Electronic cigarettes (e-cigs): views of aficionados and clinical/public health perspectives

The impact of electronic cigarettes on the outcomes of total joint arthroplasty

BACKGROUND

Cigarette smoking is known to result in poorer outcomes for patients undergoing total joint arthroplasty. Smoking tobacco cigarettes in the perioperative period is associated with higher analgesia usage, increased mortality, poorer healing, and an increased risk of medical complications. As such, many surgeons advise their patients not to smoke in the perioperative period. Electronic cigarettes are emerging as a popular alternative for usage by patients who would otherwise continue to smoke traditional cigarettes. Importantly, there has been limited investigation into the impact of electronic cigarette usage on the outcomes of total joint arthroplasty. This review investigates the potential detrimental effects caused by the usage of electronic cigarettes on the outcomes of total joint arthroplasty.

METHODS

A systematic review was carried out in accordance with the PRISMA Guidelines. We have drawn from studies that investigated the impact of the constituents of E-cigarette vapour on bone health, wound healing, the immune system and the direct impact of electronic cigarette usage on surgical outcomes.

RESULTS

Electronic cigarettes release nicotine in an inconsistent manner, resulting in many negative consequences for bone health. Furthermore, they depress the immune system, impair wound healing and may result in longer hospital stays.

CONCLUSIONS

Electronic cigarette usage should be monitored in the perioperative period to reduce the risk of complication. There is a pressing need for more comprehensive research in this area to fully understand the implications of EC usage on the outcomes of total joint arthroplasty.

Electronic Nicotine Delivery System: End to Smoking or Just a New Fancy Cigarette

Smoking and tobacco chewing are the predominant causes of oral cancer. Tobacco is the second-most widely consumed psychoactive substance. There are numerous ways to quit smoking, of which one is electronic cigarettes (e-cigarettes). E-cigarette use is a brand-new, global trend. E-cigarette is a battery-operated device that heats a liquid to create a vapor that the consumer inhales. Several countries have acknowledged that the first step toward electronic nicotine delivery system (ENDS) management is a precise classification of ENDS within the limits of current legislation. Countries have currently categorized ENDS into four generations. People's perceptions about tobacco products have altered recently as a consequence of the advertising of ENDS. The likelihood of starting to smoke cigarettes was four times higher in adolescents who used ENDS, and the probability of quitting was reduced and often prolonged in those who used ENDS. In addition, ENDS normalizes smoking-like actions including inhaling in and exhaling smoke. Adverse marketing via geographic locations and social media platforms, as well as nicotine's irreversible effects on growing adolescent and young adult brains that predispose individuals to addicted behaviors, may be responsible for their rising appeal among teenagers. Despite this, ENDS use has risen among young individuals who have never smoked and undoubtedly face more health risks than those who do not use ENDS. The oral cavity is the first to encounter ENDS in individuals and where it initially affects the human system. As a known contributor to cardiovascular diseases, neurological conditions, and cancers, nicotine seems to be a serious cause for concern. This review provides a concise summary of the research on the components, mode of action, applications, and effects of e-cigarettes on oral as well as systemic systems.

Changes in Nicotine Dependence Among Smokers Using Electronic Cigarettes to Reduce Cigarette Smoking in a Randomized Controlled Trial

INTRODUCTION

How nicotine dependence will be affected when current smokers initiate electronic cigarette (e-cigarette) use to reduce cigarette smoking is unknown. This study evaluated cigarette, e-cigarette, and total nicotine dependence more than 6 months among smokers reducing cigarette consumption by replacing with e-cigarettes.

AIMS AND METHODS

Adult cigarette smokers were randomized to one of four conditions (36 mg/ml e-cigarette, 8 mg/ml e-cigarette, 0 mg/ml e-cigarette, or cigarette-substitute [CS] [provided at no cost]) and instructed to reduce their cigarette smoking by 75% at 1 month. Participants completed follow-up at 1, 3, and 6 months. The Penn State Nicotine Dependence Index (PSNDI) measured dependence on cigarettes (PSCDI) and e-cigarettes (PSECDI). Urine cotinine measured total nicotine exposure. Linear mixed effects models for each outcome were conducted and included interaction terms between visit and condition.

RESULTS

Participants (n = 520) were 58.8% female, 67.3% White, and 48.0 years old. At baseline, the median number of cigarettes smoked per day was 17.3 and the mean PSCDI score was 13.4, with no significant differences between conditions. Participants in the e-cigarette conditions reported significantly lower PSCDI scores, compared with baseline, and with the CS condition at all follow-up visits. Those in the 36 mg/ml e-cigarette condition reported greater PSECDI scores at 6 months, compared with baseline and the 0 mg/ml and 8 mg/ml conditions. At all follow-up visits, there were no differences in total nicotine exposure compared to baseline, nor between any conditions.

CONCLUSIONS

E-cigarette use was associated with reduced cigarette dependence, compared to the CS, without significant increases in total nicotine exposure.

IMPLICATIONS

Initiation of electronic cigarette use while continuing to smoke could potentially increase nicotine dependence. In this randomized trial aimed at helping smokers to reduce their cigarette intake, we found that use of an e-cigarette was associated with a reduction in cigarette dependence and an increase in e-cigarette dependence (in the condition with the highest nicotine concentration only), with no long term increase in total nicotine dependence or nicotine exposure.

A systematic review of the effects of e-cigarette use on lung function

Given the increasing use of e-cigarettes and uncertainty surrounding their safety, we conducted a systematic review to determine the effects of e-cigarettes on measures of lung function. We systematically searched EMBASE, MEDLINE, and PsycINFO databases via Ovid, the Cochrane CENTRAL database, and the Web of Science Core from 2004 until July 2021, identifying 8856 potentially eligible studies. A total of eight studies (seven studying immediate effects and one long-term effects, 273 total participants) were included. The risk of bias was assessed using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) and Cochrane risk of bias tools. These studies suggest that vaping increases airway resistance but does not appear to impact forced expiratory volume in one second (FEV₁₎, forced vital capacity (FVC), or FEV₁/FVC ratio. However, given the limited size and follow-up duration of these studies, larger, long-term studies are required to further determine the effects of e-cigarettes on lung function.

Evaluation of a pharmacy supported e-cigarette smoking cessation intervention in Northwest England

BACKGROUND

Cigarette smoking cessation has been described as the world's most important public health intervention. Electronic cigarettes are a relatively new tool for assisting smoking cessation but there is a lack of data on their efficacy. This article reports on a pharmacy supported e-cigarette smoking cessation intervention undertaken in a metropolitan area in the north of England.

METHODS

Longitudinal mixed-methods evaluation incorporating analysis of secondary data, interviews with service users, and interviews with service providers at 3-month and 12-month follow-up, with an additional text message survey of service users at 12-month follow-up.

RESULTS

The four-week follow-up data suggest that for every twenty people given an e-cigarette, six quit smoking tobacco and three people cut their cigarette intake by more than five cigarettes per day. Long-term follow-up results were positive but only a small number of participants were still engaged with the study at 12 months. Service users and providers spoke positively about the combination of e-cigarettes and pharmacy support.

CONCLUSIONS

E-cigarette distribution combined with pharmacy support appears to be an agreeable and effective intervention for smoking cessation, but further data are needed on long-term quit rates and health effects.

Do e-cigarettes attract youths who are otherwise unlikely to use addictive substances? Cross-sectional analyses of Dutch and Flemish secondary school students

INTRODUCTION

E-cigarettes are popular among youth. There are concerns that e-cigarettes attract youth that would otherwise not use addictive substances. While e-cigarettes are thought to be less harmful than tobacco, there is reason for caution. We examined to what extent adolescent e-cigarette users have characteristics associated with increased risk of substance use.

METHODS

We collected cross-sectional survey data in 2018 among 10 schools throughout the Netherlands and Belgium (N=2794; age 10-18 years). We examined differences in characteristics and behaviors between e-cigarette ever users and never users, and former users and current users. We also explored differences in use of flavors and use of nicotine.

RESULTS

Compared to never-users, e-cigarettes users more often were boys, older, had lower education level, non-Dutch or non-Belgian ethnicity, reported more combustible tobacco use, more smoking family members or family with problematic substance use, more smoking friends, more depressive symptoms, more impulsivity, more delinquent behavior, were more susceptible to smoking, had more positive smoking expectancies, and more ever use of substances. Users of non-tobacco flavored e-cigarettes and e-cigarettes without nicotine had fewer characteristics known to be related to an increased risk of substance use, compared to users of tobacco-flavored e-cigarettes and e-cigarettes with nicotine.

