Polytobacco use and risk perceptions among young adults: The potential role of habituation to risk

Perceived relative harm and addictiveness compared with cigarettes and intentions to use modified risk tobacco products utilizing FDA-authorized marketing claims among adults in the United States

INTRODUCTION

We assessed adults' perceived relative harm and addictiveness of products using FDA-authorized modified risk tobacco products (MRTP) claims and associations with intentions to use MRTPs.

METHODS

Data were from the May 2022 Rutgers Omnibus study among US 18-45-year-old adults (n=2964), collected by the Rutgers Institute for Nicotine and Tobacco Studies (INTS). Outcomes were perceived relative harm and addictiveness versus a typical cigarette and intentions to use a product stating a reduced harm claim (General Snus) or a reduced exposure claim (VLN King). We conducted regression analyses of associations between perceived relative harm and addictiveness and intentions to use each product, stratified by smoking status.

RESULTS

The minority of participants perceived products with a reduced harm claim as much less harmful vs. cigarettes (21 %, 19 %, 7 %, and 8 % among persons who smoked daily, smoked some days, formerly smoked, and never smoked respectively) and products with a reduced exposure claim as much less addictive vs. cigarettes (24 %, 26 %, 14 %, 20 % respectively). Perceived lower relative harm and addictiveness were significantly associated with higher intentions to use products stating reduced harm or reduced exposure claim across all smoking statuses with one exception (relative addictiveness was not associated with intention to use products stating the reduced harm claim among persons who formerly smoked).

CONCLUSIONS

Two current FDA-authorized MRTP claims were not effective in conveying that MRTPs were less harmful or addictive than cigarettes to most participants. Perceiving products as less harmful or addictive were significantly associated with intentions to use MRTPs.

E-cigarette use among early adolescent tobacco cigarette smokers: testing the disruption and entrenchment hypotheses in two longitudinal cohorts

OBJECTIVE

Using longitudinal data from two large-scale cohorts in the UK and USA, we examine whether e-cigarette use steers adolescent early smokers away from tobacco cigarettes (disruption hypothesis) or deepens early patterns of tobacco smoking (entrenchment hypothesis) in comparison with early smokers who do not use e-cigarettes.

METHODS

Youth who smoked tobacco cigarettes by early adolescence (before age 15) were selected from the ongoing UK Millennium Cohort Study (n=1090) and the US Population Assessment of Tobacco and Health (n=803) study. In regression models, the focal predictor was lifetime use of an e-cigarette by early adolescence and the primary outcome was current tobacco use by late adolescence (before age 18). Logistic and multinomial models controlled for early adolescent risk factors and sociodemographic background, and were weighted for attrition and adjusted for complex survey designs.

RESULTS

Among youth who were early cigarette smokers, 57% of UK and 58% of US youth also used e-cigarettes. The odds of later adolescent smoking among early smoking youth were significantly higher among e-cigarette users relative to those who had not used e-cigarettes (adjusted OR (AORUK)=1.45; AORUSA=2.19). In both samples, multinomial models indicated that early smoking youth who used e-cigarettes were more likely to be frequent smokers relative to not smoking (AORUK=2.01; AORUSA=5.11) and infrequent smoking (AORUK=1.67; AORUSA=2.11).

CONCLUSIONS

Despite national differences in e-cigarette regulation and marketing, there is evidence e-cigarette use among early adolescent smokers in the UK and USA leads to higher odds of any smoking and more frequent tobacco cigarette use later in adolescence.

Dual and poly-nicotine and tobacco use among adolescents in the United States from 2011 to 2022

BACKGROUND

Adolescent nicotine and tobacco product use remains common despite declining smoking rates in the United States, likely due to the emergence of novel products. Concurrent use of multiple products may increase the risk of nicotine dependency and subsequent substance use.

AIM

To identify patterns and trends of dual and poly nicotine and tobacco use among adolescents in the US and explore associations of dual and poly nicotine and tobacco use with sociodemographic factors.

