A Public Health Crisis: Electronic Cigarettes, Vape, and JUUL

Factors Associated with Cigarette, E-Cigarette, and Dual Use among South Korean Adolescents

Dual use of e-cigarettes and cigarettes has become common among Korean adolescents but has decreased among adults. Dual use refers to using two tobacco products; however, in this study, it is defined as using both e-cigarettes and cigarettes. We assessed the prevalence of dual use among Korean adolescents and its relationship with socio-demographic, smoking-related characteristics, and other risk behaviors. The 2019 Korea Youth Risk Behavior Survey’s data on 57,303 adolescents were analyzed using logistic regression. Overall, 13.8% had recently (in the past 30 days), used some type of cigarette, 3.3% were dual users, 3.4% exclusively smoked conventional cigarettes, and 0.6% exclusively vaped e-cigarettes. After adjusting for socio-demographic and psychological factors, substance use, smoking initiation by 13 years, secondhand smoke in school and public, and amount of cigarette consumption proved significant for all cigarette user types. Dual use was strongly associated with younger age (≤15 years), cigarette smoking initiation before 13 years, secondhand smoke exposure at school, and heavy cigarette smoking. Limited smoking cessation attempts, secondhand smoke exposure in public, and ease of cigarette purchases decrease the odds of adolescents becoming dual users. Thus, surveillance and enforcement of the juvenile protection measures need updating to prevent a shift into dual use.

"It is the One Thing that has Worked": facilitators and barriers to switching to nicotine salt pod system e-cigarettes among African American and Latinx people who smoke: a content analysis

BACKGROUND

Electronic cigarettes are a harm reduction strategy for individuals who smoke cigarettes who cannot or do not want to quit using FDA-approved cessation methods. Identifying perceived facilitators and barriers to switching among people who smoke cigarettes is critical to optimizing health impact. This is particularly important for the most dominant e-cigarette device, nicotine salt pod electronic cigarettes. We investigate the experience using pod electronic cigarettes among African American and Latinx individuals who smoke, the two largest racial/ethnic minority groups who experience significant health disparities.

METHODS

From July 2018 to May 2019, adults who smoked cigarettes, age 21 + (N = 114; M age = 44.6, 59.6% male, 52.6% African American from Kansas City, 47.4% Latinx from San Diego) received JUUL-brand electronic cigarettes (referred to hereafter as JUUL) for 6 weeks and answered interview questions at week six. We inquired what they liked and disliked about using JUUL, what helped with switching and made switching difficult, future intentions for continued JUUL use, and how JUUL compared to past smoking reduction methods. Responses were coded into themes by independent raters. Theme frequencies were analyzed separately by race/ethnicity and week 6 use trajectory (exclusive JUUL use, dual JUUL and cigarette use, exclusive cigarette use).

RESULTS

Clean/smell was the aspect of using JUUL most commonly liked (23%), followed by convenience (19%). Coughing/harshness was a more common barrier to switching for African American (44%) than Latinx (9%), and for continuing cigarette use (56%) than for those who exclusively switched or dually used JUUL and combustible cigarettes (15-21%). Most (78% African American; 90% Latinx) reported that the benefits of using JUUL outweighed barriers, and this varied by JUUL use trajectory: 94% exclusive switch, 86% dual use, and 42% continued cigarette use. The majority said they would continue using JUUL to replace cigarettes (83% African American; 94% Latinx) and that JUUL worked better than other methods to reduce cigarettes (72%).

CONCLUSION

African American and Latinx individuals who smoked experience using pod electronic cigarettes was generally positive. Understanding facilitators and impediments to switching to electronic cigarettes among racial/ethnic minority people who smoke can inform harm reduction interventions and reduce tobacco-related health disparities. Trial Registration ClinicalTrials.gov Identifier: NCT03511001 posted April 27, 2018.

An association between electronic nicotine delivery systems use and a history of stroke using the 2016 behavioral risk factor surveillance system

ABSTRACT

Electronic nicotine delivery systems (ENDS) are growing in use and many of the health implications with these devices remain unknown. This study aims to assess, using a survey representative of the USA general population, if an association exists between a history of ENDS use and a history of stroke.This cross-sectional study was a secondary data analysis using the 2016 behavioral risk factor surveillance system survey. The main exposure variable of the study was a self-reported history of ENDS use. The main outcome was a self-reported history of stroke. Covariates included sex, race, traditional cigarette use, smokeless tobacco use, chronic kidney disease, diabetes, myocardial infarction, and coronary artery disease. Unadjusted and adjusted logistic regression analyses were done. Adjusted odds ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated.Of the 486,303 total behavioral risk factor surveillance system survey participants, 465,594 met the inclusion criteria for this study of ENDS use and stroke. This study shows that current ENDS use was positively associated with a history of stroke. AOR of some daily ENDS use with stroke was 1.28 (95% CI: 1.02-1.61) and AOR of current daily ENDS use with stroke was 1.62 (95% CI: 1.18-2.31). The majority (55.9%) of current daily ENDS users reported former traditional cigarette smoking. Female sex, non-white ethnicity, elderly age, chronic kidney disease, coronary artery disease, diabetes, and traditional cigarette use characteristics were all also associated with increased odds of reporting a stroke.This study found a statistically significant and positive association between ENDS use and a history of stroke. Further research is warranted to investigate the reproducibility and temporality of this association. Nevertheless, this study contributes to the growing body of knowledge about the potential cardiovascular concerns related to ENDS use and the need for large cohort studies.

Development and testing of relative risk-based health messages for electronic cigarette products

BACKGROUND

Health messages on e-cigarette packs emphasise nicotine addiction or harms using similar wording to warnings on cigarette packs. These may not be appropriate for e-cigarettes which constitute a reduced risk alternative for smokers. This research aimed to (1) develop and test a selection of relative risk messages for e-cigarette products; (2) compare these to the two current EU Tobacco Products Directive (TPD) nicotine addiction messages; and (3) explore differences between smokers, non-smokers and dual users.

METHOD

Twenty-six messages focusing on either harm-reduction or cessation were developed and rated by multidisciplinary experts for accuracy, persuasiveness and clarity. The eight highest ranking messages were compared alongside the TPD messages in a sample of 983 European residents (316 smokers, 327 non-smokers, 340 dual users) on understandability, believability and convincingness.

RESULTS

On all three constructs combined, the two TPD messages rated the highest, closely followed by four relative risk messages "Completely switching to e-cigarettes lowers your risk of smoking related diseases", "Use of this product is much less harmful than smoking", "Completely switching to e-cigarettes is a healthier alternative to smoking", and "This product presents substantially lower risks to health than cigarettes" which did not differ statistically from the TPD messages. Non-smokers rated TPD1 significantly higher overall than dual users. Dual users rated "This product is a safer alternative to smoking" significantly higher than non-smokers. Messages did not differ on understandability.

CONCLUSIONS

These alternative messages provide a useful resource for future research and for policy makers considering updating e-cigarette product labelling.

Predicting molecular mechanisms, pathways, and health outcomes induced by Juul e-cigarette aerosol chemicals using the Comparative Toxicogenomics Database

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Vaping chemicals of Juul aerosols were analyzed using CTD.

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CTD can be used to predict disease associations of Juul aerosol chemicals.

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Predictive pathways that relate vaping aerosols to diseases are described.

There is a critical need to understand the health risks associated with vaping e-cigarettes, which has reached epidemic levels among teens. Juul is currently the most popular type of e-cigarette on the market. Using the Comparative Toxicogenomics Database (CTD; http://ctdbase.org), a public resource that integrates chemical, gene, phenotype and disease data, we aimed to analyze the potential molecular mechanisms of eight chemicals detected in the aerosols generated by heating Juul e-cigarette pods: nicotine, acetaldehyde, formaldehyde, free radicals, crotonaldehyde, acetone, pyruvaldehyde, and particulate matter. Curated content in CTD, including chemical-gene, chemical-phenotype, and chemical-disease interactions, as well as associated phenotypes and pathway enrichment, were analyzed to help identify potential molecular mechanisms and diseases associated with vaping. Nicotine shows the most direct disease associations of these chemicals, followed by particulate matter and formaldehyde. Together, these chemicals show a direct marker or mechanistic relationship with 400 unique diseases in CTD, particularly in the categories of cardiovascular diseases, nervous system diseases, respiratory tract diseases, cancers, and mental disorders. We chose three respiratory tract diseases to investigate further, and found that in addition to cellular processes of apoptosis and cell proliferation, prioritized phenotypes underlying Juul-associated respiratory tract disease outcomes include response to oxidative stress, inflammatory response, and several cell signaling pathways (p38MAPK, NIK/NFkappaB, calcium-mediated).

