Second Generation Electronic Nicotine Delivery System Vape Pen Exposure Generalizes as a Smoking Cue

Understanding the Cardiovascular Fallout of E-cigarettes: A Comprehensive Review of the Literature

E-cigarettes (ECs) deliver chemicals, including nicotine. They can cause respiratory distress, addiction, cardiovascular effects, and death. More research is needed, especially regarding their impact on the cardiovascular system (CVS) and during pregnancy. Our article aims to fill this gap by summarizing studies elaborating upon the current impact of ECs and the components thereof on the CVS. Acute respiratory distress outbreaks, nicotine addiction, CVS effects, and deaths have been occasionally reported within this cohort, although these events are not uncommon with neighboring age groups. Randomized control trials implying ECs have some contribution toward quitting smoking have been studied. To regulate EC distribution, the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) have created key checkpoints. Additionally, taxation, pricing, age restriction, and media campaigns could be modulated to significantly reduce illicit sales. Education to the users, distributors, and regulators about this product can also play an aiding role in promoting responsible EC use. Another strategy about licensing could be employed, which could incentivize genuine resellers. The effects on CVS and child-bearing by ECs are grim, which calls for strict regulation, awareness, and avoidance by the teetotaler public. They may help individuals stop smoking but not without harming themselves. Strict regulations are necessary to prevent non-judicious use of these devices.

Displacement imposition scale assesses reactions of cigarette and e-cigarette users impacted by a campus-wide smoking ban

OBJECTIVE

The present study developed a measure assessing the emotional responses, "Displacement Imposition," of cigarette and e-cigarette users on a college campus with a smoking/vaping ban. It also examined the relationship between Displacement Imposition and readiness to quit smoking/vaping, and how this relationship differed between cigarette and e-cigarette users.

PARTICIPANTS

Participants (N = 297) were from a large, Midwestern university.

METHODS

Participants completed online questionnaires assessing demographics, cigarette and e-cigarette use, Displacement Imposition, and readiness to quit.

RESULTS

All six Displacement Imposition items loaded onto a single factor. A significant interaction emerged between Displacement Imposition and product use in predicting readiness to quit. At high levels of Displacement Imposition, cigarette users were less ready to quit than e-cigarette users.

CONCLUSIONS

Findings suggest restrictions imposed on cigarette and e-cigarette users were associated with reduced readiness to quit. Findings inform tobacco control policies as tobacco denormalization may increase the burden placed on tobacco users.

Cue Reactivity Effects of Heated Tobacco Product Use in Current, Former, and Never Smokers in the United States

INTRODUCTION

Heated tobacco products (HTPs) share similar characteristics as combustible cigarettes and electronic nicotine delivery systems (ENDS) and thus may serve as cues for smoking and vaping. While HTP familiarity is low in the United States, HTPs may be perceived as a less harmful alternative to cigarettes.

AIMS AND METHODS

The present study examined if visual exposure to HTP use influenced cigarette and e-cigarette craving in a large national sample of adults with varied smoking patterns. Current, former, and never cigarette smokers (N = 515; Mage = 40) were recruited from online crowd-sourcing panels throughout the United States from January to April 2020. Participants completed surveys before and after watching a video depicting the use of an HTP, cigarette, or bottled water. Main outcomes were changes in cigarette craving after exposure to the video cue. Secondary outcomes included changes in e-cigarette craving.

RESULTS

Relative to the water cue, the HTP and cigarette cues increased cigarette craving in current smokers. The HTP cue also increased e-cigarette craving (desire for a mod or vape pen and JUUL) across all subgroups.

CONCLUSIONS

Current smokers demonstrated cue reactivity to the use of an HTP as they reported increases in both cigarette and e-cigarette craving after exposure. All smoking groups reported e-cigarette reactivity to the HTP cue. As HTPs gain traction globally, it is crucial to consider how their use may influence active users and passive viewers to inform future health policies.

IMPLICATIONS

Noncombustible nicotine delivery systems are known cues for cigarette smoking and e-cigarette vaping, and this study examined whether relatively novel heated tobacco products (HTPs) may also act as a smoking or vaping cue in adults across varied smoking backgrounds. Results showed that passive exposure to HTP use increased desire for both a cigarette and an e-cigarette in current smokers and also increased desire for an e-cigarette in former and nonsmokers. Thus given its similarity to smoking and vaping, HTP use may affect passive observers and could play a role in perpetuating the dual use of cigarettes and vape products.

E-Cigarette Use among Male Smokers in Al-Ahsa, Kingdom of Saudi Arabia: A Cross-Sectional Study

E-cigarette use is increasing globally. Recent evidence suggests that e-cigarettes contain harmful substances that could cause adverse health outcomes. This study investigated the prevalence and associated factors of e-cigarette use among male current smokers in Saudi Arabia. We conducted a cross-sectional survey of adult male current smokers in the Al-Ahsa province of Saudi Arabia. Data were collected using a structured questionnaire. We performed logistic regression analyses to investigate the factors associated with e-cigarette use among adult male current smokers. 325 current smokers participated in the study. A third of them (33.5%) were e-cigarette users. Almost all the study participants (97.0%) had heard about e-cigarettes. Participants who were occasional smokers (Odds Ratio (OR): 2.28; 95% Confidence Interval (CI): 1.17-4.41) and had good knowledge perception of e-cigarettes (OR 3.49; 95% CI: 2.07-5.90) had higher odds of using e-cigarettes when compared to regular smokers of conventional cigarettes and current smokers with poor knowledge perception of e-cigarettes, respectively. In contrast, private employees (OR: 0.25, 95% CI: 0.07-0.85), and business owners (OR: 0.09, 95% CI: 0.01-0.63) had lower odds of using e-cigarettes compared to unemployed individuals. Compared with non-e-cigarette users, the rate of conventional cigarette smoking per day was significantly lower among e-cigarette users. Use of e-cigarette (OR: 3.57, 95% CI: 2.14-5.98), believing that e-cigarette quitting is hard (OR: 2.02, 95% CI: 1.17-3.49) and trying to quit e-cigarettes (OR: 2.17, 95% CI: 1.1-4.25) were found to be significant predictors of good knowledge perception of e-cigarettes among the current smokers. The use and knowledge perception of e-cigarettes were higher among occasional conventional male cigarette smokers than regular male smokers in Al-Ahsa province. The use of e-cigarettes as smoking cessation aids should be examined further in the Saudi Arabian setting.

