Hospitalized smokers' expectancies for electronic cigarettes versus tobacco cigarettes

Emotion Dysregulation and E-Cigarette Expectancies among College Student E-Cigarette Users

Background: E-cigarette outcome expectancies (i.e., beliefs about the expected consequences of e-cigarette use) are a key factor in motivating use. Emotion regulation difficulties have demonstrated significant associations with outcome expectancies; however, there has yet to be an examination of associations between specific emotion regulation difficulties and specific e-cigarette outcome expectancies, which could serve as targets for intervention efforts. Therefore, the current study sought to examine the unique predictive ability of specific emotion regulation difficulties in terms of e-cigarette outcome expectancies. Methods: Participants were 116 college student e-cigarette users (Mage = 19.72, SD = 1.88; 71.6% female) who completed self-report questionnaires for course credit. Results: Greater difficulties engaging in goal-directed behavior when experiencing negative emotions and fewer difficulties accessing effective emotion regulation strategies were associated with positive reinforcement outcome expectancies. Greater emotion regulation difficulties in general were also associated with negative reinforcement outcome expectancies, though there were no significant individual predictors. Conclusion: These results suggest that greater emotion regulation difficulties are associated with mood-related e-cigarette outcome expectancies, and targeting emotion regulation difficulties, particularly difficulty engaging in goal-directed behavior when upset, may be useful to incorporate into intervention efforts.

Sexy, trashy, cool: Perceptions of electronic cigarette users across sociodemographic groups and E-cigarette use among United States Air Force Airmen

E-cigarette use has increased in recent years. Military personnel have higher rates of e-cigarette use than civilian populations, with 15.3% of Air Force recruits using e-cigarettes. The current study assessed associations between perceptions of e-cigarette users and current use of e-cigarettes, and differences in sociodemographic characteristics to determine if there were different beliefs among different groups to inform intervention development among these straight-to-work young adults. Participants (N = 17,314) were United States Air Force Airmen (60.7% White, 29.7% women) who completed a survey during their first week of Technical Training. Regression results indicated that identifying as a man (B = 0.22, SE = 0.02), identifying as Black (B = 0.06, SE = 0.02), reporting younger age (B = -0.15, SE = 0.02), having less education (B = -0.04, SE = 0.02), and current e-cigarette use (B = 0.62, SE = 0.02) were associated with endorsing more positive e-cigarette user perceptions. Identifying as a woman (B = -0.04, SE = 0.02) and being younger (B = -0.06, SE = 0.02) were associated with endorsing more negative perceptions of e-cigarette users. Current e-cigarette use was inversely associated with negative e-cigarette user perceptions (B = -0.59, SE = 0.02). Differences across groups were found for individual e-cigarette user characteristics. Future intervention strategies among Airmen may benefit from addressing e-cigarette user perceptions to change use behaviors, as these perceptions may result in stigmatized beliefs related to e-cigarette users.

Measuring vaping-related expectancies in young adults: Psychometric evaluation of the Electronic Nicotine Vaping Outcomes (ENVO) scale

OBJECTIVE

Electronic cigarettes are the most commonly used tobacco products by young adults. Measures of beliefs about outcomes of use (i.e., expectancies) can be helpful in predicting use, as well as informing and evaluating interventions to impact use.

METHODS

We surveyed young adult students (N = 2296, Mean age=20.0, SD=1.8, 64 % female, 34 % White) from a community college, a historically black university, and a state university. Students answered ENDS expectancy items derived from focus groups and expert panel refinement using Delphi methods. Factor Analysis and Item Response Theory (IRT) methods were used to understand relevant factors and identify useful items.

RESULTS

A 5-factor solution [Positive Reinforcement (consists of Stimulation, Sensorimotor, and Taste subthemes, α = .92), Negative Consequences (Health Risks and Stigma, α = .94), Negative Affect Reduction (α = .95), Weight Control (α = .92), and Addiction (α = .87)] fit the data well (CFI=0.95; TLI=0.94; RMSEA=0.05) and was invariant across subgroups. Factors were significantly correlated with relevant vaping measures, including vaping susceptibility and lifetime vaping. Hierarchical linear regression demonstrated factors were significant predictors of lifetime vaping after controlling for demographics, vaping ad exposure, and peer/family vaping. IRT analyses indicated that individual items tended to be related to their underlying constructs (a parameters ranged from 1.26 to 3.18) and covered a relatively wide range of the expectancies continuum (b parameters ranged from -0.72 to 2.47).

CONCLUSIONS

A novel ENDS expectancy measure appears to be a reliable measure for young adults with promising results in the domains of concurrent validity, incremental validity, and IRT characteristics. This tool may be helpful in predicting use and informing future interventions.

IMPLICATIONS

Findings provide support for the future development of computerized adaptive testing of vaping beliefs. Expectancies appear to play a role in vaping similar to smoking and other substance use. Public health messaging should target expectancies to modify young adult vaping behavior.

Depressive symptoms and vaping: The mediating effect of outcome expectancies among young adults

OBJECTIVE

The purpose of the present study was to determine if positive affect reinforcement and social enhancement outcome expectancies mediate the longitudinal association between depressive symptoms and frequency of electronic nicotine delivery systems (ENDS) use one year later among young adults.

METHOD

Participants were 1567 young adults participating in the first three waves of the Marketing and Promotions Across Colleges in Texas project. At Wave 1 participants were 18-25 years old (M = 20.27; SD = 1.86), 61.46% female; 36.25% non-Hispanic white, 33.95% Hispanic/Latino, 14.10% Asian, 7.72% African American/Black, 7.98% two or more races/ethnicities or another race/ethnicity. The independent variable, depressive symptoms, was assessed with the CES-D-10 at Wave 1. The mediating variables, positive affect reinforcement and social enhancement ENDS outcome expectancies were assessed using items adapted from the Youth Tobacco Survey at Wave 2 six months later. The outcome variable was frequency of past 30-day ENDS use at Wave 3, one year after Wave 1. A mediation model was used to test the study hypothesis.

