Electronic Cigarette and JUUL Use Among Adolescents and Young Adults

Sex-specific alterations in pulmonary metabolic, xenobiotic and lipid signalling pathways after e-cigarette aerosol exposure during adolescence in mice

BACKGROUND

E-cigarette use is now prevalent among adolescents and young adults, raising concerns over potential adverse long-term health effects. Although it is hypothesised that e-cigarettes promote inflammation, studies have yielded conflicting evidence. Our previous work showed that JUUL, a popular e-cigarette brand, elicited minimal lung inflammation but induced significant molecular changes in adult C57BL/6 mice.

METHODS

Now, we have profiled immunological and proteomic changes in the lungs of adolescent male and female BALB/c and C57BL/6 mice exposed to a flavoured JUUL aerosol containing 18 mg/mL of nicotine for 14 consecutive days. We evaluated changes in the immune composition by flow cytometry, gene expression levels by reverse transcription-quantitative PCR and assessed the proteomic profile of the lungs and bronchoalveolar lavage (BAL) by tandem mass tag-labelled mass spectroscopy.

RESULTS

While there were few significant changes in the immune composition of the lungs, proteomic analysis revealed that JUUL exposure caused significant sex-dependent and strain-dependent differences in lung and BAL proteins that are implicated in metabolic pathways, including those related to lipids and atherosclerosis, as well as pathways related to immune function and response to xenobiotics. Notably, these changes were more pronounced in male mice.

CONCLUSIONS

These findings raise the possibility that vaping dysregulates numerous biological responses in lungs that may affect disease risk, disproportionally impacting males and raising significant concerns for the future health of male youth who currently vape.

Health outcomes of electronic cigarettes

ABSTRACT

The usage of electronic cigarettes (e-cigarettes) sparked an outbreak of unidentified vaping-related lung disease in the US during late 2019. With e-cigarettes becoming more and more popular, smokers have more options other than conventional cigarettes. Under these circumstances, a comprehensive evaluation of the general safety of new tobacco and tobacco-related products, represented by e-cigarettes, to human health is necessary. In this review, we summarize the current research on potential negative impacts of e-cigarette exposure on human health. In particular, studies detailing the relationship between e-cigarettes and the digestive system are summarized, with mechanisms mainly including hepatic metabolic dysfunction, impaired gut barrier, and worsened outcomes of inflammatory bowel disease (IBD). Although believed to be safer than traditional cigarettes, e-cigarettes exert adverse effects on systemic health and induce the development of multiple diseases including asthma, cardiovascular disease, and IBD. Moreover, nicotine-containing e-cigarettes have a negative impact on the childhood development and increase the risk of arterial stiffness compared to the non-nicotine e-cigarettes. However, non-nicotine e-cigarette components have detrimental effects including promoting liver damage and metabolic disorders.

A Systematic Literature Review on the Composition, Health Impacts, and Regulatory Dynamics of Vaping

This comprehensive review deals with the multifaceted aspects of electronic cigarettes (e-cigarettes), examining their composition, health implications, regulatory challenges, and market dynamics. E-cigarettes, also known as vaping devices, function by warming a solution of liquid containing flavors, nicotine, and various other compounds to produce an aerosol for users to inhale. This review underscores the evolution and widespread adoption of e-cigarettes since their introduction in 2003, highlighting their appeal as alternatives to traditional tobacco smoking. The essential parts of e-cigarettes are the battery, heating element, e-liquid (or e-juice), and mouthpiece. Propylene glycol and vegetable glycerin are common ingredients in e-liquids, along with nicotine and other flavors. Concerns over the health impacts of e-cigarettes have grown, particularly in light of incidents like the e-cigarette or vaping-associated lung injury outbreak in 2019 linked to vaping-associated lung injuries. Evidence suggests that while e-cigarettes may pose fewer risks than conventional cigarettes, they are not without health consequences, including potential respiratory and cardiovascular effects. Regulatory efforts worldwide have struggled to keep pace with the rapid evolution of e-cigarettes, exacerbated by their diverse flavors and marketing strategies that appeal to youth. The review discusses global regulatory responses, including bans and restrictions, to curb youth uptake and address public health concerns. Furthermore, the rise of a black market for e-cigarettes poses additional challenges to effective regulation and tobacco control efforts. In conclusion, while e-cigarettes offer potential harm reduction benefits for adult smokers seeking alternatives to traditional tobacco products, their widespread availability and evolving landscape necessitate vigilant regulatory oversight to protect public health, especially among youth. Future research should continue to explore the long-term health impacts and efficacy of e-cigarettes as smoking elimination aids, informing evidence-based policies and interventions.

Advancing youth tobacco surveillance with novel methods

Tobacco surveillance in the United States is robust but cannot be quickly modified to capture newly identified tobacco products or behaviors. We present an example of a rapidly deployed nonprobability survey using social media recruitment that collected data on rapidly changing tobacco use behaviors. We recruited 15- to 17-year old current vapers from NY, USA, using targeted social media advertisements to complete the New York Adolescent Vaping Survey (NY AVS), which asked about vaping behaviors not addressed in existing probability surveillance surveys. We used the New York Youth Risk Behavior Survey (NY YRBS) to apply calibration weights to ensure that the distribution of the demographic characteristics accurately reflected the population distribution. We found systematic differences in demographic variable distributions between the probability-based NY YRBS and the convenience sample of the NY AVS that were reconciled in the weighting calibration. We found no statistically significant differences between the NY YRBS and NY AVS estimates after calibration for two outcome variables of interest. Recruiting a sample of adolescents using social media advertising to conduct a rapid survey on vaping provided valuable data that complemented traditional surveillance surveys; this approach could be used to fill future knowledge gaps in youth tobacco surveillance.

Quantification of Free Radicals from Vaping Electronic Cigarettes Containing Nicotine Salt Solutions with Different Organic Acid Types and Concentrations

Electronic (e-) cigarette formulations containing nicotine salts from a range of organic acid conjugates and pH values have dominated the commercial market. The acids in the nicotine salt formulations may alter the redox environment in e-cigarettes, impacting free radical formation in e-cigarette aerosol. Here, the generation of aerosol mass and free radicals from a fourth-generation e-cigarette device was evaluated at 2 wt % nicotine salts (pH 7, 30:70 mixture propylene glycol to vegetable glycerin) across eight organic acids used in e-liquids: benzoic acid (BA), salicylic acid (SLA), lactic acid (LA), levulinic acid (LVA), succinic acid (SA), malic acid (MA), tartaric acid (TA), and citric acid (CA). Furthermore, 2 wt % BA nicotine salts were studied at the following nicotine to acid ratios: 1:2 (pH 4), 1:1 (pH 7), and 2:1 (pH 8), in comparison with freebase nicotine (pH 10). Radical yields were quantified by spin-trapping and electron paramagnetic resonance (EPR) spectroscopy. The EPR spectra of free radicals in the nicotine salt aerosol matched those generated from the Fenton reaction, which are primarily hydroxyl (OH) radicals and other reactive oxygen species (ROS). Although the aerosol mass formation was not significantly different for most of the tested nicotine salts and acid concentrations, notable ROS yields were observed only from BA, CA, and TA under the study conditions. The e-liquids with SLA, LA, LVA, SA, and MA produced less ROS than the 2 wt % freebase nicotine e-liquid, suggesting that organic acids may play dual roles in the production and scavenging of ROS. For BA nicotine salts, it was found that the ROS yield increased with a higher acid concentration (or a lower nicotine to acid ratio). The observation that BA nicotine salts produce the highest ROS yield in aerosol generated from a fourth-generation vape device, which increases with acid concentration, has important implications for ROS-mediated health outcomes that may be relevant to consumers, manufacturers, and regulatory agencies.

An observational human laboratory assessment of nicotine delivery, vaping topography and subjective effects of usual brand electronic cigarette use among young adults

AIMS

To measure nicotine delivery, vaping topography and subjective effects of current generations of disposable, cartridge-based and other types of electronic cigarettes (e-cigarettes) among young adults.

DESIGN, SETTING, PARTICIPANTS

Observational, human laboratory assessment of e-cigarette use in Columbus, Ohio, USA (July 2020 to June 2021). Participants (n = 96, 60.4% female, age mean = 21.7 [standard deviation = 1.7] years, 82.4% white race) were identified via their participation in a cohort study or other convenience sampling and were 18 to 25 years old, vaped ≥4 days/week for ≥4 weeks and used other tobacco products for ≤5 days of past 30 days. Participants completed a pre-vaping questionnaire, vaped their usual brand of e-cigarette ad libitum for 30 min and completed a post-vaping questionnaire.

MEASUREMENTS

Outcome variables included pre- and post-vaping measures of plasma nicotine (t = 0 and t = 30, respectively) and craving and withdrawal symptoms, as well as vaping topography (e.g. flow rate and inter-puff interval), pre-vaping expectancies and post-vaping product appeal. Variables used to characterize the sample included demographics, e-cigarette and other tobacco use history, e-cigarette dependence and e-cigarette device characteristics (e.g. device type, flavor and nicotine form).

FINDINGS

Participants reported moderate nicotine dependence on average via the E-Cigarette Dependence Scale (mean = 6.9 [standard deviation = 4.0]). Following 30 min of ad libitum vaping, participants achieved substantial plasma nicotine boost (mean = 18.8 [standard deviation = 14.5] ng/mL), corresponding with statistically significant decreases in withdrawal symptoms measured via the Minnesota Nicotine Withdrawal Scale (pre-vaping mean = 9.0 [standard deviation = 5.1], post-vaping mean = 4.3 [standard deviation = 3.9]; P-value <0.0001). Pre-vaping, participants reported moderate vaping expectancies (e.g. mean = 2.5 [standard deviation = 1.0] on a scale from 0 to 4 for smell and taste expectancies); post-vaping, participants reported high satisfaction (mean = 4.6 [standard deviation = 1.2] on a scale from 1 to 7) and moderate reward (mean = 2.9 [standard deviation = 1.2]) and respiratory sensations (mean = 3.7 [standard deviation = 1.6]). Nearly half of participants (47.9%) used disposable e-cigarettes, and most used a mint/menthol or fruit flavored (99.0%) and nicotine salt (98.9%) e-liquid.

