes towards e-cigarettes or how positive attitudes to e-cigarettes may undermine antismoking public health messages. The objectives of this study are to investigate (1) the relationship between explicit and implicit attitudes towards tobacco and e-cigarettes, (2) the effect of e-cigarette advertising on these attitudes and (3) the effect of these attitudes on the efficacy of antismoking health messages.

METHODS AND ANALYSIS

In experiment 1 an analysis of covariance will be conducted to determine whether viewing an e-cigarette advertisement, compared with a neutral image, has an effect on implicit or explicit attitudes towards tobacco and e-cigarettes, and if these attitudes differ between smokers, vapers and non-smokers aged 18 - 25 years. In experiment 2, moderation analysis will be conducted to assess whether attitudes towards e-cigarettes moderate the psychological efficacy of antismoking health messages in participants aged 18-65 years. In each experiment, attitudes will be measured preintervention and postintervention and 1 week later (n=150) in participants who are smokers (n=50), vapers (n=50) or non-smokers (n=50).

ETHICS AND DISSEMINATION

Approval for this study has been given by the London South Bank University's (LSBU) Research Ethics Committee. The findings of these studies will be submitted for publication and disseminated via conferences. The results will be integrated into course provision for practitioners training at LSBU.

Perceptions of harm and addiction of snus: An exploratory study

Tobacco companies in the United States are prohibited from making reduced harm claims without filing a modified risk tobacco product application with the Food and Drug Administration and obtaining an order to market as such. However, it is possible that product marketing may suggest reduced risk to individuals. This study examines perceptions, in particular those related to harm and addiction, of snus print advertisements using a combination of eye-tracking, survey, and semistructured interviews. Participants were 22 male smokers ages 19-29 (M = 26.64, SD = 2.92). Five snus advertisements were each displayed for 20 s and eye movements were tracked. Participants responded to questions about harm and addiction after each advertisement and interviews were conducted after seeing all advertisements. For each advertisement, descriptive statistics were calculated and regression analyses predicted harm and addiction perceptions from eye tracking areas of interest (e.g., warning label). Qualitative data were analyzed using inductive/deductive thematic analysis. For certain advertisements, areas of interest were significantly associated with harm and/or addiction perceptions. For example, higher total fixation duration on the graphic in the Smokeless for Smokers advertisement was associated with decreased perceptions of addiction (B = -.360, p = .048). Qualitative themes emerged and in many instances corroborated quantitative results. This study indicates that for some advertisements, attention on certain areas (measured through eye tracking) is associated with perceptions among young male smokers. Understanding how smokers perceive and understand products after viewing advertisements may inform regulations regarding claims about product harm and addiction and may guide public health efforts to educate smokers on the risks of emerging products. (PsycINFO Database Record

The association between sensation seeking and e-cigarette use in Texas young adults: A cross-sectional study

OBJECTIVE

To examine the associations between sensation seeking and ever and current e-cigarette use in Texas young adults (18-29 years old). Current cigarette use was examined as a potential effect modifier of the associations.

PARTICIPANTS

Participants included college students enrolled in four-year and two-year colleges in four metropolitan areas in Texas (n  =  5,418) who completed the survey between November 2014 and February 2015.

METHODS

This cross-sectional study utilized mixed effects logistic regression to determine the associations between mean sensation seeking scores and ever and current e-cigarette use after controlling for covariates.

RESULTS

After controlling for covariates, significant associations between sensation seeking and both ever and current e-cigarette use were observed; however, these associations were significant for noncurrent smokers only (adjusted odds rations [AOR]  =  1.55, 95% confidence interval (CI)  =  1.39, 1.73; AOR  =  1.82, 95% CI  =  1.54, 2.15, respectively).

CONCLUSIONS

Sensation seeking is an important factor in identifying college students who may be at increased risk for e-cigarette use behaviors.

Cute as candy: a qualitative study of perceptions of snus branding and package design among youth in Norway

OBJECTIVES

Snus use has increased among youth in Norway in recent years and is now more prevalent than smoking. Concurrently, a range of new products and package designs have been introduced to the market. The aim of this study was to explore how youth perceive snus branding and package design, and the role, if any, of snus packaging on perceptions of appeal and harm of snus among youth.

PARTICIPANTS

Adolescent tobacco users and non-users (N=35) ages 15-17 years.