RESULTS

Positive affect reinforcement ENDS outcome expectancies (b = 0.013, SE = 0.006, Bootstrap 95%CI: [0.003, 0.025]), but not social enhancement expectancies (b = -0.004, SE = 0.003, Bootstrap 95%CI: [-0.010, 0.0003]), mediated the positive association between elevated depressive symptoms and frequency of ENDS use one year later.

CONCLUSION

Results indicate young adults experiencing elevated depressive symptoms may use ENDS at a greater frequency than their peers because they believe ENDS use will alleviate stress, increase relaxation and/or concentration.

Effect of a Machine Learning Recommender System and Viral Peer Marketing Intervention on Smoking Cessation: A Randomized Clinical Trial

IMPORTANCE

Novel data science and marketing methods of smoking-cessation intervention have not been adequately evaluated.

OBJECTIVE

To compare machine learning recommender (ML recommender) computer tailoring of motivational text messages vs a standard motivational text-based intervention (standard messaging) and a viral peer-recruitment tool kit (viral tool kit) for recruiting friends and family vs no tool kit in a smoking-cessation intervention.

DESIGN, SETTING, AND PARTICIPANTS

This 2 ×2 factorial randomized clinical trial with partial allocation, conducted between July 2017 and September 2019 within an online tobacco intervention, recruited current smokers aged 18 years and older who spoke English from the US via the internet and peer referral. Data were analyzed from March through May 2022.

INTERVENTIONS

Participants registering for the online intervention were randomly assigned to the ML recommender or standard messaging groups followed by partially random allocation to access to viral tool kit or no viral tool kit groups. The ML recommender provided ongoing refinement of message selection based on user feedback and comparison with a growing database of other users, while the standard system selected messages based on participant baseline readiness to quit.

MAIN OUTCOMES AND MEASURES

Our primary outcome was self-reported 7-day point prevalence smoking cessation at 6 months.

RESULTS

Of 1487 participants who smoked (444 aged 19-34 years [29.9%], 508 aged 35-54 years [34.1%], 535 aged ≥55 years [36.0%]; 1101 [74.0%] females; 189 Black [12.7%] and 1101 White [78.5%]; 106 Hispanic [7.1%]), 741 individuals were randomly assigned to the ML recommender group and 746 individuals to the standard messaging group; viral tool kit access was provided to 745 participants, and 742 participants received no such access. There was no significant difference in 6-month smoking cessation between ML recommender (146 of 412 participants [35.4%] with outcome data) and standard messaging (156 of 389 participants [40.1%] with outcome data) groups (adjusted odds ratio, 0.81; 95% CI, 0.61-1.08). Smoking cessation was significantly higher in viral tool kit (177 of 395 participants [44.8%] with outcome data) vs no viral tool kit (125 of 406 participants [30.8%] with outcome data) groups (adjusted odds ratio, 1.48; 95% CI, 1.11-1.98).

CONCLUSIONS AND RELEVANCE

In this study, machine learning-based selection did not improve performance compared with standard message selection, while viral marketing did improve cessation outcomes. These results suggest that in addition to increasing dissemination, viral recruitment may have important implications for improving effectiveness of smoking-cessation interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03224520.

Outcome Expectancies and Resistance Self-Efficacy Mediate the Relationship Between Asthma Diagnosis and E-cigarette Use among Youth and Young Adults

Introduction: The use of electronic cigarettes (e-cigarettes) may exacerbate pulmonary complications in youth and young adults with asthma. We sought to identify the cognitive mechanisms that might explain e-cigarette use in this population. We hypothesized that e-cigarette outcome expectancies and e-cigarette resistance self-efficacy would mediate the relationship between asthma diagnosis and e-cigarette use in youth and young adults. Methods: We enrolled youth and young adults (15-25 years old) in Alabama with a clinical diagnosis of asthma (n = 130) or without a diagnosis of any chronic pulmonary disease (n = 115; reference group). Author-constructed and validated questionnaires (young adult e-cigarette use outcome expectancies and modified Self-efficacy Scale for Adolescent Smoking) were administered to collect demographic data and assess susceptibility to e-cigarette use as well as current use of e-cigarettes, e-cigarette outcome expectancies, and e-cigarette resistance self-efficacy. We then conducted structural equation modeling to test whether e-cigarette expectancies and e-cigarette resistance self-efficacy mediate the relationship between asthma and susceptibility to e-cigarette use as well as current e-cigarette use. Results: The frequency of the susceptibility to e-cigarette use and current e-cigarette use was lower among those with clinically diagnosed asthma than among those without asthma (35.8% vs 59.8% for susceptibility and 6.0% vs 18.2% for current use). Individuals with asthma reported weaker expectancies that e-cigarettes would make them feel relaxed which, in turn, was a significant predictor of lower susceptibility to e-cigarette use and current e-cigarette use, suggesting mediation. Finally, individuals with asthma demonstrated greater e-cigarette resistance self-efficacy in the context of social opportunities and friends' influence to use e-cigarettes. This self-efficacy was associated with lower susceptibility to e-cigarette use as well as current e-cigarette use. Conclusion: Although longitudinal studies are needed to determine relationships prospectively, targeted interventions that reduce outcome expectancies and increase resistance self-efficacy to e-cigarette use may further reduce e-cigarette use among youth and young adults with asthma.

Instruments to measure e-cigarette related constructs: a systematic review

BACKGROUND

Electronic cigarettes (e-cigarettes) are relatively new tobacco products that are attracting public attention due to their unique features, especially their many flavor options and their potential as an alternative to cigarettes. However, uncertainties remain regarding the determinants and consequences of e-cigarette use because current research on e-cigarettes is made more difficult due to the lack of psychometrically sound instruments that measure e-cigarette related constructs. This systematic review therefore seeks to identify the instruments in the field that are designed to assess various aspects of e-cigarette use or its related constructs and analyze the evidence presented regarding the psychometric properties of the identified instruments.

METHODS

This systematic review utilized six search engines: PubMed, Medline, CINAHL, PsycINFO, Web of Science, and EMBASE, to identify articles published in the peer-reviewed journals from inception to February 2022 that contained development or validation processes for these instruments.