CONCLUSIONS

Among young adults in the United States, the latest generations of e-cigarettes appear to deliver large quantities of nicotine (similar to cigarettes) and significantly relieve withdrawal symptoms, and they are appealing.

How to Identify e-Cigarette Brands Available in the United States During 2020-2022: Development and Usability Study

BACKGROUND

Prior studies have demonstrated that the e-cigarette market contains a large number of brands. Identifying these existing e-cigarette brands is a key element of market surveillance, which will further assist in policy making and compliance checks.

OBJECTIVE

To facilitate the surveillance of the diverse product landscape in the e-cigarette market, we constructed a semantic database of e-cigarette brands that have appeared in the US market as of 2020-2022.

METHODS

In order to build the brand database, we searched and compiled e-cigarette brands from a comprehensive list of retail channels and sources, including (1) e-liquid and disposable brands sold in web-based stores, (2) e-cigarette brands sold in brick-and-mortar stores and collected by the Nielsen Retail Scanner Data, (3) e-cigarette brands compiled by Wikipedia, (4) self-reported e-cigarette brands from the 2020 International Tobacco Control Four-Country Smoking and Vaping (ITC 4CV) US survey, and (5) e-cigarette brands on Twitter. We also estimated the top 5 e-cigarette brands by sales volume in brick-and-mortar stores, by the frequency and variety of offerings in web-based shops, and by the frequency of self-reported brands from the 2020 ITC 4CV US survey.

RESULTS

As of 2020-2022, a total of 912 e-cigarette brands have been sold by various retail channels. During 2020-2022, the top 5 brands are JUUL, vuse, njoy, blu, and logic in brick-and-mortar stores; blu, king, monster, twist, and air factory for e-liquids in web-based stores; hyde, pod mesh, suorin, vaporlax, and xtra for disposables sold in web-based stores; and smok, aspire, vaporesso, innokin, and eleaf based on self-reported survey data.

CONCLUSIONS

As the US Food and Drug Administration enforces the premarket tobacco market authorization, many e-cigarette brands may become illegal in the US market. In this context, how e-cigarette brands evolve and consolidate in different retail channels will be critical for understanding the regulatory impacts on product availability. Our semantic database of e-cigarette brands can serve as a useful tool to monitor product and marketplace development, conduct compliance checks, assess manufacturers' marketing behaviors, and identify regulatory impacts.

Assessing the public discourse on Twitter: Reactions to the JUUL e-cigarettes ban in the United States

INTRODUCTION

JUUL is a high-nicotine pod-based vaping device that is popular among adolescents and young adults. On 23 June 2022, the US Food and Drug Administration (FDA) denied authorization to market JUUL, and ordered JUUL Labs to remove products from the US market. The next day, a US federal appeals court temporarily suspended the ban. The mixed public discourse surrounding the FDA ban warrants further investigation.

METHODS

This study examined Twitter data to describe public reaction to these announcements. Posts containing terms 'JUUL' and/or '#JUUL' (N=97548 unique tweets) were collected from 23 June to 3 July 2022, from Twitter's Streaming Application Programming Interface (API). After removing retweets, we used an inductive approach to become familiar with the data, generated a codebook, and conducted a content analysis on a random sample of n=4000 tweets.

RESULTS

A total of 2755 (68.9%) tweets discussed JUUL in the context of the FDA ban. News (n=1425/2755; 51.7%) about the JUUL ban, government distrust (n=588; 21.3%), and individual rights (n=253; 9.2%) were the most prevalent themes. Less commonly discussed themes included inconsistencies between policies (n=174; 6.3%), mentions of switching to other products (n=162; 5.9%), smoking cessation (n=99; 3.6%), and craving for JUUL (n=94; 3.4%). Sentiment analysis of JUUL ban-related posts (n=2755) demonstrated that 1989 (72.2%) tweets were categorized as neutral, while anti-ban posts (n=566; 20.5%) were more prevalent than pro-ban posts (n=200; 7.3%).

CONCLUSIONS

Besides straightforward announcements of the JUUL ban and its suspension, Twitter posts discussed government distrust, individual rights, and policy inconsistencies. While most posts conveyed neutral sentiments, anti-ban posts were almost three times more prevalent than pro-ban posts. Our findings suggest that text-based social media platforms like Twitter may be an effective instrument to understand opinions, attitudes, and beliefs regarding the FDA's JUUL ban.

A Deeper Dive into Young Adults' Experiences with E-Cigarettes, E-Cigarette Cessation, and Transitioning to Cigarette Smoking

Introduction: E-cigarette use among young adults is prevalent, with some voicing their desire to quit using e-cigarettes but needing support to do so. Young adults who use e-cigarettes are at risk for progressing to smoking combustible cigarettes, placing them at risk for severe health consequences. Limited research exists describing young adults' lived experiences with using e-cigarettes, e-cigarette cessation, and progression to combustible cigarettes. Methods: Between July and August 2022, nine focus groups were conducted with 33 young adults who either (1) currently used e-cigarettes, (2) formerly used e-cigarettes, or (3) transitioned to cigarettes. Transcripts were coded and themes were identified independently by two research team members while a third researcher reviewed the coding and themes. Results: Participants described social influences, stress, and curiosity as primary reasons why they initiated e-cigarette use. The most reported negative experiences or consequences associated with e-cigarettes include the health effects, addiction, and financial costs. Participants who transitioned to cigarettes reported social influences, a desire to reduce or quit using e-cigarettes by replacing them with cigarettes, curiosity, and stress as the primary reasons for this progression to combustible cigarettes. Participants described barriers to quitting e-cigarettes, including social influences, withdrawal, and easy access to e-cigarettes, as well as facilitators of quitting, such as social support, change in environment, and finding healthier ways to manage stress. Conclusions: This qualitative work provides an in-depth look into factors that may be helpful in the development of prevention and intervention programs for both e-cigarette and combustible cigarette use in young individuals.

Sociodemographic differences in use of nicotine, cannabis, and non-nicotine E-cigarette devices

BACKGROUND

Sociodemographic differences in e-cigarette use have been documented; however, disparities in use of specific e-cigarette types with various ingredients have yet to be thoroughly investigated. This study examines ever- and past-30-day-use of nicotine, cannabis, and non-nicotine e-cigarette device types by sex, sexual orientation, race/ethnicity, and financial comfort.

METHODS

Data were drawn from a 2021 national cross-sectional survey of adolescents, young adults, and adults (N = 6131, ages 13-40 years old). Participants reported ever and past-30-day-use of (1) disposable nicotine e-cigarettes, (2) pod/cartridge-based nicotine e-cigarettes, (3) "other" nicotine e-cigarettes, (4) non-nicotine e-cigarettes, (5) e-cigarettes with THC, and (6) e-cigarettes with CBD. We constructed summary tables for each e-cigarette device type in which percentages of ever and past-30-day-use were calculated by birth year category and sociodemographic variables: (a) sex, (b) sexual orientation, (c) race/ethnicity, and (d) financial comfort.

RESULTS

Females born between 1996 and 2008 reported higher rates of past-30-day disposable e-cigarette use relative to males (females 26.4%; males 22.4%). Compared to their heterosexual counterparts, LGBTQ+ participants reported higher overall rates of past-30-day-use for disposable (LGBTQ+ 27.9%; Heterosexual 23.8%), THC (LGBTQ+ 30.8%; Heterosexual 24.1%), and CBD e-cigarettes (LGBTQ+ 20.0%; Heterosexual 16.9%). Hispanic/Latino participants generally reported higher rates of past-30-day-use across device types relative to those identifying as Black or White non-Hispanic, particularly disposable nicotine e-cigarettes.

CONCLUSIONS

Findings highlight sociodemographic disparities in e-cigarette use, though differences varied based on e-cigarette device type and participant birth year category. Tailored preventive efforts may be necessary to mitigate e-cigarette use among populations at highest risk.

Actual and perceived E-cigarettes behaviors among a national sample of U.S. college students

Objective: Electronic cigarette use represents an important college health concern. This investigation assessed demographic and behavioral correlates associated with actual and perceived e-cigarette use among a national sample of American college students. Methods: Respondents (n = 19,861) comprised college students from over 40 distinct American higher education institutions. Multivariable logistic regression assessed whether (1) alcohol, tobacco or marijuana use were associated with e-cigarette use; (2) perceived peer use of alcohol, tobacco or marijuana were associated with perceived e-cigarette use. Results: Approximately 5% of survey respondents self-reported using e-cigarettes within the past month. More than 7 out of every 10 respondents, however, thought the 'typical student' was an e-cigarette user. As perceptions of typical student substance use increased, respondents were far more likely to contend the typical student used e-cigarettes. Discussion: In addition to adopting smoke-free campus policies, university officials should disseminate accurate information regarding e-cigarette behaviors of students.

Patterns of Daily Cigarette and E-cigarette Use among United States Youth and Young Adults: Insights from the Truth Longitudinal Cohort between 2018 and 2019

Purpose

Temporal patterns of daily tobacco product use among ever users from the Truth Longitudinal Cohort (TLC) between 2018 and 2019 were explored.

Methods

The sample (N = 5274) includes individuals (15-36 years), residing in the United States, who had ever used any tobacco product at Wave 7 (February - May 2018) and provided tobacco use information at Wave 9 (September - December 2019).