CONCLUSIONS

Adolescent e-cigarette users are more like youths who experiment with addictive substances compared to non-users. Thus, e-cigarettes users were more likely to use substances, regardless of whether they used e-cigarettes first. This may not be true for all types of e-cigarettes, as users of e-cigarettes without nicotine or with non-tobacco flavors were less like youths who experiment with substances.

Atherosclerosis inflammation and burden in young adult smokers and vapers measured by PET/MR

BACKGROUND AND AIMS

Electronic cigarette (EC) use is popular among youth, touted as a safer alternative to smoking and promoted as a tool to aid in smoking cessation. EC cardiovascular safety however is not well established. The aim of this study was to examine cardiovascular consequences of EC use by evaluating their effect on the entire atherosclerotic cascade in young adults using noninvasive combined positron emission tomography (PET)/magnetic resonance imaging (MR) and comparing EC use with age matched smokers of traditional cigarettes and nonsmoking controls.

METHODS

Carotid PET/MR was applied to look at vascular inflammation (18-fluorodeoxyglucose (FDG)-PET) and plaque burden (multi-contrast MR of vessel wall) from 60 18-30 year-old subjects (20 electronic cigarette users, 20 traditional smokers and 20 nonsmokers).

RESULTS

Groups were reasonably well balanced in terms of age, gender, demographics, cardiovascular risk and most biomarkers. There were no differences in vascular inflammation as measured by 18-FDG-PET target to background ratios (TBR) between EC users, traditional cigarette smokers and nonsmokers. However, measures of carotid plaque burden - wall area, normalized wall index, and wall thickness - measured from MR were significantly higher in both traditional smokers and EC users than in nonsmokers.

CONCLUSIONS

Young adult EC users, smokers and nonsmokers in our study did not exhibit vascular inflammation as defined by 18-F-FDG-PET TBR max, but smokers and EC users had significantly more carotid plaque burden compared to matched nonsmokers. Results could indicate that vaping does not cause an increase in vascular inflammation as measured by FDG-PET.

[Studies on toxicity and inflammatory reactions induced by e-cigarettes : In vitro exposure of human nasal mucosa cells to propylene glycol at the air-liquid interface]

Hintergrund

Die E‑Zigarette erfreut sich in den letzten Jahren zunehmender Beliebtheit. Die Frage nach der Toxizität ist jedoch noch nicht eindeutig geklärt, und es herrscht global Unsicherheit im Umgang mit der E‑Zigarette.

Ziel

Ziel der vorliegenden Arbeit war es, Propylenglykol, ein Hauptbestandteil der Liquide, in Bezug auf mögliche akute Entzündungsreaktionen, zyto- und genotoxische Auswirkungen auf humane Nasenschleimhautzellen zu untersuchen.

Material und Methoden

Die Nasenschleimhautzellen wurden von zehn Probanden im Air-Liquid-Interface kultiviert und anschließend mit unterschiedlichen Konzentrationen des Propylenglykols bedampft. Die Analyse erfolgte mittels Trypanblau-Test, Comet-Assay, Mikrokerntest und IL-6- und IL-8-Sandwich-ELISA.

Ergebnis

Der Trypanblau-Test zeigte keine Reduktion der Vitalität. Im Sandwich-ELISA konnte kein Anstieg der IL-6- und IL-8-Konzentrationen nachgewiesen werden. Im Comet-Assay zeigte das Olive Tail Moment eine Schädigung im Vergleich zur Negativkontrolle in allen untersuchten Konzentrationen. Zudem zeigte sich eine dosisabhängige Schädigung. Im Mikrokerntest konnte ein Unterschied zwischen dem Reinstoff und der Negativkontrolle gefunden werden.

Schlussfolgerung

Es zeigten sich möglicherweise reparable DNS-Schädigungen im Comet-Assay. Im Mikrokerntest konnten diese nur in der Reinstoffkonzentration bestätigt werden. Es sollte ein restriktiver Umgang mit der E‑Zigarette erfolgen, bis insbesondere Langzeitstudien vorliegen. Zudem ist eine eindeutige Deklaration der Inhaltsstoffe der Liquide durch die Hersteller zu fordern, um weitergehende Schädigungspotenziale untersuchen zu können.

The inflammatory biomarker YKL-40 is elevated in the serum, but not the sputum, of E-cigarette users

METHODS

We conducted a cross-sectional study of adults between 18 and 55 years old. Inclusion criteria were: exclusive e-cigarette use or cigarette smoking for ≥ 1 year or no history of tobacco use. Participants with a history of pulmonary illness, atopy, medications (except birth control pills), marijuana, and illegal substance use were excluded. Custom Multiplex ELISA was used to measure YKL-40 and other biomarker levels in the serum and induced sputum of the participants. Multivariable linear regression was used to compare the levels of YLK-40 in healthy participants, e-cigarette, and cigarette users after adjusting for age, sex, and BMI.

RESULTS

We recruited 20 healthy controls, 23 cigarette smokers, and 22 exclusive e-cigarette users. Serum YKL-40 (ng/ml) was significantly higher in e-cigarette users (Median 21.2 [IQR 12.1-24.0] ng/ml) when compared to controls (12.2 [IQR 8.7-18.1] ng/ml, p = 0.016) but comparable to cigarette smokers (21.6 [IQR 11.62-51.7] ng/ml, p = 0.31). No significant differences were found in the serum or sputum of the other biomarkers tested.

CONCLUSION

The inflammatory biomarker, YKL-40 is elevated in the serum but not the sputum of e-cigarette users with no reported pulmonary disease. Further research is necessary to characterize this association.

Pain intensity, e-cigarette dependence, and cessation-related outcomes: The moderating role of pain-related anxiety

Pain and nicotine dependence are prevalent, co-occurring conditions posited to interact in the manner of a positive feedback loop; however, most research to date has been conducted among tobacco cigarette smokers. Initial evidence suggests that pain is a risk factor for greater e-cigarette dependence, and additional research is needed to examine covariation between pain and e-cigarette use. There is reason to suspect that pain-related anxiety (i.e., the tendency to respond to pain with anxiety or fear) may be associated with greater e-cigarette dependence and difficulty quitting, and that pain intensity and pain-related anxiety may interact to confer greater risk for e-cigarette use. The current study represents the first examination of cross-sectional associations between pain intensity, pain-related anxiety, and e-cigarette dependence, motivation to quit, history of lifetime e-cigarette quit attempts, perceived barriers to cessation, and negative expectancies during abstinence from e-cigarettes. Participants (N = 520 e-cigarette users, 52.1% female, Mage = 34.85) completed an online survey assessing health behaviors. Results indicated that pain-related anxiety was positively associated with e-cigarette dependence and perceived barriers to cessation (ps < 0.05). Pain-related anxiety was found to moderate relations between pain intensity and primary outcomes, such that pain intensity was positively associated with motivation to quit, likelihood of past failed quit attempt, and negative abstinence expectancies among participants who endorsed high (but not moderate or low) levels of pain-related anxiety. Future research would benefit from examining prospective associations between pain-related anxiety, pain intensity, and e-cigarette use/cessation trajectories among individuals with chronic pain.

Main and Interactive Effects of Nicotine Product Type on Sleep Health Among Dual Combustible and E-Cigarette Users

BACKGROUND AND OBJECTIVES

E-cigarette use is associated with concurrent use of combustible cigarettes among adults and may increase the risk of future combustible cigarette use in adolescents and young adults. Detrimental effects of combustible cigarette use on sleep health are well documented, but little is known about the additive effects of concurrent e-cigarette use. The current study examined the main and interactive effects of daily nicotine product frequency on various components of sleep health.

METHODS

Two hundred and twenty-seven dual-product users (54.2% female, M_age  = 36.89, SD = 10.17) completed questionnaires regarding demographic information, average number of cigarettes smoked per day, average number of times e-cigarettes used per day, and sleep health.

RESULTS

Combustible cigarette frequency uniquely predicted shorter sleep duration, whereas e-cigarette frequency uniquely predicted increased daytime dysfunction due to sleepiness. Further, there was an interactive effect of combustible and electronic cigarettes on the use of sleeping medications.

DISCUSSION AND CONCLUSIONS

Findings may suggest differential adverse effects on sleep, depending on the type of nicotine product used, and highlight potential intervention targets for users. Future work should examine these associations prospectively and/or use objective measurements of sleep and nicotine use to further elucidate the nature of these relationships.

SCIENTIFIC SIGNIFICANCE

This is the first study to explore the main and interactive effects of dual-product use on various dimensions of subjective sleep quality. This is important to investigate, given that dual nicotine users are at greater risk for physical health problems as well as the adverse effects of nicotine on sleep health. (Am J Addict 2020;00:00-00).

