The rise of e-cigarettes, pod mod devices, and JUUL among youth: Factors influencing use, health implications, and downstream effects

EAP and ECPCP urge ban on novel nicotine- (NNCPS) and non-nicotine-containing products (NNDS) to youth

AIM

We want to verify the correlation between the increasing use of novel nicotine-containing products (NNCPs) and non-nicotine delivery products (NNDPs) among young individuals and the escalating negative health consequences, necessitating their prohibition.

METHODS

We performed a comprehensive analysis of the most relevant literature about the utilisation of NNCPs and NNDPs among young individuals and their health effects.

RESULTS

Despite being initially seen as less harmful alternatives, for smokers aiming to quit, these products have become more popular due to misleading marketing claims. Teenagers using NNCPs and NNDPs, despite having no smoking history, are more likely to transition to tobacco smoking. Consistent use can lead to health issues like pulmonary damage, asthma, and cardiovascular and ocular problems.

CONCLUSION

The EAP and the ECPCP endorse the WHO's appeal to outlaw these hazardous products. They urge European governments to forbid the sale of NNCPs and NNDPs to children and adolescents in order to safeguard their well-being. They also propose specific recommendations (box 4) to support this cause.

Products and patterns through which adolescents, young adults, and adults initiate co-use of tobacco and cannabis

BACKGROUND

Co-use of tobacco and cannabis is common. However, few studies have examined the temporal sequencing through which individuals initiate co-use, and how these patterns vary across age. This study addresses this gap by examining the specific products and temporal sequencing through which adolescents, young adults, and adults initiate co-use of tobacco and cannabis. Among adolescents, young adults, and adults who co-used tobacco and cannabis in the past 30 days, we examined (a) whether tobacco or cannabis was used first in their lifetime and (b) which specific tobacco or cannabis product (e.g., nicotine e-cigarettes, cannabis edibles) was the first used.

METHODS

Data were from a cross-sectional national survey (N = 6,131, 13-40 years old) in which participants reported ever use, past-30-day-use, and order of use for 17 different tobacco and cannabis products. Results were analyzed overall and by age group (13-20; 21-24; 25-40).

RESULTS

38.4% of participants reported use of both tobacco and cannabis in the past 30 days. Among these participants, 70.9% used tobacco first in their lifetime (66.6% < 21; 71.7% 21-24; 76.6% > 24). Approximately 60% of participants who initiated co-use with tobacco reported nicotine e-cigarettes as their first tobacco product (63.3% < 21; 66.7% 21-24; 49.6% > 24).

CONCLUSIONS

The majority of participants who used both tobacco and cannabis used tobacco first in their lifetime, and nicotine e-cigarettes were the most common form of tobacco initiation, particularly among adolescents and young adults. Findings emphasize the need for co-use prevention programs to target common products of initiation.

Identifying the ways in which tobacco cessation interventions have been tailored for sexual and gender minority individuals: A systematic review

Sexual and gender minority (SGM) individuals smoke at higher rates than their heterosexual and cisgender peers. SGM persons, especially transgender and gender diverse (TGD) individuals, face unique, adverse health effects associated with smoking. As such, SGM individuals may benefit from smoking cessation interventions that are tailored to meet their needs. This systematic review aims to describe the ways in which these interventions have been tailored for SGM individuals and summarize available acceptability and efficacy data. Four databases were searched to identify smoking cessation interventions adapted for SGM populations. Thirteen articles were identified, with tailored aspects focusing on culturally tailored references, SGM-specific psychoeducation, and intra-community support strategies. No clear patterns of efficacy were identified, and only one study included bioverified abstinence. Preliminary evidence suggests that smoking cessation interventions can be acceptably tailored to SGM individuals, however, additional research is needed to determine if SGM-tailored interventions are more efficacious than non-tailored approaches.

Flavor & device choices among people who use ENDS: Results from the PATH Study

INTRODUCTION

In guidance published in February 2020, the FDA described their intent to prioritize enforcement against the sale of flavored cartridge-based electronic nicotine delivery systems (ENDS) except tobacco and menthol flavors. This guidance was specific to cartridge-based ENDS and did not apply to other ENDS types or e-liquids sold in the United States (U.S.). It remains unknown if use of certain types of ENDS devices and flavors changed following the publication of this guidance.

METHODS

This analysis includes PATH Study data from Wave 5 (W5, 2018-2019) and Wave 6 (W6, 2021) and examines cross-sectional estimates of 1) use of flavored ENDS and 2) use of different device types. All analyses in this study were stratified by self-reported age (youth - aged 12-17 years at W5 and aged 14-17 years at W6, and adults - aged 18-20, 21-24, and 25+). Analyses were conducted in 2023-2024.

RESULTS

Among adults aged 21 years and over, there were significant increases in the use of menthol or mint flavored ENDS. There were no substantial changes in flavors of ENDS used among youth or adults aged 18-20 years. Among all age groups, the use of cartridge-based ENDS was lower in 2021 than 2018-2019, with a notable shift to disposable-style ENDS.

CONCLUSIONS

Federal-level tobacco control actions taken in the U.S. in early 2020 prioritized enforcement against "any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product)". Based on this analysis, there was a shift following the policy to menthol or mint-flavored ENDS and disposable-style ENDS.

Assessing the association between e-cigarette use and cardiovascular disease: A meta-analysis of exclusive and dual use with combustible cigarettes

BACKGROUND

Growing evidence highlights the impact of e-cigarette use on cardiovascular health, prompting a crucial examination of its association with cardiovascular disease (CVD) in both exclusive e-cigarette and dual use scenarios with combustible cigarettes. This meta-analysis assessed the association between e-cigarette use and CVD by synthesizing the existing literature.

METHODS

Pertinent observational studies were identified using multiple electronic databases, from August 22nd, 2006, to April 10th, 2024. A meta-analysis was conducted using random-effect models. Risk of bias was assessed using the National Institutes of Health (NIH) Study Quality Assessment Tools.

FINDINGS

A total of 20 observational studies involving 8,499,444 participants were included in the meta-analysis. Dual use (e-cigarettes and combustible cigarette) increased the odds of CVD by 2.56 times (95 % CI: 2.11, 3.11) compared to never use of both. Current e-cigarette use combined with former combustible cigarette increased the odds of CVD by 2.02 times (95 % CI: 1.58, 2.58) compared to never use of either. Exclusive current e-cigarette use did not show a statistically significant association with CVD odds compared to never use of either (OR = 1.24, 95 % CI: 0.93, 1.67).

CONCLUSIONS

Dual use of e-cigarettes and combustible cigarettes was significantly associated with CVD, but results failed to show a significant association between exclusive e-cigarette use and CVD. Robust and longitudinal studies are needed to understand the long-term implications of e-cigarette use and CVD. Public health efforts should focus on awareness, smoking cessation, and regulating both e-cigarettes and combustible cigarettes.

A comprehensive toxicological analysis of panel of unregulated e-cigarettes to human health

Electronic cigarettes, commonly referred to as e-cigarettes have gained popularity over recent years especially among young individuals. In the light of the escalating prevalence of the use of these products and their potential for long-term health effects, in this study as the first of its kind a comprehensive toxicological profiling of the liquid from a panel of unregulated e-cigarettes seized in the UK was undertaken using an in vitro co-culture model of the upper airways. The data showed that e-cigarettes caused a dose dependent increase in cell death and inflammation manifested by enhanced release of IL1ß and IL6. Furthermore, the e-cigarettes induced oxidative stress as demonstrated by a reduction of intracellular glutathione and an increase in generation of reactive oxygen species. Moreover, the assessment of genotoxicity showed significant DNA strand breaks (following exposure to Tigerblood flavoured e-cigarette). Moreover, relevant to the toxicological observations, was the detection of varying and frequently high levels of hazardous metals including cadmium, copper, nickel and lead. This study highlights the importance of active and ongoing collaborations between academia, governmental organisations and policy makers (Trading standards, Public Health) and national health service in tackling vape addiction and better informing the general public regarding the risks associated with e-cigarette usage.

Changes of campus tobacco control environment and the impact on tobacco control behaviors among secondary school personnel in Shanghai, China

INTRODUCTION

Youth smoking is a serious public health problem. Nevertheless, a rigorous tobacco-free environment within schools, combined with exemplary tobacco control behavior among school personnel can effectively contribute to reducing adolescent smoking. This study compared the tobacco control environment in Shanghai secondary schools in 2017 and 2021, and explored how the tobacco control environment influenced the tobacco control behaviors of school personnel.

METHODS

Two cross-sectional studies were conducted from October to December 2017 and October to December 2021, using stratified cluster random sampling method, and 2403 and 1761 valid questionnaires were collected, respectively. The chi-squared test was used to test the differences between categorical variables. Binary logistic regression was conducted using survey data from 2021 to explore the influencing factors of staff's tobacco control behaviors.

RESULTS

Compared with 2017, the percentages of staff members who were current smokers, had smoked on campus in the past year and were exposed to secondhand smoke (SHS) on campus in the past 7 days in 2021 decreased by 2.95%, 2.30% and 8.91%, respectively. However, the proportion of personnel who knew the school had organized tobacco control education decreased. Furthermore, school personnel who had received tobacco control education and agreed the school should strictly prohibit students from smoking (AOR=1.64; 95% CI: 1.25-2.15) were more likely to inform about the harm of tobacco to students. Those who had participated in tobacco control education activities or tobacco control trainings (AOR=1.87; 95% CI: 1.30-2.69) and believed that the school did not strictly prohibit either students (AOR=0.30; 95% CI: 0.22-0.41) or personnel (AOR=0.46; 95% CI: 0.36-0.59) from smoking were more inclined to stop students from smoking.

