Electronic cigarette use among US adults in the Population Assessment of Tobacco and Health (PATH) Study, 2013-2014

Correlates of using E-cigarettes with high nicotine concentrations among U.S. adults who exclusively vape E-cigarettes or dual use with cigarettes

BACKGROUND

Identifying the correlates of using e-cigarettes with high nicotine concentrations in exclusive and dual-using vapers can elucidate which subpopulations might be most impacted by e-cigarette regulatory activities related to nicotine concentration.

METHODS

Data are drawn from Wave 5 (December 2018-November 2019) of the Population Assessment of Tobacco and Health (PATH) study. Self-reported nicotine concentration was grouped as high (5.0 %+), moderate (1.8-4.9 %), low (0.1-1.7 %), 0 %, and "I don't know." Multivariable logistic regressions estimated associations of sociodemographic factors, tobacco use status, and e-cigarette use patterns of high nicotine concentration vs. other nicotine levels, stratified by current exclusive e-cigarette use and dual use of e-cigarettes and cigarettes.

RESULTS

In the study samples (exclusive e-cigarette use [n = 1,755], dual-use [n = 1,200]), higher proportions of exclusive e-cigarette users reported using high nicotine concentrations than dual users (18.3 % vs. 8.6 %). Among exclusive e-cigarette users, never vs. former smokers and daily (vs. someday) e-cigarette users were more likely to use high vs. low nicotine. In both exclusive and dual users, younger (vs. older) adults were more likely to report using high nicotine concentration e-cigarettes than most other nicotine levels. Current dual users who did vs. did not report using e-cigarettes to quit smoking had higher odds of using high vs. 0 % nicotine concentrations.

CONCLUSIONS

High-nicotine e-cigarette use might be elevated in subpopulations that face greater risks for vaping (e.g., never smokers, young adults) than groups who benefit from the potential harm reduction. Regulatory restrictions on high-nicotine products may selectively affect some subgroups adversely impacted by vaping.

Exposure to E-Cigarette Advertisements or Reviews and E-Cigarette Use Progression: A Longitudinal Examination of Short-Term and Long-Term Associations among US Young Adults

Limited research has investigated the impact of e-cigarette advertising and reviews on the progression of e-cigarette use among young adults in the US. This study utilized five-wave longitudinal data (2018-2020) with 3006 young adults aged 18-34, reporting exposure to e-cigarette advertisements or reviews at Wave 1 (W1) and W3. Generalized estimating equations (GEE) were used to examine the prospective associations between frequent exposure to e-cigarette advertisements or reviews and e-cigarette use progression in four groups: never users (n = 1271 at W1), former users (previously used but quit ≥ 6 months ago, n = 422 at W1), recent former users (used in the past 6 months but not in the past month, n = 186 at W1), and current users (used in the past month, n = 1127 at W1). Among baseline former users, frequent exposure to e-cigarette reviews was associated with current use at 6-month follow-up (aOR = 4.40, 95%CI = 1.46-13.29). Among baseline current users, frequent exposure to e-cigarette reviews was associated with increased days of use at 6-month follow-up (IRR = 1.20, 95%CI = 1.07-1.34) and 12-month follow-up (IRR = 1.18, 95%CI = 1.03-1.35). E-cigarette reviews may contribute to relapse among recent former users and increased usage frequency among current users, highlighting the need for enhanced e-cigarette promotional activity regulation.

Tobacco Policy and ENDS Policy Influences on Adolescent Vaping Across the U.S. States

INTRODUCTION

Although the use of tobacco has declined among youth, ENDS has the potential to disrupt or reverse these trends. Policies for tobacco and ENDS may have an impact on adolescent ENDS use. The impacts of state-level policies were examined for both tobacco and ENDS indoor use bans, excise taxes, and age-of-purchase laws on past-month adolescent ENDS use from 2013 to 2019.

METHODS

This study used cohort data from the Population Assessment of Tobacco and Health study and policy data from the Americans for Nonsmokers' Rights Foundation repository-3 policies for ENDS and 2 policies for tobacco products. Policies included comprehensive indoor vaping/smoking bans, purchase-age restrictions, and excise taxes. Hybrid panel models were estimated in 2022 using data merged from the 2 longitudinal sources on past-month vaping. The analytic sample (observations=26,008) included adolescents aged 12-17 years, yielding a total of 72,684 observations.

