Vaping in adolescents: epidemiology and respiratory harm

A Qualitative Analysis of How Underage Adolescents Access Nicotine Vaping Products in Aotearoa New Zealand

INTRODUCTION

Despite policies setting a minimum legal sales age, youth continue to access electronic cigarettes (ECs). Evidence of rising youth vaping prevalence in many countries suggests existing measures have serious loopholes and raise important questions about how youth source vaping products.

AIMS AND METHODS

We explored how youth source ECs using in-depth interviews with 30 adolescents aged 16-17 who vaped at least once a month and lived in Aotearoa New Zealand. Our semistructured interview guide probed participants' vaping experiences and how they developed and used social, quasi-commercial, and commercial supply routes to access ECs. We used an inductive reflexive thematic analysis approach to interpret the data.

RESULTS

Nearly all participants shared ECs with peers and sharing was the sole access route for some. Many used proxies, often older relatives or people they knew socially, to purchase ECs on their behalf; however, others recruited proxies by approaching previously unknown people they identified on social media. Participants also sourced ECs via quasi-commercial networks that existed within schools and on social media, and some purchased in their own right, usually from smaller retail outlets that did not ask for ID.

CONCLUSIONS

Disrupting social supply will be challenging, though reducing ECs' availability, appeal, and affordability could make social supply, including sharing and proxy purchasing, more difficult. Reports that youth purchase ECs from commercial retailers known to waive age verification suggest stronger monitoring and enforcement, along with escalating retailer penalties, are required.

IMPLICATIONS

Vaping access routes sit on a continuum from informal, spontaneous sharing to carefully planned commercial purchases. While supply via friends, siblings and other social contacts is an important means of access, nicotine dependence drives some to use riskier access routes, including approaching unknown people to act as proxy purchasers. Evidence young people identify noncompliant retailers suggests policy makers should monitor and enforce existing measures more stringently and consider additional penalties for recidivist underage suppliers. A more comprehensive response that reduces the appeal, addictiveness, affordability, and availability of vaping products would address factors fostering and maintaining youth vaping.

Sex-specific alterations in pulmonary metabolic, xenobiotic and lipid signalling pathways after e-cigarette aerosol exposure during adolescence in mice

BACKGROUND

E-cigarette use is now prevalent among adolescents and young adults, raising concerns over potential adverse long-term health effects. Although it is hypothesised that e-cigarettes promote inflammation, studies have yielded conflicting evidence. Our previous work showed that JUUL, a popular e-cigarette brand, elicited minimal lung inflammation but induced significant molecular changes in adult C57BL/6 mice.

METHODS

Now, we have profiled immunological and proteomic changes in the lungs of adolescent male and female BALB/c and C57BL/6 mice exposed to a flavoured JUUL aerosol containing 18 mg/mL of nicotine for 14 consecutive days. We evaluated changes in the immune composition by flow cytometry, gene expression levels by reverse transcription-quantitative PCR and assessed the proteomic profile of the lungs and bronchoalveolar lavage (BAL) by tandem mass tag-labelled mass spectroscopy.

RESULTS

While there were few significant changes in the immune composition of the lungs, proteomic analysis revealed that JUUL exposure caused significant sex-dependent and strain-dependent differences in lung and BAL proteins that are implicated in metabolic pathways, including those related to lipids and atherosclerosis, as well as pathways related to immune function and response to xenobiotics. Notably, these changes were more pronounced in male mice.

CONCLUSIONS

These findings raise the possibility that vaping dysregulates numerous biological responses in lungs that may affect disease risk, disproportionally impacting males and raising significant concerns for the future health of male youth who currently vape.

Prevalence of Electronic Cigarette Use Among Female Residents of Al-Ahsa, Kingdom of Saudi Arabia: A Cross-Sectional Study

Background Electronic cigarettes (e-cigarettes) have gained considerable popularity on a global scale, with an increasing prevalence among younger adults. The objective of this study was to investigate the prevalence, patterns, and determinants of e-cigarette use among women in Al-Ahsa, Saudi Arabia. Methodology A cross-sectional study was conducted between October 2023 and July 2024 involving 491 adult female participants. The data were collected using a structured questionnaire and subsequently analyzed using SPSS Version 26.0 (IBM Corp., Armonk, NY, USA). Descriptive and inferential statistics, including chi-square tests, were employed to assess relationships between e-cigarette use and various independent variables. Results The prevalence of e-cigarette use among participants was 17.5%. Significant factors associated with e-cigarette use included age (highest among women aged 21 to 30 years, p = 0.038), unemployment (p = 0.011), perceived poor health (p = 0.002), and having friends or family members who use e-cigarettes (p = 0.001). The primary reasons for using e-cigarettes were influence from friends (70.9%) and family members (54.7%), curiosity (33.7%), and appealing flavors (30.2%). A considerable proportion of users reported experiencing dependence and difficulty quitting. Conclusions The prevalence of e-cigarette use among female residents of Al-Ahsa is influenced by a complex interplay of social, demographic, and perceptual factors. The findings underscore the necessity for comprehensive interventions targeting social environments and educational initiatives and addressing misconceptions about the potential risks of e-cigarettes.

Categorizing Vaping Intensity Among Youth

INTRODUCTION

Increasing electronic cigarette use among youth has led to a need for a novel intensity measure of e-cigarette use and its association with nicotine addiction variables.

AIMS AND METHODS

Using a cross-sectional study of the 2018-2019 PATH Wave 5 Youth survey, a new intensity metric of e-cigarette use, the average number of puffs per month as a function of frequency (days of use per month), number of uses per day and number of puffs per use, was developed for adolescent e-cigarette users. Using logistic regression, standard addiction measures were tested for association with higher quartile (Q) of e-cigarette intensity: Q1 (1-5 puffs), Q2 (6-50 puffs), Q3 (51-528 puffs), and Q4 (529 + puffs).

RESULTS

Among 1051 current youth e-cigarette users, cravings were associated with greater intensity of use (Q2: aOR = 1.90, 95% CI: 0.94-3.87; Q3: aOR = 6.91, 95% CI: 3.25-14.69; and Q4: aOR = 21.48, 95% CI: 10.03-45.97). Craving associations exceeded the corresponding aORs for the identical regression using the frequency of use. Higher intensity was significantly associated with being an older adolescent (aOR = 1.85), best friend use (aOR: 3.35), not thinking about quitting (aOR: 2.51), and lower perceived addiction (aOR: 1.95).

CONCLUSIONS

This study found that an intensity metric (puffs per month) was strongly associated with cravings, best friend use, harm perception, and lack of intention to quit. This metric provides a more accurate picture of the intensity of youth e-cigarette use than other commonly used measures and may be important for understanding the current and future impact of the youth e-cigarette epidemic.

IMPLICATIONS

Adolescent addiction to e-cigarettes affects learning, memory, and attention. However, it is unknown whether the intensity of use, puffs per month, differs from frequency, days of use per month, and in relation to addiction measures. This study provides evidence that high-intensity use characterized by puffs per month has a stronger association with cravings compared to frequency, which suggests puffs per month may be a better measure of nicotine exposure. This new intensity metric may give insights into youth e-cigarette use patterns, addiction, and appropriate treatment of intense but intermittent users.