CONCLUSIONS

Compared with 2017, the rates of smoking and secondhand smoke exposure among school personnel decreased in 2021, but some schools still lacked comprehensive education on tobacco control behaviors for the staff. Enhancing the health literacy and strengthening tobacco control education among staff were effective strategies to encouraging their active adoption of tobacco control behaviors.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring General Practitioners' Knowledge, Attitudes, and Practices towards E-Cigarette Use/Vaping in Children and Adolescents: A Pilot Cross-Sectional Study in Sydney

(1) Background: The increasing use of e-cigarettes/vaping in children and adolescents has been recognised as a global health concern. We aim to explore the Knowledge, Attitude, and Practice of General Practitioners (GPs) in Sydney regarding the use of e-cigarettes in children and adolescents and identify the barriers to addressing this issue. (2) Methods: This pilot study was a cross-sectional study conducted using an electronic questionnaire with a Likert scale and free-text responses. (3) Results: Fifty-three GPs participated in the study (male = 24 and female = 29) with a mean age of 50 ± 5.5 years. There was strong agreement (mean 4.5) about respiratory adverse effects and addictive potential. However, there was less awareness of cardiac side effects and the occurrence of burns. There is a lack of conversation about e-cigarettes in GP practice and a deficit of confidence in GPs regarding managing e-cigarette use in children and adolescents. (4) Conclusions: Our pilot study has shown that GPs are somewhat knowledgeable about the potential adverse effects of the use of e-cigarettes in children and adolescents, though there is a lack of knowledge of the complete spectrum of adverse effects and more importantly, there is a paucity of a structured approach to discuss the use of e-cigarettes with children and adolescents, and there is a low level of confidence in addressing these issues. There is a need for educational interventions for GPs to increase awareness of the potential adverse effects of using e-cigarettes and build confidence in providing management to children and adolescents regarding the use of e-cigarettes.

The analysis of e-liquids: A study on chemical diversity and metal content using gas chromatography-mass spectrometry and inductively coupled plasma-mass spectrometry

This work aimed to determine the chemical composition of 22 e-liquids available on the Slovenian market. Four different gas chromatography (GC) sample introduction techniques; headspace-GC-mass spectrometry (HS-GC-MS), liquid injection-GC-MS (LI-GC-MS), HS-solid-phase microextraction-GC-MS (HS-SPME-GC-MS), and direct-immersion-SPME-GC-MS (DI-SPME-GC-MS) were employed for qualitative analysis. Various experimental parameters were assessed for each GC sample introduction technique to maximize compound identification. Despite e-liquid packaging reporting a maximum of eight compounds, GC-MS identified more compounds in most samples, especially in menthol-flavored (58 identifiable compounds by HS-SPME-GC-MS), followed by nicotine-containing and fruit-flavored samples. HS-SPME-GC-MS identified the highest number of compounds, followed by HS-GC-MS, DI-SPME-GC-MS, and LI-GC-MS. Nicotine quantification in six samples was performed by LI-GC-MS with dilution in methanol. Nicotine concentration in samples ranged from 16.5 ± 0.5 to 18.5 ± 0.4 mg/mL, which was below the declared concentration of 20 mg/mL. Additionally, quantitative analysis of metals in e-liquids was performed by inductively coupled plasma-MS after microwave-assisted wet acid digestion. Iron was the most abundant metal, with its content ranging from 0.024 to 0.354 µg/g. Barium, bismuth, copper, and tin were also determined in several e-liquids.

Knowledge, Attitude, and Practice of College Students Toward E-cigarettes: A Study From the Northern Part of Karnataka, India

INTRODUCTION

E-cigarettes, also known as electronic cigarettes or vape pens, are battery-powered devices that deliver nicotine, flavorings, and other chemicals to users in the form of an aerosol. It revolutionized the landscape of nicotine consumption, marketed as a safer alternative to traditional cigarettes. Since then, e-cigarettes have become popular among young adults and adolescents. There has always been a conflict in the risks versus benefits of e-cigarettes over the decade, which has created a gap in knowledge in the population. This study aimed to attain the knowledge, attitude, and practice of students from a semi-urban background to understand the level of education needed among the young population of our country.

METHODS

This online survey was conducted among 411 students of Shri BM Patil Medical College Hospital and Research Centre (BLDE) (DU), College, Vijayapura, Karnataka. The survey consisted of 21 MCQ questionnaires to assess students' knowledge, attitude, and practice toward e-cigarettes. Later, the data was analyzed using SPSS version 28.

RESULTS

The study included a diverse group of 411 participants, with a majority being males (63%) and the rest females (37%). The age distribution highlighted a young demographic, with 93% of participants aged between 18 and 34. The study revealed a high level of awareness about e-cigarettes, with 90% of participants being familiar with them. Friends and social media emerged as the primary sources of information, accounting for 52% and 40%, respectively. While 48% of the participants believed e-cigarettes to be non-addictive, only 19% recognized their addictive potential, with the rest being unsure. A majority, 45%, did not see e-cigarette users as superior to traditional smokers, while 15.5% held the opposite view. While 58% of e-cigarette users found them to be stress-relieving, 33% did not, highlighting a subjective aspect of e-cigarette use.

CONCLUSION

The study offers critical insights into the knowledge, attitudes, and practices regarding e-cigarettes among medical students in northern Karnataka. While awareness is high, there is a notable gap in accurate understanding of e-cigarettes' safety and addictive nature. The findings emphasize the need for enhanced education and awareness campaigns to correct misconceptions about e-cigarettes.

Does the time to nicotine dependence vary by internalizing symptoms for young people who use e-cigarettes? An analysis of the Population Assessment of Tobacco and Health (PATH) study, (Waves 1-5; 2013-2019)

OBJECTIVE

To determine the relationship between past-year internalizing symptoms and the time to first report of signs of nicotine dependence among young people.

METHODS

Secondary analysis using data from the Population Assessment of Tobacco and Health (PATH) (Waves 1-5; 2013-2019). The study included 2,102 (N = 5,031,691) young people (age 12-23 years) who reported past-30-day (P30D) e-cigarette use in one or more waves. Kaplan Meier curves, stratified by past year internalizing symptoms were used to estimate the time to the first report of three nicotine dependence symptoms (i.e., use within 30 min of waking, cravings, and really needing to use) following the first P30D e-cigarette use. Cox proportional hazard models were used to estimate crude and adjusted hazard ratios (AHR), comparing any past year internalizing symptoms to no past year internalizing symptoms.

RESULTS

We found no significant differences between past year internalizing symptoms and the time to the first report of cravings (AHR = 1.30, 95 % CI = 92-1.85), really needing to use (AHR = 1.31; 95 % CI = 0.92-1.89) and use within 30 min of waking for follow-up times 0-156 weeks (AHR = 0.84; 95 % CI = 0.55-1.30) and > 156 weeks (AHR = 0.41; 95 % CI = 0.04-4.67) respectively.

CONCLUSION

Past year internalizing symptoms did not modify the time to the first report of nicotine dependence among youth with P30D e-cigarette use. Further research is needed to understand how changing internalizing symptoms and e-cigarette use frequency influence nicotine dependence over time and, how this relationship impacts cessation behavior.

Factorial randomised controlled trial to examine the potential effect of a text message-based intervention on reducing adolescent susceptibility to e-cigarette use: a study protocol

INTRODUCTION

Adolescent e-cigarette use, globally and within Australia, has increased in recent years. In response, public health agencies have called for the development of education and communication programmes targeting adolescents. Despite such recommendations, few rigorous evaluations of such interventions currently exist. The main objective of this study is to examine the potential effect of a text message intervention targeting parents and adolescents on adolescent susceptibility to e-cigarette use (eg, intentions towards using e-cigarettes). Secondary objectives are to (1): examine the effect of the intervention on adolescent e-cigarette and combustible tobacco use and (2) examine the acceptability of the intervention.

METHODS AND ANALYSIS

A randomised controlled trial employing a 2×2 factorial design will be conducted with parent-adolescent dyads (aged 12-15 years). Dyads will be randomly allocated to one of four arms: arm 1-a text message intervention delivered to adolescents only; arm 2-a text message intervention delivered to the parents of adolescents only; arm 3-a text message intervention delivered to both the parents and adolescents; and arm 4-an information only control, consisting of an e-cigarette factsheet provided to parents only. Participant recruitment commenced in March 2023 with the aim to recruit 120 parent-adolescent dyads. Data collection to assess study outcomes will occur at baseline, 6, 12 and 24 months post the commencement of the intervention. The primary endpoint will be 6-month follow-up. The primary outcome will be adolescent susceptibility to e-cigarette use, assessed using validated items. Analyses of trial outcomes will be undertaken under an intention-to-treat framework, with all participants included in the analysis in the group they were allocated.

ETHICS AND DISSEMINATION

Ethics approval has been obtained from the human research ethics committee of the University of Newcastle (H-2022-0340). Findings will be disseminated in peer-reviewed journals and at conferences.