METHODS

12 years of annual National Youth Tobacco Survey data (2011-2022) from 242,637 respondents were used to examine prevalence trends of different combinations of nicotine or tobacco product use among adolescents in the US using weighted point estimates for each year. Poisson regression models examined sociodemographic factors associated with different patterns of dual and poly-product use from 2011 to 2022.

RESULTS

Overall, the prevalence of dual (i.e. at least two products) and poly (i.e. at least three products) use decreased between 2011 and 2021 (from 9.5 % to 2.8 % and from 5.1 % to 1.1 %, respectively), but showed signs of increase between 2021 and 2022 (3.7 % for dual and 1.7 % for poly use). The most common combinations included a combustible product with either a novel or noncombustible product. The risk for dual and poly-product use was higher among non-Hispanic Whites, males, and high school students.

CONCLUSIONS

Previously declining trends in the prevalence of tobacco/nicotine dual and poly use may have been reversed. Close monitoring and targeted tobacco control policies are essential to tackle multiple product use among adolescents.

Does source matter? Examining the effects of health experts, friends, and social media influencers on young adult perceptions of Instagram e-cigarette education messages

PURPOSE

Young adults' e-cigarette use is a leading public health concern. Using messages from credible sources can help improve message acceptance, yet little research has examined the role of source credibility on young adults' responses to e-cigarette education messages.

METHODS

We examined the impact of source on young adults' perceptions of e-cigarette education messages and e-cigarettes. In July 2022, we conducted an experimental study using an online sample of young adults (N=459, Mage=24.6) who were randomized to one of three source conditions: expert, friend, or influencer, and viewed e-cigarette education messages. We used one-way ANOVA to estimate the association between the conditions and outcomes (perceived source credibility, message trust, curiosity, use interests, perceived message effectiveness, beliefs, harm perceptions, and intentions to refrain).

RESULTS

The expert condition was associated with significantly higher perceived source credibility (vs. friend, influencer; p<0.001), message trust (vs. friend, influencer; p<0.001), and curiosity (vs. influencer; p's<0.05).

CONCLUSIONS

Public health campaigns may leverage health experts to deliver e-cigarette education messages targeting young adults to improve effectiveness of the messages.

Association of Vaping Identity and e-Cigarette Perceptions among Young Adults Who Vape

Background: In the U.S., 9.3% of young adults currently vape. However, little is known about how vaping identity (i.e., internalizing vaping as an important part of oneself) can influence young adults' e-cigarette perceptions. The purpose of this study was to examine the association between vaping identity and e-cigarette perceptions among young adults. Methods: Young adults who vape (N = 252, Mage = 24.7) were recruited to participate in an online survey assessing a trusted source of health information, e-cigarette harm perceptions, and intentions to abstain from vaping. We estimated associations between vaping identity on outcomes and the interaction of vaping identity and combustible cigarette use on outcomes. Results: Participants with higher vaping identity reported lower trust in government health agencies and a doctor, and higher trust in the tobacco industry and e-cigarette industry (ps < 0.05). Those with higher vaping identity also reported lower e-cigarette harm perceptions and intentions to abstain from vaping (ps < 0.05). Conclusions: Findings show that higher vaping identity is associated with greater trust in the tobacco industry, lower trust in health experts, lower e-cigarette harm perceptions, and lower intentions to abstain from using e-cigarettes. This suggests that efforts to reduce vaping among young adults may need to leverage messages that reduce the credibility of the tobacco industry and prevent nonsmoking young adults from developing a vaping identity.

Latent Classes of Perceived Addictiveness Predict Marijuana, Alcohol, and Tobacco Use in Youth and Young Adults

