An Exploration of Smoking-to-Vaping Transition Attempts Using a "Smart" Electronic Nicotine Delivery System

The potential of new nicotine and tobacco products as tools for people who smoke to quit combustible cigarettes - a systematic review of common practices and guidance towards a robust study protocol to measure cessation efficacy

New types of nicotine and tobacco products like electronic cigarettes (ECs), heated tobacco products or nicotine pouches have been discussed as less harmful alternatives to combustible cigarettes and other toxic forms of tobacco products. Their harm reduction potential lay in the efficient transition away from smoking to those new products. Numerous studies addressing the cessation efficacy of ECs have been published with contradictory outcomes. Yet, a comprehensive Cochrane review concluded with high certainty on the cessation efficacy of ECs. This prompted us to perform a review to identify weaknesses in common study designs and to summarize best practices for the study design on the potential of new nicotine products as cessation aids. 120 articles retrieved from Medline were found to be eligible. Most of the studies in the field were interventional trials while observational studies played a minor role in the evaluation of smoking cessation. Efficacy was predominantly assessed for ECs in 77% of the reports while heated tobacco (17%) and non-combustible products (11%) were less frequently investigated up to now. Measures to determine the efficacy were questionnaire-based assessments as well as use documentation/prevalence and abstinence rates. Studies varied largely in their duration and sample size with medians of 3 months and 156.5 participants, respectively.With the help of this review, we identified several weaknesses in the common study designs. One major limitation in longitudinal trials was the lack of compliance measures suited to verify the use status over longer time periods, relying solely on self-reports. Moreover, the motivation of the participants to quit was rarely defined and a profound familiarization period was not taken into account for the majority of the studies. To what extent such weaknesses influence the outcome of the studies was beyond the scope of this review. We encourage researchers to consider the recommendations which resulted from this review in order to determine the abuse liability and cessation efficacy of the products in a more robust manner. Finally, we like to call attention to the missing data for low- and middle-income countries which would require quitting strategies most urgently to combat the tobacco smoking epidemic.

Smoking, vaping and drinking: A qualitative analysis of Aotearoa New Zealand young adults who tried e-cigarettes to stop smoking tobacco

BACKGROUND AND AIM

Social practices such as smoking-drinking co-use often go 'hand-in-hand', linked by the coordination of materials, skills and meanings. However, the experience of using e-cigarettes while drinking among people who smoke (and drink) remains underexplored. We used social practice theory to show how smoking, vaping and drinking intersect and to explain how vaping created two new social practices among people who tried e-cigarettes to stop smoking: 'vaping-drinking' co-use and 'smoking-vaping-drinking' poly-use.

METHODS

We conducted five in-depth interviews over 18-24 weeks during 2018-19, with each of nine Aotearoa New Zealand young adults aged 20-29 years. Participants smoked daily, did not regularly use e-cigarettes at entry and wished to try vaping to stop smoking. We analysed participants' reports of smoking or vaping while drinking using thematic analysis.

RESULTS

Individual participants reported both co-use and poly-use occasions throughout the study. Vaping-drinking co-use arose from practice 'replacement' processes, where vaping fully substituted smoking. Smoking-vaping-drinking poly-use arose from 'adjacency' processes where vaping complemented smoking. Participants used both processes flexibly over time, which required new skills in material, temporal, pleasure and social coordination to try to recreate valued meanings of comfort, security and communality associated with well-established smoking-drinking practices. Unsuccessful coordination attempts maintained smoking-drinking co-use.

CONCLUSION

Among Aotearoa New Zealand young adult smokers who want to use vaping to stop smoking, drinking occasions may help to maintain existing smoking-drinking practices and facilitate the development of vaping-drinking co-use and smoking-vaping-drinking poly-use practices, potentially prolonging individuals' exposure to smoking.

