Using Cognitive Interviewing to Better Assess Young Adult E-cigarette Use

The e-cigarette assessment for youth-Revised (EAsY-R): Preliminary results of a pilot study of measure refinement via cognitive interviewing

The prevalence of youth vaping has, in a relatively short time, become an "epidemic." In the wake of such labeling by the Surgeon General, a number of important examinations of vaping have been conducted. These have largely focused on high school and college-age youth as this demographic shows the greatest prevalence of use. Nonetheless, no measure has been made available which might allow for the comprehensive assessment of quantity and frequency of vaping among this age group, thus aiding in standardization across settings. The current study utilized cognitive interviews with high school and college-age youth who use vaping devices to inform the preliminary development of such an assessment. The sample consists of eight students between the ages of 15 and 24 (Mage = 18.75, SD = 2.73, 62.5% female, 75.0% Hispanic/Latino/a/x, 100.0% White). Interviewing and measure refinement were conducted in a two-phase iterative fashion. Suggestions made during cognitive interviews resulted in the refinement of assessed content type, updated categories and pictures of vaping devices, as well as updated and age-relevant terminology. Further, instructions were streamlined, and assessment items and multiple-choice options were refined to maximize clarity and to minimize participant confusion. The result of this study, the E-Cigarette Assessment for Youth Revised, is a unique tool for standardizing examinations of the quantity and frequency of vaping behaviors among high school students and college-age youth.

Emerging Adults' Experiences with E-Cigarette Cessation

Background: The use of electronic nicotine delivery systems (ENDS) is one of the most common substance use behaviors in college students, yet most individuals show some interest in quitting. The current study added to the limited literature on ENDS cessation by examining readiness to quit and the use and perceived efficacy of ENDS cessation methods in a heterogeneous sample of college students. Methods: Students 18-24 years in Psychology courses (N = 1563; 73% female) from six US universities completed an online survey between September 2021-April 2022. Results: Nearly half the sample (n = 738, 47%) reported lifetime ENDS use and nearly half of lifetime users (n = 356, 48%) reported a quit attempt. Most ENDS users reported some readiness to quit (n = 251, 67%). Quitting "cold turkey", using willpower, and replacing ENDS use with another activity were endorsed most frequently; strategies were perceived as more helpful if students had direct experience with them. Social support (e.g., counseling, groups, family/friend support) and nicotine replacement products were perceived as effective but were utilized infrequently. Digital tools (i.e., apps, text messaging) were perceived to be least helpful and were utilized infrequently. Conclusion: Most college students who use ENDS are interested in quitting and have relied on unassisted methods for cessation. Our data suggest a significant opportunity for college personnel and public health officials to further enhance awareness and uptake of ENDS cessation resources for this demographic. Digital tools that integrate social support may be especially effective given their low cost, demonstrated efficacy, and alignment with students' preferences for social support.

Assessing use of inhalable nicotine products within complex markets: the dilemma of heated tobacco products

The introduction of electronic inhalable products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs), has further diversified the nicotine market landscape. This poses unique challenges in measuring self-reported nicotine use behaviours, which have been the hallmark of tobacco surveillance systems. This paper raises concerns of potential measurement error for electronic inhalable product use in surveys due to similarities in product design between NVPs and HTPs, as well as changing trends in cannabis administration. We identify several strategies for addressing this issue (eg, including descriptive preambles in surveys that differentiate product classes from one another; incorporating survey questions that probe beyond an initial question regarding product use). In the absence of comprehensive validation studies, caution is warranted when interpreting survey results that rely on self-reported HTP use.

Evaluating cannabis exposure in survey items: Insights, strategies, and remaining challenges identified from cognitive interviewing

Background

The diversity in characteristics of cannabis products and behavior patterns make evaluation of cannabis exposure in population-based, self-report surveys challenging. Accurate identification of cannabis exposure and related outcomes necessitates a thorough understanding of participants' interpretations of survey questions assessing cannabis consumption behaviors.

Objectives

The current study utilized cognitive interviewing to gain insight on participants' interpretation of items in a self-reported survey instrument used to estimate the quantity of THC consumed in population samples.

Methods

Cognitive interviewing was used to evaluate survey items assessing cannabis use frequency, routes of administration, quantity, potency, and perceived "typical patterns" of use. Ten participants ≥18 years (n = 4 cisgender-men; n = 3 cisgender-women; n = 3 non-binary/transgender) who had used cannabis plant material or concentrates in the past week were recruited to take a self-administered questionnaire and subsequently answer a series of scripted probes regarding survey items.

Results

While most items presented no issues with comprehension, participants identified several areas of ambiguity in question or response item wording or in visual cues included in the survey. Generally, participants with irregular use patterns (i.e., non-daily use) reported more difficulty recalling the time or quantity of cannabis use. Findings resulted in several changes to the updated survey, including updated reference images and new quantity/frequency of use items specific to the route of administration.

Conclusion

Incorporating cognitive interviewing into cannabis measurement development among a sample of knowledgeable cannabis consumers led to improvements in assessing cannabis exposure in population surveys, which may otherwise have been missed.

Adolescents' Understanding of Smoking and Vaping Risk Language: Cognitive Interviews to Inform Scale Development

INTRODUCTION

Perceived message effectiveness (PME) is a common metric to understand receptivity to tobacco prevention messages, yet most measures have been developed with adults. We examined adolescents' interpretation of language within candidate items for a new youth-targeted PME measure using cognitive interviewing. We sought to understand the meaning adolescents assigned to our candidate PME items to improve item wording.

AIMS AND METHODS

Participants were 20 adolescents, ages 13-17 years from the United States. Cognitive interviews used a structured guide to elicit feedback on comprehension, answer retrieval, and language regarding a set of Reasoned Action Approach-based survey items that assessed the PME of smoking and vaping prevention ads. We employed thematic analysis to synthesize findings from the interviews.

RESULTS

Interviews identified three main issues related to survey items: ambiguity of language, word choice (risk and other terminology), and survey item phrasing. Adolescents preferred direct, definitive language over more ambiguous phrasing which they saw as less serious (eg, "will" instead of "could"). For risk terminology, they preferred terms such as "harmful" and "dangerous" over "risky," which was viewed as easy to discount. The term "negative effects" was interpreted as encompassing a broader set of tobacco harms than "health effects." Adolescents said that the term "vape" was preferable to "e-cigarette," and identified ways to simplify item wording for greater clarity.

CONCLUSIONS

Tobacco risk terms that appear similar differ in meaning to adolescents, and more direct and unambiguous language is preferred. Our findings informed changes to the PME scale items to improve clarity and reduce measurement error.

IMPLICATIONS

This study adds to the literature on how adolescents interpret tobacco prevention language. Adolescents may interpret terminology differently than adults, which could lead to ambiguity in meaning and thus measurement error. Through cognitive interviewing, we identified and improved the language in a youth-focused PME measure for tobacco and vaping prevention.

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

OBJECTIVE

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

PARTICIPANTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perceptions of electronic cigarettes among ethno-culturally diverse Latino adults in four US urban centers

OBJECTIVE

The aim of this study was to examine perceptions including knowledge, attitudes, and beliefs about e-cigarettes among ethno-culturally diverse Latino adults living in the US, a rapidly growing minority group for which we know little about their e-cigarette perceptions.