Background: Mass media substance use prevention efforts target addiction perceptions in young people. This study examined youth and young adults' (YAs) perceived addictiveness across several substances and the associations between addiction perceptions and substance use. Methods: Data were collected in 2019 in an online cohort study of Vermonters aged 12-25. Latent class analyses grouped participants by perceived addictiveness of nicotine, caffeine, alcohol, marijuana, cigarettes, electronic vapor products (EVPs), and opioids. Bivariate multinomial logistic and modified Poisson regression estimated associations between sociodemographics, substance use correlates, and subsequent use across latent classes. Results: Four latent classes captured addiction perceptions: high perceived addictiveness of EVPs, cigarettes, marijuana, and alcohol (Class 1: n = 317; 31.3%), low perceived addictiveness of marijuana, alcohol, and caffeine (Class 2: n = 151; 14.3%), low perceived addictiveness of marijuana (Class 3: n = 581; 46.5%), and low perceived addictiveness of nicotine, cigarettes, and EVPs (Class 4: n = 83; 7.9%). For each year increase in age, there was a 36% increased likelihood of being in Class 2 (vs. Class 1) and a 148% increased likelihood of belonging to Class 3 (vs. Class 1). Low perceived addictiveness classes were associated with ever and past 30-day marijuana and alcohol use and predicted past 30-day alcohol use at three-month follow-up. Membership in Classes 2 and 3 also predicted past 30-day marijuana use at Wave 3. Discussion: The strong association between age and latent classes defined by low perceived addictiveness suggests age group differences in addiction perceptions. Findings suggest that YAs may benefit from prevention messaging on addictiveness.

Exploring Transgender and Gender Diverse Young Adult Tobacco Use

Aside from prevalence estimates and comparisons to heterosexual and presumed cisgender (i.e., not transgender) samples, little is known about transgender and gender diverse (TGD) young adult tobacco use. This study explored reasons and contexts TGD young adults used a variety of tobacco products through 25 one-on-one semi-structured qualitative interviews in 2018. Thematic analysis yielded four themes: (1) smoking in response to anxiety, depression, or stress, (2) social smoking, (3) accepting smoking-related norms, and (4) appealing aspects of tobacco. The first three themes contained elements specifically tied to TGD identity; the final theme related to perceptions of tobacco unrelated to identity. Findings suggest reasons for smoking that are unique to TGD young adults, who frequently reported smoking cigarettes as a coping response to an amalgam of stressors. Accounting for unique stressors related to TGD identity will assist in developing culturally relevant interventions to reduce the disproportionate tobacco burden in TGD communities.

Associations between perceived source credibility, e-cigarettes, and e-cigarette ad perceptions

The use of e-cigarettes among U.S. adults remains high, and aggressive industry advertising is a contributor. Consumer opinions of the e-cigarette industry's credibility can influence e-cigarette product and ad perceptions. The purpose of this study was to examine the association of perceived source credibility of e-cigarette ads and consumer attitudes toward e-cigarette ads and product use. In October 2021, we conducted a survey using an online convenience sample (N = 497, Mage = 31.9). Participants viewed two randomly selected e-cigarette ads and were asked questions regarding source credibility, perceptions of the ads, and e-cigarette use. Linear mixed effects models with random intercepts were used to estimate associations between perceived source credibility with perceived ad relevance, effectiveness, liking, product use interest, and e-cigarette harms perceptions. We also tested whether associations between perceived source credibility and ad and e-cigarette perceptions were moderated by e-cigarette use. Models controlled for cigarette smoking status, age, sex, race, ethnicity, sexual orientation, and income. Perceived source credibility was positively associated with increased perceived ad relevance, effectiveness, liking, and product use interest (ps < 0.001). E-cigarette use moderated associations of perceived source credibility and perceived ad relevance, perceived ad effectiveness, and interest in using e-cigarettes, with associations being strongest among never users. Findings suggest that tobacco control messaging aiming to reduce the credibility of the e-cigarette industry might be most effective among adults who have never used e-cigarettes.

Youth vaping beliefs and behaviors: evidence from New York

Current use of vaping products has increased in recent years among youth in the United States. We conducted cross-sectional surveys of vaping product users aged 15-17 in New York in 2017 and 2019 to assess vaping freqency, reported nicotine content of vaping products used, risk perceptions of vaping and openness to vaping cannabis (2019 survey only). Between 2017 and 2019, the proportion of youth vapers who were frequent vaping product users increased from 16.8% to 26.2% (P < 0.05). The proportion of youth vapers who usually used high-nicotine vaping products also increased, from 12.6% to 40.0% (P < 0.05). In both years, the use of high-nicotine vaping products was positively associated with frequent use (P < 0.05). The perceived likelihood of harm from vaping increased (P < 0.05), but respondents' perception of harm from using tobacco-flavored vaping products remained higher than that from using menthol/mint or sweet flavors. In 2019, 60.6% of respondents reported having tried vaping cannabis. Results suggest shifts in youth vaping behavior toward more frequent use and use of higher nicotine vaping products, support previous findings about youth misperceptions about health risks of flavored vaping products and highlight openness to vaping cannabis among youth vaping product users.