An Examination of Risk Factors for Tobacco and Cannabis Smoke Exposure in Adolescents Using an Epigenetic Biomarker

Objective: Evolving patterns of nicotine and cannabis use by adolescents require new tools to understand the changing epidemiology of these substances. Here we describe the use of a novel epigenetic biomarker sensitive to both tobacco and cannabis smoke in a longitudinal sample of high-risk adolescents. We examine risk factors for positivity for this epigenetic biomarker in comparison to positivity for conventional serum biomarkers of nicotine and cannabis use. Method: Eastern Iowa 10th graders who had a friend or family member who smoked were eligible to participate in a longitudinal study over 10-12th grades. Subjects provided self-report data on nicotine, tobacco, and cannabis use patterns as well as blood samples that were used for serum cotinine and THC assays. DNA was prepared for analysis of methylation at the CpG cg05575921, a sensitive indicator of smoke exposure. Relationships between positivity for each these biomarkers and a variety of risk factors, including demographics, family and peer relationships, psychopathology, willingness to smoke, and perceptions of typical cigarette and cannabis users, were examined at the 10th (n = 442), 11th (n = 376), and 12th (n = 366) grade timepoints. Results: A increasing proportion of subjects were positive for cotinine (5-16%), THC (3-10%), and cg05575921 methylation (5-7%) across timepoints, with some overlap. Self-reported combusted tobacco and cannabis use was strongly correlated with all biomarkers, whereas cg05575921 methylation was not correlated with reported e-cigarette use. Dual users, defined as those positive for nicotine and THC in the 12th grade showed the greatest cumulative smoke exposure, indicated by cg05575921 methylation. Subjects reported more positive attitudes toward cannabis users than cigarette smokers, and willingness to smoke and positive perceptions of tobacco and cannabis smokers were significant risk factors for biomarker positivity across timepoints. Conclusion: We conclude that measurement of cg05575921 methylation in adolescents is a useful tool in detecting tobacco smoking in adolescents, and may be a novel tool for the detection of cannabis smoking and cannabis and tobacco co-use, though non-combusted forms of nicotine use do not appear to be detectable by this method.

Electronic Cigarettes and Alternative Methods of Vaping

Vaping, the inhalation of heated aerosols, received widespread attention during the outbreak of electronic-cigarette (e-cigarette) or vaping-associated acute lung injury cases in 2019. E-cigarette use is now widely recognized as a potential cause of acute lung injury. Vaping is often perceived by physicians as referring exclusively to the use of e-cigarette devices. However, inhalation of nicotine or tetrahydrocannabinol-containing aerosol through alternate methods such as "dabbing" and "dripping" are increasingly common. However, the health impact of these alternate methods remains poorly understood. The use of alternate methods and devices may go unrecognized because of lack of clinician familiarity with them. In this review, we discuss e-cigarettes devices, electronic-liquid components, the expanded spectrum of methods used to consume aerosolized substances, and the potential for lung injury.

Protective Factors Against Vaping and Other Tobacco Use

BACKGROUND AND OBJECTIVES

Vaping has gained popularity among adolescents despite negative health consequences. Few studies have focused on factors that may protect against vaping. We sought to determine if future orientation, parental monitoring, school connectedness, and social support are associated with decreased risk of vaping and other forms of tobacco use.

METHODS

Data were obtained via anonymous school-based health behavior surveys among ninth- through 12th-graders in Pittsburgh, PA (n = 2487). Protective factors were assessed through validated Likert scale instruments. The primary outcome was recent (past 30-day) vaping. Additional outcomes included other forms of tobacco use and intention to quit tobacco products. Poisson regression models examined associations between protective factors and vaping and tobacco use outcomes.

RESULTS

Mean age was 15.7 years, 1446 (58.1%) respondents were female, and 671 youth (27.0%) reported recent vaping. Positive future orientation and high parental monitoring were associated with significantly lower prevalence of recent vaping (adjusted prevalence ratio: 0.84 [95% confidence interval: 0.73-0.97] and adjusted prevalence ratio: 0.73 [95% confidence interval: 0.62-0.85], respectively). There were no significant relationships between social support or school connectedness and vaping. All 4 protective factors were inversely associated with other forms of tobacco use. No factors were significantly associated with intent to quit tobacco products.

CONCLUSIONS

Findings reveal significant inverse associations between future orientation, parental monitoring, and vaping but no relationship between protective factors and intent to quit tobacco products. Developing interventions to foster protective factors in youth and their parental supports may inform primary prevention efforts to reduce vaping and other tobacco use.

Changes in E-Cigarette Perceptions Over Time: A National Youth Tobacco Survey Analysis

INTRODUCTION

This multiyear, cross-sectional study explores the changes over time in how U.S. middle- and high-school students perceive the harm and addiction risk of E-cigarettes.

METHODS

This study analyzed 83,779 participants in the National Youth Tobacco Survey from 2015 to 2019. Associations of survey year with perceived harm and addiction risk of E-cigarettes were assessed using multivariable multinomial logistic regression models, adjusted for sociodemographic characteristics.

RESULTS

Smoking decreased over the 5 years (-1.85 percentage points, p=0.07); vaping increased (9.03 percentage points, p<0.01). Perceived harm of both combustible cigarettes and E-cigarettes increased with time. Male, older, and non-White students perceived less harm from smoking or vaping. Perceptions of the addictiveness of E-cigarettes increased over time: 26.31% of students considered E-cigarettes to be more addictive than combustible cigarettes in 2019, compared with 7.26% in 2016. Female and non-White students were more likely to think that E-cigarettes were at least as addictive as combustible cigarettes but also reported less knowledge about them.

CONCLUSIONS

The perceptions of both harm and addictiveness of E-cigarettes have increased over time, independent of current use. Perceptions vary on the basis of age, sex, race/ethnicity, and current use. Efforts should be made to further educate adolescents about E-cigarettes and to regulate their sale and advertisement. Efforts to reduce the uptake of combustible cigarettes among adolescents have been successful and should be duplicated for E-cigarettes.

Serum cotinine levels and nicotine addiction potential of e-cigarettes: an NHANES analysis

This study aims to compare serum cotinine levels in e-cigarette and combustible cigarette smokers, in an attempt to quantify the potential chronic nicotine addiction risk that e-cigarettes pose. We analyzed 428 participants in 2015-2016 NHANES: 379 (87.03%) smoked combustible cigarettes alone and 49 (12.97%) smoked e-cigarettes. Serum cotinine levels were measured by isotope-dilution high-performance liquid chromatography/atmospheric pressure chemical ionization tandem mass spectrometric method with a detection limit of 0.015 ng/ml. Electronic cigarette smokers were younger than combustible cigarette smokers (mean age 36.79 versus 42.69 years, P = 0.03), more likely to be male (64.93% versus 48.32%, P = 0.09) and significantly less likely to live with other smokers (50.17% versus 90.07%, P < 0.01). Serum cotinine levels increased linearly with self-reported days of smoking in both electronic cigarette and combustible cigarette smokers, after accounting for living with a smoker. The analysis of the subgroup who reported daily use show non-statistically significantly higher serum cotinine levels in electronic cigarette smokers versus combustible cigarette smokers (β adj = 52.50, P = 0.10). This analysis of recent US data demonstrates that electronic cigarettes expose users to nicotine levels proportionate to, and potentially higher than combustible cigarettes, and thus pose a serious risk of chronic nicotine addiction. This could be particularly relevant in otherwise tobacco naive individuals; future risk of tobacco-related dependence, addiction and relapse, as well as of tobacco-related cancers in these subjects needs to be investigated.

E-cigarette and marijuana use and the attainment of obesity prevention guidelines among U.S. adolescents

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Majority of U.S. youth still not meeting 5-2-1-0 obesity prevention guidelines.

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Current marijuana users did not meet screen time and physical activity guidelines.

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E-cigarette users met physical activity and screen time guidelines.

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Dual users are more likely to meet fruits and vegetables guidelines.