Results

There was a nonsignificant 1.1 percentage point increase in daily tobacco use (on at least 25 of the past 30 days), from 14.6% (95% CI: 12.8, 16.6) to 15.7% (95% CI: 13.8, 17.7). Tobacco product use remained stable over time, as 65.3% (95% CI: 56.4, 73.3) of daily cigarette smokers, 57.0% (95% CI: 43.6, 69.4) of daily e-cigarette vapers, and 8.5% (95% CI: 2.0, 29.3) of daily dual users stayed with their primary tobacco product. There was also some evidence of switching, as 7.5% (95% CI: 3.7, 14.8) of daily cigarette smokers became daily e-cigarette vapers and 2.3% (95% CI: 0.7, 6.8) of daily e-cigarette vapers became daily cigarette smokers.

Discussion

Although most daily tobacco users were likely to continue using their primary product, some daily users transitioned to daily use of other products - suggesting that policies and public education focused on reducing overall nicotine use are essential for addressing the nicotine epidemic among young people.

Informing the development of interventions for e-cigarette use and prevention of transition to cigarette smoking in young adults: A qualitative study

E-cigarette use in young individuals may increase risk for cigarette smoking initiation. Over half of young adults who use e-cigarettes voiced their desire to quit e-cigarettes. Mobile-based interventions may allow for an easy-to-use platform to engage young adults in cessation services and reduce risk for cigarette uptake. To inform development of such programs, this study sought to gather information about what young adults want to see included in e-cigarette cessation interventions that also target future smoking risk. Nine online focus groups (n = 33) were conducted in July and August 2022 with young adults who either (1) currently used e-cigarettes, (2) formerly used e-cigarettes, or (3) initiated nicotine use with e-cigarettes but subsequently smoked cigarettes (dual use). Two research team members independently coded the transcripts and identified themes. A third researcher independently reviewed the coding and thematic analysis. Participants believed that mobile-based interventions should include peer support, ways to track cessation progress, education about the harms of e-cigarettes, gamification, and incentivization. They also believed that to prevent future cigarette smoking, interventions need to include education about the harms of smoking, teach refusal skills for offers to smoke, and incorporate personal anecdotes from former smokers. To increase their readiness, motivation, and self-efficacy to quit, participants who continue to use e-cigarettes reported needing effective substitutions to replace e-cigarettes, barriers to hinder their access to e-cigarettes, and social support. Findings from this study may be useful to incorporate when developing interventions designed to reduce e-cigarette use and risk of progression to smoking for young adults.

Associations between use of specific social media sites and electronic cigarette use among college students

OBJECTIVE

To examine dose-response associations between use of specific social media sites and the use of electronic cigarettes (e-cigarettes) and traditional cigarettes.

METHODS

This was a cross-sectional study of 298 first-year college students enrolled in the fall 2019 semester at a large state university. Heckman selection and Probit model were used to estimate associations between use of specific social media sites and e-cigarette/traditional cigarette use.

RESULTS

Each additional hour per day spent on Snapchat was associated with a 4.61% increase in the probability of lifetime e-cigarette use. In addition, among current e-cigarette users, more time spent on Snapchat was associated with more frequent e-cigarette use (marginal effects: 0.13, p = 0.001). Facebook, Twitter, Snapchat and Instagram were not associated with traditional cigarette smoking.

CONCLUSION

Snapchat was the only major social media platform associated with both lifetime and current e-cigarette use.

Twitter Sentiment About the US Federal Tobacco 21 Law: Mixed Methods Analysis

BACKGROUND

On December 20, 2019, the US "Tobacco 21" law raised the minimum legal sales age of tobacco products to 21 years. Initial research suggests that misinformation about Tobacco 21 circulated via news sources on Twitter and that sentiment about the law was associated with particular types of tobacco products and included discussions about other age-related behaviors. However, underlying themes about this sentiment as well as temporal trends leading up to enactment of the law have not been explored.

OBJECTIVE

This study sought to examine (1) sentiment (pro-, anti-, and neutral policy) about Tobacco 21 on Twitter and (2) volume patterns (number of tweets) of Twitter discussions leading up to the enactment of the federal law.

METHODS

We collected tweets related to Tobacco 21 posted between September 4, 2019, and December 31, 2019. A 2% subsample of tweets (4628/231,447) was annotated by 2 experienced, trained coders for policy-related information and sentiment. To do this, a codebook was developed using an inductive procedure that outlined the operational definitions and examples for the human coders to annotate sentiment (pro-, anti-, and neutral policy). Following the annotation of the data, the researchers used a thematic analysis to determine emergent themes per sentiment category. The data were then annotated again to capture frequencies of emergent themes. Concurrently, we examined trends in the volume of Tobacco 21-related tweets (weekly rhythms and total number of tweets over the time data were collected) and analyzed the qualitative discussions occurring at those peak times.

RESULTS

The most prevalent category of tweets related to Tobacco 21 was neutral policy (514/1113, 46.2%), followed by antipolicy (432/1113, 38.8%); 167 of 1113 (15%) were propolicy or supportive of the law. Key themes identified among neutral tweets were news reports and discussion of political figures, parties, or government involvement in general. Most discussions were generated from news sources and surfaced in the final days before enactment. Tweets opposing Tobacco 21 mentioned that the law was unfair to young audiences who were addicted to nicotine and were skeptical of the law's efficacy and importance. Methods used to evade the law were found to be represented in both neutral and antipolicy tweets. Propolicy tweets focused on the protection of youth and described the law as a sensible regulatory approach rather than a complete ban of all products or flavored products. Four spikes in daily volume were noted, 2 of which corresponded with political speeches and 2 with the preparation and passage of the legislation.

CONCLUSIONS

Understanding themes of public sentiment-as well as when Twitter activity is most active-will help public health professionals to optimize health promotion activities to increase community readiness and respond to enforcement needs including education for retailers and the general public.

E-cigarettes may serve as a gateway to conventional cigarettes and other addictive drugs

Electronic cigarettes (e-cigarettes) are devices that allow the user to inhale nicotine in a vapor, and are primarily marketed as a means of quitting smoking and a less harmful replacement for traditional cigarette smoking. However, further research is needed to determine if vaping nicotine via e-cigarettes can be effective. Conversely, nicotine has been considered a gateway drug to alcohol and other addictive drugs and e-cigarettes containing nicotine may have the same effects. Previous reports have shown that e-cigarette use may open the gate for the use of other drugs including conventional cigarettes, cannabis, opioids, etc. The increasing prevalence of e-cigarettes, particularly among youth and adolescents in the last decade have led to an increase in the dual use of e-cigarettes with alcohol, cannabis, and other illicit drug use like heroin and 3-4-methylenedioxymethamphetamine (MDMA). The advent of e-cigarettes as a device to self-administer addictive agents such as cocaine and synthetic cathinones may bring about additional adverse health effects associated with their concurrent use. This review aims to briefly describe e-cigarettes and their different generations, and their co-use with other addictive drugs as well as the use of the device as a tool to self-administer addictive drugs, such as cocaine, etc.

Latent Classes of Tobacco and Cannabis Use among Youth and Young Adults in the United States

Background: Research characterizing patterns of tobacco and cannabis use by product type and route of administration among youth and young adults (YAs) is limited. Methods: We conducted latent class analysis of tobacco and cannabis use (i.e., cigarettes, electronic nicotine delivery systems (ENDS), cigars, blunts, cannabis vaping, and other cannabis use (without blunting/vaping)) among youth (ages 15-17) and YAs (ages 18-24) who used at least one product in the past 30 days, using data from the Population Assessment of Tobacco and Health Study (Wave 4, 2016-2017). We used multinomial logistic regression models to examine associations between sociodemographic characteristics and use classes. Results: The latent use classes for youth included cigarettes (2.5%), ENDS (2.6%), blunts (2.5%), other cannabis (6.3%), ENDS + cannabis vaping (2.7%), and cigarettes + cigars + other cannabis (1.5%), while the latent use classes for YAs included cigarettes (11.7%), ENDS (3.9%), blunts (5.3%), other cannabis (7.0%), cigarettes + cigars (8.2%), and cigarettes + ENDS + cannabis vaping (4.9%). We compared use classes to never/former use for youth (82.0%) and YAs (59.0%) and found that they differed by each sociodemographic characteristic. For example, non-Hispanic Black YAs had higher odds of cigarettes + cigar use compared to non-Hispanic White YAs, whereas racial/ethnic minority youth and YAs had lower odds of other dual/poly use groups compared to their non-Hispanic White counterparts. Conclusions: We observed differences in use classes by sociodemographic characteristics for youth and YAs. Health professionals must consider tobacco and cannabis use patterns when implementing prevention and cessation interventions.

Marijuana use behaviors on Texas college campuses

There is limited contemporary research examining marijuana use behaviors that occur on college campuses.

PURPOSE

This study aimed to determine: (1) What is the prevalence of marijuana use on college campuses, (2) where are students commonly using marijuana on college campuses, (3) what are the sociodemographic characteristics of students most likely to use marijuana on a college campus, and (4) how do these findings vary between modes of marijuana use (i.e., vaped versus another mode)?

METHODS

Participants were 14,005 college students (aged 18-25) enrolled in 19 Texas colleges during spring 2022 (Mean age = 20.16; 65.81% female; 30.85% non-Hispanic white, 42.08% Hispanic/Latino, 27.07% another race/ethnicity; 75.81% heterosexual).

RESULTS

Nearly 40% of students ever used marijuana and of these students, over 26% ever used marijuana on their college campus. Although the most common mode for marijuana use was smoking, the majority of students that used marijuana on a college campus reported vaping marijuana (64.89%). Students that ever vaped marijuana on campus were 2.35 times more likely than those that used marijuana via other modes to use marijuana in a public location on campus (i.e., not in a dormitory).

CONCLUSIONS

Findings indicate that marijuana use on college campuses is common and suggest that the ability to vape marijuana may increase marijuana use on college campuses, including in public locations such as classrooms and libraries. College campuses may consider increasing anti-marijuana enforcement efforts, especially those aimed at decreasing electronic vaping device use in general, in order to prevent and decrease marijuana use.

Risk and Protective Factors for Vaping and Smoking Among High School Students in Maine

INTRODUCTION

Vaping rates are rising among adolescents across the country, and smoking rates remain high. Understanding risk and protective factors associated with vaping and smoking can guide public health interventions. This study examined risk and protective factors associated with vaping and smoking among high school students in Maine.