DESIGN

A total of 25 focus groups with Latinos (n = 180; ages 18-64 years) were conducted in 2014. E-cigarettes users and non-users were recruited via purposive sampling techniques. Participants completed brief questionnaires on sociodemographic factors and tobacco use. Focus group discussions were conducted in English and Spanish, audio-recorded, and transcribed. Data were analyzed using thematic analysis procedures.

RESULTS

Participants were of diverse Latino backgrounds. Over one-third (35%) reported current cigarette smoking and 8% reported current e-cigarette or hookah use. Nonsmokers reported experimenting with e-cigarettes and hookah during social occasions. Participants' perceptions towards e-cigarettes were generally formed in comparison to conventional cigarettes. Perceived benefits of using e-cigarettes included their utility as a smoking cessation aid, higher social acceptability, and lower harm compared to conventional cigarettes. Negative perceptions of e-cigarettes included lower overall satisfaction compared to conventional cigarettes and high content of toxins. Socio-cultural factors (e.g. gender roles, familismo, and simpatía) also influenced perceptions of e-cigarette of study participants.

CONCLUSIONS

Overall, Latino adults knew relatively little about the potential health risks associated with e-cigarette use. The limited knowledge about and misinformation of e-cigarettes among this rapidly growing minority group have important public health implications. Findings may inform culturally tailored health communication campaigns, which are much needed among underserved US Latino populations in light of low effectiveness of tobacco control and regulatory efforts.

Multiple tobacco product use among cigarette smokers: a longitudinal examination of menthol and non-menthol smokers during young adulthood

BACKGROUND

Multiple tobacco product (MTP) use is common among young adults. Most MTP users are combustible cigarette smokers that use one or more other tobacco products. This study aims to explore menthol as a risk factor for MTP use among a cohort of young adult cigarette smokers.

METHODS

Participants were 18-29 years cigarette smokers at 24 Texas colleges in a 6-wave study. Participants (n=4700 observations) were classified as: single product users (ie, exclusive cigarette smoking); dual product users and poly product users. A multilevel, ordered logistic regression model was used to examine the association between menthol cigarette smoking and MTP use. Two longitudinal, multilevel, multinomial logistic regressions were used to examine the relationship between menthol cigarette smoking and number of tobacco products used.

RESULTS

Overall, 40.7% of the sample were single product users, 33.7% were dual product users and 25.6% were poly product users. Menthol was associated with 1.28 greater odds of MTP use. Further, menthol was associated with 1.19 greater risk of dual and 1.40 greater risk of poly product use, relative to single product use. Lastly, menthol cigarette smoking was associated with 1.18 greater risk of poly product use, relative to dual product use.

CONCLUSIONS

There was a gradient relationship between menthol cigarette smoking and number of tobacco products used among young adult cigarette smokers. Findings provide for greater regulatory and programmatic efforts to reduce the use of menthol cigarettes.

Methods and Statistical Analyses in Studies of Motivation for E-Cigarette Use Among University Students: An Integrative Review

Understanding the motivations for e-cigarette use among college and university students is essential for developing and implementing effective interventions. Evaluating existing literature is necessary to identify methodological gaps and limitations and improve the quality of future research. We aimed to evaluate the quality of the methods and statistical analyses and integrate evidence addressing motivations for e-cigarette use among college and university students. An integrative literature review was conducted by two researchers to identify and evaluate peer-reviewed, quantitative, and mixed methods research exploring motivations for e-cigarette use among college and university students. A systematic analytic method of data reduction was used to identify alignment and divergence of the data, gaps in the literature, and methodological limitations. Fifteen quantitative studies and three mixed methods studies published between 2015-2020 were included. Most studies were cross-sectional, used convenience sampling, and lacked psychometric and assumptions testing. Half performed regression analyses, however, very few adhered to research and statistical reporting standards. Current literature provides a foundation for developing and implementing interventions aimed to prevent e-cigarette use and encourage cessation. Future research should incorporate stronger sampling methods and research designs, as well as the use of rigorous statistical analyses in conjunction with thorough reporting. Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1990332.

A Longitudinal Examination of Behavioral Transitions among Young Adult Menthol and Non-Menthol Cigarette Smokers Using a Three-State Markov Model

INTRODUCTION

Young adult cigarette smoking behaviors are complex and dynamic. Emerging research suggests a growing rate of switching from non-menthol to menthol cigarettes. Transitions across cigarette smoking states are not well understood. This research longitudinally explores transitions in cigarette smoking behaviors among 18-29 year olds.

METHODS

We applied a Markov model to data collected biannually for 1542 initially 18-29 year old young adults (mean age: 20.9 years; SD = 2.6) in Texas, who provided 7021 total observations from Fall 2014 to Spring 2017. All participants were past 30 day menthol or non-menthol cigarette smokers at first observation. We examined transitions across three states of cigarette smoking (menthol, non-menthol, and nonsmoking) and compared predictors of each transition, during young adulthood.

RESULTS

Descriptively, 22.2% of menthol and 14.3% of non-menthol smokers switched products while 25.6% of menthol and 26.0% of non-menthol smokers quit smoking. Among quitters, 20.0% relapsed via menthol and 28.2% relapsed via non-menthol cigarettes. Results from Markov model indicated that Hispanic/Latinos (Hazard Ratio [HR]: 3.69) and Asians (HR: 2.85) were significantly more likely to switch from non-menthol to menthol cigarettes, relative to non-Hispanic whites. Among recent quitters, the use of non-cigarette products was associated with increased risk of relapse via menthol (HR: 1.54) and non-menthol (HR: 1.85) cigarettes.

CONCLUSION

A substantial proportion of young adult cigarette smokers transitioned across cigarette smoking states over the course of 2.5 years. Other tobacco use and nicotine dependence were impediments to becoming and remaining a non-smoker. Hispanic/Latinos and Asians, relative to non-Hispanic whites, had greater odds of transitioning from non-menthol smoking to both non-smoking and to menthol smoking. Findings suggest racial/ethnic differences in cigarette smoking transitions during young adulthood.

IMPLICATIONS

This paper examined multidirectional transitions across cigarette smoking, including switching between menthol and non-menthol cigarettes, among young adults. Results indicate that Hispanic/Latino and Asian young adults are at increased risk of transition to menthol cigarette smoking compared with non-Hispanic white young adults. Findings highlight need for further study of Hispanic/Latino and Asian young adult smoking behaviors.

Digital marketing of smokeless tobacco: A longitudinal analysis of exposure and initiation among young adults

OBJECTIVES

This study examines the relationships between recall of exposure to digital marketing of smokeless tobacco, via the internet and social media, and subsequent initiation of smokeless tobacco use at one-year follow-up, among young adult never users of smokeless tobacco in Texas.

METHODS

Data were from waves 6 (Spring 2017) and 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Study (Project M-PACT); a longitudinal study of two- and four-year Texas college students. Participants were 2731 young adult never smokeless tobacco users (ages 20-32) with complete data at both assessment periods. A multi-level, multiple logistic regression model was applied, accounting for school clustering, to examine the relationship between recall of exposure to digital marketing of smokeless tobacco at baseline (wave 6) and smokeless tobacco use initiation at one-year follow-up (wave 7). Analyses controlled for important baseline covariates (socio-demographic factors, other marketing exposure, other tobacco product use).

RESULTS

Overall, 14.6% of never smokeless tobacco users reported exposure to smokeless tobacco marketing via digital media. Exposure to digital marketing of smokeless tobacco at baseline was associated with greater odds of smokeless tobacco use initiation among young adult never users (AOR: 2.14; 95%CI: 1.12 - 4.06) at one-year follow-up.