DESIGN

We conducted interviews among 6 focus groups (each with 4-7 participants). Participants were shown snus packages with a variety of designs and with different product qualities (flavour additives, slim, regular, white and brown sachets) and group discussions focused on how they perceived packages and products. The focus group discussions were semistructured using a standard guide, and analysed thematically.

RESULTS

The participants in the focus groups narrated distinct images of snus brands and associated user identities. Package design elements such as shapes, colours, images and fonts were described as guiding these perceptions. Packaging elements and flavour additives were associated with perceptions of product harm. The appeal of flavoured snus products and new types of snus sachets seemed to blend in with these processes, reinforcing positive attitudes and contributing to the creation of particular identities for products and their users.

CONCLUSIONS

The findings indicate that packaging is vital to consumer's identification with, and differentiation between, snus brands. In view of this, snus branding and packaging can be seen as fulfilling a similar promotional role as advertising messages: generating preferences and appeal.

Electronic cigarettes: what are they and what do they do?

Electronic cigarettes (ECIGs) use electricity to power a heating element that aerosolizes a liquid containing solvents, flavorants, and the dependence-producing drug nicotine for user inhalation. ECIGs have evolved rapidly in the past 8 years, and the changes in product design and liquid constituents affect the resulting toxicant yield in the aerosol and delivery to the user. This rapid evolution has been accompanied by dramatic increases in ECIG use prevalence in many countries among adults and, especially, adolescents in the United States. The increased prevalence of ECIGs that deliver nicotine and other toxicants to users' lungs drives a rapidly growing research effort. This review highlights the most recent information regarding the design of ECIGs and their liquid and aerosol constituents, the epidemiology of ECIG use among adolescents and adults (including correlates of ECIG use), and preclinical and clinical research regarding ECIG effects. The current literature suggests a strong rationale for an empirical regulatory approach toward ECIGs that balances any potential ECIG-mediated decreases in health risks for smokers who use them as substitutes for tobacco cigarettes against any increased risks for nonsmokers who may be attracted to them.

Perceptions and Experiences with Flavored Non-Menthol Tobacco Products: A Systematic Review of Qualitative Studies

Although a few countries have banned flavored cigarettes (except menthol), flavors in most tobacco products remain unregulated across the globe. We conducted a systematic review of qualitative studies examining perceptions of and experiences with flavored non-menthol tobacco products. Of 20 studies on flavored tobacco products included in our qualitative systematic review, 10 examined hookah, six examined e-cigarettes, two examined little cigars and cigarillos (LCCs), and three examined other tobacco products, including cigarettes. The majority of studies, regardless of product type, reported positive perceptions of flavored tobacco products, particularly among young adults and adolescents. In six studies that assessed perceptions of harm (including hookah, LCCs, and other flavored tobacco products), participants believed flavored tobacco products to be less harmful than cigarettes. In studies that examined the role of flavors in experimentation and/or initiation (including three studies on e-cigarettes, one hookah study and one LCC study), participants mentioned flavors as specifically leading to their experimentation and/or initiation of flavored tobacco products. Given that many countries have not yet banned flavors in tobacco products, these findings add to existing research on why individuals use flavored tobacco products and how they perceive harm in flavored tobacco products, providing further support for banning non-menthol flavors in most tobacco products.

Flavored e-cigarette use: Characterizing youth, young adult, and adult users

The purpose of this study is to investigate how the use of flavored e-cigarettes varies between youth (12-17 years old), young adults (18-29 years old), and older adults (30 + years old). Cross-sectional surveys of school-going youth (n = 3907) and young adult college students (n = 5482) in Texas, and young adults and older adults (n = 6051) nationwide were administered in 2014-2015. Proportions and 95% confidence intervals were used to describe the percentage of e-cigarette use at initiation and in the past 30 days that was flavored, among current e-cigarette users. Chi-square tests were applied to examine differences by combustible tobacco product use and demographic factors. Most e-cigarette users said their first and "usual" e-cigarettes were flavored. At initiation, the majority of Texas school-going youth (98%), Texas young adult college students (95%), and young adults (71.2%) nationwide said their first e-cigarettes were flavored to taste like something other than tobacco, compared to 44.1% of older adults nationwide. Fruit and candy flavors predominated for all groups; and, for youth, flavors were an especially salient reason to use e-cigarettes. Among adults, the use of tobacco flavor at initiation was common among dual users (e-cigarettes + combustible tobacco), while other flavors were more common among former cigarette smokers (P = 0.03). Restricting the range of e-cigarette flavors (e.g., eliminating sweet flavors, like fruit and candy) may benefit youth and young adult prevention efforts. However, it is unclear what impact this change would have on adult smoking cessation.

