Use of Electronic Cigarettes to Aid Long-Term Smoking Cessation in the United States: Prospective Evidence From the PATH Cohort Study

An overview of traditional smoking cessation interventions and E-cigarettes

Many people still struggle with quitting smoking despite available treatment options, making it one of the most significant public health challenges that our society faces. The use of electronic cigarettes (E-cigarettes) has become increasingly popular among people who are seeking to quit smoking. The objective of this review paper is to present a comprehensive analysis of the mechanisms, several types, and impact of E-cigarettes, along with supporting evidence indicating their efficacy in aiding smokers to quit tobacco usage. Additionally, the review discusses recent developments in the treatment of smoking cessation, which include conventional smoking cessation methods. Also, the review discusses the challenges, potential risks, ethical considerations, and controversies surrounding the use of E-cigarettes. The present review presents a comprehensive examination of the existing methods and approaches employed in smoking cessation, including the emerging utilization of E-cigarettes as an effective option in smoking cessation. It explores their efficacy as a valuable instrument in promoting smoking cessation.

Changes in e-cigarette use and subsequent cigarette smoking cessation in the USA: evidence from a prospective PATH study, 2013-2018

AIMS

To examine the relationship between changes in electronic cigarette (e-cigarette) use and subsequent cigarette smoking cessation.

METHODS

Using data from the Population Assessment of Tobacco and Health Study (wave 1-wave 4), we analysed a study cohort of 3014 current adult cigarette smokers at wave 1 who tried to quit during the past 12 months. We categorised changes in e-cigarette use from wave 1 to wave 2 as: daily initiation, non-daily initiation, increase to daily use, increase to non-daily use, stable daily use, stable non-daily use, decrease from daily use, quit non-daily use and non-use. We estimated multivariable logistic regressions on short-term (≥1 month and <12 months) cigarette smoking cessation at wave 3 and long-term (≥12 months) cigarette smoking cessation at wave 4. We conducted sensitivity analyses using alternative study cohorts.

RESULTS

Among the study cohort, 2.4% initiated daily, 7.5% initiated non-daily, 1.0% increased to daily, 1.4% increased to non-daily, 1.5% maintained daily, 3.0% maintained non-daily, 2.4% decreased from daily and 3.8% quit non-daily e-cigarette use between waves 1 and 2; 7.9% and 6.9% reported short-term and long-term cigarette smoking cessation. 15.1% of short-term and 16.3% of long-term cigarette quitters used e-cigarettes. Compared with non-users, smokers who initiated daily, increased to daily or quit non-daily e-cigarette use between waves 1 and 2 had higher odds of short-term cigarette smoking cessation at wave 3. These results are robust to different study cohort specifications.

CONCLUSION

The findings suggest a complex relationship between changes in e-cigarette use and subsequent cigarette smoking cessation.

Relationship Between Tobacco Product Use and Health-Related Quality of Life Among Individuals With COPD in Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study

Introduction

We examined the association between tobacco product use and health-related quality of life (HRQoL) among individuals with chronic obstructive pulmonary disease (COPD) in Waves 1-5 of the Population Assessment of Tobacco and Health (PATH) Study.

Methods

Adults ≥40 years with an ever COPD diagnosis were included in cross-sectional (Wave 5) and longitudinal (Waves 1 to 5) analyses. Tobacco use included 13 mutually exclusive categories of past 30-day (P30D) single use and polyuse with P30D exclusive cigarette use and ≥5-year cigarette cessation as reference groups. Multivariable linear regression and generalized estimating equations (GEE) were used to examine the association between tobacco use and HRQoL as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 questionnaire.

Results

Of 1670 adults, 79.4% ever used cigarettes; mean (standard error [SE]) pack years was 30.9 (1.1). In cross-sectional analysis, P30D exclusive cigarette use, and e-cigarette/cigarette dual use were associated with worse HRQoL compared to ≥5-year cigarette cessation. Compared to P30D exclusive cigarette use, never tobacco use and ≥5-year cigarette cessation were associated with better HRQoL, while e-cigarette/cigarette dual use had worse HRQoL. Longitudinally (n=686), e-cigarette/cigarette dual use was associated with worsening HRQoL compared to both reference groups. Only never tobacco use was associated with higher HRQoL over time compared to P30D exclusive cigarette use.

Conclusions

E-cigarette/cigarette dual use was associated with worse HRQoL compared to ≥5-year cigarette cessation and exclusive cigarette use. Never use and ≥5-year cigarette cessation were the only categories associated with higher HRQoL compared to exclusive cigarette use. Findings highlight the importance of complete smoking cessation for individuals with COPD.

Improving Prediction of Tobacco Use Over Time: Findings from Waves 1-4 of the Population Assessment of Tobacco and Health Study

INTRODUCTION

First-order Markov models assume future tobacco use behavior is dependent on current tobacco use and are often used to characterize patterns of tobacco use over time. Higher-order Markov models that assume future behavior is dependent on current and prior tobacco use may better estimate patterns of tobacco use.

AIMS AND METHODS

This study compared Markov models of different orders to examine whether incorporating information about tobacco use history improves model estimation of tobacco use and estimated tobacco use transition probabilities. We used data from four waves of the Population Assessment of Tobacco and Health Study. In each Wave, a participant was categorized into one of the following tobacco use states: never smoker, former smoker, menthol cigarette smoker, non-menthol cigarette smoker, or e-cigarette/dual user. We compared first-, second-, and third-order Markov models using multinomial logistic regression and estimated transition probabilities between tobacco use states.

`RESULTS

The third-order model was the best fit for the data. The percentage of former smokers, menthol cigarette smokers, non-menthol cigarette smokers, and e-cigarette/dual users in Wave 3 that remained in the same tobacco use state in Wave 4 ranged from 63.4% to 97.2%, 29.2% to 89.8%, 34.8% to 89.7%, and 20.5% to 80.0%, respectively, dependent on tobacco use history. Individuals who were current tobacco users, but former smokers in the prior two years, were most likely to quit.

CONCLUSIONS

Transition probabilities between tobacco use states varied widely depending on tobacco use history. Higher-order Markov models improve estimation of tobacco use over time and can inform understanding of trajectories of tobacco use behavior.

