Electronic nicotine delivery systems use predicts transitions in cigarette smoking among young adults

Factors associated with transitions in tobacco product use states among young adults aged 18-29 years

BACKGROUND AND OBJECTIVES

This study examined young adults' tobacco use transitions based on their past 30-day use states, and identified factors associated with their transitions.

METHODS

Participants (N = 12377) were young adults aged 18-29 years at Wave 1 of the Population Assessment of Tobacco and Health (PATH) study. Self-reported tobacco use states were categorized by the number of past-month use days (0, 1-4, 5-8, 9-12, 13-30 days) for cigarettes, electronic cigarettes [e-cigarettes], traditional cigars, filtered cigars, cigarillos, smokeless tobacco (SLT), and hookah. Multistate Markov models examined transitions between use states across Waves 1-5 of unweighted PATH data and multinomial logistic regressions examined predictors of transitions.

RESULTS

Most young adults remained nonusers across adjacent waves for all products (88%-99%). Collapsed across waves, transitioning from use at any level to nonuse (average 46%-67%) was more common than transitioning from nonuse to use at any level (average 4%-10%). Several factors that predicted riskier patterns of use (i.e., transitioning to use and/or remaining a user across adjacent waves) were similar across most products: male, Black, Hispanic, lower education levels, and lower harm perceptions. In contrast, other factors predicted riskier patterns for only select products (e.g., e-cigarette and SLT use among Whites).

DISCUSSION AND CONCLUSIONS

Few sampled young adults escalated their tobacco use over time, and escalations for many products were predicted by similar factors.

SCIENTIFIC SIGNIFICANCE

Prevention and regulatory efforts targeted towards adolescents should continue, but also be expanded into young adulthood. These same efforts should consider both shared and unique factors that influence use transitions.

Multistate transition modelling of e-cigarette use and cigarette smoking among youth in the UK

INTRODUCTION

E-cigarette use remains a controversial topic, with questions over how people transition between e-cigarette use and cigarette smoking. This paper examined transitions into and out of nicotine product use in a representative sample of UK youth.

METHODS

We used Markov multistate transition probability models on data from 10 229 participants (10-25 years old) in the UK Household Longitudinal Study (2015-2021). We used four product use states ('never', 'non-current use', 'e-cigarette only' and 'smoking and dual use') and estimated likelihood of transitions according to sociodemographic characteristics.

RESULTS

Among participants who had never used nicotine products, most were still non-users a year later (92.9% probability; 95% CI 92.6%, 93.2%); a small proportion transitioned to using e-cigarettes only (4.0%; 95% CI 3.7%, 4.2%) and cigarettes (2.2%; 95% CI 2.0%, 2.4%). Those aged 14-17 years were the most likely to start using a nicotine product. E-cigarette use was less persistent overtime than cigarette smoking, with a 59.1% probability (95% CI 56.9%, 61.0%) of e-cigarette users still using after 1 year compared with 73.8% (95% CI 72.1%, 75.4%) for cigarette smoking. However, there was a 14% probability (95% CI 12.8%, 16.2%) that e-cigarette users went onto smoke cigarettes after 1 year, rising to 25% (95% CI 23%, 27%) after 3 years.

CONCLUSION

This study found that although overall nicotine product use was relatively rare, participants were more likely to experiment with e-cigarette use than cigarette smoking. This was mostly not persistent over time; however, approximately one in seven transitioned to cigarette smoking. Regulators should aim to deter all nicotine product use among children.

A systematic review and meta-analysis of the association between e-cigarette use among non-tobacco users and initiating smoking of combustible cigarettes

INTRODUCTION

The rapid increase in e-cigarette use over the past decade has triggered an important public health question on the potential association between e-cigarette use and combustible cigarette smoking. Following AMSTAR 2 and PRISMA guidelines, this evidence synthesis sought to identify and characterize any associations between e-cigarette use among individuals not smoking cigarettes and initiation of cigarette smoking.

METHODS

The protocol was registered on September 24, 2018 (PROSPERO 2018 CRD42018108540). Three databases were queried from January 01, 2007 to April 26, 2023. Search results were screened using the PICOS review method.