CONCLUSIONS

Findings reveal exposure to smokeless tobacco marketing via digital media was common. Further, there appears to be a strong relationship between this exposure and subsequent smokeless tobacco use among young adult never smokeless tobacco users.

Critical challenges and creative solutions for quantifying nicotine vaping: qualitative reports from young adults

BACKGROUND

Previous studies suggest that young adults who vape nicotine experience difficulty when answering survey items assessing quantity of vaping. The current study asked young adults who vape to provide suggestions for improving the scientific measurement of vaping.

METHODS

We conducted semi-structured qualitative interviews with 62 young adults who vape in Los Angeles, California between June 2018 and June 2019. We analyzed participants' responses to the following question: "What do you think is the best way for us to understand how much people vape?" using thematic content analysis.

RESULTS

We identified two major themes: (1) challenges stemming from differences between the way researchers query about vaping and how individuals self-monitor vaping frequency, and (2) insights for future measurement of vaping. Participants reported that challenges of accurately quantifying vaping were due to inherently hard-to-answer questions (e.g., puffs per day), lack of awareness of or not actively monitoring consumption of vaping products, or because vaping behaviors vary considerably between and within individuals over time, making "on-average" questions challenging. Participants discussed ideas for improving survey measures that could accurately assess vaping quantity, including querying about type of device used, and frequency of replenishment of nicotine solutions.

CONCLUSION

Existing vaping behavior survey measures may not accurately capture quantity of vaping as they differ from how (or if) participants track their own vaping consumption patterns. While continued research is needed to optimally refine survey measures on vaping consumption, future measures may better align with vapers' self-monitoring by including questions on device-type and replenishment frequency.

Multidirectional Pathways of Tobacco and Marijuana Use, Including Comorbid Use, Among Young Adults (Aged 18-25 Years) in Texas: A Six-Wave Cross-Lagged Model

PURPOSE

Prevalence of past 30-day tobacco and marijuana use are highest among young adults in the U.S., and comorbid use of these products is common. However, it is unclear whether the use of one product precedes the other-an important consideration, given the new climate surrounding marijuana legalization and the popularity of e-cigarette products.

METHODS

Six-panel cross-lagged regression models, with 6 months between each panel/wave, were used to model bidirectional paths between past 30-day use and comorbid use of marijuana and tobacco products from 2014 to 2017 among young adults (N = 5,221 college students, aged 18-25 years).

RESULTS

Combustible tobacco use and e-cigarette use were prospectively associated with greater risk of future marijuana use while controlling for the stability of use over time, age, race/ethnicity, and sex. Marijuana use was prospectively associated with greater risk of future combustible tobacco and e-cigarette use. Comorbid use was common, but while the odds of comorbid use decreased with increasing age, odds of tobacco use increased.

CONCLUSIONS

More young adults may be consolidating their use than are successfully ceasing their tobacco or marijuana use as they mature through young adulthood. Although we observed decreases in comorbid use of combustible tobacco with marijuana and e-cigarettes with marijuana, we simultaneously observed strong stability in single use of these products over time. Taken together, these results should help structure interventions specific to young adults that target use and comorbid use in early young adulthood to discourage initiation, encourage cessation, and curb subsequent escalation in later young adulthood.

Electronic Cigarette Use Among Youth: Understanding Unique Risks in a Vulnerable Population

PURPOSE OF REVIEW

This review discusses prevalence rates of electronic (e-)cigarette use among youth and factors that likely contribute to their growing popularity among this population. Trends shaping the e-cigarette landscape, the appeal of e-cigarettes among youth, perceptions contributing to the initiation of e-cigarettes, available assessments capturing the usage of and attitudes towards e-cigarettes, and e-cigarette policies and regulations are reviewed.

RECENT FINDINGS

E-cigarette use among this vulnerable group may relate to factors associated with the promotion of social status, individuality, and enjoyment, along with low perceptions of risk and harm. Measures assessing factors unique to e-cigarette use among youth (e.g., individuality) still need to be developed and validated. Effects of existing regulations to limit youth access to e-cigarettes may be limited, and shortcomings of current policy measures are discussed with recommendations.

SUMMARY

The rise of e-cigarette use among youth culminated through a perfect storm of clever marketing targeting youth appeal, innovations in more effective nicotine delivery systems, capitalizing on increased susceptibility of the adolescent brain, and regulatory gaps. Understanding risk and protective factors specific to this vulnerable group, which can be gleaned in part by psychometrically valid assessments, could inform regulatory strategies and prevention programming efforts. Yet, few validated measures exist that assess attitudes, behaviors, and patterns of e-cigarette use that are specific to youth. Ultimately, it is incumbent upon policymakers to create comprehensive regulations that prioritize harm reduction and can evolve in lockstep with the constantly changing e-cigarette product landscape.

Personality and impulsivity as predictors of tobacco use among emerging adults: A latent class analysis

The tobacco industry markets their products toward emerging adults (18-29), with the goal of increasing use among this age group. To inform prevention efforts, researchers are investigating how specific demographic and psychological traits may predict tobacco initiation and continuation. Participants were 578 incoming university freshmen from the Appalachian region. Participants provided information on demographics, personality traits, impulsivity characteristics, lifetime use of cigarettes and electronic cigarettes (ECIGs), and current use of cigarettes, ECIGs, small cigars/cigarillos, large cigars, smokeless tobacco, and waterpipe. Latent class analysis identified tobacco-use classes and regressions identified psychological predictors of class membership. Participants were Nonusers, Experimenters, and Polytobacco Users. Lower agreeableness and conscientiousness as well as higher extraversion and neuroticism were associated with being Experimenters or Polytobacco Users. Lower impulsivity was associated with being Nonusers. Distinct types of emerging adults belong to each tobacco use class, suggesting that individual differences be incorporated in prevention efforts.

Research on Youth and Young Adult Tobacco Use, 2013-2018, From the Food and Drug Administration-National Institutes of Health Tobacco Centers of Regulatory Science

The Tobacco Regulatory Science Program is a collaborative research effort between the National Institutes of Health (NIH) and the Food and Drug Administration (FDA). In 2013, the NIH funded 14 Tobacco Centers of Regulatory Science (TCORS), which serve as partners in establishing research, training, and professional development programs to guide FDA. Each of the fourteen TCORS, and two other NIH-funded research programs, the Center for the Evaluation of Nicotine in Cigarettes (CENIC) and the Consortium on Methods Evaluating Tobacco (COMET), pursued specific research themes relevant to FDA's priorities. A key mandate for FDA is to reduce tobacco use among young people. This article is a review of the peer-reviewed research, including published and in-press manuscripts, from the TCORS, CENIC, and COMET, which provides specific data or other findings on youth (ages 10-18 years) and/or young adults (ages 18-34 years), from 2013 to 2018. Citations of all TCORS, CENIC, and COMET articles from September 2013 to December 2017 were collected by the TCORS coordinating center, the Center for Evaluation and Coordination of Training and Research. Additional citations up to April 30, 2018 were requested from the principal investigators. A scoring rubric was developed and implemented to assess study type, primary theme, and FDA priority area addressed by each article. The major subareas and findings from each priority area are presented. There were 766 articles in total, with 258 (34%) focusing on youth and/or young adults. Findings relevant to FDA from this review concern impact analysis, toxicity, health effects, addiction, marketing influences, communications, and behavior.