RESULTS

Eighteen articles describing the development or validation of 22 unique instruments were identified. Beliefs, perceptions, motives, e-cigarette use, and dependence, were the most commonly assessed e-cigarette related constructs. The included studies reported either construct or criterion validity, with 14 studies reporting both. Most studies did not report the content validity; for reliability, most reported internal consistencies using Cronbach's alpha, with 15 instruments reporting Cronbach's alpha > 0.70 for the scale or its subscales.

CONCLUSIONS

Twenty-two instruments with a reported development or validation process to measure e-cigarette related constructs are currently available for practitioners and researchers. This review provides a guide for practitioners and researchers seeking to identify the most appropriate existing instruments on e-cigarette use based on the constructs examined, target population, psychometric properties, and instrument length. The gaps identified in the existing e-cigarette related instruments indicate that future studies should seek to extend the validity of the instruments for diverse populations, including adolescents. Instruments that explore additional aspects of e-cigarette use and e-cigarette related constructs to help build a strong theoretical background and expand our current understanding of e-cigarette use and its related constructs, should also be developed.

Emotion dysregulation, transdiagnostic vulnerabilities, and e-cigarette expectancies in a young adult sample

OBJECTIVE

Use of e-cigarettes is more common among youth with psychological distress. Negative affect reduction outcome expectancies (beliefs about ability of a product to reduce unpleasant emotional states) and emotional transdiagnostic vulnerabilities (maladaptive responses to emotional states common to multiple forms of emotional psychopathology) are both positively related to tobacco susceptibility and use. However, it is unclear if expectancies mediate the effects between emotional issues and use.

METHOD

College students aged 18 to 24 (N = 216; 79.6% female; 36.6% African American) completed an online survey with measures on e-cigarette negative affect reduction outcome expectancies (ENAROE), e-cigarette use, and the following emotional transdiagnostic vulnerabilities (ETV): difficulties in emotion regulation, distress tolerance (DT), positive/negative urgency, and positive/negative affect.

RESULTS

In individual predictor path analysis models, ENAROE mediated the relationship between ETVs and e-cigarette use. Expectancies (ENAROE) mediated 47.3% of the total relationship between positive urgency and use. Significant effects were found for a comprehensive model, in which negative urgency was related to higher ENAROE (b = 0.47, 95% BCCI [0.04, 0.96]), controlling for all other transdiagnostic vulnerabilities. Higher positive urgency was related to an increased likelihood of current use.

CONCLUSIONS

This study provides a novel examination of expectancies as a potential mediator for current e-cigarette use via emotional vulnerabilities. Negative Affect Reduction outcome expectancies mediated the relationship between vulnerabilities and e-cigarette use, indicating that the association between positive urgency and e-cigarette use may be explained partially though emotional expectancies. Thus, expectancies are important targets for prevention and further ETV research.

The moderating role of anxiety sensitivity in terms of fatigue severity and e-cigarette use expectancies

Little is understood about individual difference factors related to e-cigarette expectancies about use. This study examined the interactive effects of fatigue severity and anxiety sensitivity in relation to e-cigarette expectancies among 525 e-cigarette users (51.0% female, Mage = 35.25 years, standard deviation = 10.10). Results indicated a significant interaction between fatigue severity and anxiety sensitivity in terms of positive expectancies (β = 0.57, p < 0.001, 95% confidence interval = (0.002, 0.01)), but not for negative expectancies (β = 0.25, p = 0.08, 95% confidence interval = (0, 0.005)) for e-cigarette use. These results support anxiety sensitivity as a moderator in the relation between fatigue severity and positive outcome expectancies for e-cigarette use.

Dripping Technology Use Among Young Adult E-Cigarette Users

BACKGROUND

Young adults are increasingly using electronic nicotine delivery systems (ENDS). The standard ENDS device involves an electric coil that heats a wick to vaporize an e-liquid solution. "Dripping" is another method that involves applying e-liquid directly to the coil. Dripping increases risk of harmful toxic compounds in vapor aerosols. Despite evidence of high levels of dripping among adolescents, young adult prevalence is unknown.

METHODS

Young adults aged 18 to 24 completed an online survey assessing vaping and dripping status, type of devices used, tobacco use, and vaping expectancies. Among ever-vapers, univariate and multivariate logistic regression models assessed whether demographics predicted dripping and use of dripping devices. Multivariate Analysis of Variance compared never- and ever-drippers on expectancies for vaping outcomes.

RESULTS

Over 2 in 5 young adult ever-vapers (43.7%) reported dripping. A multivariate regression model found that male gender (AOR = 1.83), identifying as White (AOR = 2.37), and use of other tobacco products (hookah; AOR = 1.91; cigars; AOR = 2.26; cigarettes; AOR = 2.51) were associated with dripping. E-cigarette users who reported lifetime dripping were more likely to consider vaping stimulating, socially facilitating, and flavorful. They ascribed lower health risks to vaping and felt it could reduce negative affect, weight gain, nicotine cravings, and boredom (all P < .05).

CONCLUSION

Dripping was a highly prevalent behavior among this sample of young adults, particularly among White males. These findings point to the importance of gaining a greater understanding of the drivers and consequences of vaping and dripping behavior.

Emotion dysregulation, fatigue, and electronic cigarette expectancies

Emotion dysregulation and the experience of fatigue have both been linked to the maintenance of substance use. However, limited empirical data has evaluated individual differences in these constructs in terms of e-cigarette use expectancies. The present study examined a theoretically relevant model focused on whether the experience of more severe fatigue explains, in part, the relation between individual differences in emotion dysregulation and positive and negative e-cigarette expectancies among 525 adult e-cigarette users (50.9% female, Mage = 35.25 years, SD = 10.10). It was hypothesized that emotion dysregulation, via fatigue severity, would significantly predict greater positive and negative e-cigarette expectancies, which was examined in two separate mediation models. Fatigue severity significantly explained, in part, the relation between emotion dysregulation and positive (b = 0.02, CI [0.01, 0.02]) and negative expectancies of e-cigarette use (b = 0.02, 95% CI [0.02, 0.03]). The current findings suggest that the experience of fatigue helps explain the relation between emotion dysregulation and positive and negative e-cigarette expectancies among adult e-cigarette users. Future work is needed to explicate how reducing fatigue severity in the context of emotion dysregulation may change expectancies about e-cigarette expectancies.

