Adolescents' interest in trying flavoured e-cigarettes

Chemical Analysis of Exhaled Vape Emissions: Unraveling the Complexities of Humectant Fragmentation in a Human Trial Study

Electronic cigarette smoking (or vaping) is on the rise, presenting questions about the effects of secondhand exposure. The chemical composition of vape emissions was examined in the exhaled breath of eight human volunteers with the high chemical specificity of complementary online and offline techniques. Our study is the first to take multiple exhaled puff measurements from human participants and compare volatile organic compound (VOC) concentrations between two commonly used methods, proton-transfer-reaction time-of-flight mass spectrometry (PTR-ToF-MS) and gas chromatography (GC). Five flavor profile groups were selected for this study, but flavor compounds were not observed as the main contributors to the PTR-ToF-MS signal. Instead, the PTR-ToF-MS mass spectra were overwhelmed by e-liquid thermal decomposition and fragmentation products, which masked other observations regarding flavorings and other potentially toxic species associated with secondhand vape exposure. Compared to the PTR-ToF-MS, GC measurements reported significantly different VOC concentrations, usually below those from PTR-ToF-MS. Consequently, PTR-ToF-MS mass spectra should be interpreted with caution when reporting quantitative results in vaping studies, such as doses of inhaled VOCs. Nevertheless, the online PTR-ToF-MS analysis can provide valuable qualitative information by comparing relative VOCs in back-to-back trials. For example, by comparing the mass spectra of exhaled air with those of direct puffs, we can conclude that harmful VOCs present in the vape emissions are largely absorbed by the participants, including large fractions of nicotine.

The e-liquid flavoring cinnamaldehyde induces cellular stress responses in human proximal tubule (HK-2) kidney cells

Flavored e-liquid use has become popular among e-cigarette users recently, but the effects of such products outside the lung are not well characterized. In this work, acute exposure to the popular flavoring cinnamaldehyde (CIN) was performed on human proximal tubule (HK-2) kidney cells. Cells were exposed to 0-100 µM CIN for 24-48 h and cellular stress responses were assessed. Mitochondrial viability via MTT assay was significantly decreased at 20 µM for 24 and 48 h exposure. Seahorse XFp analysis showed significantly decreased mitochondrial energy output at 20 µM by 24 h exposure, in addition to significantly reduced ATP Synthase expression. Seahorse analysis also revealed significantly decreased glycolytic function at 20 µM by 24 h exposure, suggesting inability of glycolytic processes to compensate for reduced mitochondrial energy output. Cleaved caspase-3 expression, a mediator of apoptosis, was significantly increased at the 24 h mark. C/EBP homologous protein (CHOP) expression, a mediator of ER-induced apoptosis, was induced by 48 h and subsequently lost at the highest concentration of 100 µM. This decrease was accompanied by a simultaneous decrease in its downstream target cleaved caspase-3 at the 48 h mark. The autophagy marker microtubule-associated protein 1 A/1B light chain 3 (LC3B-I and LC3B-II) expression was significantly increased at 100 µM by 24 h. Autophagy-related 7 (ATG7) protein and mitophagy-related proteins PTEN-induced putative kinase 1 (PINK1) and PARKIN expression were significantly reduced at 24 and 48 h exposure. These results indicate acute exposure to CIN in the kidney HK-2 model induces mitochondrial dysfunction and cellular stress responses.

Using Eye tracking to Examine Young Adults' Visual Attention to E-cigarette Advertising Features and Associated Positive E-cigarette Perceptions

BACKGROUND

Little is known about the influence of e-cigarette marketing features on the antecedents of e-cigarette use.

PURPOSE

Using an eye-tracking experiment, we examined visual attention to common features in e-cigarette ads and its associations with positive e-cigarette perceptions among young adults.

METHODS

Young adults (ages 18-29) who smoke cigarettes (n = 40) or do not use tobacco (n = 71) viewed 30 e-cigarette ads on a computer screen. Eye-tracking technology measured dwell time (fixation duration) and entry time (time to first fixation) for 14 pre-defined ad features. Participants then completed a survey about perceptions of e-cigarettes shown in the ads. We used regression models to examine the associations between ad features and standardized attention metrics among all participants and by tobacco-use status and person-aggregated standardized attention for each ad feature and positive e-cigarette perceptions.

RESULTS

Dwell time was the longest for smoker-targeted claims, positive experience claims, and price promotions. Entry time was the shortest for multiple flavor descriptions, nicotine warnings, and people. Those who do not use tobacco had a longer dwell time for minor sales restrictions and longer entry time for purchasing information than those who smoke. Longer dwell time for multiple flavor descriptions was associated with e-cigarette appeal. A shorter entry time for fruit flavor description was associated with positive e-cigarette-use expectancies.

CONCLUSIONS

Young adults allocated attention differently to various e-cigarette ad features, and such viewing patterns were largely similar by tobacco-use statuses. Multiple or fruit flavors may be the features that contribute to the positive influence of e-cigarette marketing among young adults.

Impact of Electronic Cigarette use on Cardiovascular Health: Current Evidence, Causal Pathways, and Public Health Implications

Electronic cigarette (e-cigarette) use is increasing in Europe and the USA. While mounting evidence exists regarding an array of associated adverse health effects, to date limited evidence exists regarding the health effects of e-cigarette use on cardiovascular (CV) disease (CVD). The present review summarizes the effects of e-cigarette use on CV health. A search strategy of in vivo experimental, observational studies (including population-based cohort studies), and interventional studies was conducted in PubMed, MEDLINE, and Web of Science (April 1, 2009-April 1, 2022). The main findings revealed that the influence of e-cigarette on health are attributed mainly to the individual and interactive effects of flavors and additives used in e-cigarette fluids, along with the extended heating. The above collectively stimulate prolonged sympathoexcitatory CV autonomic effects, such as increased heart rate and diastolic blood pressure (BP), as well as decreased oxygen saturation. Hence, e-cigarette users are at increased risk of developing atherosclerosis, hypertension, arrhythmia, myocardial infarction, and heart failure. Such risks are anticipated to increase, especially among the young who are increasingly adopting e-cigarette use particularly with flavored additives. Further investigations are urgently needed to evaluate the long-term effects of e-cigarette use, particularly among susceptible population groups such as youth.

The E-liquid flavoring vanillin alters energy and autophagic pathways in human proximal tubule (HK-2) epithelial cells

The use of flavored e-liquids in electronic nicotine delivery systems (ENDS) has become very popular in recent years, but effects of these products have not been well characterized outside the lung. In this study, acute exposure to the popular flavoring vanillin (VAN) was performed on human proximal tubule (HK-2) kidney cells. Cells were exposed to 0-1000 μM VAN for 24 or 48 h and cellular stress responses were determined. Mitochondrial viability using MTT assay showed a significant decrease between the control and 1000 μM group by 48 h. Seahorse XFp analysis showed significantly increased basal respiration, ATP production, and proton leak after 24 h exposure. By 48 h exposure, these parameters remained significantly increased in addition to non-mitochondrial respiration and maximal respiration. Glycolytic activity after 24 h exposure showed significant decreases in glycolysis, glycolytic capacity, glycolytic reserve, and non-glycolytic acidification. The autophagy markers microtubule-associated protein 1A/1B light chain 3 (LC3B-I and LC3B-II) were probed via western blotting. The ratio of LC3B-II/LC3B-I was significantly increased after 24 h exposure to VAN, but by 48 h this ratio significantly decreased. The mitophagy marker PINK1 showed an increasing trend at 24 h, and its downstream target Parkin was significantly increased between the control and 750 μM group only. Finally, the oxidative stress marker 4-HNE was significantly decreased after 48 h exposure to VAN. These results indicate that acute exposure to VAN in the kidney HK-2 model can induce energy and autophagic changes within the cell.

Analysis of e-cigarette warning letters issued by the Food and Drug Administration in 2020 and 2021

PURPOSE

This study analyses the Food and Drug Administration (FDA) warning letters sent to e-cigarette companies from 1 January 2020 to 9 September 2021. Study results can inform regulation of e-cigarettes.

METHODOLOGY

Warning letters retrieved from FDA's website were coded for company type (retailer, manufacturer or distributor), location (domestic or international), infractions listed (PMTA (premarket tobacco product application), selling to minors, advertising to youth or packaging violation/mislabelling), product type (e-liquid, device or both), flavour (fruit, candy, tobacco, menthol/mint, concept flavour) and consequence (civil money penalties, product seizure and injunction, product detention and refusal of entry to the USA, no-tobacco-sales order, criminal prosecution).

RESULTS

Of 303 coded letters (126 from 2020 and 177 from 2021), 97.4% were sent to small online retailers. Overall, 94.1% of the companies cited were located within the USA, 75.2% of the infractions were identified by reviewing a company's website and 70.5% were PMTA violations. In 2020, 55.6% of infractions were PMTA violations; in 2021, nearly all infractions were PMTA violations. The letters cited 880 products; 92.2% of which were e-liquid products, with 32.4% fruit and 31.1% concept flavours.