IMPLICATIONS

The Tobacco Centers of Regulatory Science, CENIC, and COMET have had a high output of scientific articles since 2013. These Centers are unique in that the FDA supports science specifically to guide future regulatory actions. The 258 articles that have focused on youth and/or young adults are providing data for regulatory actions by the FDA related to the key priority areas such as the addictiveness of non-cigarette products, the effects of exposure to electronic cigarette marketing on initiation and cessation, and the impact of flavored products on youth and young adult tobacco use. Future regulations to reduce tobacco use will be guided by the cumulative evidence. These Centers are one innovative mechanism to promote important outcomes to advance tobacco regulatory science.

Exposure and engagement with tobacco-related social media and associations with subsequent tobacco use among young adults: A longitudinal analysis

BACKGROUND

This study examines whether self-reported exposure to cigarette, e-cigarette, cigar, and hookah advertising, and engagement with pro-tobacco and anti-tobacco social media, are associated with past 30-day tobacco use one-year later, among young adults.

METHODS

Data were from two waves of the Marketing and Promotions Across Colleges in Texas study, a multi-wave study of two- and four-year Texas college students (N = 3947; M age = 23.3, SD = 2.3; 64% female; 35% white, 31% Hispanic, 19% Asian, 8% African-American/black, 7% multi-racial/other) from 24 urban-area schools. Multiple logistic regression examined longitudinal associations between recall of exposure and engagement at baseline (wave 6, spring 2017) and tobacco use at one-year follow-up (wave 7, spring 2018), accounting for baseline demographic characteristics and tobacco use.

RESULTS

Self-reported exposure to and engagement with tobacco-related social media were significantly associated with past 30-day use of e-cigarettes, cigars, and hookah at one-year follow up; engagement was also associated with cigarette use. Controlling for other social media, exposure to any product advertising via Reddit increased risk for e-cigarette use (AOR = 1.92 [95% CI: 1.17-3.14]). Pinterest exposure increased risk for cigar use (2.92 [1.24-6.85]). Snapchat exposure increased risk for hookah use (2.94 [1.70-5.11]). Pro-tobacco engagement increased risk for future use of all products (1.77 [1.29-2.42]). Anti-tobacco engagement increased risk for use of cigars (1.59 [1.12-2.27]) and hookah (1.69 [1.27-2.25]).

CONCLUSIONS

Findings demonstrate that encountering tobacco-related social media is an important risk factor for future tobacco use among young people. Social media should be a focus of federal regulation, counter-marketing and health communication campaigns, and intervention.

Orthodox and Unorthodox Uses of Electronic Cigarettes: A Surveillance of YouTube Video Content

INTRODUCTION

Open electronic cigarette (e-cigarette) systems are customizable by consumers and often allow for potential "unorthodox" use of the product; that is, use not as intended by the manufacturer. Little is known about the types and prevalence of unorthodox uses and how these practices are transmitted via popular social media.

METHODS

Monthly searches of YouTube were conducted from June through November 2016 using the following search terms: "e-cigarettes," "vaping," and "e-juice." After collecting static and dynamic data on the 150 videos identified, two coders independently coded videos for general information, unorthodox use behaviors, health claims, and production quality and characteristics for orthodox and unorthodox use. Intercoder reliability was high (Cohen's κ 0.81, p < .001).

RESULTS

One hundred fifty videos were included in the study with a total of 115 551 563 views. We identified nine categories of unorthodox uses of e-cigarettes. Unorthodox use was three times as prevalent as orthodox use. Seventy-seven percent of the unorthodox use videos included recreational e-cigarette use, 57% included modification of mechanical parts and components, and 44.6% included unorthodox substance application (dripping). There were more than twice as many social media links in videos depicting unorthodox compared to orthodox use, but the level of engagement was lower for unorthodox use.

CONCLUSIONS

E-cigarette unorthodox use on YouTube is more prevalent than orthodox use, suggesting the need to further investigate the prevalence of unorthodox use among e-cigarette users and the influence of social media on consumer uptake of unorthodox and orthodox uses of e-cigarettes.

IMPLICATIONS

The US Food and Drug Administration has regulatory authority over e-cigarettes, parts and components. Many e-cigarettes currently marketed are open systems. Closed systems may allow less manipulation and may influence the safety of these products. This study provides valuable information on ways that open system e-cigarettes are used and it can inform safety tests that can be conducted by the US Food and Drug Administration to determine whether or not these products should remain on the market. In addition, our definitions of unorthodox use can be incorporated into the Population Assessment of Tobacco on Health Study to better understand the prevalence of these behaviors.

Who is JUULing and Why? An Examination of Young Adult Electronic Nicotine Delivery Systems Users

PURPOSE

The purpose of this study was to compare characteristics of usual JUUL users versus other electronic nicotine delivery systems (ENDS) users, examine differences in reasons for use and perceptions across ENDS user groups, and identify significant correlates of usual JUUL use.

METHODS

This study used data from 510 young adult ENDS users (ages 18-29 years) from Wave 7 (Spring 2018) of the Marketing and Promotions Across Colleges in Texas Project (Project M-PACT). Chi-Square analyses, independent t-tests, and mixed-effects logistic regression analyses were conducted to identify factors associated with usual JUUL use. Four separate regression analyses were conducted based on independent variables of interest; all models included demographics and ENDS/other tobacco use behaviors as covariates.

RESULTS

Compared with other ENDS users, usual JUUL users were more likely to be male, younger, smoke cigarettes, reported a higher socioeconomic status (SES), used ENDS on more days in the past 30 days, and reported nicotine "hit" as a reason for use. Usual JUUL users had a higher prevalence of perceiving JUUL/pod vapes as addictive compared with other ENDS users, although perceived addictiveness was not significant in the multivariable models nor were the cessation and dependence measures different between ENDS user groups.

CONCLUSIONS

Results highlight concerns about the dual use of JUUL and cigarettes and raise additional concerns about the high nicotine concentration of JUUL. Future longitudinal research is needed to determine if usual JUUL users are more likely to develop symptoms of nicotine dependence compared with other ENDS users.

Development of Dietary Knowledge and Adherence Questionnaires for Lebanese Adolescents and Their Parents

The availability of practical tools to assess dietary knowledge and adherence is essential to evaluate the effectiveness of dietary interventions. The aims of this paper were to develop reliable dietary knowledge and adherence questionnaires, suitable for Lebanese adolescents and their parents, and to estimate the feasibility of conducting studies involving such participants in the school-based setting. Eight Lebanese high schools participated in this study (involving 220 adolescents aged 15–18 years). Self-administered dietary knowledge and adherence questionnaires (the Dietary Knowledge Questionnaire (DKQ) and the Dietary Adherence Questionnaire (DAQ), respectively) were completed by the high school students and their parents. A 24 h recall was additionally administered for the adolescents by a dietitian and a trained interviewer at school, in order to validate the adolescents’ answers in the DAQ. The cognitive interview method was used to qualitatively evaluate the questionnaires. The resulting Cronbach’s alpha ranged from 0.61 to 0.78 for the adolescent questionnaires and from 0.46 to 0.89 for the parental ones. In addition, 23 items (out of 25) of the adolescent DAQ matched with the administered 24 h recall. A significant negative correlation was found between the knowledge score (DKQ) and the unhealthy items of the adolescent DAQ. There was a significant positive correlation between the DKQ of the parents and the knowledge score of their children. This is the first study of dietary questionnaires involving Lebanese high school students from different regions, while also including their parents.

