E-cigarette use frequency and motivations among current users in middle school

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.

A Survey of Vaping Use, Perceptions, and Access in Adolescents from South-Central Texas Schools

Despite efforts to dissuade major manufacturers and retailers from marketing and selling vape products to adolescents, the practice of vaping continues to increase in this population. Few studies have assessed adolescent perceptions of vaping, access to vaping, and use of vaping, and most rely, at least in part, on inferential conclusions drawn from data on smoking traditional combustible cigarettes. A novel electronic survey was created to assess the use of vapes, perceptions of vaping, and access to vaping among a convenience sample of adolescents (ages 12-20 years) in eleven schools in South-Central Texas from May to August 2021. The students' perceived threat of negative health outcomes due to vaping was calculated based on questions soliciting perceptions of severity (perceived danger) and susceptibility (perceived likelihood of illness). Trends were identified using descriptive and bivariate statistical tests. A total of 267 respondents were included; 26% had tried vaping. A majority (63%) did not believe vaping and smoking were synonymous. Most (70%) thought it was easy to obtain supplies and (76%) vape before and after (88%) or even during (64%) school. Respondents who vaped had a 34% lower perceived threat when compared to respondents who did not vape. In this sample of adolescents from South-Central Texas, one in four reported that they had tried vaping. Easy access to vapes and misperceptions regarding the safety of vaping might create a false sense of security with respect to vaping as an alternative to smoking, particularly among those who reported vaping, and is likely contributing to the increased use of vapes.

Adolescents' own views on their risk behaviors, and the potential effects of being labeled as risk-takers: A commentary and review

Adolescents are stereotypically viewed as risk-takers ("stereotypical risk-takers") in science, mainstream media, fictional literature and in everyday life. However, increasing research suggests that adolescents do not always engage in "heightened" risk-taking, and adolescents' own perspectives (motives) on risk-taking are largely neglected in research. Hence, this paper is a commentary and review with two aims. First, taking a cross-national perspective, we discuss the definition of adolescence and risk behavior. We argue that much of the research on what drives adolescent risk behavior (e.g., substance use) focuses on the harms that this behavior promotes rather than on the need to explore and grow into adulthood. Thereafter we summarize the dominant approach to studying motives behind substance use, which has mostly considered young adults, and which has typically not focused on adolescents' own self-generated motives. The few empirical studies (including one of our qualitative studies) on adolescents' own motivations for engaging in risk behavior (i.e., cannabis use, alcohol use, and tobacco smoking) show that the most frequently mentioned motives by adolescents were being cool/tough, enjoyment, belonging, having fun and experimenting and coping. Interestingly, the "cool/tough identity" motive is virtually overlooked in research on adolescent risk-taking. The above-mentioned motives, however, generally support newer theories, such as the Developmental Neuro-Ecological Risk-taking Model (DNERM) and the Life-span Wisdom Model that suggest that adolescents' motivations to engage in risk-taking include experimentation, identity development, explorative behavior, and sensation seeking, all of which run counter to the stereotype of adolescents engaging in risk-taking due to "storm and stress." Hence, we also briefly consider additional recent attempts to study positive forms of risk taking. Second, extrapolating from sociological/criminological theories on labeling, we suggest that caution is warranted when (inaccurately) labeling adolescents as the "stereotypical risk-takers," because this can instigate a risk-taking identity in adolescents and/or motivate them to associate with risk-taking peers, which could in turn lead to maladaptive forms of risk-taking. Empirical research testing these hypotheses is needed. To conclude we argue that research on adolescent risk-taking could further benefit from considering adolescent's own motivations, which is also in line with the participatory approach advocated by international children's rights standards.