TRIAL REGISTRATION NUMBER

The trial was registered prospectively with Australian New Zealand Clinical Trials Registry (ACTRN12623000079640).

Nicotine use during late adolescence and young adulthood is associated with changes in hippocampal volume and memory performance

Background

With the advent of electronic nicotine delivery systems, the use of nicotine and tobacco products (NTPs) among adolescents and young adults remains high in the US. Use of e-cigarettes additionally elevates the risk of problematic use of other substances like cannabis, which is often co-used with NTPs. However, their effects on brain health, particularly the hippocampus, and cognition during this neurodevelopmental period are poorly understood.

Methods

Healthy late adolescents/young adults (N = 223) ages 16-22 completed a structural MRI to examine right and left hippocampal volumes. Memory was assessed with the NIH Toolbox Picture Sequence Memory Test (PSMT) and Rey Auditory Verbal Learning Test (RAVLT). Cumulative 6-month NTP and cannabis episodes were assessed and modeled continuously on hippocampal volumes. Participants were then grouped based on 6-month NTP use to examine relationships with the hippocampus and memory: current users (CU) endorsed weekly or greater use; light/abstinent users (LU) endorsed less than weekly; and never users (NU).

Results

NTP use predicted larger hippocampal volumes bilaterally while cannabis use had no impact nor interacted with NTP use. For memory, larger left hippocampal volumes were positively associated with PSMT performance, RAVLT total learning, short delay and long delay recall for the NU group. In contrast, there was a negative relationship between hippocampal volumes and performances for LU and CU groups. No differences were detected between NTP-using groups.

Conclusion

These results suggest that the hippocampus is sensitive to NTP exposure during late adolescence/young adulthood and may alter typical hippocampal morphometry in addition to brain-behavior relationships underlying learning and memory processes.

Effects of E-Cigarettes on the Lung and Systemic Metabolome in People with HIV

The popularity of e-cigarettes (vaping) has soared, creating a public health crisis among teens and young adults. Chronic vaping can induce gut inflammation and reduce intestinal barrier function through the production of the proinflammatory molecule hydrogen sulfide (H2S). This is particularly concerning for people with HIV (PWH) as they already face impaired immune function and are at a higher risk for metabolic dysregulation, diabetes, and chronic liver disease. Furthermore, PWH experience unhealthy behaviors, making it crucial to understand the systemic metabolic dysregulation and pathophysiological mechanisms associated with vaping in this population. Here, we employed liquid chromatography-mass spectrometry (LC-MS)-based metabolomics to investigate the upper respiratory, circulation, and gut metabolic profiles of PWH who vape (n = 7) and smoke combustible tobacco/marijuana (n = 6) compared to control participants who did not vape or smoke (n = 10). This hypothesis-generating exploratory study revealed systemic alterations in purine, neurotransmitter, and vitamin B metabolisms and tissue-specific changes in inflammatory pathways and cryptic sulfur cycling associated with vaping and combustible tobacco/marijuana smoking in PWH. In addition, this study provides the first link between microbial-derived metabolite 2,3-dihydroxypropane-1-sulfonate (DHPS) and vaping/smoking (tobacco and marijuana)-induced metabolic dyshomeostasis in the gut. These findings highlight the importance of identifying the full biological and clinical significance of the physiological changes and risks associated with vaping.

Primed for positive perceptions? Applying the acquired preparedness model to explain college students' e-cigarette use and dependence

OBJECTIVE

College students use electronic nicotine delivery systems (ENDS) more often than any other US demographic group. In a novel application of the acquired preparedness model, we examined how proximal (e.g., cognitions) and distal (e.g., dispositional) influences accounted for ENDS use and dependence.

PARTICIPANTS

Undergraduates (N = 1075; 72% female, 74% White) from seven US campuses completed an online survey between October 2019-March 2020.

METHODS

We modeled ENDS use and dependence, respectively, as zero-inflated Poisson distributions with impulsivity as an independent variable and perceived risks and benefits of e-cigarettes as mediators.

RESULTS

Students higher in impulsivity perceived more benefits and, in turn, reported greater ENDS use and dependence. Curiosity and friends' use motivated ENDS initiation; stress management and nicotine motivated continued use.

CONCLUSIONS

ENDS interventions should be tailored to students higher in impulsivity, as they hold more favorable perceptions of ENDS, and should enhance skills to manage stress and nicotine cravings.

Vaping Frequency in Young Users: The Role of Gender and Age Among Regular Users

Background: Vaping is popular among adolescents and emerging adults; however, little is known about regular vaping patterns in older adolescents and emerging adults. Objective: The current study explored whether gender and age are associated with nicotine-based vaping frequency to ascertain ascertaining which subgroups of youth are most at-risk for frequent use. Methods: In a cross-sectional survey, participants using nicotine-based vaping devices (N=535, age range 16-24) reported frequency measured as vaping days in a week, number of episodes during which participants vaped, and puff numbers for each episode. A two-way multivariate analysis of variance was used to test the effects and interactions of gender and age groups on the three frequency outcomes. Results: Emerging adults and males vaped more frequently than their older adolescent and female counterparts, respectively. Specifically, emerging adults vaped more days per week in comparison to older adolescents, whereas males vaped more days per week and had more vaping episodes per day relative to females. Further, emerging adult males had more vaping episodes in comparison to other subgroups, and adolescent females as well as emerging adult males took more puffs per episode in comparison to emerging adult females. Conclusion: Vaping differences among subgroups suggests the need for policies to reduce regular nicotine vaping targeted toward specific gender and age groups.

Disposable e-cigarette use: Factors, frequency and cigarette smoking among United States high school students

BACKGROUND AND AIMS

Disposable e-cigarette use has increased among United States (US) high school students in recent years. However, there is limited research on the profile of these users, how often they use these products, and whether they displace cigarette smoking. This study aimed to measure how disposable e-cigarette use among US youth varies according to demographic characteristics and whether there is any association between e-cigarette use and reduced use of traditional cigarettes.

DESIGN

We used cross-sectional data from the 2022 National Youth Tobacco Survey and conducted a multinomial logistic regression to examine factors associated with the types of e-cigarette devices used in the prior 30 days, adjusting for sex, sexual identity, grade level and race/ethnicity. We also used a finite mixture model to account for unobserved differences among users and identify e-cigarette use patterns in different subgroups of users.

SETTING

United States.

PARTICIPANTS

High school students in grades 9-12 (n = 14 389).

MEASUREMENTS

Survey participants self-reported the type of e-cigarette device used, the frequency of e-cigarettes used and cigarettes smoked over the past 30 days.

FINDINGS

Disposable e-cigarettes were the most popular e-cigarette type. Sex, sexual orientation, grade level and race/ethnicity were associated with disposable e-cigarette use. The odds of disposable e-cigarette use were lower in male students than in female students (odds ratio [OR] = 0.78, 95% confidence interval [CI] = [0.64-0.96]), and higher in students who identified as gay or lesbian (OR = 1.70, 95% CI = [1.11-2.61]) or bisexual (OR = 1.52, 95% CI = [1.16-1.99]) than in heterosexual students. The odds of disposable use were higher among students in higher grades (10th, 11th and 12th) than in 9th graders (OR = 1.71, 2.24 and 2.52, respectively). Disposable e-cigarette users had a lower frequency of traditional cigarette use than other e-cigarette users, both in the low-frequency class (incidence rate ratio [IRR] = 0.33, 95% CI = [0.12-0.92]) and the high-frequency class (IRR = 0.27, 95% CI = [0.08-0.92]).

CONCLUSIONS

Disposable e-cigarette use appears to be higher among United States high school students who are female, older and/or identify as gay, lesbian or bisexual. Disposable e-cigarettes appear to be associated with reduced traditional cigarette use.

Nicotine Vaping Expectancies: Organization and Activation in Memory Based on Vaping Use Patterns

OBJECTIVE

The prevalence of smoking combustible cigarettes has decreased, but rates of nicotine vaping among adolescents and young adults have increased dramatically. Vaping is associated with acute health problems and exposes users to toxic metals with unknown long-term consequences. Research on factors influencing vaping is needed to inform the development of effective prevention and intervention methods. Nicotine vaping expectancies, or expected effects related to vaping, may be an important target as they can predict vaping behaviors. The purpose of this study was to examine nicotine expectancy activation patterns with corresponding nicotine vaping behaviors.

METHOD

Using methods from alcohol expectancy research, we applied a memory model approach to identifying nicotine vaping expectancies and modeling organization and activation patterns concerning the frequency of nicotine vaping. We created a memory model-based nicotine expectancy measure based on information from 200 adolescents in 8th and 12th grades, and college students. Our expectancy measure was completed by a second sample of 862 college students.

RESULTS

We mapped expectancies into network format using Individual Differences Scaling (INDSCAL) and we modeled likely paths of expectancy activation using Preference Mapping (PREFMAP). Nonusers primarily emphasized a positive-negative expectancy dimension and were more likely to activate expectancies of negative internal experiences about vaping. Students who vaped nicotine daily or almost daily primarily emphasized an external appearance-internal experience expectancy dimension and were more likely to activate expectancies of negative affect reduction and withdrawal relief.

CONCLUSIONS

Our results identify specific targets for expectancy-based prevention and intervention methods that have the potential to be as effective as similar approaches to preventing and reducing alcohol use.