Competitive inhibition of nicotine acetylcholine receptors using microneedles of nicotine and varenicline for smoking withdrawal therapy

Current strategies for smoking withdrawal conditions involve monotherapy of nicotine and combinational therapy of nicotine with varenicline or bupropion as per the CDC and FDA. The available dosage forms for nicotine are patches, gums, inhalers and nasal sprays, bupropion and varenicline are available in tablet form. This research work focused on developing a microneedle delivery system to deliver combination drug for overcoming the obstacles encountered by oral route of administration of varenicline such as severe side effects (mood swings, agitation, depressed behaviour, seizures, etc), and nicotine therapy challenges such as short half-life, repeated dosing, nausea, and vomiting. The nanoparticles of nicotine prepared by nanoprecipitation method showed particle size PTZ (356.6 ± 65.98), percentage entrapment efficiency (35.55 % ± 0.007), in-vitro drug release (47.89 % ± 0.7) for 72 h. Microneedles showed height (600 μm), width (350 μm), and tip diameter (10 μm). The nanoparticles encapsulated in microneedles showed in-vitro sustained delivery of nicotine (67.00 % ± 4.92) and varenicline (79.78 % ± 1.09) in 48 h. Nicotine released in a sustained manner attaches to the nicotine acetylcholine receptors (nAchR) to release dopamine for controlling the withdrawal challenges such as anxiety, irritability, cravings, disturbed sleep pattern, etc. The varenicline released from microneedles binds to the nAchR and inhibits dopamine release responsible for the euphoric effect induced by nicotine, and thus assists in curbing the nicotine withdrawal symptoms. This combination microneedle system offers prolonged treatment in a single application for smoking withdrawal conditions wherein patients are not in stage of oral dosing because of repeated dosing resulting in adverse effects like seizures, hypertension, sleep disturbances, insomnia, and nausea.

Navigating social interactions and constructing vaping social identities: A qualitative exploration with New Zealand young adults who smoke

INTRODUCTION

Social interactions help smoking and vaping practices evolve, and are essential when constructing social identities. Among people who smoke, vaping offers an alternative practice to 'smoking' and 'non-smoking', and using e-cigarettes blurs the boundaries between 'smoker' and 'non-smoker' social identities. In this study, we explored the development of vaping and smoking social identities over time among young adults who smoked and used e-cigarettes.

METHODS

Over 18-24 weeks during 2018-2019, we conducted five interviews with each of 11 New Zealand young adults aged 19-29 years who tried vaping to stop smoking. We analysed participants' interview transcripts for social interactions involving smoking or vaping and used social identity theory to explore their construction of vaping social identities.

RESULTS

Participants entered the study with smoke-free goals, and constructed social identities explicitly in relation to a smoke-free transition. Two key identity processes, 'adopting legitimacy' and 'transferring considerateness', informed participants' social identity construction as they attempted to reconcile their e-cigarette use with their pre-study characterisations of vaping as 'illegitimate' and 'obnoxious'. Our findings suggest that adopting a 'legitimate' vaper identity focussed on smoking cessation, and being perceived and accepted by others as a 'legitimate vaper', were essential in participants' identification as 'vapers'. Identifying as a 'legitimate' vaper was a pre-requisite to transferring a 'considerate' identity from smoking to vaping.

DISCUSSION AND CONCLUSION

Participants' construction of vaping social identities suggests that negotiating and reconciling valued aspects of a smoking social identity with nascent vaping practices may be important during smoking-to-vaping transition attempts.

A new statistical model for longitudinal ecological momentary assessment data on dual use of electronic and combustible cigarettes

Background: Existing studies of dual use of electronic and combustible cigarettes either collected longitudinal data with long gaps in between waves or conducted ecological momentary assessment (EMA) over a short period of time. In recent years, the measurement burst design that embeds an EMA protocol in each wave assessment of a traditional longitudinal study has become more popular and yet conventional generalized linear mixed models (GLMM) have important limitations for handling data from this design.Objectives: This study proposed a new statistical method to analyze data from the measurement burst design.Methods: This new statistical method was designed to model the short-term (within-wave) as well as long-term (between-wave) changes and was validated by a simulation study. Secondary analysis was conducted to analyze data from 205 dual users (52% male) and 146 exclusive smokers (50% male) who participated in a recent study using the measurement burst design.Results: The simulation study shows that the proposed method can handle the gap between waves well and is also robust to nonlinear changes across waves. Although no short-term change in smoking was found, dual users reported a long-term reduction in cigarette use that was more rapid compared to exclusive smokers (β ˆ = - 0.0127 , p = .0167 ). Vaping more was associated with smoking less (β ˆ = - 0.0058 , p = .0054 ).Conclusion: The proposed method is highly applicable as it can be easily implemented by substance use researchers and the results can be straightforwardly interpreted. The results suggest that e-cigarette use may play a role in promoting a long-term reduction in smoking among dual users.