Potential Impact of FDA Flavor Enforcement Policy on Vaping Behavior on Twitter

In January 2020, the FDA announced an electronic cigarette (e-cigarette) flavor enforcement policy to restrict the sale of all unauthorized cartridge-based flavored e-cigarettes except tobacco and menthol flavors, which was implemented on 6 February 2020. This study aimed to understand the potential influence of this policy on one vaping behavior change-quitting vaping-using Twitter data. Twitter posts (tweets) related to e-cigarettes were collected between June 2019 and October 2020 through a Twitter streaming API. Based on the geolocation and keywords related to quitting vaping, tweets mentioning quitting vaping from the US were filtered. The demographics (age and gender) of Twitter users who mentioned quitting vaping were further inferred using a deep learning algorithm (deepFace). The proportion of tweets and Twitter users mentioning quitting vaping were compared between before and after the announcement and implementation of the flavor policy. Compared to before the FDA flavor policy, the proportion of tweets (from 0.11% to 0.20% and 0.24%) and Twitter users (from 0.15% to 0.70% and 0.86%) mentioning quitting vaping were significantly higher after the announcement and implementation of the policy (p-value < 0.001). In addition, there was an increasing trend in the proportion of female and young adults (18-35 years old) mentioning quitting vaping on Twitter after the announcement and implementation of the policy compared to that before the policy. Our results showed that the FDA flavor enforcement policy did have a positive impact on quitting vaping on Twitter. Our study provides an initial evaluation of the potential influence of the FDA flavor enforcement policy on user vaping behavior.

An International Systematic Review of Prevalence, Risk, and Protective Factors Associated with Young People's E-Cigarette Use

While the prevalence of young people's conventional cigarette use has decreased in many countries, the use of e-cigarettes has risen. To effectively counteract the growing popularity of e-cigarettes among young people internationally, researchers should know the exact prevalence as well as the protective and risk factors associated with vaping. Based on five eligibility criteria, 53 articles were chosen and analyzed by general characteristics, prevalence, sample characteristics, gender difference, protective factors, and risk factors. In this study, the international pooled prevalence of young people's lifetime e-cigarette use was 15.3%, the current use was 7.7%, and dual use was 4.0%. While the highest lifetime, current, and dual prevalence were found in Sweden, Canada, and the United Kingdom, respectively, the lowest prevalence was found in Germany, followed by South Korea and Sweden. Some protective and risk factors include perceived cost and danger of vaping, parental monitoring, internal developmental assets, cigarette use, family and peer smoking, exposure to online advertisements, and the presence of nearby retail stores. Based on this review, researchers and practitioners can develop different intervention programs and strategies for young smokers.

Preferences, use, and perceived access to flavored e-cigarettes among United States adolescents and young adults

Background:

Citing concern over youth use, the Food and Drug Administration announced a prioritized enforcement policy against cartridge-based (reusable pod) e-cigarettes in non-menthol, non-tobacco flavors, effective February 2020. Data are needed regarding youth e-cigarette access and use behaviors following this policy.

Methods:

This cross-sectional national (USA) online panel survey, conducted March/April 2021, included 2253 participants ages 14–20 who ever used e-cigarettes ≥3 times (73% past 30-day users). Participants reported their flavor preferences, use reasons, and perceived ease of access. Latent class analysis categorized participants according to their preferred e-cigarette flavors, and multinominal logistic regression identified sociodemographic and behavioral correlates of class membership.

Results:

Most past 30-day e-cigarette users used reusable pod (77%) or modern disposable (68%) devices, ≥1 non-tobacco (92%), sweet (76%), and/or menthol flavors including fruit-ice (70%) (flavor and device categories not mutually exclusive). Most past 30-day users (70%) and non-users (63%) perceived it would be somewhat or very easy to acquire e-cigarettes in flavors they like. Latent class analysis identified four e-cigarette flavor preference classes: mint (34% of sample), no preference (29%), fruit/sweet (28%), and dislikes ≥1 flavor (10%). Relative to no preference, membership in fruit/sweet (RRR: 1.87; 95% CI: 1.37, 2.57) and mint (RRR: 3.85; 95% CI: 2.77, 5.36) classes was associated with using e-cigarettes ≥50 times. Fruit/sweet membership was inversely associated with combustible tobacco use (RRR: 0.50; 95% CI: 0.38, 0.66).