Knowledge, Perception, and Associated Factors of Electronic Cigarette Consumption Among the Saudi Population in Jeddah City

Introduction Electronic cigarettes (e-cigarettes) are rising in popularity among young adults and teenagers. Previous studies have shown that among high and middle schoolers, the percentage of e-cigarette smokers was noticeably higher than tobacco cigarette smokers. Various research papers focusing on different communities have reported a low-to-moderate level of knowledge and awareness of e-cigarette's effects on health. E-cigarettes were initially advertised as devices to help people quit smoking, but the use of e-cigarettes in modern days has changed considerably. A big chunk of the population perceived that e-cigarettes have no harmful effects because they are nicotine-free and thus are used as a replacement for regular cigarettes rather than as a way to quit smoking. Objectives The study aimed to assess the perception of e-cigarette consumption and associated factors among the Saudi population in Jeddah city. Methodology A cross-sectional study was conducted on the Saudi population in Jeddah, Saudi Arabia, during the year 2023. The study assessed the participant's perceptions of e-cigarette consumption and its risk factors. A pre-existing online questionnaire created by Google Forms was distributed among the population through social media applications to collect data after obtaining their informed consent. Results A total of 515 participants were included in this study. Relatives and friends were the most common sources (54%) for information about e-cigarettes. Of the sample, 17.5% thought that e-cigarettes were safer than conventional cigarettes, 13.4% used e-cigarettes on a regular basis, and 65% had not smoked electronically before. Vaping pushed only 17.2% to try traditional tobacco cigarettes, and 25% stopped using traditional tobacco products after starting to smoke e-cigarettes. Gender, age group, and total family salary were the associated factors with the use of e-cigarettes. In addition, an association between the perception of e-smoking and its use was noticed, as well as a significant association between gender and withdrawal symptoms. Conclusion A minority of the participants perceived that e-cigarette smoking is safer than conventional methods of smoking. The majority did not practice e-smoking at all. Furthermore, results showed that relatives and friends were the most common sources of information. The findings from the correlation testing underscore several noteworthy associations within the studied population. Notably, gender, age, total family salary, and occupation exhibited statistically significant correlations with e-cigarette usage.

The effect of smoking on 30-day complications following primary repair of Achilles tendon ruptures

PURPOSE

There exists a gap in the knowledge of the impact of smoking on Achilles tendon rupture repair. This study evaluates perioperative and postoperative complications associated with smoking to allow for a more informed evaluation and discussion with the patients when considering the surgical management of Achilles tendon repair in this patient population.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing Achilles tendon rupture repair from 2006 to 2019. Two patient cohorts were defined in this retrospective study: smokers and patients who did not smoke. The various patient demographics, medical comorbidities, and postoperative outcomes were compared using bivariate and multivariate analyses between the smoking and non-smoking groups.

RESULTS

Of 4209 patients who underwent Achilles tendon repair, 3662 patients (87%) did not smoke, whereas 547 patients (13%) were smokers. Patients who were smokers were more likely to be younger and have a higher body mass index. Following multivariate analyses, those who smoked had an increased risk of experiencing wound dehiscence (OR 3.57; p = 0.013) and urinary tract infections (OR 1.21; p = 0.033) compared to non-smoking patients.

CONCLUSION

Despite the rate of complications being relatively low in the short-term perioperative period, individuals who smoke should be counseled on the surgical risks they may experience following Achilles tendon repair, including wound dehiscence and urinary tract infections. Discussion preoperatively between the physician and patient who smoke can include ways in which postoperative care will be done to minimize the risk of adverse events, ultimately reducing costs for both the patient and the hospital.

Sociodemographic differences in use of nicotine, cannabis, and non-nicotine E-cigarette devices

BACKGROUND

Sociodemographic differences in e-cigarette use have been documented; however, disparities in use of specific e-cigarette types with various ingredients have yet to be thoroughly investigated. This study examines ever- and past-30-day-use of nicotine, cannabis, and non-nicotine e-cigarette device types by sex, sexual orientation, race/ethnicity, and financial comfort.

METHODS

Data were drawn from a 2021 national cross-sectional survey of adolescents, young adults, and adults (N = 6131, ages 13-40 years old). Participants reported ever and past-30-day-use of (1) disposable nicotine e-cigarettes, (2) pod/cartridge-based nicotine e-cigarettes, (3) "other" nicotine e-cigarettes, (4) non-nicotine e-cigarettes, (5) e-cigarettes with THC, and (6) e-cigarettes with CBD. We constructed summary tables for each e-cigarette device type in which percentages of ever and past-30-day-use were calculated by birth year category and sociodemographic variables: (a) sex, (b) sexual orientation, (c) race/ethnicity, and (d) financial comfort.

RESULTS

Females born between 1996 and 2008 reported higher rates of past-30-day disposable e-cigarette use relative to males (females 26.4%; males 22.4%). Compared to their heterosexual counterparts, LGBTQ+ participants reported higher overall rates of past-30-day-use for disposable (LGBTQ+ 27.9%; Heterosexual 23.8%), THC (LGBTQ+ 30.8%; Heterosexual 24.1%), and CBD e-cigarettes (LGBTQ+ 20.0%; Heterosexual 16.9%). Hispanic/Latino participants generally reported higher rates of past-30-day-use across device types relative to those identifying as Black or White non-Hispanic, particularly disposable nicotine e-cigarettes.

CONCLUSIONS

Findings highlight sociodemographic disparities in e-cigarette use, though differences varied based on e-cigarette device type and participant birth year category. Tailored preventive efforts may be necessary to mitigate e-cigarette use among populations at highest risk.

Interventions for Preventing E-Cigarette Use Among Children and Youth: A Systematic Review

INTRODUCTION

Many nonregulatory interventions targeting children and youth have been implemented at three levels: directed at the individual (e.g., interactive video games), delivered to students at school (e.g., campus bans), and launched in the community (e.g., mass media campaigns). This systematic review aims to synthesize the evidence on the effectiveness of interventions aimed at preventing e-cigarette initiation among children and youth.

METHODS

MEDLINE, CINAHL, Embase, APA PsycINFO, and Web of Science Core Collection were searched for papers published between January 1, 2004 and September 1, 2022 that reported more than one outcome on vaping prevention among individuals aged less than 21-years-old: vaping prevalence/incidence, initiation intentions, knowledge/attitudes, and other tobacco product use prevalence/initiation intentions. Interventions were at the individual, school, or community level. The risk of bias was assessed using ROBINS-I and RoB 1.

RESULTS

Thirty-nine publications met the eligibility criteria. Fourteen individually-based (4 parental monitoring, 3 video games, 2 text messages, 3 graphic message themes, 2 healthcare), 19 school-based (14 educational and skill interventions, 5 vape-free policies/bans), and 6 community-based (3 social media, 3 mass media campaigns) interventions were reported. E-cigarette initiation prevention was observed with high perceived parental monitoring; however, the cross-sectional study designs precluded causal claims. There was promising but limited evidence that social-emotional skills curricula and peer leader programming prevented vaping initiation.

DISCUSSION

Some individual- and school-based interventions showed promise for preventing e-cigarette initiation among children and youth.

Youth Exposure and Response to the FDA Health Warning Label on Electronic Cigarettes Packaging: Policy Implications

INTRODUCTION

Youth represent a high-priority group for e-cigarette health communication. This study examined youth exposure to the Food and Drug Administration (FDA) e-cigarette warning label over 4 years and its association with change in youth harm perception and intention.

AIMS AND METHODS

We pooled data from the 2018-2021 National Youth Tobacco Survey (age 10-17; n = 67 159). Participants were divided into four groups: never users (58.5%), susceptible nonusers (16.3%), former users (12.7%), and current users (12.5%). We examined the prevalence, time-trend, correlates, and association of youth exposure to the warning with addictiveness and harm perception, intention to use e-cigarettes, and intention to quit all tobacco products.