The development and validation of an electronic nicotine delivery system (ENDS) image cue stimulus set

RATIONALE

Responsiveness to drug-related cues assesses drug reward in research studies. There are currently no validated visual image cues related to electronic nicotine delivery systems (ENDS), thus, this study aimed to develop and validate affective ENDS image cues.

METHODS

ENDS users and non-vaping individuals in the United States and Canada were recruited via Amazon MTurk. A total of 120 ENDS-related images and 56 neutral images, matched for visual similarity, were assessed. These images were either selected from public databases or were photographed by study staff. Closely adhering to the International Affective Picture System procedure, each participant rated 66 images one-by-one on dimensions of valence, arousal, dominance, and desire-to-vape where higher scores indicated greater feelings of happiness, excitement, loss of control, and desire to vape.

RESULTS

After excluding patterned responses, the data from 926 participants (610 ENDS users, and 316 non-vaping controls) were analyzed. When viewing ENDS-related images, desire-to-vape scores were correlated with valence (r = 0.55, p < 0.0005), arousal (r = 0.72, p < 0.0005), and dominance (r = 0.58, p < 0.0005) scores. Images that elicited greater desires to vape also elicited greater feelings of happiness and excitement, but less perceived control. Correlations between arousal and valence (r = 0.42, p < 0.0005) and dominance (r = 0.71, p < 0.0005) suggest that images that increased feelings of excitement also increased happiness and decreased perceived control.

CONCLUSIONS

Correlational findings of the affective ENDS-related images were similar to those of previous studies validating collections of tobacco and alcohol picture cues, supporting the future use of these stimuli in ENDS research.

Cue Reactivity to Electronic Cigarettes: A Systematic Review

Cue reactivity to Electronic Nicotine Delivery Systems (ENDS) has been studied by several researchers, yet the variability in user types (smokers, former smokers, dual users, exclusive ENDS users) and ENDS designs used between the studies may have undermined consistent results. This systematic review aims to give an overview of ENDS cue reactivity and how smoking status and device design may moderate this. A systematic search of Medline, Embase, Web of Science, PubMed and Cochrane was completed. All studies which reported findings on reactivity to ENDS cues in the form of craving or desire for ENDS or cigarettes, attention to cue, delay of gratification or economic decisions were included. Exclusion criteria were non-human subjects, non-adult participants or participants with comorbidities. Literature selection was carried out by 2 independent reviewers. The risk of bias and study quality were assessed using tools developed by Cochrane, BMJ and NHLBI. A total of 711 papers were screened and 22 studies were included in the current review. Study design, research question(s), population of interest, number of participants, dependent variable(s), ENDS generation and nicotine content used and study results were extracted. ENDS cues reliably induced ENDS craving, with no clear moderation by smoking status and no apparent moderation by device generation. In about half of the studies, ENDS cues induced craving for conventional cigarettes. Most studies used a smoker sample, thus limiting the conclusions that can be drawn on the moderation of cue reactivity by smoking status. The quality varied among studies but comparing the findings against the outcomes of only high-quality studies did not yield any different results. The results of this review support the notion of cue reactivity to ENDS, identifies gaps in current research on different user types and implies that ENDS design iterations have little impact on cue reactivity.

Pilot Ecological Momentary Assessment Study of Subjective and Contextual Factors Surrounding E-Cigarette and Combustible Tobacco Product Use among Young Adults

BACKGROUND

Dual use of e-cigarettes and combustible tobacco products is common in young adults. We aimed to explore how ratings of subjective and contextual factors differed between discrete episodes of e-cigarette use vs. combustible tobacco product smoking among a sample of young adults.

METHODS

Young adults (N = 29, ages 18-30) who used e-cigarettes and ≥1 combustible tobacco product at least once weekly completed a 1-week smartphone-based ecological momentary assessment (EMA). Twice daily random prompts assessed past-15-min use of tobacco products, ratings of subjective factors (e.g., negative affect, craving), and contextual factors related to activity, location, and companionship. A multivariable GEE model assessed whether subjective or contextual factors were associated with e-cigarette vs. combustible tobacco product episodes.

RESULTS

184 tobacco use episodes were reported (39.7% e-cigarette, 60.3% combustible tobacco product). High baseline cigarette dependence, as measured by the Fagerström Test for Cigarette Dependence, was associated with lower odds of e-cigarette vs. combustible tobacco product episodes (aOR 0.01, 95% CI (0.002-0.08); p < 0.001). Neither between- or within-subjects negative affect or craving scores were associated with e-cigarette use. Activities of eating/drinking (aOR 0.20, 95% CI (0.08-0.49); p = 0.001) and being in the companionship of a person who smoked cigarettes (aOR 0.13, 95% CI (0.04-0.43); p = 0.001) were associated with lower odds of e-cigarette vs. combustible tobacco product use episodes. However, traveling (aOR 12.02, 95% CI (3.77-38.26); p ≤ 0.001) and being in a public space (aOR 2.76, 95% CI (1.10-6.96); p = 0.03) were associated with higher odds of e-cigarette than combustible tobacco product use episodes.