The Role of Anxiety Sensitivity and Fatigue Severity in Predicting E-Cigarette Dependence, Barriers to Cessation, and Cravings among Young Adults

Background: Electronic cigarette (e-cigarette) use has risen dramatically in the United States among young adults; however, little is understood about potential factors that are related to e-cigarette use and maintenance among this population. Fatigue severity is one promising individual difference factor, as past work indicates that it is related to greater withdrawal symptoms and greater dependence on e-cigarettes, and more barriers to quitting. In addition, anxiety sensitivity and severe fatigue are both uniquely related to poor e-cigarette use outcomes; yet, no known studies have examined whether these individual difference factors are related to e-cigarette outcomes among young adults. Method: The current study sought to examine the unique and interactive effects of anxiety sensitivity and fatigue severity in predicting a variety of e-cigarette outcomes among 685 (69.1% female; M_age = 19.61 years, SD = 1.44) young adult e-cigarette users. Results: Results indicated that anxiety sensitivity was significantly associated with greater barriers for cessation (β = .63, p <.001) and e-cigarette cravings (β = .67, p =.001), but not dependence. Fatigue severity was significantly associated with greater e-cigarette dependence (β = .58, p <.001), barriers to cessation (β = 1.56, p <.001), and e-cigarette cravings (β = 3.34, p <.001). The interactive effects of anxiety sensitivity and fatigue severity did not significantly predict the outcomes. Discussion: Results suggest that anxiety sensitivity and fatigue severity independently predict greater e-cigarette maintenance factors among young adults. The current investigation highlights the importance of targeting anxiety sensitivity and fatigue severity among young adult e-cigarette users.

Exploring positive expectancies and quit status among adult electronic cigarette users

Initial research on electronic cigarette (e-cigarette) use suggests differences exist in levels of use, beliefs, and cessation difficulties among users. However, little research has explored how these factors interact to confer worse e-cigarette outcomes. The current study examined the association between positive expectancies of e-cigarette use and e-cigarette processes among 544 (51.1% female; M_age = 35.4 years, SD = 10.12) adult e-cigarette users who had and had not attempted to quit e-cigarettes, a defining characteristic believed to distinguish those with and without greater e-cigarette quit difficulty. Results indicated that greater positive outcome expectancies of e-cigarette use were significantly related to increased perceived risks, benefits, and barriers to quitting. The strength of the associations was stronger for those who reported past quit attempts compared to those who never attempted quitting. Overall, the current study highlights the potentially important role that positive expectancies for e-cigarette use and quit attempt status play in e-cigarette processes. Findings suggest a possible need to contextualize positive expectancies for e-cigarette use within future e-cigarette cessation tactics and tailoring treatments based on quit attempt status.

A preliminary validation of the adolescent e-cigarette consequences questionnaire

INTRODUCTION

Given the recent dramatic increase among adolescents in the use of electronic nicotine delivery systems (ENDS) or electronic cigarettes (e-cigarettes), there is a growing need to identify outcome expectancies that influence the initiation or continued use of e-cigarettes. While a self-report measure exists for assessing adolescent outcome expectancies for cigarette use, there is currently not one available for e-cigarette use. Validation and use of such a measure would provide insight into the growing popularity of e-cigarettes.

METHODS

The sample consisted of 264 (50.76 % female, 86.36 % White, 84.47 % Hispanic/Latinx) freshmen and sophomores from South Florida high schools who were identified as at-risk for e-cigarette use. The current study adapted the Adolescent Smoking Consequences Questionnaire (ASCQ) to derive the Adolescent E-Cigarette Consequences Questionnaire (AECQ) to characterize e-cigarette outcome expectancies. A confirmatory factor analysis was estimated to test the underlying factor structure.

RESULTS

The confirmatory factor analysis provided support for a seven-factor structure (negative affect reduction, taste/sensorimotor manipulation, social facilitation, weight control, negative physical feelings, boredom reduction, and negative social impression) after removing two items with low factor loadings from the social facilitation subscale. After removing these items, factor loadings ranged from 0.46 to 0.86.

CONCLUSION

The current study provides preliminary evidence to suggest that the Adolescent E-Cigarette Consequences Questionnaire is a psychometrically sound measure. Future work should continue to test this measure among diverse samples of adolescents (e.g., non-Latinx samples) with varying levels of use.

Nicotine or expectancies? Using the balanced-placebo design to test immediate outcomes of vaping

INTRODUCTION

Electronic (e-)cigarette use has increased in popularity, especially among those attempting to quit smoking. Previous studies evaluating the therapeutic efficacy of e-cigarettes have suggested that non-pharmacologic factors, such as expectancies about nicotine effects, may influence the experienced effects of e-cigarettes.

METHOD

The independent and synergistic influences of drug and expectancies were parsed using a balanced-placebo design, whereby 128 participants (52 dual users) were provided an e-cigarette that either contained nicotine or non-nicotine solution, while told that it did or did not contain nicotine. We hypothesized main effects of nicotine content on physiological, objective outcomes (attention, appetite, aversion, respiratory tract sensations), and main effects of the instructions on more subjective, psychosocial outcomes (affect, reward, satisfaction). Sex was included as a moderator.

RESULTS

Results showed that nicotine increased sustained attention, and more so among females. Nicotine delivery was associated with aversion among females, but not males. Among those who were both told and did not receive nicotine, higher enjoyment of respiratory tract sensations was reported. Nicotine with complementary instructions produced the highest reward ratings; additionally, nicotine was rewarding to males but not females.

DISCUSSION

Findings demonstrated that both nicotine content and non-pharmacologic factors impact acute outcome effects of e-cigarettes, with moderation by sex in some cases. Results are relevant to the interpretation of clinical trials of e-cigarettes and suggest a more nuanced view of reinforcement pathways.