METHODS

We used 2019 Maine Integrated Youth Health Survey (MIYHS) data to examine risk and protective factors for vaping and smoking among Maine high school students. Our analytic sample consisted of 17,651 Maine high school students. In addition to bivariate analyses, we used unadjusted and adjusted logistic regression models to assess risk and protective factors.

RESULTS

Factors with the greatest effect on students' likelihood to vape, smoke, or do both were parental attitude toward adolescent smoking and depressive symptoms. Students who reported their parents feel it is a little wrong or not wrong at all if they smoked had 4.9 times higher adjusted odds of smoking and 4.6 times higher adjusted odds of vaping and smoking compared with students who said their parents feel it would be wrong or very wrong if they smoked. Students who reported depressive symptoms had 2.1 times higher adjusted odds of vaping, 2.7 times higher adjusted odds of smoking, and 3.0 times higher adjusted odds of vaping and smoking compared with students who did not report depressive symptoms.

CONCLUSION

Understanding risk and protective factors for smoking and vaping among high school students can help tailor adolescent-focused vaping and smoking public health interventions to increase effectiveness.

Perceived Sensory Characteristics of Blended and Ambiguous "Concept" Flavors Among Adolescent and Young Adult E-cigarette Users

INTRODUCTION

Flavors with names describing blended tastes/sensations or with ambiguous terminology ("concept flavors") are available on the e-cigarette market.

AIMS AND METHODS

This study investigates adolescent and young adult use and sensory perceptions of blended and concept flavors. Current e-cigarette users aged 15-24 years (N = 2281) completed an online convenience sample survey (October 20-November 23, 2020) and rated the sensory attributes (fruity, cooling, sweet, and minty) of their current flavor(s) using nine-point scales. T-tests compared mean sensory perception scores within and between flavors. To compare concept flavors to blends, reference categories used the average of blends with relevant descriptors: fruit (Banana Ice, Iced Mango, Melon Ice, Cool Cucumber); cooling (Banana Ice, Iced Mango, Melon Ice, Blue B Ice, Cool Cucumber, Lush Ice, and Menthol Purple); sweet (Vivid Vanilla) and mint (Mint-sation).

RESULTS

Most respondents had used at least one product with blended descriptors (74.8%) or concept flavor (57.9%) in the past 30 days. All flavors had high perceived strength for at least two sensory attributes. Mint taste was not perceived to be a strong sensory characteristic for all but two flavors (Mint-sation and Winter) in the study. The most commonly used flavors used blended descriptors (Iced Mango was used by 30.2% of the sample; Banana Ice: 26.2%; Lush Ice: 23.8%; Melon Ice: 22.9%). Some concept flavors did not significantly differ from flavor blend reference categories for strength of: fruit taste (Bahama Mama and Tropic); cooling sensation (Marigold, Island Breeze, Winter); sweet taste (Bahama Mama, Honeymoon, Island Breeze, Island Cream, Meteor Milk, OMG, Royal Dagger and Tropic); and mint taste (Winter).

CONCLUSIONS

Blended and concept flavors are used by most young e-cigarette users, who describe these products as fruity, sweet, and cooling. A variety of flavored products with high youth appeal are available in the U.S. market.

IMPLICATIONS

This study of adolescent and young adult e-cigarette users finds evidence of the popularity of e-cigarette flavors combining a cooling sensation with fruity and sweet flavorings. Some products with this flavor profile do not use characterizing descriptors. Findings inform public health interventions intended to reduce e-cigarette use in young people.

Chronic low-level JUUL aerosol exposure causes pulmonary immunologic, transcriptomic, and proteomic changes

E-cigarettes currently divide public opinion, with some considering them a useful tool for smoking cessation and while others are concerned with potentially adverse health consequences. However, it may take decades to fully understand the effects of e-cigarette use in humans given their relative newness on the market. This highlights the need for comprehensive preclinical studies investigating the effects of e-cigarette exposure on health outcomes. Here, we investigated the impact of chronic, low-level JUUL aerosol exposure on multiple lung outcomes. JUUL is a brand of e-cigarettes popular with youth and young adults. To replicate human exposures, 8- to 12-week-old male and female C57BL/6J mice were exposed to commercially available JUUL products (containing 59 mg/ml nicotine). Mice were exposed to room air, PG/VG, or JUUL daily for 4 weeks. After the exposure period, inflammatory markers were assessed via qRT-PCR, multiplex cytokine assays, and differential cell count. Proteomic and transcriptomic analyses were also performed on samples isolated from the lavage of the lungs; this included unbiased analysis of proteins contained within extracellular vesicles (EVs). Mice exposed to JUUL aerosols for 4 weeks had significantly increased neutrophil and lymphocyte populations in the BAL and some changes in cytokine mRNA expression. However, BAL cytokines did not change. Proteomic and transcriptomic analysis revealed significant changes in numerous biological pathways including neutrophil degranulation, PPAR signaling, and xenobiotic metabolism. Thus, e-cigarettes are not inert and can cause significant cellular and molecular changes in the lungs.

JUUL preference among Korean adult tobacco users and its effect on attempts to quit tobacco: A follow-up survey four months post JUUL launch

INTRODUCTION

This study examined the various factors in the selection of JUUL (and/or), a pod-mod type electronic cigarette (EC), and the changes in EC patterns before and after the JUUL debut on 24 May 2019, using follow-up survey data of adult tobacco users in South Korea.

METHODS

This study examined transition outcomes among tobacco users and factors associated with future JUUL use. Convenience sample data were collected from adult tobacco users in South Korea, from March-April 2019 (baseline, n=2173) to September 2019 (follow-up, n=779). Results were obtained from the 779 respondents in the follow-up survey, and user data of one or more tobacco products were analyzed. The changes in the proportion of EC and JUUL use during this period were calculated, and multivariate logistic regression analysis was conducted to investigate the selection factors of JUUL.

RESULTS

Four months after the JUUL launch, the proportion of current EC and JUUL users among the whole sample increased by 10.3% (42.6-52.9%, p<0.001) and 17.7 % (4.0-21.7%, p<0.001), respectively, while the proportion of triple users doubled (18.7% vs 37.5%, p<0.001). Among current EC users, the percentage of quitting EC within one month decreased from 18.7% to 8.7%; this change was more pronounced among concurrent JUUL users than non-JUUL users (p<0.001). In the multivariate logistic analysis with adjustment for possible confounders, JUUL use was significantly associated with male sex, young and middle age, and metropolitan residency status at the baseline survey.

CONCLUSIONS

After the launch of JUUL in South Korea, EC users, including JUUL and triple users, increased significantly, but the intention to stop EC decreased significantly. Given the serious interests of the tobacco industry in these products, additional regulation is warranted.

Juul use among emerging adults transitioning from high school to college

Objective: Assess the prevalence, perceptions, sociodemographic/personal factors that influence Juul use among incoming freshmen.Participants: Incoming undergraduate students (N = 1,706) attending a public university in the southeastern U.S.Methods: Cross-sectional survey administered August 2018. Bivariate relationships assessed using chi-square test of association. Multinomial logistic regression to determine factors associated with Juul use status.Results: 41% had ever used Juul, 24% had used within the past month. Among current users, one-third had used 20-30 days. Risk factors for current use: heterosexual orientation (relative to other sexual orientation) AOR = 2.16, 95% CI: 1.20-3.91), those who planned to join sorority/fraternity (relative to those who did not plan to; AOR = 2.15, 95% CI: 1.59-2.90), current smokers (relative to nonsmokers; AOR = 24.39, 95% CI: 7.52-76.92), current marijuana users (compared with nonusers of marijuana; AOR = 6.45, 95% CI: 3.92-10.64) and alcohol users (compared with nondrinkers; AOR = 7.81, 95% CI: 5.75-10.54).Conclusion: Prevention and treatment efforts are needed for emerging adults transitioning to college.

How Age and E-cigarette Use Status Interact to Influence E-cigarette Ad Perceptions

Background: The prevalence of e-cigarette use among young people remains high. Young people are susceptible to e-cigarette advertising, although potential heterogeneity in perceptions of e-cigarette ads with respect to age and e-cigarette use history remains unexplored. We aimed to assess differences in perceptions of e-cigarette ads and product use intention, by age and e-cigarette use status. Methods: Participants from an online convenience sample (N = 497, Mage=31.9) viewed two randomly selected e-cigarette ads and reported their perceptions of the ads and product use intention. We used mixed effects linear regression models to estimate associations between age group (18-20 years, 21-25 years, 26+ years), e-cigarette use status (never, former, and current use), and their interaction effects, on outcomes related to perceptions of ads and use intention. Models controlled for demographics and other tobacco use. Results: Current e-cigarette users (vs. never users) and participants who were 26+ years old (vs. 18-20 years old) had greater liking of the ads, perceived ad relevance, and perceived ad effectiveness. Among current e-cigarette users, participants who were 26+ years old (vs. 18-20 years old) had lower use intention. Conclusion: The effect of e-cigarette ad exposures on perceptions of the ad and use intention is heterogeneous with respect to age group and e-cigarette use history. While ads appealed more to adults who were 26+ years old across e-cigarette use groups, current e-cigarette users who were 18-20 years old demonstrated high use intention following ad exposure, suggesting a need for marketing interventions to mitigate continued e-cigarette use among young people.