CONCLUSIONS

This pilot data suggests that unique contextual factors may be associated with e-cigarette use, compared to combustible tobacco smoking in a sample of young adults who use both e-cigarettes and combustible tobacco products. Future research with larger samples is needed to better characterize varying contexts and cues for tobacco use among young adults who are dual users.

Electronic nicotine delivery systems (ENDS) cue reactivity in dual users: A combined analysis

BACKGROUND

Cigarette smokers report increases in smoking urge in response to exposure to electronic nicotine delivery systems (ENDS) and dual users, i.e. smokers who also vape ENDS, may exhibit greater cue reactivity than exclusive smokers. The current investigation examined reactivity to a variety of ENDS cues across a large sample of cigarette smokers and dual ENDS users.

METHODS

Young adult smokers (N = 345; >5 cigarettes per day) were recruited between 2013-2019 for participation in a series of within-subjects laboratory-based studies. Participants completed surveys before and after exposure to a confederate-delivered control cue (water) and an active cue, including cigarette or ENDS cues ranging from first generation "cigalikes" to a fourth generation "pod-mod". Main outcomes were post-cue changes in desire for combustible cigarettes and e-cigarettes, and smoking behavior as determined by the smoking latency portion of the Smoking Lapse Paradigm after cue exposure.

RESULTS

Relative to smokers who do not use ENDS, dual users demonstrated higher baseline desire for ENDS and greater ENDS cue reactivity (across product types) in terms of post-cue increases in smoking urge and shorter latency to smoking choice. In contrast, reactivity to the cigarette cue was similar across groups.

CONCLUSIONS

Dual users show heightened ENDS cue reactivity on smoking urge and behavior relative to never users of ENDS, regardless of the type of ENDS cue. Given their reactivity to both cigarette and ENDS cues, it may be difficult for dual users to transition to exclusive vaping or quit tobacco product use altogether.

An Experimental Test of the Relationship between Electronic Nicotine Delivery System Use and Alcohol Consumption

BACKGROUND

Increasing research shows that the use of electronic nicotine delivery systems (ENDS) is associated with a higher rate and quantity of alcohol consumption.

METHODS

The present study used a 2-session, within-subjects design to experimentally examine the relationship between ENDS use and laboratory ad libitum alcohol consumption. A total of N = 31 (mean age = 28.71, SD = 11.17; 45.2% women; 54.8% White/Caucasian) healthy adults from the community who use ENDS and endorsed liking beer completed the study, which included a beer consumption taste-test task that assessed the volume of beer consumed by the participants across 2 counterbalanced sessions: 1 in which concurrent ENDS use was allowed and 1 in which it was not. All analyses controlled for age, race, and gender.

RESULTS

The effect of ENDS condition on the volume of beer consumed was not statistically significant, F(1, 30) = 0.03, p = 0.86). Results of linear mixed modeling showed that ENDS puffs were significantly related to alcohol sips (estimate = 0.23, SE = 0.07, p = 0.002) across the ad libitum session.

CONCLUSIONS

Overall, ENDS use did not increase alcohol consumption; however, the data suggest that ENDS puffs might act as a prime for beer sips or that these 2 behaviors are linked through habit. Future studies should more fully measure and compare global and event-level data on ENDS and alcohol use as they might show disparate patterns of relationships.

Effects of Visual Exposure to IQOS Use on Smoking Urge and Behavior

Objectives

In this study, we examined whether visual exposure to the heated tobacco product (HTP) IQOS, which was authorized for sale by the US Food and Drug Administration in 2019, acts as a cue to increase cigarette craving and smoking behavior among smokers.

Methods

Young adult smokers (N = 105) were randomly assigned to view a video depicting use of either IQOS or bottled water. Main outcomes were changes in cigarette and e-cigarette desire and latency to smoke between the groups. We also examined participants' attitudes about the actors using IQOS and drinking water in the videos.

Results

Exposure to the use of IQOS acutely increased observers' ratings of smoking urge and desire for a cigarette and an e-cigarette. The IQOS cue, compared with the water cue, also produced a marginally significant shorter latency to smoke. Participants perceived actors as less likeable and friendly when using IQOS than when drinking water.

Conclusions

Results showed that exposure to IQOS produced smoking urge and behavior in young adult smokers, implicating IQOS use as a smoking and vaping cue. As HTPs gain popularity, product impact on passive observers should be included in their risk-benefit profile.

Vaping in the Workplace: Implications for Employer-Sponsored Tobacco Cessation Programs

OBJECTIVE

Assess workplace vaping as a trigger for tobacco use; examine interest in and prevalence of vaping cessation programs; determine needs of parents whose children vape.

METHODS

Employees of companies with more than 150 employees, drawn from an opt-in national online panel (N = 1607), ages 18 to 65, completed an online survey in November 2019.

RESULTS

Among tobacco users, 46% to 48% reported workplace vaping was a trigger for smoking and vaping, respectively; 7% of former users reported it as a trigger. Quit vaping support is important to 85% of employees; 1/3 of workplaces have such programs, with industry variation. Child vaping results in presenteeism and absenteeism among roughly 1/3 of parents.

CONCLUSIONS

Workplace vaping is a trigger for smoking and vaping among current and former tobacco users. A gap exists between desired support for vaping cessation and current employer-sponsored cessation programs.

Prevalence and perceptions of e-cigarette use among medical students in a Saudi University

Background and Aims:

We hypothesized that the prevalence of electronic cigarette vaping among the medical student population is on the rise. Our aims were to assess the prevalence of electronic cigarette vaping among medical students in Saudi Arabia, to understand and analyze the reasons that led them to try it, and to investigate students’ perceptions towards electronic cigarette vaping.