Vaping Expectancies: A Qualitative Study among Young Adult Nonusers, Smokers, Vapers, and Dual Users

BACKGROUND

"Expectancies," or beliefs about outcomes, robustly correlate with and predict several behaviors including electronic nicotine delivery system ("e-cigarette") use. However, there is limited qualitative research available regarding relevant e-cigarette vaping expectancies.

OBJECTIVES

The present study used a qualitative approach to derive and refine e-cigarette expectancy themes among young adults.

METHODS

We conducted 12 focus groups and two individual interviews with young adult nonusers, e-cigarette vapers, cigarette smokers, and dual users to assess beliefs about the effects of e-cigarettes. After a series of open-ended questions, follow-up questions assessed reactions to domains previously examined in expectancy measures for cigarette smoking and e-cigarette vaping. The constant comparative method was used to derive themes from transcripts.

RESULTS

Four main themes (Positive Reinforcement, Social Benefits, Negative Affect Reduction, Negative Consequences) emerged from the results. Each theme contained three associated subthemes (Positive Reinforcement: Sensorimotor Experiences, Taste, Stimulation; Social Benefits: Social Facilitation, Influence on Others, Convenience; Negative Affect Reduction: Stress Reduction, Appetite Reduction, Boredom Reduction; and Negative Consequences: Health Risks, Addiction, Secondhand Effects).

CONCLUSIONS/IMPORTANCE

Previously identified smoking expectancies appear relevant for young adult vaping, with some notable refinements. Positive reinforcement aspects encompassed aerosol clouds, vaping tricks, and unique flavors. Social benefits included influencing others via social media and competitive activity, as well as the convenience of use in a variety of places. Negative affect reduction was controversial among user groups, but vaping was seen as more interesting than smoking and thus more effective at boredom reduction. Young adults were uncertain regarding negative consequences, but appreciated a potential for secondhand effects. Measure refinement via qualitative research and future field testing can enhance our understanding of this relatively new behavior, supporting tobacco control surveillance, marketing/labeling regulations, and counter-advertising development/evaluation.

Electronic cigarettes: a task force report from the European Respiratory Society

There is a marked increase in the development and use of electronic nicotine delivery systems or electronic cigarettes (ECIGs). This statement covers electronic cigarettes (ECIGs), defined as "electrical devices that generate an aerosol from a liquid" and thus excludes devices that contain tobacco. Database searches identified published articles that were used to summarise the current knowledge on the epidemiology of ECIG use; their ingredients and accompanied health effects; second-hand exposure; use of ECIGs for smoking cessation; behavioural aspects of ECIGs and social impact; in vitro and animal studies; and user perspectives.ECIG aerosol contains potentially toxic chemicals. As compared to conventional cigarettes, these are fewer and generally in lower concentrations. Second-hand exposures to ECIG chemicals may represent a potential risk, especially to vulnerable populations. There is not enough scientific evidence to support ECIGs as an aid to smoking cessation due to a lack of controlled trials, including those that compare ECIGs with licenced stop-smoking treatments. So far, there are conflicting data that use of ECIGs results in a renormalisation of smoking behaviour or for the gateway hypothesis. Experiments in cell cultures and animal studies show that ECIGs can have multiple negative effects. The long-term effects of ECIG use are unknown, and there is therefore no evidence that ECIGs are safer than tobacco in the long term. Based on current knowledge, negative health effects cannot be ruled out.

Reasons for Exclusion from a Smoking Cessation Trial: An Analysis by Race/Ethnicity

Objective

The exclusion criteria of tobacco cessation randomized clinical trials (RCTs) may have unintended consequences on inclusion and cessation disparities. We examined racial/ethnic differences in: a) exclusion from a group-based cessation RCT; and b) reasons for exclusion.

Design

Quasi-experimental. Inclusion criteria were self-identification as African American/Black, non-Hispanic White, or Hispanic (any race), adults, minimum five cigarettes/day or carbon monoxide reading of ≥ 8 parts per million (ppm), interest in quitting, and spoke/read English. Data were obtained from a parent trial, which is ongoing and will be completed in 2019. Analyses for our present study on participant screening and enrollment were conducted in 2018.

Main Outcome Measures

Study ineligibility, and reasons for exclusion (contraindications for nicotine patch use, serious mental illness [SMI, eg, bipolar disorder or schizophrenia], alcohol dependence or illicit drug use, current tobacco treatment, attendance barriers [eg, transportation], and other concerns [eg, aggressive, intoxicated, disruptive, visibly ill]).

Results

Of 1,206 individuals screened, 36% were ineligible. The most frequent reasons were SMI (28%), alcohol dependence or drug use (10%), and attendance barriers (7%). Ineligibility was greater among African Americans (42%) and Hispanics (37%), compared with Whites (24%; P<.001). Compared with African Americans and Hispanics, Whites were more likely to be excluded for single reasons, including attendance barriers, and medical conditions (P<.05). African Americans were more than twice as likely as Whites to be excluded for 3 or more reasons (12% vs 5% respectively, P<.05).

Conclusions

A notable proportion of smokers were ineligible for this RCT, with SMI as the greatest single cause. Racial/ethnic minorities were more likely to be excluded, with African Americans deemed ineligible for multiple reasons. Findings have implications for RCT generalizability, addressing tobacco disparities and health equity.

E-Cigarette Outcome Expectancies among Nationally Representative Samples of Adolescents and Young Adults

Objectives: We conducted nationally representative surveys of adolescents and young adults to examine associations between e-cigarette outcome expectancies and e-cigarette use. Background: E-cigarette use among adolescents and young adults has grown rapidly in recent years, yet little research has examined the beliefs that may underlie this behavior among nationally representative samples. Methods:N = 1,298 adolescents (13-17) and 2,219 young adults (18-25) were surveyed using a probability-based web panel. Participants completed a survey that included a new outcome expectancy measure examining 3 positive (enjoyment, social influences, advantage over cigarettes) and 2 negative (health concerns, smoker association) expectancy domains and ever having used e-cigarettes [ever use]. Results: Confirmatory factor analyses demonstrated a good fit of the outcome expectancies' factor structure to the data. All outcome expectancies were associated with e-cigarette use in both populations in univariate analyses. In multiple logistic regression models controlling for several covariates, higher expected enjoyment was positively associated with a greater likelihood of e-cigarette use (aOR = 2.10, p < .05) among adolescents. Among young adults, enjoyment (aOR = 3.08, p < .001) was positively associated with a greater likelihood of use while both health concerns (aOR = 0.70, p < .01) and smoker association (aOR = 0.73, p < .05) were negatively associated with e-cigarette use. Conclusions: This study suggests that expected enjoyment is robustly associated with e-cigarette use among both adolescents and young adults. Health concerns may also play a role in e-cigarette use. Implications for e-cigarette prevention efforts and future research directions are discussed.