E-cigarette aerosol impairs male mouse skeletal muscle force development and prevents recovery from injury

To date, there has been a lag between the rise in E-cigarette use and an understanding of the long-term health effects. Inhalation of E-cigarette aerosol delivers high doses of nicotine, raises systemic cytokine levels, and compromises cardiopulmonary function. The consequences for muscle function have not been thoroughly investigated. The present study tests the hypothesis that exposure to nicotine-containing aerosol impairs locomotor muscle function, limits exercise tolerance, and interferes with muscle repair in male mice. Nicotine-containing aerosol reduced the maximal force produced by the extensor digitorum longus (EDL) by 30%-40% and, the speed achieved in treadmill running by 8%. Nicotine aerosol exposure also decreased adrenal and increased plasma epinephrine and norepinephrine levels, and these changes in catecholamines manifested as increased muscle and liver glycogen stores. In nicotine aerosol exposed mice, muscle regenerating from overuse injury only recovered force to 80% of noninjured levels. However, the structure of neuromuscular junctions (NMJs) was not affected by e-cigarette aerosols. Interestingly, the vehicle used to dissolve nicotine in these vaping devices, polyethylene glycol (PG) and vegetable glycerin (VG), decreased running speed by 11% and prevented full recovery from a lengthening contraction protocol (LCP) injury. In both types of aerosol exposures, cardiac left ventricular systolic function was preserved, but left ventricular myocardial relaxation was altered. These data suggest that E-cigarette use may have a negative impact on muscle force and regeneration due to compromised glucose metabolism and contractile function in male mice.NEW & NOTEWORTHY In male mice, nicotine-containing E-cigarette aerosol compromises muscle contractile function, regeneration from injury, and whole body running speeds. The vehicle used to deliver nicotine, propylene glycol, and vegetable glycerin, also reduces running speed and impairs the restoration of muscle function in injured muscle. However, the predominant effects of nicotine in this inhaled aerosol are evident in altered catecholamine levels, increased glycogen content, decreased running capacity, and impaired recovery of force following an overuse injury.

Changes in Availability of ENDS: 2019-2020, U.S

INTRODUCTION

Events during 2019 and 2020, such as the outbreak of e-cigarette, or vaping, product use‒associated lung injury; manufacturer product withdrawals; federal regulations; and coronavirus disease 2019, potentially affected the retail availability of ENDS in the U.S. Measuring changes in ENDS availability informs the understanding of the ENDS marketplace and contextualizes sales trends.

METHODS

Joinpoint regression was used to estimate slope changes in the number of available ENDS in 2019 and 2020 and considered correspondence with tobacco marketplace events. Availability, the weekly number of unique universal product codes with nonzero sales, was derived from NielsenIQ scanner data. U.S. ENDS availability was modeled overall and by subproduct and flavor category within subproduct: mint, menthol, tobacco flavored, and undetermined.

RESULTS

ENDS availability increased by 66% from January 2019 to December 2020. Availability decreased by 43% among prefilled cartridges and increased by 511% among disposables, both led by flavored varieties. During January 2020-February 2020, prefilled cartridge availability decreased by 23.71 universal product codes per week. During July 2020-August 2020, disposable availability increased by 27.90 universal product codes per week, led by flavored products.

CONCLUSIONS

ENDS availability increased during 2019 through 2020, led by a rise in flavored disposables. Multiple slope changes in ENDS availability occurred, many coinciding with tobacco marketplace events. The slope of ENDS explicitly prioritized for federal enforcement (i.e., flavored prefilled cartridges) notably decreased in early 2020 and, soon thereafter, the slope of ENDS not explicitly prioritized for enforcement (e.g., flavored disposables) notably increased, suggesting an association with U.S. Food and Drug Administration's prioritized enforcement guidance.

The Influence of COVID-19 Pandemic on the Frequent Use of E-Cigarettes and Its Association with Substance Use and Mental Health Symptoms

BACKGROUND

Although several studies examined the association between e-cigarettes, substance use, and mental health conditions, there is limited research on whether COVID-19-related stress and health outcomes, mental health symptoms, and substance use differ by the frequency of e-cigarette use during the COVID-19 pandemic. We assessed the association of past 30-day frequent use of e-cigarettes with alcohol, cannabis, anxiety/depression, and COVID-19 impact.

METHODS

We conducted a national online cross-sectional survey among a random sample of US adults aged 18 years or older (N = 5065) between 13 May 2021, and 9 January 2022. A multinomial logistic regression analysis was performed to assess the study aims.

RESULTS

Of the participants, 7.17% reported once to several times per month (OSTPM), 6.95% reported once to several times per week (OSTPW), and 6.57% reported every day to several times per day (ESTPD) use of e-cigarettes in the past month. Alcohol and cannabis use ESTPD and once to several times per week/month (OSTPW/M) were associated with a higher likelihood of e-cigarette use ESTPD and OSTPW/M, respectively. Anxiety/depression was associated with e-cigarette use ESTPD and OSTPW. Individuals who considered social distancing to be stressful were more likely to use e-cigarettes ESTPD and OSTPW/M compared to those that considered social distancing as not stressful.

CONCLUSION

Individuals who engaged in the frequent use of alcohol or cannabis, had depression/anxiety, and considered social distancing to be stressful were more likely to engage in frequent e-cigarette use. Improving efforts geared toward reducing the use of substances may help decrease the health risks associated with e-cigarette use.

Association between Harmful and Addictive Perceptions of E-Cigarettes and E-Cigarette Use among Adolescents and Youth-A Systematic Review and Meta-Analysis

BACKGROUND

Recognising the association between the perceived risks of e-cigarettes and e-cigarette usage among youth is critical for planning effective prevention and intervention initiatives; thus, a systematic review and meta-analysis were performed.

METHODS

Fourteen databases were searched for eligible studies from the Inception of database until March 2022 to examine the effect estimates of the association between perceptions of harmfulness and addictiveness and overall e-cigarette usage among adolescents and youth.

RESULTS

The meta-analysis showed that in comparison to non-users, young people who were ever e-cigarette users were two times more likely to disagree that e-cigarettes are harmful (OR: 2.20, 95% CI: 1.41-3.43) and perceived e-cigarettes as less harmful than tobacco cigarettes (OR: 2.01, 95% CI 1.47-2.75). Youths who were ever e-cigarette users were also 2.3 and 1.8 times more likely to perceive e-cigarettes as less addictive (OR: 2.28, 95% CI: 1.81-2.88) or perceive e-cigarettes as more addictive (OR: 1.82, 95% CI: 1.22-2.73) than tobacco cigarettes, as compared with non-users. The subgroup analysis reported that adolescents were more likely to believe that e-cigarettes are less harmful than tobacco cigarettes, while youth users perceived otherwise.

CONCLUSION

the risk perceptions of e-cigarettes are associated with e-cigarette use among adolescents and youth and could be the focus of health promotion to prevent and curb the uptake of e-cigarettes among young people.

Review of Use Prevalence, Susceptibility, Advertisement Exposure, and Access to Electronic Nicotine Delivery Systems among Minorities and Low-Income Populations in the United States

Increased use of electronic nicotine delivery systems (ENDS) and improper disposal after use pose a public health and an environmental justice (EJ) concern if use prevalence is disproportionately high among minorities and people of low socioeconomic status (SES) (broadly termed "EJ populations" for the purposes of this review). This review synthesizes literature on demographic patterns of use prevalence, susceptibility, advertisement exposure, and access to ENDS, and extrapolates environmental tobacco exposure (ETE) from ENDS among EJ populations. Seven electronic databases were searched using ENDS-related terms. We included studies published between 2017 and May 2020 that described ENDS use prevalence, susceptibility to ENDS use, advertisement exposure, and access to ENDS by race, ethnicity, or SES. Data synthesis was based on the assumptions that ETE increases with high use prevalence, susceptibility may influence future use, and advertisement exposure and access may impact demographic differences in use. We identified 32 studies describing use prevalence, susceptibility, advertisement exposure, or access to vape shops and other tobacco retail outlets by race/ethnicity or SES. We found higher prevalence of ENDS use among non-Hispanic Whites and inconclusive use patterns by SES. Patterns of susceptibility to use, advertisement exposure, and access were also mixed, with slightly higher outcomes observed among low SES youth. However, the evidence base on advertisement exposure was limited, with limited generalizability. Our findings indicate low prevalence of ENDS use among EJ populations. While this suggests low potential ETE among these groups, mixed outcomes on susceptibility, advertisement exposure, and access to ENDS among low SES groups may affect future ENDS use and ETE. Educational campaigns that discourage ENDS uptake should target EJ youth. Initiatives aimed at managing vape shop presence in EJ communities and monitoring targeted advertisement are also needed.

Association between E-Cigarette Advertising Exposure and Use of E-Cigarettes among a Cohort of U.S. Youth and Young Adults

Youth and young adult (YYA) use of e-cigarettes increased rapidly between 2010 and 2019 in the United States, during which exposure to e-cigarette advertising was also increased. We aimed to examine whether exposure to e-cigarette advertising among YYAs may lead to subsequent e-cigarette use. A cohort of 3886 YYAs ages 13-24 was recruited from two survey panels in 2018 and followed up until 2019. Survey data were collected online and by telephone. The primary outcome was past 30-day use of e-cigarettes at the follow-up survey. Among 2304 YYAs who retained at the follow-up survey and were not past 30-day e-cigarette users at baseline, both youth and young adults exposed to e-cigarette advertising at baseline had elevated odds of past 30-day e-cigarette use at follow-up (Youth adjusted odds ratio (aOR): 2.77, 95% CI: 1.23, 6.24; Young adults aOR: 2.34, 95% CI: 1.08, 5.11) compared with those not reporting baseline advertising exposure. The majority of YYAs reported exposure to e-cigarette advertising at baseline (Youth: 63.7%, 95% CI: 59.8, 67.4; Young adults: 58.3%, 95% CI: 53.6, 62.8). Our findings suggest that exposure to e-cigarette advertising was associated with an increase in subsequent past 30-day use of e-cigarettes among YYAs. Restricting advertising targeted at YYAs may reduce the likelihood of e-cigarette use among YYAs.

Assessing the Testability of the Multi-Theory Model (MTM) in Predicting Vaping Quitting Behavior among Young Adults in the United States: A Cross-Sectional Survey

PURPOSE

Given the increased exposure to e-cigarettes and nicotine among young adults, difficulty in quitting vaping is likely, which supports the need for effective behavioral interventions. Therefore, this cross-sectional study aims to assess the testability of the contemporary multi-theory model of health behavior change in predicting the vaping quitting behavior among young adults in the United States.