A Descriptive Analysis of Transitions from Smoking to Electronic Nicotine Delivery System (ENDS) Use: A Daily Diary Investigation

OBJECTIVES

We aimed to examine patterns in smoking and electronic nicotine delivery system (ENDS) use over an extended period of time (up to 20 weeks) in people who smoked and who had never previously made a successful quit attempt using an ENDS.

DESIGN AND SETTING

We conducted a longitudinal mixed-methods study in Dunedin, New Zealand, during 2018 and 2019.

PARTICIPANTS

Purposively selected participants (N = 45; age (≥18 years), gender, ethnicities, cigarettes/day) who wished to quit smoking.

INTERVENTIONS

Participants were provided with a second-generation ENDS device (vape pen or starter "tank" device) at the start of their quit attempt, and asked to complete smartphone-based daily diary surveys assessing smoking and ENDS use.

OUTCOME MEASURES

Sunburst plots and a sequence plot were used to describe weekly and daily patterns of smoking and ENDS use (smoking only, ENDS use only, dual use, abstinent).

RESULTS

The most frequently reported movements among participants, classified according to their study week behaviour, occurred between dual use and exclusive ENDS use (and vice versa). A smaller group reported moving from dual use to exclusive smoking (and often back to dual use), and a small number reported moving between abstinence and different ENDS and smoked tobacco usage behaviours. Data visualisations focussing on those participants who had provided data during each of weeks 9-12 indicate that only a minority reported sustained dual use; instead, most participants indicated varied smoked tobacco and ENDS use, which included periods of dual use.

CONCLUSIONS

The considerable variety observed within and between study participants suggests that high variability is typical rather than exceptional. Transitions from smoking to ENDS use may involve considerable periods of dual use, which is likely to be dynamic and potentially sustained over several months.

Assessing Young Adults' ENDS Use via Ecological Momentary Assessment and a Smart Bluetooth Enabled ENDS Device

INTRODUCTION

The assessment of electronic nicotine delivery systems (ENDS) use poses unique challenges that go beyond established assessment methods for tobacco cigarettes. Recent studies have proposed using ecological momentary assessment (EMA), a method to collect self-reported data on mobile devices, or data passively collected by "smart" Bluetooth enabled ENDS to assess use. The current study sought to compare ENDS use data using EMA and puff counts collected from a smart device.

AIMS AND METHODS

We recruited 18 young adult ENDS users (age M = 23.33; 44.4% female) from the San Francisco Bay Area. For a total of 30 days, participants completed daily diaries by EMA and used a second-generation smart Bluetooth enabled ENDS that collected puff data. Repeated measures correlations, multilevel regressions, and paired t tests assessed concordance of EMA reports and ENDS data. A subset of four highly compliant participants were selected for sensitivity analyses.

RESULTS

Among all 18 participants, completion of EMA daily diaries was high (77.4%). The ENDS device collected approximately twice as many puffs per day as participants reported. Compared with self-reported number of sessions and amount of e-liquid used, self-reported puff counts had the highest correlation with device-collected puff counts (rrm = 0.49; p < .001). Correlations between self-reported and device-collected puff counts improved among the subset of four highly compliant participants (rrm = 0.59; p < .001).

CONCLUSIONS

Self-reports potentially underestimate use of ENDS. Puff counts appear to be the best self-reported measure to assess ENDS use compared with number of sessions or liquid volume.