Sex and Sexual Identity Differences in Poly-tobacco Use and Psychological Distress in U.S. Adults: Results From the National Health Interview Survey

INTRODUCTION

Poly-tobacco use (PTU), or the concomitant use of two or more nicotine and tobacco products, are a growing public health concern. Adults reporting increased psychological distress (PD) experience profound nicotine and tobacco health-related disparities. Sexual minority (SM) adults report more PTU and higher levels of PD than heterosexuals, yet little is known about patterns of nicotine and tobacco use and its relationship to PD in SM populations.

AIMS AND METHODS

The purpose of this study was to investigate sexual identity differences in PD and PTU. Data were drawn from the 2016-2018 National Health Interview Survey (N = 83 017), an annual cross-sectional survey of a nationally representative sample of U.S. adults. PD was assessed using the Kessler Psychological Distress Scale (K6). We fit sex-stratified, weighted, adjusted logistic models to compare PTU and PD by sexual identity.

RESULTS

PTU was more prevalent in adults with higher K6 scores. Female adults and SM adults had significantly higher K6 scores and were significantly more likely to experience serious PD when compared to their male and heterosexual counterparts.

CONCLUSIONS

The current study provides a snapshot of trends in PTU in relation to PD, gender, and sexual identity. Findings suggest higher rates of both PD and PTU in SM adults. Further research examining the mechanisms underlying this disparity is critical to the development of effective intervention and prevention strategies.

IMPLICATIONS

Little is known about sex and sexual identity differences in the relations between patterns of tobacco product use and PD. This study is the first to examine the effect of gender and sexual identity on both PD and PTU. SMs reported higher rates of PD and were more likely to be poly-tobacco users. As new ways of engaging nicotine/tobacco continue to proliferate, health risks will endure especially for marginalized populations. An increased understanding of the psychological and social correlates of PTU in SMs is warranted.

Integrating Self-Report and Psychophysiological Measures in Waterpipe Tobacco Message Testing: A Novel Application of Multi-Attribute Decision Modeling

BACKGROUND

Waterpipe (i.e., hookah) tobacco smoking (WTS) is one of the most prevalent types of smoking among young people, yet there is little public education communicating the risks of WTS to the population. Using self-report and psychophysiological measures, this study proposes an innovative message testing and data integration approach to choose optimal content for health communication messaging focusing on WTS.

METHODS

In a two-part study, we tested 12 WTS risk messages. Using crowdsourcing, participants (N = 713) rated WTS messages based on self-reported receptivity, engagement, attitudes, and negative emotions. In an in-lab study, participants (N = 120) viewed the 12 WTS risk messages while being monitored for heart rate and eye-tracking, and then completed a recognition task. Using a multi-attribute decision-making (MADM) model, we integrated data from these two methods with scenarios assigning different weights to the self-report and laboratory data to identify optimal messages.

RESULTS

We identified different optimal messages when differently weighting the importance of specific attributes or data collection method (self-report, laboratory). Across all scenarios, five messages consistently ranked in the top half: four addressed harms content, both alone and with themes regarding social use and flavors and one addiction alone message.

DISCUSSION

Results showed that the self-report and psychophysiological data did not always have the same ranking and differed based on weighting of the two methods. These findings highlight the need to formatively test messages using multiple methods and use an integrated approach when selecting content.

Global Patterns and Prevalence of Dual and Poly-Tobacco Use: A Systematic Review

INTRODUCTION

Improving understanding of the epidemiology of dual and poly-tobacco product use is essential for tobacco control policy and practice. The present study aimed to systematically review existing epidemiologic evidence on current dual and poly-tobacco use among adults globally.