DISCUSSION

Warning letters targeted small online retailers rather than large e-cigarette brands or products most used by youth: pod mods and disposables. The focus of these enforcement actions comprises a small share of the market and the impact on use was likely minimal. With PMTA decisions pending for the largest brands of e-cigarettes, the FDA should use its enforcement powers to target manufacturers, distributors and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.

Personality Risk Factors for Vape Use amongst Young Adults and Its Consequences for Sleep and Mental Health

(1) Background: The surge in vape (e-cigarette) use among young adults is concerning, as there is limited knowledge about risk factors and health consequences. This study explores the personality traits linked to vape use, and associations between vaping and chronotype, sleep quality, and mental health, among young adults. (2) Methods: 316 participants, aged 18-25, completed measurements of mindfulness, rumination, self-compassion, anxiety/depression, chronotype, and sleep quality. (3) Results: the vape user group scored significantly lower on mindfulness, higher on rumination, and lower on self-compassion. Vape users were more likely to be evening types and had significantly lower sleep quality and higher anxiety symptoms, as well as higher alcohol use and loneliness (at trend) (4) Conclusions: These novel findings enhance our understanding of what might predispose young adults to vaping and the potential impact on their mental health and sleep quality. Findings point to specific cognitive/personality traits as vaping risk factors, which could inform intervention strategies.

Qualitative perspective on nicotine pouches from adults who smoke cigarettes in North Carolina

BACKGROUND

Little is known about how nicotine pouch products are perceived by people who smoke, including if they are perceived as a cessation aid or a substitute for when they cannot smoke. We qualitatively investigated the reactions and perceptions about On!, a leading brand of nicotine pouches.

METHODS

We conducted online semistructured interviews with 30 adults who smoke cigarettes. Participants viewed an On! brochure and an image of an opened nicotine pouch and were asked about their initial impression, who the intended user is, and how they thought of the product's safety compared with other tobacco and cessation products. Transcripts were independently coded and the data were analysed using thematic content analysis.

RESULTS

Among the participants, half identified as female and slightly more than half were white (n=16). The mean age was 43 years old. The following are the central themes that emerged: (1) participants perceived the concealability, flavours and packaging of On! as appealing to youth and young adults; (2) participants perceived nicotine pouches as a product that would supplement rather than replace tobacco use; and (3) the product raised health concerns, which decreased interest in trying nicotine pouches.

CONCLUSIONS

Participants believed that the On! nicotine pouch promotional material may promote youth and young adult nicotine product initiation and dual product use for people who smoke. Most viewed On! as a product to use with cigarettes, rather than a way to quit cigarettes. Increased surveillance of nicotine pouches is warranted to monitor the trajectory of this emerging tobacco product and prevent youth initiation.

A clinical overview of adolescent e-cigarette use (vaping)

E-cigarette use (also known as "vaping") has become increasingly popular among adolescents over the past decade and grown into a significant public health concern in North America, the United Kingdom, and other countries. Concerns about this new trend have generated numerous new research studies. This aim of this study was to summarize recent scientific findings, with a focus on their relevance to clinicians working with adolescents. The first half covers epidemiology, risk factors for e-cigarette use, characteristics of e-cigarette use, youth perceptions of e-cigarettes, physical health risks of e-cigarettes, evidence for "gateway effects" of e-cigarette exposure on subsequent substance use, and the relationship between e-cigarette use and mental health. The review concludes with a clinical focus on assessment of youth who vape, psychoeducation for youth and families, clinical management of vaping, and regulatory considerations.

Trajectories of body mass index and combustible and electronic cigarette use across adolescence: Findings from the PATH study

PURPOSE

Associations between empirically-generated body mass index (BMI) trajectories and risk of current use of combustible cigarettes and e-cigarettes across adolescence were examined using longitudinal data from the Population Assessment of Tobacco and Health (PATH) study.

METHODS

The PATH study is an ongoing annual longitudinal population-based study of adolescents. We utilized Waves 1-4 conducted from 2013 to 2017. Adolescents completed self-reported surveys of their height, weight, and current tobacco use at Waves 1-4 and their tobacco weight control beliefs at Waves 1-2.

RESULTS

Using latent growth mixture modeling, six trajectories of BMI were identified. The largest group ("normal weight increasing;" n = 4,858; 86.6 %), which was used as the comparator in subsequent analyses, consisted of adolescents ages 12-17 who were normal weight at Wave 1 with a significant increase in BMI across Waves 2--4. The "overweight early increasing," "overweight late increasing," and "obesity stable" classes had greater likelihood of current combustible cigarette use during the study compared to the "normal weight increasing class." The "overweight early increasing," "overweight late increasing," and "overweight increasing then decreasing" classes showed elevated risk for e-cigarette use during the study. Compared to those in the "normal weight increasing" class, those in the "overweight increasing then decreasing" and "obesity stable" classes had greater weight control beliefs at Wave 1 and those in the "obesity stable" class had greater weight control beliefs at Wave 2.

CONCLUSIONS

Findings highlight the importance of weight trajectories and weight control beliefs by tobacco product use across adolescence and the need for mechanistic and intervention research.

Cross-state Border Nicotine Vaping Products Purchase - Early Evidence from State Emergency Sales Restrictions in 2019

INTRODUCTION

While retail sales and retailer inspection studies generally indicate high compliance with state sales restrictions on Nicotine Vaping Products (NVPs) within the restricted area, studies using survey data generally indicate that most users could readily continue gaining access to restricted NVPs. Our study bridges a gap in the current literature and investigates the potential role of cross-state border purchases to evade state emergency NVP sales restrictions in 2019.

METHODS

The study sample was restricted to NVP sales from the states neighboring Massachusetts (MA), Rhode Island (RI), and Washington (WA), three states that implemented all NVP or flavored NVP sales restrictions in 2019. Among these neighboring states, the 2019 weekly county-level NVP sales by flavors (tobacco, mint/menthol, and other flavors) were compiled using Nielsen Scanner data. A quasi-experimental, comparison group pre-post study design was used to study the impacts of NVP sales restrictions on cross-state border NVP purchases.

RESULTS

Weekly NVP sales for border counties significantly increased in response to the MA, RI, and WA bans for tobacco flavored (56%, 45%, 14%, respectively), menthol/mint flavored (51%, 2%, 41%, respectively), and other flavored (79%, 3%, 4%, respectively) products, compared to sales for non-border counties (all p-values <0.01).

CONCLUSIONS

Our study identified significant cross-state border NVP purchases in all studied states to circumvent NVP emergency sales restrictions in response to the EVALI outbreak. Policymakers should factor in these purchasing behaviors to evade sales restrictions when evaluating any future potential policies at the state or local levels.

IMPLICATIONS

While retail sales data and retailer inspections indicate high compliance with Nicotine Vaping Product (NVP) flavor sales restrictions from major retail outlets, survey data obtain mixed findings on the effects of sales restrictions on vaping behaviors. Our study identified a significant increase in cross-state border NVP purchases to circumvent NVP sales restrictions in 2019, consistent across all three settings of Massachusetts, Rhode Island, and Washington. Policymakers should factor in these cross-state border NVP purchases in response to sales restrictions when evaluating any future potential NVP sales restrictions.

Exposure to Aldehyde Cherry e-Liquid Flavoring and Its Vaping Byproduct Disrupt Pulmonary Surfactant Biophysical Function

Over the past decade, there has been a significant rise in the use of vaping devices, particularly among adolescents, raising concerns for effects on respiratory health. Pressingly, many recent vaping-related lung injuries are unexplained by current knowledge, and the overall implications of vaping for respiratory health are poorly understood. This study investigates the effect of hydrophobic vaping liquid chemicals on the pulmonary surfactant biophysical function. We focus on the commonly used flavoring benzaldehyde and its vaping byproduct, benzaldehyde propylene glycol acetal. The study involves rigorous testing of the surfactant biophysical function in Langmuir trough and constrained sessile drop surfactometer experiments with both protein-free synthetic surfactant and hydrophobic protein-containing clinical surfactant models. The study reveals that exposure to these vaping chemicals significantly interferes with the synthetic and clinical surfactant biophysical function. Further atomistic simulations reveal preferential interactions with SP-B and SP-C surfactant proteins. Additionally, data show surfactant lipid-vaping chemical interactions and suggest significant transfer of vaping chemicals to the experimental subphase, indicating a toxicological mechanism for the alveolar epithelium. Our study, therefore, reveals novel mechanisms for the inhalational toxicity of vaping. This highlights the need to reassess the safety of vaping liquids for respiratory health, particularly the use of aldehyde chemicals as vaping flavorings.

Effects of flavour and modified risk claims on nicotine pouch perceptions and use intentions among young adults who use inhalable nicotine and tobacco products: a randomised controlled trial

BACKGROUND

Availability of flavours and potential modified risk tobacco product (MRTP) claims may influence young adults' (YAs') perceptions of and intentions to use nicotine pouches ('pouches').