IMPLICATIONS

The comparison of EMA self-reports and passively collected ENDS device data can inform future efforts to assess ENDS use. Self-reported puff counts are preferable over number of sessions or amount of liquid used, but compared with objective usage data, self-reported puff counts may still underestimate actual use. ENDS use behavior is likely higher than users estimate and report. Future research on improved measures of ENDS use is needed.

Characterizing ENDS use in young adults with ecological momentary assessment: Results from a pilot study

INTRODUCTION

Ecological Momentary Assessment (EMA) allows for assessment of electronic nicotine delivery systems (ENDS) use in real-time. This EMA study aimed to 1) describe study participation rates; 2) evaluate the concordance of EMA and survey items measuring frequency and quantity of ENDS use; and 3) assess the relationships between EMA items measuring frequency and quantity of ENDS use with ENDS dependence, measured at baseline and with saliva cotinine collected at follow-up.

METHODS

Fifty young adult ENDS users completed baseline surveys, EMAs (i.e., random, event-based, daily diaries), and follow-up questionnaires over a 14-day period. Spearman correlations were conducted to determine concordance of survey items. Linear regression models assessed the relationships between EMA ENDS use characteristics (e.g., puffs, number of days used, quantity of e-liquid) with dependence items at baseline and saliva cotinine at follow-up.

RESULTS

Overall completion for the prompted EMAs (random and daily diaries) was 68%. Correlations between EMA measures assessing ENDS use ranged from weak (ρ = -0.02; NS) to strong (ρ = 0.69, p < .001); EMA to follow-up items ranged from weak (ρ = 0.16; p < .05) to moderate (ρ = 0.54; p < .001). Significant associations were found between ENDS use measured via random and daily diary EMAs and saliva cotinine at follow-up after controlling for cigarette smoking (B = 0.70-1.76; p < .01), but not for event-based EMAs. Items measuring frequency/quantity of use from random EMAs were consistently associated with ENDS dependence at baseline (B = 0.74-1.58; p < .01).

CONCLUSION

EMA represents a promising methodology to capture real-time ENDS use behaviors, primarily through daily diary and random EMAs.

Methods to reduce the incidence of false negative trial results in substance use treatment research

Treatment development and evaluation for substance use disorders are hindered when randomized controlled trials fail to show a treatment effect when one exists. This manuscript provides an overview of addressable methodological factors that may contribute to incorrect trial results. The collection of remote, naturalistic, real-time adherence and substance use data through ambulatory assessment methods in everyday life is presented as a partial solution. Other recommendations related to participant recruitment and selection, ensuring adequate consistency/fidelity and dose of treatment, and rigorously assessing clinical outcomes are discussed. With implementation of eligibility criteria verification, treatment adherence monitoring, and remote assessment of substance use and biomarkers, ambulatory assessment may help improve clinical trial success rates by improving precision, increasing reproducibility, and reducing the impact of methodological issues that may lead to inaccurate trial results.

Vape Club: Exploring Non-Profit Regulatory Models for the Supply of Vaporised Nicotine Products

Vaporised nicotine products (VNPs) that are not approved as therapeutic goods are banned in some countries, including Australia, Singapore, and Thailand. We reviewed two non-profit regulatory options, private clubs and the Australian Therapeutic Goods Administration Special Access Scheme (SAS) that have been applied to other controlled substances (such as cannabis) as a potential model for regulating VNPs as an alternative to prohibition. The legal status of private cannabis clubs varies between the United States, Canada, Belgium, Spain, and Uruguay. Legal frameworks exist for cannabis clubs in some countries, but most operate in a legal grey area. Kava social clubs existed in the Northern Territory, Australia, until the federal government banned importation of kava. Access to medical cannabis in Australia is allowed as an unapproved therapeutic good via the SAS. In Australia, the SAS Category C appears to be the most feasible option to widen access to VNPs, but it may have limited acceptability to vapers and smokers. The private club model would require new legislation but could be potentially more acceptable if clubs were permitted to operate outside a medical framework. Consumer and regulator support for these models is currently unknown. Without similar restrictions applied to smoked tobacco products, these models may have only a limited impact on smoking prevalence. Further research could explore whether these models could be options for regulating smoked tobacco products.