Dependence on nicotine in US high school students in the context of changing patterns of tobacco product use

Dual and poly-nicotine and tobacco use among adolescents in the United States from 2011 to 2022

BACKGROUND

Adolescent nicotine and tobacco product use remains common despite declining smoking rates in the United States, likely due to the emergence of novel products. Concurrent use of multiple products may increase the risk of nicotine dependency and subsequent substance use.

AIM

To identify patterns and trends of dual and poly nicotine and tobacco use among adolescents in the US and explore associations of dual and poly nicotine and tobacco use with sociodemographic factors.

METHODS

12 years of annual National Youth Tobacco Survey data (2011-2022) from 242,637 respondents were used to examine prevalence trends of different combinations of nicotine or tobacco product use among adolescents in the US using weighted point estimates for each year. Poisson regression models examined sociodemographic factors associated with different patterns of dual and poly-product use from 2011 to 2022.

RESULTS

Overall, the prevalence of dual (i.e. at least two products) and poly (i.e. at least three products) use decreased between 2011 and 2021 (from 9.5 % to 2.8 % and from 5.1 % to 1.1 %, respectively), but showed signs of increase between 2021 and 2022 (3.7 % for dual and 1.7 % for poly use). The most common combinations included a combustible product with either a novel or noncombustible product. The risk for dual and poly-product use was higher among non-Hispanic Whites, males, and high school students.

CONCLUSIONS

Previously declining trends in the prevalence of tobacco/nicotine dual and poly use may have been reversed. Close monitoring and targeted tobacco control policies are essential to tackle multiple product use among adolescents.

Adolescents Who Vape Nicotine and Their Experiences Vaping: A Qualitative Study

Introduction

Understanding adolescent perceptions of vaping and roles it plays in their lives is needed to design effective interventions to help adolescents quit. We explored vaping experiences of 11 adolescents from initiation through quit attempts.

Methods

A convenience sample of students who vaped in the last 90 days was recruited from one suburban high school in Massachusetts. Qualitative interviews were transcribed and coded. An inductive thematic analysis approach was employed. Areas of agreement and range of responses in code reports were summarized.

Results

Eleven open-ended semi-structured interviews were conducted (mean = 32.5 minutes each). Vaping initiation often occurred when socializing with friends who also supplied vaping devices. Vaping was "something to do" and new flavors engaged adolescents further. Solitary activities coupled with vaping included video gaming, getting ready for school, talking on the phone, or studying. Peak hours for vaping included morning, before and after school, before parents returned from work, and after parents went to bed. Several vaped to address anxiety/stress. For some, anxiety control was a main reason for vaping. Participants were concerned about health effects and nicotine dependence. Cost and health effects were drivers of quitting. Quit strategies relied on willpower and distraction.

Conclusions

Peers have powerful influences on the initiation and maintenance of adolescent vaping. Vaping habits can become routinized into adolescent lives. Addiction is a concern although nicotine's anxiolytic effects were valued by many. Social connection was enhanced by communal vaping, sharing, and common vernacular, secrecy and rule-breaking. We describe the context in which adolescents vape nicotine, their reasons for vaping, and reasons to quit. This information can inform the development of interventions to better address adolescents' triggers to vape, and social and psychosocial barriers to quitting. Our findings suggest a desire to quit vaping but a limited awareness of quitting strategies.

A Close Look at Vaping in Adolescents and Young Adults in the United States

Vaping by adolescents and young adults is a legitimate concern as there is a risk that some may start smoking and that electronic cigarette (EC) use may have adverse effects in the developing lungs of adolescents. This commentary provides updated information on vaping patterns among adolescents and young adults in the United States, as well as the impact of EC usage on respiratory health. EC use has surged greatly among high school students and young adults over the last decade but fortunately has declined significantly since its peak in 2019. During the same time period, smoking rates have constantly fallen to new low record levels. These trends argue against EC use as a gateway to smoking. Most EC usage is infrequent and unlikely to increase a person's risk of negative health consequences. Furthermore, the majority of EC usage has happened among those who have previously smoked. There is a dearth of data on the long-term health implications of EC usage in adolescents and young adults. We do not know whether short-term or intermittent use of EC in youth can lead to negative health outcomes in adulthood, and long-term high-quality studies in well-defined groups are needed. Although vaping has been linked to respiratory symptoms, they tend to be transient and of uncertain significance. This commentary provides up-to-date information so health care providers can give objective and responsible medical advice on EC usage.