RESULTS

Only 24.5% of youth were exposed to the warning. Exposure increased from 14.9% in 2018 to 30.8% in 2019, then declined to 25.2% in 2021. Hispanic (adjusted odds ratio (aOR) = 0.76 [95% CI = 0.641 to 0.89]) and non-Hispanic black current users (0.53 [0.40 to 0.69]) were less likely to be exposed to the warning than white current users. Youth exposure was positively associated with a higher perception of e-cigarette addictiveness (1.12 [1.04 to 1.19]) and intention to quit all tobacco products (1.28 [1.13 to 1.46]). However, exposure was negatively associated with harm perception (0.91 [0.85 to 0.96]) and the intention to use e-cigarettes among e-cigarette nonusers (2.38 [1.99 to 2.84]).

CONCLUSIONS

The decline in youth exposure to the warning indicates wear-out effects. Strengthening the label by using compelling designs, adding themes on e-cigarette harm to youth, periodically rotating warning content, and using culturally tailored messaging may improve its impact on youth and address racial/ethnic disparities.

IMPLICATIONS

The FDA e-cigarette label reached only 24.5% of youth, and exposure to the warning declined to indicate wear-out effects. Exposure was significantly lower among minorities. Exposure was associated with a higher perception of e-cigarette addictiveness and intention to quit all tobacco products. Still, it did not increase harm perception or reduce intention to use e-cigarettes among nonusers. Strengthening the label by using more compelling designs, including diverse themes focusing on e-cigarette harm relevant to youth, and periodically rotating warning content may improve its impact on youth. Continued surveillance of the implementation of e-cigarette policies is needed to ensure that they equally affect youth across racial/ethnic subpopulations.

Development of transtheoretical model measures for assessing decisional balance and temptation to vape

Introduction: Vaping is common among young adults in the United States. The Transtheoretical Model (TTM) has demonstrated success in smoking cessation efforts; however, it has not been comprehensively applied to vaping cessation, and core TTM vaping measures have not been developed. Method: A cross-sectional survey including measures of stage of change (SOC), temptation to vape, and decisional balance (DCBL) was disseminated (n = 459). Items were adapted from TTM smoking scales. The sample was split for exploratory and confirmatory factor analyses (EFA/CFA). Analyses of variance assessed relationships between constructs and SOC. Results: EFA/CFA resulted in one Temptation scale (CFI = .95; α = .87) and two DCBL scales (CFI = .91; Pros α = .72; Cons α = .72). Temptation to vape and Pros of vaping decreased significantly across SOC, while Cons increased significantly. Conclusions: TTM vaping measures for two key TTM constructs were developed utilizing a college sample. Results suggest that the developed measures map well onto the TTM framework.

E-cigarette Use Among Community-Recruited Adults with a History of Asthma in North Central Florida

Use of e-cigarettes have become an important public health concern in the US, particularly among those with health issues like asthma, which has remained high over the last decade. We examined associations between lifetime e-cigarette use and traditional cigarette use, cannabis use, and related health factors among community members with a history of asthma in North Central Florida. Data came from HealthStreet, a University of Florida community engagement program. Adults with a history of asthma (n = 1,475) were interviewed between 2014 and 2021. Bivariate and logistic regression analyses were conducted to examine differences between participants with and without a history of lifetime e-cigarette use. In this sample, lifetime prevalence of e-cigarette use was 19.9%. Over half of the sample reported ever smoking traditional cigarettes (54.4%) or cannabis (55.4%). Compared to those who identified as White, those who identified as Black/African American had lower odds for lifetime e-cigarette use (aOR = 0.30, 95% CI: 0.22, 0.42). Those reporting lifetime traditional cigarette use (aOR = 10.60, 95% CI: 6.93, 16.68) or cannabis use (aOR = 1.81, 95% CI: 1.27, 2.61) had higher odds for reporting lifetime e-cigarette use. Overall, among a community sample of adults with a history of asthma, nearly a fifth reported lifetime e-cigarette use. The use of e-cigarettes was most common among those with lifetime traditional cigarette use and cannabis use. Findings can inform prevention and intervention efforts in this population.

Impact of Vaping on Lungs: An Indian Prospect

Electronic cigarettes, or vape pens, have gained popularity among young people due to their attractive appearance, but they also have numerous side effects. These devices come in various shapes, sizes, and costs, with many brands and various flavors to choose from. As of now, there are around 2,807 people hospitalized in the United States due to vaping. Electronic cigarettes are illegal in many countries, with laws varying from country to country. The health service has been criticized for the implementation of the ban, with states implementing month-long drives and submitting reports. The Indian Police have also conducted raids and arrested five individuals under the 2019 ban on Electronic Cigarettes (Production, Manufacture, Trade, Transport, Sale, Distribution, Storage, and Advertisement) Act. The history of vapes can be traced back to the invention of the first electric vaporizer in 1927 by Joseph Robinson. Other pioneers like Herbert Gilbert and Jed Rose developed nicotine fixes using refined smoke. The vape was made in 2003 by Chinese smoker Hon Lik, who created the device as a better option to traditional smoking.

Effects of Nicotine on the Central Nervous System and Sleep Quality in Relation to Other Stimulants: A Narrative Review

Nicotine is used extensively across the globe despite the common awareness of the fact that it might stimulate the neurological system in those who indulge in its consumption. Nicotine can be consumed in a wide number of various forms and can also be delivered in a wide variety of different ways. After it has been heated, it can be smoked, consumed sublingually, or brought into touch with mucosal surfaces, with the buccal mucosa being the most popular one. These three methods of consumption account for the vast majority of its use. It has been demonstrated without a reasonable doubt that people who partake in nicotine do, in fact, experience an increase in their levels of alertness, wakefulness, attention, and focus. The half-life of the substance, in addition to its effects, is highly variable depending on the forms in which it is consumed, viz. cigarettes, tobacco, gums, lozenges, and the manner in which it is administered. This is the case regardless of whether the chemical is administered orally or intravenously. It is common for a person to require multiple "hits" of the chemical throughout the course of the day, though the frequency of these needs and the intervals between them can vary greatly. The time interval between each of these "hits" can range anywhere from a few hours to a few minutes. The user has the potential to develop a tolerance to the neurostimulatory and systemic effects of nicotine, as well as a heightened sensitivity to those effects, and even hereditary predispositions to specific adverse consequences. There is also a possibility that the user will develop an addiction to nicotine. This literature review aims to explore the relationship between nicotine consumption and its effects on the central nervous system, especially on sleep.

Analysis of illicit drugs in purchased and seized electronic cigarette liquids from the United Kingdom 2014-2021

Increasing popularity and known shortfalls in the regulation of electronic cigarettes (ECs) emphasises the urgent need for closer content monitoring and for comprehensible information on their possible health effects. This study investigated components of EC liquids in samples submitted from 2014 to 2021 and discussed the trends driven by legislation changes. Samples originating from prisoners, teenagers and 'test purchases' of commercially available ECs were analysed by gas chromatography-mass spectrometry (GC-MS). For those containing delta-9-tetrahydrocannabinol (THC) and/or cannabidiol (CBD), the content of these components was quantified by liquid chromatography with quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) to show variation of these compounds in EC liquids; 112 EC liquids were included in this study. Nicotine was detected in 87 (78%) of the EC liquids analysed. Twenty-two, including samples from before and after introduction of the UK Psychoactive Substances Act (2016), contained one or more synthetic cannabinoid receptor agonist (SCRA). THC was detected in only 11 samples, whereas a single sample was found to contain CBD only. Six samples contained a mixture of THC and CBD. In all cases where information was available, the THC/CBD content was less than that stated on the product label. The data collected showed great variation in EC liquid content. Therefore, it is important that users are educated regarding risks associated with EC use. Additionally, substances now controlled under both the UK Misuse of Drugs Act and Psychoactive Substances Act were present. These substances each carry a potential risk to health, which is possibly exacerbated if multiple compounds are inhaled concomitantly.