Methods:

An anonymous, paper-based, cross-sectional questionnaire was distributed amongst 401 undergraduate medical students from years 1-5 at Alfaisal University in Riyadh, Saudi Arabia. Prevalence, intensity of e-cigarette use and reasons for it, relation of electronic cigarettes to cessation of tobacco smoking, and side effects were studied.

Results:

The prevalence of vaping was 49/401 (12.2%). There was a strong association between gender and vaping, with males being 3 times more likely to vape compared to females (χ2 (1) =13.62, P <.001). The three most common reasons for using electronic cigarettes were to enjoy the variability in flavours (61.4%, n = 30), to reduce or quit tobacco cigarettes (29.5%, n = 14), and to avert the public smoking ban (13.6%, n = 7). The three most common side effects experienced by users were coughing (26.7%, n = 13), dry mouth/throat (24.4%, n = 12), and dizziness (20%, n = 10).

Conclusion:

Use of the electronic cigarettes is not uncommon amongst medical students, mostly due to their appealing flavor variability. Further research is required to define long-term safety and side effect profiles, and to generate evidence-based guidelines concerning e-cigarette safety and efficacy for smoking cessation.

Exposure to JUUL use: cue reactivity effects in young adult current and former smokers

BACKGROUND

Exposure to the use of first, second and third generations of electronic cigarettes (e-cigarettes) elicits the desire to vape and smoke among observers, as well as facilitates smoking behaviour. Given the rapid rise in the popularity of the pod mod JUUL, we examined whether observing the use of this device would elicit similar responses in smokers. Exploratory analyses were also conducted to determine whether JUUL can act as a smoking cue for former smokers.

METHODS

The sample consisted of 82 young adult participants (62 current smokers and 20 former smokers approximately 1 year smoke free). The study examined their response to observing use of bottled water (control cue) and JUUL (active cue) in a controlled laboratory paradigm. Both cues were delivered by a trained study confederate under the guise of a social interaction task, and participants completed mood and desire and urge surveys precue and postcue exposures.

RESULTS

In current smokers, exposure to the JUUL cue increased smoking urge and desire for a cigarette, mod/vape pen and JUUL, and two-thirds chose to smoke in the behavioural analogue task. In former smokers, the JUUL cue evoked modest and transient increases in desire for a cigarette and JUUL.

CONCLUSIONS

The use of JUUL affects the user and elicits responses in observers; this study is the first to demonstrate that exposure to JUUL use may act as a smoking cue and exposure to JUUL use may affect tobacco control efforts.

Intersection of E-Cigarette Use and Gender on Transitions in Cigarette Smoking Status: Findings Across Waves 1 and 2 of the Population Assessment of Tobacco and Health Study

INTRODUCTION

Cigarette smokers report using electronic cigarettes (e-cigarettes) to reduce or quit smoking, but findings are mixed regarding the benefit and risk of e-cigarettes in this population, and effects of gender are unknown.

METHODS

The Population Assessment of Tobacco and Health (PATH; waves 1 and 2; adult interviews) was used to evaluate relationships among wave 1 e-cigarette use (daily, nondaily, never) and gender and their association with transitions (quit vs. current; relapse vs. former) in cigarette smoking status across waves 1 and 2 of the PATH study.

RESULTS

Daily e-cigarette users had higher odds of quitting smoking (odds ratio [OR] = 1.56, 95% confidence interval [CI] = 1.12 to 2.18) compared with never e-cigarette users. Conversely, daily and nondaily e-cigarette users were at greater risk of smoking relapse (OR = 1.84, 95% CI = 1.15 to 2.94 and OR = 1.85, 95% CI = 0.99 to 3.46, respectively) compared with never e-cigarette users. Women were less likely to quit smoking compared with men independent of e-cigarette use (OR = 0.76, 95% CI = 0.59 to 0.99). In stratified analyses, daily or nondaily e-cigarette use did not increase the likelihood of quitting or relapse in women. In men, daily and nondaily e-cigarette users were at greater risk of smoking relapse (OR = 2.96, 95% CI = 1.49 to 5.86 and OR = 3.05, 95% CI = 1.29 to 7.17, respectively) compared with men who were never e-cigarette users.

CONCLUSIONS

Findings identify e-cigarettes as a potential aid for smoking cessation but also as a potential risk for smoking relapse in men only. Overall, women were less likely to quit smoking, and e-cigarette use did not impact their ability to quit or to stay quit.

IMPLICATIONS

Cigarette smokers report using e-cigarettes to reduce or quit smoking, but findings are mixed regarding the benefit and risk of e-cigarettes in this population. Using data from the newly available PATH (waves 1 and 2; adult interviews), our findings identify e-cigarettes as a potential aid for smoking cessation but also identify e-cigarettes as a potential risk for smoking relapse in men only. These findings may have implications for the regulation of e-cigarettes by the Food and Drug Administration and the benefit-cost ratio of e-cigarette use in smokers.

Tobacco and electronic cigarette cues for smoking and vaping: an online experimental study

OBJECTIVE

This study examined whether exposure to smoking and vaping cues the urge to smoke or vape. It extends previous studies on first-generation cigalikes (visually similar to cigarettes) and second-generation devices (visually similar to pens) by including third-generation tank system devices (larger bulky units). In an online experiment, participants were randomly assigned to view one of four videos, which included smoking, vaping (cigalike or tank system), or neutral cues. The primary outcome was urge to smoke. Secondary outcomes were urge to vape, desire to smoke and vape, and intention to quit or remain abstinent from smoking.