Marketing exposure and smokeless tobacco use initiation among young adults: A longitudinal analysis

OBJECTIVES

This study examines the relationships between self-reported exposure to smokeless tobacco marketing and initiation/onset of smokeless tobacco use/susceptibility at 6-month follow-up, among a cohort of young adults in urban Texas.

METHODS

Participants were 3597 18-25 year old never smokeless tobacco users, attending 24 Texas two-year colleges and four-year universities. A multi-level, multivariate logistic regression model, accounting for school clustering, examined the impact of self-reported recall of smokeless tobacco marketing exposure at baseline and subsequent initiation of smokeless tobacco use. A subsample analysis of non-susceptible never users (n = 3097) examined the impact of self-reported exposure to smokeless tobacco marketing at baseline and onset of susceptibility to use smokeless tobacco. Both outcomes were assessed at 6-month follow-up. Baseline covariates included age, race/ethnicity, sex, two-/four-year institution, and other tobacco use. For the full analysis, susceptibility to use smokeless tobacco at baseline was included as a covariate.

RESULTS

From baseline to 6-month follow-up, 6.1% of never users initiated smokeless tobacco use (n = 219) and 7.0% of non-susceptible never users became susceptible to smokeless tobacco use (n = 221). Self-reported recall of smokeless tobacco marketing exposure at baseline was associated with initiation of smokeless tobacco (Adj OR: 1.17; 95% CI: 1.08-1.27) and onset of susceptibility to use smokeless tobacco (Adj OR: 1.11; 95% CI: 1.02-1.21) at 6-month follow-up, controlling for all covariates.

CONCLUSIONS

Findings build on previous research by demonstrating an association between recall of smokeless tobacco marketing and subsequent use. Findings are concerning given the 300% increase in smokeless tobacco marketing expenditures from 2006 to 2016.

Item Development and Performance of Tobacco Product and Regulation Perception Items for the Health Information National Trends Survey

INTRODUCTION

Emerging tobacco products have become increasingly popular, and the US Food and Drug Administration extended its authority to all products meeting the definition of a tobacco product in 2016. These changes may lead to shifts in public perceptions about tobacco products and regulation, and national surveys are attempting to assess these perceptions at the population level. This article describes the item development and cognitive interviewing of the tobacco product and regulation perception items included in two tobacco-focused cycles of the Health Information National Trends Survey (HINTS-FDA), referred to as HINTS-FDA.

METHODS

Cognitive interviewing was used to investigate how respondents comprehended and responded to tobacco product and regulation perception items. Adult participants (n = 20) were selected purposively to oversample current tobacco users and were interviewed in two iterative rounds. Weighted descriptive statistics from the fielded HINTS-FDA surveys (N = 5474) were also calculated.

RESULTS

Items were generally interpreted as intended, and participants meaningfully discriminated between tobacco products when assessing addiction perceptions. Response selection issues involved inconsistent reporting among participants with little knowledge or ambivalent opinions about either government regulation or tobacco products and ingredients, which resolved when a "don't know" response option was included in the survey. The fielded survey found that a non-negligible proportion of the population do not have clear perceptions of emerging tobacco products or government regulation.

CONCLUSIONS

A "don't know" response option is helpful for items assessing many emerging tobacco products but presents several analytic challenges that should be carefully considered. Multiple items assessing specific tobacco product and regulation perception items are warranted in future surveys.

IMPLICATIONS

The findings from this study can serve as a foundation for future surveys that assess constructs related to emerging tobacco products, harm perceptions across multiple tobacco products, and tobacco-related government regulatory activities. The data provide unique insight into item-specific motivation for selecting a "don't know" response option for tobacco survey items.

Limited utility of detailed e-cigarette use measures: An analysis of NESARC-III

INTRODUCTION

The heterogeneity of e-cigarette products and e-liquids pose challenges to surveillance of e-cigarette exposure. The goal of this study was to evaluate the internal consistency of e-cigarette use frequency, quantity, and duration measures in a national population-based survey.

METHODS

Data were drawn from the 2012-2013 for the National Epidemiologic Survey on Alcohol and Related Conditions-III (n = 36,309; NESARC-III). Adults who used e-cigarettes/e-liquid during the past year (≤18 years old; n = 1,229) were asked about their age of first use, recency of use, quantity (i.e., cartridges, drops), nicotine concentration, and duration (hours). Several internal consistency parameters were compared for e-cigarette measures in past-year (n = 750) and past 30-day e-cigarette users (n = 472) overall, and by frequency of use (i.e., infrequent [≤3 days/month], non-daily [1-6 days/week], daily).

RESULTS

There were no significant differences in quantity, nicotine concentration, or duration by frequency of use in past 30-day e-cigarette users. One-third of past 30-day and almost half of past-year users did not know the nicotine concentration of their cartridge or e-liquid. Correlations between all e-cigarette use measures were low, with the highest correlations seen between e-liquid quantity and cartridge quantity in all past 30-day users (r = 0.28) and those reporting any e-liquid use (r = 0.40). Cronbach's alpha and mean interitem correlations were low across all user groups.

CONCLUSIONS

Low to moderate correlation across e-cigarette measures in e-cigarette users implies low internal consistency of these measures in a population survey. Findings suggest measures such as quantity and nicotine concentration might more appropriate in samples of recent experienced e-cigarette users than in general population samples.

Type of E-Cigarette Device Used Among Adolescents and Young Adults: Findings From a Pooled Analysis of Eight Studies of 2166 Vapers

Background

A recent study of adult smokers who vape found that disposable/cigalike electronic (e-) cigarette devices were more commonly used than later generation devices. However, whether these trends reflect patterns among adolescents and young adults, many of whom have limited or no history of combustible cigarette use, has not been studied.

Methods

Participants were drawn from eight locally, regionally, and US nationally representative studies. Surveys took place between Fall 2014 and Spring 2016; participants were residents of California (3 studies), Texas (2 studies), Connecticut (1 study), or randomly selected from the US population (2 studies). Data were collected from middle and high school students (4 studies), young adults under 30 (3 studies), or a mixture (1 study) to assess type of e-cigarette device used among past-30 day e-cigarette users: disposable/cigalike, or later generation e-cigarette device.

Results

Fewer than 15% of participants in each study reported primarily using a disposable/cigalike device in the past month (across all studies: 7.5%; 95%CI: 4.9%, 10.5%). The proportion using later generation devices ranged from 58% to 86% across studies; overall, 77.0% (95%CI: 70.5%, 82.9%) reported primary use of a later generation device. Combined, 13.2% (95%CI: 5.9%, 22.8%) reported "don't know" or were missing data.

Conclusions

Among adolescent and young adult e-cigarette users, primary use of disposable/cigalike devices was rare. Future research should continue to evaluate the type of device used by adolescents and young adults, as these data may be relevant to regulatory oversight of e-cigarettes recently acquired by the Food and Drug Administration Center for Tobacco Products.

Implications

In this pooled analysis of adolescent and young adult vapers, primary use of later generation e-cigarette devices was substantially more common than use of disposable/cigalike devices. The type of device predominantly used by adolescents and young adults has regulatory implications for policy to reduce adolescent use of e-cigarettes.

Flavored Cigars Appeal to Younger, Female, and Racial/Ethnic Minority College Students

Introduction

This study examined the association of sociodemographic characteristics, tobacco and substance use behaviors, and reasons to use cigars in young adults' flavored and non-flavored cigar use.

Methods

Participants were 523, 18- to 29- year-old young adult college students (60.4% male; 40.9% non-Hispanic white) who reported current (past 30-day) cigar use.