The study objectives were to examine the associations of exclusive and dual use of e-cigarettes and marijuana and the attainment of the “Let’s Go! 5–2-1–0” obesity prevention guidelines and perceptions of weight status among U.S. adolescents. Data from the 2017 Youth Risk Behavior Survey, a school-based nationally representative cross-sectional study, were analyzed (N = 12,578). Participants were categorized based on their past 30-day e-cigarette and marijuana use as: non-users, exclusive e-cigarette users, exclusive marijuana users, and dual users. Adjusted logistic regression models were conducted. Of adolescents, 5.2% were exclusive e-cigarette users, 10.3% were exclusive marijuana users, and 7.4% were dual users. Compared to non-users, exclusive e-cigarette users were more likely (aOR = 1.55, 95%CI = 1.16–2.07) to meet the physical activity recommendation. Compared to dual-users, exclusive e-cigarette users were more likely (aOR = 1.47, 95%CI = 1.10–1.97) to meet the screen time recommendation. Compared to non-users, exclusive marijuana users were at increased odds to meet the fruit/vegetable recommendation (aOR = 1.33, 95%CI = 1.03–1.71), but were at decreased odds to meet the sugar-sweetened beverages recommendation (aOR = 0.81, 95%CI = 0.65–0.99). Compared to exclusive e-cigarette users, exclusive marijuana users were less likely to meet the screen time (aOR = 0.71, 95%CI = 0.54–0.93) and physical activity recommendations (aOR = 0.60, 95%CI = 0.43–0.84). Compared with dual users, exclusive marijuana users were more likely (aOR = 1.38, 95%CI = 1.01–1.88) to perceive themselves as slightly/very overweight. Compared to non-users, dual users were less likely to meet the sugar-sweetened beverages recommendation (aOR = 0.63, 95%CI = 0.46–0.87). Adolescent current marijuana users and dual users were less likely to meet obesity prevention guidelines. Prevention efforts are needed to reduce e-cigarette and marijuana use and increase adherence to these guidelines.

Risk Factors and Medical Symptoms Associated With Electronic Vapor Product Use Among Adolescents and Young Adults

The use of electronic vapor products (EVPs) has increased dramatically in the past decade. The objectives of our study were to examine the frequency of EVP use; to identify demographic characteristics, risk-taking behaviors, and beliefs about vaping; and to determine symptoms associated with EVPs among adolescents. A questionnaire addressing these objectives was administered to a convenience sample of subjects aged 12 to 23 years. Among 494 completed questionnaires, 80% of responders were considered experimenters/nonusers (never tried or tried one time) and 20% were considered frequent users (at least once a month). We identified demographic features and risk-taking behaviors associated with EVP use. In the previous 6 months, frequent users were more likely to report headache, cough, sleep disturbances, dehydration, weakness, racing heart, chest pain, and tremors. Our findings provide evidence to support efforts to decrease EVP use through screening, education, and preventative strategies.

Alternative tobacco products use and its impact on urologic health - will the lesser evil still be evil? A commentary and review of literature

INTRODUCTION

Alternative tobacco products, including electronic cigarettes (e-cigarettes) and non-combustible tobacco products or heat-not-burn (HNB) products, are substitutes to conventional combustible cigarettes with the potential to impact urologic health, similar to traditional smoking. Most urologists, however, have limited knowledge of these products and are unfamiliar with their potential health implications. We conducted a review to assess the impact of e-cigarettes and HNB products on urologic health.

MATERIAL AND METHODS

A bibliographic search covering the period up to April, 2021 was conducted using MEDLINE®/PubMed® and Google Scholar. Articles were reviewed and categorized based on the potential impact on erectile dysfunction, semen quality, lower urinary tract symptoms, genitourinary malignancies, and smoking cessation. Data were extracted, analyzed and summarized.

RESULTS

Mature data on the long-term impact of e-cigarette and HNB product use on urologic health are lacking. E-cigarette and HNB vapors appear to contain decreased concentrations of chemicals responsible for erectile dysfunction compared to tobacco smoke but may play a role through endothelial damage. Use of e-cigarettes is associated with lower sperm counts. No definitive data has shown a link between e-cigarette or HNB product use and lower urinary tract symptoms. Multiple carcinogens including those specifically linked to bladder cancer have been identified in the urine of e-cigarette and HNB product users. Limited data suggest e-cigarettes may aid in smoking cessation.

CONCLUSIONS

Urologists may benefit from understanding the urologic health concerns surrounding e-cigarettes and HNB product use and patients may benefit from being properly educated.

Effect of Grandmaternal Smoking on Body Size and Proportions at Birth

Many long-term adverse effects of smoking during pregnancy are known. Increasingly, adverse effects in the grandchild after grandmaternal smoking during pregnancy are reported. We explored this in a birth cohort of 24,000 grandmother–mother–child triads identified from the Finnish Medical Birth Register in 1991–2016. Multiple logistic regression was used to analyze the association between any smoking during pregnancy by both grandmother and mother, or only grandmother or mother on adverse birth outcomes. No smoking by neither grandmother nor mother was used as the reference. As endpoints, preterm birth, low birth weight, small for gestational age (birth weight, birth length, head circumference), and body proportionality (low ponderal index, high brain-to-body ratio, high head-to-length ratio) were included. Smoking by both grandmother and mother was consistently associated with higher risks than smoking only by the mother. Birth length and weight were especially sensitive to (grand)maternal smoking. In conclusion, the combined effect of grandmaternal and maternal smoking is associated with higher risks than only maternal smoking.

Carrier Solvents of Electronic Nicotine Delivery Systems Alter Pulmonary Surfactant

In late 2019, hundreds of users of electronic products that aerosolize a liquid for inhalation were hospitalized with a variety of respiratory and gastrointestinal symptoms. While some investigations have attributed the disease to the presence of vitamin E acetate in liquids that also contained tetrahydrocannabinol, some evidence suggests that chronic inhalation of two common solvents used in electronic nicotine delivery systems (ENDS), propylene glycol (PG) and vegetable glycerin (VG), can interfere with the lipid components of pulmonary surfactant and cause or exacerbate pulmonary injury. The interaction between PG, VG, and lung surfactant is not yet understood. This study presents an examination of the molecular interactions of PG and VG with lung surfactant mimicked by 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC). The interaction of DPPC and PG-VG is studied by attenuated total reflectance fourier transform infrared spectroscopy. The results showed that PG and VG altered the molecular alignment of the DPPC surfactant. The orientation of the surfactant at the surface of the lung affects the surface tension at the air–water interface, thereby influencing breathing. These findings suggest that chronic aerosolization of the primary solvents in ENDS might alter the function of pulmonary surfactant.

What parents of adolescents in residential substance use treatment want from continuing care: A content analysis of online forum posts

BACKGROUND

Parents of adolescents in residential substance use (SU) treatment face a myriad of barriers to continuing care services. Growing research suggests that mobile health (mHealth) technologies can overcome common barriers to continuing care services, yet no work has addressed parents' needs. To gain insight into parents' continuing care needs, we analyzed online forum posts made by parents who received a novel mHealth intervention. Methods: Thirty parents received access to an online networking forum where they could connect with our adolescent SU expert or the community of parents also navigating their adolescent's post-discharge transition. In real-time, participants could ask questions and share information, experiences, and emotional support. Results: Twenty-one parents (70%) posted at least once; 12 parents made 15 posts to our expert, while 18 parents made 50 posts to the parent community. Thematic analysis uncovered five major themes: parenting skills; parent support; managing the post-discharge transition; adolescent SU; and family functioning. Conclusions: Parents discussed a range of topics directly and indirectly related to their adolescent's treatment. Incorporating networking forums into mHealth continuing care interventions offers parents a secure space to ask questions, share concerns, and gather information needed to support their adolescent's transition home.

Differences in JUUL Appeal Among Past and Current Youth JUUL Users

INTRODUCTION

JUUL, a closed system e-cigarette with disposable pods, is popular among youth, with positive attributes of this product linked to current use by youth. However, many youth try JUUL and do not continue using; understanding differences in the appeal of this device between current users and those who chose not to continue use can inform regulation and prevention efforts. The aim of the current study is to compare JUUL appeal in youth among past users (ie, used, but not in past month) and current users (ie, used in past month).