Conclusion:

Young e-cigarette users maintained ample access to flavored and cartridge-based products. Stronger access restrictions and enforcement are required to reduce youth e-cigarette use.

Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation

BACKGROUND AND AIMS

There is concern that young people may be attracted to e-liquid flavours, prompting long-term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e-liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences.

DESIGN

Systematic review, including interventional, observational and qualitative studies reporting on the use of e-cigarette flavours by young people (aged < 18 years).

SETTING

Studies published in English language from any country or cultural setting.

PARTICIPANTS

Young people and their carers (aged < 18 years).

MEASUREMENTS

A meta-analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non-interventional study designs; thus, we narratively report findings.

FINDINGS

In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross-sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross-sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e-liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours.

CONCLUSIONS

Flavours may be an important motivator for e-cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e-cigarette flavours by young people is low overall.

Achievements, challenges, priorities and needs to address the current tobacco epidemic in Latin America

Most Latin American countries have signed and ratified the FCTC, although implementation has been uneven. Countries across the region were relatively quick to adopt mandatory smoke-free workplace policies, but regional progress in other areas has been slower. In taxation, for example, Uruguay and Brazil have made considerable progress while Paraguay and Bolivia have relatively weak policies. More recently, the region is grappling with challenges regulating novel tobacco and nicotine products. Market share for flavor capsule cigarettes in Latin America is the highest in the world; electronic cigarettes and heated tobacco products are, for the most part, dissimilarly regulated; and uptake of these emerging products by adolescents and young adults is on the rise. In examining the needs and challenges in the region, we conclude that the adoption of a strong regulatory framework based on the FCTC and its Protocols is needed to accelerate a positive public health impact. In particular, countries in the region need more consistent progress in implementing FCTC provisions while strengthening regulation of flavored tobacco products, electronic cigarettes and heated tobacco products. Failing to do so threatens to undermine the progress Latin America has made in tobacco use prevention and control.

A commentary on adolescent electronic cigarette use and nicotine addiction

Adolescent electronic cigarette (e-cigarette) use has continued due to the ongoing struggle with nicotine addiction affecting teenagers. By briefly discussing the timeline of the emergence of e-cigarettes and nicotine addiction in adolescents, this author hopes to shed some light on mitigation strategies to curtail this ongoing epidemic of youth e-cigarette use and nicotine addiction through public health education and advocacy.

Metal exposure and biomarker levels among e-cigarette users in Spain

The use of electronic cigarettes (e-cigarettes) has increased due to the belief that they are healthier than tobacco cigarettes. E-cigarettes contain a metallic heating coil (composed of Ni, Cr, Al and other metals) to heat a solution (commonly called e-liquid) and convert it into an aerosol. This aerosol is inhaled (vaped) by the users who can be potentially exposed to a wide variety of metals. We investigated the possible transfer of metals from the coil to the e-liquid and the generated aerosol, and how the exposure to this aerosol can increase metal body burden in e-cigarette users. We recruited 75 e-cigarette users (50 who only vaped and 25 dual users who vaped and smoked) and 25 controls who neither vaped nor smoked. E-liquid samples before (dispenser e-liquid) and after (tank e-liquid) being added to their devices were collected. Aerosol samples were collected using a condensation method. All participants provided urine and hair samples. All samples were analyzed for metals by ICP-MS. We observed higher metal concentrations in the aerosol and tank e-liquid (in contact with the coil) compared to the dispenser e-liquid (before contact with the coil). The median concentrations for some of the metals with the most remarkable increases in aerosol and tank e-liquid vs. dispenser e-liquid were 36.90 and 62.73 vs. 18.29 μg/kg for Al; 6.71 and 28.97 vs. 0.98 μg/kg for Cr; 91.39 and 414.47 vs. 1.64 μg/kg for Ni; 738.99 and 744.24 vs. 16.56 μg/kg for Zn; and 10.17 and 22.31 vs. 0.88 μg/kg for Pb. We also found detectable and potentially high concentrations of other metals such as Mn, Cu, Sb and Sn. In urine, increases in the median levels (μg/g creatinine) in vapers/duals vs. controls were observed for some metals, including Cr (0.34/0.28 vs. 0.20), Cu (1.72/2.36 vs. 1.46), Sn (0.26/0.31 vs. 0.18) and Pb (0.39/0.44 vs. 0.22). In hair, there were no differences in metal concentrations among the three groups. In conclusion, e-cigarettes are likely a source of metals such as Cr, Cu, Ni, Pb or Sn. These metals come from the device, likely the heating resistance, as their concentrations were low in the dispenser e-liquid and higher in the aerosol and the e-liquid left in the tank. Although the exposure to e-cigarette aerosol can have an influence in the body burden of metals, aerosol metal levels were not clearly associated with metal levels in biological samples such as urine or hair in e-cigarette users in this study.