IMPLICATIONS

Findings from this study suggest that transition probabilities between tobacco use states vary widely depending on tobacco use history. Tobacco product users (cigarette or e-cigarette/dual users) who were in the same tobacco use state in the prior two years were least likely to quit. Individuals who were current tobacco users, but former smokers in the prior two years, were most likely to quit. Quitting smoking for at least two years is an important milestone in the process of cessation.

Exploring the Rise of E-cigarette Use Among Male Adolescents in Al-Ahsa, Saudi Arabia: Prevalence, Patterns, and Influencing Factors

BACKGROUND

The rising prevalence of electronic cigarette (E-cigarette) use among adolescents is a major public health concern. This study investigates the prevalence of E-cigarette use among male adolescents in Al-Ahsa, Saudi Arabia, and explores associated factors.

METHODOLOGY

A cross-sectional study was conducted from December 2022 to April 2023, involving 476 male students aged 12 to 19. Data were collected through structured questionnaires, covering sociodemographic information, E-cigarette usage patterns, reasons for use, sources of acquisition, awareness of nicotine content, and perceptions of harm. Statistical analysis was performed using SPSS 25 (IBM Corp., Armonk, NY), with significance set at p < 0.05.

RESULTS

The study revealed a prevalence of 17.4% E-cigarette use among participants, with 12.6% using E-cigarettes exclusively and 4.8% concurrently with traditional tobacco cigarettes. Key findings included initiation as early as age eight, sustained and frequent use, and motivations including peer influence (61.4%), curiosity (31.3%), and flavored options (26.5%). Online platforms (34.9%) and shopping malls (28.9%) were the primary sources of E-cigarette acquisition. Most participants were aware of the nicotine content (84.3%) and believed E-cigarettes were harmful (86.7%). Importantly, 69.9% expressed intentions to quit, with 44.6% planning to do so within 30 days. Significant associations were found between E-cigarette use, education level, and having friends who smoke.

CONCLUSION

This study highlights the prevalence of E-cigarette use among male adolescents in Al-Ahsa, Saudi Arabia, and identifies peer influence, curiosity, and appealing flavors as driving factors. Targeted prevention and intervention programs, along with regulatory efforts to restrict access, are urgently needed to address this growing public health issue. Increasing awareness of E-cigarette risks and providing cessation support are vital steps towards mitigating E-cigarette use among Saudi male adolescents.

"We adjusted for race": now what? A systematic review of utilization and reporting of race in American Journal of Epidemiology and Epidemiology, 2020-2021

Race is a social construct, commonly used in epidemiologic research to adjust for confounding. However, adjustment of race may mask racial disparities, thereby perpetuating structural racism. We conducted a systematic review of articles published in Epidemiology and American Journal of Epidemiology between 2020 and 2021 to (1) understand how race, ethnicity, and similar social constructs were operationalized, used, and reported; and (2) characterize good and poor practices of utilization and reporting of race data on the basis of the extent to which they reveal or mask systemic racism. Original research articles were considered for full review and data extraction if race data were used in the study analysis. We extracted how race was categorized, used-as a descriptor, confounder, or for effect measure modification (EMM)-and reported if the authors discussed racial disparities and systemic bias-related mechanisms responsible for perpetuating the disparities. Of the 561 articles, 299 had race data available and 192 (34.2%) used race data in analyses. Among the 160 US-based studies, 81 different racial categorizations were used. Race was most often used as a confounder (52%), followed by effect measure modifier (33%), and descriptive variable (12%). Fewer than 1 in 4 articles (22.9%) exhibited good practices (EMM along with discussing disparities and mechanisms), 63.5% of the articles exhibited poor practices (confounding only or not discussing mechanisms), and 13.5% were considered neither poor nor good practices. We discuss implications and provide 13 recommendations for operationalization, utilization, and reporting of race in epidemiologic and public health research.

Influence of Disclosed and Undisclosed Funding Sources in Tobacco Harm Reduction Discourse: A Social Network Analysis

INTRODUCTION

Tobacco harm reduction (THR) discourse has been divisive for the tobacco control community, partially because it sometimes aligns public health and tobacco industry interests. Industry funding is contentious as it influences study outcomes, and is not always disclosed in scientific publications. This study examines the role of disclosed and undisclosed industry support on THR publications via social network analysis.

METHODS

We reviewed 826 English-language manuscripts (1992-2016) to determine disclosed and undisclosed industry (pharmaceutical, tobacco, and e-cigarette) and non-industry (including government) support received by 1405 authors. We used social network analysis to identify the most influential authors in THR discourse by assessing the number of their collaborators on publications, the frequency of connecting other authors in the network, and tendency to form groups based on the presence of sponsorship disclosures, sources of funding, and THR stance.

RESULTS

About 284 (20%) out of 1405 authors were supported by industry. Industry-sponsored authors were more central and influential in the network: with twice as many publications (Median = 4), 1.25 as many collaborators on publications (Median = 5), and higher likelihood of connecting other authors and thus having more influence in the network, compared to non-industry-sponsored authors. E-cigarette industry-sponsored authors had the strongest association with undisclosed industry support.

CONCLUSIONS

Authors with industry support exerted a stronger influence on the THR scientific discourse than non-industry-supported authors. Journals should continue adhering to strict policies requiring conflicts of interest disclosures. An increase in public health spending on tobacco control research may be necessary to achieve funding parity.

Effectiveness of e-cigarettes as aids for smoking cessation: evidence from the PATH Study cohort, 2017-2019

OBJECTIVE

To assess the effectiveness of e-cigarettes in smoking cessation in the USA from 2017 to 2019, given the 2017 increase in high nicotine e-cigarette sales.

METHODS

In 2017, the PATH Cohort Study included data on 3578 previous year smokers with a recent quit attempt and 1323 recent former smokers. Respondents reported e-cigarettes or other products used to quit cigarettes and many covariates associated with e-cigarette use. Study outcomes were 12+ months of cigarette abstinence and tobacco abstinence in 2019. We report weighted unadjusted estimates and use propensity score matched analyses with 1500 bootstrap samples to estimate adjusted risk differences (aRD).