Results

Almost 75% of the sample regularly chose flavored cigar products. Multilevel logistic regression analyses indicated that younger, female, and racial/ethnic minority cigar users had significantly greater odds of using flavored cigars than their counterparts. Current marijuana smokers, ever-blunt smokers, and students who reported using cigars because they were affordable and/or available in flavors they liked had a greater odds of flavored cigar use compared to their counterparts. Moreover, among dual users of cigars and cigarettes, those who cited using cigars because they were cheaper than cigarettes and because cigars felt like smoking regular cigarettes had greater odds of using flavored cigars compared to their peers. Number of days cigars were smoked and current use of other tobacco products were not associated with flavored cigar use.

Conclusions

Appealing attributes of flavored cigars have the potential to contribute to the tobacco use and subsequent nicotine addiction of younger, female, and racial/ethnic minority young adults. The wide variety of cigar flavors, their attractive price, and similarity to cigarette smoking underscore the need for additional research that links these unique traits to sustained tobacco use, and underscore the need for regulation of flavored products.

Implications

This study extends the current literature by finding that younger, female, and racial/ethnic minorities have greater odds of flavored cigar use than their peers. Flavored cigars have characteristics that appeal to members of these populations, which can contribute to their long-term use and potential for addiction.

Exposure to ENDS advertising and use of marijuana in ENDS among college students

BACKGROUND

Factors associated with marijuana use in electronic nicotine delivery systems (ENDS) are largely unknown. ENDS advertising, through subtle normative cues as well as explicit and implicit messages suggesting ENDS products are socially condoned and healthier alternatives, may influence the use of marijuana in ENDS. The aim of our study was to examine the association between exposure to ENDS advertising and subsequent use of ENDS with marijuana among college students.

METHODS

Data for this study were from waves 2 and 4 of the Marketing and Promotions across Colleges in Texas (M-PACT) study. Participants included 3720 college students (mean age = 21.4, SD = 2.3; 35.78% white; 35.7% male) across 24 colleges in Texas who completed online tobacco behavior surveys one year apart. Multilevel logistic regression was conducted to examine the association between ENDS advertising exposure at wave 2 (spring 2015) and use of marijuana in ENDS one year later at wave 4 (spring 2016), controlling for age, sex, race/ethnicity, and wave 2 sensation-seeking, impulsivity, current tobacco use, current marijuana use, and ever use of ENDS with marijuana. Use of ENDS to consume marijuana in the past six months was the outcome variable and ENDS advertising exposure was the independent variable.

RESULTS

Nearly half of participants reported ever ENDS use at waves 2 and 4, and 10% used marijuana in ENDS in the past 6-months at wave 4. Multilevel logistic regression analyses indicated that for every unit increase in ENDS advertising exposure, the odds of subsequently using ENDS with marijuana one year later were 1.08 times (95% CI = 1.01-1.14) greater.

CONCLUSIONS

ENDS advertising uniquely contributed to the subsequent use of marijuana in an ENDS, over and above the effects of other risk factors.

Longitudinal predictors of cigarette use among students from 24 Texas colleges

Objective: The purpose of this study is to examine differences between current and non-current cigarette users, focusing on sociodemographic factors, non-cigarette tobacco product use, parental and friend use, and alcohol and marijuana use; and to identify predictors of cigarette use sixmonths later. Participants: Participants included young adults (n = 4,296) from 24 Texas colleges, participating in a young adult cohort study, beginning in fall 2014. Methods: Mixed effects logistic regressions were conducted accounting for school-level variability. Results: Cigarette users were older, more likely to report use of non-cigarette tobacco products and peer use of cigarettes than non-current users. Wave 1 cigarette and non-cigarette tobacco product use, marijuana use and binge drinking, and peer use all uniquely predicted cigarette use at wave 2. Conclusions: Colleges need prevention programs targeting multiple tobacco products, because non-cigarette tobacco use and other risky behaviors appear to be independent risk factors for cigarette use in young adults.

E-Cigarette Use in a Country With Prevalent Tobacco Smoking: A Population-Based Study in Taiwan

BACKGROUND

The different profiles of e-cigarette users in different age groups have seldom been investigated, particularly in populations facing a high prevalence of cigarette smoking. This study aims to examine the prevalence and correlates of e-cigarette use separately for adolescents and adults in nationally representative samples in Taiwan.

METHODS

Among 17,837 participants in the 2014 National Survey of Substance Use in Taiwan, 4445 were aged 12 to 17 years and 13,392 were aged 18 to 64 years. Individuals' lifetime tobacco use was divided into four groups: non-use, exclusive e-cigarette use, exclusive cigarette use, and dual use. Questions on sociodemographic features, use and problematic use of tobacco, alcohol, and other drugs, and psychosocial distress, among others, were administered using a computer-assisted self-interview on tablet computers.

RESULTS

Among lifetime users of e-cigarette (2.2% for adults and 0.8% for adolescents), 4.5% for adults and 36.6% for adolescents were exclusive e-cigarette users. From use of exclusive e-cigarettes to use of exclusive cigarettes to dual use, those usage groups were related to an increasing trend of adjusted odds ratios for use of other psychoactive substances, particularly problematic use of alcohol or drugs, and with more depressive symptoms. Two correlates were specific to e-cigarette use: alcohol use had stronger relationships with e-cigarette use among adolescents, and younger adults (18-34) were more likely to try e-cigarettes compared to older adults.

CONCLUSIONS

These results provide essential information regarding e-cigarette use in the general population, and future prevention strategies should account for its specific correlates in young people.

Adolescents' understanding and use of nicotine in e-cigarettes

INTRODUCTION

Nicotine harms adolescent brain development and contributes to addiction. Some adolescents report using nicotine-free e-cigarettes, but the accuracy of their reporting is unclear. We explored adolescents' use of nicotine-free e-cigarettes and understanding of chemicals in e-cigarettes, including nicotine.

METHODS

Using social media, we recruited 1589 US adolescents (aged 15-17) who reported past 30-day use of e-cigarettes in 2016. We assessed perceptions of the nicotine source in e-liquid and whether e-cigarette aerosol is just "water vapor." We explored differences among adolescents who usually used e-cigarettes with nicotine (n = 473) and without nicotine (n = 452). We used weights to calibrate our sample to the Youth Risk Behavior Survey.

RESULTS

Twenty-nine percent usually used e-cigarettes without nicotine, 28% with nicotine, 39% with "both," and 5% were "not sure." Few participants (17% of non-nicotine users vs. 34% of nicotine users, p < .001) understood the nicotine was derived from tobacco. Youth who thought e-cigarette aerosol was just water vapor were more likely to usually use without nicotine. Older adolescents and current tobacco users were less likely to usually use without nicotine.

CONCLUSIONS

The adolescents who reported usually using e-cigarettes without nicotine had poorer knowledge of e-cigarettes. This lack of understanding could contribute to inaccurate reporting of nicotine use. Most youth thought the nicotine in e-cigarettes was artificial, potentially indicating a belief that this nicotine is "safer." The US Food & Drug Administration will require nicotine warnings on e-cigarettes in 2018; a complementary educational campaign could address youths' misperceptions about nicotine and other chemicals in e-cigarette aerosol.

A longitudinal study of risk perceptions and e-cigarette initiation among college students: Interactions with smoking status

BACKGROUND

Recent data suggest that lower perceived risks of e-cigarettes are associated with e-cigarette use in young adults; however, the temporality of this relationship is not well-understood. We explore how perceptions of harmfulness and addictiveness of e-cigarettes influence e-cigarette initiation, and specifically whether this association varies by cigarette smoking status, in a longitudinal study of tobacco use on college campuses.