RESULTS

Among 55 included studies (40 "good" and 15 "fair"; evidence grade: "high") that adjusted for gender, age, and race/ethnicity between groups, generally, there was a significant association between non-regular e-cigarette use and initiation of cigarette smoking, further supported by the meta-analytic results (AOR 3.71; 95% CI 2.86-4.81). However, smoking initiation was most often measured as ever/current cigarette smoking. Two studies (quality: 2 "good") evaluated progression to regular cigarette smoking among individuals with regular use of e-cigarettes, and generally found no significant associations. One study ("good") evaluated smoking initiation among individuals with regular use of e-cigarettes, finding an increasing probability of ever smoking cigarettes with increased e-cigarette use. Twelve studies (10 "good" and two "fair") examining progression to regular smoking among individuals with non-regular use of e-cigarettes reported inconsistent findings.

CONCLUSIONS

Numerous methodological flaws in the body of literature limit the generalizability of these results to all individuals who are not smoking cigarettes with few studies measuring established/regular use/smoking of e-cigarettes and cigarettes. Further, studies did not control adequately for specific confounding variables representing common liabilities between e-cigarette use and cigarette smoking, nor did they account for sufficient follow-up durations. Collectively, these flaws limit the generalizability of findings to the question of an association between e-cigarette use and cigarette smoking initiation.

Electronic cigarette use in relation to changes in smoking status and respiratory symptoms

INTRODUCTION

How e-cigarette use relates to changes in smoking status and respiratory symptoms in the population remains controversial. The aim was to study the association between e-cigarette use and, changes in smoking status and changes in respiratory symptoms.

METHODS

A prospective, population-based study of random samples of the population (age 16-69 years) was performed within The Obstructive Lung Disease in Northern Sweden (OLIN) study and West Sweden Asthma Study (WSAS). A validated postal questionnaire containing identical questions was used in OLIN and WSAS at baseline in 2006-2008 and at follow-up in 2016. In total, 17325 participated on both occasions. Questions about respiratory symptoms and tobacco smoking were included in both surveys, while e-cigarette use was added in 2016.

RESULTS

In 2016, 1.6% used e-cigarettes, and it was significantly more common in persistent tobacco smokers (10.6%), than in those who quit smoking (2.1%), started smoking (7.8%), or had relapsed into tobacco smoking at follow-up (6.4%) (p<0.001). Among current smokers at baseline, tobacco smoking cessation was less common in e-cigarette users than e-cigarette non-users (14.2% vs 47.6%, p<0.001) and there was no association with a reduction in the number of tobacco cigarettes smoked per day. Those who were persistent smokers reported increasing respiratory symptoms. In contrast, the symptoms decreased among those who quit tobacco smoking, but there was no significant difference in respiratory symptoms between quitters with and without e-cigarette use.

CONCLUSIONS

E-cigarette use was associated with persistent tobacco smoking and reporting respiratory symptoms. We found no association between e-cigarette use and tobacco smoking cessation, reduction of number of tobacco cigarettes smoked per day or reduction of respiratory symptoms.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021

Introduction

The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019.

Methods

Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group.

Results

Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use.

Conclusions

Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Systematic Review and Critical Analysis of Longitudinal Studies Assessing Effect of E-Cigarettes on Cigarette Initiation among Adolescent Never-Smokers

Prospective longitudinal studies mainly conclude on a causal role of e-cigarettes in the initiation of cigarettes in flagrant contradiction with conclusions drawn from epidemiology and other studies showing a sharp decline in cigarette use in parallel with the spread of e-cigarette use. This systematic review explores the reasons for this discrepancy.

METHODS

Among 84 publications on e-cigarette/cigarette association in adolescents identified in the Medline database from 2011 to 2022, 23 concern 22 never-smoker longitudinal sub-cohorts.

RESULTS

A link between e-cigarette experimentation at T1 and cigarette initiation at T2 is reported in sub-cohort analyses of never-smokers (AOR: 1.41 to 8.30). However, studies exclude 64.3% of T1 e-cigarette experimenters (because of dual-use) and 74.1% of T2 cigarette experimenters. With this study design, e-cigarettes contribute only to 5.3% of T2 cigarette experimentation, casting major doubt on the external validity of results and authors' conclusions that e-cigarettes have a significant effect on the initiation of cigarettes (Gateway effect) at the population level. This sub-cohort design prohibits highlighting any Diversion effect, which is the most likely mechanism accounting for the competition between these two products.