RESULTS

In 2017, 12.6% (95% CI 11.3% to 13.9%) of recent quit attempters used e-cigarettes to help with their quit attempt, a decline from previous years. Cigarette abstinence for e-cigarette users (9.9%, 95% CI 6.6% to 13.2%) was lower than for no product use (18.6%, 95% CI 16.0% to 21.2%), and the aRD for e-cigarettes versus pharmaceutical aids was -7.3% (95% CI -14.4 to -0.4) and for e-cigarettes versus any other method was -7.7% (95% CI -12.2 to -3.2). Only 2.2% (95% CI 0.0% to 4.4%) of recent former smokers switched to a high nicotine e-cigarette. Subjects who switched to e-cigarettes appeared to have a higher relapse rate than those who did not switch to e-cigarettes or other tobacco, although the difference was not statistically significant.

CONCLUSIONS

Sales increases in high nicotine e-cigarettes in 2017 did not translate to more smokers using these e-cigarettes to quit smoking. On average, using e-cigarettes for cessation in 2017 did not improve successful quitting or prevent relapse.

Toward a better understanding of adult dual use of cigarettes and e-cigarettes based on use intensity and reasons for dual use

BACKGROUND

Dual use of combustible cigarettes and e-cigarettes is an emerging phenomenon among U.S. adults. Literature suggests two primary reasons for this emerging use (i.e., to help quit smoking and to stealth vape). This study investigated user profiles based on use intensity and the reasons for dual use.

METHODS

A total of 1,151 U.S. adult dual users were drawn from the 2018-2019 Tobacco Use Supplement to the Current Population Survey. We divided them into four groups: daily dual users (n = 189), predominant smokers (n = 608), predominant vapers (n = 143), and non-daily dual users (n = 211). We performed weighted multivariable logistic regressions to identify factors associated with the two primary reasons for dual use.

RESULTS

3 in 10 of U.S. adult dual users used e-cigarettes to help quit smoking while 2 in 10 of U.S. adult dual users used e-cigarettes to stealth vape. Compared to daily dual users, predominant smokers [adjusted odds ratio (AOR) = 0.61, 95% CI = 0.23, 0.62] were less likely to use e-cigarettes to help quit smoking whereas predominant vapers (AOR = 1.80, 95% CI = 1.04, 3.13) were more likely to use e-cigarettes to help quit smoking and less likely to use e-cigarettes to stealth vape (AOR = 0.30, 95% CI = 0.10, 0.89).

CONCLUSIONS

There was notable heterogeneity among the four groups of dual users. As the landscape of tobacco use is rapidly changing with an increasing popularity of e-cigarettes, reasons as well as behaviors of dual users need to be regularly monitored for effective tobacco control.

Association between Electronic Cigarettes Use and Asthma in the United States: Data from the National Health Interview Survey 2016-2019

PURPOSE

This article aimed to investigate 1) whether electronic cigarette (EC) users are more likely to experience asthma attacks or emergency room (ER) visits due to asthma than non-users and 2) how age and smoking behaviors moderate the effect size of the association.

MATERIALS AND METHODS

We used National Health Interview Survey data from 2016-2019. Multiple logistic regression analysis was performed to identify the association between current EC use and having an asthma attack and ER visitation due to asthma. Interaction terms were included to explore the moderation effects of age and cigarette smoking status. Subgroup analysis was conducted according to age group.

RESULTS

Of the 218911 participants, 2.0% of them experienced an asthma attack, and 0.5% visited the ER due to asthma. Current EC use was associated with higher odds of having an asthma attack. In interaction analysis, age and smoking status were identified as a moderator in the relationship between EC use and asthma attacks. Participants in their 20s or 30s showed the highest interaction effect.

CONCLUSION

Our analysis indicates the potential impact of EC use on public health and the moderating effects of smoking behavior.

Recommendations to advance equity in tobacco control

Reducing racial and socioeconomic inequities in smoking has been declared a priority for tobacco control in the USA for several decades. Yet despite the rhetoric, these inequities persist and some have actually worsened over time. Although tobacco companies have targeted racially and ethnically diverse and lower-income tobacco users, which substantially contributes to these disparities, less attention has been given to the role of individuals and organisations within the tobacco control movement who have allowed progress in eliminating disparities to stagnate. We examine the failure of tobacco control professionals to ensure the widespread adoption of equity-focused tobacco control strategies. Review of major US tobacco control reports found that the focus on equity often stops after describing inequities in tobacco use. We suggest ways to advance equity in tobacco control in the USA. These recommendations fall across five categories: surveillance, interventions, funding, accountability and addressing root causes. Policy interventions that will have a pro-equity impact on smoking and related disease should be prioritised. Funding should be designated to tobacco control activities focused on eliminating racial and socioeconomic inequities in smoking, and tobacco control programmes should be held accountable for meeting equity-related goals.

Longer-term use of electronic cigarettes when provided as a stop smoking aid: Systematic review with meta-analyses

Moderate certainty evidence supports use of nicotine electronic cigarettes to quit smoking combustible cigarettes. However, there is less certainty regarding how long people continue to use e-cigarettes after smoking cessation attempts. We set out to synthesise data on the proportion of people still using e-cigarettes or other study products at 6 months or longer in studies of e-cigarettes for smoking cessation. We updated Cochrane searches (November 2021). For the first time, we meta-analysed prevalence of continued e-cigarette use among individuals allocated to e-cigarette conditions, and among those individuals who had successfully quit smoking. We updated meta-analyses comparing proportions continuing product use among individuals allocated to use nicotine e-cigarettes and other treatments. We included 19 studies (n = 7787). The pooled prevalence of continued e-cigarette use at 6 months or longer was 54% (95% CI: 46% to 61%, I2 86%, N = 1482) in participants assigned to e-cigarette conditions. Of participants who had quit combustible cigarettes overall 70% were still using e-cigarettes at six months or longer (95% CI: 53% to 82%, I2 73%, N = 215). Heterogeneity in direction of effect precluded meta-analysis comparing long-term use of nicotine e-cigarettes with NRT. More people were using nicotine e-cigarettes at longest follow-up compared to non-nicotine e-cigarettes, but CIs included no difference (risk ratio 1.15, 95% CI: 0.94 to 1.41, n = 601). The levels of continued e-cigarette use observed may reflect the success of e-cigarettes as a quitting tool. Further research is needed to establish drivers of variation in and implications of continued use of e-cigarettes.

Adult smokers' discussions about vaping with health professionals and subsequent behavior change: a cohort study

AIMS

To measure the prevalence and changes in smokers' discussions with health professionals (HPs) about nicotine vaping products (NVPs) and HPs' recommendations about NVPs between 2016 and 2020, and their associations with tobacco product use transitions.