METHODS

A cross-sectional survey was conducted in four Connecticut high schools in Spring 2018. This survey assessed JUUL use and reasons for liking/disliking JUUL, including its' pharmacological effects (eg, nicotine "buzz"), product characteristics (eg, flavors), peer influence, appeal compared to other e-cigarettes, and concealability. Logistic regressions were conducted to examine differences in liking/disliking JUUL by use status (past vs. current).

RESULTS

Among JUUL users (N = 1374; 43% of total sample), 30.4% were past users and 69.6% were current users. Compared to current users, past users were less likely to like JUUL for positive pharmacological effects (eg, nicotine "buzz"), product characteristics (eg, flavors), and peer use and more likely to dislike JUUL for the adverse pharmacological effects (eg, headache), product characteristics (eg, flavors), and for "other" reasons (open-ended response; eg, perceived harm).

CONCLUSIONS

Findings suggest that altering JUUL appeal through regulating nicotine content and flavors may be key in policy aimed at shifting youth to become past JUUL users.

IMPLICATIONS

This study investigates how current and past youth JUUL users differ in their report of the appeal of JUUL. Past users are less likely to report experiencing positive pharmacological effects and product characteristics of JUUL and are less likely to report appeal due to peer use. Understanding how appeal of JUUL may differ among past and current users can aid in our understanding of how to regulate these products so that they are less appealing to current youth users.

Adolescent's Health Perceptions of E-Cigarettes: A Systematic Review

CONTEXT

E-cigarette use is increasing among adolescents, particularly in high-income countries. This review examines the health perceptions of E-cigarettes among adolescents (aged 12-17 years) residing in the U.S., United Kingdom, Canada, Australia, and New Zealand and their sources of E-cigarette information.

EVIDENCE ACQUISITION

Peer-reviewed literature published in January 2009-April 2019 in MEDLINE, Embase, and ProQuest were systematically reviewed using identified keywords. The search identified 654 references. Studies (n=99) that met the inclusion criteria were subjected to full-text screening. A total of 27 articles were subjected to quality appraisal using the Joanna Briggs Institute's critical appraisal checklists.

EVIDENCE SYNTHESIS

A total of 7 qualitative and 18 quantitative studies were included in the review, and the study characteristics, results, and limitations were extracted. A total of 4 main themes emerged from the study findings: (1) perceived relative harm of E-cigarettes versus that of cigarettes, (2) perceived health effects of E-cigarettes, (3) perceived benefits and safety of E-cigarettes, and (4) sources of E-cigarette information and exposure. Most adolescents perceived E-cigarettes to be less harmful than cigarettes; however, often, their health perceptions of E-cigarettes were conflicting. Sources of exposure to E-cigarette information included friends, family, retail point of sale, TV and online advertising, national agencies, healthcare providers, and from direct experience.

CONCLUSIONS

Findings indicate that adolescents, particularly E-cigarette users, have more favorable perceptions of E-cigarettes than of cigarettes; however, these perceptions are conflicting. Advertising, marketing, and peer and family networks appear to influence adolescents' perceptions. More research is required, particularly in Australia and New Zealand, to better understand adolescents' health perceptions of E-cigarettes and where they source information from so that misperceptions can be addressed through appropriate channels with suitable messaging.

ENDS Device Type and Initiation of Combustible Tobacco Products Among Adolescents

INTRODUCTION

The aim of this study was to determine whether Electronic Nicotine Delivery Systems (ENDS) device type (disposable devices, replaceable cartridges, and refillables) at initial or first ENDS use predicts subsequent initiation of combustible tobacco products (cigarettes, hookah, cigars) among adolescents and/or differentiates between those who initiate use of both ENDS and combustible tobacco products at the same time.

METHODS

The study examined data from the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS), a longitudinal population-based cohort of students in major metropolitan areas of Texas (n = 3907; N = 461 069). Data were collected every 6 months, from 2014 to 2018; 33.9% (n = 1324; N = 151 784) of the sample initiated ENDS use across this period. Unadjusted and adjusted logistic regression models were used to assess the odds of initiating combustible tobacco products at a subsequent or similar wave as ENDS initiation, given initial ENDS device type.

RESULTS

After adjusting for sociodemographic factors, the odds of initiating combustible tobacco use subsequent to ENDS initiation were significantly lower among those who reported using Cartridges as their initial device type compared to those who reported Refillables as their initial device type (adjusted odds ratio = 0.42 [0.18-0.98], p = .05). In addition, after controlling for sociodemographic variables, the odds of initiating combustible tobacco use in the same wave as ENDS initiation were significantly higher among those who reported using Cartridges as their initial device type, compared with those who reported Refillables as their initial device type (adjusted odds ratio = 2.31 [1.05-5.10], p = .04). No significant differences were found in adjusted models when Disposables were compared to Refillables and Cartridges to Disposables.

CONCLUSION

ENDS device type differentiates between adolescents who start using combustible tobacco products at the same time as initial ENDS use, or subsequently.

IMPLICATIONS

Previous research has shown ENDS use predicts subsequent combustible use among adolescents, but there is lack of research on the role of specific ENDS device types and the timing of initiation. Findings from this longitudinal study show that initiation of combustible tobacco product use varies by initial ENDS device type among adolescents. These findings can become a focal point for developing interventions for adolescents and could have regulatory implications for ENDS products.

Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Electronic cigarettes (e-cigarettes) or vaping use in adolescents has emerged as a public health crisis that impacts the perioperative care of this vulnerable population. E-cigarettes have become the most commonly used tobacco products among youth in the United States. Fruit and mint flavors and additives such as marijuana have enticed children and adolescents. E-cigarette, or vaping, product use-associated lung injury (EVALI) is a newly identified lung disease linked to vaping. Clinical presentation of EVALI can be varied, but most commonly includes the respiratory system, gastrointestinal (GI) tract, and constitutional symptoms. Clinical management of EVALI has consisted of vaping cessation and supportive therapy, including supplemental oxygen, noninvasive ventilation, mechanical ventilation, glucocorticoids, and empiric antibiotics, until infectious causes are eliminated, and in the most severe cases, extracorporeal membrane oxygenation (ECMO). Currently, although there is an insufficient evidence to determine the safety and the efficacy of e-cigarettes for perioperative smoking cessation, EVALI clearly places these patients at an increased risk of perioperative morbidity. Given the relatively recent introduction of e-cigarettes, the long-term impact on adolescent health is unknown. As a result, the paucity of postoperative outcomes in this potentially vulnerable population does not support evidence-based recommendations for the management of these patients. Clinicians should identify "at-risk" individuals during preanesthetic evaluations and adjust the risk stratification accordingly. Our societies encourage continued education of the public and health care providers of the risks associated with vaping and nicotine use and encourage regular preoperative screening and postoperative outcome studies of patients with regard to smoking and vaping use.

A deep learning approach to identify unhealthy advertisements in street view images

While outdoor advertisements are common features within towns and cities, they may reinforce social inequalities in health. Vulnerable populations in deprived areas may have greater exposure to fast food, gambling and alcohol advertisements, which may encourage their consumption. Understanding who is exposed and evaluating potential policy restrictions requires a substantial manual data collection effort. To address this problem we develop a deep learning workflow to automatically extract and classify unhealthy advertisements from street-level images. We introduce the Liverpool [Formula: see text] Street View (LIV360SV) dataset for evaluating our workflow. The dataset contains 25,349, 360 degree, street-level images collected via cycling with a GoPro Fusion camera, recorded Jan 14th-18th 2020. 10,106 advertisements were identified and classified as food (1335), alcohol (217), gambling (149) and other (8405). We find evidence of social inequalities with a larger proportion of food advertisements located within deprived areas and those frequented by students. Our project presents a novel implementation for the incidental classification of street view images for identifying unhealthy advertisements, providing a means through which to identify areas that can benefit from tougher advertisement restriction policies for tackling social inequalities.