Perioperative Implications of Vaping

Over the past 10 - 15 years, there has been a significant increase in the use of electronic cigarettes. These devices are generally used to deliver nicotine through inhalation by aerosolization. While the long-term risk of lung cancer is yet to be known, the chemicals and impurities in the solutions may have other acute and chronic effects on the respiratory system including respiratory failure from adult respiratory distress syndrome. Recent concerns have been raised regarding the potential for significant acute and chronic health care risks of these devices including pneumonitis, airway reactivity and respiratory failure. Given that many of the acute effects are related to the respiratory system, anesthetic care may be required during diagnostic procedures including bronchoscopy to investigate the etiology of acute respiratory symptomatology. We present an adolescent who presented to the operating room for bronchoscopy and bronchoalveolar lavage to investigate the etiology of respiratory involvement following an episode of vaping. The healthcare and end-organ effects of nicotine, tobacco smoke and vaping are discussed, and potential anesthetic implications are presented.

Adult E-Cigarettes Use Associated with a Self-Reported Diagnosis of COPD

The use of electronic cigarettes (e-cigarettes) has increased in the US, but little is known about the effects of these products on lung health. The main purpose of this study was to examine the association between e-cigarette use and a participant's report of being diagnosed with chronic obstructive pulmonary disease (COPD) in a nationally representative sample of adults. Methods: The first wave of the Population Assessment of Tobacco and Health (PATH) survey adult data was used (N = 32,320). Potential confounders between e-cigarette users and non-users were balanced using propensity score matching. Odds ratios (OR) were calculated to examine the association between e-cigarette use and COPD in the propensity-matched sample, the entire sample, different age groups, and in nonsmokers. Replicate weights and balanced repeated replication methods were utilized to account for the complex survey design. Results: Of the 3642 participants who met the criteria for e-cigarette use, 2727 were propensity matched with 2727 non e-cigarette users. In the propensity-matched sample, e-cigarette users were more likely to report being diagnosed with COPD (OR 1.43, 95% confidence interval [CI] 1.12-1.85) than non-e-cigarette users after adjusting for confounders. The result was similar in the entire sample and in the different age subgroups. Among nonsmokers, the odds of reporting a COPD diagnosis were even greater among e-cigarette users (OR 2.94, 95% CI 1.73-4.99) compared to non-e-cigarette users. Conclusion: Our findings demonstrate that e-cigarette use was associated with a reported diagnosis of COPD among adults in the US. Further research is necessary to characterize the nature of this association and on the long-term effects of using e-cigarettes.

Nicotine absorption during electronic cigarette use among regular users

BACKGROUND

The capability of electronic cigarette devices (e-cigs) to deliver nicotine is key to their potential to replace combustible cigarettes. We compared nicotine delivery and subjective effects associated with the use of two classes of e-cigarettes and cigarettes.

METHODS

14 e-cigarette users were instructed to vape their own e-cigarette device every 20 seconds for 10 minutes while blood was drawn at 1, 2, 4, 6, 8, 10,12, and 15 minutes after initiating vaping. Users rated withdrawal symptoms and side effects before and after vaping. E-cigarette devices were classified as first-generation (same size as cigarette, no activation button) or advanced (larger than cigarette with an activation button). Separately, 10 cigarette smokers completed a similar protocol. Fisher's Exact Test and two-sided t-tests were used as appropriate to determine differences in outcomes between first-generation e-cigarette users, advanced e-cigarette users, and smokers.

RESULTS

Compared to first-generation devices, advanced devices were associated with greater serum nicotine Cmax (ng/ml) (11.5 v. 2.8, p = 0.0231) and greater nicotine boost (ng/ml) (10.8 v. 1.8, p = 0.0177). Overall, e-cigarettes users experienced a significant reduction in withdrawal and craving, although there were no significant differences between users of first-generation and advanced devices. Comparing e-cigarettes overall to cigarettes, cigarettes were associated with greater Cmax (25.9 v. 9.0, p = 0.0043) and greater nicotine boost (21.0 v. 8.2, p = 0.0128).

CONCLUSIONS

Advanced e-cigarettes delivered significantly more nicotine than first-generation devices but less than combustible cigarettes. Overall, e-cigarette use was associated with a reduction in withdrawal and craving with no reported side effects. The wide variation in nicotine absorption from different e-cigarette devices should be considered in studies of e-cigarettes for smoking cessation.

Electronic cigarettes in the indoor environment

The use of electronic cigarettes (e-cigarettes or "vaping") has seen an unprecedented increase worldwide. Vaping has been promoted as a beneficial smoking cessation tool and an alternative nicotine delivery device that contains no combustion by-products. However, nicotine is highly addictive, and the increased use of nicotine-containing e-cigarettes among teens and individuals who are not in need of smoking cessation may lead to overall greater nicotine dependence in the population. Furthermore, available research indicates that vaping solutions and their emissions may contain much more than just nicotine, including aerosolized flavorings, propylene glycol (PG), and other intentional and unintentional contaminants. These materials could present undefined potential health hazards to both e-cigarette users and bystanders, the full extent of which is not well understood at this time. Whereas e-cigarette usage and exposures may lower some or most of the risks associated with conventional cigarette use, the health effects of nicotine and aerosol exposures from e-cigarettes are not well understood. Research indicates that vaping aerosols are not benign, especially for nearby people in areas with limited ventilation and people with compromised health conditions. In addition, e-juice liquids have already been responsible for an increase in accidental poisonings in children. Because the magnitude of health and safety hazards that vaping may present to nonusers remains unclear, it is prudent to manage and control vaping in indoor locations where smoking is currently restricted. Based on a review of current scientific information, the American Industrial Hygiene Association (AIHA) recommends that e-cigarettes should be considered a source of aerosols, volatile organic compounds (VOCs), and particulates in the indoor environment that have not been thoroughly characterized or evaluated for health risk or safety.

Experiences of women with cervical dysplasia and associated diagnoses using electronic cigarettes for smoking substitution

Introduction

The aim of this qualitative study was to describe the motivation and experiences of women with cervical dysplasia and associated diagnoses who used electronic cigarettes (ECs) to reduce the number of cigarettes they smoked.

Methods

Qualitative interviews were conducted with 26 women aged 18‐65 years with cervical dysplasia and associated diagnoses who smoked at least three cigarettes daily for the past year or more and who enrolled in an intervention designed to substitute regular cigarettes with ECs. At the 12‐week follow‐up, patients were contacted by telephone. Semi‐structured interviews were recorded, then transcribed, coded and analysed for themes.

Results

When confronted with a new diagnosis associated with smoking, women in this study were eager to try ECs to help them reduce their intake of cigarettes. Women reported that physical cues similar to smoking, delivery of nicotine sufficient to assist with smoking reduction and the security of having the device available to use in instances where temptations to smoke may occur were all positive experiences in trying the device. Other women in the study reported negative experiences, such as a lack of sufficient nicotine to eliminate cravings, heaviness of the device and the need to keep it charged. Depression, nicotine addiction and habit were factors that made it difficult to decrease cigarette consumption.

Conclusions

Findings suggest that ECs may help with smoking substitution in patients who must reduce smoking due to medical conditions or diagnoses.

Validation of the electronic cigarette attitudes survey (ECAS) for youth

Electronic cigarette (e-cigarette) use among adolescents has rapidly increased in recent years, especially among Latinx and non-Latinx Black adolescents. Yet, limited research exists on adolescent attitudes that may contribute to the popularity of these products. This is in part due to the lack of measures focused on assessing adolescent attitudes towards e-cigarette use. The aim of this study was to develop a measure of adolescent e-cigarette use attitudes. The sample consisted mainly of Latinx and non-Latinx Black adolescents. Data were collected from 247 youth (M age = 16.0, SD = 1.2), 63.6% were girls, a majority (69.2%) were non-Latinx Black, and 27.1% were Latinx. The Electronic Cigarette Attitudes Survey (ECAS) is comprised of 12 items reflecting attitudes associated with e-cigarettes, which were derived from prior theoretical, quantitative, and qualitative work with e-cigarette users. To determine the factor structure, a parallel analysis scree plot and an exploratory factor analysis (EFA) of the ECAS was conducted using half of the sample chosen at random (n = 113). Results supported a one-factor solution. A confirmatory factory analysis (CFA) was conducted on the other randomly chosen half of participants (n = 121). Results confirm a one-factor solution. No significant differences were found on ECAS scores based on race/ethnicity or e-cigarette use status (lifetime e-cigarette use vs. no use). The ECAS represents a viable measure for assessing e-cigarette attitudes among youth.