METHODS

YAs aged 21-34 years (N=47, M age=24.5, SD=3.1) with past-month nicotine/tobacco use (10.6% cigarette-only, 51.1% e-cigarette-only, 38.3% dual use) and no intention to quit were randomised to self-administer four Zyn 3 mg nicotine pouches in a 4 (flavour; within-subjects: smooth, mint, menthol, citrus) × 2 (MRTP claim on packaging; between subjects: present or absent) mixed-factorial design. After self-administering each pouch, participants reported appeal, use intentions and perceived harm compared with cigarettes and e-cigarettes. Three mixed-factorial analysis of variances (ANOVAs) examined main and interactive effects of flavour and MRTP claim on appeal, use intentions and comparative harm perceptions.

RESULTS

Mint (M=55.9, SD=26.4), menthol (M=49.7, SD=26.8) and citrus (M=46.6, SD=24.8) flavours were significantly more appealing than smooth (M=37.6, SD=25.4; p<0.001). MRTP claim did not significantly affect product appeal (p=0.376). Use intentions were greater for mint (M=2.6, SD=1.3) and menthol (M=2.0, SD=1.1) flavours than smooth (M=1.8, SD=1.0; p=0.002). Flavour did not affect comparative harm perceptions (p values>0.418). MRTP claims increased use intention (p=0.032) and perceptions of pouches as less harmful than cigarettes (p=0.011), but did not affect perceived harm relative to e-cigarettes (p=0.142). Flavour × MRTP claim interactions were not significant.

CONCLUSIONS

Flavoured (vs smooth) pouches were more appealing to YAs. MRTP claims reduced perceived harm of pouches compared with cigarettes; however, intentions to switch were low. To protect YAs' health, regulatory restrictions could target flavours and MRTP claims.

E-cigarette attitudes and behaviours amongst 15-30-year-olds in the UK

BACKGROUND

The use of e-cigarettes has been rising in the UK, particularly by young people. This study investigated behaviours, attitudes and beliefs about e-cigarettes amongst 15-30-year-olds in the UK.

METHODS

An online survey was administered to a sample of 1009 15-30-year-olds in the UK.

RESULTS

About one in five participants currently used e-cigarettes at least monthly, with 1 in 10 using them daily. Amongst those using e-cigarettes at least monthly, 90% had used e-cigarettes containing nicotine. E-cigarettes were mainly obtained from vape shops and used at home. Having friends who used e-cigarettes and using them to help quit/reduce smoking were the most common reasons for vaping. About half of participants had been exposed to e-cigarette advertising, especially online, and warning labels on e-cigarettes. Most participants agreed that e-cigarettes are addictive (75%), help people quitting smoking (64%) and are bad for health (63%). Previous or current tobacco smokers were 9 and 22 times more likely to use e-cigarettes than never smokers, respectively. Perceiving e-cigarettes as harmful was associated with a 40% lower likelihood of use.

CONCLUSION

Raising awareness on the uncertain long-term consequences of vaping and regulation of marketing and sales are crucial to protect young people in the UK.

Flavoring Agents in E-cigarette Liquids: A Comprehensive Analysis of Multiple Health Risks

The availability of a wide range of flavored e-cigarettes is one of the primary reasons for vaping initiation and persistent use among adolescents and young people. This plethora of flavors available on the market are crafted using different flavoring agents such as cinnamaldehyde, vanillin, benzaldehyde, ethyl maltol, menthol, and dimethylpyrazine. Recent studies have brought to light the potential risks associated with e-cigarette flavoring agents and their effects on various organ systems, both with and without nicotine. Research has demonstrated that flavoring agents can induce inflammation, endothelial dysfunction, epithelial barrier disruption, oxidative stress, DNA damage, electrophysiological alterations, immunomodulatory effects, and behavioral changes, even independently of nicotine. Notably, these negative outcomes adversely affect cardiovascular system by reducing cell viability, decreasing endothelial nitric oxide synthase, nitric oxide bioavailability, soluble guanylyl cyclase activity and cyclic guanosine monophosphate accumulation, impairing endothelial proliferation and tube formation, and altering vasoreactivity resulting in vascular dysfunction. In the heart, these agents decrease parasympathetic activity, induce depolarization of resting membrane potential, loss of rhythmicity, increase isovolumic relaxation time, and change in ventricular repolarization and ventricular tachyarrhythmias. It is found that the specific response elicited by flavoring agents in different organ systems varies depending on the flavor used, the concentration of the flavoring agent, and the duration of exposure. However, the literature on the effects of flavoring agents is currently limited, emphasizing the need for more preclinical and randomized clinical trials to gain a deeper understanding and provide further evidence of the harmful effects of flavored e-cigarette use. In summary, recent research suggests that flavoring agents themselves can have detrimental effects on the body. To fully comprehend these effects, additional preclinical and clinical studies are needed to explore the risks associated with flavored e-cigarette usage.

Adverse Biophysical Impact of e-Cigarette Flavors on Pulmonary Surfactant

The attractiveness and abundance of flavors are primary factors eliciting youth to use e-cigarettes. Emerging studies in recent years revealed the adverse health impact of e-cigarette flavoring chemicals, including disruption of the biophysical function of pulmonary surfactants in the lung. Nevertheless, a comprehensive understanding of the biophysical impact of various flavoring chemicals is still lacking. We used constrained drop surfactometry as a new alternative method to study the biophysical impact of flavored e-cigarette aerosols on an animal-derived natural pulmonary surfactant. The dose of exposure to e-cigarette aerosols was quantified with a quartz crystal microbalance, and alterations to the ultrastructure of the surfactant film were visualized using atomic force microscopy. We have systematically studied eight representative flavoring chemicals (benzyl alcohol, menthol, maltol, ethyl maltol, vanillin, ethyl vanillin, ethyl acetate, and ethyl butyrate) and six popular recombinant flavors (coffee, vanilla, tobacco, cotton candy, menthol/mint, and chocolate). Our results suggested a flavor-dependent inhibitory effect of e-cigarette aerosols on the biophysical properties of the pulmonary surfactant. A qualitative phase diagram was proposed to predict the hazardous potential of various flavoring chemicals. These results provide novel implications in understanding the environmental, health, and safety impacts of e-cigarette aerosols and may contribute to better regulation of e-cigarette products.

Flavored Cannabis Use and Cannabis-Tobacco Co-use: Patterns In U.S. States With Legalized Nonmedical Adult Use

INTRODUCTION

Little is known about inhaled flavored cannabis use. This study aimed to investigate the prevalence and patterns of flavored cannabis use and cannabis-tobacco co-use.

METHODS

This study surveyed adult past 30-day cannabis users in U.S. states and districts that have legalized cannabis for nonmedical/adult use (n=9) (November 2018; n=2,978). By product/behavior (any cannabis, cannabis extract vaporizers, mixed cannabis-nicotine vaporizers, blunts, chasing), the association between flavored (versus non-flavored) use and sociodemographic characteristics, cannabis use disorder symptoms, and tobacco use was estimated using weighted multivariable logistic regression in January 2022.

RESULTS

Almost half of adult cannabis users reported using at least one flavored cannabis product (46.5%). Flavored cannabis use was more likely among respondents who were female (AOR=1.2, CI=1.0, 1.4), were Black (ref: White; AOR=2.2, CI=1.5, 3.1), were Hispanic/Latino/a/x (ref: White; AOR=1.6, CI=1.2, 1.9), had cannabis use disorder symptoms (AOR=2.0, CI=1.6, 2.4), or were currently using tobacco (AOR=2.4, CI=2.1, 2.9). Use was less likely among middle-aged/older adults (ref: ages 21-34 vs 35-49 years; AOR=0.6, CI=0.5, 0.7).

CONCLUSIONS

Observed differences in flavored cannabis use are concerning if flavors raise appeal or dependence. Integrating flavored cannabis and tobacco research and practice is warranted.

Factors associated with e-cigarette use among vocational students: A cross-sectional multistage cluster survey, Thailand

INTRODUCTION

The use of e-cigarettes has steadily increased, and vocational students are one primary target of e-cigarette marketing. This cross-sectional survey research aimed to explore e-cigarette use and examine the factors associated with it.

METHODS

Multistage cluster random sampling was employed to select 1536 students in vocational education institutions. A self-administered questionnaire was used to collect the data from September to December 2019. Multinomial logistic regression analysis was used to obtain the adjusted odds ratio (AOR) to determine the associated factors of e-cigarette use.

RESULTS

Altogether, 28.7% of the subjects were currently e-cigarette users, 7.4% used e-cigarettes only, and 21.3% were dual users. Various factors were found to be significantly associated with e-cigarette use by 43.7%. Those consisted of sex (male) (AOR=2.183; 95% CI: 1.510-3.157), grade point average (GPA) of <2.5 (AOR=2.363; 95% CI: 1.502-3.717), having neutral attitudes toward e-cigarette use (AOR=2.676; 95% CI: 1.499-4.779) and positive attitudes toward e-cigarette use (AOR=4.171; 95% CI: 2.250-7.734), moderate level of perceived behavioral control on e-cigarette use (AOR=3.520; 95% CI: 2.287-5.418) and low level of perceived behavioral control on e-cigarettes use (AOR=4.959; 95% CI: 3.274-7.511), moderate price of e-cigarettes (AOR=1.436; 95% CI: 1.009-2.044), and e-cigarette use of their parents (AOR=1.827; 95% CI: 1.137-2.938), close friends (AOR=4.327; 95% CI: 2.954-6.338) and idols (AOR=4.604; 95% CI: 1.844-11.497).