Mechanism Linking AR-Based Presentation Mode and Consumers’ Responses: A Moderated Serial Mediation Model

The technological development of online product presentation modes (e.g., augmented reality, virtual reality) will greatly impact the future of e-retailing. The potential benefits of applying these new technologies for e-retailers need further investigation. Based upon the stimulus-organism-response (S-O-R) model, this study examines the effect of AR-based presentation modes on consumer patronage intention, with the mediating role of immersion, enjoyment, perceived product risk and attractiveness of the online store. Furthermore, it explores the moderating effect of technophilia that reflects consumers’ positive attitude towards technology. A single factor between-subject experiment study was conducted with a sample of 420 university students. Results suggest that the serial indirect effects of AR presentation on patronage intention through immersion/enjoyment/perceived product risk and attractiveness of online store are conditional upon the level of technophilia. Technophilia is a critical factor that explains consumers’ psychological and behavioral responses when they are using new technologies. The study provides new knowledge for e-marketing practitioners, as well as AR literature by indicating how and when new technology-based presentation works in evoking consumers’ patronage intention.

Identifying emerging predictors for adolescent electronic nicotine delivery systems use: A machine learning analysis of the Population Assessment of Tobacco and Health Study

Intervention strategies to prevent adolescents from using electronic nicotine delivery systems (ENDS) should be based on robust predictors of ENDS use that may differ from predictors of conventional cigarette use. Literature points to the need for uncovering emerging predictors of ENDS use. This study identified emerging predictors of adolescent ENDS use using machine learning (ML) techniques. We analyzed nationally representative multi-wave longitudinal survey data (2013-2018) drawn from the Population Assessment of Tobacco and Health Study. A sample of adolescents (12-17 years) who never used any tobacco products at baseline and completed Wave 2 (n = 7958), Wave 3 (n = 6260) and Wave 4 (n = 4544) were analyzed. We developed a supervised ML prediction model using the penalized logistic regression to assess self-reported past-month ENDS use (i.e., current use) at Waves 2-4 based on the variables measured at the previous wave. We then extracted important predictors from each model. The penalized logistic regression models showed suitable capability to discriminate between ENDS uses and non-uses at each wave based on the area under the receiver operating characteristic curve and the area under the precision-recall curve. Interestingly, social media use emerged as an important variable in predicting adolescent ENDS use. ML models appear to be a promising method to identify unique population-level predictors for U.S. adolescent ENDS use behaviors. More research is warranted to investigate emerging predictors of ENDS use and experimentally examine the mechanism by which these emerging predictors affect ENDS use behavior across different spectrum of populations.