Health Insurance Challenges in the Post-Affordable Care Act (ACA) Era: a Qualitative Study of the Perspective of Low-Income People of Color in Metropolitan Detroit

Low-income people of color are at risk of remaining uninsured due to a variety of factors. This study examined Affordable Care Act (ACA)-related and other health insurance enrollment experiences, observations, navigation needs, and experiences maintaining health insurance coverage among low-income communities of color in an economically disadvantaged community (Metropolitan Detroit). We conducted nine focus groups (n = 87) between May and June 2015. Participants were recruited through community-based organizations serving our key populations of interest. Using an inductive thematic analysis approach, codes and themes were generated. Findings from six themes demonstrated that although health insurance is perceived as important, confusion and frustration persist around health plan benefits and coverage, eligibility requirements and key provisions of the ACA, and enrollment. Individuals face difficulties justifying the cost of health insurance. More focused insurance outreach efforts are needed to achieve the ultimate goal of improving the health of low-income communities of color.

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.

Determinants associated with E-cigarette adoption and use intention among college students

OBJECTIVE

This study investigated characteristics of potential and current e-cigarette users based on four different levels of use acceptability along with the determinants that promote e-cigarette use acceptability among college students.

METHODS

College students (N=1198) aged 18-25years at a Midwestern university were surveyed in September-October 2015. Participants were categorized into four groups based on e-cigarette use acceptability adapted from the Diffusion of Innovation Theory (i.e., laggards, late majority, early majority, and adopters). Multinomial logistic regressions and Heckman two-step selection procedures were performed to examine the determinants that promote e-cigarette use acceptability.

RESULTS

Approximately 40% of the participants reported ever using e-cigarettes. E-cigarette adopters agreed that e-cigarettes are more socially acceptable than traditional tobacco cigarettes (relative risk ratio [RRR]=1.43, p<0.01). Unique features such as flavor appeared to encourage college students' experimentation with e-cigarettes (ps<0.05). Participants mentioned positive sensory experiences as a reason for e-cigarette use (ps<0.01) and reported caring about their appearance more than their health (ps<0.05) when asked about possible outcomes of e-cigarette use.

CONCLUSIONS

Study findings indicate a possible explosive increase in e-cigarette experimentation or use among college students. Unique features of e-cigarettes such as flavor and USB rechargeability appear to be strong factors making e-cigarettes more acceptable and appealing to young adults regardless of their smoking status. Concerted efforts should be initiated to effectively counter or eliminate attractive features that lure young adults to experiment with e-cigarettes.

E-cigarette use, perceptions, and cigarette smoking intentions in a community sample of young adult nondaily cigarette smokers

E-cigarettes have been suggested as a strategy for reducing harm from cigarettes. Although e-cigarettes could be a less-harmful alternative to cigarettes for those trying to quit, there may also be costs that outweigh any benefits of reduction. The purpose of the present study was to prospectively investigate perceptions of e-cigarettes, cigarette smoking intentions, and their associations with e-cigarette use over time. Community participants (N = 348, 57% male) aged 18 to 24 years were recruited for a longitudinal study of tobacco use. Inclusion criteria included nondaily cigarette smoking for ≥ 6 months with no history of daily smoking. Participants reported e-cigarette use over the past 14 days at baseline, and for the past 9 days at 3, 6, and 9 months. Assessments were completed online or via mobile phone. Across the 4 assessments, 22% to 33% of participants reported recent e-cigarette use. Intent to quit smoking cigarettes and intent to maintain smoking were unrelated to e-cigarette frequency. E-cigarette frequency was positively associated with perceiving e-cigarettes as less harmful than cigarettes and more positive e-cigarette expectancies (ps < .05). E-cigarette use was also more frequent among those who smoked cigarettes frequently and who used e-cigarettes to circumvent cigarette bans more often (ps < .05). The combination of these findings suggests that, at least among nondaily smoking young adults, other factors may influence frequency of e-cigarette use more than harm reduction. Findings instead seem consistent with the hypothesis that e-cigarettes are more often used to complement ongoing cigarette smoking. (PsycINFO Database Record

Initiation, Progression, and Sustained Waterpipe Use: A Nationally Representative Longitudinal Study of U.S. Young Adults