DESIGN

Cohort study using multinomial logistic regression analyses on data from waves 1 (2016), 2 (2018) and 3 (2020) from the International Tobacco Control Four Country Smoking and Vaping Surveys.

SETTING

Four countries with varying NVP regulatory environments: 'most restrictive' (Australia), 'somewhat restrictive' (Canada) and 'less restrictive' (England and the United States).

PARTICIPANTS

Adult exclusive daily smokers who did not report NVP use at the time of their baseline survey and had visited a HP in the last 12-24 months. Prevalence data came from 4125, 4503 and 4277 respondents, respectively, for each year. Longitudinal data were from 4859 respondents who participated in at least two consecutive surveys.

MEASUREMENTS

Prevalence of self-reported discussions with HPs and recommendations from HPs about NVPs. Longitudinal transitions from smoking to vaping (either exclusively or concurrently with smoking) and quitting (regardless of NVP uptake).

FINDINGS

The prevalence of NVP discussions was low among countries with varying regulatory environments and study waves (range = 1.4-6.2%). In 2020, a low percentage of smokers who discussed NVPs with a HP reported that their HPs recommended they use NVPs in the United States (14.7%), Australia (20.2%), Canada (25.7%), with a higher percentage in England (55.7%) where clinical guidelines for smoking cessation include NVPs. Compared with 12.0% of smokers who reported no discussion, 37.0% of those whose HPs recommended NVPs transitioned to vaping at follow-up. Transition to quitting was 9.6% with HPs' recommendation of NVPs versus 13.5% without discussion, a non-significant difference.

CONCLUSIONS

In Australia, Canada, England and the United States between 2016 and 2020, health professionals' discussions with smokers about nicotine vaping products (NVPs) were infrequent. NVP discussions were associated with NVP uptake, but not with quitting smoking.

E-Cigarettes and the Multiple Responsibilities of the FDA

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence.

Understanding the role of e-cigarette use in smoking cessation based on the stages of change model

Objective

We explored the role of e-cigarette use in smoking cessation based on the stages of change (SOC) model, which is a framework for describing the process of smoking cessation.

Methods

We used nationwide, cross-sectional data on adults (19+ years) from the seventh Korea National Health and Nutrition Examination Survey (KNHANES, 2016–2018) and restricted the participants to 3,929 recent smokers, consisting of current smokers and recent quitters (≤2 years). A multinomial logistic regression analysis was performed to reveal the relationships between e-cigarette use and cigarette quitting behaviors (e.g., current quitting status, past quit attempts, intention to quit, and duration of quitting) and all stages in smoking cessation, with adjustment for sociodemographic and smoking-related factors.

Results

E-cigarette use was positively related to past quit attempts, while not having quit, intention to quit, and longer duration of quitting. Based on the cessation stages, current and former e-cigarette users were significantly more likely to be in the ‘Precontemplation’ and ‘Contemplation’ stages than never users, while not to be in the ‘Preparation’ and ‘Action’ stages. Current users were particularly less likely to be in the ‘Maintenance’ stage compared to never users.

Conclusion

E-cigarette use was closely linked with early-stage behavior than late-stage behavior in the smoking cessation process. E-cigarettes might promote quit attempts and short-term quitting in some smokers, but the negative role of inducing smokers to continue cigarette smoking with no immediate quit-intention for future attempts is dominant in the real world.

Chemosensory Contributions of E-Cigarette Additives on Nicotine Use

While rates of smoking combustible cigarettes in the United States have trended down in recent years, use of electronic cigarettes (e-cigarettes) has dramatically increased, especially among adolescents. The vast majority of e-cigarette users consume "flavored" products that contain a variety of chemosensory-rich additives, and recent literature suggests that these additives have led to the current "teen vaping epidemic." This review, covering research from both human and rodent models, provides a comprehensive overview of the sensory implications of e-cigarette additives and what is currently known about their impact on nicotine use. In doing so, we specifically address the oronasal sensory contributions of e-cigarette additives. Finally, we summarize the existing gaps in the field and highlight future directions needed to better understand the powerful influence of these additives on nicotine use.

Investigating the effect of e-cigarette use on quitting smoking in adults aged 25 years or more using the PATH study

Background: The evidence on harms and benefits of e-cigarettes partly concerns whether their use encourages smokers to quit.  We addressed this using data from the nationally representative PATH study, with detailed accounting for potential confounding variables.

Methods: We considered adults aged 25+.  Our original analyses, reported in version 1 of this paper, used data for Waves 1 to 3, separate analyses considering Waves 1 to 2, 2 to 3 and 1 to 3.  These related baseline ever e-cigarette use (or e-product use at Wave 2) to quitting at follow-up, adjusting for confounders derived from 55 candidates.  Sensitivity analyses omitted ever other product users, linked quitting to current e-cigarette use, and used values of some predictors modified using follow-up data.  Additional analyses used data for Waves 1 to 4, separately considering sustained, delayed and temporary quitting during Waves 1 to 3, 2 to 4 and 1 to 4.  Sensitivity analyses considered 30-day quitting, restricted attention to smokers attempting to quit, and considered ever smokeless tobacco or snus use.

Results: In the original analyses, unadjusted odds ratios (ORs) of quitting smoking for ever e-cigarette use were 1.29 (95% CI 1.01-1.66), 1.52 (1.26-1.83) and 1.47 (1.19-1.82) for the Wave 1 to 2, 2 to 3, and 1 to 3 analyses.  These reduced after adjustment, to 1.23 (0.94-1.61), 1.51 (1.24-1.85) and 1.39 (1.11-1.74).  Quitting rates remained elevated in users in all sensitivity analyses.  The additional analyses found associations of e-cigarette use with sustained, delayed and temporary quitting, associations little affected by considering 30-day quitting, and only slightly reduced restricting attention to quit attempters.  Ever use of smokeless tobacco or snus also predicted increased quitting.  

Conclusions: As does most evidence from clinical trials, other analyses of PATH, and other epidemiological studies, our results suggest using e-cigarettes helps adult smokers to quit.

Patterns and associations of smoking and electronic cigarette use among survivors of tobacco related and non-tobacco related cancers: A nationally representative cross-sectional analysis

BACKGROUND

Tobacco-use among cancer survivors leads to preventable morbidity, mortality, and increased healthcare costs. We sought to explore the prevalence of smoking and e-cigarette use among survivors of tobacco and non-tobacco related cancers.