CONCLUSIONS

Students should be encouraged to develop negative attitudes toward e-cigarette use and increase their self-confidence to control the use of e-cigarettes. This can be achieved by regularly distributing information on the product's risks. Moreover, students can find inspiration and guidance from peers, close friends, or their idols, who will act as positive role models and inspire them not to initiate e-cigarette use.

"I Get the Flavors and It Makes Me Love Vaping More": How and Why Youth Users Modify Electronic Nicotine Delivery Systems

INTRODUCTION

Youth in the United States are using electronic nicotine delivery systems (ENDS) at a high rate. Modifications to ENDS by youth can introduce additional health hazards which have not been previously considered. To better understand these risks, we need more information on what these modifications are, the motivations behind them, and the sources of information on modifications.

AIMS AND METHODS

Utilizing a trained moderator, in 2020-2021, we conducted one-on-one interviews with 19 youth ENDS users aged 16-17 living in the United States and analyzed their responses using a qualitative description approach.

RESULTS

The most prominent modification was to the e-liquid; youth indicated they mixed e-juices to create new flavors and added substances not intended for vaping, including illicit drugs such as cannabis and cocaine. Few youths from our sample were interested in achieving a specific nicotine level to vape, and modifications to the battery, coil and wick were less frequently mentioned. Some of these modifications were motivated by a desire to achieve specific experiences with their device. At other times, modifications were made due to necessity because of limited access to ENDS devices and supplies. YouTube and peers were the main sources of information about modifying.

CONCLUSIONS

Youth are making modifications that are both intended and unintended by the manufacturer. Adding illicit drugs and other substances not made for vaping is of particular concern. Understanding how youth modify ENDS and how that changes their use is important to guide regulatory policy intended to reduce harm to youth from ENDS use.

IMPLICATIONS

Youth from our study indicated that they make modifications to the ENDS devices, specifically to the e-liquid. These modifications are both intended by the manufacturer, such as changing the e-liquid and replacing coils, and unintended, such as adding substances not meant for vaping. Future policies aimed at reducing youth ENDS use should consider mandating better safeguards against modifications that appeal to youth.

Longitudinal Association Between Exclusive and Dual Use of Cigarettes and Electronic Nicotine Delivery Systems and Asthma Among U.S. Adolescents

PURPOSE

Electronic Nicotine Delivery Systems (ENDS) use among adolescents has increased greatly over the past decade, but its impact on chronic respiratory health conditions, like asthma, is not fully understood.

METHODS

We examined data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study using discrete time hazard models to analyze the association between time-varying tobacco product use and incident diagnosed asthma among adolescents aged 12-17 years at baseline. We lagged the time-varying exposure variable by one wave and categorized respondents by current use status (1+ days in the past 30 days): never or non-current, exclusive cigarette, exclusive ENDS, and dual cigarette and ENDS use. We also controlled for sociodemographic (age, sex, race/ethnicity, parental education) and other risk factors (urban/rural setting, secondhand smoke exposure, household combustible tobacco use, body mass index).

RESULTS

At baseline, over half the analytic sample (n = 9,141) was 15-17 years old (50.4%), female (50.2%), and non-Hispanic White (55.3%). Adolescents who exclusively smoked cigarettes had a statistically significant higher risk of incident diagnosed asthma at follow-up (adjusted Hazard Ratio (aHR): 1.68, 95% confidence interval (CI): 1.21-2.32) compared to those not currently using cigarettes or ENDS, but adolescents using ENDS exclusively (aHR: 1.25, 95% CI: 0.77-2.04) or in combination with cigarettes (aHR: 1.54, 95% CI: 0.92-2.57) did not.

DISCUSSION

Short-term exclusive cigarette use was associated with a higher risk of incident diagnosed asthma over five years of follow-up among adolescents. We did not find conclusive evidence for an association between exclusive ENDS or dual use and incident diagnosed asthma.

The nicotine and tobacco epidemic among adolescents: new products are addicting our youth

PURPOSE OF REVIEW

New nicotine and tobacco products such as electronic cigarettes and oral nicotine products have increased in use and threaten to addict a new generation of youth. This review summarizes current literature on nicotine and tobacco products used by youth, epidemiology, health effects, prevention and treatment of nicotine dependence, and current policies and regulations.

RECENT FINDINGS

Electronic cigarettes and oral nicotine products are popular among youth, attracting adolescents through exposure to deceptive marketing and fruit, candy and dessert flavors. Electronic cigarettes and oral nicotine product use can lead to nicotine addiction and is associated with respiratory, cardiovascular, and oral health problems, although long-term health effects are not fully known. The Food and Drug Administration (FDA) has authority to regulate nicotine and tobacco products; however, thousands of unregulated and unauthorized products remain on the market.

SUMMARY

Millions of adolescents continue to use nicotine and tobacco products, which puts them at risk for health problems, including nicotine addiction. Pediatric providers can provide prevention messages, screen youth for tobacco and nicotine use, and offer appropriate treatment options. Regulation of tobacco and nicotine products by the FDA is critical to reverse this public health epidemic of youth nicotine and tobacco use.

E-cigarettes may serve as a gateway to conventional cigarettes and other addictive drugs

Electronic cigarettes (e-cigarettes) are devices that allow the user to inhale nicotine in a vapor, and are primarily marketed as a means of quitting smoking and a less harmful replacement for traditional cigarette smoking. However, further research is needed to determine if vaping nicotine via e-cigarettes can be effective. Conversely, nicotine has been considered a gateway drug to alcohol and other addictive drugs and e-cigarettes containing nicotine may have the same effects. Previous reports have shown that e-cigarette use may open the gate for the use of other drugs including conventional cigarettes, cannabis, opioids, etc. The increasing prevalence of e-cigarettes, particularly among youth and adolescents in the last decade have led to an increase in the dual use of e-cigarettes with alcohol, cannabis, and other illicit drug use like heroin and 3-4-methylenedioxymethamphetamine (MDMA). The advent of e-cigarettes as a device to self-administer addictive agents such as cocaine and synthetic cathinones may bring about additional adverse health effects associated with their concurrent use. This review aims to briefly describe e-cigarettes and their different generations, and their co-use with other addictive drugs as well as the use of the device as a tool to self-administer addictive drugs, such as cocaine, etc.

A network approach to the symptom-level associations between smoking and posttraumatic stress disorder (PTSD) among young adults exposed to childhood sexual abuse

Background

Previous empirical literature has examined the associations between childhood sexual abuse (CSA) exposure, posttraumatic stress disorder (PTSD), and smoking. However, few studies examined symptom-level associations between smoking and PTSD among CSA victims. Thus, the aims of this study were 1) to explore symptom-level associations between smoking and PTSD among combustible cigarette (CC) and electronic cigarette (EC) users exposed to CSA and 2) to compare the differences manifested in two network structures between EC and CC users with CSA experiences.

Methods

This cross-sectional study covers all 63 universities and colleges in Jilin province, China, from October 26 to November 18, 2021. A total of 117 769 students participated in this study, while 3479 young adults were exposed to CSA (3.62%, 95% CI = 3.50%-3.73%). Childhood sexual abuse, PTSD, and smoking symptoms were measured using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), 10-item Trauma Screening Questionnaire (TSQ-10), and the 6-item Fagerstrom Test for Nicotine Dependence (FTND-6), respectively. In addition, network analysis was applied to analyse psychopathological symptoms between EC and CC users with CSA experiences. Both the edges and centralities were computed, and the network properties were compared among the two groups.

Results

Four symptoms of PTSD (i.e. emotional cue reactivity, hypervigilance, nightmares, and difficulty concentrating) were both central and bridge symptoms between PTSD and smoking among EC and CC users with CSA experiences. Moreover, compared with CC users with CSA, there were significantly stronger associations between "nightmares" - "difficulty with restrictions" and "irritability / anger" - "more during wake up" among young EC users with CSA.

Conclusions

The four symptoms (i.e. emotional cue reactivity, hypervigilance, nightmares, and difficulty concentrating) were keystones for treatments or interventions targeting these CSA victims with PTSD and smoking symptoms. Increasing efforts should be taken to restrict morning smoking among EC users with CSA. In addition, target interventions and strategies founded on these core symptoms and associations should be implemented to relieve the comorbid PTSD and smoking in EC and CC users with CSA experiences.

The characteristics and risk factors of e-cigarette use among adolescents in Shanghai: A case-control study

INTRODUCTION

This study was conducted to explore the characteristics and risk factors of e-cigarette use in adolescents, aiming for tobacco control and reducing e-cigarette use in this population.

METHODS

Using 1:1 matching, 88 students from three vocational high schools in Shanghai were recruited to conduct a case (using e-cigarettes) - control (not using e-cigarettes) study. Group interviews and questionnaire surveys were used for this qualitative and quantitative mixed-methods study. The keywords were extracted from the interview data and analyzed by the Colaizzi seven-step method.