Electronic Cigarette Awareness, Use, and Perceptions among Cancer Patients

Objective

Electronic cigarettes (e-cigs) are an emerging trend, yet little is known about their use in the cancer population. The objectives of this study were (1) to describe characteristics of e-cig use among cancer patients, (2) to define e-cig advertising exposure, and (3) to characterize perceptions of traditional cigarettes versus e-cigs.

Study Design

Cross-sectional study.

Setting

Comprehensive cancer center.

Subjects and Methods

Inpatient, current smokers with a cancer diagnosis. E-cig exposure and use were defined using descriptive statistics. Wilcoxon rank test was used to compare perceptions between e-cigs and traditional cigarettes.

Results

A total of 979 patients were enrolled in the study; 39 cancer patients were identified. Most cancer patients were women (59%), with an average age of 53.3 years. Of the patients, 46.2% reported e-cig use, most of which (88.9%) was “experimental or occasional.” The primary reason for e-cig use was to aid smoking cessation (66.7%), alternative use in nonsmoking areas (22.2%), and “less risky” cigarette replacement (5.6%). The most common sources for e-cig information were TV (76.9%), stores (48.7%), friends (35.9%), family (30.8%), and newspapers or magazines (12.8%). Compared with cigarettes, e-cigs were viewed as posing a reduced health risk (P < .001) and conferring a less negative social impression (P < .001). They were also viewed as less likely to satisfy nicotine cravings (P = .002), to relieve boredom (P = .0005), to have a calming effect (P < .001), and as tasting pleasant (P = .006)

Conclusions

E-cig use and advertising exposure are common among cancer patients. E-cig use is perceived as healthier and more socially acceptable but less likely to produce a number of desired consequences of cigarette use.

Young adult e-cigarette use outcome expectancies: Validity of a revised scale and a short scale

The revised youth e-cigarette outcome expectancies measure adds new items informed by recent qualitative research with young adult e-cigarette users, especially in the domain of positive "smoking" experience. Positive "smoking" experience represents beliefs that use of e-cigarettes provides outcomes associated with a better "smoking" alternative: for example, an alternative that is more socially approved, more suitable for indoor use, and that provides a safer means of enjoying nicotine. In addition, we tested a short, 8-item version of the measure which may be more easily incorporated into surveys. We tested the validity of the revised measure, both long and short versions, in terms of factor structure and associations of the expectancy factors with current e-cigarette use, e-cigarette use susceptibility, and e-cigarette use dependence. Participants were young adults (N=470; 65% women; mean age=20.9, SD=2.1). Results replicated the findings of the previous study as well as highlighted the importance of the added domain of positive "smoking" experience and the validity of the short scale. Furthermore, results showed that positive outcome expectancies are strongly associated with e-cigarette use dependence. The long and short versions of the revised youth e-cigarette outcome expectancies scale appear to be valid and useful for application not only among cigarette smokers and e-cigarette users but also among never smokers and never e-cigarette users.

The Relationships of Expectancies With E-cigarette Use Among Hospitalized Smokers: A Prospective Longitudinal Study

Background

Expectancies demonstrate cross-sectional associations with e-cigarette use, but the prospective relationships between expectancies and e-cigarette use are unknown. This study examined the longitudinal associations of expectancies with e-cigarette use among hospitalized tobacco cigarette smokers.

Methods

E-cigarette expectancies (e-cigarette-specific Brief Smoking Consequences Questionnaire-Adult [BSCQ-A]), tobacco cigarette expectancies (tobacco-specific BSCQ-A), and number of days used e-cigarettes in the past 30 days were assessed at baseline hospitalization, 6-months post-hospitalization, and 12-months post-hospitalization among 978 hospitalized tobacco cigarette smokers. Expectancy difference scores (e-cigarette-specific expectancies minus tobacco-specific expectancies) were computed for each of the 10 BSCQ-A scales. Cross-lagged panel models tested the relationships between expectancy difference scores and number of days used e-cigarettes in the past 30 days for each of the 10 BSCQ-A scales.

Results

Though some models revealed partial associations between expectancies and e-cigarette use, only one yielded results consistent with hypotheses. Greater e-cigarette use at baseline predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 6 months, which then predicted greater e-cigarette use at 12 months. To a lesser degree greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at baseline predicted greater e-cigarette use at 6 months, which then predicted greater expectancies that e-cigarettes taste pleasant as compared to tobacco cigarettes at 12 months.

Conclusions

Expectancies that e-cigarettes provide similar or more pleasant taste sensations as compared to tobacco cigarettes may be both a cause and consequence of e-cigarette use. Focusing on the taste experience may prove most effective in modifying e-cigarette use behavior.

Implications

The current study offers the first longitudinal examination of expectancies and e-cigarette use. Results suggest expectancies that e-cigarettes provide similar or more pleasant taste sensations relative to tobacco cigarettes are both a cause and consequence of e-cigarette use. Efforts that focus on the e-cigarette taste experience may prove most effective in modifying e-cigarette use behavior.

Electronic Cigarette Use Among Counseled Tobacco Users Hospitalized in 2015

OBJECTIVES

Few studies have examined the prevalence of electronic cigarette use among the inpatient population regardless of the patients' cessation goals. The objectives of this study were to examine the prevalence of electronic cigarette use among counseled tobacco users admitted to 2 academic hospitals.