RESULTS

UK adults varying in smoking (current or former) and vaping (user or non-user) status (n = 1120) completed the study: 184 (16%) failed study attention checks meaning 936 were included in the final analysis. Urges to smoke were similar across cue groups. Urges to vape were higher following exposure to vaping compared to neutral cues. There was no clear evidence of an interaction between cue group and smoking or vaping status. The lack of cueing effects on smoking urges is inconsistent with previous research, raising questions about the ability to assess craving in online settings.

Cue salience of the use of an electronic nicotine delivery system (ENDS) device marketed to women

INTRODUCTION

Passive exposure to the use of electronic nicotine delivery systems (ENDS or e-cigarettes) has been shown to generalize as a smoking cue. As young adult women in particular are increasingly targeted by ENDS distributors, the present study examined whether passive exposure to the use of a female-marketed ENDS product selectively enhanced smoking urge, cigarette and e-cigarette desire, and smoking behavior among women (vs men) smokers.

METHODS

Using a mixed design, young adult smokers (n = 64; mean age 28.2 yrs.; ≥5 cigarettes/day) observed a study confederate drink bottled water (control cue) and then vape a female-marketed tank-based ENDS (active cue). Main measures were the Brief Questionnaire of Smoking Urges (BQSU) and visual analog scales (VAS) for cigarette and e-cigarette desire pre- and post-cue exposure, followed by a smoking latency task.

RESULTS

Compared to the control cue, the female-marketed ENDS cue increased smoking urge and desire for cigarettes and e-cigarettes to a similar extent in women and men. It also affected subsequent smoking behavior similarly between the sexes, with 68% of men and 58% of women opting to smoke (vs. obtaining monetary reinforcers).

CONCLUSIONS

Both women and men were sensitive to the use of the female-marketed ENDS as a smoking cue. Consistent with prior work by our group, findings demonstrate the cue salience of ENDS, which may be attributable to the aspects of vaping that resemble traditional smoking (e.g. hand-to-mouth and inhalation and exhalation behaviors).

Social influence of e-cigarette smoking prevalence on smoking behaviours among high-school teenagers: Microsimulation experiments

The prevalence of electronic cigarette (e-cigarette) use has rapidly increased among young people, while conventional cigarette use has decreased in this age group. However, some evidence suggests that e-cigarette use is likely to induce conventional cigarette smoking. The present study explored the social influence of the prevalence of e-cigarette use in the peer network and in the general population as a potential mechanism by which e-cigarette use affects adolescents’ overall smoking behaviours. For this purpose, we developed an agent-based model in which young agents repeatedly choose to smoke conventional cigarettes and/or e-cigarettes, or to remain non-smokers. The choice is based on the agent’s evaluation of the utility derived from smoking and attitude towards smoking (‘openness’), which is influenced by smoking prevalence in the agent’s peer network and in the broader society. We also assumed a ‘crossover’ effect between the different types of smoking. The model was calibrated with United States National Youth Tobacco Survey data to reflect real-world numbers. We further simulated the prevalence of different types of smoking under counterfactual scenarios with different levels of openness and crossover effects. The models developed successfully reproduced actual prevalence trends in different types of smoking from 2011 to 2014. Openness to smoking is associated with a dramatic increase in e-cigarette smoking and especially in dual smoking, which cancels out the decline in sole conventional smoking. Larger crossover effects are associated with a higher prevalence of conventional smoking. The simulation results indicate that the social influence of the prevalence of e-cigarette use may influence young people to initiate or continue conventional cigarette smoking. Assessing the impact of e-cigarettes in the general population as a ‘healthier’ alternative to conventional smoking may require carefully monitoring trends in young people’s smoking behaviours.

The role of E-liquid vegetable glycerin and exhaled aerosol on cue reactivity to tank-based electronic nicotine delivery systems (ENDS)

RATIONALE

Electronic nicotine delivery systems (ENDS or e-cigarettes) share salient features of combustible smoking, such as inhalation and exhalation behaviors, and evidence indicates that first- and second-generation ENDS generalize as smoking cues. The present study examined whether newer, tank-based third-generation ENDS ("mods") also evoke smoking urges, and whether enhancing the visibility of exhaled aerosol clouds-by increasing the e-liquid vegetable glycerin (VG) content-strengthens the cue salience of ENDS.

OBJECTIVES

The objective was to assess the role of exhaled aerosol clouds on ENDS cue potency using a standardized laboratory paradigm designed to mimic real-world exposures.

METHODS

Using a mixed design, young adult smokers (n = 50; mean age 26.5 years; ≥ 5 cigarettes/day) observed a study confederate drinking bottled water (control cue) and vaping an ENDS mod containing e-liquid with either high (73%) or low (0%) VG. Participants completed the Brief Questionnaire on Smoking Urges (BQSU) and visual analog scales (VAS) assessing cigarette and e-cigarette desire pre- and post-cue exposure.

RESULTS

Increasing the e-liquid content of VG enhanced the size and visibility of the exhaled aerosol clouds and evoked a greater increase in smoking desire and a more sustained increase in e-cigarette desire relative to the low VG cue. Both cues elicited increases in smoking urges. These results remained after controlling for sex, prior ENDS experience, recent smoking behavior, and menthol preference.

CONCLUSIONS

Observation of tank-based ENDS use generalizes as a smoking cue and its cue salience is strengthened by increasing the e-liquid content of VG to enhance the visibility of the exhaled aerosol cloud.

Survey of the effect of viewing an online e-cigarette advertisement on attitudes towards cigarette and e-cigarette use in adults located in the UK and USA: a cross-sectional study

OBJECTIVES

This study explored the potential for e-cigarette advertisements to (1) enhance attitudes towards cigarettes and/or (2) reduce barriers to e-cigarettes uptake. The study tested whether exposure to an online electronic cigarette advertisement changed attitudes towards cigarettes and e-cigarettes in smokers, non-smokers, e-cigarette users and dual users (smokers who also use e-cigarettes).