E-cigarette palatability in smokers as a function of flavorings, nicotine content and propylthiouracil (PROP) taster phenotype

BACKGROUND

The popularity of E-cigarettes is due in part to their flavorings. The purpose of this study was to determine the effect on smokers' sensory perceptions and liking of various e-cigarette flavorings, and the degree to which those perceptions are influenced by nicotine level, sex, and PROP bitter taster phenotype.

METHODS

We recruited 132 non-treatment-seeking, daily cigarette smokers. In repeated trials in one laboratory session participants vaped the Joyetech eGo-C e-cigarette with each of the following flavorings (in random order): unflavored, tobacco, cherry, chocolate, and menthol. Participants vaped the e-juice first without nicotine and then with high nicotine (18 mg/ml), and provided sensory (bitterness/sourness, irritation, sweetness) and liking ratings. Perceived intensity of 6-n-propylthiouracil (PROP) was used to classify the participants as non-tasters (n = 28), medium-tasters (n = 74), or supertasters (n = 28). Mixed-effects linear models and generalized estimating equations were used to evaluate ratings as a function of flavor interacting with nicotine content, sex and taster phenotype, adjusting for age, race/ethnicity, menthol use, and nicotine dependence.

RESULTS

Regardless of nicotine level, cherry (β = 1.76, p < .001) and chocolate (β = 0.69, p < .001) were rated as sweeter, but were not better liked, than unflavored e-juice. Menthol elicited the highest liking rating, especially for women (β = 12.23, p < .05) and supertasters (β = 20.52, p < .05). Regardless of flavor, high nicotine was rated as more irritating (OR = 1.43, 95% CI = 1.02-2.01) than the no-nicotine e-juice. Irritation (β = -13.65, p < .001), bitterness/sourness (β = -11.38, p < .001), and sweetness (β = 4.79, p < .001) were associated with liking.

CONCLUSION

Menthol may enhance e-cigarette palatability for some smokers, which may increase e-cigarette utility in smoking cessation.

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.

In times of tobacco-free nicotine consumption: The influence of nicotine on vascular calcification

BACKGROUND

Smoking remains the most important avoidable cause of global mortality. Even though the number of cigarette smokers declines in first world countries, the uses of alternative nicotine delivery products increase and may even surpass the sells of cigarettes. In this light, the explicit role of nicotine in the development of cardiovascular diseases should be elucidated.

OBJECTIVES

This narrative review attempts to connect current literature about possible effects of nicotine on the environment of the vasculature to the pathogenesis of vascular calcification, focusing on the tunica media of the vessel wall.

METHODS

For this review, papers found on Pubmed and Medline until December 2018 by searching for the keywords nicotine, vascular calcification, oxidative stress, osteoblastic transdifferentiation and matrix degradation were considered.

RESULTS

Nicotine creates an environment that probably facilitates and maybe even induces osteogenic transdifferentiation of VSMC by inflammation, endothelial dysfunction and reactive oxygen species. This process is believed to be a key event in calcification of the tunica media of the vessel wall. Furthermore, nicotine could lead to the formation of nucleation sites for hydroxyapatite by facilitating matrix vesicles and extracellular matrix degradation.

CONCLUSIONS

There is a growing body of evidence implicating that nicotine alone could impair vascular function and lead to vascular calcification. Further research is necessary to elucidate the explicit influence of nicotine on arteriosclerosis.

Potential harms from legalization of recreational cannabis use in Canada

With the recent legalization of recreational cannabis use in Canada, questions remain concerning optimal regulation to minimize harms and ensure public health and safety. Patterns of use are subject to change following legalization, and it is important to consider the potential adverse effects that this may have on public health. Important areas of consideration are methods of consumption (e.g., vaping, edibles) and product proliferation; acute and long-term health and behavioural effects (including impaired driving); and use in vulnerable groups, such as children and youth, pregnant women, individuals with mental illness, individuals with low socio-economic status, and Indigenous populations. To support harm reduction measures and evidence-based policy, there is a need to anticipate the potential ramifications that legalization of recreational cannabis use may have on public health in Canada.

An Economic Analysis of the Pre-Deeming US Market for Nicotine Vaping Products

OBJECTIVES

Public health policies are often enacted without adequate consideration of the existing market structure or their impacts on that market structure. This paper provides context for the potential impact of regulations on nicotine vaping products (NVP) use by providing a structural analysis of competition in the US NVP market before FDA regulation.

METHODS

A literature review was conducted with the aim of providing a framework for analysis that: 1) defines the market; 2) evaluates market concentration; 3) identifies entry barriers; and 4) examines firm conduct.

RESULTS

The NVP market includes retail, internet sellers and vape shops. Although conventional retail became more concentrated after the major cigarette companies entered the NVP market, the vape shop and internet sectors remain substantially less concentrated, producing an overall low market concentration, with few entry barriers and competitive behavior.

CONCLUSIONS

The largely unregulated US NVP market has been highly competitive, with a high degree of innovation. However, new FDA deeming regulations as applied to NVPs could make it difficult for smaller companies to remain in the market and could discourage new companies and new product innovations from entering the market.

Association between stages of change for smoking cessation and electronic cigarette use among adult smokers: A nationwide cross-sectional study in Korea

This study aimed to investigate whether smokers who are ready to quit are more likely to use electronic cigarette (e-cigarette) than those who are not. The association between the ever and current use of e-cigarettes with the stages of change (SOC) model was examined, which reflects the readiness to quit smoking. Current smokers were categorized based on the SOC (precontemplation, contemplation, and preparation). We investigated the associations between quit attempts, intention to quit, and stage of change with e-cigarette use in the general population and different age groups. We used data from the Korea Community Health Survey that was conducted nationwide in 2014, and 45,378 current smokers were included in the study. Adult smokers were more likely to use e-cigarettes simultaneously in the preparation and contemplation stages than in the precontemplation stage (adjusted odds ratio [AOR] of preparation stage: 2.88 and 95% confidence interval [CI]: 2.26–3.66; AOR of contemplation stage: 1.93 and 95% CI: 1.67–2.24). Ever use of e-cigarette was significantly associated with the contemplation stage in smokers younger than 50 years, while current e-cigarette use was greater in the contemplation stage than in the precontemplation stage at all ages. Both ever and current use of e-cigarettes were significantly related with the preparation stage among all age groups except 50–59 years. Because the use of e-cigarette among smokers may continually increase, public health guidance must be provided to different types of dual users. Previous studies on the association between e-cigarette use and the cognitive and behavioral aspects of smokers have conflicting results. This study highlights whether the use of e-cigarettes can be used as an indicator for the readiness to quit smoking. Thus, counselors can encourage smoking cessation and provide tailored interventions.

Surface Chemistry of Electronic Cigarette Electrical Heating Coils: Effects of Metal Type on Propylene Glycol Thermal Decomposition

INTRODUCTION

Carbonyls, a class of compounds strongly linked to pulmonary disease in smokers, are probably the most reported non-nicotine toxicants found aerosols. Reported emissions vary from negligible quantities to those far exceeding combustible cigarettes. Observations of high emissions are commonly attributed to "dry puffing", whereby the ECIG heating filament runs dry of liquid and reaches temperatures that induce thermal degradation of the ECIG vapor components at the filament's metal surface. Using a pyrolysis flow reactor, in this study we examined the potential role of surface chemistry in the formation of carbonyl compounds in ECIGs, and whether the different commercially available filament materials could potentially impact their toxicant emissions through catalysis. This information could inform nascent efforts to regulate the design of ECIGs for public health ends.

METHODS

Nitrogen or air saturated with propylene glycol vapor was drawn through a temperature and residence time controlled tubular quartz pyrolysis flow reactor in which nichrome, Kanthal, or stainless steel ECIG heating filament wires were inserted. A control condition with no inserted wire was also included. Concentrations of carbonyl products at the reactor outlet were measured as a function of temperature, heating filament wire material, and carrier gas composition (N2 vs air). Carbonyls were sampled using DNPH cartridges and analyzed by HPLC.

RESULTS

ECIG heating filament wires were found to have a strong catalytic effect. Carbonyl formation initiated at temperatures lower than 250°C in the presence of the metallic wires, compared to 460°C without them. Carbonyl formation was found to be a function of the material of construction, and whether the wire was new or aged. New nichrome wires were the least reactive, but when aged they exhibited the highest reactivity. Carbonyls were formed via dehydration or oxidation reactions of PG.