A review of nicotine-containing electronic cigarettes-Trends in use, effects, contents, labelling accuracy and detection methods

Electronic cigarettes (ECs) are thought to be less harmful than traditional combustible cigarettes and were originally intended to help smokers quit. Over the past two decades, they have especially gained popularity with the younger generation. To date, there are over 7000 unique e-liquid flavours available and over 400 different e-cigarette brands. The accuracy of nicotine strength labelling in e-liquids was assessed in this work. Twenty-three studies from around the world were chosen to assess the level and frequency of nicotine mislabelling in 545 e-liquid products. Nicotine strengths were most commonly mislabelled by between 5% and 20%, with the majority testing lower than what the label indicated. Fifteen European e-liquids that were assessed were labelled as 20 mg/ml or less, yet when tested, they contained more than 20 mg/ml of nicotine. One e-liquid that was supposed to contain no nicotine in fact contained 23.91 mg/ml of nicotine. Furthermore, the difference between the medians of the available labelled and experimental nicotine concentrations was significant (p < 0.001, Wilcoxon signed rank test). Preliminary studies show that high nicotine levels delivered via aerosol increase the risk for nicotine poisoning and cause airway inflammation. Other EC ingredients, such as flavourings, contribute to EVALI and 'popcorn lung'. There is evidence that certain flavourings, such as menthol, reinforce the effects of nicotine and modify drug absorption and metabolism. There is a global need for better quality control in EC products in order to make these safe for consumers.

Potential Suppressive Effect of Nicotine on the Inflammatory Response in Oral Epithelial Cells: An In Vitro Study

Smoking is a well-recognized risk factor for oral mucosal and periodontal diseases. Nicotine is an important component of cigarette smoke. This study aims to investigate the impact of nicotine on the viability and inflammatory mediator production of an oral epithelial cell line in the presence of various inflammatory stimuli. Oral epithelial HSC-2 cells were challenged with nicotine (10⁻⁸–10⁻² M) for 24 h in the presence or absence of Porphyromonas gingivalis lipopolysaccharide (LPS, 1 µg/mL) or tumor necrosis factor (TNF)-α (10⁻⁷ M) for 24 h. The cell proliferation/viability was determined by MTT assay. Gene expression of interleukin (IL)-8, intercellular adhesion molecule (ICAM)-1, and β-defensin was assayed by qPCR. The production of IL-8 protein and cell surface expression of ICAM-1 was assessed by ELISA and flow cytometry, respectively. Proliferation/viability of HSC-2 cells was unaffected by nicotine at concentrations up to 10⁻³ M and inhibited at 10⁻² M. Nicotine had no significant effect on the basal expression of IL-8, ICAM-1, and β-defensin. At the same time, it significantly diminished P. gingivalis LPS or the TNF-α-induced expression levels of these factors. Within the limitations of this study, the first evidence was provided in vitro that nicotine probably exerts a suppressive effect on the production of inflammatory mediators and antimicrobial peptides in human oral epithelial cells.

Five-year changes in support for tobacco control policy options among students, faculty and staff at a public university

Over 2500 U.S. colleges and universities have instituted smoke-free (prohibiting combustible tobacco) or tobacco-free (prohibiting all tobacco) campus policies, and support for such policies by students, faculty and staff is an essential ingredient for successful implementation. Cross-sectional studies have found that these policies are well supported, but longitudinal studies that track change in support over time are rare. The present study reports on two campus-wide web-based surveys conducted five years apart, 2013 and 2018, at a public university campus for which a smoke-free policy was in effect. The 2013 samples included 5691 students (26% response rate) and 2051 faculty and staff (43% response rate); the 2018 samples included 4883 students (21% response rate) and 1882 faculty/staff (37% response rate). Question wordings and procedures were largely consistent across the two surveys. Changes in support among students and faculty/staff for both a smoke-free and a tobacco-free campus were measured, including separate analyses for past-month tobacco users and non-users. Chi-square tests revealed that support for both policy options by all respondent groups (student tobacco users and non-users; faculty/staff tobacco users and non-users) increased significantly and substantially, with the exception of student non-users' support of a smoke-free campus, which was already high in 2013 (83.7% support) and remained relatively unchanged. Increases in support for the tobacco-free option were particularly large. Results are discussed in light of theories of social norm change. These findings provide evidence from one university that tobacco control policies, especially those making a campus fully tobacco-free, increase in popularity over time.

Social media's influence on e-cigarette use onset and escalation among young adults: What beliefs mediate the effects?

As an extension of a previous cross-sectional study, this study employed prospective data to test positive outcome expectancy beliefs as mediators of social media's influence on e-cigarette use progression among young adults. Self-report data were collected from 2327 young adult college students (Mean age = 21.2; SD = 2.1; 54% women) between 2017 and 2019, every 6-month, at 3 time-points. Structural equation modeling was used to test the mediational models. Among baseline never e-cigarette users, higher affect regulation expectancies-e.g., beliefs that e-cigarette use results in feeling good, reduced boredom and stress-mediated the effects of higher baseline social media e-cigarette exposure on e-cigarette use onset one year later. Among baseline lifetime e-cigarette users, higher positive sensory, positive "smoking" experience, and affect regulation expectancy beliefs mediated the effects of higher social media e-cigarette exposure at baseline on increased current e-cigarette use one year later. E-cigarette content on social media may persuade young adults to try e-cigarettes by imparting the sense that e-cigarettes make one feel good and help reduce stress. E-cigarette content on social media that promote e-cigarette flavors and e-cigarettes as cleaner and a socially more acceptable alternative to cigarettes may work to escalate e-cigarette use among experimenters. Efforts to prevent e-cigarette use onset and escalation may need to target the outcome expectancy beliefs influenced by social media.

Social Learning, Social Bonds, Self-Control and Adolescent Nicotine Vaping

The aim of this study was to examine whether three theories of adolescent substance use-social learning, social bonding, and self-control-were useful for predicting adolescent nicotine vaping. Methods: The analysis utilized data on U.S. 8th and 10th grade students from the 2017 and 2018 Monitoring the Future (MTF) studies, repeated cross-sectional surveys that included 11,624 youth who responded to questions about past 12-month nicotine vaping. Measures from each of the three theories were used to predict the outcome using a zero-inflated negative binomial model. Results: The results demonstrated that variables from social learning and self-control theories were key predictors of nicotine vaping. Friends' substance use appeared as the most consequential predictor, followed by low self-control or higher risk-taking propensities. An interaction effect also suggested that friends' substance use had a stronger association with nicotine vaping among youth who reported higher self-control. Conclusions/Importance: The findings suggested that adolescent nicotine vaping is a consequence of social learning influences and low self-control. Future research should explore these and similar factors in more detail.

JUUL E-Cigarette Quit Attempts and Cessation Perceptions in College Student JUUL E-Cigarette Users

PURPOSE

This study describes the frequency of JUUL e-cigarette (referred to as JUUL) quit attempts and identifies characteristics associated with confidence in quitting and perceived difficulty quitting JUUL.

DESIGN

Cross-sectional study from a self-administered online survey.

SETTING

Two public southern California universities.

PARTICIPANTS

A total of 1,001 undergraduate students completed the survey from February to May 2019.

MEASURES

Self-report measures about JUUL included use, history of quit attempts, time to first use, perceived difficulty with cessation/reduction, and confidence in quitting.

ANALYSIS

Binary logistic regressions were used to identify demographic and tobacco-related behavioral correlates of JUUL cessation-related perceptions and behaviors.

RESULTS

Nearly half of ever-JUUL users (47.8%) reported a JUUL quit attempt. Adjusting for demographic factors and other tobacco product use, shorter time to first JUUL use after waking was associated with lower confidence in quitting JUUL (aOR = 0.02, 0.00-0.13) and greater perceived difficulty in quitting JUUL (aOR = 8.08, 2.15-30.35). Previous JUUL quit attempt history was also associated with greater odds of perceived difficulty quitting JUUL (aOR = 5.97, 1.74-20.53).

CONCLUSIONS

History of JUUL quit attempts among college students was common. Those who had previously tried quitting were more likely to perceive difficulty with cessation. Time to first JUUL use, a marker of dependence, was linked with greater perceived cessation difficulty and lower confidence in quitting. These findings suggest that there is a need for cessation and relapse prevention support for college student JUUL users.

High school students' use of JUUL pod flavors before and after JUUL implemented voluntary sales restrictions on certain flavors in 2018

Objectives

In November 2018, JUUL, Inc. restricted sales of mango, fruit medley, crème brûlée, and cucumber pods to its website. Physical/online sales of tobacco, menthol, and mint pods continued. We examined rates of adolescent JUUL device and flavored pod use before and after restrictions were implemented to examine their potential impact.