METHODS

We systematically searched online databases for studies published up to June 30, 2020. We included quantitative studies with measures of nationally representative prevalence of current dual or poly-tobacco use among adults. Prevalence estimates for each country were extracted manually and stratified by WHO regions and World Bank income classifications.

RESULTS

Twenty studies with nationally representative prevalence data on current dual or poly-tobacco use in the adult population across 48 countries were included. Definitions of dual and poly-tobacco use varied widely. Prevalence of dual and poly-tobacco use was higher in low- and lower-middle-income countries compared to other higher-income countries. Current dual use of smoked and smokeless tobacco products among males ranged from 0.2% in Ukraine (2010) and Mexico (2009) to 17.9% in Nepal (2011). Poly-tobacco use among males ranged from 0.8% in Mexico (2009) and 0.9% in Argentina (2010) to 11.4% in the United Kingdom and 11.9% in Denmark in 2012. Dual tobacco use was generally higher in South-East Asia; poly-tobacco use was prevalent in Europe as well as in South-East Asia.

CONCLUSIONS

This is the first systematic review of the prevalence estimates of dual and poly-tobacco use among adults globally. The results of the current study could significantly help health policy makers to implement effective tobacco control policies.

IMPLICATIONS

This study demonstrates that dual/poly-tobacco use is common in many countries of the world, and highlights the need for in-depth exploration of this field in future studies, especially in high prevalence regions such as South-East Asian and European countries. In light of this, the global tobacco control community and health authorities should also agree upon a consistent operational definition of dual and poly-tobacco use to propel research and improve surveillance of dual/poly-use in health surveys for better communication and understanding of these phenomena.

Exploratory evaluation of online brief education for JUUL pod-mod use and prevention

INTRODUCTION

Initiation of e-cigarette use by young adults is a significant public health issue within the debate on vaping. The current study is an exploratory evaluation of brief educational information among young adults and investigated outcomes as a function of JUUL use and smoking status.

METHODS

Participants (N = 947) were young adults (<30 years old) recruited from Amazon's Mechanical Turk based on smoking and JUUL use status. Participants completed baseline assessments, viewed a brief JUUL educational handout, and completed post-assessments.

RESULTS

There was a significant Time X Group interaction for JUUL-related knowledge (p < .001), with never JUUL/never smokers showing the greatest increase in knowledge. Brief education increased JUUL-related knowledge and risk perceptions and had a modest impact on commitment to quitting and readiness to quit JUUL (all p ≤ 0.001; ds = 0.06-0.74; time × group p > .05 for all contrasts except JUUL-related knowledge). Participants showed modest decreases in interest in future JUUL use, interest in purchasing, and interest in future regular use (all p ≤ 0.001; ds = 0.07-0.08; time × group p > .05 for all contrasts). In terms of smoking outcomes, participants reported reduced perceived harm to others (p < .001; d = 0.09) and decreased intentions to smoke regularly (p = .001; d = 0.07).

CONCLUSIONS

Brief education was effective in increasing knowledge and risk perceptions while showing a modest effect on intentions for future use. The information was most effective in increasing knowledge among non-users, suggesting that brief education may be useful for preventing initiation. Analysis of group differences suggest current JUUL use status is more important in informing JUUL-related attitudes than smoking status.

Heated tobacco product use and its relationship to quitting combustible cigarettes in Korean adults

OBJECTIVE

We assessed the prevalence of, and factors associated with, heated tobacco product (HTP) use and analysed the association between HTP use and quitting combustible cigarettes (CCs) in Korean adults.

METHODS

We conducted an online survey with 7,000 adults (males, 2,300; females, 4,700; ages 20-69) out of 70,000 age-, sex- and provincial-distribution-matched individuals based on 2018 national population statistics. Females were oversampled because the prevalence of tobacco product use is very low among women in Korea. Chi-square tests were used for bivariate analyses, and odds ratios were assessed after adjusting for sociodemographic variables.