CONCLUSIONS

While nicotine abstinence remains the best medical option, over-regulation of e-cigarettes because of misinterpretation of longitudinal study results may be detrimental to public health and tobacco control.

Behavioral intentions assessment of a disposable e-cigarette among adult current, former, and non-smokers in the United States

Modeling the public health effects of e-cigarettes requires estimates of the likelihood that different individuals and population subgroups will start using e-cigarettes and subsequently transition to and from combustible cigarette use. To begin to generate input values for modeling efforts, this study assessed adults' behavioral intentions in relation to a disposable e-cigarette, "BIDI® Stick." An online questionnaire assessed intentions to try and use a BIDI® Stick regularly in 11 flavor variants among United States (U.S.) nationally representative samples of adult (21+ years) non-smokers (n = 2284), current smokers (n = 2391), former smokers (n = 2241), and young adult (21-24 years) non-smokers (n = 1140) of combustible cigarettes following exposure to product information and images. Current smokers rated their intentions to use a BIDI® Stick to partially or completely replace cigarettes. Positive intention to try a BIDI® Stick at least once was, for each flavor variant, highest among current smokers (22.4%-28.1%), lower among former smokers (6.0%-9.7%) and non-smokers (3.4%-5.2%), and lowest among never-smokers (1.0%-2.4%). Among current smokers, former smokers, and non-smokers, trial and regular use intentions were lowest among e-cigarette non-users and e-cigarette never-users. Approximately 23.6% of current smokers reported an intention to use a BIDI® Stick in at least one flavor to completely switch from cigarettes and/or to reduce cigarette consumption. Low trial and regular use intentions suggest that U.S. adults who do not currently smoke cigarettes and/or use e-cigarettes are unlikely to initiate use of the BIDI® Stick e-cigarette. Trial and regular use intentions are highest among adults who currently smoke cigarettes and/or use e-cigarettes. A moderate proportion of current smokers may try using a BIDI® Stick e-cigarette as a partial or complete replacement for combustible cigarettes.

Electronic Cigarette Harms: Aggregate Evidence Shows Damage to Biological Systems

Evidence of the harms of e-cigarettes has been unfolding slowly and has been documented in many reviews and reports worldwide. A narrative review of new evidence is presented since, as research has continued, newly aggregated evidence of the dangers of electronic cigarettes on the brain, heart, and lungs is vital to inform decisions on restricting the use of e-cigarettes. Several biomedical research databases were searched for electronic cigarette health effects, emphasizing reviews, systematic reviews, and meta-analyses. Over 50 review studies, primarily in 2022 and 2023, illustrate some of the latest information on e-cigarette harms. Results show studies of respiratory, neurological, and cardiovascular effects. Researchers call for expanding studies through new methods to elaborate on initial findings of multiple harms emerging in clinical investigations. Since the use of electronic cigarettes for adult cessation is not sanctioned in most countries, it is clear that health authorities see significant costs to the health of the general population if the promotion and use of electronic cigarettes occur worldwide. Regulatory action to control electronic cigarettes should consider the substantial evidence of electronic cigarette harm.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of youth and adults in the PATH Study in 2015-2017 vs 2017-2019

INTRODUCTION

It is unknown how recent changes in the tobacco product marketplace have impacted transitions in cigarette and electronic nicotine delivery system (ENDS) use.

METHODS

A multistate transition model was applied to 24 242 adults and 12 067 youth in waves 2-4 (2015-2017) and 28 061 adults and 12 538 youth in waves 4 and 5 (2017-2019) of the Population Assessment of Tobacco and Health Study. Transition rates for initiation, cessation and product transitions were estimated in multivariable models, accounting for gender, age group, race/ethnicity and daily versus non-daily product use.