CONCLUSIONS

Carbonyl formation chemistry is catalyzed by commonly used ECIG heating filament materials, at temperatures that are well below those expected during "dry puffing". The variability in the distribution and yield of carbonyl compounds across ECIG filament materials suggests that this heretofore unaccounted variable may partially explain the wide ranges reported in the literature to date. More importantly, it suggests that ECIG construction materials may be an important variable for regulations designed to protect public health.

Early Subjective Sensory Experiences with "Cigalike" E-cigarettes Among African American Menthol Smokers: A Qualitative Study

Introduction

Despite smoker interest in e-cigarettes as a harm reduction or cessation aid, many smokers prematurely discontinue vaping after trying a product. This study explored the role of early subjective sensory experiences in vaping persistence and desistance.

Methods

African American menthol cigarette smokers aged ≥18 years (N = 15; M = 54.1 years; SD = 8.2), motivated to quit smoking, and interested in trying e-cigarettes were recruited in Washington, DC. Participants were followed for 3 weeks and provided menthol cigalike e-cigarettes after Week 1. Participants completed three interviews about their vaping experiences. Thematic analysis of responses was designed to understand the sensory aspects of vaping.

Results

During the first 2 weeks of vaping, four participants reported a positive vaping experience while 11 reported decreased satisfaction. Salient sensory attributes of dissatisfaction included poor taste, insufficient throat hit, difficulty pulling, and a lack of "whole body" satisfaction compared to their preferred cigarette brand.

Conclusions

The sensory experiences with a specific cigalike e-cigarette were related to vaping persistence and desistence. Although this was a small volunteer sample of African American menthol smokers motivated to quit smoking, 27% (N = 4) of participants with a positive vaping experience continued using the product, while 73% (N = 11) of participants' vaping experience was unsatisfactory across several experiential categories. In future research of e-cigarettes' efficacy as a smoking cessation or reduction aid, both device characteristics and smokers' expectations for these devices should be considered, so vapers do not expect the same taste sensations, throat sensations, and "whole body" satisfaction as they experienced with their menthol cigarettes.

Implications

The subjective sensory experiences associated with initial e-cigarette product use are associated with use patterns. Subjective sensory experiences may also help understand the differences in the appeal, satisfaction, and harm-reduction potential of the rapidly evolving diverse types of products emerging in the marketplace. How products meet the sensory needs of smokers wanting to switch or quit smoking may influence adherence and success rates.

Tobacco-specific nitrosamines: A literature review

Cigarette smoke is a complex mixture of chemicals, including several tobacco-specific nitrosamines (TSNA). Most TSNA are formed in tobacco during the post-harvest period, while a number are produced when a cigarette is burned. Considerable evidence supports the role of TSNA important causative factors for cancers of the lung, pancreas, esophagus, and oral cavity in people who use tobacco products. Of the known TSNA, nicotine-derived nitrosamine ketone (NNK) and N-nitrosonornicotine (NNN) are the most carcinogenic. Other TSNA include N'-nitrosoanatabine (NAT) and N-nitrosoanabasine (NAB). New tobacco products (e.g., e-cigarettes) designed to attract consumers who are concerned about the health effects of tobacco have been appearing on the market. Several studies have reported that certain TSNA have been detected in the replacement liquids and vapour of e-cigarettes, but the levels are generally considerably lower than in tobacco cigarettes. Additionally, the FDA recently announced its intention to regulate TSNA in e-cigarettes, cigar tobacco and pipe tobacco. With the rise of new technologies for reducing the use of tobacco products-such as e-cigarettes- to evaluate exposure levels to these harmful chemicals over time, researchers will be monitoring levels of TSNA in the body as a result of the use of these devices.

Cigarette and e-cigarette dual use and risk of cardiopulmonary symptoms in the Health eHeart Study

E-cigarettes are promoted as healthier alternatives to conventional cigarettes. Many cigarette smokers use both products. It is unknown whether the additional use of e-cigarettes among cigarette smokers (dual users) is associated with reduced exposure to tobacco-related health risks. Cross-sectional analysis was performed using baseline data from the Health eHeart Study, among English-speaking adults, mostly from the United States. Cigarette use (# cigarettes/day) and/or e-cigarette use (# days, # cartridges, and # puffs) were compared between cigarette only users vs. dual users. Additionally, we examined cardiopulmonary symptoms/ conditions across product use: no product (neither), e-cigarettes only, cigarettes only, and dual use. Among 39,747 participants, 573 (1.4%) reported e-cigarette only use, 1,693 (4.3%) reported cigarette only use, and 514 (1.3%) dual use. Dual users, compared to cigarette only users, reported a greater median (IQR) number of cigarettes per day, 10.0 (4.0-20.0) vs. 9.0 (3.0-15.0) (p < .0001), a lower (worse) median (IQR) SF-12 general health score, 3.3 (2.8-3.8) vs. 3.5 (2.8-3.9) (p = .0014), and a higher (worse) median (IQR) breathing difficulty score in the past month, 2.0 (1.0-2.0) vs. 1.0 (1.0-2.0) (p = .001). Of the 19 cardiopulmonary symptoms/ conditions, having a history of arrhythmia was significantly different between cigarette only users (14.2%) and dual users (17.8%) (p = .02). In this sample, dual use was not associated with reduced exposure to either (i) cigarettes, compared to cigarette only users or (ii) e-cigarettes, compared to e-cigarette only users. E-cigarette only use, compared to no product use, was associated with lower general health scores, higher breathing difficulty scores (typically and past month), and greater proportions of those who responded 'yes' to having chest pain, palpitations, coronary heart disease, arrhythmia, COPD, and asthma. These data suggest the added use of e-cigarettes alone may have contributed to cardiopulmonary health risks particularly respiratory health risks.

The Effect of Electronic Cigarettes on Voice Quality

OBJECTIVES

Cigarette-associated diseases have frequently been detected in the field of otolaryngology. Cigarettes can cause changes in voice performance. The aim of the present study was to investigate the effect of e-cigarettes on voice performance compared with conventional cigarettes.

MATERIALS AND METHODS

This is a cross-sectional study that included 81 healthy volunteers. To provide standardization, all patients were men. The patients were divided into three groups: e-cigarette users (group 1, n = 21), conventional cigarette users (group 2, n = 30), and nonsmokers who had never smoked (group 3, n = 30). The subjective and objective voice analyses were performed for all the three groups in the study. F0, jitter %, shimmer %, shimmer dB, harmonics-to-noise ratio (HNR) values, and Voice Handicap Index 10 were statistically compared between all groups.

RESULTS

The mean Voice Handicap Index 10 values of the conventional cigarette users were higher than those of the e-cigarette users and control group. No significant difference regarding the F0, jitter, and shimmer percentage values between the groups was detected; however, a significant difference was detected regarding the shimmer dB and HNR values between the groups. The mean shimmer dB values of the conventional cigarette group were higher than those of the control group and electronic cigarette users, but the mean HNR values were lower than those of the control group and electronic cigarette users.

CONCLUSIONS

The effects of e-cigarettes on voice were detected as mild compared with conventional cigarettes, according to the subjective and objective voice analysis results in our study.

Does E-cigarette Use at Baseline Influence Smoking Cessation Rates among 2-Year College Students?

INTRODUCTION

This study evaluates the impact of baseline e-cigarette use on smoking cessation rates in a national sample of two-year college student smokers.

METHODS

Participants were 1400 students from over 60 two-year colleges across 25 states who were current smokers enrolled in a web-assisted tobacco intervention (WATI) trial. Survey data were collected at baseline, 1-, 6-, and 12-months, with primary outcomes evaluated at 6-months.

RESULTS

At 6-months, baseline e-cigarette users were more likely to report cessation of traditional cigarettes compared to non-users (OR 1.39, 95% CI 1.002-1.92). Cessation was also associated with higher baseline confidence in quitting and greater time to first cigarette in the morning. Baseline e-cigarette use was not found to be associated with self-reported cessation of all nicotine/tobacco products (OR 1.09, 95% CI 0.75-1.58) nor biochemically verified cessation of all nicotine/tobacco products (OR 0.83, 95% CI 0.47-1.47). Higher confidence was again associated with both self-reported and biochemically verified cessation of all nicotine/tobacco products. Female gender was associated only with biochemically verified cessation of all nicotine/tobacco products at 6-months.

CONCLUSIONS

Two-year college students represent a priority population for cessation interventions. The findings from this study highlight the complexities of evaluating the impact of e-cigarette use on cessation.