The genitourinary impacts of electronic cigarette use: a systematic review of the literature

PURPOSE

Electronic cigarette (e-cig) use is prevalent. The health implications of e-cig use on the genitourinary (GU) system are uncertain. This systematic review aims to evaluate how e-cig use impacts the GU system.

METHODS

A systematic search was conducted in PubMed, Embase and Ovid alongside citation searching. Review articles, non-English papers, animal model/cell line studies or articles only on combustible cigarettes were excluded. Quality assessment was undertaken using the Joanna Briggs Institute checklists. The primary endpoint was the impact of e-cig use on bladder cancer incidence. Secondary outcomes included urinary carcinogens, chronic kidney disease (CKD), reproductive disorders, and other GU diseases.

RESULTS

The search yielded 244 articles, 28 were ultimately included. One study assessed risk of bladder cancer and found the use of e-cig was associated with an increased odds ratio of 1.577 for its diagnosis. Twenty-one articles measured potential urinary carcinogens-including crotonaldehyde and benzene-associated with bladder cancer. Two articles evaluated the association of e-cig use with CKD and reported mixed outcomes. Three articles reported on reproductive disorders, specifically, stuttering priapism and changes to sperm quantity and quality. One study reported on other GU diseases, specifically burns to the GU system. After quality assessment, all articles were deemed to be of acceptable quality for inclusion.

CONCLUSIONS

E-cig use was associated with an increased risk of bladder cancer, increased exposure to carcinogenic compounds, mixed evidence on CKD, increased risk of reproductive disorders and burns to the GU system. Further studies are needed to understand long-term GU effects.

How do underage youth access e-cigarettes in settings with minimum age sales restriction laws? A scoping review

BACKGROUND

Despite measures to reduce young people's access to electronic cigarettes (ECs), or "vapes", many countries have recorded rising youth vaping prevalence. We summarised studies documenting how underage youth in countries with minimum age sales restrictions (or where sales are banned) report accessing ECs, and outline research and policy implications.

METHODS

We undertook a focused literature search across multiple databases to identify relevant English-language studies reporting on primary research (quantitative and qualitative) and EC access sources among underage youth.

RESULTS

Social sourcing was the most prevalent EC access route, relative to commercial or other avenues; however, social sourcing dynamics (i.e., who is involved in supplying product and why) remain poorly understood, especially with regard to proxy purchasing. While less prevalent, in-person retail purchasing (mainly from vape shops) persists among this age group, and appears far more common than online purchasing.

CONCLUSIONS

Further research examining how social supply routes operate, including interaction and power dynamics, is crucial to reducing youth vaping. Given widespread access via schools and during social activities and events, exploring how supply routes operate and evolve in these settings should be prioritized. Inadequate compliance with existing sales regulations suggest greater national and local policy enforcement, including fines and licence confiscation for selling to minors, is required at the retailer level.

Vaping, Environmental Toxicants Exposure, and Lung Cancer Risk

Lung cancer (LC) is the second-most prevalent tumor worldwide. According to the most recent GLOBOCAN data, over 2.2 million LC cases were reported in 2020, with an estimated new death incident of 1,796,144 lung cancer cases. Genetic, lifestyle, and environmental exposure play an important role as risk factors for LC. E-cigarette, or vaping, products (EVPs) use has been dramatically increasing world-wide. There is growing concern that EVPs consumption may increase the risk of LC because EVPs contain several proven carcinogenic compounds. However, the relationship between EVPs and LC is not well established. E-cigarette contains nicotine derivatives (e.g., nitrosnornicotine, nitrosamine ketone), heavy metals (including organometal compounds), polycyclic aromatic hydrocarbons, and flavorings (aldehydes and complex organics). Several environmental toxicants have been proven to contribute to LC. Proven and plausible environmental carcinogens could be physical (ionizing and non-ionizing radiation), chemicals (such as asbestos, formaldehyde, and dioxins), and heavy metals (such as cobalt, arsenic, cadmium, chromium, and nickel). Air pollution, especially particulate matter (PM) emitted from vehicles and industrial exhausts, is linked with LC. Although extensive environmental exposure prevention policies and smoking reduction strategies have been adopted globally, the dangers remain. Combined, both EVPs and toxic environmental exposures may demonstrate significant synergistic oncogenicity. This review aims to analyze the current publications on the importance of the relationship between EVPs consumption and environmental toxicants in the pathogenesis of LC.

Pneumomediastinum in Vaping-Associated Acute Lung Injury: An Unusual Presentation

The use of vaping products among adolescents continues to be on the rise despite known health risks. As a result, there are increasing cases of E-cigarette or vaping product use-associated lung injury (EVALI) across the United States especially among male Caucasian users of vaping products. The clinical presentation of EVALI follows the classic pattern of acute lung injury; however, there are peculiar cases with unusual symptomatology and radiographic findings. In this report, we present a case of a 25-year-old male with hemoptysis, subcutaneous emphysema, and pneumomediastinum in the setting of EVALI. He was treated with nebulized tranexamic acid and methylprednisolone with the resolution of symptoms. The diagnostic workup and management of suspected EVALI are discussed in detail. This case highlights how EVALI can present in an atypical manner and why clinicians must be cognizant of the variations in manifestations in order to facilitate early management. Overall, this case further highlights the need for clinicians to continuously push against the use of vaping products in the adolescent group, given that the occurrence of acute lung injury at a younger age predisposes to early-onset chronic lung disease.

Electronic Cigarette Prevalence and Knowledge Among Medical Students in Saudi Arabia and Bahrain: A Cross-National Study

Background Electronic cigarettes (e-cigarettes and vapour devices) are the most commonly used form of alternative tobacco products (ATPs). The use of these vapour devices has been dramatically increasing worldwide, especially among current and former traditional cigarette smokers. A strong influence that will affect patients' health attitudes and play a crucial role in tobacco control and smoking cessation are medical students, as they are future physicians. Therefore, in our study, we aimed to determine the prevalence rate of e-cigarettes and the level of knowledge among medical students in Saudi Arabia and Bahrain. Methods  We conducted a cross-sectional study of medical students in Saudi Arabia and Bahrain using an online survey. This was distributed through social media platforms such as Twitter, WhatsApp, Telegram, and Facebook. Medical students of all years were included. The questionnaire was adapted from two previous studies. Results  The study enrolled 1730 medical students. The majority of the participants did not recommend the use of e-cigarettes as a method for smoking cessation or believed that these types of ATPs lower the risk of cancer in comparison with traditional cigarettes. The data showed a strong association between gender and e-cigarette smoking, with the majority of current smokers being men (n = 184) and experimental smokers being women (n = 800). Moreover, an educational gap was discovered, as few of the students had received an education in their medical school's curriculum on the use of e-cigarettes. There was a significant association between receiving an education at a medical school and having adequate knowledge of e-cigarettes. Conclusion  The increasing number of e-cigarette users among medical students is concerning. Our study showed that students are not receiving a decent education on the use of ATPs during medical school, which urges further adjustment of the curriculum. This will play a huge role in their behaviour and the provision of future treatment plans to patients as physicians.