METHODS

A cross-sectional analysis was conducted using the 2015-2018 National Health Interview Survey. Our primary outcome was the prevalence of current cigarette smoking or e-cigarette use among adults with self-reported history of tobacco related or non-tobacco related cancer. Logistic regression analysis was to assess the association of reported cancer type with cigarette smoking or e-cigarette use. Secondary outcomes included yearly trends and dual use.

RESULTS

A total of 12,984 respondents reported a history of cancer, representing a weighted estimate of 5,060,059 individuals with a history of tobacco-related malignancy and 17,583,788 with a history of a tobacco and non-tobacco related cancer, respectively. Survivors of tobacco-related cancers had a significantly higher prevalence of current cigarette use (18.2 % vs 9.7 %, P < 0.0001), e-cigarette use (2.7 % vs 1.6 %, P < 0.0001) and similar rates of dual use. The prevalence of cigarette smoking among all survivors increased as time increased from the year of diagnosis up to 2 years post-diagnosis (P = 0.047). Odds of reporting current cigarette smoking use was higher for survivors of tobacco-related cancers, adjusted for sociodemographic factors (OR1.69, 95 % CI 1.44-1.99).

CONCLUSIONS

Survivors of tobacco-related cancers have a higher prevalence of current cigarette smoking and e-cigarette use compared to survivors of non-tobacco related cancers. There was a sequential increase in the prevalence of cigarette use during each subsequent year from the time of a new cancer diagnosis, underscoring the need for long term tobacco cessation support among newly diagnosed adults with cancer.

Association of E-Cigarettes With Erectile Dysfunction: The Population Assessment of Tobacco and Health Study

INTRODUCTION

Smoking is independently associated with erectile dysfunction and cardiovascular disease. Given existing similarities in the constituents of e-cigarettes or ENDS and cigarettes, this study examines the association between ENDS use and erectile dysfunction.

METHODS

Data from Wave 4 (2016-2018) of the Population Assessment of Tobacco and Health study were analyzed in 2020. Male participants aged ≥20 years who responded to the erectile dysfunction question were included. Multivariable logistic regression models examined the association of ENDS use with erectile dysfunction within the full sample and in a restricted sample (adults aged 20-65 years with no previous cardiovascular disease diagnosis) while adjusting for multiple risk factors.

RESULTS

The proportion of erectile dysfunction varied from 20.7% (full sample) to 10.2% (restricted sample). The prevalence of current ENDS use within the full and restricted samples was 4.8% and 5.6%, respectively, with 2.1% and 2.5%, respectively, reporting daily use. Current daily ENDS users were more likely to report erectile dysfunction than never users in both the full (AOR=2.24, 95% CI=1.50, 3.34) and restricted (AOR=2.41, 95% CI=1.55, 3.74) samples. In the full sample, cardiovascular disease history (versus not present) and age ≥65 years (versus age 20-24 years) were associated with erectile dysfunction (AOR=1.39, 95% CI=1.10, 1.77; AOR= 17.4, 95% CI=12.15, 24.91), whereas physical activity was associated with lower odds of erectile dysfunction in both samples (AOR range=0.44-0.58).

CONCLUSIONS

The use of ENDS seems to be associated with erectile dysfunction independent of age, cardiovascular disease, and other risk factors. While ENDS remain under evaluation for harm reduction and smoking-cessation potential, ENDS users should be informed about the possible association between ENDS use and erectile dysfunction.

Within-person longitudinal associations between electronic nicotine delivery systems use and smoking cessation efforts among U.S. continuing adult cigarette smokers

OBJECTIVES

Prior studies that examined the role of electronic nicotine delivery systems (ENDS) use in smoking cessation have shown divergent conclusions. This study examined the time-course of ENDS-associated smoking abstinent behaviors among continuing cigarette smokers who were willing but unable to quit smoking.

METHODS

Data were drawn from the four waves of the Population Assessment of Tobacco and Health Study. Of the 1,684 smokers who tried to quit smoking completely at Wave 1, a total of 1,094 who were continuing smokers until Wave 4 and were not lost to follow-ups comprised the sample. Using generalized linear mixed modeling, we fitted weighted negative binomial regression models to examine within-person associations of ENDS use with quit attempts and number of days abstinent from smoking.

RESULTS

Quit attempt frequency and smoking abstinent days were highest at Wave 1, dropped at Wave 2, and then either increased a little or remained stagnant in later waves. ENDS use to quit smoking was associated with more frequent quit attempts (aIRR=1.67, 95% CI=1.42-1.95) and more abstinent days (aIRR=3.28, 95% CI=2.43-4.44), and the magnitude of such associations became stronger over time. ENDS use was associated with becoming a non-daily smoker among baseline daily smokers.

CONCLUSIONS

ENDS use among continuing smokers may help increase the number of quit attempts and smoking abstinent days. Given that the study sample is continuing smokers who failed in complete smoking cessation, future research would be desirable that evaluates whether such abstinent behaviors sustain and manifest harm reduction with improved health outcomes.

IMPLICATIONS

Smokers increasingly adopt electronic nicotine delivery systems (ENDS) to quit smoking. However, the association of ENDS use with smoking cessation efforts among continuing cigarette smokers who were willing but unable to quit smoking is largely unknown. This study found that quit attempts and smoking abstinent days increased with ENDS use to quit smoking by following up with population-representative continuing smokers. Additionally, this study assessed whether cigarette smokers' abstinent behaviors vary with their use of ENDS by estimating within-person associations with frequent assessments of both exposures and outcomes in a long-term perspective.

e-Cigarette Cessation: Content Analysis of a Quit Vaping Community on Reddit

Background

e-Cigarette use, also known as vaping, has increased dramatically over the past few years, especially among younger demographics. However, researchers have found that a large number of e-cigarette users want to quit. Little is known about the unique aspects of vaping cessation, which is critical to informing the development of relevant resources and interventions for e-cigarette users who want to quit. Social media forums such as Reddit provide opportunities to understand the experiences of behavior change such as quitting vaping from the perspective of end users.

Objective

This study aims to examine a quit vaping subreddit to understand how e-cigarette users are experiencing and approaching vaping cessation. Specifically, we examine methods used to approach quitting, reasons for quitting, and barriers and facilitators to quitting.