METHODS

Data are from a 5-wave 24-college study in Texas. Only students who reported never using e-cigarettes at wave 1 were included (n = 2565). Multilevel discrete-time hazard models, accounting for school clustering, were used. The dependent variable, ever e-cigarette use, was assessed at each wave. Both time-varying (e-cigarette perceptions of harmfulness and addictiveness, age, use of cigarettes, use of other tobacco products, and use of other substances) and time-invariant demographic covariates were included. Two-way interactions between each e-cigarette perception variable and current conventional cigarette use were tested to determine if the hypothesized relationship differed among smokers and non-smokers.

RESULTS

21% of all never e-cigarette users at baseline had initiated e-cigarette ever use by wave 5. Significant two-way interactions qualified the relationship between risk perceptions and e-cigarette initiation. Specifically, perceptions of a lower degree of harmfulness (OR = 1.13, p = .047) and addictiveness (OR = 1.34, p < .001) of e-cigarettes predicted initiation among non-smokers, but not among current smokers.

CONCLUSION

Perceiving a lower degree of risk of e-cigarettes contributes to subsequent e-cigarette initiation among non-smokers, but not among current smokers.

FINDINGS

have implications for prevention campaigns focusing on the potential harm of e-cigarettes for non-smoking college students.

Measuring perceptions related to e-cigarettes: Important principles and next steps to enhance study validity

Measuring perceptions associated with e-cigarette use can provide valuable information to help explain why youth and adults initiate and continue to use e-cigarettes. However, given the complexity of e-cigarette devices and their continuing evolution, measures of perceptions of this product have varied greatly. Our goal, as members of the working group on e-cigarette measurement within the Tobacco Centers of Regulatory Science (TCORS) network, is to provide guidance to researchers developing surveys concerning e-cigarette perceptions. We surveyed the 14 TCORS sites and received and reviewed 371 e-cigarette perception items from seven sites. We categorized the items based on types of perceptions asked, and identified measurement approaches that could enhance data validity and approaches that researchers may consider avoiding. The committee provides suggestions in four areas: (1) perceptions of benefits, (2) harm perceptions, (3) addiction perceptions, and (4) perceptions of social norms. Across these 4 areas, the most appropriate way to assess e-cigarette perceptions depends largely on study aims. The type and number of items used to examine e-cigarette perceptions will also vary depending on respondents' e-cigarette experience (i.e., user vs. non-user), level of experience (e.g., experimental vs. established), type of e-cigarette device (e.g., cig-a-like, mod), and age. Continuous formative work is critical to adequately capture perceptions in response to the rapidly changing e-cigarette landscape. Most important, it is imperative to consider the unique perceptual aspects of e-cigarettes, building on the conventional cigarette literature as appropriate, but not relying on existing conventional cigarette perception items without adjustment.

Establishing consensus on survey measures for electronic nicotine and non-nicotine delivery system use: Current challenges and considerations for researchers

The development and validation of survey measures for electronic nicotine and non-nicotine delivery system (ENDS) use has not kept pace with the burgeoning research on them. This, along with the diverse and evolving nature of ENDS, presents several unique measurement challenges and hampers surveillance and tobacco regulatory research efforts. In this commentary, we identify four important areas related to ENDS use (describing ENDS products; defining current use; evaluating frequency and quantity of use; and characterizing devices and e-liquids) and summarize a selective review of the measurement and definitions of these constructs across prominent national tobacco use surveys and 30 projects within the 14 federally-funded Tobacco Centers of Regulatory Science. Across these national, regional, and local studies, there was considerable variability and relatively little consensus in ENDS use measures - thus highlighting the need for caution when comparing findings across studies or over time until more research is available to evaluate the sensitivity of findings to differing measures. Drawing from the nascent ENDS use measurement research literature and our experiences, we conclude with general considerations for measuring ENDS use for tobacco researchers as an initial step towards the development of consensus measures.

Exposure to e-cigarette marketing and product use among Mexican American young adults on the US-Mexico border: A pilot study

Historically, the tobacco industry has marketed directly to minority groups, which is associated with increased product use; the advent of e-cigarettes poses a new risk. The purpose of this study is to examine associations between exposure to tobacco marketing via traditional and digital marketing channels and ever use of e-cigarettes among Mexican-American young adults. Ninety-two Mexican-American young adults between 18 and 29 years of age (61% female) were recruited from the Cameron County Hispanic Cohort, a well-characterized population-based cohort on the U.S.- Mexico border. Participants reported their use of e-cigarettes and exposure to pro- and anti-media messages about these products in traditional and digital venues. Nearly one third reported ever using e-cigarettes and exposure to media overall was low. However, exposure to pro e-cigarette messages via digital sources was associated with increased odds of ever using e-cigarettes (OR: 2.86; 95% CI: 1.11-7.38). Results suggest that regulations on e-cigarette digital media may help to reduce e-cigarette use.

Relationship between spending on electronic cigarettes, 30-day use, and disease symptoms among current adult cigarette smokers in the U.S

OBJECTIVE

To examine the relationship between spending on electronic cigarettes (e-cigarettes) and disease symptoms compared with the relationship between 30-day e-cigarette use and disease symptoms among adult cigarette smokers in the U.S.

METHODS

We analyzed data from the Tobacco and Attitudes Beliefs Survey which included 533 respondents aged 24+ who were current cigarette smokers and e-cigarette ever users. Fifteen self-reported disease symptoms were included as outcome variables. Separate multivariable logistic regression models were estimated for each disease symptom with total spending on e-cigarettes in the past 30 days and with reported 30-day e-cigarette use. All models controlled for cigarettes smoked per day (CPD) and sociodemographic characteristics.

RESULTS

We found that those who spent more on e-cigarettes were more likely to report chest pain (AOR = 1.25, 95% CI 1.02-1.52), to notice blood when brushing their teeth (AOR = 1.23, 95% CI 1.02-1.49), to have sores or ulcers in their mouth (AOR = 1.36, 95% CI 1.08-1.72), and to have more than one cold (AOR = 1.36, 95% CI 1.05-1.78) than those with no spending on e-cigarettes in the past 30 days in an adjusted analysis. After controlling for CPD and other covariates, there were no significant relationships between 30-day e-cigarette use and symptoms. Even after controlling for CPD, e-cigarette expenditures or use was associated with greater odds of wheezing and shortness of breath.

CONCLUSIONS

E-cigarette expenditures might be a more useful measure of intensity of e-cigarette use. The additional health effect of e-cigarette use or expenditures among smokers independent of the effect of CPD suggests that e-cigarette use adds adverse health effects even among cigarette smokers.

Use of Nicotine in Electronic Nicotine and Non-Nicotine Delivery Systems by US Adults, 2015

Nicotine in electronic nicotine and non-nicotine delivery systems (ENDS/ENNDS) may present a risk of harm to those with cardiovascular disease and the fetuses of pregnant women. We assessed the extent to which adult users of ENDS/ENNDS used these products with nicotine. We obtained data for this study from a national probability survey of 6051 US adults that was conducted in August and September 2015. Of 399 adult ENDS/ENNDS users who were current smokers, 337 (80.7%) used ENDS/ENNDS containing nicotine, whereas only 29 of 71 (36.9%) ENDS/ENNDS users who were never smokers used ENDS/ENNDS containing nicotine. Assessments of the population health impact of ENDS/ENNDS use among never smokers should take into account the extent to which use involves nicotine.