Pulmonary immune response regulation, genotoxicity, and metabolic reprogramming by menthol- and tobacco-flavored e-cigarette exposures in mice

Menthol and tobacco flavors are available for almost all tobacco products, including electronic cigarettes (e-cigs). These flavors are a mixture of chemicals with overlapping constituents. There are no comparative toxicity studies of these flavors produced by different manufacturers. We hypothesized that acute exposure to menthol and tobacco-flavored e-cig aerosols induces inflammatory, genotoxicity, and metabolic responses in mouse lungs. We compared two brands, A and B, of e-cig flavors (PG/VG, menthol, and tobacco) with and without nicotine for their inflammatory response, genotoxic markers, and altered genes and proteins in the context of metabolism by exposing mouse strains, C57BL/6J (Th1-mediated) and BALB/cJ (Th2-mediated). Brand A nicotine-free menthol exposure caused increased neutrophils and differential T-lymphocyte influx in bronchoalveolar lavage fluid and induced significant immunosuppression, while brand A tobacco with nicotine elicited an allergic inflammatory response with increased Eotaxin, IL-6, and RANTES levels. Brand B elicited a similar inflammatory response in menthol flavor exposure. Upon e-cig exposure, genotoxicity markers significantly increased in lung tissue. These inflammatory and genotoxicity responses were associated with altered NLRP3 inflammasome and TRPA1 induction by menthol flavor. Nicotine decreased surfactant protein D and increased PAI-1 by menthol and tobacco flavors, respectively. Integration of inflammatory and metabolic pathway gene expression analysis showed immunometabolic regulation in T cells via PI3K/Akt/p70S6k-mTOR axis associated with suppressed immunity/allergic immune response. Overall, this study showed the comparative toxicity of flavored e-cig aerosols, unraveling potential signaling pathways of nicotine and flavor-mediated pulmonary toxicological responses, and emphasized the need for standardized toxicity testing for appropriate premarket authorization of e-cigarette products.

The role of insufficient sleep and circadian misalignment in obesity

Traditional risk factors for obesity and the metabolic syndrome, such as excess energy intake and lack of physical activity, cannot fully explain the high prevalence of these conditions. Insufficient sleep and circadian misalignment predispose individuals to poor metabolic health and promote weight gain and have received increased research attention in the past 10 years. Insufficient sleep is defined as sleeping less than recommended for health benefits, whereas circadian misalignment is defined as wakefulness and food intake occurring when the internal circadian system is promoting sleep. This Review discusses the impact of insufficient sleep and circadian misalignment in humans on appetite hormones (focusing on ghrelin, leptin and peptide-YY), energy expenditure, food intake and choice, and risk of obesity. Some potential strategies to reduce the adverse effects of sleep disruption on metabolic health are provided and future research priorities are highlighted. Millions of individuals worldwide do not obtain sufficient sleep for healthy metabolic functions. Furthermore, modern working patterns, lifestyles and technologies are often not conducive to adequate sleep at times when the internal physiological clock is promoting it (for example, late-night screen time, shift work and nocturnal social activities). Efforts are needed to highlight the importance of optimal sleep and circadian health in the maintenance of metabolic health and body weight regulation.

Content Analysis of YouTube Videos Related to E-cigarettes and COVID-19

INTRODUCTION

E-cigarettes are frequently promoted on social media and portrayed in ways that are attractive to youth. While COVID-19 pandemic significantly affected people's lives, less known is how the pandemic influenced e-cigarette-related marketing and information on social media. This study identifies how e-cigarettes are portrayed during the COVID-19 pandemic on YouTube, one of the most popular social media platforms.

METHODS

We searched for combinations of search terms related to e-cigarettes (i.e., "electronic cigarette", "e-cigarette", "e-cig", "vape" and "vaping") and COVID-19 (i.e., "corona", "COVID", "lockdown" and "pandemic"). To be included in the analysis, the video must be: uploaded after February 1, 2020, in English, related to e-cigarettes and COVID-19 and less than 30 minutes in length. We assessed video themes related to e-cigarettes and COVID-19, uploader characteristics, and featured e-cigarette products.

RESULTS

We examined N=307 videos and found that N=220 (73.6%) were related to the health effects of e-cigarette use on COVID-19, followed by videos of how COVID-19 affects e-cigarette access/sales (N=40, 12.9%), and face mask-related videos (N=16, 5.1%) which included content regarding masks and e-cigarette use. Instructional videos on how to modify e-cigarettes to use with masks had the highest number of likes (Median=23; IQR=32) and comments (Median=10; IQR=7).

CONCLUSIONS

This study identified various e-cigarette contents on YouTube during the COVID-19 pandemic. Our findings support the need for continuous surveillance on novel vaping-related content in reaction to policies and events such as the global pandemic on social media is needed.

The association of amygdala-insula functional connectivity and adolescent e-cigarette use via sleep problems and depressive symptoms

BACKGROUND

Adolescent electronic cigarette (e-cigarette) use remains high. Elucidating contributing factors may enhance prevention strategies. Neurobiologically, amygdala-insula resting-state functional connectivity (rsFC) has been linked with aspects of sleep, affect, and substance use (SU). As such, we hypothesized that amygdala's rsFC with the insula would be associated with e-cigarette use via sleep problems and/or depression levels.

METHODS

An adolescent sample (N = 146) completed a rs-fMRI scan at time 1 and self-reports at time 2 (∼15 months later). Given consistent associations between mental health outcomes and the rsFC of the laterobasal amygdala (lbAMY) with the anterior insula, we utilized a seed region (lbAMY) to region of interest (ROI) analysis approach to characterize brain-behavior relationships. Two serial mediation models tested the interrelations between amygdala's rsFC with distinct anterior insula subregions (i.e., ventral insula [vI], dorsal insula [dI]), sleep problems, depression levels, and days of e-cigarette use.

RESULTS

An indirect effect was observed when considering the lbAMY's rsFC with the vI. Greater rsFC predicted more sleep problems, more sleep problems were linked with greater depressive symptoms, and greater depressive symptoms were associated with more e-cigarette use (indirect effect = 0.08, CI [0.01,0.21]). Indicative of a neurobiological dissociation, a similar indirect effect linking these variables was not observed when considering the lbAMY's rsFC with the dI (indirect effect = 0.03, CI [-0.001,0.10]).

CONCLUSIONS

These outcomes highlight functional interactions between the amygdala and insula as a neurobiological contributor to sleep problems, depressive symptoms, and ultimately SU thereby suggesting potential intervention points to reduce teen e-cigarette use.

Co-substance use of nicotine vaping and non-cigarette tobacco products among U.S. grade 12 students from 2017-2019

Background

Nicotine vaping among U.S. adolescents has risen rapidly over the past decade, particularly for youth in grade 12. While previous studies examined the relationship between nicotine vaping and combustible cigarette use, less is known about the co-occurrence between vaping and other tobacco products.

Methods

Using Monitoring the Future grade 12 data (2017-2019), we investigated associations between past 30-day nicotine vaping and non-vaping, non-cigarette tobacco use (smokeless tobacco, large cigars, cigarillos, hookah). Population prevalences of four categories were assessed: neither, vaping only, non-vaping of non-cigarette tobacco only, or both. We further investigated these relationships with logistic regressions accounting for the complex survey design (unadjusted, demographic-adjusted, and further adjusted for other substance use). Finally, analyses were stratified by combustible cigarette use.