RESULTS

Changes in ENDS initiation/relapse rates depended on age, including among adults. Among youth who had never established tobacco use, the 1-year probability of ENDS initiation increased after 2017 from 1.6% (95% CI 1.4% to 1.8%) to 3.8% (95% CI 3.4% to 4.2%). Persistence of ENDS-only use (ie, 1-year probability of continuing to use ENDS only) increased for youth from 40.7% (95% CI 34.4% to 46.9%) to 65.7% (95% CI 60.5% to 71.1%) and for adults from 57.8% (95% CI 54.4% to 61.3%) to 78.2% (95% CI 76.0% to 80.4%). Persistence of dual use similarly increased for youth from 48.3% (95% CI 37.4% to 59.2%) to 60.9% (95% CI 43.0% to 78.8%) and for adults from 40.1% (95% CI 37.0% to 43.2%) to 63.8% (95% CI 59.6% to 67.6%). Youth and young adults who used both products became more likely to transition to ENDS-only use, but middle-aged and older adults did not.

CONCLUSIONS

ENDS-only and dual use became more persistent. Middle-aged and older adults who used both products became less likely to transition to cigarette-only use but not more likely to discontinue cigarettes. Youth and young adults became more likely to transition to ENDS-only use.

Alternative Tobacco Use and Cigarette Smoking Transitions among College Students in Texas

Background: High prevalence of very light cigarette smoking and use of alternative tobacco products (ATPs; i.e. electronic nicotine delivery systems [ENDS], cigars, and hookah) among young adult college students are causes for concern. The purpose of this study is to examine transitions in cigarette smoking (never vs. non-current vs. very light vs. heavier) among college students across 2.5 years and determine if the use of ATPs is related to these transitions. Methods: This study used six waves of data across 2.5 years from Project M-PACT. Participants who were 18-25 years of age at baseline were included in this study (n = 4,806). Cigarette smoking state was categorized as never smoking, non-current smoking [0 cigarettes smoked per day (cpd) in past month], very light smoking (< =5 cpd in past month), and heavier smoking (>5 in past month). Multi-state Markov models were used to examine temporal transitions in the four smoking states and examine the association of time-varying current ATP use with transitions in smoking states. Results: The probabilities of remaining in a smoking state decreased over time. The time-varying current ATP use was significantly related to increased odds of transitioning from never smoking to non-current smoking, from never smoking to very light smoking, and from non-current to very light smoking. Conclusions: Findings highlight the need to prevent ATP use among college students and in turn inhibit initiation and escalation of cigarette smoking.

A Systematic Review Investigating Associations Between E-Cigarette Use Among Former Cigarette Smokers and Relapse to Smoking Cigarettes

As e-cigarette use has steadily increased over the recent years, the public health interest in the potential implications of e-cigarette use on cigarette smoking has grown in parallel. With strict adherence to PRISMA guidelines, this systematic review examined the potential associations between e-cigarette use and relapse to cigarette smoking among former cigarette smokers. The protocol was registered on November 06, 2018 (PROSPERO 2018 CRD42018115674). Literature searches were executed from January 01, 2007 to August 20, 2022 and search results were screened according to the PICOS review method. One RCT and 10 adjusted studies examined relapse to cigarette smoking (evidence grade "moderate") among regular e-cigarette users, reporting mixed and inconsistent findings according to varying definitions of e-cigarette use and relapse. Findings were similarly inconsistent among the 8 adjusted studies examining relapse to cigarette smoking among non-regular e-cigarette users. The inconsistency in findings among studies evaluating regular measures of e-cigarette use, combined with the numerous methodological flaws in the overall body of literature, limit the generalizability of results associated with a causal association between e-cigarette use and relapse to cigarette smoking. Based on findings from this review, more robust studies are required to determine whether a causal association exists between e-cigarette use and relapse to cigarette smoking. Future studies should apply consistent measures of regular e-cigarette use to examine causality with future use patterns, and sufficiently account for known or suspected confounding variables to support inform determinations related to e-cigarette use and cigarette smoking behaviors.

Anesthesiologists and the Other Pandemic: Tobacco Use

Tobacco use will kill a projected 1 billion people in the 21st century in one of the deadliest pandemics in history. Tobacco use disorder is a disease with a natural history, pathophysiology, and effective treatment options. Anesthesiologists can play a unique role in fighting this pandemic, providing both immediate (reduction in perioperative risk) and long-term (reduction in tobacco-related diseases) benefits to their patients who are its victims. Receiving surgery is one of the most powerful stimuli to quit tobacco. Tobacco treatments that combine counseling and pharmacotherapy (e.g., nicotine replacement therapy) can further increase quit rates and reduce risk of morbidity such as pulmonary and wound-related complications. The perioperative setting provides a great opportunity to implement multimodal perianesthesia tobacco treatment, which combines multiple evidence-based tactics to implement the four core components of consistent ascertainment and documentation of tobacco use, advice to quit, access to pharmacotherapy, and referral to counseling resources.