METHODS

A nationally representative sample of 619 young adults engaged in vaping behavior and aged 18-24 years was recruited to complete a 49-item web-based survey. A structural equation model was used to test relationships between MTM constructs. Hierarchical multiple regression was utilized to predict the variance in the initiation and sustenance of vaping quitting behavior by predictor variables, such as demographic characteristics, history of behaviors, and MTM constructs.

RESULTS

Of 619 respondents, over 75% were White and nearly 70% had educational attainment equal to high school or some college. In total, 62% of respondents were using nicotine, followed by 33.3% were using cannabis. About 80% of the respondents reported being engaged in drinking alcohol, and nearly 45% were engaged in cigarette smoking. The predictive effect of all MTM constructs on vaping quitting initiation (adjusted R2 = 0.417, F (23, 595) = 20.215, p < 0.001) and sustenance (adjusted R2 = 0.366, F (23, 595) = 16.533, p < 0.001) was statistically significant.

CONCLUSIONS

The findings of this study point to the usability and applicability of MTM in operationalizing and developing vaping quitting behavior interventions targeting young adults.

The Australia Smoking and Vaping Model: The Potential Impact of Increasing Access to Nicotine Vaping Products

BACKGROUND

We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia.

AIMS AND METHODS

A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a U.S. smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on U.S. trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios. Sensitivity analysis is conducted regarding the NVP excess risk and other factors.

RESULTS

Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates.

CONCLUSIONS

The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions.

IMPLICATIONS

Australia has implemented a strong array of cigarette-oriented policies, but has restricted access to NVPs. The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.

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

OBJECTIVES

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

DATA SOURCES AND STUDY SELECTION

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

DATA EXTRACTION

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

DATA SYNTHESIS

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

CONCLUSIONS

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

PROSPERO REGISTRATION NUMBER

CRD42021241630.

Duration of the effectiveness of nicotine electronic cigarettes on smoking cessation and reduction: Systematic review and meta-analysis

Background

The success of pharmacotherapies for smoking cessation in real-life remains limited, with a significant number of long-term relapses. Despite first promising results, the duration of the effectiveness of electronic cigarettes is still unknown. Our objective was to assess the duration of the effectiveness of electronic cigarettes on smoking cessation and reduction in daily smokers.

Methods

The databases EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and PUBMED were consulted until March 23, 2022. We selected only randomized controlled trials with daily adult smokers. The intervention was the nicotinic electronic cigarette vs. non-nicotine electronic cigarette or other validated pharmacotherapies (varenicline, bupropion and nicotine replacement therapy). The minimum duration of the intervention was 3 months, with a follow-up of at least 6 months. Two independent reviewers used the PRISMA guidelines. The primary endpoint was smoking cessation at the end of the intervention and follow-up periods confirmed by a reduction in expired CO < 10 ppm. The reduction was defined as at least 50% of the initial consumption or by a decrease of daily mean cigarette consumption at the end of the intervention and follow-up periods.

Results

Abstinence at the end of the intervention and follow-up periods was significantly higher in the nicotine electronic cigarette group, compared to nicotine replacement therapy (NRT) [respectively: RR: 1.37 (CI 95%: 1.32-2.93) and RR: 1.49 (CI 95%: 1.14-1.95)] and to the non-nicotine electronic cigarette condition [respectively: RR: 1.97 (CI 95%: 1.18-2.68) and RR: 1.66 (CI 95%: 1.01-2.73)]. With regard to smoking reduction, the electronic cigarette with nicotine is significantly more effective than NRT at the end of the intervention and follow-up periods [respectively RR: 1.48 (CI 95%: 1.04-2.10) and RR: 1.47 (CI 95%: 1.18-1.82)] and non-nicotine electronic cigarette in the long term [RR: 1.31 (CI 95%: 1.02-1.68)].

Conclusions

This meta-analysis shows the duration of the effectiveness of the nicotine electronic cigarette vs. non-nicotine electronic cigarette and NRT on smoking cessation and reduction. There are still uncertainties about the risks of its long-term use and its potential role as a gateway into smoking, particularly among young people.

Adolescents, Young Adults, and Adults Continue to Use E-Cigarette Devices and Flavors Two Years after FDA Discretionary Enforcement

This study assesses the use of e-cigarette devices and flavors using a large, cross-sectional survey of adolescents, young adults, and adults (N = 6131; ages 13−40 years old; Mage = 21.9) conducted from November to December 2021, 22 months after the FDA announced its prioritized enforcement policy against some flavored pod/cartridge-based e-cigarettes. We analyzed the patterns of use by age group: adolescents and young adults (AYAs) under 21 (minimum age of e-cigarette sales), young adults (21−24 years old), and adults (25−40 years old). The participants reported using e-cigarettes ever (44.2% < 21; 67.1% 21−24; 58.0% > 24), in the past 30 days (29.8% < 21; 52.6% 21−24; 43.3% > 24), and in the past 7 days (24.5% < 21; 43.9% 21−24; 36.5% > 24). Disposables were the most used e-cigarette device type across age groups (39.1% < 21; 36.9% 21−24; 34.5% > 24). Fruit, sweet, mint, and menthol flavors were popular across age groups; however, chi-squared tests for trends in proportions revealed age-related trends in past 30-day flavor use by device type. Findings suggest current AYA e-cigarette use may be higher than recorded by the NYTS 2021. The FDA, states, and localities should adopt more comprehensive restrictions on flavored e-cigarette products in order to reduce adolescent and young adult e-cigarette use.

Use of Electronic Cigarettes Among Cannabis-Naive Adolescents and Its Association With Future Cannabis Use

IMPORTANCE

Electronic cigarette (e-cigarette) use has been reported to increase the likelihood of future cigarette smoking among adolescents. The prospective association between e-cigarette use and cannabis use has been less clear, especially in recent years.

OBJECTIVE

To examine the association between e-cigarette use among cannabis-naive adolescents and cannabis use 1 year later.

DESIGN, SETTING, AND PARTICIPANTS

The Population Assessment of Tobacco and Health (PATH) Study, a nationally representative cohort study, uses a 4-stage, stratified probability sample design to select participants aged 12 years or older from the US civilian, noninstitutionalized population. This study sample included 9828 cannabis-naive adolescents at the baseline survey who participated in both wave 4.5 (2017-2018) and wave 5 (2018-2019) of PATH.

EXPOSURES

e-Cigarette use, assessed by ever use, past 12-month use, and past 30-day use.

MAIN OUTCOMES AND MEASURES

Cannabis use in wave 5, assessed by past 12-month and past 30-day use. Multivariable logistic regressions assessed the association between e-cigarette use and cannabis use 1 year later. Results were weighted to produce nationally representative findings.

RESULTS

Of the 9828 adolescents included in the analysis, 5361 (57.3%) were aged 12 to 14 years, 5056 (50.7%) were male, and 4481 (53.0%) were non-Hispanic White. After adjustment for sociodemographic characteristics, environmental factors, other substance use, and sensation seeking, e-cigarette use among cannabis-naive adolescents was associated with increased likelihoods of both self-reported past 12-month and past 30-day cannabis use 1 year later. The adjusted relative risks (aRRs) of subsequent past 12-month cannabis use with ever use of e-cigarettes was 2.57 (95% CI, 2.04-3.09), with past 12-month use of e-cigarettes was 2.62 (95% CI, 2.10-3.15), and with past 30-day use of e-cigarettes was 2.18 (95% CI, 1.50-2.85). The aRRs of subsequent past 30-day cannabis use with ever use of e-cigarettes was 3.20 (95% CI, 2.10-4.31), with past 12-month use of e-cigarettes was 3.40 (95% CI, 2.17-4.63), and with past 30-day use of e-cigarettes was 2.96 (95% CI, 1.52-4.40).

CONCLUSIONS AND RELEVANCE

This cohort study's findings suggest a strong association between adolescent e-cigarette use and subsequent cannabis use. However, despite the strong association at the individual level, e-cigarette use seems to have had a minimal association with the prevalence of youth cannabis use at the population level.

Use Patterns, Flavors, Brands, and Ingredients of Nonnicotine e-Cigarettes Among Adolescents, Young Adults, and Adults in the United States

IMPORTANCE

Nonnicotine e-cigarettes contain chemicals, flavorants, and solvents that have known health harms and/or have not been proven safe for inhalation.

OBJECTIVE

To evaluate nonnicotine e-cigarette use patterns, including common flavors, brands, and ingredients.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included a convenience sample of US residents aged 13 to 40 years who completed an online survey in November and December 2021. Quota sampling was used for an equal proportion of participants aged 13 to 17 years, 18 to 20 years, and 21 to 40 years, balanced for sex, race, and ethnicity per the latest US Census.

MAIN OUTCOMES AND MEASURES

Nonnicotine e-cigarette use (ever, past 30- and past 7-day, number of times used, time taken to finish); co-use with nicotine e-cigarettes; age at first try; and flavors, brands, and ingredients used.