Results

Depending on the non-cigarette tobacco product, 2.5% to 5.4% of grade 12 students vaped nicotine and used a non-cigarette tobacco product. Controlling for demographics, cigarillo use was associated with nicotine vaping (adjusted RR = 3.44, 95% CI: 3.08, 3.84), as was hookah use (aRR = 3.51, 95% CI: 2.92, 4.23), smokeless tobacco (aRR = 2.97, 95% CI: 2.51, 3.52), and cigar use (aRR = 2.90, 95% CI: 2.49, 3.37). Controlling for cannabis and all non-cigarette tobacco products simultaneously attenuated associations. Associations were stronger among students who did not use cigarettes.

Discussion

Nicotine vaping is associated with use of many non-cigarette tobacco products, including smokeless tobacco, cigarillos, cigars, and hookah. As prevalence of nicotine vaping remains high among adolescents, we should monitor co-use of vaping and other tobacco products.

Cross-sectional online survey of clinicians' knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use

OBJECTIVE

To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.

DESIGN

A 2016 cross-sectional survey.

SETTING

Academic departments and community-based internal medicine, family medicine and paediatrics practices.

PARTICIPANTS

Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.

RESULTS

Participants were asked what percentage of their 10-17 years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17 years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.

CONCLUSIONS

This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.

Ethyl maltol, vanillin, corylone and other conventional confectionery-related flavour chemicals dominate in some e-cigarette liquids labelled 'tobacco' flavoured

BACKGROUND

The increased popularity of electronic cigarettes (e-cigarettes) has been linked to the abundance of flavoured products that are attractive to adolescents and young adults. In the last decade, e-cigarette designs have evolved through four generations that include modifications in battery power, e-cigarette liquid (e-liquid) reservoirs and atomiser units. E-liquids have likewise evolved in terms of solvent use/ratios, concentration and number of flavour chemicals, use of nicotine salts and acids, the recent increased use of synthetic cooling agents and the introduction of synthetic nicotine. Our current objective was to evaluate and compare the evolving composition of tobacco-flavoured e-liquids over the last 10 years.

METHODS

Our extensive database of flavour chemicals in e-liquids was used to identify trends and changes in flavour chemical composition and concentrations.

RESULTS

Tobacco-flavoured products purchased in 2010 and 2011 generally had very few flavour chemicals, and their concentrations were generally very low. In tobacco-flavoured refill fluids purchased in 2019 and Puff Bar Tobacco e-cigarettes, the total number and concentration of flavour chemicals were higher than expected. Products with total flavour chemicals >10 mg/mL contained one to five dominant flavour chemicals (>1 mg/mL). The most frequently used flavour chemicals in tobacco e-liquids were fruity and caramellic.

CONCLUSIONS

There is a need for continuous surveillance of e-liquids, which are evolving in often subtle and harmful ways. Chemical constituents of tobacco flavours should be monitored as they clearly can be doctored by manufacturers to have a taste that would appeal to young users.

Identifying Promising Themes for Adolescent Vaping Warnings: A National Experiment

INTRODUCTION

Adolescent vaping remains a problem in the United States, yet little is known about what health warning themes most discourage vaping among adolescents. We sought to identify the most compelling themes for vaping warnings for US adolescents.

METHODS

Participants were a national probability sample of 623 US adolescents aged 13-17 years, recruited in the summer of 2020. Adolescents were randomized to one of the five warning message themes about the potential health effects of vaping: 1. chemical harms, 2. lung harms, 3. Coronavirus Disease 2019 (COVID-19) harms, 4. nicotine addiction, or 5. control (messages about vape litter). The primary outcome was perceived message effectiveness (PME; 3-item scale). Secondary outcomes were negative affect (fear), attention, anticipated social interactions, and message novelty.

RESULTS

Adolescents rated the chemical, lung, and COVID-19 harms warning messages higher on PME than nicotine addiction and control (all p < .05), while nicotine addiction was rated higher than control (p < .05). The chemical, lung, and COVID-19 harms warning themes also elicited greater negative affect than nicotine addiction and control (all p < .05). For all other secondary outcomes, the COVID-19 harms warning message theme was rated higher than nicotine addiction and control (all p < .05).

CONCLUSION

Adolescents perceived warning message themes about lung, chemical and COVID-19 health effects of vaping as more effective than nicotine addiction. To discourage vaping, the FDA and others should communicate to youth about the health effects of vaping beyond nicotine addiction.

IMPLICATIONS

Adolescents rated warning message themes about the lung, chemical, and COVID-19 health effects of vaping as more effective than nicotine addiction, while nicotine addiction was rated as more effective than control themes about vaping litter. To discourage vaping among adolescents, health messaging should expand message themes to communicate about a broader set of health effects of vaping beyond nicotine addiction.

Three Seizures Provoked by E-cigarette Use in a Five-Year Period: A Case Report

We report a case of three seizures provoked by e-cigarette use (vaping) within the time span of five years from youth to young adult. At presentation, the neurological exam was unremarkable. Computerized tomography (CT) of the head, magnetic resonance image (MRI) of the brain, electroencephalograms (EEG), electrocardiogram (EKG), and transthoracic echocardiogram (TTE) were normal. Multiple toxicology screens were normal as well. Each seizure occurred within minutes of vaping, thereby suggesting a temporal association and a possible causal relationship between e-cigarettes and seizures.

Liquid Nicotine, E-Cigarettes, and Vaping: Information for the Pediatric Emergency Medicine Provider

ABSTRACT

E-cigarettes, or electronic cigarettes, are electronic nicotine delivery systems that are marketed as a healthier alternative to tobacco cigarettes. There has been an exponential increase in their use among youth since their introduction to the United States market in 2007. With increased use and popularity, there has been an increase in calls to poison control centers regarding liquid nicotine toxicity in children and adolescents. Recent US Food and Drug Administration and other federal regulations of e-cigarettes have attempted to limit availability to youth. This article reviews trends in e-cigarette use among youth, the background and mechanism of action of e-cigarettes, liquid nicotine toxicity, management of liquid nicotine toxicity, and recent policy updates regarding e-cigarettes.

Online E-Cigarette Information Exposure and Its Association with E-Cigarette Use among Adolescents in Shanghai, China

E-cigarettes are widely advertised, while the potential risks of e-cigarette use have been reported among adolescents. This study assessed online e-cigarette information exposure and its association with adolescents’ e-cigarette use in Shanghai, China. A total of 12,470 students aged 13–18 years participated. A questionnaire collected information on students’ sociodemographic factors, e-cigarette information exposure, cigarette use, e-cigarette use, and e-cigarette use intention. A multivariate logistic regression was performed to assess correlates of exposure to e-cigarette information and the association between e-cigarette information exposure and e-cigarette use. Overall, 73.9% of students knew about e-cigarettes and the primary sources of information were the internet (42.4%), movies/TV (36.4%), bulletin boards in retail stores or supermarkets (34.9%), advertising flyers (33.9%), and friends (13.8%). Students who had friends using e-cigarettes were curious about e-cigarettes and showed a greater monthly allowance; smokers and females were at a higher risk of social media and website exposure. Moreover, online information exposure (social media exposure, website exposure, and total internet exposure) was significantly associated with the intention to use e-cigarettes. The enforcement of regulations on online e-cigarette content should be implemented. Moreover, efforts to prevent young people from using e-cigarettes may benefit from targeting students at a higher risk of online e-cigarette information exposure.