Methods

A total of 1228 posts were collected. The posts were inductively coded to generate categories and subcategories using conventional content analysis. Data were analyzed using the NVivo 12 qualitative data analysis software.

Results

Most users reported a preference for approaching quitting through gradual reduction, particularly through the use of their own devices by tapering the nicotine content. Their reasons for quitting were primarily related to experiencing negative physical consequences associated with vaping, especially in relation to their lungs (eg, tight chest), and tired of feeling stuck to the vape because of nicotine addiction. Top barriers to quitting were related to withdrawal symptoms and intensity of addiction. The top facilitators to quitting were related to using distraction techniques (eg, hobby, gaming, and mindfulness exercises), as well as having a positive mindset.

Conclusions

The findings of this study reveal unique aspects that encompass the process of quitting vaping. These findings have significant implications for both policy and intervention development.

Oral and periodontal implications of tobacco and nicotine products

Tobacco use contributes to more mortality and morbidity globally than any other behavioral risk factor. Adverse effects do not spare the oral cavity, with many oral diseases more common, and treatments less successful, in the tobacco-using patient. Many of the oral health effects of cigarette smoking are well established, but other forms of tobacco, including cigars and smokeless tobacco, merit dental professionals' attention. Recently, an expanding variety of new or emerging tobacco and/or nicotine products has been brought to market, most prominently electronic cigarettes, but also including heated tobacco and other noncombustible nicotine products. The use of cannabis (marijuana) is increasing and also has risks for oral health and dental treatment. For the practicing periodontist, and all dental professionals, providing sound patient recommendations requires knowledge of the general and oral health implications associated with this wide range of tobacco and nicotine products and cannabis. This review provides an overview of selected tobacco and nicotine products with an emphasis on their implications for periodontal disease risk and clinical management. Also presented are strategies for tobacco use counselling and cessation support that dental professionals can implement in practice.

Incidence of Cigarette Smoking Relapse Among Individuals Who Switched to e-Cigarettes or Other Tobacco Products

IMPORTANCE

Although e-cigarettes are not approved as a cessation device, many who smoke believe that e-cigarettes will help them quit cigarette smoking successfully.

OBJECTIVE

To assess whether people who recently quit smoking and who had switched to e-cigarettes or another tobacco product were less likely to relapse to cigarette smoking compared with those who remained tobacco free.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed a nationally representative sample of US households that participated in 4 waves of the Population Assessment of Tobacco and Health Study (conducted 2013 through 2017), combining 2 independent cohorts each with 3 annual surveys. Eligible participants were individuals who smoked at baseline, had recently quit at the first follow-up, and completed the second follow-up survey.

EXPOSURES

Use of e-cigarettes or alternate tobacco products at follow-up 1 after recently quitting smoking.

MAIN OUTCOMES AND MEASURES

Weighted percentage of participants with over 12 months abstinence by follow-up 2.

RESULTS

Of a total of 13 604 participants who smoked cigarettes at baseline, 9.4% (95% CI, 8.7%-10.0%) recently had quit smoking (mean age, 41.9; 95% CI, 39.7-46.6 years; 641 [43.2%] women) Of these, 22.8% (95% CI, 19.7%-26.0%) had switched to e-cigarettes, with 17.6% (95% CI, 14.8%-20.5%) using them daily. A total of 37.1% (95% CI, 33.7%-40.4%) used a noncigarette tobacco product and 62.9% (95% CI, 59.6%-66.3%) were tobacco free. Rates of switching to e-cigarettes were highest for those who were in the top tertile of tobacco dependence (31.3%; 95% CI, 25.0%-37.7%), were non-Hispanic White (26.4%; 95% CI, 22.3%-30.4%), and had higher incomes (annual income ≥$35 000, 27.5%; 95% CI, 22.5%-32.4% vs <$35 000, 19.3%; 95% CI, 16.3%-22.3%). At follow-up 2, unadjusted relapse rates were similar among those who switched to different tobacco products (for any tobacco product: successfully quit, 41.5%; 95% CI, 36.2%-46.9%; relapsed with significant requit, 17.0%; 95% CI, 12.4%-21.6%; currently smoking, 36.2%; 95% CI, 30.9%-41.4%). Controlled for potential confounders, switching to any tobacco product was associated with higher relapse rate than being tobacco free (adjusted risk difference, 8.5%; 95% CI, 0.3%-16.6%). Estimates for those who switched to e-cigarettes, whether daily or not, were not significant. While individuals who switched from cigarettes to e-cigarettes were more likely to relapse, they appeared more likely to requit and be abstinent for 3 months at follow-up 2 (17.0%; 95% CI, 12.4%-21.6% vs 10.4%; 95% CI, 8.0%-12.9%).

CONCLUSIONS AND RELEVANCE

This large US nationally representative study does not support the hypothesis that switching to e-cigarettes will prevent relapse to cigarette smoking.

Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data

BACKGROUND

Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication.

METHOD

Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. 'Cessation' was defined as being a former cigarette smoker in wave 4. χ², logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used.

RESULTS

Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes.

CONCLUSION

No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.

Factors associated with dual and polytobacco use among people in residential substance use disorder treatment

BACKGROUND AND OBJECTIVES

Little is known about whether people in substance use disorder (SUD) treatment are at risk for multiple-tobacco use. We examined the factors associated with dual- and polytobacco use among clients in SUD treatment.

METHODS

A cross-sectional survey was conducted in 2019 among 562 clients (M_age  = 39, 74% male) in 20 residential SUD treatment programs in California, USA. The outcomes included single-, dual- (use of two products), and polytobacco use (use of three of more products). Independent variables were nicotine dependence, quitting-related factors, blunt/spliff use, and health-related factors. A multinomial model examined associations between the independent variables and the outcome, controlling for demographics, and time in treatment.

RESULTS

Overall, 32.6%, 18.9%, and 14.0% of the sample were single-, dual-, and polytobacco users, respectively. Factors associated with increased odds of polytobacco use included greater nicotine dependence (adjusted odds ratio [AOR] = 1.60; 95% CI = 1.19, 2.16), ever using e-cigarettes for quitting (AOR = 4.56; 95% CI = 2.23, 9.34), and past 30-day use of blunt/spliff (AOR = 2.96; 95% CI = 1.48, 5.89). Factors associated with increased odds of dual use were ever using e-cigarettes for quitting (AOR = 3.19; 95% CI = 1.79, 5.66) and reporting more mentally unhealthy days (AOR = 1.05; 95% CI = 1.02, 1.07).