METHODS

Cross-sectional data of hospitalized adult tobacco users who were admitted between January 1, 2015 and December 31, 2015 and who received bedside tobacco cessation counseling from a tobacco treatment service counselor were examined. Demographic and smoking history items were compared as a function of electronic cigarette use using chi-square and independent t tests. Logistic regression was used to test independent associations with electronic cigarette use.

RESULTS

Of 2194 hospitalized tobacco users counseled, 22% had used an electronic cigarette. Most of these patients used electronic cigarettes to quit or reduce use of combustible cigarettes. Adjusted odds of electronic cigarette use were higher for females (adjusted odds ratio [AOR] 0.60 for male patients, 95% confidence interval [CI] 0.47-0.76), younger patients (AOR 0.98 for older patients, 95% CI 0.97-0.99), and individuals who initiated tobacco use earlier in life (AOR 0.97 for later smoking initiation, 95% CI 0.95-0.99).

CONCLUSIONS

Screening hospitalized cigarette smokers for electronic cigarette use offers an opportunity to counsel all patients on evidence-based quit aids. Young, female patients are most likely to use electronic cigarettes and may benefit most from directed discussions about electronic cigarette use and Federal Drug Administration-approved cessation methods during smoking cessation counseling.

The Theory of Planned Behavior and E-cig Use: Impulsive Personality, E-cig Attitudes, and E-cig Use

The current paper applied the Theory of Planned Behavior (TPB; Ajzen & Fishbein, 1988) to understand how impulsive personality traits and attitudes concerning e-cig use relate to the likelihood of electronic cigarette (e-cig) use. Seven hundred and fourteen participants (Mean age = 34.04, SD = 10.89, 48.6% female) completed cross-sectional measures of e-cig use attitudes (CEAC) and the Short UPPS-P Impulsive Behavior Scale. A structural path analysis suggested that urgency and deficits in conscientiousness were significantly related to e-cig attitudes (CFI = 0.99, TLI = 0.99, RMSEA = 0.02; urgency: β = 0.32, p = .001; deficits in conscientiousness: β = -0.48, p < .001). E-cig attitude scores were significantly higher for e-cig users than non-users, β = 0.85, p < .001. There was no significant direct path from impulsive personality traits to e-cig use. Findings provide initial support for a model in which impulsive traits are related to e-cig use through positive e-cig attitudes.

Beliefs About the Direct Comparison of E-Cigarettes and Cigarettes

BACKGROUND

Recent data suggests that positive beliefs about electronic cigarettes (e-cigs) use can lead to later e-cig use. Considering that many advertisements claim that e-cigs are superior to cigarettes, individuals' likelihood to view e-cigs more favorably than cigarettes can also influence subsequent e-cig use; however, no studies have directly assessed such a comparison.

OBJECTIVES

The present study created and validated the Comparing E-Cigarettes and Cigarettes questionnaire (CEAC), which asks individuals to directly compare e-cigs and cigarettes on a number of dimensions, in two independent samples.

METHODS

In sample 1 (451 undergraduates; mean age = 20.35, SD = 5.44, 72.4% female, 73.4% Caucasian) we explored the factor structure of the CEAC and in sample 2 (699 community adults collected via Amazon's Mechanical Turk; mean age = 34.04, SD = 10.9, 47.7% female, 83.3% Caucasian) we replicated the factor structure.

RESULTS

Exploratory factor analysis suggested a three-factor structure: General Benefits (α = 0.80), General Effects (α = 0.86), and Health Benefits (α = 0.88), which was replicated via confirmatory factor analysis, χ² = 4.36; RMSEA = 0.07, 90% CI = 0.06-0.08; TLI = 0.99; CFI = 0.99, and was relatively invariant across product use and gender. Individuals reported viewing e-cigs as safer and more beneficial than cigarettes and these beliefs were higher in e-cig users.

CONCLUSIONS

Future work should establish how these comparative beliefs are influenced by e-cig use and/or influence subsequent transition to and increases in e-cig use. Although e-cigs are likely less harmful than cigarettes, and thus these comparative beliefs represent that state of nature, e-cigs are not completely without risk.

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

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

User identified positive outcome expectancies of electronic cigarette use: A concept mapping study

Electronic cigarette (ECIG) use is growing in popularity, but little is known about the perceived positive outcomes of ECIG use. This study used concept mapping (CM) to examine positive ECIG outcome expectancies. Sixty-three past 30-day ECIG users (38.1% female) between the ages of 18 and 64 (M = 37.8, SD = 13.3) completed a CM module. In an online program, participants provided statements that completed a prompt: "A specific positive, enjoyable, or exciting effect (i.e., physical or psychological) that I have experienced WHILE USING or IMMEDIATELY AFTER USING an electronic cigarette/electronic vaping device is. . . ." Participants (n = 35) sorted 123 statements into "piles" of similar content and rated (n = 43) each statement on a 7-point scale (1 = Definitely NOT a positive effect to 7 = Definitely a positive effect). A cluster map was created using data from the sorting task, and analysis indicated a 7 cluster model of positive ECIG use outcome expectancies: Therapeutic/Affect Regulation, High/Euphoria, Sensation Enjoyment, Perceived Health Effects, Benefits of Decreased Cigarette Use, Convenience, and Social Impacts. The Perceived Health Effects cluster was rated highest, although all mean ratings were greater than 4.69. Mean cluster ratings were compared, and females, younger adults, past 30-day cigarette smokers, users of more "advanced" ECIG devices, and nonlifetime (less than 100 lifetime cigarettes) participants rated certain clusters higher than comparison groups (ps < 0.05). ECIG users associate positive outcomes with ECIG use. ECIG outcome expectancies may affect product appeal and tobacco use behaviors and should be examined further to inform regulatory policies. (PsycINFO Database Record

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

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

EVIDENCE ACQUISITION

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

EVIDENCE SYNTHESIS

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

CONCLUSIONS

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

Electronic Cigarette Expectancies in Smokers with Psychological Distress

OBJECTIVES

Very few studies have evaluated perceptions of electronic nicotine delivery systems (ENDS) among smokers with mental illness. This study assessed expectancies about the effects of smoking combustible cigarettes or using ENDS among current smokers with and without severe psychological distress (SPD).