RESULTS

The prevalence of current CC, electronic cigarette (EC), and HTP use was 24.8% (males, 40.4%; females, 9.3%), 6.8% (males, 10.1%; females, 3.4%), and 10.2% (males, 16.2%; females, 4.3%), respectively. Among the 574 current HTP users, 77 (13.4%) were HTP-only users and >80% were either dual users of HTP and CC/EC, or triple users of HTP, EC, and CC. Among the current CC users, the odds of having attempted to quit CCs in the past year were greater among EC-only users (aOR 2.92; 95% CI 1.81-4.69) and dual users of HTPs and ECs (aOR 8.42; 95% CI 4.85-14.62) than among non-HTP and non-EC users. Among 2,121 ever CC smokers, the likelihood of being a former CC smoker was 0.19 (95% CI 0.15-0.24) for HTP users, 0.29 (95% CI 0.20-0.42) for EC users, and 0.03 (95% CI 0.01-0.06) for users of both HTPs and ECs compared with non-HTP and non-EC users.

CONCLUSION

EC-only use and dual use of HTPs and ECs were associated with increased attempts to quit CCs; however, HTP and EC use was associated with lower odds of CC smoking abstinence.

Correlates of Awareness and Use of Heated Tobacco Products in a Sample of US Young Adults in 2018-2019

INTRODUCTION

Tobacco companies have devoted increased resources in recent years to developing and marketing heated tobacco products (HTPs) as alternatives to combustible products like cigarettes. However, little is known about correlates of awareness and use of these products in American young adults.

METHODS

Two thousand four hundred ninety-seven young adults (mean age = 21.6) completed survey items on HTP awareness and lifetime use in 2018-2019. Logistic regression models compared young adults who were (1) unaware of HTPs (reference group) with those who were, (2) aware of HTPs, and (3) had ever used HTPs on demographic, tobacco, and other substance use characteristics. Among current smokers, these groups were compared on cigarette use, dependence, and readiness to quit.

RESULTS

Approximately 12% of respondents (n = 293) were aware of HTPs, and 5% (n = 134) reported lifetime HTP use. Controlling for demographics, HTP awareness and use were both associated with greater use of all types of tobacco products, number of different tobacco products, and use of marijuana and other drugs. Among current smokers, HTP awareness and use correlated with heavier cigarette consumption, greater dependence, and past-month marijuana use, but not with recent quit attempts or thinking about quitting cigarettes.

CONCLUSIONS

Awareness and use of HTPs among young adults were associated with greater use of tobacco products and other substances and, among current smokers, with greater cigarette dependence (but not cessation-related factors). As these products become increasingly available in the United States, additional surveillance and monitoring activities are needed to better understand use patterns, consequences, and reasons for using HTPs.

IMPLICATIONS

Few studies have examined factors associated with awareness and use of heated tobacco products (HTPs) among US young adults. HTP awareness and lifetime use correlated with a range of factors, including male gender, white race/ethnicity, and tobacco and other substance use. Lifetime use of HTPs was low (5%); most lifetime HTP users reported history of other tobacco use, but a sizeable minority (14%) reported no other tobacco product use history. Among current cigarette smokers, cigarette dependence, poly-tobacco use, and marijuana use-but not cigarette cessation attempts or contemplation-were associated with greater likelihood of awareness and use of HTPs.

Harm Perceptions of the JUUL E-Cigarette in a Sample of Ever Users

BACKGROUND

Monitoring trends and perceptions of new nicotine salt-based electronic cigarettes (ECs), like JUUL, is important to identify associations with product experimentation and use. Understanding harm perceptions of these new devices will inform prevention and intervention efforts. The current study assesses perceptions of the absolute harmfulness of JUUL use in addition to comparing it to other tobacco products.

METHODS

Participants (N = 839, 52% male) reporting ever use of JUUL were recruited from Amazon's Mechanical Turk from January to March 2018. Respondents completed questionnaire items assessing demographics, co-use of non-JUUL products, JUUL use status (i.e., daily users (10.8%), non-daily users (29.4%), and triers (59.9%)), and JUUL and other tobacco products absolute harm perceptions.