DESIGN

Cross-sectional study SETTING: Online survey PARTICIPANTS: Adults (n=964) aged 18 to 65 years old (M=36 years, SD=11.6) from the UK and USA. Participants were grouped into current non-smokers, e-cigarette users, dual users and smokers.

INTERVENTIONS

Participants viewed 1 of 15 randomly assigned online e-cigarette advertisements.

PRIMARY MEASURES

Three single seven-point Likert scales measuring health, desirability, social acceptability were completed pre and post advertisement exposure.

RESULTS

Post exposure all smoking groups showed a decrease or no change in how socially acceptable or desirable they rated cigarettes. Paradoxically, dual users rated cigarettes as being significantly healthier after viewing the advertisement (p=0.01) while all other smoking group ratings remained the same. There was an increase or no change in how all smoking groups perceived the healthiness and desirability of e-cigarettes CONCLUSIONS: We observed no evidence that exposure to an e-cigarette advertisement renormalises or encourages smoking in smokers, non-smokers or e-cigarette users. However, there is some indication that viewing an e-cigarette advertisement may increase duals users' perceptions of the health of smoking.

Acute Effects of Heat-Not-Burn, Electronic Vaping, and Traditional Tobacco Combustion Cigarettes: The Sapienza University of Rome-Vascular Assessment of Proatherosclerotic Effects of Smoking ( SUR - VAPES ) 2 Randomized Trial

Background Little clinical research on new-generation heat-not-burn cigarettes ( HNBC ) in comparison with electronic vaping cigarettes ( EVC ) and traditional tobacco combustion cigarettes ( TC ) has been reported. We aimed to appraise the acute effects of single use of HNBC , EVC, and TC in healthy smokers. Methods and Results This was an independent, cross-over, randomized trial in 20 TC smokers, with allocation to different cycles of HNBC , EVC , and TC . All participants used all types of products, with an intercycle washout of 1 week. End points were oxidative stress, antioxidant reserve, platelet activation, flow-mediated dilation, blood pressure, and satisfaction scores. Single use of any product led to an adverse impact on oxidative stress, antioxidant reserve, platelet function, flow-mediated dilation, and blood pressure. HNBC had less impact than EVC and TC on soluble Nox2-derived peptide (respectively, P=0.004 and 0.001), 8-iso-prostaglandin F2α- III ( P=0.004 and <0.001), and vitamin E ( P=0.018 and 0.044). HNBC and EVC were equally less impactful than TCs on flow-mediated dilation ( P=0.872 for HNBC versus EVC ), H2O2 ( P=0.522), H2O2 breakdown activity ( P=0.091), soluble CD 40 ligand ( P=0.849), and soluble P-selectin ( P=0.821). The effect of HNBC and, to a lesser extent EVC , on blood pressure was less evident than that of TC , whereas HNBC appeared more satisfying than EVC (all P<0.05). Conclusions Acute effects of HNBC , EVC, and TC are different on several oxidative stress, antioxidant reserve, platelet function, cardiovascular, and satisfaction dimensions, with TCs showing the most detrimental changes in clinically relevant features. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 03301129.

Patterns of awareness and use of electronic cigarettes in Mexico, a middle-income country that bans them: Results from a 2016 national survey

Among high-income countries, awareness and use of e-cigarettes is lower in countries with more restrictive e-cigarette regulations. Little is known about e-cigarettes in middle-income countries, many of which like Mexico, ban e-cigarette sales and marketing. The current study determined the national-level prevalence and correlates of e-cigarette awareness and consumption in Mexico. Data were analyzed from a 2016 nationally representative survey. Prevalence of e-cigarette awareness, trial and current use was estimated separately for adolescents (n = 12,436), adult nonsmokers (n = 36,966), and adult smokers (n = 7347). For each group, crude and adjusted logistic models regressed e-cigarette outcomes on sociodemographic and smoking-related variables, adjusting for the sampling design and weights. Prevalence varied across subgroups for e-cigarette awareness (adolescents = 45.3%; adult nonsmokers = 33.9%; adult smokers = 54.3%), e-cigarette trial (adolescents = 6.5%; adult nonsmokers = 2.6%; adult smokers = 18.2%) and current use of electronic cigarettes (adolescents = 1.1%; adult nonsmokers = 0.3%; adult smokers = 4.5%). Among adolescents and adults, current smoking and higher smoking frequency were significantly associated with e-cigarette awareness, trial and use. Among adolescents and nonsmokers, awareness, trial and use of e-cigarette were significantly lower among females than males. Among adult smokers, however, females were more likely to use e-cigarettes than males (AOR = 1.80; 95% CI = 1.08-3.02). Higher education and greater wealth increased the likelihood of trial of e-cigarettes among adult nonsmokers and smokers. Despite the ban on the distribution and sales of e-cigarettes, a substantial number of Mexicans, have access to e-cigarettes. Decision makers and advocates should consider e-cigarette regulations as recommended by the WHO, at the same time Mexico must invest in the infrastructure needed to enforce these regulations.

IQOS labelling will mislead consumers

Background

Philip Morris International (PMI) continually expands and diversifies their nicotine product portfolio, which includes IQOS, a heated tobacco product. In December 2016, PMI filed a modified risk tobacco product (MRTP) application with the US Food and Drug Administration (FDA), seeking authorisation to market IQOS in USA with three claims of reduced harm: ‘switching completely from conventional cigarettes to the IQOS system…’ (1) ‘can reduce the risks of tobacco-related diseases;’ (2) ‘significantly reduce[s] your body’s exposure to harmful or potentially harmful chemicals;’ and (3) ‘presents less risk of harm than continuing to smoke cigarettes.’ Consumers may misunderstand what is meant by ‘switching completely'.