Adverse events of smoking cessation treatments (nicotine replacement therapy and non-nicotine prescription medication) and electronic cigarettes in the Food and Drug Administration Adverse Event Reporting System, 2004-2016

Objectives:

Several smoking cessation treatments (nicotine replacement therapy and non-nicotine prescription medication) and electronic cigarettes are widely used. We evaluated the adverse events related to smoking cessation treatments and electronic cigarettes in the US Food and Drug Administration Adverse Event Reporting System database.

Methods:

We analyzed reports of adverse events associated with smoking cessation treatment and electronic cigarettes terms dated between January 2004 and December 2016. We used the reporting odds ratio with 95% confidence intervals to detect a signal for each adverse event.

Results:

In total, 8,867,135 reports in the Food and Drug Administration Adverse Event Reporting System database were analyzed. The numbers of adverse events for nicotine replacement therapy (transdermal, buccal, oral, and respiratory administration) were 1673, 1016, 425, and 56, respectively. Nicotine replacement therapy (transdermal, buccal, and oral) demonstrated adverse events of nausea, nicotine dependence, and dizziness. For nicotine (transdermal) exposure, the top 5 adverse events reported were nausea (149 cases, reporting odds ratio: 2.28 (95% confidence interval: 1.92–2.69)), dizziness (132 cases, reporting odds ratio: 3.04 (95% confidence interval: 2.54–3.63)), application site erythema (108 cases, reporting odds ratio: 32.52 (95% confidence interval: 26.74–39.55)), headache (98 cases, reporting odds ratio: 1.84 (95% confidence interval: 1.50–2.25)), and dyspnea (94 cases, reporting odds ratio: 1.93 (95% confidence interval: 1.57–2.38)). Many cases of improper use of nicotine replacement therapies were reported. Nausea, depression, abnormal dreams, insomnia, and other adverse events were reported for varenicline. Insomnia, rash, anxiety, and dizziness were reported for bupropion. We observed electronic cigarettes–related adverse events such as dizziness, dyspnea, nausea, heart rate increased, and tremor.

Conclusion:

Our findings suggest that an association exists between nicotine-related adverse events and nicotine replacement therapy. Healthcare professionals should closely monitor smokers trying to quit nicotine use for the misuse of nicotine replacement therapy. These findings may be informative to healthcare professionals in order to improve the management of smoking cessation treatment.

Effects of Solvent and Temperature on Free Radical Formation in Electronic Cigarette Aerosols

The ever-evolving market of electronic cigarettes (e-cigarettes) presents a challenge for analyzing and characterizing the harmful products they can produce. Earlier we reported that e-cigarette aerosols can deliver high levels of reactive free radicals; however, there are few data characterizing the production of these potentially harmful oxidants. Thus, we have performed a detailed analysis of the different parameters affecting the production of free radical by e-cigarettes. Using a temperature-controlled e-cigarette device and a novel mechanism for reliably simulating e-cigarette usage conditions, including coil activation and puff flow, we analyzed the effects of temperature, wattage, and e-liquid solvent composition of propylene glycol (PG) and glycerol (GLY) on radical production. Free radicals in e-cigarette aerosols were spin-trapped and analyzed using electron paramagnetic resonance. Free radical production increased in a temperature-dependent manner, showing a nearly 2-fold increase between 100 and 300 °C under constant-temperature conditions. Free radical production under constant wattage showed an even greater increase when going from 10 to 50 W due, in part, to higher coil temperatures compared to constant-temperature conditions. The e-liquid PG content also heavily influenced free radical production, showing a nearly 3-fold increase upon comparison of ratios of 0:100 (PG:GLY) and 100:0 (PG:GLY). Increases in PG content were also associated with increases in aerosol-induced oxidation of biologically relevant lipids. These results demonstrate that the production of reactive free radicals in e-cigarette aerosols is highly solvent dependent and increases with an increase in temperature. Radical production was somewhat dependent on aerosol production at higher temperatures; however, disproportionately high levels of free radicals were observed at ≥100 °C despite limited aerosol production. Overall, these findings suggest that e-cigarettes can be designed to minimize exposure to these potentially harmful products.

Electronic cigarettes and indoor air quality: a review of studies using human volunteers

OBJECTIVE

This paper is primarily aimed to review articles on electronic cigarettes (e-cigarettes) focusing on indoor air quality (IAQ) assessment that were conducted using human volunteers under natural settings that mimic actual vaping scenarios. Such studies may give a better representation of the actual potential exposure towards e-cigarettes emissions in indoor settings.

METHODS

A systematic literature search was conducted using PubMed search engine database. Search terms such as "electronic cigarette", "e-cigarette", "electronic nicotine delivery system", and "indoor air quality" were used to identify the relevant articles to be included in this review. Articles that involved human volunteers who were asked to vape in natural settings or settings that mimic the actual vaping scenario were chosen to be reviewed. The search yielded a total of 15 published articles. Eleven articles were excluded due to 1) unavailability of its full-text (n=1), 2) did not involve human volunteers (n=5) and 3) did not involve an IAQ study (n=5). Four articles were critically reviewed in this paper.

RESULTS

From the four selected articles, two of the papers focused on the determination of nicotine level released by e-cigarettes whereas the other two covered IAQ parameters namely; particulate matters (PM), propylene glycols, formaldehyde, metals and polycyclic aromatic hydrocarbons (PAHs). Only two of the studies involved determination of biomarkers of exposure. The level of chemical contents released varied between studies. The differences in the brands of e-cigarette used, number of vapers recruited and the sensitivity of the methodologies employed in these studies may be the possible causes for such differences. However, studies using human volunteers conducted in a natural setting are more relevant to portray the actual exposure to vapors among e-cigarettes users and non-users compared to studies using a smoking machine/an exposure chamber. This is because such studies take into account the behavior of consumers and individual retention of nicotine. Such method will therefore avoid the possibility of overestimation in terms of exposures toward e-cigarettes users and non-users.

CONCLUSION

There are limited e-cigarette studies on the impact of IAQ performed using human volunteers in natural settings. The available studies however, provided inconsistent scientific evidence on the actual exposure towards the vapor contents as unstandardized methodology were used in conducting such research. Therefore, there is a need to conduct IAQ studies in natural settings by using a standardized protocol in terms of the number of vapers recruited, the size of the indoor settings, the methods used in detecting and quantifying the contents and levels of emissions and the sensitivity of the equipment used in analyzing the contents. This will help in better utilization of the findings from such studies for the use of risk assessment of the exposures towards e-cigarette emissions. There is also a need to emphasize that it is the onus of the manufacturers in providing and proving scientifically sound safety claims for their products prior to commercializing it in the market.

Mists, vapors and other illusory volatilities of electronic cigarettes

In this article, we analyze the discourse of electronic cigarette suppliers directed at convincing potential users (smokers, former smokers or never smokers) to acquire and use the new product. This is a qualitative, descriptive and exploratory study on sellers' discourse found in eight on-line sales websites which, between 2011 and 2013, had the highest search frequencies. The websites were identified through Google Trends based on the number of accesses and search frequencies related to electronic cigarettes. Our methodological reference was dialectical-hermeneutics. We categorized the empirical material within the "understanding/interpretation" scheme within four broad meanings: appropriation of the anti-smoking discourse; comparison between conventional and electronic cigarettes; appeal to the trustworthiness of science and projection of e-cigarettes' image. The analysis of these meanings configured the argumentative elements of the marketing discourse used by electronic cigarette makers and suppliers.

An opportune and unique research to evaluate the public health impact of electronic cigarettes

In response to the growing public health concern regarding the risks or benefits of electronic cigarettes (e-cig) use relative to smoking, the National Institute on Drug Abuse (NIDA) has recently introduced the first standardized- and well- characterized e-cig device to the research community (see, https://www.drugabuse.gov/funding/supplemental-information-nida-e-cig ). E-cig are promoted as safe alternatives to conventional tobacco cigarettes and/or as aides to smoking cessation. E-cig are highly popular among cigarette smokers who are unable/unwilling to quit but are willing to switch to putatively less-harmful tobacco substitutes. E-cig are also becoming increasingly popular among youth who have never experimented with combustible cigarettes. However, chemical analyses of e-cig juices (both in liquid form and after being heated into vapor) have shown that many carcinogens present in cigarette smoke are also found in a range of e-cig products. To date, the cancer-causing potential of e-cig has not been investigated in e-cig users (i.e., vapers). Use of e-cig without a prior history of smoking is currently a rare phenomenon in adults, but is increasingly common among youth. Consequently, investigating the carcinogenic potential of e-cig in nonsmoking youth provides a unique opportunity to verify the health impact of e-cig use, without the confounding effects of cigarette smoking. Within this context, the availability of the NIDA Standard Research e-cig offers a unique research opportunity with tremendous public health implications. Comparing and contrasting the cancer-causing potentials of standard vaping and smoking in youth will help determine the health risks or benefits of e-cig use relative to cigarette smoking. This information will be instrumental in making scientifically based decisions on the development and evaluation of policies and regulations on e-cig manufacture, marketing, and distribution. Ultimately, evidence-based guidelines and legislations on e-cig will help reduce the burden of tobacco-related diseases, particularly on minors and vulnerable populations.