RESULTS

The characteristics of adolescents' use of e-cigarettes include young age at first use, consumption of a large amount, as well as smoking in discrete locations in order to hide from adults. The reasons for using e-cigarettes include curiosity and wanting to replace traditional cigarettes. The risk factors of using e-cigarettes include insufficient understanding of the harm of e-cigarettes at the individual level (The positive outcome expectancy points: Z= -3.746, p<0.001; The negative outcome expectancy points: Z= -3.882, p<0.001), peer influence at the interpersonal level (χ²=6.510, p<0.01), and the influence of social and environmental factors such as e-cigarette sales in the stores and WeChat Moments (p<0.05 for all associations).

CONCLUSIONS

Having friends who use e-cigarettes, curiosity and sales exposure about e-cigarettes are important factors affecting the use of e-cigarettes by adolescents. It is necessary to strengthen the publicity of the potential hazards of e-cigarettes and to reduce overall usage by improving relevant laws and regulations.

Strawberry Additive Increases Nicotine Vapor Sampling and Systemic Exposure But Does Not Enhance Pavlovian-Based Nicotine Reward in Mice

Nicotine is an addictive drug whose popularity has recently increased, particularly among adolescents, because of the availability of electronic nicotine devices (i.e., "vaping") and nicotine e-liquids containing additives with rich chemosensory properties. Some efforts to understand the role of these additives in nicotine reward suggest that they increase nicotine reward and reinforcement, but the sensory contributions of additives, especially in their vapor forms, are largely untested. Here, to better understand how a fruit-flavored (i.e., strawberry) additive influences nicotine reward and aversion, we used a conditioned place preference (CPP) procedure in which nicotine and a strawberry additive were delivered as a vapor to male and female adolescent mice. We found that nicotine vapor alone can lead to a dose-dependent CPP when using a biased design. The strawberry additive did not produce CPP on its own, and we did not observe an effect of the strawberry additive on nicotine vapor-induced reward. Nevertheless, mice exposed to nicotine plus strawberry additive vapor had higher plasma cotinine concentrations, which did not appear to reflect altered nicotine metabolism. Instead, by directly measuring vapor sampling through respiration monitoring, we uncovered an increase in the amount of sniffing toward strawberry-containing nicotine vapor compared with nicotine vapor alone. Together these data indicate that chemosensory-rich e-liquid additives may enhance the perceived sensory profile of nicotine vapors rather than the reward value per se, which leads to overall increased nicotine exposure.

A Machine Learning Approach Reveals Distinct Predictors of Vaping Dependence for Adolescent Daily and Non-Daily Vapers in the COVID-19 Era

Since 2016, there has been a substantial rise in e-cigarette (vaping) dependence among young people. In this prospective cohort study, we aimed to identify the different predictors of vaping dependence over 3 months among adolescents who were baseline daily and non-daily vapers. We recruited ever-vaping Canadian residents aged 16-25 years on social media platforms and asked them to complete a baseline survey in November 2020. A validated vaping dependence score (0-23) summing up their responses to nine questions was calculated at the 3-month follow-up survey. Separate lasso regression models were developed to identify predictors of higher 3-month vaping dependence score among baseline daily and non-daily vapers. Of the 1172 participants, 643 (54.9%) were daily vapers with a mean age of 19.6 ± 2.6 years and 76.4% (n = 895) of them being female. The two models achieved adequate predictive performance. Place of last vape purchase, number of days a pod lasts, and the frequency of nicotine-containing vaping were the most important predictors for dependence among daily vapers, while race, sexual orientation and reporting treatment for heart disease were the most important predictors in non-daily vapers. These findings have implications for vaping control policies that target adolescents at different stages of vape use.

Psychoactive Comfort Products or Snacks: How Chinese Young Adults Perceive the Potentially Addictive Nature of E-Cigarettes

The potential health value and pitfalls of e-cigarettes are currently under dispute in the scientific community. Exploring young adult e-cigarette users' perceptions would assist in adding a public dimension of understanding to the literature and in scientific public health decision making. Therefore, in this study, we collected and analyzed data from interviews with young adult (n = 14) e-cigarette users and found that many referred to e-cigarettes as "snacks," indicating that they considered that both their frequency of use and addiction were manageable and that they could stop using e-cigarettes at any time. To further understand the behavior of Chinese young adults in relation to their perception of e-cigarettes as a "snack", the study developed a social context framework (crossroads model) and psychological judgment model to explain how youth e-cigarette users' perception of "controlled addiction and ready cessation" arises. These models can be used to assess the effectiveness of e-cigarette policy.

Untargeted Metabolomics to Characterize the Urinary Chemical Landscape of E-Cigarette Users

The health and safety of using e-cigarette products (vaping) have been challenging to assess and further regulate due to their complexity. Inhaled e-cigarette aerosols contain chemicals with under-recognized toxicological profiles, which could influence endogenous processes once inhaled. We urgently need more understanding on the metabolic effects of e-cigarette exposure and how they compare to combustible cigarettes. To date, the metabolic landscape of inhaled e-cigarette aerosols, including chemicals originated from vaping and perturbed endogenous metabolites in vapers, is poorly characterized. To better understand the metabolic landscape and potential health consequences of vaping, we applied liquid chromatography-mass spectrometry (LC-MS) based nontargeted metabolomics to analyze compounds in the urine of vapers, cigarette smokers, and nonusers. Urine from vapers (n = 34), smokers (n = 38), and nonusers (n = 45) was collected for verified LC-HRMS nontargeted chemical analysis. The altered features (839, 396, and 426 when compared smoker and control, vaper and control, and smoker and vaper, respectively) among exposure groups were deciphered for their structural identities, chemical similarities, and biochemical relationships. Chemicals originating from e-cigarettes and altered endogenous metabolites were characterized. There were similar levels of nicotine biomarkers of exposure among vapers and smokers. Vapers had higher urinary levels of diethyl phthalate and flavoring agents (e.g., delta-decalactone). The metabolic profiles featured clusters of acylcarnitines and fatty acid derivatives. More consistent trends of elevated acylcarnitines and acylglycines in vapers were observed, which may suggest higher lipid peroxidation. Our approach in monitoring shifts of the urinary chemical landscape captured distinctive alterations resulting from vaping. Our results suggest similar nicotine metabolites in vapers and cigarette smokers. Acylcarnitines are biomarkers of inflammatory status and fatty acid oxidation, which were dysregulated in vapers. With higher lipid peroxidation, radical-forming flavoring, and higher level of specific nitrosamine, we observed a trend of elevated cancer-related biomarkers in vapers as well. Together, these data present a comprehensive profiling of urinary biochemicals that were dysregulated due to vaping.

E-cigarette Use Patterns, Flavors, and Device Characteristics Associated With Quitting Smoking Among a U.S. sample of Adults Using E-cigarettes in a Smoking Cessation Attempt

INTRODUCTION

Many adults who smoke cigarettes use e-cigarettes to try to quit smoking; however, some are not successful. Identifying factors that are associated with successfully quitting smoking using e-cigarettes is important for maximizing cigarette cessation.

AIMS AND METHODS

Online survey data were collected in 2021 from 857 adults in the United States who reported using e-cigarettes in a recent attempt to quit smoking. Survey items assessed patterns of e-cigarette use and device characteristics (flavors, device, and nicotine) used when trying to quit smoking. Multivariable linear regression models examined characteristics associated with the longest duration of smoking abstinence when using e-cigarettes to try to quit.

RESULTS

The average duration of smoking abstinence when using e-cigarettes during a quit attempt was 65 days (SD = 104). In the multivariable model, greater frequency of e-cigarette use when quitting and abruptly switching to e-cigarettes from cigarettes (vs. gradually reducing) were significantly associated with longer durations of abstinence (p < .001). Preference for non-tobacco (relative to tobacco) flavors and nicotine concentration were not associated with duration of abstinence, although preference for rechargeable pod and mod device types (vs. cig-a-likes) was associated with longer durations of abstinence.

CONCLUSIONS

Patterns of e-cigarette use were related to abstinence duration, which may provide guidance for adults who are using e-cigarettes to quit smoking to encourage complete substitution and maximize smoking cessation. Findings indicate that non-tobacco e-cigarette flavors and nicotine strength are not related to longer durations of cessation success for adults, which may inform tobacco regulatory policies limiting these constituents to protect public health.

IMPLICATIONS

This study provides important new information about the characteristics of e-cigarettes used during an attempt to quit smoking among adults across the United States and identifies factors associated with quitting success. Patterns of e-cigarette use were associated with longer durations of abstinence. In contrast, few e-cigarette characteristics were associated with abstinence. Although preference for some pod and mod device types was associated with longer abstinence duration compared to earlier cig-a-like devices, preference for non-tobacco (vs. tobacco) flavor and nicotine concentration were not associated with abstinence. Findings may help inform guidance for adults using e-cigarettes to quit smoking and support tobacco regulatory policies.

Effects of electronic cigarette e-liquid flavouring on cigarette craving

BACKGROUND

E-liquid flavour restrictions may discourage electronic cigarette (e-cigarette) uptake among youth. However, possible unintended consequences may include reduced appeal and effectiveness of e-cigarettes for smoking cessation. Non-tobacco flavours appear to be important for smoking cessation, but how and why are currently unclear.