La escala de afluencia familiar en la investigación sobre inequidades sociales en salud en adolescentes latinoamericanos

Objetivo. Evaluar la escala de afluencia familiar (EAF), que consiste en el autorreporte sobre número de computadoras y automóviles del hogar, dormitorio propio y vacaciones, como indicador de nivel socioeconómico (NSE) familiar en adolescentes escolarizados de tres países latinoamericanos. Material y métodos. Fueron encuestados 14 717 estudiantes de secundaria de Argentina, México y Guatemala. Se evaluó la asociación de la EAF con otros indicadores de NSE a nivel familiar (nivel educativo parental, posesión de bienes y servicios tecnológicos) y de entorno escolar (índice de marginación, escuela pública o privada y matrícula escolar). Resultados. La EAF mostró menos datos faltantes que los otros indicadores familiares de NSE. Además, mostró asociaciones en la dirección esperada con los otros indicadores de NSE. Conclusiones. La EAF parece constituir un indicador válido tanto de la riqueza material familiar como del NSE a nivel de la escuela, útil para estudios sobre inequidades en salud en adolescentes latinoamericanos.

Cross-sectional study on the awareness, susceptibility and use of heated tobacco products among adolescents in Guatemala City, Guatemala

OBJECTIVES

Heated tobacco products (HTPs) are increasingly marketed worldwide, yet limited research on HTPs has been conducted in low and middle-income countries (LMICs) or among adolescents. Guatemala is one of the few LMICs where HTPs are available. This study examined prevalence and correlates of HTP awareness, susceptibility and use among adolescents in Guatemala.

DESIGN, SETTING AND PARTICIPANTS

A cross-sectional survey on HTP awareness, susceptibility and use was conducted among 2870 students between the ages of 13 and 17 in private schools in Guatemala City, Guatemala.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was susceptibility to future use of HTP among school-aged current and never smokers in Guatemala. We also explored awareness and use of HTPs. Multivariate binomial regression models were used to explore associations between these outcomes and both sociodemographic factors and established smoking correlates.

RESULTS

Of all students (n=2870), about half were aware of HTPs (52.4%) and susceptible to future or continued use (52.4%). Whereas 8.4% of students had tried HTPs in the lifetime (but not in the last month), only 2.9% used HTPs in the past month. Independent correlates of HTP susceptibility and ever-use included: use of other tobacco products (current smoking: adjusted OR (AOR)=10.53 and 6.63, respectively; current e-cigarette use: AOR=21.87 and 10.40, respectively), moderate alcohol consumption (AOR=1.49 and 1.19, respectively), marijuana use in the past 30 days (AOR=3.49 and 2.29, respectively) and having friends who use HTPs (AOR=1.83 and 7.28, respectively).

CONCLUSIONS

Among this sample of adolescents in Guatemala City, where tobacco control is weak, the prevalence of HTP use was low but susceptibility to future use was high. Tobacco prevention and intervention strategies for cigarettes and e-cigarettes should now also include HTPs, which tend to be used by similar adolescent populations (ie, those who use other substances or are exposed to tobacco through family and friends).

E-cigarettes: How can they help smokers quit without addicting a new generation?

The dramatic increase in youth use of electronic nicotine delivery systems (ENDS; e.g., e-cigarettes) in the United States has focused regulatory efforts to address this concern while still encouraging smokers to switch completely to lower risk products or quit all tobacco product use. Increases in the minimum age for purchase of all tobacco products and changes in enforcement policy for ENDS have been recently enacted in an effort to address the youth vaping epidemic. Since all ENDS marketed after February 15, 2007 will be required to meet the "appropriate for the protection of public health" standard for marketing authorization of new products, ENDS manufacturers will have to demonstrate, in part, that their products help lessen the adverse impact on youth use. Some, such as disallowing flavors other than tobacco or menthol or limiting nicotine delivery, may help reduce youth use but could also inhibit smokers from quitting smoking. Other approaches, including reducing the high-tech appearance and discreteness of ENDS, discontinuing use of coupons and two-for-one type price incentives for ENDS, limiting retail sales of these products to adult-only facilities, and incorporating technological innovations such as biometrics or geofencing into ENDS, may help manufacturers demonstrate that marketing of their products would help reduce youth use of ENDS and lessen the epidemic, while still assuring adult smokers have access to products that encourage discontinuing combusted product use.