Comparison of Ecological Momentary Assessment Versus Direct Measurement of E-Cigarette Use With a Bluetooth-Enabled E-Cigarette: A Pilot Study

BACKGROUND

Assessing the frequency and intensity of e-cigarette use presents special challenges beyond those posed by cigarette use. Accurate measurement of e-cigarette consumption, puff duration, and the stability of these measures over time will be informative for estimating the behavioral and health effects of e-cigarette use.

OBJECTIVE

The purpose of this pilot study was to compare the accuracy of self-reported e-cigarette puff counts collected via ecological momentary assessment (EMA) to objective puff count data collected by a Bluetooth-enabled e-cigarette device and to examine the feasibility and acceptability of using a second-generation e-cigarette among adult smokers.

METHODS

A total of 5 adult smokers were enrolled in a longitudinal parent study assessing how e-cigarette use affects cigarette use among e-cigarette-naïve smokers. Using a text message-based EMA system, participants reported e-cigarette puffs for 2 weeks. Participants were also given a Bluetooth-enabled e-cigarette (Smokio) that passively collected puff counts and puff duration. Comparisons between mean reports of Smokio (device-report) and EMA (self-report) use were evaluated using paired t tests. Correlation and agreement between device- and self-reports were evaluated using Pearson correlation and the concordance correlation coefficient (CCC), respectively. A linear mixed effect model was used to determine the fixed effect of timing and Smokio-reported daily puffs on report accuracy. We examined the relationship between time of day and reporting accuracy using Tukey's test for multiple pairwise comparisons.

RESULTS

A total of 5 African American participants, 4 men and 1 woman, who ranged in age from 24 to 59 years completed the study, resulting in 5180 observations (device-report) of e-cigarette use. At baseline, participants reported smoking for 5 to 25 years and consumed a mean of 7 to 13 cigarettes per day (CPD); 4 smoked within 30 minutes of waking. At the 30-day follow-up, CPD range decreased to 1 to 3 cigarettes; 4 participants reported past 7-day e-cigarette use, and 1 participant reported no cigarette smoking in the past 7 days. Over 2 weeks of e-cigarette use, participants took an average of 1074 e-cigarette (SD 779.0) puffs per person as captured by the device reports. Each participant took a mean of 75.0 (SD 58.8) puffs per day, with each puff lasting an average of 3.6 (SD 2.4) seconds. Device reports captured an average of 33.3 (SD 47.8) more puffs per person per day than the self-reported e-cigarette puffs. In 87% of days, participants underestimated the number of puffs they had taken on the Smokio. There was significant moderate correlation (r=.47, P<.001) but poor agreement (p_c=0.31, 95% CI 0.15-0.46) between the device- and self-reported data. Reporting accuracy was affected by amount and timing of e-cigarette use.

CONCLUSIONS

Compared to self-reported e-cigarette use, the Bluetooth-enabled device captured significantly more e-cigarette use and allowed for examination of puff duration in addition to puff counts. A Bluetooth-enabled e-cigarette is a powerful and feasible tool for objective collection of e-cigarette use behavior in the real world.

Medical Residents' and Practicing Physicians' e-Cigarette Knowledge and Patient Screening Activities: Do They Differ?

Purpose:

The purpose of this study was to compare medical residents and practicing physicians in primary care specialties regarding their knowledge and beliefs about electronic cigarettes (e-cigarettes). We wanted to ascertain whether years removed from medical school had an effect on screening practices, recommendations given to patients, and the types of informational sources utilized.

Methods:

A statewide sample of Florida primary care medical residents (n = 61) and practicing physicians (n = 53) completed either an online or paper survey, measuring patient screening and physician recommendations, beliefs, and knowledge related to e-cigarettes. χ² tests of association and linear and logistic regression models were used to assess the differences within- and between-participant groups.

Results:

Practicing physicians were more likely than medical residents to believe e-cigarettes lower cancer risk in patients who use them as an alternative to cigarettes (P = .0003). Medical residents were more likely to receive information about e-cigarettes from colleagues (P = .0001). No statistically significant differences were observed related to e-cigarette knowledge or patient recommendations.

Conclusions:

Practicing primary care physicians are accepting both the benefits and costs associated with e-cigarettes, while medical residents in primary care are more reticent. Targeted education concerning the potential health risks and benefits associated with the use of e-cigarettes needs to be included in the current medical education curriculum and medical provider training to improve provider confidence in discussing issues surrounding the use of this product.

Electronic nicotine delivery system (ENDS) use during smoking cessation: a qualitative study of 40 Oklahoma quitline callers

OBJECTIVES

Approximately 10% (40 000) of US quitline enrollees who smoke cigarettes report current use of electronic nicotine delivery systems (ENDS); however, little is known about callers' ENDS use. Our aim was to describe why and how quitline callers use ENDS, their beliefs about ENDS and the impact of ENDS use on callers' quit processes and use of FDA-approved cessation medications.

DESIGN

Qualitative interviews conducted 1-month postregistration. Interviews were recorded, transcribed, double-coded and analysed to identify themes.

SETTING

Oklahoma Tobacco Helpline.

PARTICIPANTS

40 callers aged ≥18 who were seeking help to quit smoking were using ENDS at registration and completed ≥1 programme calls.

RESULTS

At 1-month postregistration interview, 80% of callers had smoked cigarettes in the last 7 days, almost two-thirds were using ENDS, and half were using cessation medications. Nearly all believed ENDS helped them quit or cut down on smoking; however, participants were split on whether they would recommend cessation medications, ENDS or both together for quitting. Confusion and misinformation about potential harms of ENDS and cessation medications were reported. Participants reported using ENDS in potentially adaptive ways (eg, using ENDS to cut down and nicotine replacement therapy to quit, and stepping down nicotine in ENDS to wean off ENDS after quitting) and maladaptive ways (eg, frequent automatic ENDS use, using ENDS in situations they did not previously smoke, cutting down on smoking using ENDS without a schedule or plan to quit), which could impact the likelihood of quitting smoking or continuing ENDS use.

CONCLUSIONS

These qualitative findings suggest quitline callers who use ENDS experience confusion and misinformation about ENDS and FDA-approved cessation medications. Callers also use ENDS in ways that may not facilitate quitting smoking. Opportunities exist for quitlines to educate ENDS users and help them create a coordinated plan most likely to result in completely quitting combustible tobacco.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Vape Shop Employees: Public Health Advocates?

INTRODUCTION

E-cigarettes have increased in popularity and given rise to a new type of sales outlet—the vape shop. Expanding on work examining vape shop employee e-cigarette and tobacco attitudes and behaviors¹, this study examined key messages that vape shop employees communicate to customers.

METHODS

Using informal interviews, observations, and a cross-sectional survey, we examined vape shop employees’ (n=16) perceptions and e-cigarette use. Data were collected in nine vape shops in Louisville, Kentucky. We used open coding to analyze the qualitative interviews, observation notes, and open-ended survey responses. Descriptive statistics were used to analyze survey data.

RESULTS

The findings revealed that nearly all employees were former smokers (93.8%), who now only use e-cigarettes. Over one-third of the employees (37.5%) began using e-cigarettes as a replacement for traditional cigarettes, and 93.8% reported better health (e.g., easier breathing, less coughing) since starting to use e-cigarettes. Although most employees believed e-cigarettes should be regulated, 56.3% thought regulations should be different from those governing traditional cigarettes. Analysis of qualitative data revealed that employees see themselves as health advocates who: 1) provide instructions on vaping and promote a vape community, 2) encourage cessation of traditional cigarettes, and 3) support some regulations.

CONCLUSIONS

The findings reveal that vape shop employees regard e-cigarettes as viable smoking cessation tools and relish their role in assisting others in taking what employees view as positive health actions. Future research addressing communication between vape shop employees and customers, especially related to smoking cessation and health, is needed.