Chemical Analysis of Exhaled Vape Emissions: Unraveling the Complexities of Humectant Fragmentation in a Human Trial Study

Electronic cigarette smoking (or vaping) is on the rise, presenting questions about the effects of secondhand exposure. The chemical composition of vape emissions was examined in the exhaled breath of eight human volunteers with the high chemical specificity of complementary online and offline techniques. Our study is the first to take multiple exhaled puff measurements from human participants and compare volatile organic compound (VOC) concentrations between two commonly used methods, proton-transfer-reaction time-of-flight mass spectrometry (PTR-ToF-MS) and gas chromatography (GC). Five flavor profile groups were selected for this study, but flavor compounds were not observed as the main contributors to the PTR-ToF-MS signal. Instead, the PTR-ToF-MS mass spectra were overwhelmed by e-liquid thermal decomposition and fragmentation products, which masked other observations regarding flavorings and other potentially toxic species associated with secondhand vape exposure. Compared to the PTR-ToF-MS, GC measurements reported significantly different VOC concentrations, usually below those from PTR-ToF-MS. Consequently, PTR-ToF-MS mass spectra should be interpreted with caution when reporting quantitative results in vaping studies, such as doses of inhaled VOCs. Nevertheless, the online PTR-ToF-MS analysis can provide valuable qualitative information by comparing relative VOCs in back-to-back trials. For example, by comparing the mass spectra of exhaled air with those of direct puffs, we can conclude that harmful VOCs present in the vape emissions are largely absorbed by the participants, including large fractions of nicotine.

Pitfalls in the Detection of Volatiles Associated with Heated Tobacco and e-Vapor Products When Using PTR-TOF-MS

We investigated the applicability of proton transfer reaction-time-of-flight mass spectrometry (PTR-TOF-MS) for quantitative analysis of mixtures comprising glycerin, acetol, glycidol, acetaldehyde, acetone, and propylene glycol. While PTR-TOF-MS offers real-time simultaneous determination, the method selectivity is limited when analyzing compounds with identical elemental compositions or when labile compounds present in the mixture produce fragments that generate overlapping ions with other matrix components. In this study, we observed significant fragmentation of glycerin, acetol, glycidol, and propylene glycol during protonation via hydronium ions (H3O+). Nevertheless, specific ions generated by glycerin (m/z 93.055) and propylene glycol (m/z 77.060) enabled their selective detection. To thoroughly investigate the selectivity of the method, various mixtures containing both isotope-labeled and unlabeled compounds were utilized. The experimental findings demonstrated that when samples contained high levels of glycerin, it was not feasible to perform time-resolved analysis in H3O+ mode for acetaldehyde, acetol, and glycidol. To overcome the observed selectivity limitations associated with the H3O+ reagent ions, alternative ionization modes were investigated. The ammonium ion mode proved appropriate for analyzing propylene glycol (m/z 94.086) and acetone (m/z 76.076) mixtures. Concerning the nitric oxide mode, specific m/z were identified for acetaldehyde (m/z 43.018), acetone (m/z 88.039), glycidol (m/z 73.028), and propylene glycol (m/z 75.044). It was concluded that considering the presence of multiple product ions and the potential influence of other compounds, it is crucial to conduct a thorough selectivity assessment when employing PTR-TOF-MS as the sole method for analyzing compounds in complex matrices of unknown composition.

Perception of e-cigarette control policies and education in schools on increased legal knowledge, harm perception, susceptibility and e-cigarette use among students in Thailand: A cross-sectional classroom-based survey

INTRODUCTION

In Thailand, school smoke-free policies initially targeted cigarette smoking but now extend to include electronic cigarettes (e-cigarettes). Yet, the impact of this expansion on curbing e-cigarette use in schools is uncertain. This study seeks to explore how e-cigarette control policies and educational initiatives in Thai secondary schools influence students' legal knowledge, perception of harm, current e-cigarette use, and susceptibility to future use.

METHODS

This cross-sectional survey was conducted in four regions of Thailand between May and August 2023, involving 6147 students selected through multistage sampling. Data collection utilized a self-reported online questionnaire in Thai, developed using Google Forms. For continuous outcomes, multiple linear regression models assessed relationships between school e-cigarette policy perceptions, covariates, knowledge of e-cigarette laws, and harm perception. Multiple logistic regression models analyzed the association between policy perceptions, covariates, and categorical outcomes: current e-cigarette use and susceptibility.

RESULTS

Adjusting for covariates, a positive association was found between students' perceptions of e-cigarette policies and teachings and their knowledge of e-cigarette control laws (B=0.083, p<0.001) and harm perceptions (B=0.491, p<0.001). Additionally, these perceptions were protective against current e-cigarette use (AOR=0.970; 95% CI: 0.95-0.99, p=0.002) and susceptibility among non-users (AOR=0.962; 95% CI: 0.95-0.97; p<0.001).

CONCLUSIONS

A heightened perception of e-cigarette policies and teachings in schools is associated with increased legal knowledge, heightened harm perception, and a lower likelihood of current or future e-cigarette use. This underscores the importance of enforcing the e-cigarette-free policy in schools to mitigate vaping susceptibility amid the ongoing youth e-cigarette epidemic.

Unveiling the Impact of Smokers' Self-Construals on the Effectiveness of Smoking Cessation Campaigns: A Comparative Analysis of E-Cigarettes and Combustible Cigarettes

Objective

This research conducted two studies in South Korea to explore the relationship between smokers' self-construals and the types of cigarettes they use, emphasizing their combined effects on cessation campaign effectiveness.

Methods

Study 1 explored how smokers' self-construals influenced their intentions to quit smoking or vaping, considering their primary cigarette usage. Study 2 further investigated this relationship within cessation campaigns, employing messages framed by both self-construal (independent vs. interdependent) and cigarette type (combustible vs. electronic).

Results

The results of Study 1 showed that individuals with a strong interdependent self-construal were more likely to express intentions to quit smoking or vaping when using e-cigarettes compared to combustible cigarettes. Similarly, Study 2 demonstrated that cessation messages for e-cigarettes were more effective in eliciting intentions to quit when presented with an interdependent self-construal frame, while messages for combustible cigarettes showed greater effectiveness with an independent self-construal frame.

Conclusion

Campaigns solely focused on independent self-construals might not effectively persuade e-cigarette users to quit, as they may prioritize communal wellbeing over individual benefits. Adapting anti-e-cigarette campaigns to align with the values of interdependent self-construals could yield better outcomes in promoting cessation among e-cigarette users.

The efficacy and acceptability of pharmacological monotherapies and e-cigarette on smoking cessation: a systemic review and network meta-analysis

Background and aims

Several pharmacological interventions, such as nicotine replacement therapy (NRT), varenicline, and bupropion, have been approved for clinical use of smoking cessation. E-cigarettes (EC) are increasingly explored by many RCTs for their potentiality in smoking cessation. In addition, some RCTs are attempting to explore new drugs for smoking cessation, such as cytisine. This network meta-analysis (NMA) aims to investigate how these drugs and e-cigarettes compare regarding their efficacy and acceptability.

Materials and methods

This systematic review and NMA searched all clinical studies on smoking cessation using pharmacological monotherapies or e-cigarettes published from January 2011 to May 2022 using MEDLINE, COCHRANE Library, and PsychINFO databases. NRTs were divided into transdermal (TDN) and oronasal nicotine (ONN) by administrative routes, thus 7 network nodes were set up for direct and indirect comparison. Two different indicators measured the efficacy: prevalent and continuous smoking abstinence. The drop-out rates measured the acceptability.

Results

The final 40 clinical studies included in this study comprised 77 study cohorts and 25,889 participants. Varenicline is more effective intervention to assist in smoking cessation during 16-32 weeks follow-up, and is very likely to prompt dropout. Cytisine shows more effectiveness in continuous smoking cessation but may also lead to dropout. E-cigarettes and oronasal nicotine are more effective than no treatment in encouraging prevalent abstinence, but least likely to prompt dropout. Finally, transdermal nicotine delivery is more effective than no treatment in continuous abstinence, with neither significant effect on prevalent abstinence nor dropout rate.

Conclusion

This review suggested and agreed that Varenicline, Cytisine and transdermal nicotine delivery, as smoking cessation intervention, have advantages and disadvantages. However, we had to have reservations about e-cigarettes as a way to quit smoking in adolescents.

Susceptibility to Electronic Cigarette and Consumption Patterns in Adolescents

The use of electronic cigarettes (ECs) is a major problem globally. Susceptibility and curiosity are important factors that develop prior to the onset of substance use, such as ECs, and are therefore considered as predictors. Both factors are used to obtain an extended index of susceptibility (ESIe-c), which allows the identification of adolescents who are at risk of starting to use these devices. The aim of this study was to determine the prevalence of EC consumption and to assess the association of possible predictors with susceptibility to use and experimentation with ECs among adolescents. A cross-sectional study was carried out in 377 adolescents (53.0% female). Participants were compared according to their experimentation with ECs. A total of 45.9% had already used electronic cigarettes, and 20.8% were current users. Among those who had not tried electronic cigarettes, 43.3% had a medium-high susceptibility to EC initiation. Consumption among close friends, receiving offers of consumption and alcohol consumption were associated with initiation. There was an inverse association between a medium susceptibility index electronic cigarette score and the consumption of cigarettes and positive affect; on the other hand, the lack of premeditation was associated with a higher susceptibility index score. Intrapersonal factors and social factors seem to influence the ESIe-c and onset of EC use, respectively. The main conclusion in this study is that susceptibility is influenced by intrapersonal factors such as affectivity and impulsivity through the lack of premeditation, and by social factors such as EC consumption by best friends.