Methods

Students from 4 Connecticut high schools completed cross-sectional surveys in 2018 (N = 3170) and 2019 (N = 3074).

Results

Compared to 2018, current (past-month) JUUL use decreased in 2019 (30.2–25.6%). Among current JUUL users, restricted flavor use (mango [62.8–36.9%]; cucumber [27.7–11.9%]; fruit [23.5–11.4%]; crème brûlée [12.3–5.0%]) and the total number of flavors used (2.09[SD = 1.71]-1.51[SD = 1.33]) decreased (p-values < .001), while mint pod use increased (62.0–68.6%, p < .01). Tobacco and menthol pod use remained stable.

Conclusions

Following voluntary sales restrictions implemented by JUUL, Inc., restricted flavor use and the total number of flavors used decreased among JUUL users while mint use increased. Results suggest flavor restrictions may impact adolescents’ e-cigarette use. While 2020 Food and Drug Administration restrictions on mint pods may further limit youth JUUL use, research is needed to determine where youth acquire restricted flavors and if restrictions prompt increased popularity of unrestricted devices/e-liquids.

Trends in Selected Chronic Conditions and Related Risk Factors Among Women of Reproductive Age: Behavioral Risk Factor Surveillance System, 2011-2017

Introduction: Chronic diseases in the United States are the leading drivers of disability, death, and health care costs. In women of reproductive age (WRA), chronic disease and related risk factors can also affect fertility and reproductive health outcomes. This analysis of trends from 2011 to 2017 adds additional indicators and updates an analysis covering 2001-2009. Methods: Data from the 2011-2017 Behavioral Risk Factor Surveillance System were analyzed for 265,544 WRA (18-44 years). To assess trends in 12 chronic conditions and related risk factors, we calculated annual prevalence estimates and adjusted prevalence ratios (APRs) with predicted marginals accounting for age, race, Hispanic ethnicity, education, and health care coverage. Results: From 2011 to 2017, prevalence decreased for current smoking (20.7%-15.9%; p < 0.001), gestational diabetes (3.1%-2.7%; p = 0.003), and high cholesterol (19.0%-16.7%; p < 0.001); prevalence increased for depression (20.4%-24.9%; p < 0.001) and obesity (24.6%-27.6%; p < 0.001). After adjustment, in 2017 WRA were more likely to report asthma (APR = 1.06; 95% confidence interval [CI] = 1.01-1.11), physical inactivity (APR = 1.08; 95% CI = 1.04-1.12), obesity (APR = 1.15; 95% CI = 1.11-1.19), and depression (APR = 1.29; 95% CI = 1.25-1.34) compared with 2011. They were less likely to report high cholesterol (APR = 0.89; 95% CI = 0.85-0.94) in 2015 compared with 2011, and current smoking (APR = 0.86; 95% CI = 0.82-0.89) and gestational diabetes (APR = 0.84; 95% CI = 0.75-0.94) in 2017 compared with 2011. Conclusions: Some chronic conditions and related risk factors improved, whereas others worsened over time. Research clarifying reasons for these trends may support the development of targeted interventions to promote improvements, potentially preventing adverse reproductive outcomes and promoting long-term health.

Vaping-Related Mobile Apps Available in the Google Play Store After the Apple Ban: Content Review

BACKGROUND

In response to health concerns about vaping devices (eg, youth nicotine use, lung injury), Apple removed 181 previously approved vaping-related apps from the App Store in November 2019. This policy change may lessen youth exposure to content that glamorizes vaping; however, it may also block important sources of information and vaping device control for adults seeking to use vaping devices safely.

OBJECTIVE

Understanding the types of nicotine and cannabis vaping-related apps still available in the competing Google Play Store can shed light on how digital apps may reflect information available to consumers.

METHODS

In December 2019, we searched the Google Play Store for vaping-related apps using the keywords "vape" and "vaping" and reviewed the first 100 apps presented in the results. We reviewed app titles, descriptions, screenshots, and metadata to categorize the intended substance (nicotine or cannabis/tetrahydrocannabinol) and the app's purpose. The most installed apps in each purpose category were downloaded and evaluated for quality and usability with the Mobile App Rating Scale.

RESULTS

Of the first 100 apps, 79 were related to vaping. Of these 79 apps, 43 (54%) were specific to nicotine, 3 (4%) were specific to cannabis, 1 (1%) was intended for either, and for the remaining 31 (39%), the intended substance was unclear. The most common purposes of the apps were making do-it-yourself e-liquids (28/79, 35%) or coils (25/79, 32%), games/entertainment (19/79, 24%), social networking (16/79, 20%), and shopping for vaping products (15/79, 19%). Of the 79 apps, at least 4 apps (5%) paired with vaping devices to control temperature or dose settings, 8 apps (10%) claimed to help people quit smoking using vaping, and 2 apps (3%) had the goal of helping people quit vaping.

CONCLUSIONS

The majority of vaping-related apps in the Google Play Store had features either to help users continue vaping, such as information for modifying devices, or to maintain interest in vaping. Few apps were for controlling device settings or assisting with quitting smoking or vaping. Assuming that these Google Play Store apps were similar in content to the Apple App Store apps that were removed, it appears that Apple's ban would have a minimal effect on people who vape with the intention of quitting smoking or who are seeking information about safer vaping via mobile apps.

Effect of Pod e-Cigarettes vs Cigarettes on Carcinogen Exposure Among African American and Latinx Smokers: A Randomized Clinical Trial

IMPORTANCE

Fourth-generation nicotine salt pod system (NSPS) electronic cigarettes (e-cigarettes) are the leading class of e-cigarettes. They contain high nicotine concentrations, which may facilitate switching among smokers, but could also lead to increased exposure to nicotine and biomarkers of potential harm. African American and Latinx smokers experience significant tobacco-related health disparities. The potential of NSPS e-cigarettes to reduce smoking-related harm among these groups is unknown.

OBJECTIVE

To compare the harm reduction potential of NSPS e-cigarette vs combustible cigarettes.

DESIGN, SETTING, AND PARTICIPANTS

This unblinded randomized clinical trial compared 6 weeks of e-cigarette use vs cigarettes as usual from to 2018 to 2019 among smokers in the San Diego, California, and Kansas City, Missouri, areas. Participants included African American and Latinx adult combustible cigarette smokers who smoked at least 5 cigarettes/d on at least 25 of the past 30 days for at least 6 months and were interested in switching to e-cigarettes. Data were analyzed from September 18, 2019, to September 4, 2020.

INTERVENTIONS

6 weeks of e-cigarette use in a choice of pod flavors (5% nicotine) along with brief education, training, and action planning to completely switch to e-cigarettes from combustible cigarettes. The control group smoked combustible cigarettes as usual.

MAIN OUTCOMES AND MEASURES

The primary outcome was reduction in urinary 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) concentration at week 6. Secondary outcomes were change in urinary cotinine, expired carbon monoxide (CO), respiratory symptoms, lung function, blood pressure, past 7-day consumption of combustible cigarettes, and switching rates (e-cigarette group only) at weeks 2 and 6.

RESULTS

This study included 186 participants, including 92 African American participants and 94 Latinx participants. The mean (SD) age was 43.3 (12.5) years, and 75 (40.3%) were women. Participants smoked a mean (SD) of 12.1 (7.2) cigarettes/d on 6.8 (0.6) d/wk at baseline. A total of 125 participants were randomized to the e-cigarette group and 61 were randomized to the control group. At baseline, median (interquartile range) NNAL was 124 (45-197) pg/mL in the e-cigarette group and 88 (58-197) pg/mL in the control group. At week 6, the e-cigarette group had significantly greater reductions in NNAL (relative risk [RR], 0.36 [95% CI, 0.23-0.54]; P < .001), CO (RR, 0.53 [95% CI, 0.42-0.68]; P < .001), respiratory symptoms (RR, 0.63 [95% CI, 0.47-0.85]; P = .002), and number of cigarettes smoked in the past 7 days among those still smoking (RR, 0.30 [95% CI, 0.20-0.43]; P < .001) than the control group and maintained their cotinine levels (RR, 0.80 [95% CI, 0.58-1.10]; P = .17). Lung function and diastolic and systolic blood pressure remained unchanged and did not differ between groups. For participants randomized to receive e-cigarettes, 32 participants (28.1%) were exclusively using e-cigarettes at week 6, while 66 participants (57.9%) were dual using and 16 participants (14%) resumed exclusively using cigarettes.