CONCLUSION AND SCIENTIFIC SIGNIFICANCE

This study extends the literature on tobacco use among people in SUD treatment by revealing the high prevalence of dual- and polytobacco use and the unique characteristics of users. The findings have implications for interventions reducing all types of tobacco use in this understudied population.

The association between heated tobacco product use and cigarette cessation outcomes among youth smokers: A prospective cohort study

INTRODUCTION

The U.S. Food and Drug Administration authorized the marketing of heated tobacco products (HTPs) with modified-risk information for adults on July 7, 2020. However, the effects of HTP use on cigarette cessation among youth smokers remain unclear. This study aimed to explore the association of HTP use with cigarette abstinence and cessation outcomes among youth smokers in Hong Kong who were willing to receive telephone counseling for smoking cessation.

METHODS

This prospective cohort study included youth smokers aged ≤25 years who were enrolled in the Hong Kong Youth Quitline service. From December 1, 2016, to September 30, 2019, this study identified as HTP users 106 youth cigarette smokers who reported using HTPs on at least 1 of the past 30 days at enrollment, and identified as non-HTP users 473 smokers who reported smoking at least one conventional cigarette in the past 30 days and never using HTPs. The participants received follow-ups at 1 week and 1-, 3-, and 6-months postenrollment. The primary outcome was self-reported 7-day point prevalence of cigarette abstinence (PPA) at the 6-month follow-up. Secondary outcomes included reduction in cigarette smoking (excluding quitters), the number of cessation attempts, and the level of readiness to quit.

RESULTS

The self-reported 7-day PPA was statistically significantly lower among HTP users than among non-HTP users after 6 months (19.0% vs. 34.2%; p = 0.009), with an adjusted relative risk of 0.47 (95% confidence interval: 0.24-0.91; p = 0.03). The study identified no significant differences in secondary outcomes between the two groups.

CONCLUSIONS

Youth HTP users were less likely to abstain from tobacco use than their non-HTP-using counterparts. These results suggest that HTPs should not be promoted as smoking cessation or reduction aids among the youth population.

Knowledge and Perceptions of Tobacco-Related Harm Associated with Intention to Quit among Cigarette Smokers, e-Cigarette Users, and Dual Users: Findings from the US Population Assessment of Tobacco and Health (PATH) Wave 1

OBJECTIVE

To study the association between knowledge of diseases caused by smoking, perceptions of harm of cigarettes and intention to quit among cigarettes and e-cigarettes users. Methods: Using US Population Assessment of Tobacco and Health (PATH) Wave 1 data (2013-2014), we investigated the mean knowledge of diseases due to smoking and perceptions of harm of cigarettes scores among cigarette smokers (n = 8,263), e-cigarette users (n = 829), and dual users (n = 745) and examined the association between knowledge, perceptions of harm and intention to quit. Results: E-cigarette users had the highest scores in both knowledge and perceptions of harm items. We found a stronger association between knowledge and intention to quit among females (aOR: 1.25; 95% CI: 1.18, 1.34) compared to males (aOR: 1.11; 95% CI: 1.05, 1.18). We observed a strong association between perceptions of harm and intention to quit among cigarette smokers (p < 0.0001) and dual users (p = 0.0001), but not e-cigarette users. Conclusions: Our study indicates it is urgent for federal and state governments to develop comprehensive guidelines for targeted health messaging regarding the harms of cigarettes, noncombustible tobacco products, and dual use, and the benefits of cessation. Further, findings suggest that effective health education should include tobacco product-specific risks and the comprehensive negative health impacts of tobacco given the strong positive association of perceptions of harm and intention to quit.

Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1879145.

Association between observing peers vaping on campus and E-cigarette use and susceptibility in middle and high school students

BACKGROUND

This study examines the association between exposure to e-cigarette use on school campus and e-cigarette use behaviors among adolescents in the United States.

METHODS

Data were obtained from the 2019 National Youth Tobacco Survey. First, two multivariate logistic regression models examined the association between in-school exposure to e-cigarette use and ever and past 30-day (i.e., current) e-cigarette use. Next, a multivariate logistic regression model to examine the relationship between in-school exposure to e-cigarette use and susceptibility to use was conducted among a subsample (n = 11,958) of never e-cigarette users. Covariates included grade, race/ethnicity, marketing exposure, and ever use of other tobacco products.

RESULTS

Approximately 64.3 % of adolescents reported seeing someone use an e-cigarette on school campus; the most common locations being in the bathroom/locker room (34.4 %) and parking lot (34.0 %). In-school exposure to e-cigarette use was associated with greater odds of ever (Adj OR: 2.06; 95 % CI: 1.82-2.33) and current (Adj OR: 1.70; 95 % CI: 1.46-1.98) e-cigarette use among adolescents as well as greater odds of susceptibility to use (Adj OR: 2.00; 95 % CI: 1.82-2.20) among never e-cigarette users.

CONCLUSIONS

Observing e-cigarette use on school campus was associated with greater odds of e-cigarette use and susceptibility. It is plausible that observing e-cigarette use on campus reinforces the social acceptability of adolescent e-cigarette use. Findings inform on the prevalence of e-cigarettes use on-campus as well as how this phenomenon may influence e-cigarette use/susceptibility among youth. The observed relationship highlights the role of schools in the efforts to reduce adolescent e-cigarette use.

A Population-Level Assessment of Smoking Cessation following a Diagnosis of Tobacco- or Nontobacco-Related Cancer among United States Adults

Introduction

Smoking cessation after a cancer diagnosis can significantly improve treatment outcomes and reduce the risk of cancer recurrence and all-cause mortality.

Aim

We sought to measure the association between cancer diagnosis and subsequent smoking cessation.