The impact of chronic electronic cigarette use on endothelial dysfunction measured by flow-mediated vasodilation: A systematic review and meta-analysis

INTRODUCTION

Despite electronic cigarettes (e-cigarettes) being marketed as a safer alternative to combustible cigarettes, the effects of chronic e-cigarette use on vascular health remain uncertain. Our meta-analysis aimed to assess the health implications of chronic exclusive e-cigarette use on endothelial dysfunction, as measured by flow-mediated vasodilation (FMD).

METHODS

PubMed, Embase and Scopus were searched for studies from 1 January 2004 to 31 March 2024. Four cross-sectional studies (n=769) were pooled using a random-effects model. The mean differences (MD) of FMD were reported by comparing exclusive e-cigarette use versus non-use; exclusive e-cigarette use versus combustible cigarette use; and combustible cigarette use versus non-use.

RESULTS

A non-significant reduction in FMD in exclusive e-cigarette use compared to non-use was reported (MD of FMD: -1.47%; 95% CI: -3.96 - 1.02; I2= 84%). Similar MD of FMD in exclusive e-cigarette use and exclusive combustible cigarette use (vs non-use) suggested that both of these products might have comparable adverse influences on endothelial health.

CONCLUSIONS

The limited availability of studies assessing the chronic impact of e-cigarette use restricted our ability to provide definitive findings. We emphasize the importance of additional research that explores the long-term impact of e-cigarette use on endothelial dysfunction, and identify key areas and give suggestions for further study.

Feasibility of restricting e-cigarettes to prescription only for smoking cessation

E-cigarette use among youth in Canada has risen to epidemic proportions. E-cigarettes are also moderately useful smoking cessations aids. Restricting e-cigarettes to prescription only smoking cessation aids could help limit youth's access to them while keeping them available as therapies for patients who smoke conventional cigarettes. In Canada, drugs or devices must be approved by regulatory bodies such as Health Canada in order to become licensed prescription medications. A similar situation is underway in Australia, where e-cigarettes have been restricted to prescription only. This commentary explores the feasibility of a similar regulation for e-cigarettes in Canada as prescription smoking cessation aids.

Racial/ethnic disparities in exposure to e-cigarette advertising among U.S. youth

OBJECTIVES

This study aims to assess exposure to e-cigarette advertising across multiple marketing channels among U.S. youth and to examine whether racial/ethnic disparities exist in exposure to e-cigarette advertisements.

STUDY DESIGN

This is a cross-sectional study.

METHODS

Cross-sectional data were drawn from a longitudinal survey of participants recruited from two nationally representative panels (NORC's AmeriSpeak® and GfK's KnowledgePanel). A total of 2043 youth aged 13-17 completed the initial 2018 survey, and 2013 youth completed the follow-up survey in 2019 (including a replenishment sample of 690 youth). Outcome variables were self-reported e-cigarette advertisement exposure in the past three months through various sources, such as television, point of sale, and online/social media. Generalized estimating equation models were used to estimate the adjusted odds ratios (AOR) of the association between racial/ethnic identity and e-cigarette advertisement exposure.

RESULTS

The prevalence of reported exposure to e-cigarette advertisements through any channel was 79.8% (95% CI: 77.1-82.2) in 2018 and 74.9% (95% CI: 72.5-77.1) in 2019, respectively. Point of sale was the most common source of e-cigarette advertisement exposure in both years. Non-Hispanic Black and non-Hispanic Asian youth were more likely to report exposure to e-cigarette advertisements through television (AOR = 2.07, 95% CI: 1.44-2.99 and AOR = 2.11, 95% CI: 1.17-3.82, respectively) and online/social media (AOR = 1.61; 95% CI: 1.11-2.33 and AOR = 1.99, 95% CI: 1.10-3.59, respectively) channels compared with non-Hispanic White youth.

CONCLUSIONS

A substantial proportion of U.S. youth reported exposure to e-cigarette advertising through a variety of marketing channels. Significant racial/ethnic disparities existed, with non-Hispanic Black and Asian youth reporting more marketing exposure than their non-Hispanic White counterparts.

Reinforcing and adverse observable effects of nicotine and minor tobacco alkaloids in squirrel monkeys

The most prevalent psychoactive chemical in tobacco smoke is nicotine, which has been shown to maintain tobacco consumption as well as cause acute adverse effects at high doses, like nausea and emesis. Recent studies in laboratory animals have suggested that many non-nicotine constituents of tobacco smoke (e.g., minor tobacco alkaloids) may also contribute to tobacco's overall reinforcing and adverse effects. Here, we used intravenous (IV) self-administration (n = 3) and observation (n = 4) procedures in squirrel monkeys to, respectively, compare the reinforcing and adverse observable effects of nicotine and three prominent minor tobacco alkaloids, nornicotine, anatabine, and myosmine. In self-administration studies, male squirrel monkeys were trained to respond under a second-order fixed-interval schedule of reinforcement and dose-effects functions for nicotine and each of the minor tobacco alkaloids nornicotine, anatabine, and mysomine were determined. Observation studies were conducted in a different group of male squirrel monkeys to quantify the ability of nicotine, nornicotine, anatabine, and mysomine to produce adverse overt effects, including hypersalivation, emesis, and tremors. Results show that nicotine and to a lesser extent nornicotine were readily self-administered, whereas anatabine and myosmine were not. In observation studies, all minor tobacco alkaloids produced adverse observable effects that were either comparable or more pronounced than nicotine. Collectively, the present results showing that nicotine and the minor tobacco alkaloids nornicotine, anatabine, and myosmine produce differential reinforcing and acute adverse observable effects in monkeys provides further evidence that these constituents may differently contribute to the psychopharmacological and adverse effects of tobacco consumption.

Targeted Education for School Staff on Electronic Nicotine Delivery Systems: A Nurse Led Intervention

There is a public health epidemic in adolescents' use of Electronic Nicotine Delivery Systems (ENDSs), also known as electronic cigarettes, vaping products, or JUULs. However, little is known about the level of knowledge school staff have about ENDS. The purpose of this study is to examine outcomes of a nurse-led educational intervention designed to increase school staff knowledge about ENDS. A descriptive, nonrandomly selected pre-test/post-test design was used with 125 Wisconsin school staff. Results revealed further educational needs of school staff in content areas including advertising to youth and flavoring of ENDS. Following the educational intervention, post-test results showed a significant overall improvement in participant knowledge scores. Recommendations include implementing nurse-led education about ENDS to a more diverse population of school staff. Providing nurse-led ENDS education to school staff offers an upstream, proactive approach for school nurses to help address this public health epidemic.

Perceiving E-Cigarettes as Safe and Safer Alternative to Cigarettes Among Young Adults

BACKGROUND

Young adults are using e-cigarettes at high rates. While the literature on the health risks associated with e-cigarettes is extensive and growing, little is known about young adults' thoughts and perceptions of the safety and harms of e-cigarettes.

METHODS

We conducted one-on-one interviews with young adults aged 18 to 25 years in Los Angeles, California between June 2018 and June 2019. We interviewed and audio-recorded young adults (N = 62) who consented to the study and self-reported to have used e-cigarettes on a weekly basis or more for at least 5 months prior to study enrollment. Interviews examined participants' thoughts, feelings, and experiences related to e-cigarette use. We audio-recorded, transcribed, and coded the interviews using grounded theory analysis methods.

RESULTS

Young adults often believed that e-cigarettes were safer than cigarettes and were safe to use, especially following positive vaping experiences. Young adults were skeptical of the available science on e-cigarette use and felt there was not conclusive data on the harms of e-cigarettes. In their selection of e-cigarettes over cigarettes, young adults felt they were making a conscious and healthier choice. Because young adults viewed e-cigarettes to be better for them based on their personal experiences with vaping, they felt e-cigarettes were a superior alternative to combustible tobacco.

CONCLUSIONS

Young adults in our study believed that the long-term health effects of e-cigarette use are not clearly understood and were generally skeptical of the research on e-cigarette harms. Policy, education, and anti-smoking campaigns need to clarify the negative health-related consequences of e-cigarette use for young people.

Cell signaling and epigenetic regulation of nicotine-induced carcinogenesis

Nicotine, a naturally occurring tobacco alkaloid responsible for tobacco addiction, has long been considered non-carcinogenic. However, emerging evidence suggests that nicotine may possess carcinogenic properties in mice and could be a potential carcinogen in humans. This review aims to summarize the potential molecular mechanisms underlying nicotine-induced carcinogenesis, with a specific focus on epigenetic regulation and the activation of nicotinic acetylcholine receptors (nAChRs) in addition to genotoxicity and excess reactive oxygen species (ROS). Additionally, we explore a novel hypothesis regarding nicotine's carcinogenicity involving the downregulation of stem-loop binding protein (SLBP), a critical regulator of canonical histone mRNA, and the polyadenylation of canonical histone mRNA. By shedding light on these mechanisms, this review underscores the need for further research to elucidate the carcinogenic potential of nicotine and its implications for human health.