Background: Waterpipe tobacco smoking (WTS) is increasing in popularity despite evidence of harm and potential for dependence. Intervention development has been hampered by a lack of longitudinal, nationally representative data on usage patterns and factors independently associated with WTS initiation. Therefore, we aimed to characterize key transitions between WTS states in a nationally representative group of young adults, with particular attention to factors independently associated with initiation.Methods: Participants were randomly selected from a national probability-based panel representing 97% of the United States. A total of 1,785 adults ages 18 to 30 at baseline completed two Web-based surveys 18 months apart in 2013 and 2014. Assessments included knowledge of waterpipe tobacco smoke composition, positive and negative attitudes toward WTS, normative beliefs, intention to use waterpipe, and WTS behavior. We used multivariable logistic regression to assess the association between predictive factors and subsequent WTS initiation.Results: In fully adjusted models, overall knowledge about toxicants associated with WTS was not associated with subsequent WTS initiation. Similarly, negative attitudes and normative beliefs were not associated with WTS uptake. However, baseline positive attitudes were strongly and significantly associated with WTS initiation [adjusted OR (AOR) = 1.7; 95% confidence interval (CI), 1.2-2.3]. Similarly, baseline intention to use WTS was strongly associated with subsequent initiation (AOR = 7.0; 95% CI, 3.5-13.7).Conclusions: Prevention efforts may be most successful if they target individuals with clear intentions to use WTS and challenge positive attitudes surrounding WTS.Impact: Surveillance of WTS trajectories will help inform health care and policy surrounding this emerging risk behavior among U.S. young adults. Cancer Epidemiol Biomarkers Prev; 26(5); 748-55. ©2017 AACR.

'A good method of quitting smoking' or 'just an alternative to smoking'? Comparative evaluations of e-cigarette and traditional cigarette usage by dual users

The development of e-cigarettes was initially hailed as a resource in facilitating a reduction in or cessation of cigarette smoking. Many users of e-cigarettes are ‘dual users’, smoking traditional cigarettes and e-cigarettes. The present qualitative study examines the factors that a group of 20 dual users considered to have been influential in their decisions to use e-cigarettes and their comparative evaluations of e-cigarettes and traditional cigarettes. Health concerns were not found to be sole motivators. Participants pointed to financial and contextual considerations, particularly peer influence on uptake and continued usage of e-cigarettes. E-cigarettes were evaluated as comparable to cigarettes in some ways but not in other important respects such as sensation and satisfaction. Different social evaluations of cigarette and e-cigarette usage were discerned which influenced how participants identified as smokers, ‘vapers’ or neither. Findings are discussed in relation to social representations, identity and implications for continued e-cigarette usage among dual users.

A Qualitative Study of Adolescent Perceptions of Electronic Cigarettes and Their Marketing: Implications for Prevention and Policy

This study examined youths' perceptions of electronic cigarettes ("e-cigarettes"), sources of e-cigarettes exposure, and preferred sources of e-cigarette health information. Participants (n = 25, M age 15.0 years) recruited during primary care visits completed an in-depth qualitative interview assessing these topics. Most participants (72%) perceived e-cigarettes as "healthier" than cigarettes and reported e-cigarette advertising exposure (80%) and interpersonal exposure (60%). Participants reported advertisements portray e-cigarettes as less harmful than cigarettes and novel products. Most (72%) indicated their doctor was their preferred source of e-cigarette health information, suggesting pediatric health care providers are well-positioned to counsel patients to prevent e-cigarette use.

Acute effects of snus in never-tobacco users: a pilot study

BACKGROUND

Snus tobacco characteristics may attract non-tobacco users, including relatively low, but pharmacologically active, doses of nicotine. Lower nicotine doses may limit adverse drug effects while also producing a physiologically active response.

OBJECTIVES

This pilot study is the first to profile the acute effects of snus on physiological and subjective assessments in a sample of never-tobacco users.

METHODS

Eleven never-tobacco users (five women; <100 uses/lifetime) were recruited from the community via university-approved advertisements. Using a within-subject design, participants consumed six pouches in ascending dose order (0, 1.6, 3.2, 4.8, 6.4, and 8.0 mg nicotine) within one session. The start of each snus bout was separated by 45 minutes, and pre- and post-pouch assessments included ratings of drug effects and physiological response.