METHODS

We used a crowdsourcing system to survey 268 smokers on their expectancies for the effects of combustible cigarettes and ENDS. Positive expectancies assessed included negative affect reduction, stimulation, positive social effects and weight control, and negative expectancies included negative physical effects, negative psychosocial effects and future health concerns.

RESULTS

Smokers with SPD had higher positive expectancies for weight control and social effects of both products compared to those without such distress, and higher expectancies for stimulation from combustible cigarettes compared to ENDS. All participants had significantly lower negative expectancies for ENDS compared to combustible cigarettes, with no significant differences between the groups.

CONCLUSIONS

Smokers with SPD may be more vulnerable toward ENDS use, as they are for combustible cigarette use, due to greater positive expectancies of the products. Challenging positive expectancies may increase the efficacy of tobacco control efforts in this vulnerable population.

Factors and motivations associated with use of e-cigarette among primary care patients in a prospective cohort study: e-TAC study protocol

INTRODUCTION

While the relationship between electronic cigarette use and smoking has often been studied, the association between electronic cigarette use and socioeconomic factors has received less attention. This is a study protocol aiming to describe the relationship between the consumption of psychoactive products (in particular: smoking) or some socioeconomic factors and the evolution of the use of electronic cigarette in primary healthcare over 1 year.

METHODS AND ANALYSIS

Electronic cigarette, Tobacco, Alcohol and Cannabis (e-TAC) is a prospective multisite cohort study, including 473 patients at baseline and carrying out in general practices in the Aquitaine area (France). The volunteer patients participated in the study regardless of their initial reason for consultation. They filled out a self-administered questionnaire at baseline and will also do so after 12 months by phone, email or letter. The study will focus on the factors that explain the experimentation with or the current use of the electronic cigarette, as well as factors associated with their evolutions over time using multivariate logistic regression modelling or Cox regression modelling.

ETHICS AND DISSEMINATION

This study received ethical approval from the University of Bordeaux Committee for the protection of persons. It was also approved by the National Commission for Data Processing and Freedoms. Findings will be submitted for publication in peer-reviewed journals and we will disseminate them by presentations at national or international conferences.

TRIAL REGISTRATION NUMBER

RCB: 2015-A00778-41; Pre-results.

E-cigarettes and expectancies: why do some users keep smoking?

BACKGROUND AND AIMS

Many smokers who have tried electronic cigarettes ('e-cigarettes') continue to smoke, perhaps influenced by their beliefs about the outcomes of using e-cigarettes ('e-cigarette expectancies'). The primary aims of this study were to compare expectancies of dual users to former smokers, and to examine the association between expectancies and intentions to quit or reduce 'vaping' among former smokers.

DESIGN AND SETTING

A large cross-sectional online survey of e-cigarette users conducted in the United States.

PARTICIPANTS

We surveyed current e-cigarette users (n = 1815), including both current cigarette smokers ('dual users', n = 381) and former smokers (n = 1434). We further subdivided former smokers into those with (n = 686) and without (n = 748) intentions to reduce or quit e-cigarette use.

MEASUREMENTS

The primary outcomes were self-reported past-month smoking status and, among former smokers, current intentions to reduce or quit e-cigarette use, both adjusted for potential confounders. E-cigarette expectancy items were derived primarily from a previously validated measure of smoking expectancies.

FINDINGS

Dual users reported less positive expectancies than former smokers about e-cigarettes, rating e-cigarettes as more physically irritating (β = 0.10, P < 0.001) and addictive (β = 0.06, P = 0.016), as well as less satisfying (β = -0.11, P < 0.001). Former smokers with intentions to quit e-cigarettes also rated e-cigarettes less positively than former smokers without intentions to quit e-cigarettes, rating them more likely to damage health (β = 0.16, P < 0.001) and cause addiction (β = 0.10, P < 0.001), but less likely to taste good (β = -0.08, P = 0.006).

CONCLUSIONS

Positive e-cigarette expectancies among e-cigarette users are associated with a greater likelihood of having quit smoking, but lower likelihood of intention to quit e-cigarette use.

Young adult e-cigarette users' reasons for liking and not liking e-cigarettes: A qualitative study

OBJECTIVE

To gain an in-depth understanding of what young adult electronic- or e-cigarette users like or dislike about e-cigarettes. We aimed to determine the reasons that may encourage young adults to use e-cigarettes or discourage them from using e-cigarettes.

DESIGN

Twelve focus group discussions were conducted with 62 current daily e-cigarette users (63% men) of mean age = 25.1 years (standard deviation = 5.5). Data were analysed following principles of inductive content analysis.

RESULTS

Results indicated 12 categories of reasons for liking e-cigarettes (e.g., recreation, smoking cessation) and 6 categories of reasons for not liking e-cigarettes (e.g. poor product quality, poor smoking experience).

CONCLUSIONS

Young adults' motives for using or not using e-cigarettes appear to be varied and their relative importance in terms of predicting e-cigarette use initiation, dependence, and cigarette/e-cigarette dual use needs to be carefully studied in population-based, empirical studies. The current findings suggest that e-cigarettes may serve social, recreational, and sensory expectancies that are unique relative to cigarettes and not dependent on nicotine. Further, successful use of e-cigarettes in smoking cessation will likely need higher standards of product quality control, better nicotine delivery efficiency and a counselling component that would teach smokers how to manage e-cigarette devices while trying to quit smoking cigarettes.

Electronic Cigarettes: Vulnerability of Youth

Electronic cigarettes have become popular and are heavily promoted as a safer cigarette and an aid to quit smoking. Although they may have value in reducing cigarette use among smokers, they are of limited value in smoking cessation and pose many problems, particularly in children. Nicotine is highly addictive and affects virtually all cells in the body. It is particularly harmful to developing brains and other organs. The electronic nicotine delivery systems are largely uncontrolled and safety risks are manifold. Initiating nicotine use and increasing dependence in the population may be linked with increased tobacco and other addictive substance abuse even if the individual electronic cigarette delivers less harm than a combustible cigarette does.