Comparative systematic review on the safety of e-cigarettes and conventional cigarettes

BACKGROUND

This systematic review evaluated the health risks of electronic cigarettes (e-cigarettes) compared to traditional cigarettes. It examines various studies and research on the subject to provide a comprehensive analysis of potential health risks associated with both smoking methods.

METHODS

The systematic review, incorporating searches in PubMed, Scopus, Web of Science, and the Cochrane Library up to July 2023, examines the results obtained in relevant studies, and provides a critical discussion of the results.

RESULTS

E-cigarettes exhibit reduced exposure to harmful toxins compared to traditional cigarettes.

CONCLUSION

However, concerns persist regarding respiratory irritation and potential health risks, especially among youth, emphasizing the need for comprehensive, long-term research and protective legislation.

Evaluating The Real Cost Digital and Social Media Campaign: Longitudinal Effects of Campaign Exposure on E-cigarette Beliefs

INTRODUCTION

Over the past decade, youth e-cigarette use has risen exponentially. At the same time, digital media use increased markedly while the use of traditional broadcast TV declined. In response, the U.S. Food and Drug Administration's The Real Cost public education campaign shifted to communicating the harms of e-cigarette via primarily digital and social platforms. This study evaluated longitudinal associations between exposure to campaign advertisements and changes in campaign-specific beliefs among US youth.

METHODS

A nationally representative longitudinal cohort of youth (aged 11-16 years at baseline) was surveyed five times. Building on earlier work, we analyzed data from the last three waves (April-July 2020; January-April 2021; and August-October 2021; N = 2625). We assessed self-reported exposure to six ads and agreement with 11 beliefs that were each targeted by one or more ads. Eleven weighted panel regression models assessed whether ad exposure predicted changes in campaign-specific beliefs over time.

RESULTS

We observed significant associations between ad exposure and increases in at least one campaign-specific belief for five of the six ads. Across the 11 beliefs, we observed associations between increased exposure and increases in 6 beliefs related to e-cigarettes and toxic metals, lung damage, dangerous ingredients, anxiety, cigarette use, and disappointing important people.

CONCLUSIONS

We found evidence that self-reported exposure to this digital and social media campaign was successful at influencing youth, providing support for the effectiveness of the campaign's adaption to address youth's changes in tobacco and media use habits.

IMPLICATIONS

The Food and Drug Administration's The Real Cost public education campaign educates youth about the dangers of e-cigarette use. This study evaluates longitudinal associations between exposure to The Real Cost's advertisements and changes in campaign-specific beliefs among youth. Considering evolving trends in youth media consumption, the campaign adapted its media approach to increase delivery across digital and social media platforms. Our findings indicate that the campaign reached its intended audience and increased youth beliefs around the harm of e-cigarettes and the consequences of e-cigarette use, offering evidence for the effectiveness of digital and social media youth prevention efforts within a fragmented digital environment.

Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina

BACKGROUND

Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches.

METHODS

We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis.

RESULTS

Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches.

CONCLUSIONS

Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Symptoms of nicotine dependence by e-cigarette and cigarette use behavior and brand: A population-based, nationally representative cross-sectional study

BACKGROUND

Many modern e-cigarette brands contain equivalent or higher nicotine levels than traditional cigarettes.

OBJECTIVE

To examine differences in four nicotine dependence indicators (i.e., use within 30minutes of waking, cravings, needing to use, and frequent use) among adolescents (aged 12-17 years) with past 30-day (P30D) exclusive use of e-cigarettes, cigarettes, or dual use of both.

METHODS

Data were from Wave 5 (2018-2019) of the Population Assessment of Tobacco and Health (PATH) study (n=1060; N=2053,659). Multivariable logistic regression was performed to determine differences in indicators by P30D e-cigarette and cigarette use behavior (exclusive vs. dual use) and brand (e-cigarette use: JUUL vs. non-JUUL vs. Unknown).

RESULTS

The odds of frequent use among adolescents with JUUL (AOR: 2.11; 95% CI=1.02-4.37) and non-JUUL (AOR: 2.12; 95% CI=0.95-4.77) use were similar and paralleled that for dual use (AOR: 3.50; 95% CI=1.46-8.43) but were stronger (JUUL only) than exclusive cigarette use. The odds of using within 30minutes of waking for adolescents with JUUL (AOR: 2.23; 95% CI=0.80-6.25) and non-JUUL (AOR:1.42; 95% CI=0.47-4.32) use were similar and paralleled that for both dual (AOR=3.00; 95% CI=1.01-8.88) and exclusive cigarette use. For adolescents who used unknown brands, the odds of all indicators paralleled exclusive cigarette use but were lower than JUUL, non-JUUL, and dual use.

CONCLUSION

Compared to exclusive cigarette use, symptoms of nicotine dependence are similar for adolescents with exclusive e-cigarette use, irrespective of brand. Symptoms of nicotine dependence for JUUL and non-JUUL use parallel dual use. Tobacco regulation should consider these findings when assessing the abuse liability of e-cigarettes.

Use of Brand Engagement Appeals in US Cigarette and E-Cigarettes Ads (2019-2020)

Background: The tobacco industry has historically used brand engagement - communication tactics companies use to increase customer attachment to a brand and brand loyalty - to recruit and retain consumers. Limited information is available to assess the brand engagement tactics used to promote the two most popular tobacco products in the US - cigarettes and electronic cigarettes (e-cigarettes) - across different advertising platforms (e.g., direct-to-consumer (DTC), social media). Material and methods: We acquired 520 cigarette and 5,502 e-cigarette ads that ran in the US January 2019 to December 2020 from market research firms (Kantar, Numerator), Rutger's University ad surveillance website (trinketsandtrash.org), and branded social media accounts. Ads were double-coded for eight types of brand engagement tactics: Price Promotion, Sweepstakes, Mobile App, Email/Mail List, Free Gift, Social Media engagement request, Sponsored Events, and Auto-Ship subscription program. We report presence of brand engagement tactics by product type and advertising platform. Results: Overall, 62.9% of cigarette ads and 49.9% of e-cigarette ads contained at least one brand engagement tactic. For cigarette ads, the most common tactics were Sweepstakes and Mobile App requests, which were most commonly featured in DTC ads. For e-cigarettes, the most common tactic was Price Promotion which was featured in most DTC and online e-cigarette ads. Conclusions: Brand engagement was common in this sample of cigarette and e-cigarette ads. Our findings highlight key differences in the type of brand engagement tactic used to promote each product on different advertising platforms. Results can inform continued advertising surveillance studies and regulatory efforts.

E-cigarette exposure causes early pro-atherogenic changes in an inducible murine model of atherosclerosis

Introduction: Evidence suggests that e-cigarette use (vaping) increases cardiovascular disease risk, but decades are needed before people who vape would develop pathology. Thus, murine models of atherosclerosis can be utilized as tools to understand disease susceptibility, risk and pathogenesis. Moreover, there is a poor understanding of how risk factors for atherosclerosis (i.e., hyperlipidemia, high-fat diet) intersect with vaping to promote disease risk. Herein, we evaluated whether there was early evidence of atherosclerosis in an inducible hyperlipidemic mouse exposed to aerosol from commercial pod-style devices and e-liquid. Methods: Mice were injected with adeno-associated virus containing the human protein convertase subtilisin/kexin type 9 (PCSK9) variant to promote hyperlipidemia. These mice were fed a high-fat diet and exposed to room air or aerosol derived from JUUL pods containing polyethylene glycol/vegetable glycerin (PG/VG) or 5% nicotine with mango flavoring for 4 weeks; this timepoint was utilized to assess markers of atherosclerosis that may occur prior to the development of atherosclerotic plaques. Results: These data show that various parameters including weight, circulating lipoprotein/glucose levels, and splenic immune cells were significantly affected by exposure to PG/VG and/or nicotine-containing aerosols. Discussion: Not only can this mouse model be utilized for chronic vaping studies to assess the vascular pathology but these data support that vaping is not risk-free and may increase CVD outcomes later in life.

Strengths and Limitations of Web-Based Cessation Support for Individuals Who Smoke, Dual Use, or Vape: Qualitative Interview Study

BACKGROUND

Tobacco use has shifted in recent years, especially with the introduction of e-cigarettes. Despite the current variable and intersecting tobacco product use among tobacco users, most want to quit, which necessitates cessation programs to adapt to these variable trends (vs focusing on combustible cigarettes alone). The use of web-based modalities for cessation support has become quite popular in recent years and has been compounded by the COVID-19 pandemic. Therefore, understanding the current strengths and limitations of existing programs to meet the needs of current various tobacco users is critical for ensuring the saliency of such programs moving forward.

OBJECTIVE

The purpose of this study was to understand the strengths and limitations of web-based cessation support offered through QuitNow to better understand the needs of a variety of end users who smoke, dual use, or vape.

METHODS

Semistructured interviews were conducted with 36 nicotine product users in British Columbia. Using conventional content analysis methods, we inductively derived descriptive categories and themes related to the strengths and limitations of QuitNow for those who smoke, dual use, or vape. We analyzed the data with the support of NVivo (version 12; QSR International) and Excel (Microsoft Corporation).