METHODS

We conducted an experimental study in a UK sample of adult daily smokers using an independent groups design (N=84). Participants were randomised to use an e-cigarette with nicotine-containing fruit/sweet-flavoured e-liquid (blackcurrant, strawberry, vanilla, caramel) or unflavoured e-liquid for 1 week. The primary outcomes were average, peak and cue-elicited cigarette craving (the latter was assessed using a cue exposure task). The secondary outcomes were smoking lapse occurrence, enjoyment of the e-cigarette, ease of transitioning from smoking to using an e-cigarette, intentions to continue using an e-cigarette, intentions and motivation to quit smoking, return to smoking, and continuation of e-cigarette use.

RESULTS

E-liquid flavouring did not appear to have an effect on average cigarette craving (b 0.18, 95% CI -0.44 to 0.79, p=0.57), peak cigarette craving (b -0.12, 95% CI -0.59 to 0.35, p=0.62) or cue-elicited cigarette craving (b -0.21, 95% CI -3.86 to 3.43, p=0.91). We did not find evidence of a difference in secondary outcomes.

CONCLUSIONS

We did not find evidence to suggest that nicotine-containing fruit/sweet-flavoured and unflavoured e-liquids have different effects on cigarette cravings after 1 week of use. Further research is needed to establish if differences emerge over longer periods of exposure and extend to smoking cessation outcomes.

The implications of vaping on surgical wound healing: A systematic review

BACKGROUND

E-cigarette use is rapidly growing, and little is known about the postoperative complications. Cigarette smoking has been well-established to be associated with delayed wound healing and increased complications in surgical patients. Due to the intricate and harmonious nature of the wound-healing process, vaping may impair tissue regeneration, posing a risk for patients undergoing surgery. This systematic review aimed to review the evidence on the implications of vaping on wound healing.

METHODS

A systematic search of PubMed and Scopus databases was conducted on October 2022 per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The following keywords were used to conduct the search: vaping, vape, e-cigarettes, electronic cigarettes, wound healing, tissue regeneration, postoperative complications, wound infection, and blood flow.

RESULTS

Of 5,265 screened articles, only 37 were eligible for qualitative synthesis. A total of 18 articles studied the effect of e-cigarettes on human volunteers, 14 investigated e-cigarette extract on human cell lines, and 5 used animal rat models.

CONCLUSION

Despite limited objective data, the recommendation is that e-cigarettes be treated as tobacco cigarettes; hence, vaping should be stopped in the perioperative period to decrease the incidence of wound healing complications. Clinical trials are required to understand the health hazards of e-cigarettes further and maximize patient safety and clinical outcomes.

Age, gender and socioeconomic patterns of awareness and usage of e-cigarettes across selected WHO region countries: evidence from the Global Adult Tobacco Survey

OBJECTIVES

The study explores the awareness and e-cigarette use by demographic and socio-economic characteristics of selected 14 Global Adult Tobacco Survey (GATS) countries.

DESIGN

Cross-sectional.

SETTING

14 countries.

PARTICIPANTS

Surveyed population ≥15 years selected through multi-stage cluster sampling.

PRIMARY AND SECONDARY OUTCOME MEASURES

We selected 14 countries from 6 different WHO regions where GATS was conducted in different years during 2011-2017.

RESULTS

Awareness and usage of e-cigarette were highest in Greece and lowest in India. Females were less aware of e-cigarette across ages. The gender gap in awareness is wide in Greece post 50 years of age, while the gap is distinct in early ages in Kazakhstan and Qatar. The gender difference in use of e-cigarette was negligible in most of the countries except among the younger cohorts of Russia, Philippines Malaysia and Indonesia. Relatively higher prevalence of e-cigarette smoking among females in the older adult age was observed in some of the Asian countries like India. Multivariate analysis indicates that those who were younger, male, residing in urban areas, current tobacco smokers were more likely to use e-cigarette than their counterparts. Though prevalence of e-cigarette use increased with wealth and education, such pattern is not strong and consistent. Promotional advertisement plays important role in higher use of e-cigaratte. The predicted national prevalence of e-ciragette use was highest in Malaysia .

CONCLUSIONS

E-cigarette use is more among urban adults, current smokers, males and in countries with promotional advertisement of e-cigarette. Area specific interventions are needed to understand the nature of e-cigarette use. Russia, Ukraine, Costa Rica and Mexico need better understanding to explore whether e-cigaratte use is an indulgence to new mode of addiction, as youth being highly likely to adopt this practice.

Prevalence, patterns, and determinants of electronic cigarette and heated tobacco product use in Greece: A cross-sectional survey

BACKGROUND

Electronic cigarettes (EC) and heated tobacco products (HTP) have been introduced in the global market as safer nicotine delivery systems; however, there is skepticism about their link to smoking and long-term risks. The aim of this study was to evaluate the prevalence, patterns, and determinants of EC/HTP use in Greece.

METHODS

This was a cross-sectional survey of 1,044 individuals aged ≥15 years old, who were randomly selected from the general Greek population. The study was conducted in May 2022, and participants were assessed through face-to-face interviews using a questionnaire designed to collect information on smoking and EC/HTP use, as well as their sociodemographic, lifestyle, and medical data.

RESULTS

The use of EC/HTP was reported by 16.2% of the participants, slightly more prevalent in males (17.2%) than in females (15.2%), and significantly more prevalent in <40-year-olds (21.3%) than ≥40-year-olds (11.3%). Most EC/HTP users (72.8%) were current smokers, 13.0% were former smokers, and 14.2% were never smokers. Among users, 60.6% used nicotine-containing products, 30.2% used EC/HTP in parallel with conventional tobacco, and 56.9% used EC/HTP for the first time while being <25 years old. In multiple logistic regression analysis, younger age, being employed, being a former/current smoker, adopting a Western-type diet, and believing that EC/HTP are less harmful than conventional tobacco products and can help toward smoking cessation emerged as significant determinants of EC/HTP use.

CONCLUSIONS

EC/HTP are commonly used in combination with conventional tobacco, are quite popular among the youth, and also appeal to a small fraction of nonsmokers.

Electronic Nicotine Delivery Systems: An Updated Policy Statement From the American Association for Cancer Research and the American Society of Clinical Oncology

Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15%-42% of adults who use ENDS have never used another tobacco product, and another 36%-54% dual use both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.

Electronic Nicotine Delivery Systems: An Updated Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology

Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15% to 42% of adults who use ENDS have never used another tobacco product, and another 36% to 54% "dual use" both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.

Global frequency and epidemiological profile of electronic cigarette users: a systematic review

OBJECTIVE

Electronic cigarette (e-cigarette) use is growing significantly worldwide, especially among young people. This product has been associated with renormalizing smoking and hindering quit attempts in smokers. Moreover, among nonsmokers, it can lead to subsequent cigarette smoking and nicotine dependence. The present study aimed to assess the epidemiological profile of e-cigarette users worldwide.

STUDY DESIGN

A systematic review was performed using 3 main electronic databases (Medline/PubMed, SCOPUS, and EMBASE). Studies were independently assessed by 2 reviewers based on established eligibility criteria. The risk of bias was assessed using the MAStARI critical appraisal instrument.

RESULTS

From 4,496 records, 43 were included. Among the 1,238,392 participants, 132,786 (10.72%) were e-cigarette users. The age range with the highest percentage of e-cigarette users was 18-24 years old, with 40,989 (30.86%) males, 34,875 (26.26%) females, and 33.6% being current cigarette smokers. The highest prevalence of users was 52.88% in Croatia and 49.62% in New Zealand. Other possible correlations were observed with e-cigarette use, such as a high level of education.

CONCLUSION

Overall, e-cigarette users tended to be male young adults with a higher level of education. The highest prevalence of use was found in Croatia. This systematic review provides valuable information to improve the development of appropriate intervention strategies targeting e-cigarette users for more accurate anti-smoking actions.

Expanding the E-Liquid Flavor Wheel: Classification of Emerging E-Liquid Flavors in Online Vape Shops

INTRODUCTION

Electronic cigarettes are the most popular tobacco product among U.S. youth, and over 80% of current youth users of e-cigarettes use flavored e-cigarettes, with fruit, mint/menthol, and candy/sweets being the most popular flavors. A number of new e-liquid flavors are currently emerging in the online e-cigarette market. Menthol and other flavored e-cigarettes could incentivize combustible tobacco smokers to transition to e-cigarette use.

METHODS

From February to May 2021, we scraped data of over 14,000 e-liquid products, including detailed descriptions of their flavors, from five national online vape shops. Building upon the existing e-liquid flavor wheel, we expanded the semantic databases (i.e., key terms) to identify flavors using WordNet-a major database for keyword matching and group discussion. Using the enriched databases, we classified 14,000+ e-liquid products into the following 11 main flavor categories: "fruit", "dessert/candy/sweets", "coffee/tea", "alcohol", "other beverages", "tobacco", "mint/menthol", "nuts", "spices/pepper", "other flavors", and "unspecified flavor".