A Medical Student-Delivered Smoking Prevention Program, Education Against Tobacco, for Secondary Schools in Germany: Randomized Controlled Trial

BACKGROUND

More than 8.5 million Germans suffer from chronic diseases attributable to smoking. Education Against Tobacco (EAT) is a multinational network of medical students who volunteer for school-based prevention in the classroom setting, amongst other activities. EAT has been implemented in 28 medical schools in Germany and is present in 13 additional countries around the globe. A recent quasi-experimental study showed significant short-term smoking cessation effects on 11-to-15-year-old adolescents.

OBJECTIVE

The aim of this study was to provide the first randomized long-term evaluation of the optimized 2014 EAT curriculum involving a photoaging software for its effectiveness in reducing the smoking prevalence among 11-to-15-year-old pupils in German secondary schools.

METHODS

A randomized controlled trial was undertaken with 1504 adolescents from 9 German secondary schools, aged 11-15 years in grades 6-8, of which 718 (47.74%) were identifiable for the prospective sample at the 12-month follow-up. The experimental study design included measurements at baseline (t1), 6 months (t2), and 12 months postintervention (t3), via questionnaire. The study groups consisted of 40 randomized classes that received the standardized EAT intervention (two medical student-led interactive modules taking 120 minutes total) and 34 control classes within the same schools (no intervention). The primary endpoint was the difference in smoking prevalence from t1 to t3 in the control group versus the difference from t1 to t3 in the intervention group. The differences in smoking behavior (smoking onset, quitting) between the two groups, as well as gender-specific effects, were studied as secondary outcomes.

RESULTS

None of the effects were significant due to a high loss-to-follow-up effect (52.26%, 786/1504). From baseline to the two follow-up time points, the prevalence of smoking increased from 3.1% to 5.2% to 7.2% in the control group and from 3.0% to 5.4% to 5.8% in the intervention group (number needed to treat [NNT]=68). Notable differences were observed between the groups for the female gender (4.2% to 9.5% for control vs 4.0% to 5.2% for intervention; NNT=24 for females vs NNT=207 for males), low educational background (7.3% to 12% for control vs 6.1% to 8.7% for intervention; NNT=30), and migrational background (students who claimed that at least one parent was not born in Germany) at the 12-month follow-up. The intervention appears to prevent smoking onset (NNT=63) but does not appear to initiate quitting.

CONCLUSIONS

The intervention appears to prevent smoking, especially in females and students with a low educational background.

Initial Development of an E-cigarette Purchase Task: A Mixed Methods Study

OBJECTIVES

Behavioral economic purchase tasks, which estimate demand for drugs, have been successfully developed for cigarettes and are widely used. However, a validated purchase task does not yet exist for e-cigarettes. The aim of this project was to identify the relevant units for an e-cigarette purchase task (E-CPT).

METHODS

Focus groups (N=28 participants in 7 groups, 2-7 participants per group) consisting of current e-cigarette users were conducted. Participants discussed their daily use patterns, completed a preliminary E-CPT which asked how many puffs of their e-cigarette they would consume per day at escalating prices, and discussed the extent to which the task accurately reflected their real-world behavior. Groups were recorded and transcribed; analysis focused on statements related to daily consumption and the E-CPT.

RESULTS

Participants were unlikely to quantify their daily use in terms of puffs, and perceptions about the appropriate unit for an E-CPT varied across device type. Users of first-generation devices (eg, cigalikes) reported that the relevant unit was the individual device/cartridge; however, participants who purchased nicotine liquid for their device emphasized that e-liquid volume in milliliters would better reflect their use.

CONCLUSIONS

Multiple versions of the E-CPT may be necessary to provide valid measures of e-cigarette demand.

College students' perceptions of risk and addictiveness of e-cigarettes and cigarettes

BACKGROUND

As conventional cigarette use is declining, electronic cigarette ("e-cigarette") use is rising and is especially high among college students. Few studies examine dual use of e-cigarettes and cigarettes among this population. This study explores the relationship between dual and exclusive e-cigarette / cigarette use and perceptions of harm and addictiveness of both products.

METHODS

This is a cross-sectional analysis of data from students attending 24 colleges in Texas (n=5,482). Multinomial logistic regression was employed to test the association between current e-cigarette / cigarette use and perceived harm and addictiveness of both products. Three tobacco groups were included: cigarette only users, e-cigarette only users, and dual users.

RESULTS

Dual users reported lower perceived harm of e-cigarettes most consistently (p<0.001, all comparisons). Perceived harm of cigarettes was significantly lower among cigarette only and dual users only, compared to non-users (p<0.001, all comparisons). Compared to non-users, all three groups reported significantly lower perceived addictiveness of e-cigarettes (p<0.001, all comparisons). The same finding was observed for perceived addictiveness of cigarettes, though findings were less consistent for the e-cigarette only group (p<0.02, all comparisons except one).

CONCLUSION

Findings demonstrate that among college students, perceptions of harm and addictiveness of e-cigarettes are lower than those for conventional cigarettes. For both products, perceptions of harm and addictiveness were lower among exclusive and dual users, compared to non-users.

Clinical Laboratory Evaluation of Electronic Cigarettes/Electronic Nicotine Delivery Systems: Methodological Challenges

OBJECTIVE

Evaluating electronic cigarettes (ECIGs) in the clinical laboratory is critical to understanding their effects. However, laboratory evaluation of ECIGs can be challenging, as they are a novel, varied, and evolving class of products. The objective of this paper is to describe some methodological challenges to the clinical laboratory evaluation of ECIGs.

METHODS

The authors gathered information about challenges involved in the laboratory evaluation of ECIGs. Challenges were categorized and solutions provided when possible.

RESULTS

Methods used to study combustible cigarettes may need to be adapted to account for ECIG novelty and differences within the class. Challenges to ECIG evaluation can include issues related to 1) identification of ECIG devices and liquids, 2) determination of short -term ECIG abstinence, 3) measurement of use behavior, and 4) assessment of dependence. These challenges are discussed, and some suggestions to inform ECIG evaluation using clinical laboratory methods are provided.

CONCLUSIONS

Awareness of challenges and developing, validating, and reporting methods used to address them aids interpretation of results and replication efforts, thus enhancing the rigor of science used to protect public health through appropriate, empirically-based, ECIG regulation.

College Students' Polytobacco Use, Cigarette Cessation, and Dependence

OBJECTIVES

We examined patterns of tobacco and electronic cigarette (e-cigarette) use among college students. Differences in sociodemographic characteristics between non-users of these products and 4 mutually exclusive groups of tobacco/e-cigarette users were assessed. Differences in cigarette cessation attempts and dependence between exclusive cigarette smokers and users of cigarettes and at least one alternative tobacco product also were examined.

METHODS

Participants were 5468 18-29 year-old students from 24 colleges in Texas who completed an online survey.

RESULTS

Multiple-product use was more prevalent than single-product use. All 4 current tobacco/e-cigarette-user groups were more likely than non-users to be men and older. College students who were younger when they smoked their first cigarette, and those reporting ever needing a cigarette, were more likely to be multiple-product users than cigarette-only users. There were no group differences in cigarette cessation attempts or any other variables.

CONCLUSIONS

Using multiple products is associated with some indicators of dependence, but does not seem to aid or deter college students' smoking cessation attempts. Longitudinal research is needed given that transitions in tobacco/e-cigarette use continue throughout young adulthood.