Tobacco Use, Dependence, and Age of Initiation among Youths with Cognitive Disability

OBJECTIVES

To examine the prevalence of tobacco use by product type among youths with cognitive disability; the prevalence of tobacco dependence among youths with cognitive disability; and the relationship between age of tobacco use initiation and cognitive disability.

STUDY DESIGN

This cross-sectional study analyzed data from the 2019 National Youth Tobacco Survey (NYTS). Participants were a nationally representative sample of 19 018 students in grades 6-12. Estimates were calculated for ever use, current use, age of tobacco use initiation, and tobacco dependence. Associations between use patterns and cognitive disability status were examined using bivariate analyses and multivariable logistic regression.

RESULTS

Compared with youths without cognitive disability, youths with cognitive disability had significantly greater odds of ever using any tobacco product (aOR, 1.49; 95% CI, 1.31-1.70), currently using any tobacco product (aOR, 1.41; 95% CI, 1.26-1.58), and currently using electronic cigarettes (e-cigarettes), cigarettes, cigars, hookahs, roll-your-own cigarettes, and heated tobacco products, specifically. They had higher prevalence and odds of reporting younger age of tobacco use initiation (aOR, 1.25; 95% CI, 1.10-1.43). Higher prevalence and odds of tobacco dependence were also observed among youths with cognitive disability compared with youths without cognitive disability (P < .001).

CONCLUSIONS

These findings reinforce the importance of developing early primary prevention efforts to reduce or delay tobacco use among adolescents with cognitive disability. They also suggest the need to address co-occurring disorders during tobacco cessation programs with this high-risk group.

Cigarillo Flavor and Motivation to Quit among Co-Users of Cigarillos and Cannabis: A Structural Equation Modeling Approach

Flavored cigar restrictions have the potential to benefit public health. Flavor availability facilitates cigarillo use, but it is unknown if flavor impacts patterns of co-use of cigarillos and cannabis, an increasingly prevalent behavior among young adults. Data were collected (2020-2021) in a cross-sectional online survey administered to a convenience sample of young adults who smoked cigarillos from 15 areas with high cigar use prevalence. We assessed the relationship between flavored cigarillo use and motivation to quit cannabis and cigarillo use among past 30-day co-users (N = 218), as well as several covariates (e.g., cigarillo price and flavor/cannabis policy). Flavored cigarillo perceived appeal and harm were hypothesized parallel mediators. Most co-users reported usually using flavored cigarillos (79.5%), which was not significantly associated with motivation to quit cigarillos or cannabis. Perceived cigarillo harm (β = 0.17, 95% CI = 0.00, 0.33), advertising exposure (β = 0.12, 95% CI = 0.00, 0.24), and income (among racial/ethnic minorities; β = -0.13, 95% CI = -0.25, -0.02) were significant predictors of motivation to quit cigarillos. There were no significant predictors of motivation to quit cannabis. Cigarillo flavor was not associated with motivation to quit, so findings could suggest that banning flavors in cigars may have a neutral impact on co-use with cannabis among young adults.

Balancing Consideration of the Risks and Benefits of E-Cigarettes

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes' risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public-including most smokers-now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers' use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay's authors, encourage the health community, media, and policymakers to more carefully weigh vaping's potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

Trends in Nicotine Product Use Among US Adolescents, 1999-2020

IMPORTANCE

With increasing e-cigarette use among US adolescents and decreasing use of other tobacco products, it is unclear how total use of nicotine products, and its long-term health risks, have changed. The Centers for Disease Control and Prevention's standard measure-any tobacco product use in the past 30 days-considers neither frequency of use nor product risk implications.