RESULTS

We find that the most prominent flavor sold in the five online vape shop in 2021 was fruit flavored products, followed by dessert/candy/other sweets. Online vendors often label a product with several flavor profiles, such as fruit and menthol.

CONCLUSIONS

Given that online stores market products with multiple flavor profiles and most of their products contain fruit flavor, the FDA may have issued marketing denial orders to some of these products. It is important to further examine how online stores respond to the FDA flavor restrictions (e.g., compliance or non-compliance).

E-cigarette use and the relationship to smoking among Aboriginal and Torres Strait Islander and non-Indigenous Australian Secondary Students, 2017

OBJECTIVE

Estimate the prevalence of e-cigarette use (vaping) among Aboriginal and Torres Strait Islander adolescents and explore the relationship between vaping and tobacco use.

METHODS

N=18,199 students aged 12-17 years (n=1,097 Aboriginal and Torres Strait Islander) participating in the 2017 Australian Secondary Students' Alcohol and Drug (ASSAD) Survey self-reported their e-cigarette and lifetime, past month and past week smoking behaviours.

RESULTS

Twenty-two per cent of Aboriginal and Torres Strait Islander students (14% all) reported having ever used e-cigarettes. Significantly greater odds of e-cigarette use among Aboriginal and Torres Strait Islander students was observed overall, but not among regular (past month/week) smokers. There were significant associations between e-cigarette use and any level of smoking for all students (p<0.001), with no variation by Indigenous status. While e-cigarette use was more common among smokers, 28% of Aboriginal and Torres Strait Islander ever-vapers (35% all ever-vapers) were never smokers.

CONCLUSIONS

There is substantial prevalence of e-cigarette ever-use among Australian secondary students, including Aboriginal and Torres Strait Islander students, and a strong relationship with tobacco use.

IMPLICATIONS FOR PUBLIC HEALTH

Policies facilitating e-cigarette access must not undercut tobacco control efforts for adolescents, particularly Aboriginal and Torres Strait Islander people who continue to experience higher smoking rates.

Adolescents and E-cigarettes in India: A Qualitative Study of Perceptions and Practices

PURPOSE

Global Youth Tobacco Survey-4, India conducted in 2019 showed 'ever use' of e-cigarettes among adolescents to be 2.8%. However, there is dearth of qualitative data on adolescent use of e-cigarettes in the country. This study was conducted to explore and gain better understanding on adolescents' perceptions and practices about e-cigarette use.

METHODS

In-depth interviews were conducted with 24 adolescents who self-reported use of e-cigarettes. The participants were recruited from ten municipal schools of Mumbai, India that cater to students from lower socio-economic background. Participants were from 7th to 9th grades, and aged 11-16 years. Data from in-depth interviews were analyzed using inductive thematic analysis.

RESULTS

Adolescents referred to 'e-cigarette' as 'pen-hookah.'  E-cigarettes were perceived as relatively harmless compared to regular hookahs and conventional cigarettes. Initiation was influenced by a friend, peer, or sibling. A variety of flavors, the after-taste, the ability to perform playful tricks with smoke, and fun-time spent with friends were cited as reasons for continued use. Social media influenced both initiation and continuation. Most adolescents' regular use was with a group of friends; the device was shared with or obtained from friends or siblings. Adolescents were unclear about the presence of nicotine in refill liquids and the harmful health effects.

CONCLUSION

Increasing awareness among adolescents about the harms of e-cigarettes is urgently required through comprehensive tobacco-prevention programs. More research is needed to examine the role of flavors in increasing acceptability of e-cigarettes and how it affects perceived harmfulness of tobacco products.

E-Cigarettes Reexamined: Product Toxicity

The introduction of e-cigarettes, or electronic nicotine delivery systems (ENDS), has been accompanied by controversy regarding their safety and effectiveness as a cessation aid and by an explosion in their use by youth. Their use does not involve the combustion of tobacco and the creation of harmful combustion products; they have been seen as a "harm reduction" tool that may be of assistance in promoting smoking cessation. Recognition that ENDS can deliver an array of chemicals and materials with known adverse consequences has spurred more careful examination of these products. Nicotine, nitrosamines, carbonyl compounds, heavy metals, free radicals, reactive oxygen species, particulate matter, and "emerging chemicals of concern" are among the constituents of the heated chemical aerosol that is inhaled when ENDS are used. They raise concerns for cardiovascular and respiratory health that merit the attention of clinicians and regulatory agencies. Frequently cited concerns include evidence of disordered respiratory function, altered hemodynamics, endothelial dysfunction, vascular reactivity, and enhanced thrombogenesis. The absence of evidence of the consequences of their long-term use is of additional concern. Their effectiveness as cessation aids and beneficial impact on health outcomes continue to be examined. It is important to ensure that their production and availability are thoughtfully regulated to optimise their safety and permit their use as harm reduction devices and potentially as smoking-cessation aids. It is equally vital to effectively prevent them from becoming ubiquitous consumer products with the potential to rapidly induce nicotine addiction among large numbers of youth. Clinicians should understand the nature of these products and the implications of their use.

Vaping Flavors and Flavor Representation: A Test of Youth Risk Perceptions, Novelty Perceptions, and Susceptibility

INTRODUCTION

Whether novelty-flavored vaping devices should be available in the marketplace has been a hotly contested debate. From one perspective, the variety of different flavors, such as fruit and mint, may help adult cigarette smokers who are seeking to switch to reduced-harm nicotine products. However, these flavors are also wildly popular among youth, creating concerns about new nicotine product use among minors.

AIMS AND METHODS

This experiment (n = 176) tests whether vaping flavors (tobacco vs fruit) and flavor representations on packages (flavor color, flavor image) influence how middle school youth perceive vaping products.

RESULTS

While results show no difference in risk perceptions based on condition, novelty perceptions (eg, how fun, interesting) and susceptibility to vaping are highest among those who view the fruit-flavored vaping product with flavor color and flavor image. Those who viewed this condition reported higher novelty perceptions and susceptibility than those who viewed the fruit-flavored vaping product with no flavor color and no flavor image. Additionally, they reported higher novelty perceptions than those who viewed the tobacco-flavored vaping product with flavor color and flavor image. A post-hoc analysis in supplemental data shows that youth who report lower risk perceptions and higher susceptibility have higher behavioral intentions to vape in the next year.

CONCLUSION

Findings suggest that restricting flavor representation on packaging might reduce how fun and interesting youth perceive these products to be and how susceptible they are to using them.

Association between the implementation of tobacco control policies and adolescent vaping in 44 lower-middle, upper-middle, and high-income countries

AIM

To (i) estimate the prevalence of adolescent vaping in 47 lower-middle, upper-middle and high-income countries, and (ii) test the association between implementation of World Health Organisation (WHO) tobacco control policies and adolescent e-cigarette use (also known as vaping) in 44 countries where implementation data were available.

DESIGN

Cross-sectional surveys.

SETTINGS

A total of 47 lower-middle, upper-middle and high-income countries.

PARTICIPANTS

A total of 151 960 adolescents (typically ages 13-15) who participated in WHO's Global Youth Tobacco Survey between 2015 and 2018.

MEASUREMENTS

Prevalence of past-30-day vaping and past 30-day frequent vaping (≥10 days) were estimated from the surveys. Data on the implementation of six tobacco control measures including monitoring, smoke-free policies, cessation programs, warning about the dangers of tobacco, advertising bans and taxation were taken from WHO's report on global tobacco epidemic.

FINDINGS

The overall weighted prevalence of adolescent vaping and frequent vaping in the past 30 days was 8.6% (95% CI, 8.3-8.9) and 1.7% (95% CI, 1.6-1.8), respectively. For five of WHO's policies (monitoring, smoking-free environment, cessation programs, health warning and advertising bans), their association with adolescent vaping was inconclusive because of large variation of their effects across countries. Higher tax on combustible tobacco products was associated with higher adolescent vaping (> = 75% tax vs < 25% tax; odds ratio = 2.58; 95% CI, 1.25-5.21).

CONCLUSION

In 47 lower-middle, upper-middle and high-income countries from 2015 to 2018, ~1 in 12 (8.6%) adolescents reported vaping in the past 30 days, but prevalence of frequent vaping was low (1 in 60; 1.7%). A higher tobacco tax was associated with higher adolescent vaping.

Flavored Tobacco Product Use Among Young Adults by Race and Ethnicity: Evidence From the Population Assessment of Tobacco and Health Study

PURPOSE

Describe racial/ethnic patterns of flavored tobacco use to illuminate equity implications of flavored tobacco policies.

METHODS

Using data on US young adults (ages 18-34; n = 8,114) in the Population Assessment of Tobacco and Health Study Wave 5 (2018-2019) and survey-weighted logistic regression, we estimated any flavors (regular brand) and mint/menthol (vs. other flavors) use by race/ethnicity among cigarette, e-cigarette, cigar, blunt, hookah, smokeless tobacco, and any tobacco product users.