RESULTS

Participants described several strengths and limitations of QuitNow and provided suggestions for improvement, which fell under 2 broad categories: look and feel and content and features. Shared strengths included the breadth of information and the credible nature of the website. Individuals who smoke were particularly keen about the site having a nonjudgmental feeling. Moreover, compared with individuals who smoke, individuals who dual use and individuals who vape were particularly keen about access to professional quit support (eg, quit coach). Shared limitations included the presence of too much text and the need to create an account. Individuals who dual use and individuals who vape thought that the content was geared toward older adults and indicated that there was a lack of information about vaping and personalized content. Regarding suggestions for improvement, participants stated that the site needed more interaction, intuitive organization, improved interface esthetics, a complementary smartphone app, forum discussion tags, more information for different tobacco user profiles, and user testimonials. Individuals who vape were particularly interested in website user reviews. In addition, individuals who vape were more interested in an intrinsic approach to quitting (eg, mindfulness) compared with extrinsic approaches (eg, material incentives), the latter of which was endorsed by more individuals who dual use and individuals who smoke.

CONCLUSIONS

The findings of this study provide directions for enhancing the saliency of web-based cessation programs for a variety of tobacco use behaviors that hallmark current tobacco use.

Vaping product exposure system (VaPES): a novel in vitro aerosol deposition system

OBJECTIVE

Due to recent increases in the use of vaping devices, there is a high demand for research addressing the respiratory health effects of vaping products. Given the constantly changing nature of the vaping market with new devices, flavors, metals, and other chemicals rapidly emerging, there is a need for inexpensive and highly adaptable vaping device exposure systems. Here, we describe the design and validation of a novel in vitro aerosol exposure system for toxicity testing of vaping devices.

MATERIALS AND METHODS

We developed an inexpensive, open-source in vitro vaping device exposure system that produces even deposition, can be adapted for different vaping devices, and allows for experiments to be performed under physiological conditions. The system was then validated with deposition testing and a representative exposure with human bronchial epithelial cells (hBECs).

RESULTS

The Vaping Product Exposure System (VaPES) produced sufficient and uniform deposition for dose-response studies and was precise enough to observe biological responses to vaping exposures. VaPES was adapted to work with both pod and cartridge-based vaping devices.

CONCLUSION

We have designed and validated a novel vaping device exposure system that will eliminate the need to use high-cost commercial exposure systems, lowering the barrier to entry of physiologically relevant vaping studies.

Interventions to prevent or cease electronic cigarette use in children and adolescents

BACKGROUND

The prevalence of e-cigarette use has increased globally amongst children and adolescents in recent years. In response to the increasing prevalence and emerging evidence about the potential harms of e-cigarettes in children and adolescents, leading public health organisations have called for approaches to address increasing e-cigarette use. Whilst evaluations of approaches to reduce uptake and use regularly appear in the literature, the collective long-term benefit of these is currently unclear.

OBJECTIVES

The co-primary objectives of the review were to: (1) evaluate the effectiveness of interventions to prevent e-cigarette use in children and adolescents (aged 19 years and younger) with no prior use, relative to no intervention, waitlist control, usual practice, or an alternative intervention; and (2) evaluate the effectiveness of interventions to cease e-cigarette use in children and adolescents (aged 19 years and younger) reporting current use, relative to no intervention, waitlist control, usual practice, or an alternative intervention. Secondary objectives were to: (1) examine the effect of such interventions on child and adolescent use of other tobacco products (e.g. cigarettes, cigars types, and chewing tobacco); and (2) describe the unintended adverse effects of the intervention on individuals (e.g. physical or mental health of individuals), or on organisations (e.g. intervention displacement of key curricula or learning opportunities for school students) where such interventions are being implemented.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, Ovid PsycINFO, EBSCO CINAHL, and Clarivate Web of Science Core Collection from inception to 1 May 2023. Additionally, we searched two trial registry platforms (WHO International Clinical Trials Registry Platform; US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov), Google Scholar, and the reference lists of relevant systematic reviews. We contacted corresponding authors of articles identified as ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cluster-RCTs, factorial RCTs, and stepped-wedge RCTs. To be eligible, the primary targets of the interventions must have been children and adolescents aged 19 years or younger. Interventions could have been conducted in any setting, including community, school, health services, or the home, and must have sought to influence children or adolescent (or both) e-cigarette use directly. Studies with a comparator of no intervention (i.e. control), waitlist control, usual practice, or an alternative intervention not targeting e-cigarette use were eligible. We included measures to assess the effectiveness of interventions to: prevent child and adolescent e-cigarette use (including measures of e-cigarette use amongst those who were never-users); and cease e-cigarette use (including measures of e-cigarette use amongst children and adolescents who were e-cigarette current-users). Measures of e-cigarette use included current-use (defined as use in the past 30 days) and ever-use (defined as any lifetime use).

DATA COLLECTION AND ANALYSIS

Two review authors independently screened the titles and abstracts of references, with any discrepancies resolved through consensus. Pairs of review authors independently assessed the full-text articles for inclusion in the review. We planned for two review authors to independently extract information from the included studies and assess risk of bias using the Cochrane RoB 2 tool. We planned to conduct multiple meta-analyses using a random-effects model to align with the co-primary objectives of the review. First, we planned to pool interventions to prevent child and adolescent e-cigarette use and conduct two analyses using the outcome measures of 'ever-use' and 'current-use'. Second, we planned to pool interventions to cease child and adolescent e-cigarette use and conduct one analysis using the outcome measure of 'current-use'. Where data were unsuitable for pooling in meta-analyses, we planned to conduct a narrative synthesis using vote-counting approaches and to follow the Cochrane Handbook for Systematic Reviews of Interventions and the Synthesis Without Meta-analysis (SWiM) guidelines.

MAIN RESULTS

The search of electronic databases identified 7141 citations, with a further 287 records identified from the search of trial registries and Google Scholar. Of the 110 studies (116 records) evaluated in full text, we considered 88 to be ineligible for inclusion for the following reasons: inappropriate outcome (27 studies); intervention (12 studies); study design (31 studies); and participants (18 studies). The remaining 22 studies (28 records) were identified as ongoing studies that may be eligible for inclusion in a future review update. We identified no studies with published data that were eligible for inclusion in the review.

AUTHORS' CONCLUSIONS

We identified no RCTs that met the inclusion criteria for the review, and as such, there is no evidence available from RCTs to assess the potential impact of interventions targeting children and adolescent e-cigarette use, tobacco use, or any unintended adverse effects. Evidence from studies employing other trial designs (e.g. non-randomised) may exist; however, such studies were not eligible for inclusion in the review. Evidence from studies using non-randomised designs should be examined to guide actions to prevent or cease e-cigarette use. This is a living systematic review. We search for new evidence every month and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review.

E-Cigarette Use Among US Adults in the 2021 Behavioral Risk Factor Surveillance System Survey

Importance

After the initial disruption from the COVID-19 pandemic, it is unclear how patterns of e-cigarette use in the US have changed.

Objective

To examine recent patterns in current and daily e-cigarette use among US adults in 2021.

Design, Setting, and Participants

This cross-sectional study used data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) database. The BRFSS is the largest national telephone-based survey of randomly sampled adults in the US. Adults aged 18 years or older, residing in 49 US states (all except Florida), the District of Columbia, and 3 US territories (Guam, Puerto Rico, and the US Virgin Islands), were included in the data set. Data analysis was performed in January 2023.

Main Outcomes and Measures

The main outcome was age-adjusted prevalence of current and daily e-cigarette use overall and by participant characteristics, state, and territory. Descriptive statistical analysis was conducted, applying weights to account for population representation.

Results

This study included 414 755 BRFSS participants with information on e-cigarette use. More than half of participants were women (51.3%). In terms of race and ethnicity, 0.9% of participants were American Indian or Alaska Native, 5.8% were Asian, 11.5% were Black, 17.3% were Hispanic, 0.2% were Native Hawaiian or Other Pacific Islander, 62.2% were White, 1.4% were of multiple races or ethnicities, and 0.6% were of other race or ethnicity. Individuals aged 18 to 24 years comprised 12.4% of the study population. The age-standardized prevalence of current e-cigarette use was 6.9% (95% CI, 6.7%-7.1%), with almost half of participants using e-cigarettes daily (3.2% [95% CI, 3.1%-3.4%]). Among individuals aged 18 to 24 years, there was a consistently higher prevalence of e-cigarette use, with more than 18.6% reporting current use and more than 9.0% reporting daily use. Overall, among individuals reporting current e-cigarette use, 42.2% (95% CI, 40.7%-43.7%) indicated former combustible cigarette use, 37.1% (95% CI, 35.6%-38.6%) indicated current combustible cigarette use, and 20.7% (95% CI, 19.7%-21.8%) indicated never using combustible cigarettes. Although relatively older adults (aged ≥25 years) who reported current e-cigarette use were more likely to report former or current combustible cigarette use, younger adults (aged 18-24 years) were more likely to report never using combustible cigarettes. Notably, the proportion of individuals who reported current e-cigarette use and never using combustible cigarettes was higher in the group aged 18 to 20 years (71.5% [95% CI, 66.8%-75.7%]) compared with those aged 21 to 24 years (53.0% [95% CI, 49.8%-56.1%]).

Conclusion and Relevance

These findings suggest that e-cigarette use remained common during the COVID-19 pandemic, particularly among young adults aged 18 to 24 years (18.3% prevalence). Notably, 71.5% of individuals aged 18 to 20 years who reported current e-cigarette use had never used combustible cigarettes. These results underscore the rationale for the implementation and enforcement of public health policies tailored to young adults.