OBJECTIVE

To investigate how nicotine product use, including frequency of use, and its associated risks have changed among middle school and high school students since 1999.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the 1999-2020 National Youth Tobacco Survey, an in-school survey of a nationally representative sample of students in grades 6 through 12; each survey recruited between 15 000 and 36 000 participants.

EXPOSURES

Nicotine product use in the past 30 days.

MAIN OUTCOMES AND MEASURES

Use of nicotine products assessed by nicotine product days (NPDs), the number of days that the average student consumed these products in the past 30 days. Risk-adjusted NPDs account for differential long-term health risks of various products.

RESULTS

This study included 16 years of cross-sectional survey data. Each survey recruited between 15 000 and 36 000 participants in grades 6 through 12 (male students: mean, 50.4% [minimum, 48.5%; maximum, 58.4%]; mean age, 14.5 years [minimum, 14.0 years; maximum, 14.7 years]). Nationally representative cross-sectional data for high school students showed that NPDs decreased steadily from 5.6 days per month in 1999 (95% CI, 5.0-6.2 days per month) to 2.2 days per month in 2017 (95% CI, 1.9-2.6 days per month), increased to 4.6 days per month in 2019 (95% CI, 4.1-5.1 days per month), and then decreased to 3.6 days per month in 2020 (95% CI, 3.0-4.1 days per month). For a risk weight of 0.1 for e-cigarettes, compared with combustible products, risk-adjusted NPDs decreased from 2.5 days per month in 2013 (95% CI, 2.2-2.9 days per month) (prior to the popularity of e-cigarettes) to 2.0 days per month in 2019 (95% CI, 1.6-2.5 days per month) and 1.4 days per month in 2020 (95% CI, 1.0-1.8 days per month). However, with a risk weight of 1.0 for e-cigarettes (identical to that of combustible products), risk-adjusted NPDs increased to 5.3 days per month in 2019 (95% CI, 4.4-6.2 days per month) and 3.9 days per month in 2020 (95% CI, 3.1-4.7 days per month). Similar trends were found for middle school students.

CONCLUSIONS AND RELEVANCE

This study suggests that NPDs represent an improvement, albeit an imperfect one, compared with any 30-day tobacco product use by incorporating the frequency of use of various products. By distinguishing products, NPDs permit consideration of the health consequences associated with different mixes of products over time. Health risks of adolescent nicotine product use could have decreased during vaping's popularity if assessment of the long-term risks associated with vaping compared with those of smoking is low. There is a need to closely monitor youth nicotine and tobacco product use patterns.

Trends in use of e-cigarette device types and heated tobacco products from 2016 to 2020 in England

This study examined use trends of e-cigarette devices types, heated tobacco products (HTPs) and e-liquid nicotine concentrations in England from 2016 to 2020. Data were from a representative repeat cross-sectional survey of adults aged 16 or older. Bayesian logistic regression was used to estimate proportions and 95% credible intervals (CrIs). Of 75,355 participants, 5.3% (weighted = 5.5%) were currently using e-cigarettes or HTPs, with the majority (98.7%) using e-cigarettes. Among e-cigarette users, 53.7% (CrI 52.0-55.1%) used tank devices, 23.7% (22.4-25.1%) mods, 17.3% (16.1-18.4%) pods, and 5.4% (4.7-6.2%) disposables. Tanks were the most widely used device type throughout 2016-2020. Mods were second until 2020, when pods overtook them. Among all e-cigarette/HTP users, prevalence of HTP use remains rare (3.4% in 2016 versus 4.2% in 2020), whereas JUUL use has risen from 3.4% in 2018 to 11.8% in 2020. Across all years, nicotine concentrations of ≤ 6 mg/ml were most widely (41.0%; 39.4-42.4%) and ≥ 20 mg/ml least widely used (4.1%; 3.4-4.9%). Among e-cigarette/HTP users, ex-smokers were more likely than current smokers to use mod and tank e-cigarettes, but less likely to use pods, disposables, JUUL and HTPs. In conclusion, despite growing popularity of pods and HTPs worldwide, refillable tank e-cigarettes remain the most widely used device type in England.