Self-reported smoking effects and comparative value between cigarettes and high dose e-cigarettes in nicotine-dependent cigarette smokers

The objective of this experiment was to evaluate the comparative value of cigarettes versus high dose e-cigarettes among nicotine-dependent cigarette smokers when compared with money or use of their usual cigarette brand. The experiment used a within-subject design with four sessions. After baseline assessment, participants attended two 15-min unrestricted smoking sessions: one cigarette smoking session and one e-cigarette smoking session. Participants then attended two multiple-choice procedure (MCP) sessions: a session comparing cigarettes and money and a session comparing e-cigarettes and money. Participants (n=27) had used cigarettes regularly, had never used e-cigarettes, and were not currently attempting to quit smoking. The sample consisted primarily of males (72%), with a mean age of 34 years. When given the opportunity to choose between smoking a cigarette or an e-cigarette, participants chose the cigarette 73.9% of the time. Findings from the MCP demonstrated that after the first e-cigarette exposure sessions, the crossover value for cigarettes ($3.45) was significantly higher compared with the crossover value for e-cigarettes ($2.73). The higher participant preference, self-reported smoking effects, and higher MCP crossover points indicate that cigarettes have a higher comparative value than high dose e-cigarettes among e-cigarette naive smokers.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cigarette smoking and electronic cigarette vaping patterns as a function of e-cigarette flavourings

INTRODUCTION

The present study examined the influence of flavouring on the smoking and vaping behaviour of cigarette smokers asked to adopt e-cigarettes for a period of 6 weeks.

METHODS

Participants were 88 current male and female smokers with no intention to stop smoking, but who agreed to substitute e-cigarettes for their current cigarettes. On intake, participants were administered tests of taste and smell for e-cigarettes flavoured with tobacco, menthol, cherry and chocolate, and were given a refillable e-cigarette of their preferred flavour or a control flavour. Participants completed daily logs of cigarette and e-cigarette use and were followed each week.

RESULTS

Analyses over days indicated that, during the 6-week e-cigarette period, cigarette smoking rates dropped from an average of about 16 to about 7 cigarettes/day. e-Cigarette flavour had a significant effect such that the largest drop in cigarette smoking occurred among those assigned menthol e-cigarettes, and the smallest drop in smoking occurred among those assigned chocolate and cherry flavours. e-Cigarette vaping rates also differed significantly by flavour assigned, with the highest vaping rates for tobacco- and cherry-flavoured e-cigarettes, and the lowest rates for those assigned to chocolate.

CONCLUSIONS

The findings suggest that adoption of e-cigarettes in smokers may influence smoking rates and that e-cigarette flavourings can moderate this effect. e-Cigarette vaping rates are also influenced by flavourings. These findings may have implications for the utility of e-cigarettes as a nicotine replacement device and for the regulation of flavourings in e-cigarettes for harm reduction.

Cigarette smoking and electronic cigarette vaping patterns as a function of e-cigarette flavourings

INTRODUCTION

The present study examined the influence of flavouring on the smoking and vaping behaviour of cigarette smokers asked to adopt e-cigarettes for a period of 6 weeks.

METHODS

Participants were 88 current male and female smokers with no intention to stop smoking, but who agreed to substitute e-cigarettes for their current cigarettes. On intake, participants were administered tests of taste and smell for e-cigarettes flavoured with tobacco, menthol, cherry and chocolate, and were given a refillable e-cigarette of their preferred flavour or a control flavour. Participants completed daily logs of cigarette and e-cigarette use and were followed each week.

RESULTS

Analyses over days indicated that, during the 6-week e-cigarette period, cigarette smoking rates dropped from an average of about 16 to about 7 cigarettes/day. e-Cigarette flavour had a significant effect such that the largest drop in cigarette smoking occurred among those assigned menthol e-cigarettes, and the smallest drop in smoking occurred among those assigned chocolate and cherry flavours. e-Cigarette vaping rates also differed significantly by flavour assigned, with the highest vaping rates for tobacco- and cherry-flavoured e-cigarettes, and the lowest rates for those assigned to chocolate.

CONCLUSIONS

The findings suggest that adoption of e-cigarettes in smokers may influence smoking rates and that e-cigarette flavourings can moderate this effect. e-Cigarette vaping rates are also influenced by flavourings. These findings may have implications for the utility of e-cigarettes as a nicotine replacement device and for the regulation of flavourings in e-cigarettes for harm reduction.

Beliefs, Practices, and Self-efficacy of US Physicians Regarding Smoking Cessation and Electronic Cigarettes: A National Survey

INTRODUCTION

We sought to assess physician knowledge/beliefs, self-efficacy, and experience/practice patterns surrounding smoking cessation and electronic cigarettes.

METHODS

An eight-page survey sent via US Postal service. The initial invitation included a $10 cash incentive and up to three invitations were sent. Fifteen hundred US physicians were identified with equal representation from primary care physicians (internal medicine and family practice), surgical care physicians (general surgeons and anesthesiologists), and pulmonologists.

RESULTS

Two hundred fourteen were not included in the analysis (183 non-deliverable, one deceased, 30 not practicing). 561/1286 (44%) remaining surveys were returned for analysis. Greater than 90% agreed that advising and assisting with smoking cessation is their responsibility; 86% advise and 65% assist their patients with smoking cessation more than 75% of the time. Approximately two-thirds of respondents report that their patients ask them about electronic cigarettes at least some of the time (≥25%); 58.4% report that they ask their patients about electronic cigarette use at least some of the time. Overall, 37.9% have at some point recommended electronic cigarettes to their patients that smoke, with 11.5% reporting recommending them at least 25% of the time. Surgical care providers appear less confident and less self-efficacious with smoking cessation, as well as with electronic cigarettes and appear less likely to endorse use of electronic cigarettes.

DISCUSSION

US physicians are frequently discussing electronic cigarettes in a clinical context and a substantial proportion of US physicians have recommended electronic cigarettes to their patients.

IMPLICATIONS

This study documents several important previously poorly characterized aspects of the role of electronic cigarettes in clinical care. The majority of US physicians are discussing electronic cigarettes in clinical contexts and a substantial proportion of US physicians have recommended electronic cigarettes to their patients. The extent of physician engagement on the topic of electronic cigarettes should be met with increased efforts to better characterize electronic cigarettes' appropriate role in smoking cessation and reduction.

E-cigarettes for the management of nicotine addiction

In this review, we discuss current evidence on electronic cigarettes (ECs), a rapidly evolving class of nicotine delivery system, and their role in managing nicotine addiction, specifically in helping smokers to quit smoking and/or reduce the amount of tobacco they smoke. The current evidence base is limited to three randomized trials (only one compares ECs with nicotine replacement therapy) and a growing number of EC user surveys (n=6), case reports (n=4), and cohort studies (n=8). Collectively, these studies suggest modest cessation efficacy and a few adverse effects, at least with the short-term use. On this basis, we provide advice for health care providers on providing balanced information for patients who enquire about ECs. More research, specifically well-conducted large efficacy trials comparing ECs with standard smoking cessation management (eg, nicotine replacement therapy plus behavioral support) and long-term prospective studies for adverse events, are urgently needed to fill critical knowledge gaps on these products.

Appeal of electronic cigarettes in smokers with serious mental illness

INTRODUCTION

Up to 75% of people with serious mental illness (SMI) smoke, and most are highly dependent on nicotine, consuming more cigarettes per day than smokers without mental illness. Even with evidence-based treatment, relapses are common, resulting in high morbidity and early mortality from tobacco-related diseases. Electronic cigarettes (e-cigarettes) are theoretically safer because they deliver no tar or carbon monoxide; however, their appeal is largely untested in people with SMI.

METHODS

We enrolled 21 chronic smokers with SMI who had failed a quit attempt and were not engaged in cessation treatment. Research staff provided e-cigarettes and instructions on how to use them, and assessed participants weekly for 4weeks.

RESULTS

Of the enrolled participants, 19 completed weekly assessments. From baseline to the final study visit, mean self-reported use of combustible tobacco declined from 192 to 67cigarettes/week (t=3.62, df=17, p=0.005), confirmed by reduction in breath carbon monoxide from 27ppm to 15ppm (t=3.246, df=18, p=0.004). Use of e-cigarettes did not escalate over the 4weeks. Temporary and mild side effects, including dry/sore throat, nausea, dizziness, and cough, were reported by 58% of participants. End of trial ratings of enjoyment, satisfaction compared to regular cigarettes, and willingness to buy e-cigarettes were high (ranging from 3.82-4.51 on a 5-point scale).

CONCLUSIONS

Results of this study suggest that people with SMI may find e-cigarettes an appealing substitute for combustible cigarettes. We found no evidence of increasing nicotine dependence. Further randomized studies are needed to better assess e-cigarette appeal and toxicity.