Methods

We critically reviewed study reports submitted to FDA by PMI in support of proposed marketing claims in its MRTP application for IQOS and focused on the statement that switching completely to IQOS reduces risk.

Results

We found deficiencies with evidence provided by PMI supporting their assertions that: current smokers will understand what is meant by the phrase ‘switching completely'; the proposed claims will not decrease smokers’ intentions to quit; and IQOS users will in fact ‘switch completely’ from smoking cigarettes to using IQOS. The studies and measurement instruments employed by PMI suffer from design flaws and their reporting of associated findings is misleading.

Conclusion

Consumers will not understand the condition of the claims—that they must quit using cigarettes completely to achieve the inferred health benefits of IQOS. Rather, they are likely to misunderstand the unsupported claims of reduced risks to mean IQOS are harm-free.

When Visual Cues Activate Moral Foundations: Unintended Effects of Visual Portrayals of Vaping within Electronic Cigarette Video Advertisements

Within multimodal persuasive messages, the roles of visual cues in producing unintended effects have been understudied. In an experiment on a sample of former and current smokers (N = 991), we manipulated the presence of visual vaping cues within electronic cigarette video advertisements (N = 25) to evaluate opinions towards vape-free policies. Such cues diminished the effects of pro-vaping arguments to increase support for vape-free policies, inadvertently benefiting public health. Consistent with the moral foundations theory (MFT), endorsement of the care/harm moral foundation strengthened message effects. Furthermore, cognitions and emotions related to moral intuitions mediated the effects of visual vaping cues. These findings suggest that MFT can help explain unintended effects of visual cues when outcomes are related to morality.

Effects of exposure to anti-vaping public service announcements among current smokers and dual users of cigarettes and electronic nicotine delivery systems

INTRODUCTION

Anti-vaping public service announcements (PSAs) are intended to discourage vaping or use of electronic nicotine delivery systems (ENDS). However, vaping portrayals in PSAs may have unintended effects if they increase smoking or vaping urges. This study examined benefits and unintended effects of anti-vaping PSAs with vapor portrayals on smoking and vaping-related outcomes.

METHODS

Young adult smokers (N = 171) and dual users (N = 122) aged 21-30 years were randomly assigned to view: 1) anti-vaping PSAs with vapor; 2) anti-vaping PSAs without vapor; 3) physical activity PSAs; or 4) anti-smoking PSAs with smoking cues. Outcomes were changes in vaping and smoking urges before and after viewing PSAs, post-test vaping and smoking intentions in the next hour, and post-test intention to purchase ENDS and traditional cigarettes.

RESULTS

Smokers only: Exposure to anti-vaping PSAs with vapor (vs. physical activity) was associated with lower intention to vape and to purchase ENDS (ps < 0.001) and lower intention to smoke and purchase cigarettes (ps < 0.05). Exposure to anti-vaping PSAs with vapor (vs. PSAs without vapor and vs. anti-smoking PSAs with smoking cues) was associated with lower intention to vape in the next hour (ps < 0.05). Exposure to anti-vaping PSAs without vapor (vs. physical activity) was associated with lower change in vaping urge (p < 0.05) and intention to purchase ENDS (p < 0.001). Dual users: Exposure to anti-vaping PSAs without vapor (vs. anti-smoking PSAs) was associated with lower intention to purchase ENDS (p < 0.05).

CONCLUSION

Viewing anti-vaping PSAs with vapor was not associated with unintended effects and may have benefits on reducing smoking and vaping-related outcomes.

Glutathione and Inter-α-trypsin inhibitor heavy chain 3 (Itih3) mRNA levels in nicotine-treated Cd44 knockout mice

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Chronic nicotine use that replaces tobacco smoking weakens antioxidant defense.

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Depletion of glutathione by chronic nicotine delivery may compromise liver health.

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Inter-α-trypsin Inhibitor Heavy Chain 3 (Itih3) mRNA correlates with glutathione.

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Nicotine and sex interact with Cd44 signaling in regulation of liver glutathione.

Cluster of differentiation 44 (Cd44), a hyaluronan receptor, and the secreted hyaluronan-binding protein Inter-α-trypsin Inhibitor Heavy chain 3 (Itih3) play an important role in cancer and oxidative stress. Smoking of tobacco reduces Itih3 in the plasma and activates hyaluronan signaling through Cd44, but the impact of Cd44 on Itih3 expression is unknown. Here, we studied changes induced by the tobacco component nicotine on the glutathione (GSH) antioxidant system and Itih3 gene expression in Cd44 knockout mice. Cd44 deficiency decreased baseline total GSH and oxidized glutathione (GSSG) levels in the liver compared to wildtype mice. However, contrary to wildtype mice, chronic oral nicotine administration (200 μg/ml) failed to further reduce total GSH and GSSG in Cd44 mice. Sex differences with lowered glutathione levels in females was also detectable only in wildtype but not Cd44 knockout mice. Itih3 mRNA levels in the liver and hypothalamus were not affected by nicotine, Cd44 genotype or sex. Nonetheless, the correlation between Itih3 and total GSH levels in the liver (r = 0.42, p < 0.05) suggested a role of Itih3 in glutathione metabolism in WT mice. Again this effect was diminished in Cd44 knockout mice. The disappearance of nicotine effects, sex differences and correlations between Itih3 and total GSH in Cd44 knockout mice compared to wildtype animals suggests an interaction between nicotine, Cd44 and/or sex-dependent signaling in the regulation of glutathione metabolism.