RESULTS

Overall, 6131 participants (mean [SD] age, 21.9 [6.8] years; range, 13-40 years; 3454 [56.3%] identifying as female) completed the survey (55.1% completion rate). Among all participants, 1590 (25.9%) had ever used a nonnicotine e-cigarette, 1021 (16.7%) used one in the past 30 days, and 760 (12.4%) used one in the past 7 days. By age group, 227 of 1630 participants aged 13 to 17 years (13.9%), 497 of 2033 participants aged 18 to 20 years (24.4%), 399 of 1041 participants aged 21 to 24 years (38.3%), and 467 of 1427 participants aged 25 to 40 years (32.7%) had ever used nonnicotine e-cigarettes. Among 1590 participants who had ever used a nonnicotine e-cigarette, 549 (34.5%) had used one more than 10 times; 1017 (63.9%) finished 1 nonnicotine e-cigarette in less than 1 week. Co-use of nonnicotine with nicotine e-cigarettes was reported by 1155 participants (18.8%), 1363 (22.2%) exclusively used nicotine e-cigarettes, and 431 (7.0%) exclusively used nonnicotine e-cigarettes. Most-used flavors were sweet, dessert, or candy (578 [36.3%]); fruit (532 [33.4%]); and mint or menthol (321 [20.2%]); similar flavor patterns were observed for the top 2 flavors among those who used nonnicotine e-cigarettes in the past 30 days, followed by combinations of coffee, alcohol, flower, plant, and mint or menthol flavors by age group. Participants most reported using tetrahydrocannabinol (587 [36.9%]), cannabidiol (537 [33.7%]), melatonin (438 [27.5%]), caffeine (428 [26.9%]), and essential oils (364 [22.9%]) in their nonnicotine e-cigarettes.

CONCLUSIONS AND RELEVANCE

In this study of adolescents, young adults, and adults, a sizeable proportion reported having used nonnicotine e-cigarettes and co-using them with nicotine e-cigarettes. Surveillance studies should further assess nonnicotine e-cigarette use patterns and regulations, and prevention should be developed to address youth appeal, unsubstantiated health claims, and possible health harms.

Pediatric Preventive Care in Middle-High Resource Countries-The Padova Chart for Health in Children

Importance

The Padova Chart for Health in Children (PCHC) aims to gather the evidence of healthcare promotion and protection for chidren and adolescents (i.e., aged <18 y) into a single document in order to guide families, healthcare providers and social actors on healthy choices. No more than 2% of Europeans and North Americans aged <30 y have a healthy lifestyle. This, together with metabolic and brain plasticity during childhood, creates the ideal opportunity to implement preventive strategies. Guided interventions promoting healthy lifestyle in children and families therefore have a key role in abating the unprecedented pandemic of non-communicable diseases (NCDs) in adulthood.

Observations

The PCHC is divided into four sections: nutrition, cardiovascular health, respiratory health, and mental and social health. Each section is structured in an ALICE approach (assessment, lobbying, intervention, call-for-action, evaluation): assessment of necessity, describing relevance to healthcare; lobbying to identify those who can effect the proposed interventions; interventions involving family, school and peers; a call-for-action to define priorities among the proposed interventions; and objective evaluation measures that can be applied on a population basis.

Conclusions and Relevance

Interventions promoting health in childhood require joint action from multiple institutional, local and family representatives, with the shared goal of promoting health across the entire age group. These lifestyle interventions have the potential to change the lifetime risk trajectory for NCDs.

Harm perceptions, JUUL dependence, and other tobacco product use among young adults who use JUUL

INTRODUCTION

The study identified groups of JUUL using young adults based on their use patterns and compared harm perceptions, JUUL dependence, and other tobacco product use among these groups.

METHODS

Online cross-sectional survey data were gathered in March 2019 from 667 undergraduate students who used JUUL weekly (50.4% females, average age: 20.3 years) at a southwest U.S. university.

RESULTS

Latent class analysis identified four groups of young adults who used JUUL: 1) Light Social JUUL Using Young Adults (LS, 52.5%) who used JUUL occasionally with friends when drinking alcohol, 2) Daily Sensation Seekers (DSS, 16.2%) who used JUUL daily with alcohol, 3) Daily Activity Driven JUUL Using Young Adults (DAD, 26.0%) who used JUUL daily while drinking, watching media, or studying, and 4) Daily All Occasion JUUL Using Young Adults (DAO, 5.3%) who used JUUL heavily, daily and in various occasions. While all four groups reported some extent of JUUL dependence, DAO reported the highest dependence and were more likely than LS to have used cigarettes and other e-cigarettes besides JUUL. They also tended to believe different pod flavors could cause different types of lung damage while the other groups were unsure/disagreed with this belief. LS were more likely than DSS and DAD to believe that JUUL use indicated openness to new experiences.

CONCLUSION

Young adults with different JUUL use patterns perceived JUUL harms differently and faced varied risks of JUUL dependence and other tobacco product use. Effective cessation interventions should be adapted to meet the needs of these groups.

Increased JUUL Emissions from Initial Puffs after Removing and Reinserting Pod

Standard laboratory electronic cigarette (ECIG) puffing protocols that do not consider user behaviors, such as removing and resinserting a pod, may underestimate emissions. This study compared JUUL emissions from four 10-puff bout procedures. We generated ECIG aerosol in a chamber using a JUUL device and measured concentrations of particulate matter ≤2.5 μm in diameter (PM2.5). The JUUL pod was removed and reinserted 0 times, 1 time, 4 times, and 9 times in experiments 1-4, respectively. Mean real-time PM2.5 concentration was 65.06 μg/m3 (SD = 99.53) for experiment 1, 375.50 μg/m3 (SD = 346.45) for experiment 2, 501.94 μg/m3 (SD = 450.00) for experiment 3, and 834.69 μg/m3 (SD = 578.34) for experiment 4. In this study, removing and reinserting a JUUL pod resulted in greater PM2.5 concentrations compared to puffing protocols in which the JUUL pod was not removed and reinserted. ECIGs should be examined and evaluated based on ECIG users' real-world behaviors.

Differential impact of JUUL flavors on pulmonary immune modulation and oxidative stress responses in male and female mice

JUUL is a popular e-cigarette brand that manufactures e-liquids in a variety of flavors, such as mango and mint. Despite their popularity, the pulmonary effects of flavored JUUL e-liquids that are aerosolized and subsequently inhaled are not known. Therefore, the purpose of this study was to evaluate if acute exposure to JUUL e-cigarette aerosols in three popular flavors elicits an immunomodulatory or oxidative stress response in mice. We first developed a preclinical model that mimics human use patterns of e-cigarettes using 1 puff/min or 4 puffs/min exposure regimes. Based on cotinine levels, these exposures were representative of light/occasional and moderate JUUL users. We then exposed C57BL/6 mice to JUUL e-cigarette aerosols in mango, mint, and Virginia tobacco flavors containing 5% nicotine for 3 days, and assessed the inflammatory and oxidative stress response in the lungs and blood. In response to the 1 puff/min regime (light/occasional user), there were minimal changes in BAL cell composition or lung mRNA expression. However, at 4 puffs/min (moderate user), mint-flavored JUUL significantly increased lung neutrophils, while mango-flavored JUUL significantly increased Tnfα and Il13 mRNA in the lungs. Both the 1- and 4 puffs/min regimes significantly increased oxidative stress markers in the blood, indicating systemic effects. Thus, JUUL products are not inert; even short-term inhalation of flavored JUUL e-cigarette aerosols differentially causes immune modulation and oxidative stress responses.

Evaluating tobacco industry 'transformation': a proposed rubric and analysis

Some tobacco companies claim they are 'transforming' by adopting harm reduction goals or even seeking to achieve a 'smokefree' world. What characterises transformation and whether companies can or are transforming is unclear. Nevertheless, such claims are gaining traction. We critically investigated tobacco industry transformation by exploring the definition and criteria for evaluating transformation, and assessed whether transformation is occurring and feasible.Companies' transformation claims centre on increasing sales of new tobacco and nicotine products like e-cigarettes ('new products') with little attention to reducing sales of more hazardous smoked and oral products ('conventional products').We define a transforming tobacco company as one demonstrating substantial, rapid and verifiable progress towards eliminating the production and sale of conventional tobacco products within 5 years in all markets where it operates.We found no evidence any tobacco company is meeting the three essential criteria of rapidly progressing towards eliminating conventional products, ceasing to obstruct effective tobacco control measures and taking action to minimise smoking uptake and disparities. While some companies are developing new product portfolios, their actions are more consistent with profit maximisation than eliminating conventional product use. This approach is best described as 'pseudo-transformation', designed to delay implementation of effective tobacco control policies. In addition, our analysis suggests replacing conventional products with new nicotine products is unlikely to be a viable long-term business model.Public health practitioners should not rely on tobacco industry claims but should lead the transformation debate, establish credible definitions and criteria, and monitor and assess whether transformation is occurring.

Relationships between ENDS-Related Familial Factors and Oral Health among Adolescents in the United States

The influence of familial and social environments plays a significant role in Electronic Nicotine Delivery System (ENDS) use and may contribute to poor oral health among adolescents. This study utilized the Population Assessment of Tobacco and Health (PATH) database and included youths aged 12 to 17 years who reported no history of dental health issues at baseline. Adjusted odds ratios (AOR) were used to examine the association between END-related familial factors and oral health among adolescents in the United States, with statistical significance set at p < 0.05. The sample consisted of 3892 adolescents (weighted N = 22,689,793). Parents’ extremely negative reaction towards ENDS when they found their children using ENDS (AOR = 0.309) was connected to a lower risk of oral health issues. The findings suggest that clinicians and policymakers need to consider the roles of these factors when developing strategies to improve oral health outcomes.

Factors Associated with Quit Interest and Quit Attempts among Young Adult JUUL Users

Despite reports suggesting young people are interested in quitting e-cigarettes, little work has examined predictors of quit outcomes. This study aimed to identify factors associated with quit outcomes among JUUL e-cigarette users in a longitudinal sample of young adults. We assessed undergraduate past-30-day JUUL users during autumn 2018 (N = 225); Our outcomes included short-term quit attempts and interest (spring 2019), and long-term quit attempts (spring 2020). We used logistic regression to examine the associations between our outcomes and JUUL use characteristics, other tobacco use, and sociodemographic factors. Findings indicated 76% of users were interested in quitting JUUL, and more than 40% reported a quit attempt. Quit outcomes were not related to sociodemographics. Short-term quit outcomes were more likely among freshmen and less likely among recent cigarillo users. Heavy JUUL users were more likely to report short- and long-term quit attempts, but JUUL device owners were less likely to report short- and long-term quit attempts. Higher nicotine dependence reduced the likelihood of a long-term quit attempt. There is a need for policy level actions that address tobacco control among this population. Findings suggest a range of unique factors that can inform such policies and programs to curb young adult e-cigarette use.