CONCLUSIONS AND RELEVANCE

These findings suggest that e-cigarettes may be an inclusive harm reduction strategy for African American and Latinx smokers.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03511001.

Young adult e-cigarette use: A latent class analysis of device and flavor use, 2018-2019

OBJECTIVE

The myriad of e-cigarette devices and flavors used by young adults (YAs) complicates identification of the particular e-cigarette products that are associated with more frequent tobacco use and merit consideration for regulation. The current study used latent class analysis to identify distinct patterns of e-cigarette device and flavor use and evaluate their association with vaping and smoking frequency.

METHODS

Cross-sectional survey data (2018-2019) from a Southern California cohort were analyzed. YAs reporting past 30-day nicotine vaping (N = 550; M age = 19.2 years) self-reported e-cigarette device type/brand and flavor. Six device (e-cig/vape pen, mech mod, box mod, JUUL, non-JUUL pod, disposable) and three flavor (tobacco, mint/menthol, sweet/fruit) indicators were included in a latent class analysis. Past 30-day nicotine vaping and cigarette smoking frequency were assessed as correlates of device and flavor class membership.

RESULTS

Three classes were identified: Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (prevalance:47%); Non-JUUL-Sweet/Fruit Flavor Users (28%); and Poly-Device-Poly-Flavor Users (25%). Greater frequency of vaping and smoking were associated with higher odds of belonging to the Poly-Device-Poly-Flavor Users class vs. the Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.36[1.16, 1.59], p < .001; smoking: aOR[95%CI] = 1.25[1.02, 1.54], p = .03) and Non-JUUL-Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.30[1.10, 1.53], p < .01; smoking: aOR[95%CI] = 1.42[1.07, 1.88], p = .02) classes.

CONCLUSIONS

Although YAs that predominately used pod devices alongside non-tobacco flavors were most common, YAs characterized by a proclivity toward using many different devices and flavors were appreciably prevalent and smoked and vaped more frequently. Regulations targeting a wide spectrum of vaping products may be optimal in protecting YA health.

Association of flavored electronic nicotine delivery system (ENDS) use with self-reported chronic obstructive pulmonary disease (COPD): Results from the Population Assessment of Tobacco and Health (PATH) study, Wave 4

INTRODUCTION

Flavors other than tobacco flavor have been identified as a major reason for electronic nicotine delivery system (ENDS) initiation in youth and are thought to contribute to the continued use of ENDS in users of all ages. Our previous research showed a significant association between overall ENDS use and COPD. This study aims to identify the association of ENDS flavor categories with self-reported COPD.

METHODS

The data analysis included 4909 adults from Population Assessment of Tobacco and Health (PATH) Wave 4 data who were ever established ENDS users and responded to an item about diagnosis of COPD. Weighted multivariable logistic regression models were used to examine the association between different ENDS flavors and self-reported COPD considering complex sampling design.

RESULTS

Among 4909 ever established ENDS users, 418 adults (weighted percentage 9.8%) had self-reported COPD. Self-reported COPD prevalence differed between different ENDS flavor categories, with the highest (weighted percentage 19.9%) occurring among tobacco flavor users. Compared to non-tobacco flavor categories, tobacco flavor category showed significantly higher association with self-reported COPD (AOR=2.05; 95% CI: 1.20–3.53), after adjusting for potential confounding variables. No significant associations with self-reported COPD were found for other examined ENDS flavor categories including menthol/mint, fruit, candy/ desserts/other-sweets, and other flavors, compared to their corresponding non-users.

CONCLUSIONS

Tobacco flavored ENDS use was significantly associated with self-reported COPD. Future studies are needed to confirm the biological and epidemiological association of flavored ENDS use with COPD.

Measurement-Based Care in the Treatment of Adolescents with Substance Use Disorders

Measurement-based care in adolescent substance use is an important element of the evidence-based framework of Screening, Brief Intervention, and Referral to Treatment (SBIRT). Use of a validated measure for detecting substance use, misuse, and substance use disorders is significantly more effective than the use of unvalidated tools or clinician intuition. There are now a variety of established and new validated screening tools that are available for use with adolescents and that capture the range of adolescent substance use behaviors. This area, however, continues to evolve rapidly.

Investigating the Attitudes of Adolescents and Young Adults Towards JUUL: Computational Study Using Twitter Data

Background

Increases in electronic nicotine delivery system (ENDS) use among high school students from 2017 to 2019 appear to be associated with the increasing popularity of the ENDS device JUUL.

Objective

We employed a content analysis approach in conjunction with natural language processing methods using Twitter data to understand salient themes regarding JUUL use on Twitter, sentiment towards JUUL, and underage JUUL use.

Methods

Between July 2018 and August 2019, 11,556 unique tweets containing a JUUL-related keyword were collected. We manually annotated 4000 tweets for JUUL-related themes of use and sentiment. We used 3 machine learning algorithms to classify positive and negative JUUL sentiments as well as underage JUUL mentions.

Results

Of the annotated tweets, 78.80% (3152/4000) contained a specific mention of JUUL. Only 1.43% (45/3152) of tweets mentioned using JUUL as a method of smoking cessation, and only 6.85% (216/3152) of tweets mentioned the potential health effects of JUUL use. Of the machine learning methods used, the random forest classifier was the best performing algorithm among all 3 classification tasks (ie, positive sentiment, negative sentiment, and underage JUUL mentions).

Conclusions

Our findings suggest that a vast majority of Twitter users are not using JUUL to aid in smoking cessation nor do they mention the potential health benefits or detriments of JUUL use. Using machine learning algorithms to identify tweets containing underage JUUL mentions can support the timely surveillance of JUUL habits and opinions, further assisting youth-targeted public health intervention strategies.

E-Cigarettes: The Truth About Vaping

The prevalence of e-cigarette use among youth has risen dramatically over the past several years. Many concerns have been raised by this epidemic, including the increased likelihood that those adolescents who "vape" will also go on to smoke conventional cigarettes and use illicit drugs. Pediatricians are appropriately positioned to discuss vaping with patients and provide further education to families. This article aims to provide clinicians with a better understanding of vaping products and terminology, as well as the prevalence and potential harms of e-cigarette use. [Pediatr Ann. 2020;49(9):e365-e368.].

Injuries and poisonings associated with e-cigarettes and vaping substances, electronic Canadian Hospitals Injury Reporting and Prevention Program, 2011-2019

Electronic cigarettes are devices that deliver nicotine to the user by heating an e-liquid. In Canada, the Tobacco and Vaping Products Act became law on May 23, 2018. The purpose of this study was to describe the cases of injuries and poisonings associated with e-cigarette and vaping substances that presented to Canadian emergency departments within the electronic Canadian Hospitals Injury Reporting and Prevention Program network between 2011 and 2019. A total of 68 cases were retrieved (54.4% males). Of the 68 cases, 8 occurred between 2011 and 2014, while 35 (51.5%) occurred in 2018 or 2019. Ingestions, inhalations and burns were observed.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Impaired lung function following e-cigarette or vaping product use associated lung injury in the first cohort of hospitalized adolescents

BACKGROUND

Beginning June 2019, Children's Wisconsin was the first hospital to identify a cohort of adolescent patients hospitalized with symptoms likely associated with e-cigarette use. Our report adds to the growing literature describing the radiographic, gross and cytopathologic bronchoscopic findings, and short-term lung function outcomes in this cohort of adolescents with e-cigarette or vaping product use associated lung injury (EVALI).

METHODS

We present 15 adolescents hospitalized from June to September, 2019 with confirmed EVALI. We abstracted data from inpatient hospitalization and first outpatient pulmonary clinic visit.

RESULTS

There were 15 patients (11 male, 12 White) with a mean age of 17.1 years. All patients presented with subacute pulmonary, gastrointestinal and constitutional complaints. Diagnostic workup was guided by the Centers for Disease Control criteria for confirmed EVALI case surveillance. Flexible bronchoscopy was performed in 13/15 patients with 10/13 demonstrating gross pathologic abnormalities. Seven of 15 patients required intensive care and 2 met criteria for pediatric Acute Respiratory Distress Syndrome. Patients had dramatic improvement with systemic glucocorticoid therapy and 14/15 were discharged on room air. Eleven patients were seen as outpatients. Despite 11/11 patients reporting resolved or improved symptoms, 7/11 had abnormalities on pulmonary function testing. We initiated inhaled corticosteroids for 5/11 patients and 4/11 patients remained on their corticosteroid wean.