RESULTS

Overall, participants rated JUUL as significantly less harmful than all other tobacco products (p < 0.001), except other ECs. Daily JUUL users rated JUUL as less harmful compared to non-daily JUUL users and JUUL triers (p < 0.05). JUUL was rated as more harmful by women compared to men (p < 0.05).

CONCLUSIONS

Increased frequency of JUUL use was associated with decreased harm perceptions. JUUL was associated with reduced perceptions of absolute harm compared to most other tobacco products, except other ECs. Public health practitioners should develop public health interventions that increase harm perceptions of ECs.

How and Why California Young Adults Are Using Different Brands of Pod-Type Electronic Cigarettes in 2019: Implications for Researchers and Regulators

PURPOSE

The aim of the study was to describe young adult use and perceptions of different brands of pod-based electronic cigarettes (e-cigarettes) and compare with earlier types of non-pod-based e-cigarettes (e.g., mods and tanks).

METHODS

Data were collected from January to March 2019 and derive from the final wave of a cohort study recruited in 2013-2014 using a convenience sample from 10 large California high schools with racially/ethnically and socioeconomically diverse populations. A total of 445 participants completed an online survey (mean age = 20.1 years [SD = 1.66], 64.8% female [n = 278], 38.8% white [n = 161], 23.9% each for Asian and "more than one race" [n = 99], 13.5% other [n = 56], and 36.9% Hispanic [n = 160]). The main outcomes were description of and reasons to use pods, perceived nicotine content, and use patterns.

RESULTS

Although <25% of participants reported smoking cigarettes and using non-pod-based e-cigarettes, >25% reported ever use of JUUL. Similarly, <33% of cigarette smokers and non-pod-based e-cigarette users reported use in the past 30 days, and >50% of JUUL ever users did. The most agreed upon reason (58%) for using pods was because they are "easy to hide." About half of pod users "do not know" if they mix brands of e-juice and pods, the nicotine concentration in their e-juice cartridges, nor time to finish a cartridge. Of the 50% of participants who shared their pod, 23 (15%) did "sometimes," 20 (13%) "always," and 16 (11% each) "about half the time" or "often." There was no consensus about how to refer to different brands of pods.

CONCLUSIONS

Our findings indicate young adults harbor confusion about pod-based e-cigarettes, including nicotine content, usage patterns, and labeling, and that pod use is largely because of the ease with which they can "stealth" vape. The findings suggest needed regulation and education about these products.

Cigarette, E-Cigarette and Waterpipe Use among Young Adults: Differential Cognitions about These Three Forms of Smoking

Background: Polytobacco use is common among young adults. The purpose of the present study was to investigate a number of cognitions related to the use of three tobacco products (cigarettes, e-cigarettes and waterpipes) among young adults. Methods: Participants (n = 799, 59.4% women) aged 18–25 years old (M = 21.8, SD = 1.7) completed an online tobacco cognitions questionnaire. Results: For all three tobacco products, there was significantly more agreement with the cognition “I would smoke if my best friend offered” among tobacco users (used one or more tobacco products) than among non-users. For e-cigarettes and waterpipes, there was significantly more agreement with the cognition “It would be easy to quit these products” than was reported by non-users. Polytobacco users (three tobacco products) endorsed the cognitions scale (the six cognition items were combined to form a single cognitions scale for each tobacco product) significantly more than non-users for cigarettes and e-cigarettes. Furthermore, waterpipe users, polytobacco users, dual users and single users all endorsed the combined cognitions scales more strongly than non-users. Conclusions: Efforts to prevent polytobacco use should ensure that young adults have the necessary self-efficacy to resist peer pressure and provide them with clear information about the health risks associated with using alternative tobacco products.

Prevalence and predictors of heated tobacco product use and its relationship with attempts to quit cigarette smoking among Korean adolescents

INTRODUCTION

Heated tobacco products (HTPs) have been available in the Korean market since June 2017. In this study, we examined the prevalence and predictors of HTP use among Korean adolescents and the association between HTP and electronic cigarette (EC) use and attempts to quit conventional cigarette (CC) smoking.