Methods

Data was sourced from the Population Assessment of Health and Tobacco (PATH) study, a representative population-based sample of United States adults. Our analytic sample included all adult smokers at Wave I, our baseline. The exposure of interest was either a tobacco-related cancer diagnosis, nontobacco-related cancer diagnosis, or no cancer diagnosis (the referent) reported at Wave II or III. The primary outcome was smoking cessation after diagnosis, at Wave IV. Results/Findings. Our sample was composed of 7,286 adult smokers at the baseline representing an estimated 40.9 million persons. Smoking cessation rates after a diagnosis differed after a tobacco-related cancer (25.9%), a nontobacco-related cancer (8.9%), and no cancer diagnosis (17.9%). After adjustment, diagnosis with a tobacco-related cancer was associated with a higher odds of smoking cessation (OR 1.83, 95% CI 1.00-3.33) compared to no cancer diagnosis. Diagnosis with a nontobacco-related cancer was not significantly linked to smoking cessation (OR 0.52, 95% CI 0.48-1.45).

Conclusion

Diagnosis with a tobacco-related cancer is associated with greater odds of subsequent smoking cessation compared to no cancer diagnosis, suggesting that significant behavioral change may occur in this setting.

Vaping and lung cancer - A review of current data and recommendations

OBJECTIVES

Lung cancer is the most common cause of cancer mortality worldwide and, while tobacco smoke remains the primary cause, there is increasing concern that vaping and E-cigarette use may also increase lung cancer risk. This review concentrates on the current data, scholarship and active foci of research regarding potential cancer risk and oncogenic mechanisms of vaping and lung cancer.

MATERIALS AND METHODS

We performed a literature review of current and historical publications on lung cancer oncogenesis, vaping device/e-liquid contents and daughter products, molecular oncogenic mechanisms and the fundamental, potentially oncogenic, effects of electronic cigarette smoke/e-liquid products.

RESULTS

E-cigarette devices and vaping fluids demonstrably contain a series of both definite and probable oncogens including nicotine derivatives (e.g. nitrosnornicotine, nitrosamine ketone), polycyclic aromatic hydrocarbons, heavy metals (including organometal compounds) and aldehydes/other complex organic compounds. These arise both as constituents of the e-liquid (with many aldehydes and other complex organics used as flavourings) and as a result of pyrolysis/complex organic reactions in the electronic cigarette device (including unequivocal carcinogens such as formaldehyde - formed from pyrolysis of glycerol). Various studies demonstrate in vitro transforming and cytotoxic activity of these derivatives. E-cigarette device use has been significantly increasing - particularly amongst the younger cohort and non-smokers; thus, this is an area of significant concern for the future.

CONCLUSION

Although research remains somewhat equivocal, there is clear reason for concern regarding the potential oncogenicity of E-Cigarettes/E-Liquids with a strong basic and molecular science basis. Given lag times (extrapolating from tobacco smoke data) of perhaps 20 years, this may have significant future public health implications. Thus, the authors feel further study in this field is strongly warranted and consideration should be made for tighter control and regulation of these products.

How effective are electronic cigarettes for reducing respiratory and cardiovascular risk in smokers? A systematic review

Background

Electronic cigarettes (e-cigarettes) are widely promoted as harm-reduction products for smokers, and smokers commonly perceive them as less harmful than combustible cigarettes. One of the key questions regarding public health consequences of e-cigarettes is the magnitude of harm reduction achievable by smokers who switch from combustible cigarettes to e-cigarettes. We conducted a systematic literature review of epidemiological studies that estimated odds of respiratory and cardiovascular outcomes among former smokers who use e-cigarettes compared to current smokers.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement. We searched the PubMed and Embase databases in September 2020 to identify epidemiological studies that compared odds of cardiovascular and respiratory outcomes among former smokers who transitioned to e-cigarettes relative to odds among current smokers not using e-cigarettes (current exclusive smokers). We included studies that provided direct estimates of relevant odds ratios (ORs). We also included studies where indirect estimates of relevant ORs could be calculated based on published results. Two reviewers independently extracted data and conducted quality appraisals.

Results

Six population-based studies with sample sizes ranging from 19,475 to 161,529 respondents met review inclusion criteria, five of which were cross-sectional and one longitudinal. Three studies reported respiratory outcomes and three reported cardiovascular outcomes. ORs of respiratory outcomes (including chronic obstructive pulmonary disease, chronic bronchitis, emphysema, asthma, and wheezing) in former smokers who transitioned to e-cigarettes versus current exclusive smokers were below 1.0, ranging from 0.58 (95%CI 0.36–0.94) to 0.66 (95%CI 0.50–0.87; all p < 0.05). All ORs for cardiovascular outcomes (including stroke, myocardial infarction, and coronary heart disease) did not differ significantly from 1.0.

Conclusion

Though our review included a small number of studies, it provided consistent results. Former smokers who transitioned to e-cigarettes showed ~ 40% lower odds of respiratory outcomes compared to current exclusive smokers. Switching from smoking to e-cigarette does not appear to significantly lower odds of cardiovascular outcomes. Since the utility of cross-sectional studies for causal inference remains limited, both randomized controlled trials and prospective cohort studies are needed to better evaluate contributions of e-cigarettes as harm reduction tools for smokers.

Switching stories: user testimonials on juul.com continue to contradict JUUL's switch ≠ cessation narrative

BACKGROUND

In January 2019, electronic nicotine delivery systems (ENDS) market leader Juul Labs (JUUL) launched an advertising campaign encouraging adult smokers to 'make the switch' from combustible cigarettes to JUUL. Our primary aim was to describe consumer perceptions of JUUL as communicated by members of JUUL's online social community via testimonials promoted on JUUL's website.

METHODS

User testimonials that were displayed on the JUUL website in December 2019 and January 2020 were collected and coded by three reviewers. A total of 220 testimonials were coded for primary and secondary themes (eight codes within four broader themes).

RESULTS

Testimonial writers were, on average, 43.0 years old (range 28 to 74) and reported using JUUL for an average of 21.8 months (range 9 to 59 months). The most prominent theme, present in nearly half of the testimonials, was a description of how to use JUUL, with a mention of JUUL's benefits and tips on how to use the product. Nearly four in 10 statements encouraged smokers to give JUUL a try or noted that JUUL is a better product compared with cigarettes. About one in 10 statements focused on switching from smoking cigarettes to using JUUL.

CONCLUSION

This study presents a foundation for understanding how adult users describe JUUL, including their experiences using JUUL to 'switch' or stop smoking. Currently, the effectiveness of ENDS for smoking cessation is not supported by substantial evidence; however, if cessation is defined as 'quitting combustible tobacco products', then regulators should be aware that switch and cessation messages may not be distinct.