CONCLUSIONS AND RELEVANCE

We report short-term outcomes of the first cohort of adolescent patients hospitalized with EVALI. An association is observed between clinical improvement and treatment with systemic corticosteroids. However, residual airway reactivity or diffusion abnormalities persisted when patients were re-evaluated in the short-term period (mean 4.5 weeks).

The importance of anti-vaping vigilance-EVALI in seven adolescent pediatric patients in Northeast Ohio

As of 18 February 2020, the e-cigarette or vaping product use-associated lung injury (EVALI) epidemic has claimed the lives of 68 patients in the USA with the total number of reported cases standing at 2807 to date. We present the clinical and radiologic findings, course of illness, and treatment of EVALI in seven adolescent patients in Northeast Ohio. Five of our patients required supplemental oxygen with four requiring intensive care unit care for respiratory support during admission. Three patients were treated with systemic steroids while inpatient. Bilateral opacities were seen on radiographic imaging of all seven of our patients. All patients were discharged alive on room air. However, impaired diffusing capacity of the lungs for carbon monoxide (DLCO) with nonobstructive spirometry was seen in patients that were tested postdischarge. This suggests that although recovery from the acute illness process of EVALI is achieved, there may be long-term impact on lung function in these patients. We recommend close follow-up with a pediatric pulmonologist where spirometry and DLCO can be performed.

Review of Health Consequences of Electronic Cigarettes and the Outbreak of Electronic Cigarette, or Vaping, Product Use-Associated Lung Injury

Electronic cigarettes (e-cigarettes) are battery-operated devices to insufflate nicotine or other psychoactive e-liquid aerosols. Despite initial claims of e-cigarettes as a nicotine-cessation device, aggressive marketing of e-cigarettes has led to an explosion in adolescents' and young adults' use over the last few years. Coupled with a lack of adequate investigation and regulation of e-cigarettes, the USA is facing an outbreak of e-cigarette, or vaping, product use-associated lung injury (EVALI) starting in mid-2019. While little long-term health hazard data are available, the components and constituents of e-cigarettes may adversely impact health. Propylene glycol and glycerin are humectants (water-retaining excipients) that generate pulmonary irritants and carcinogenic carbonyl compounds (e.g., formaldehyde, acetaldehyde, and acrolein) when heated in e-cigarettes. Metals contained in heating coils and cartridge casings may leach metals such as aluminum, chromium, iron, lead, manganese, nickel, and tin. Flavoring agents are considered safe for ingestion but lack safety data for inhalational exposures. Diacetyl, a common buttery flavoring agent, has known pulmonary toxicity with inhalational exposures leading to bronchiolitis obliterans. In 2019, clusters of lung injury associated with e-cigarette use were identified in Wisconsin and Illinois. Patients with EVALI present with a constellation of respiratory, gastrointestinal, and constitutional symptoms. Radiographically, patients have bilateral ground glass opacifications. As of February 18, 2020, the Centers for Disease Control has identified 2807 hospitalized patients diagnosed with either "confirmed" or "probable" EVALI in the US. Currently, vitamin E acetate (VEA) used as a diluent in tetrahydrocannabinol vape cartridges is implicated in EVALI. VEA cuts tetrahydrocannabinol oil without changing the appearance or viscosity. When inhaled, pulmonary tissue lacks the mechanism to metabolize and absorb VEA, which may lead to its accumulation. While most EVALI patients were hospitalized, treatment remains largely supportive, and use of corticosteroids has been associated with clinical improvement. The outbreak of EVALI highlights the need for regulation of e-cigarette devices and e-liquids. Clinicians need to be aware of the health hazards of e-cigarettes and be vigilant in asking about vaping.

An Observational Study of Vaping Knowledge and Perceptions in a Sample of U.S. Adults

Background

Vaping is the use of e-cigarettes that contain inhalants such as nicotine, tetrahydrocannabinol, and cannabidiol. Vaping is associated with e-cigarette or vaping product use associated lung injury (EVALI) and is a recognized public health crisis. Despite rising numbers of hospitalizations due to EVALI, public knowledge and perceptions of the dangers of vaping require further investigation.

Objectives

This exploratory study assessed knowledge and perceptions of vaping in U.S. adults.

Methods

This study was approved by an ethical board, and informed consent was obtained from all participants. A cohort of U.S. adults was recruited by shared links on social media. Participants completed an anonymous online survey that contained vaping knowledge and perceptions items. An a priori power analysis was conducted at 95% power and alpha = 0.05. Statistics were calculated using IBM SPSS Statistics Version 26 (IBM Corp., Armonk, NY, USA).

Results

A sample of 413 (N = 413) U.S. adults participated in the survey. The majority of participants (79.18%) were females, and 65.62% were between 18 and 24 years of age. Over half (62.71%) of participants were never asked about vaping use by a clinician at any visit, and 56.51% agreed that vaping can reduce stress. Of all participants, 70.91% agreed that drinking alcohol makes someone more inclined to vape. Significant positive Spearman’s rho correlations were found between vaping and the use of cannabis, cocaine, ecstasy, hallucinogens, and inhalants (p < 0.05).

Conclusions

We found a significant correlation between vaping and drug use. We also found that if the dangers of vaping are discussed by their health care providers, participants are more inclined to quit vaping. Unfortunately, many physicians report that they avoid discussing vaping with their patients due to lack of vaping knowledge. Our results illuminate the communication gap between patients and physicians. All clinicians need to counsel patients on the dangers of vaping, which might help prevent EVALI and related conditions.

E-cigarettes and respiratory health: the latest evidence

The E-cigarette market continues to expand at an alarming rate with thousands of flavours available for purchase and continuously evolving devices. Now that it is a multi-billion dollar industry and one without stringent regulation, there is rising concern over the safety of vaping products. Since June 2019, over 2800 cases of E-cigarette-associated acute lung toxicity have been reported in the USA, over 60 of which resulted in death. Many argue that E-cigarettes offer a safer alternative to smoking, but we are evidently far from fully understanding the potential hazards that they pose to respiratory health. Although the risk of an outbreak in the UK has been considered low due to tighter E-cigarette regulations, we cannot fully eliminate the possibility of similar events occurring in the future. With evidence frequently emerging of the harmful effects of E-cigarettes to pulmonary health, there is an urgent need to define the long-term implications of vaping. Studies show that E-cigarette exposure can disrupt pulmonary homeostasis, with reports of gas exchange disturbance, reduced lung function, increased airway inflammation and oxidative stress, downregulation of immunity, and increased risk of respiratory infection. In this review, the latest research on the effect of E-cigarette use on respiratory health will be presented.

Prevalence of e-cigarette use among tobacco smokers in six states and regions of Myanmar

BACKGROUND

Emergence of electronic cigarettes (e-cigarettes) in the past decade has the potential to undermine the global tobacco control efforts and undo the successes achieved to date. There are also concerns that e-cigarettes may become a gateway for future tobacco use and its use is increasing globally. There is no published evidence on this issue from Myanmar. Hence, we aimed to assess prevalence of e-cigarette use among tobacco smokers and its associated socio-demographic factors in six states and regions of Myanmar.

METHODS

This was a secondary analysis of data collected as part of a programme evaluation conducted by the National Tobacco Control Programme of Myanmar in 2018, which involved sampling 100 smokers from each state/region. We used modified Poisson regression to measure associations.

RESULTS

There were 629 tobacco smokers included in the programme evaluation. Among them, 246 (39.2%, 95% CI: 24.0%-56.7%) smokers reported that they had heard of e-cigarettes and 73 (11.6%, 95% CI: 5.1%-24.3%) reported having ever used e-cigarettes. There was no e-cigarette use among female smokers. The prevalence of e-cigarette use was significantly higher among males, students, young adults aged 18-29 years, heavy smokers (greater than 20 cigarettes per day) and those who lived in the Mandalay region.

CONCLUSION

Our study provides preliminary evidence about e-cigarette use in Myanmar and fills an important knowledge gap. One limitation was small sample size, which is reflected by wide confidence intervals around the estimate. We recommend a national survey to obtain precise and nationally representative information.