Rising vape pod popularity disrupted declining use of electronic nicotine delivery systems among young adults in Texas, USA from 2014 to 2019

AIMS

To examine the longitudinal trajectory of young Texan (US) adults' electronic nicotine delivery systems (ENDS) use from 2014 to 2019, and to determine if there are changes in the trajectory among younger and older young adults post-2017, when vape pods surged in popularity in the United States.

DESIGN

Nine-wave longitudinal study, with 6 months between each of the first eight waves and 1 year between the last two waves. Discontinuous, or piecewise, growth curve models were used to test the hypotheses that (a) the overall current/past 30-day ENDS use trajectory would decline from 2014 to spring 2017 but then increase from fall 2017 to 2019, and (b) the increasing trajectory from 2017 to 2019 would occur only for younger participants, but not older participants. All models included socio-demographic covariates of sex, race/ethnicity, type of college attended at baseline (2- or 4-year) and time-varying age.

SETTING AND PARTICIPANTS

A total of 5218 students (aged 18-25 years at baseline; 63.7% female) from 24 colleges in the five counties surrounding Austin, Dallas/Fort Worth, Houston and San Antonio, Texas, USA.

MEASUREMENTS

Participants completed on-line surveys regarding past 30-day ENDS use at all nine waves.

FINDINGS

Current ENDS use significantly declined from 2014 to spring 2017 [odds ratio (OR) = 0.63, 95% confidence interval (CI) = 0.59-0.68], and then significantly increased from autumn 2017 to 2019 (OR = 1.14, 95% CI = 1.01-1.29). Further examination indicated the increase in current ENDS use from autumn 2017 to 2019 occurred only for younger [-1 standard deviation (SD) below the mean age, 22.6 years old], but not older (+1 SD above the mean age, 26.2 years old), participants.

CONCLUSION

The surge in the popularity of vape pods in the United States in late 2017 may have contributed to increasing use of electronic nicotine delivery systems among younger young adults (below 22.6 years) from late 2017 to 2019.

Effect of Puffing Behavior on Particle Size Distributions and Respiratory Depositions From Pod-Style Electronic Cigarette, or Vaping, Products

The current fourth generation ("pod-style") electronic cigarette, or vaping, products (EVPs) heat a liquid ("e-liquid") contained in a reservoir ("pod") using a battery-powered coil to deliver aerosol into the lungs. A portion of inhaled EVP aerosol is estimated as exhaled, which can present a potential secondhand exposure risk to bystanders. The effects of modifiable factors using either a prefilled disposable or refillable pod-style EVPs on aerosol particle size distribution (PSD) and its respiratory deposition are poorly understood. In this study, the influence of up to six puff profiles (55-, 65-, and 75-ml puff volumes per 6.5 and 7.5 W EVP power settings) on PSD was evaluated using a popular pod-style EVP (JUUL® brand) and a cascade impactor. JUUL® brand EVPs were used to aerosolize the manufacturers' e-liquids in their disposable pods and laboratory prepared "reference e-liquid" (without flavorings or nicotine) in refillable pods. The modeled dosimetry and calculated aerosol mass median aerodynamic diameters (MMADs) were used to estimate regional respiratory deposition. From these results, exhaled fraction of EVP aerosols was calculated as a surrogate of the secondhand exposure potential. Overall, MMADs did not differ among puff profiles, except for 55- and 75-ml volumes at 7.5 W (p < 0.05). For the reference e-liquid, MMADs ranged from 1.02 to 1.23 μm and dosimetry calculations predicted that particles would deposit in the head region (36-41%), in the trachea-bronchial (TB) region (19-21%), and in the pulmonary region (40-43%). For commercial JUUL® e-liquids, MMADs ranged from 0.92 to 1.67 μm and modeling predicted that more particles would deposit in the head region (35-52%) and in the pulmonary region (30-42%). Overall, 30-40% of the particles aerosolized by a pod-style EVP were estimated to deposit in the pulmonary region and 50-70% of the inhaled EVP aerosols could be exhaled; the latter could present an inhalational hazard to bystanders in indoor occupational settings. More research is needed to understand the influence of other modifiable factors on PSD and exposure potential.

A one year prospective examination of risk factors for pod-vape use among young adults

BACKGROUND

Young adults have the highest prevalence of pod-vape use, compared to adolescents and older adults. Despite the increased use of pod-vapes among young adults, very few studies have explored the determinants associated with pod-vape use.

PURPOSE

The purpose of the current study was to examine the roles of social norms and risk perceptions in subsequent pod-vape use one year later among a cohort of 21-34-year-old young adults.

METHOD

Participants were 3543 young adults from the last two waves (spring 2018 and 2019) of the Marketing and Promotions across Colleges in Texas project (M-PACT). A multivariable logistic regression model was used to examine the role of social norms and risk perceptions on subsequent pod-vape use one year later.

RESULTS

The prevalence of current pod-vape use in the present sample increased by 139.3% between 2018 and 2019. The social norm variables of close friends' pod-vape use and inclination to date someone that uses pod-vapes, but not social acceptability of pod-vapes, predicted subsequent pod-vape use one year later. Neither of the risk perception variables predicted subsequent pod-vape use.

CONCLUSION

The current study highlights the importance of social norms as predictors of subsequent pod-vape use among older young adults (21-34 years old). The rise in pod-vape use indicates that preventative efforts that target young adults are warranted, especially those that consider the role of peers in pod-vape use.

Conceptual model for the evaluation of attractiveness, addictiveness and toxicity of tobacco and related products: The example of JUUL e-cigarettes

Many new tobacco and related products (nTRP) have emerged on the market, with unknown health risks. Here, we present a conceptual model containing the factors and relations between them that contribute to the nTRP's health effects. Factors that determine attractiveness, addictiveness and toxicity of nTRP were defined based on previous assessments, literature, and expert discussions. Our model will aid in identifying key risk factors contributing to increased risk of adverse health effects for a product in a qualitative manner. Additionally, it can gauge attractiveness for specific user groups, as a determinant for population prevalence of use. Our model can be used to identify aspects of nTRP that require attention for public information or product regulation. As an example, we applied this to JUUL, a popular e-cigarette in the US. Aspects of concern for JUUL are its attractive and discrete shape, user-friendly prefilled pods, flavors, high aerosol nicotine levels, and liquids containing nicotine salts instead of free-based nicotine. The addictiveness and especially attractiveness are sufficiently high to have a large potential impact on population health due to its contribution to use and hence exposure. Products and their use can change over time; therefore market research and monitoring are crucial.

Changes in knowledge, perceptions and use of JUUL among a cohort of young adults

OBJECTIVE

E-cigarettes have gained popularity, most recently with pod-style devices, such as JUUL. We examined changes in JUUL awareness, use, perceptions, nicotine content knowledge, number of days a pod lasts and exposure to JUUL retail advertising over a 6-month period in a cohort of young adults.

METHODS

In spring and fall 2018, 1836 young adults completed online surveys on tobacco use, including JUUL perceptions and use behaviours. Demographics, tobacco use and JUUL advertising exposure in spring 2018 were examined as predictors of current JUUL use in fall 2018.

RESULTS

Ever and current JUUL use doubled in 6 months (5.9% vs 12.7%, p<0.001; 1.6% vs 3.4%, p<0.001). The number of days a JUUL pod lasts significantly changed (p=0.049). Although there was an increase in those reporting JUUL has as much or more nicotine than a pack of cigarettes, 58% are 'not sure' of JUUL's nicotine content. Exposure to JUUL's advertising significantly increased (31.8% to 46.4%; p<0.001). In multivariable models, those perceiving JUUL as or more harmful than cigarettes, and former and never cigarette smokers had significantly lower odds of current JUUL use at 6 months compared with their respective counterparts (p<0.0001). Those reporting exposure to JUUL's advertising had significantly increased odds of current JUUL use 6 months later (p<0.03).

CONCLUSIONS

Findings demonstrate changes in knowledge of JUUL's nicotine content, perceptions and use over a short period of time, suggesting frequent measurement is necessary. Additionally, efforts are needed to regulate retail advertising and ensure consumer education about product risks as they are associated with current use.

Conjoint Developmental Trajectories of Adolescent E-cigarette and Combustible Cigarette Use

OBJECTIVES

In this study, we sought to identify which adolescents progress to regular electronic cigarette (e-cigarette) use (without cigarette smoking), which adolescents become dual users of both types of cigarettes, and how dual use develops across time.

METHODS

Adolescents (N = 1808) from public high schools outside Philadelphia, Pennsylvania, completed in-classroom surveys at wave 1 (fall 2016, beginning of ninth grade) and at 6-month intervals for the following 36 months (fall 2019, beginning of 12th grade).

RESULTS

A sequential processes growth mixture model identified 4 conjoint latent classes: later, rapid e-cigarette uptake (class 1: n = 230); no use of e-cigarettes or combustible cigarettes (class 2: n = 1141); earlier, steady e-cigarette uptake (class 3: n = 265); and dual use of e-cigarettes and combustible cigarettes (class 4: n = 204). Using a rich set of potential risk factors, multinomial logistic regression assessed the likelihood of belonging to each conjoint class compared with the comparison class (dual use). Adolescents in the dual use class were characterized by a greater number and severity of e-cigarette and combustible cigarette risk factors. Adolescents in the 2 e-cigarettes-only classes were characterized by either e-cigarette-specific risk factors (earlier onset) or no risk factors (later onset). The no use class had an absence of risk factors for e-cigarette and cigarette use.

CONCLUSIONS

This study provides new prospective evidence for distinct patterns and profiles of adolescents who progress to current e-cigarette use, including adolescents who were initially cigarette smokers. The findings have implications for prevention intervention timing, tobacco product focus, content, and the adolescent subgroups to target.