Vaping Behavior in Young Adults During the COVID-19 Pandemic

BACKGROUND

Electronic nicotine delivery systems (ENDS) continue to be popular among young adults. These devices are often advertised as a healthy alternative to quitting tobacco cigarettes. However, young adults represent a population who view it as a novel behavior that provides a sense of popularity, social acceptance, and desired physiologic properties. The objective of this study was to examine characteristics of vaping behavior among college students and explore possible associations between groups of vaping behavior (stopped, initiated, increased, decreased, stayed the same).

METHODS

In a multi-center cross-sectional study, 656 students from University of Tampa in the United States and University of Applied Sciences in Germany (IST) were recruited to answer a 31-item online questionnaire. A chi-square test was used to evaluate associations between the groups.

RESULTS

Prevalence rates indicated approximately 31% of all students were currently using ENDS. Even though more negative than positive experiences with ENDS were reported, most students stated their vaping increased during COVID-19 lockdowns. Addiction and stress relief emerged to be predictors (P < .001) of an increase in vaping, whereas social motives were not statistically significant. Living situation (P = .63) and depression (P = .10) were not significantly associated with vaping behavior.

CONCLUSIONS

ENDS products continue to yield very high levels of nicotine creating addiction in young adults. Addiction counseling and evidenced-based practices should be employed at every level (individual, community, and school). Additionally, mental health counseling for students in pandemic and high-stress environments may help to combat stress in a more proactive manner than self-medicating.

Trends of Single, Dual, and Polytobacco Use Among School-Based Students in the United States: An Analysis of the National Youth Tobacco Survey

PURPOSE

To examine trends in single, dual, and polytobacco use between 2014-2020 for US youth and to identify disparities in these trends by grade level, sex, and race/ethnicity.

DESIGN

A secondary analysis of the National Youth Tobacco Survey (NYTS).

SUBJECTS

A total of 122 566 students.

MEASURES

Past 30-day exclusive use of cigarettes, e-cigarettes, other combustibles (cigars, little cigars, cigarillos, hookah, pipe tobacco, bidis) and smokeless tobacco (snus, smokeless, dissolvable); dual use of each product with e-cigarettes; polyuse with e-cigarettes; dual/polyuse without e-cigarettes.

ANALYSIS

Multivariable modified Poisson regression.

RESULTS

Compared to 2014, exclusive e-cigarette use (APR = 2.51, 95% CI: 1.96, 3.21) trended upward while exclusive cigarette (APR = .34, 95% CI: .23, .50), 'other' combustibles (APR = .47, 95% CI: .37, .58), and smokeless tobacco (APR = .40, 95% CI: .25, .65) use trended downward in 2020. Polytobacco use with and without e-cigarettes trended downward in 2020 compared to 2014. We also saw differences in trends across sociodemographic groups. Comparing 2020 to 2014, exclusive e-cigarette use was higher for females than males, 'other' combustible tobacco use remained stable for Non-Hispanic Black students but decreased for other racial/ethnic groups, and dual e-cigarette/cigarette use trended upward more for middle school students than high school students.

CONCLUSIONS

Despite decreased trends in tobacco product use without e-cigarettes between 2014-2020, differences in tobacco product use trends by grade level, sex, and race/ethnicity were identified. Prevention efforts targeting disparities in tobacco product use are needed.

Adverse Biophysical Impact of e-Cigarette Flavors on Pulmonary Surfactant

The attractiveness and abundance of flavors are primary factors eliciting youth to use e-cigarettes. Emerging studies in recent years revealed the adverse health impact of e-cigarette flavoring chemicals, including disruption of the biophysical function of pulmonary surfactants in the lung. Nevertheless, a comprehensive understanding of the biophysical impact of various flavoring chemicals is still lacking. We used constrained drop surfactometry as a new alternative method to study the biophysical impact of flavored e-cigarette aerosols on an animal-derived natural pulmonary surfactant. The dose of exposure to e-cigarette aerosols was quantified with a quartz crystal microbalance, and alterations to the ultrastructure of the surfactant film were visualized using atomic force microscopy. We have systematically studied eight representative flavoring chemicals (benzyl alcohol, menthol, maltol, ethyl maltol, vanillin, ethyl vanillin, ethyl acetate, and ethyl butyrate) and six popular recombinant flavors (coffee, vanilla, tobacco, cotton candy, menthol/mint, and chocolate). Our results suggested a flavor-dependent inhibitory effect of e-cigarette aerosols on the biophysical properties of the pulmonary surfactant. A qualitative phase diagram was proposed to predict the hazardous potential of various flavoring chemicals. These results provide novel implications in understanding the environmental, health, and safety impacts of e-cigarette aerosols and may contribute to better regulation of e-cigarette products.

Association between e-cigarette use and asthma among US adolescents: Youth Risk Behavior Surveillance System 2015-2019

BACKGROUND

Previous studies have suggested that e-cigarette use, which has increased rapidly among US adolescents, may cause respiratory distress. This cross-sectional study aimed to investigate the factors associated with e-cigarette use and the relationship between e-cigarette use and asthma among US adolescents.

METHODS

Data from the Youth Risk Behavior Surveillance System between 2015 and 2019 were analyzed, and multivariable logistic regression was used to identify demographic and behavioral factors associated with e-cigarette use. Stratified analyses were conducted to assess the relationship between e-cigarette use and asthma among adolescents by previous combustible product use.

RESULTS

This study found that Hispanic adolescents had lower odds of e-cigarette use than White adolescents in Texas, with factors such as age, substance use, and depression being associated with use. In the US, male gender, previous combustible and substance use, and depression were associated with higher odds of ever using e-cigarettes, while current use was associated with several factors including age and White race. E-cigarette use was significantly associated with asthma among adolescents who have never used combustible products in both Texas and the entire US after adjusting for covariates (OR 1.32, 95% CI 1.06-1.66 and OR 1.18, 95% CI 1.02-1.37, respectively).

CONCLUSION

The findings from this study can be used to inform public health strategies and policies aimed at reducing e-cigarette use and its associated health risks among adolescents.

Prevalence of active and passive smoking among asthma and asthma-associated emergency admissions: a nationwide prevalence survey study

Asthma affects 7% of children and 8% of adults in the United States. There is a paucity of studies examining the association between passive smoking and an increased risk of asthma exacerbations that led the authors to examine the association between various modes of smoking and rates of asthma exacerbations. A retrospective cross-sectional/case-control study was conducted using the National Health and Nutrition Examination Survey dataset (2013-2018). Out of 312,979 respondents, 35,758 (11.43%) had a history of asthma, 9083 (2.9%) had asthma attacks in the past year, and 4731 (1.51%) had asthma-related emergency room admissions in the past year. Prevalence of asthma-related emergency admissions were higher among active cigarette smoking (46.25 vs 35.46%), e-cigarette smoking (26.63 vs 16.07%), and passive smoking at home (37.53 vs 25.67%), workplace passive smoking (14.35 vs 12.11%), in bar (32.38 vs 26.16%), and car (26.21 vs 14.44%) (p < 0.0001). In multivariate regression analysis, we found regular cigarette smoking (OR 1.13, 95% confidence interval (CI) 1.009-1.260, p = 0.0252), e-cigarette (OR 2.13, 95% CI 1.92-2.36, p = 0.0043), cigar use (OR 1.21, 95% CI 1.1-1.33, p < 0.001), ultra-long cigarette length (OR 4.85, 95% CI 3.33-7.06, p < 0.0001), and passive smoking (OR 5.25, 95% CI 3.43-8.06, p < 0.0001) were associated with increased rates of asthma exacerbations over last 12 months. The study shows increased odds of asthma exacerbations among those using ultra-long cigarettes, e-cigarettes, and cigars. Consequently, passive inhalation from even a single smoker in the home, workplace, bars and cars is associated with worsening outcomes in asthma patients.

Profiling flavourings in strawberry-flavoured e-liquid using headspace-gas chromatography-mass spectrometry

E-liquids typically contain nicotine and flavourings in a matrix of propylene glycol (PG) and vegetable glycerine (VG). Some nicotine-free e-liquids are flavouring only in the aerosol carrier with the option for users to add their own nicotine. It is only the nicotine that is monitored in terms of level, as specified by the manufacturers. Little is known of the toxicological effect for some of the flavourings in the context of vaping as these are only regulated for ingestion and not inhalation. A method was developed to analyse volatile organic compounds (VOCs) evolved when e-liquids are vaporised based on headspace-gas chromatography-mass spectrometry (HS-GC-MS) for e-liquids. An in-house standard was prepared with sample matrix and purchased strawberry flavouring to simulate a simple e-liquid but with known levels. This standard was then used to optimise the analysis for use with e-liquid samples but not for full quantification purposes. These were purchased from a range of retailers and with different batches but mainly focussed on strawberry flavour. The results identified three key components indicative of strawberry flavour (ethyl-3-methyl butanoate, ethyl 2-methyl butanoate and ethyl butanoate) and showed considerable variation between both manufacturers and batches. Flavouring VOCs are regulated for ingestion but are not regulated for e-liquid inhalation, so these could have toxicological implications. In addition, the inconsistency between samples suggests further issues when users add their own nicotine to the e-liquids as the viscous sample matrix makes homogeneous mixing difficult.