E-Cigarettes Reexamined: Product Toxicity

The introduction of e-cigarettes, or electronic nicotine delivery systems (ENDS), has been accompanied by controversy regarding their safety and effectiveness as a cessation aid and by an explosion in their use by youth. Their use does not involve the combustion of tobacco and the creation of harmful combustion products; they have been seen as a "harm reduction" tool that may be of assistance in promoting smoking cessation. Recognition that ENDS can deliver an array of chemicals and materials with known adverse consequences has spurred more careful examination of these products. Nicotine, nitrosamines, carbonyl compounds, heavy metals, free radicals, reactive oxygen species, particulate matter, and "emerging chemicals of concern" are among the constituents of the heated chemical aerosol that is inhaled when ENDS are used. They raise concerns for cardiovascular and respiratory health that merit the attention of clinicians and regulatory agencies. Frequently cited concerns include evidence of disordered respiratory function, altered hemodynamics, endothelial dysfunction, vascular reactivity, and enhanced thrombogenesis. The absence of evidence of the consequences of their long-term use is of additional concern. Their effectiveness as cessation aids and beneficial impact on health outcomes continue to be examined. It is important to ensure that their production and availability are thoughtfully regulated to optimise their safety and permit their use as harm reduction devices and potentially as smoking-cessation aids. It is equally vital to effectively prevent them from becoming ubiquitous consumer products with the potential to rapidly induce nicotine addiction among large numbers of youth. Clinicians should understand the nature of these products and the implications of their use.

Associations of Demographics, Dependence, and Biomarkers With Transitions in Tobacco Product Use in a Cohort of Cigarette Users and Dual Users of Cigarettes and E-cigarettes

INTRODUCTION

It is uncertain whether e-cigarettes facilitate smoking cessation in the real world. We aimed to understand whether and how transitions among cigarette, e-cigarette, and dual use are associated with sociodemographics, dependence measures, and biomarkers.

AIMS AND METHODS

We followed 380 adult daily cigarette users and dual users every 2 months for up to 2 years. We estimated transition rates between noncurrent, cigarette-only, e-cigarette-only, and dual use states using a multistate transition model. We estimated univariable hazard ratios (HR) for demographics, dependence measures for cigarettes and e-cigarettes, biomarkers, spousal or partner behaviors, and other measures.

RESULTS

We estimated that participants transitioned from cigarette-only to e-cigarette-only through a period of dual use. Dual users ceased smoking (transitioning to e-cigarette-only use) at a greater rate than cigarette-only users did (HR 2.44, 95% CI: 1.49, 4.02). However, of the 60% of dual users estimated to transition to single product use in 1 year, 83% would transition to cigarette-only use and only 17% to e-cigarette-only use. E-cigarette dependence measures were generally associated with reduced e-cigarette cessation rather than enhanced cigarette cessation. E-cigarette users motivated by harm or toxicity reduction or because of restrictions on where or when they could smoke had reduced rates of smoking relapse. Cigarette dependence and spousal smoking were barriers to cigarette cessation for dual users, while using e-cigarettes first in the morning, motivation to quit smoking, and sensory, social, and emotional enjoyment of e-cigarettes (secondary dependence motives) were facilitators of smoking cessation among dual users.

CONCLUSIONS

Tobacco control policy and interventions may be informed by the barriers and facilitators of product transitions.

IMPLICATIONS

Although e-cigarettes have the potential to promote smoking cessation, their real-world impact is uncertain. In this cohort, dual users were more likely to quit smoking than cigarette-only users, but the overall impact was small because most dual users returned to cigarette-only use. Moreover, e-cigarette dependence promoted continued dual use rather than smoking cessation. Yet, high motivation to quit smoking and the sensory, social, and emotional enjoyment of e-cigarettes facilitated smoking cessation in dual users. Better understanding the barriers and facilitators of transitions can help to develop regulations and interventions that lead to more effective use of e-cigarettes for smoking cessation.