RESULTS

The average heart rate and systolic blood pressure increased significantly from pre- to post-pouch use as a function of dose, though these increases were reliable for 8.0 mg nicotine only (p < .05). Collapsed across time, diastolic blood pressure was significantly higher for 8.0 mg nicotine than for all other doses (p < .05). Subjective ratings for "excessive salivation" and "satisfying" increased significantly from pre- to post-pouch use (p < .05), independent of dose.

CONCLUSION

Significant increases in physiological response at some doses suggest that users were exposed to pharmacologically active doses of nicotine. The lack of reliable subjective effects may be the product of the dosing regimen or the relatively small sample size. Findings highlight the need for identification of doses of snus that may promote abuse among naïve users.

A longitudinal, naturalistic study of U.S. smokers' trial and adoption of snus

To refine public health policy amidst a changing landscape of tobacco products in the United States, it is first necessary to describe fully the nature of smokers' alternative product use. Little research addresses smokers' snus use, and most studies are limited by small samples, cross-sectional designs, and crude outcome measurement. This study sample includes 626 adult US smokers who denied intention to quit in the next month and were randomized to receive free snus during a 6-week sampling period, after which no snus was provided. Participants were then followed for one year. Outcome data were collected via phone. Participants (mean age: 48.7years) were predominately female, White non-Hispanic. Eighty-four percent reported trial of snus. Eleven percent reported purchase (i.e., adoption). Current use declined from 47.1% at the end of the sampling period to 6.5% at the end of follow-up. Frequency and quantity of snus use among current users was low. Among snus users, 79.3% said it functioned as an alternative to smoking and 58.4% said it provided a means of coping with smoking restrictions; options not mutually exclusive. In logistic regressions, men were more likely to report trial (odds ratio [OR]=2.33, p<0.01) and adoption (OR=1.84, p<0.05) than women. Baseline expectations about the nature of snus use also predicted snus outcomes (OR=1.28-1.78, p<0.05). Smokers showed willingness to try snus, but product interest waned over time. Snus as currently marketed is unlikely to play a prominent role in US tobacco control efforts.

E-cigarettes, a safer alternative for teenagers? A UK focus group study of teenagers' views

OBJECTIVE

Concerns exist that e-cigarettes may be a gateway to traditional cigarettes and/or (re)normalise teenage smoking. This qualitative study explores how teenagers in the UK currently perceive e-cigarettes and how and why they do or do not use them.

DESIGN

16 focus groups were conducted across the UK between November 2014 and February 2015, with 83 teenagers aged 14-17. All discussions were digitally recorded, transcribed verbatim, imported into NVivo 10 and thematically analysed.

RESULTS

Teenagers generally agreed that e-cigarettes are useful products for smokers, including teenage smokers, to quit or reduce traditional cigarette use. Concerns were expressed about lack of information on their precise ingredients and any unknown risks for users and bystanders. However, teenagers typically viewed e-cigarettes as substantially less harmful than traditional cigarettes. They perceived e-cigarettes as attractive, with products described as 'fun' and having 'great flavourings'. Seeing websites or social media featuring e-cigarettes, especially YouTube 'vaping tricks', prompted some experimentation and imitation. E-cigarettes were used in a variety of situations, including at parties or when they could not smoke traditional cigarettes. A very few participants suggested covert use was a possibility and that e-cigarettes might help maintain a fledgling nicotine habit.

CONCLUSIONS

Teenagers support the use of e-cigarettes as smoking cessation aids for established adult smokers. However, they engage with these products differently from adults, with the novel hypothesis that covert use could potentially reinforce traditional cigarette smoking requiring further investigation. Policy responses should more clearly meet the needs of young people, as well as helping established adult smokers.

Social Norms, Perceptions and Dual/Poly Tobacco Use among Texas Youth

OBJECTIVES

We assessed risk perceptions and social norms about tobacco use across adolescent non-users of tobacco, single- product users, and dual/poly-product users.

METHODS

Use behaviors specific to e-cigarettes, cigarettes, hookah, cigars, and smokeless tobacco were assessed among 6th, 8th and 10th grade students (sample [n] = 3907 from a population of [N] = 461,069 students). Multivariate regression was used to examine differences in these factors across use categories, adjusted for demographic factors.

RESULTS

Results highlight differences between non-users and single- or dual/poly-product users for most tobacco products. Dual/poly-product users differed from single-product users most notably in their higher perceived use of tobacco products by close friends and dating partners, and a higher proportion of single-product users reported most products were not harmful and not addictive compared to non-users. Few differences were seen between dual/poly-product users and single-product users in their perceptions of harm and addictiveness.