Assessing cigarette packaging and labelling policy effects on early adolescents: results from a discrete choice experiment

INTRODUCTION

Cigarette packaging is a primary channel for tobacco advertising, particularly in countries where traditional channels are restricted. The current study evaluated the independent and interactive effects of cigarette packaging and health warning label (HWL) characteristics on perceived appeal of cigarette brands for early adolescents in Mexico.

METHODS

A discrete choice experiment (DCE) was conducted with early adolescents, aged 12-14 years (n=4251). The DCE involved a 3×25 design with six attributes: brand (Marlboro, Pall Mall, Camel), tobacco flavour (regular, menthol), flavour capsule (none, 1 or 2 capsules), presence of descriptive terms, branding (vs plain packaging), HWL size (30%, 75%) and HWL content (emphysema vs mouth cancer). Participants viewed eight sets of three cigarette packs and selected a pack in each set that: (1) is most/least attractive, (2) they are most/least interested in trying or (3) is most/least harmful, with a no difference option.

RESULTS

Participants perceived packs as less attractive, less interesting to try and more harmful if they had plain packaging or had larger HWLs, with the effect being most pronounced when plain packaging is combined with larger HWLs. For attractiveness, plain packaging had the biggest influence on choice (43%), followed by HWL size (19%). Interest in trying was most influenced by brand name (34%), followed by plain packaging (29%). Perceived harm was most influenced by brand name (30%), followed by HWL size (29%).

CONCLUSION

Increasing the size of HWLs and implementing plain packaging appear to reduce the appeal of cigarettes to early adolescents. Countries should adopt these policies to minimise the impact of tobacco marketing.

History repeats itself: Role of characterizing flavors on nicotine use and abuse

The popularity of e-cigarettes has skyrocketed in recent years, and most vapers use flavored e-cigarette products. Consumption of flavored e-cigarettes exceeds that of combustible cigarettes and other tobacco products among adolescents, who are particularly vulnerable to becoming nicotine dependent. Flavorings have been used by the tobacco industry since the 17th century, but the use of flavors by the e-cigarette industry to create products with "characterizing" flavors (i.e. flavors other than tobacco or menthol) has sparked a public health debate. This review addresses the possibility that characterizing flavors make nicotine more appealing, rewarding and addictive. It also discusses ways in which preclinical and clinical studies could improve our understanding of the mechanisms by which flavors may alter nicotine reward and reinforcement. This article is part of the special issue on 'Contemporary Advances in Nicotine Neuropharmacology'.

What influences adolescents to continuously use e-cigarettes?

OBJECTIVE

The use of e-cigarettes is rapidly increasing in adolescents. Health care providers pay attention to e-cigarette users because of the risk of developing addiction and problematic behavior. Based on ecological perspective, this study investigated factors influencing continued e-cigarette use.

METHODS

We classified 1556 current e-cigarette users into experimental and continued users using the Korean national representative data. Data were analyzed using the chi-square test and logistic regression based on a complex sample analysis.

RESULTS

Among current e-cigarette users, 55.1% were continued users. Adolescents who use e-cigarettes because of the belief that they are less harmful than cigarettes, concealment, easy purchase, and adding various flavors had a high risk of continued use. Continued users were more likely to have a higher weekly allowance, lower rate of living with family, and higher chance of smoking parents and exposure to passive smoking at home.

CONCLUSIONS

Continued e-cigarette use was influenced by interpersonal and environmental factors, such as ease of purchase and addition of flavoring substances. Improving the environment of adolescents can prevent continued use of e-cigarettes.