E-cigarette or vaping product use associated lung injury (EVALI) in the time of COVID-19: A clinical dilemma

AIM

To report on the clinical, laboratory, and radiological findings of adolescents who presented during the SARS-CoV-2 surge with symptoms of Coronavirus disease 2019 (COVID-19), did not test positive for the infection, and were diagnosed with E-cigarette and vaping product use associated lung injury (EVALI).

METHODS

A retrospective review of 12 cases of EVALI admitted to the Bristol Meyers Squibb Children's Hospital between February 2020 and June 2020 was conducted.

RESULTS

The ages of the patients ranged from 14 to 19 years. There were six males and six females. Three patients had a past history of anxiety, depression, or other psychiatric/mental health disorder, 9 had prolonged coagulation profile (prothrombin time, partial thromboplastin time, and/or International Normalized Ratio), and 11 had elevated inflammatory markers. Eight needed respiratory support. All 12 were negative for SARS-CoV-2 PCR. Four were tested for IgG antibodies and were negative. As these cases were admitted to rule out COVID infection, initial treatment included hydroxychloroquine. Steroids were started only after SARS-CoV-2 PCR was shown to be negative. Urine tetrahydrocannabinol was positive in all cases. Chest X-ray and computed tomography findings showed ground glass opacities.

CONCLUSIONS

Clinical and radiological features are similar in both EVALI and SARS-CoV-2 infection. Inflammatory markers are elevated in both conditions. A detailed social and substance use history in patients presenting with "typical" COVID pneumonia like illness is important. EVALI should be ruled in early to start the appropriate treatment. Given the ongoing pandemic, pediatricians and other health-care providers need to be aware of other conditions that can masquerade as SARS-CoV-2.

Treatment Trials in Young Patients with Chronic Obstructive Pulmonary Disease and Pre-Chronic Obstructive Pulmonary Disease Patients: Time to Move Forward

Chronic obstructive pulmonary disease (COPD) is the end result of a series of dynamic and cumulative gene-environment interactions over a lifetime. The evolving understanding of COPD biology provides novel opportunities for prevention, early diagnosis, and intervention. To advance these concepts, we propose therapeutic trials in two major groups of subjects: "young" individuals with COPD and those with pre-COPD. Given that lungs grow to about 20 years of age and begin to age at approximately 50 years, we consider "young" patients with COPD those patients in the age range of 20-50 years. Pre-COPD relates to individuals of any age who have respiratory symptoms with or without structural and/or functional abnormalities, in the absence of airflow limitation, and who may develop persistent airflow limitation over time. We exclude from the current discussion infants and adolescents because of their unique physiological context and COPD in older adults given their representation in prior randomized controlled trials (RCTs). We highlight the need of RCTs focused on COPD in young patients or pre-COPD to reduce disease progression, providing innovative approaches to identifying and engaging potential study subjects. We detail approaches to RCT design, including potential outcomes such as lung function, patient-reported outcomes, exacerbations, lung imaging, mortality, and composite endpoints. We critically review study design components such as statistical powering and analysis, duration of study treatment, and formats to trial structure, including platform, basket, and umbrella trials. We provide a call to action for treatment RCTs in 1) young adults with COPD and 2) those with pre-COPD at any age.

Youth vaping: a review and update on global epidemiology, physical and behavioral health risks, and clinical considerations

Worldwide, youth electronic cigarette use (vaping) has risen significantly over the past decade. This public health concern has spurred many high-quality studies characterizing country-specific prevalence, risk factors, physical and behavioral health complications, and optimal methods of assessment and counseling for youth vaping. Clinicians remain underexposed to this recent work, limiting translation of evidence into higher quality patient care. This review aims to provide pediatricians and other clinicians working with youth a clinically focused survey of key research findings and considerations based on recent evidence. This narrative review surveys emerging trends in EC use across different countries, reasons for youth vaping, characteristics of vaping materials that promote youth use, associations with combustible cigarette use, relation with cannabis and other illicit substances, physical and behavioral health risks associated with vaping, and methods of assessment, counseling, and intervention for problematic vaping in youth. Since vaping remains a relatively new phenomenon, long-term health consequences remain unknown.Conclusion: Youth vaping is an increasingly well-studied phenomenon with both physical and behavioral health risks. Pediatricians and other youth-focused clinicians can apply the lessons of recent research in work with youth and their families. What is Known: • Youth vaping is an increasingly prevalent public health concern. • Recent research demonstrates physical and behavioral health risks associated with vaping as well as methods for assessment, counseling, and intervention. What is New: • The current review summarizes the latest evidence in a clinically focused framework to facilitate translation of emerging knowledge to practice.

Association Between Bully Victimization and Vaping Among Texas High School Students

INTRODUCTION

Bullying and vaping among adolescents in Texas is a major public health concern. Bully victimization has been associated with substance use in adolescents; however, research examining the association between bully victimization and vaping in adolescents is sparse. This study aims to examine the independent association between bully victimization and vaping among Texas high school students.

METHODS

Pooled data from the 2017 and 2019 Texas Youth Risk Behavior Survey (N=3,486) were analyzed in July 2020. Past-year bully victimization was categorized into 4 mutually exclusive groups: no bully victimization, school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization. Current vape use was measured as a binary variable. Multivariable logistic regression was used to examine the association.

RESULTS

In the total sample, the past-year prevalence of school bully victimization only, cyberbully victimization only, and both school bully and cyberbully victimization was 8.3%, 4.6%, and 7.7%, respectively. Approximately 1 in 7 students (14.5%) reported vaping during the past 30 days. Female students who experienced both school bullying and cyberbullying had 68% greater odds of vaping than female students who did not experience bullying (AOR=1.68, 95% CI=1.02, 3.41). Bully victimization was not significantly associated with vaping in male students.

CONCLUSIONS

Female Texas high school students who are victims of both school bullying and cyberbullying have a greater likelihood of vaping. Healthcare providers, school counselors, and educators should be aware of the association and sex differences that exist while developing intervention programs to address bullying and vaping in high school students.

A novel approach to training educators to conduct school-based adolescent e-cigarette education and prevention: Using the Tobacco Prevention Toolkit

BACKGROUND AND OBJECTIVE

Emerging tobacco products, especially e-cigarettes, present a challenge for educators tasked with providing adolescent tobacco prevention education, as they typically have insufficient time to stay uptodate with the latest information on all tobacco products. To equip educators to implement e-cigarette and other prevention materials, we developed a novel, experiential training of the Tobacco Prevention Toolkit, comprising three components: (1) information session, (2) website navigation demonstration, and (3) hands-on curriculum demonstration allowing educators to present and practice Toolkit lessons.

METHODS

We evaluated this experiential training using a post-training survey, conducted with 486 participants (75% female) from 21 separate trainings. Surveys included demographic questions, training evaluation questions, and 4 open-ended questions administered via Qualtrics. Quantitative data were analyzed for frequencies via R statistical software. Qualitative data were analyzed using grounded theory.

RESULTS

Training participants overwhelmingly agreed or strongly agreed that their knowledge of e-cigarettes increased as a result of the training; they were satisfied with the overall training; and they indicated intention to use the Toolkit in the future. Participants favored the enthusiastic presenters, the information about e-cigarettes, the website navigation, and the curriculum demonstration features of the training. Participants requested more time for various components of the training, more in-depth information about e-cigarettes, and more direction for Toolkit implementation.

CONCLUSIONS

This novel, experiential training increased educator-reported knowledge of tobacco products and was overwhelmingly well-received, suggesting that such training can be important for effective dissemination of other e-cigarette prevention and intervention curricula.