CONCLUSIONS

Findings demonstrate the importance of proximal social influences (ie, close friends and dating partners) for adolescent dual/poly-tobacco product users. Understanding similarities and differences in risk factors between these adolescent groups can guide effective public health prevention and treatment programs.

Gender differences in snus versus nicotine gum for cigarette avoidance among a sample of US smokers

INTRODUCTION

Women are more susceptible to the harmful effects of cigarette smoking. Thus, identifying effective harm reduction approaches for women is necessary. The goal of this project was to examine gender differences in response to snus versus nicotine gum for cigarette avoidance, as a means of harm reduction.

METHODS

Participants were randomly assigned to use snus or nicotine gum as a method to avoid cigarette smoking. Participants attended clinic visits to receive study product, as well as provide biological samples to assess smoking avoidance and biomarkers and report on use of study product and cigarettes. A secondary analysis comparing men and women by randomization to study product was conducted.

RESULTS

Participants (n=391; 47% women) were randomized into the snus group (n=196; 45% women) and the gum group (n=195; 49% women). Men used more snus whereas women used more gum (p=0.02). During treatment, men in the snus group had higher total nicotine equivalent values whereas women did not vary by group (p=0.03). Overall, fewer men in the snus group completely avoided cigarettes compared to men in the gum group (e.g., continuous abstinence at Week 12: odds ratio=0.43, 95% confidence interval=0.20-0.93). Among women, there were no differences by randomization in cigarette avoidance.

CONCLUSIONS

Despite a number of gender differences in response to snus versus nicotine gum, these data suggest that snus may not be an optimal harm reduction approach for either gender.

Evaluating Point of Sale Tobacco Marketing Using Behavioral Laboratory Methods

With passage of the 2009 Family Smoking Prevention and Tobacco Control Act, the FDA has authority to regulate tobacco advertising. As bans on traditional advertising venues and promotion of tobacco products have grown, a greater emphasis has been placed on brand exposure and price promotion in displays of products at the point-of-sale (POS). POS marketing seeks to influence attitudes and behavior towards tobacco products using a variety of explicit and implicit messaging approaches. Behavioral laboratory methods have the potential to provide the FDA with a strong scientific base for regulatory actions and a model for testing future manipulations of POS advertisements. We review aspects of POS marketing that potentially influence smoking behavior, including branding, price promotions, health claims, the marketing of emerging tobacco products, and tobacco counter-advertising. We conceptualize how POS marketing potentially influence individual attention, memory, implicit attitudes, and smoking behavior. Finally, we describe specific behavioral laboratory methods that can be adapted to measure the impact of POS marketing on these domains.

Ever-Use and Curiosity About Cigarettes, Cigars, Smokeless Tobacco, and Electronic Cigarettes Among US Middle and High School Students, 2012-2014

Introduction

Among young people, curiosity about tobacco products is a primary reason for tobacco experimentation and is a risk factor for future use. We examined whether curiosity about and ever-use of tobacco products among US middle and high school students changed from 2012 to 2014.

Methods

Data came from the 2012 and 2014 National Youth Tobacco Surveys, nationally representative surveys of US students in grades 6 through 12. For cigarettes, cigars, smokeless tobacco, and e-cigarettes (2014 only), students were classified as ever-users or never-users of each product. Among never-users, curiosity about using each product was assessed by asking participants if they had “definitely,” “probably,” “probably not,” or “definitely not” been curious about using the product.

Results

From 2012 to 2014, there were declines in ever-use of cigarettes (26% to 22%; P = .005) and cigars (21% to 18%; P = .003) overall and among students who were Hispanic (cigarettes, P = .001; cigars, P = .001) or black (cigarettes, P = .004; cigars, P = .01). The proportion of never-users reporting they were “definitely not” curious increased for cigarettes (51% to 54%; P = .01) and cigars (60% to 63%; P = .03). Ever-use and curiosity about smokeless tobacco did not change significantly from 2012 to 2014. In 2014, the proportion of young people who were “definitely” or “probably” curious never-users of each product was as follows: cigarettes, 11.4%; e-cigarettes, 10.8%; cigars, 10.3%; and smokeless tobacco, 4.4%.

Conclusion

The proportion of US students who are never users and are not curious about cigarettes and cigars increased. However, many young people remain curious about tobacco products, including e-cigarettes. Understanding factors driving curiosity can inform tobacco use prevention for youth.