Public versus internal conceptions of addiction: An analysis of internal Philip Morris documents

BACKGROUND

Tobacco addiction is a complex, multicomponent phenomenon stemming from nicotine's pharmacology and the user's biology, psychology, sociology, and environment. After decades of public denial, the tobacco industry now agrees with public health authorities that nicotine is addictive. In 2000, Philip Morris became the first major tobacco company to admit nicotine's addictiveness. Evolving definitions of addiction have historically affected subsequent policymaking. This article examines how Philip Morris internally conceptualized addiction immediately before and after this announcement.

METHODS AND FINDINGS

We analyzed previously secret, internal Philip Morris documents made available as a result of litigation against the tobacco industry. We compared these documents to public company statements and found that Philip Morris's move from public denial to public affirmation of nicotine's addictiveness coincided with pressure on the industry from poor public approval ratings, the Master Settlement Agreement (MSA), the United States government's filing of the Racketeer Influenced and Corrupt Organizations (RICO) suit, and the Institute of Medicine's (IoM's) endorsement of potentially reduced risk products. Philip Morris continued to research the causes of addiction through the 2000s in order to create successful potentially reduced exposure products (PREPs). While Philip Morris's public statements reinforce the idea that nicotine's pharmacology principally drives smoking addiction, company scientists framed addiction as the result of interconnected biological, social, psychological, and environmental determinants, with nicotine as but one component. Due to the fragmentary nature of the industry document database, we may have missed relevant information that could have affected our analysis.

CONCLUSIONS

Philip Morris's research suggests that tobacco industry activity influences addiction treatment outcomes. Beyond nicotine's pharmacology, the industry's continued aggressive advertising, lobbying, and litigation against effective tobacco control policies promotes various nonpharmacological determinants of addiction. To help tobacco users quit, policy makers should increase attention on the social and environmental dimensions of addiction alongside traditional cessation efforts.

Do current and former cigarette smokers have an attentional bias for e-cigarette cues?

The similarity of e-cigarettes to tobacco cigarettes with regard to shape and usage raises the question of whether e-cigarette cues have the same incentive motivational properties as tobacco cigarette cues. The objective of the present study was to examine whether e-cigarette cues capture and hold smokers' and former smokers' attention and whether the attentional focus is associated with subsequent craving for tobacco cigarettes. It was also examined whether device type (cigalike or mod) moderated this relationship. Participants (46 current daily smokers, 38 former smokers, 48 non-smokers) were randomly assigned to a device type condition in which their eye-movements were assessed while completing a visual probe task. Craving was assessed before and after the task. Smokers, but not former or non-smokers, maintained their gaze longer on e-cigarette than on neutral pictures ( p = 0.004). No difference in dwell time was found between device type. None of the smoking status groups showed faster initial fixations or faster reaction times to e-cigarette compared with neutral cues. Baseline craving was associated with dwell time on e-cigarette cues ( p = 0.004). Longer dwell time on e-cigarette cues was associated with more favorable attitudes towards e-cigarettes. These findings indicate that e-cigarette cues may contribute to craving for tobacco cigarettes and suggest the potential regulation of e-cigarette marketing.

"Essentially, All Models are Wrong, but Some Are Useful": A Preliminary Conceptual Model Of Co-Occurring E-Cig and Alcohol Use

PURPOSE OF REVIEW

As prevalence rates of electronic cigarette (e-cig) use increase, researchers and clinicians should not only be paying careful attention to the direct health effects of e-cigs, but also the potential impact e-cigs may have on alcohol use behaviors. We review the current state of the literature and propose a conceptual model for the relationship between e-cig and alcohol use, including important consequences, mechanisms, and moderators of this relationship.

RECENT FINDINGS

The model is based in emerging literature examining the direct relationship between e-cig and alcohol use, as well as indirect evidence concerning potential mechanisms from research on cigarette and alcohol use. Overall, research indicates a robust relationship between e-cig and alcohol use.

SUMMARY

We suggest that a relationship between e-cig use and alcohol use could be particularly problematic, especially for adolescents and for those with or at risk for alcohol use disorders. We hope the presented conceptual model can stimulate research in this area. We make research recommendations, including the need for more methodological rigor, including improved measurement of e-cig use, and expanding research to longitudinal and experimental designs.

Influence of legislations and news on Indian internet search query patterns of e-cigarettes

BACKGROUND

There is a paucity of data on the use of electronic nicotine delivery systems (ENDS) in India. In addition, the Indian internet search pattern for ENDS has not been studied. We aimed to address this lacuna. Moreover, the influence of the tobacco legislations and news pieces on such search volume is not known. Given the fact that ENDS could cause oral lesions, these data are pertinent to dentists.

METHODS

Using a time series analysis, we examined the effect of tobacco-related legislations and news pieces on total search volume (TSV) from September 1, 2012, to August 31, 2016. TSV data were seasonally adjusted and analyzed using time series modeling. The TSV clocked during the month of legislations and news pieces were analyzed for their influence on search pattern of ENDS.

RESULTS

The overall mean ± standard deviation (range) TSV was 22273.75 ± 6784.01 (12310-40510) during the study with seasonal variations. Individually, the best model for TSV-legislation and news pieces was autoregressive integrated moving average model, and when influence of legislations and news events were combined, it was the Winter's additive model. In the legislation alone model, the pre-event, event and post-event month TSV was not a better indicator of the effect, barring for post-event month of 2^nd legislation, which involved pictorial warnings on packages in the study period. Similarly, a news piece on Pan-India ban on ENDS influenced the model in the news piece model. When combined, no "events" emerged significant.

CONCLUSIONS

These findings suggest that search for information on ENDS is increasing and that these tobacco control policies and news items, targeting tobacco usage reduction, have only a short-term effect on the rate of searching for information on ENDS.