The impact of flavored ENDS use among adolescents on daily use occasions and number of puffs, and next day intentions and willingness to vape

BACKGROUND

The FDA's policies restricting sale of sweet flavored cartridge-based and disposable electronic nicotine delivery systems (ENDS) comprise important steps toward curbing adolescent ENDS use. However, additional evidence is needed about the contribution of specific flavors to adolescents' ENDS use. This study investigated the effects of flavor use on same day vaping behaviors, and next day intentions and willingness.

METHODS

We collected ecological momentary assessments (EMA) from 50 adolescent past two-week vapers (ages 14-17) over 14 days. Daily EMA data were collected on vaping occasions, total puffs, vaping intentions, vaping willingness, and flavor used.

RESULTS

On average, data were obtained on 13.4 days per participant (670 observations). Participants vaped flavors on 87% of days (fruit = 55%; mint = 30%; tobacco = 6%; menthol = 5%, and candy, sweets, or chocolate = 5%). On days when participants vaped fruit flavors, they took more puffs (r = 0.13, p = .030). On days when they vaped tobacco flavor, they reported more vaping occasions (r = 0.20, p = .005) and more puffs (r = 0.15, p = .033). On days when they vaped because of flavor appeal, they reported more vaping occasions (r = 0.19, p = .001) and more puffs (r = 0.24, p < .001). On days when they vaped menthol flavor, they were less likely to report willingness to vape the next day (r = -0.14, p = .042). Adolescents who reported vaping due to flavor appeal were more likely to report intentions (OR = 5.63, p = .035) and willingness to vape the next day (r = 0.23, p < .001) CONCLUSION: These findings provide additional support for policies restricting the sale of flavored ENDS products to adolescents.

Acute electronic vapour product whole aerosol exposure of 3D human bronchial tissue results in minimal cellular and transcriptomic responses when compared to cigarette smoke

The use of electronic vapour products (EVPs) continues to increase worldwide and with advances in cell culture systems, molecular biology and the computational sciences there is also accumulating evidence of their potential reduced toxicity and reduced potential harm when compared to cigarette smoke. To further understand the potential risks and health effects associated with exposure to EVP aerosols we have assessed the cellular and transcriptomic response from a commercially available lung tissue culture system (MucilAirTM) following a single sub-cytotoxic exposure to cigarette smoke and the equivalent nicotine delivered dose of EVP aerosol. The transcriptomic, cellular (cilia beat frequency (CBF) and percent active area (%AA), trans epithelial electrical resistance (TEER), histology) and cytokine release were assessed at 4- and 48- hours following recovery from air, EVP aerosol (8.4% V/V: mybluTM blueberry flavour, 2.4% nicotine) and 3R4F smoke (3.5% V/V: exposure). No pathological changes were observed at either recovery time point from any exposure. Air and EVP aerosol exposure had no effect on CBF, %AA nor TEER at 48 hours. Exposure to cigarette smoke resulted in a decrease in TEER, an increase in CBF and the release of proinflammatory cytokines at both recovery time points. Although the number of significantly expressed genes was minimal following exposure to EVP aerosol, exposure to 3R4F smoke resulted in a significant upregulation of several disease relevant pathways. These data provide evidence that following an acute exposure to EVP aerosol there is significantly less damage to lung cells in culture than the equivalent, nicotine based, dose of cigarette smoke.

Rethink Vape: Development and evaluation of a risk communication campaign to prevent youth E-cigarette use

INTRODUCTION

E-cigarettes are now the most common form of tobacco use among adolescents, and use is associated with increased risk of initiation of cigarette smoking. This project used a community-engaged research process to develop and pilot a risk communication campaign to prevent youth vaping.

METHOD

The research team worked with a 36-member Teen Advisory Council and a 19-member Expert Panel. Together, the team employed survey (N = 674) and focus group (N = 82) methodologies, and hired a marketing company to partner on development of the campaign. Campaign concepts were developed, eliminated, and/or modified through an iterative process of feedback and refinement. The final campaign included video ads (https://bit.ly/2QMR8gH) a microsite (rethinkvape.org), and social media sites (@rethinkvape). The campaign communicated three messages to teens: what's in the vapor, health risks, and connections to big tobacco. Prior to launch of the campaign, a randomized controlled 2 (time) × 2 (group) online experiment was conducted to evaluate the campaign (N = 268).

RESULTS

Repeated measures mixed analyses of variance indicated that vaping knowledge, perceptions of risk, and anti-vape intentions significantly increased among teens viewing the Rethink Vape Materials compared to their own baseline, while control participants did not change. Following evaluation, the team launched a 6-week online media campaign with a teen-targeted geo-fence radius to deliver 3,838,465 impressions, 770,443 completed video views, and 18,316 clicks in mobile app, Snapchat, YouTube, and Spotify platforms. The majority of placements exceeded industry standards, with mobile pre-roll and Snapchat as top performers.

CONCLUSIONS

The e-cigarette campaign showed promising signs of effectiveness and scalability.

An update on controversies in e-cigarettes

E-cigarettes are electronic nicotine delivery systems (ENDS) which mimic tobacco smoking without the combustion of tobacco. These devices have been misleadingly marketed as "less harmful" alternatives to conventional smoking tobacco products. The e-liquid in e-cigarettes include nicotine, a humectant and other additives including flavourings, colourants, or adulterants such as bacterial and fungal products. In this review, we discuss the contrasting views of the tobacco lobby and most professional societies. We describe the epidemiology of the use of these devices, with a widespread and significant rise in youth e-cigarette use seen in both the USA and Europe. We also describe what is known about the toxicity and mechanisms of EVALI (e-cigarette or vaping associated lung injury). This characterised by respiratory failure with an intense inflammatory response. The presentations are diverse and clinicians should consider vaping as a possible cause of any unusual respiratory illness in patients who have a history of vaping or other use of e-cigarette-related products. Second hand exposure to e-cigarettes is also harmful through respiration and transdermal absorption. E-cigarettes have a worse acute toxicity than tobacco and their long-term toxicity is unknown, and we advocate for the immediate, most vigorous anti-vaping legislation possible.

Association Between Youth Smoking, Electronic Cigarette Use, and COVID-19

PURPOSE

This study aimed to assess whether youth cigarette and electronic cigarette (e-cigarette) use are associated with coronavirus disease 2019 (COVID-19) symptoms, testing, and diagnosis.

METHODS

An online national survey of adolescents and young adults (n = 4,351) aged 13-24 years was conducted in May 2020. Multivariable logistic regression assessed relationships among COVID-19-related symptoms, testing, and diagnosis and cigarettes only, e-cigarettes only and dual use, sociodemographic factors, obesity, and complying with shelter-in-place.

RESULTS

COVID-19 diagnosis was five times more likely among ever-users of e-cigarettes only (95% confidence interval [CI]: 1.82-13.96), seven times more likely among ever-dual-users (95% CI: 1.98-24.55), and 6.8 times more likely among past 30-day dual-users (95% CI: 2.40-19.55). Testing was nine times more likely among past 30-day dual-users (95% CI: 5.43-15.47) and 2.6 times more likely among past 30-day e-cigarette only users (95% CI: 1.33-4.87). Symptoms were 4.7 times more likely among past 30-day dual-users (95% CI: 3.07-7.16).

CONCLUSIONS

COVID-19 is associated with youth use of e-cigarettes only and dual use of e-cigarettes and cigarettes, suggesting the need for screening and education.