METHODS

We analysed the data of a representative sample (n=60 040) of 13-18-year-old middle-school and high-school students in Korea who had participated in the 14th Korea Youth Risk Behavior Web-based Survey in 2018.

RESULTS

The prevalence of ever HTP use among Korean adolescents was 2.9% (men: 4.4%, women: 1.2%), a year after the introduction of HTPs in the Korean market. Furthermore, 81.3% of the 1568 ever HTP users were triple users of HTPs, ECs and CCs. Multivariate analysis revealed that ever HTP use was greater among men, higher-grade students, current CC and/or EC users and risky alcohol drinkers. Among current CC smokers, ever users of ECs (28%-30%) and ever HTP users and current EC users (48%) were more likely to have attempted to quit CC smoking than those who had never used HTPs and ECs. However, there were fewer HTP and/or EC ever users among ever CC smokers who successfully quit smoking.

CONCLUSIONS

Many adolescents, especially CC and EC users, had already used HTPs shortly after the introduction of HTPs in Korea. The use of newer types of tobacco products is associated with lower odds of abstinence from CCs; therefore, it is important to protect adolescents from them.

Sex and Polytobacco Use among Spanish and Turkish University Students

Polytobacco use has become increasingly popular among young adults, particularly males, and can be defined as the concurrent use of regular cigarettes and other tobacco products (e.g., e-cigarettes). The present study investigated the use of legal smoking products (cigarettes, waterpipe and electronic cigarettes) among young adults (n = 355) in Spain and Turkey. The survey measured demographics, lifetime and past month tobacco use, waterpipe and e-cigarette use, whether waterpipes and e-cigarettes contained nicotine and reasons for using these substances. The majority of the Turkish (men = 80% and women = 63.9%) and Spanish sample (men = 61.4% and women = 69.3%) were polytobacco users. The most common reason for using e-cigarettes was “to experiment, to see what is like” (Turkish sample: men 66.7% and women 57.1; Spanish sample: men 72.7% and women 93.8%). The most common reason to use regular cigarettes was “to relax and relieve tension” (Turkish sample: men 88.9% and women 77.6%; Spanish sample: men 78.1% and women 76%), while for waterpipe users, the most common reason was “to experiment, to see what it is like” (Turkish sample: men 93.3% and women 80%; Spanish sample: men 78.9% and women 93.8%). The implications for prevention and future research are discussed.

Age differences in electronic nicotine delivery systems (ENDS) usage motivations and behaviors, perceived health benefit, and intention to quit

INTRODUCTION

Data from comprehensive studies are sparse regarding age differences in issues related to electronic nicotine delivery systems (ENDS) usage. This study examined age differences in usage motivations and behaviors, perceived health benefit, and quit intentions in a large and diverse sample recruited online.

METHODS

The sample included 1,432 current ENDS users, ages 18-64, drawn from a national online survey conducted in 2016. Descriptive and multivariable analyses were used.

RESULTS

The sample included participants in the following age groups: 18-24 (17.5%), 25-34 (38.6%), 35-44 (23.3%), and 45-64 (20.7%). With multiple adjustments, the 18-24 age group was more likely to vape for reasons such as flavors or friends' use, and to use multiple flavors and products with varying nicotine content. For example, the odds (95% CI) of vaping initiation due to flavor attraction vs. other reasons in the 18-24 age group were 1.40 (1.02-1.92), 2.73 (1.85-3.99), and 2.12 (1.41-3.18) compared to the 25-34, 35-44, and 45-64 age groups, respectively. In contrast, compared to older age groups, the 18-24 age group was less likely to use ENDS as an alternative to cigarettes or as a quitting device; they also used ENDS less frequently and perceived less health benefit of ENDS use. The 18-24 age group, especially those who had only used ENDS, had the lowest odds of likely quitting use of tobacco/nicotine products compared to other groups (lower by 44-73%).

CONCLUSION

There were significant age differences in ENDS usage motivations and behaviors, perceived health benefit, and quit intentions.