RESULTS

Any flavored tobacco use was common and was significantly higher for Black (75.1%; OR: 1.4; 95% CI: 1.2, 1.7) and Hispanic/Latinx (77.2%; OR: 1.4; 95% CI: 1.1, 1.7) users than White users (73.5%). The most pronounced difference across products was in menthol cigarette use between Black and White smokers (OR: 4.5; 95% CI: 3.5, 5.9). Among flavored product users, mint/menthol use was significantly higher for Latinx blunt and hookah users.

DISCUSSION

Racial/ethnic disparities in flavored tobacco use include and extend beyond menthol cigarettes. Comprehensive flavored tobacco restrictions that include mint/menthol and non-cigarette products will likely have more equitable impact.

Effect of menthol/mint-flavored pods on young JUUL E-cigarette users' subjective experience, puffing behavior, and nicotine exposure: A pilot study

BACKGROUND

Recent regulations have banned all flavors except menthol/mint and classic tobacco from pod-based e-cigarette devices such as JUUL. However, menthol/mint flavor can present a potential risk given its increasing popularity among young people in the US and its puffing and nicotine-enhancing properties. This study examines the impact of menthol/mint flavor manipulation on users' puffing behavior, subjective experience, and nicotine exposure among young people.

METHODS

JUUL users (n = 33, 18-24 years) attended two 60-min ad libitum e-cigarette use sessions (menthol/mint flavor vs. classic tobacco flavor) in a cross-over design. Puff topography and plasma nicotine concentration were measured, and participants completed subjective experience questionnaires.

RESULTS

Following the use of the menthol/mint-flavored pod, increases were observed in measures of satisfaction, pleasurable/interest to use, willingness to use again, enjoyment, urge to vape, product appeal, taste, and concentration (p < .05 for all). For example, compared to the classic tobacco flavor, participants experienced significantly more satisfaction of the product (4.24 vs. 3.09; p = .001) and sensation enjoyment of the product (3.55 vs. 2.48; p = .002) when using the menthol/mint flavor. While means of the plasma nicotine boost and puff parameters were lower in the classic tobacco condition compared to the menthol/mint flavor condition, no statistical significance was observed between the two conditions (p > .05 for all).

CONCLUSIONS

Results of this pilot study suggest that menthol/mint-flavor increases e-cigarette users' subjective experience significantly. Regulating menthol/mint flavor is a potentially promising strategy to curb e-cigarette use among young people.

A chocolate cake or a chocolate vape? Young adults describe their relationship with food and weight in the context of nicotine vaping

INTRODUCTION

Emerging research has found that some young adults report vaping nicotine to control appetite and lose weight. Yet, there is little research on how young adults use vaping to manage weight, where they learn about weight-motivated vaping, and the role that food and weight motivations play in decisions to vape.

METHODS

We conducted one-on-one qualitative interviews with young adults aged 18-25 years old in Los Angeles, California (N = 62) from June 2018 to June 2019, who self-reported using e-cigarettes on a weekly basis or more for at least 5 months prior to study enrollment. Interviews examined participants' thoughts, feelings, and experiences related to e-cigarette use, including their understanding of the relation of vaping with eating behaviors and weight management. We analyzed the interviews using the rigorous and accelerated data reduction (RADaR) technique.

RESULTS

Participants reported pairing nicotine vaping with caffeinated beverages like coffee, pop/soda, tea, and after every meal (like patterns of combustible cigarette use). Participants also reported vaping nicotine as a tool to avoid binge eating and increase concentration while studying. Reports of vaping effecting appetite and eating behaviors also emerged. Vaping nicotine to suppress appetite and/or achieve weight loss was often reported in conjunction with an eating disorder. Participants reported learning about weight-motivated vaping from peers or deducing from cigarette effects and their own experiences with nicotine. Others mentioned controlling food cravings by vaping a similar e-liquid flavor.

CONCLUSION

Nicotine vaping was used as a tool to control weight and suppress appetite, paralleling food- and weight-related behaviors associated with cigarette use. Findings suggest a need for targeted interventions that address the role of nicotine vaping in eating/weight-related behaviors.

A content analysis of website marketing for cooling flavored e-liquids in a sample of brick-and-mortar vape shops in the Greater Los Angeles area

INTRODUCTION

Menthol is a characterizing flavor in combustible cigarettes and electronic nicotine delivery systems (ENDS). E-liquids are recognized as an important reason for ENDS use. Yet, compared to menthol cigarettes, menthol flavored e-liquids and other cooling flavors, including mint and 'ice' for ENDS, are an understudied area of investigation. The present study examined cooling flavored e-liquid website marketing among brick-and-mortar vape shops in Greater Los Angeles Area.

METHODS

A total of 104 brick-and-mortar vape shops were identified, and 38 had active websites. Over a 30-day period (28 September - 28 October 2020), we collected marketing for all flavored refillable e-liquids (photos/images) from each website. Data were collected for 1330 products. Only refillable e-liquid bottles were selected for this study, excluding prefilled pod vapes and disposable vapes. Each e-liquid per website was coded (e.g. menthol or not) and grouped into categories (e.g. type of menthol). The three flavor descriptor categories that the e-liquids were grouped into were menthol, mint, or ice. An 'other' category was also created for identified e-liquids with flavor descriptors that did not mention menthol, mint, or ice.

RESULTS

A total of 1330 e-liquid flavors were identified from 38 active websites. Among them, 219 were coded as menthol/mint/ice flavor e-liquids. Frequencies included ice/iced/icy (n=123; 56%), menthol (n=32; 15%), mint (n=23; 11%), and other (n=41; 19%). Of the 123 ice-flavor e-liquids, 70.3% (n=83) were in combination with fruit (e.g. 'Apple Ice', 'Grape Iced', 'Icy Mango'). Of the 32 menthol-flavored e-liquids, 63.3% (n=19) were in combination with fruit (e.g. 'Dragon Fruit Menthol', 'Blue Raspberry Menthol', 'Fresh Peach Menthol'). Flavors in the other category were ice-related flavor descriptors (e.g. 'Arctic Air', 'Brain Freeze', 'Frozen Hulk Tears').

CONCLUSIONS

Brick-and-mortar vape shops in the Greater Los Angeles Area market a variety of cooling flavor e-liquids on their websites. Such marketing focused largely on ice fruit flavor combinations. Future research is needed to understand how exposure to and appeal of cooling flavored e-liquid marketing differs among diverse consumer groups, including adult menthol cigarette smokers and non-smoking youth.

Factors associated with changes in flavored tobacco products used: Findings from wave 2 and wave 3 (2014-2016) of the population assessment of tobacco and health (PATH) study

INTRODUCTION

Flavored non-cigarette tobacco product use is widespread in the U.S. The availability of flavor options could be playing a role in recent increases in use, especially for non-cigarette tobacco products, among youth and young adults. Little is known about specific flavor preferences of youth and adult flavored tobacco product users, as well as how preferences may change over time.

METHODS

This study analyzes PATH Study data from completed Wave 2 (2014-2015) and Wave 3 (2015-2016) youth (12-17 years), and adult (18 + years) interviews to estimate the prevalence of flavored non-cigarette tobacco product use. We assess flavor switching by examining changes between flavors and characteristics of those who changed flavors between waves.

RESULTS

Across age groups, and at both waves, fruit-flavored products were the most frequently used flavor by past 30-day electronic nicotine delivery systems (ENDS), cigar, cigarillo, and hookah users. In the past 30 days, a higher proportion of youth and young adults used candy/sweets-flavored ENDS than adults. Among adult ENDS users, the odds of changing flavors were highest among younger users and decreased with increasing age.

CONCLUSIONS

Flavored tobacco product use is prevalent across non-cigarette tobacco products. Stability in the number of flavors used, as well as specific flavors, is higher among adult tobacco users, while the use of multiple flavors, and change in specific flavor, is more prevalent among youth tobacco users. Additional longitudinal research can further examine the role flavors play in appeal, product trial, and switching.

Discussions of Flavored ENDS Sales Restrictions: Themes Related to Circumventing Policies on Reddit

Objective: To examine conversations among JUUL users on Reddit related to restrictions on flavored ENDS and the shifting policy landscape. Methods: Posts and comments (n = 166,169) between May 2019 and May 2020 on the subreddit r/JUUL were scraped using pushshift.io API. Keyword filters were used to identify texts discussing flavored ENDS products (n = 33,884 texts). These were further narrowed down to texts discussing flavor policy workaround strategies (n = 7429) and N-gram analysis was performed. Finally, findings from the N-gram analysis were triangulated through qualitative review of a separate sample of texts (n = 488) from the flavor policy-related posts and comments. Results: Overall activity on the subreddit r/JUUL peaked around the time of the EVALI outbreak (September 2019) and when FDA issued guidance restricting flavored ENDS product sales (January 2020). The N-gram analysis revealed an active discussion of banned products one can “still get” or “JUUL compatible” alternatives, including specific brands, brick and mortar locations, and specific flavors. Ten dominant themes emerged from the qualitative review, with some posts containing more than one theme. Conclusion: Many users turned to Reddit for information related to the shifting regulatory landscape concerning flavored ENDS. Discussions focused on both legal alternatives to banned products as well as illegal means of acquiring JUUL pods, including residual retail supply, online, and mail vendors.