RESULTS

The odds of adolescent ENDS use were 21.4% lower when the state had an ENDS purchase-age restriction and 55.0% lower when the state had a comprehensive tobacco smoking ban than in the years when the state did not have the ban.

CONCLUSIONS

During a period of significant growth in ENDS use among U.S. youth, ENDS purchase-age restrictions and smoking bans reduced the odds of past-month vaping among adolescents. Wider implementation of policies may help intervene in youth vaping.

Patterns of flavored e-cigarette use among adult vapers in the USA: an online cross-sectional survey of 69,233 participants

BACKGROUND

Flavored e-cigarettes remain a controversial topic with regulators planning or already implementing restrictions worldwide. In this study, we examined patterns of flavor use in e-cigarettes among a convenience sample of US adult vapers.

METHODS

Participants aged ≥ 18 years who reported ever using an e-cigarette were included in the study (N = 69,233) and responded to an online questionnaire. Their smoking status was recorded as well as patterns of flavor use at e-cigarette use initiation, at the time of the survey and at the time of smoking cessation (for participants who used to smoke and were using e-cigarettes at the time of quitting).

RESULTS

The most popular flavors at e-cigarette use initiation were fruit (82.8%), followed by dessert/pastry/bakery (68.6%) and candy/chocolate/sweet (52.2%). Slightly higher prevalence of using fruit and dessert/pastry/bakery flavors was observed in those who never smoked compared to those who were currently and formerly smoking. Tobacco flavors were used by 20.8% of the participants and was by far the least prevalent among participants who never smoked. Similar patterns were observed with participants' choices at the time of the survey, but tobacco flavor use was substantially reduced (7.7%). Only 2.1% reported tobacco as the single most often used flavor. The most prevalent flavor at the time of quitting smoking was again fruit (83.3%), followed by dessert/pastry/bakery (68.0%) and candy/chocolate/sweet (44.5%). These flavors were considered the most helpful for quitting smoking. Tobacco flavor use at the time of smoking cessation was reported by 15.0%, while 9.3% considered it helpful for quitting smoking.

CONCLUSION

Non-tobacco flavors were popular among the US adult vapers who participated in the study, and were popular choices at the time of quitting smoking for those who formerly smoked. Tobacco flavor use prevalence was low and was further reduced over time. Regulators should consider the flavor choice of adult consumers, especially those who quit smoking, when preparing legislation on flavored e-cigarettes.

Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association

Vaping and electronic cigarette (e-cigarette) use have grown exponentially in the past decade, particularly among youth and young adults. Cigarette smoking is a risk factor for both cardiovascular and pulmonary disease. Because of their more limited ingredients and the absence of combustion, e-cigarettes and vaping products are often touted as safer alternative and potential tobacco-cessation products. The outbreak of e-cigarette or vaping product use-associated lung injury in the United States in 2019, which led to >2800 hospitalizations, highlighted the risks of e-cigarettes and vaping products. Currently, all e-cigarettes are regulated as tobacco products and thus do not undergo the premarket animal and human safety studies required of a drug product or medical device. Because youth prevalence of e-cigarette and vaping product use was as high as 27.5% in high school students in 2019 in the United States, it is critical to assess the short-term and long-term health effects of these products, as well as the development of interventional and public health efforts to reduce youth use. The objectives of this scientific statement are (1) to describe and discuss e-cigarettes and vaping products use patterns among youth and adults; (2) to identify harmful and potentially harmful constituents in vaping aerosols; (3) to critically assess the molecular, animal, and clinical evidence on the acute and chronic cardiovascular and pulmonary risks of e-cigarette and vaping products use; (4) to describe the current evidence of e-cigarettes and vaping products as potential tobacco-cessation products; and (5) to summarize current public health and regulatory efforts of e-cigarettes and vaping products. It is timely, therefore, to review the short-term and especially the long-term implications of e-cigarettes and vaping products on cardiopulmonary health. Early molecular and clinical evidence suggests various acute physiological effects from electronic nicotine delivery systems, particularly those containing nicotine. Additional clinical and animal-exposure model research is critically needed as the use of these products continues to grow.

The Substitution of Fifty Percent of Combustible Tobacco Smoke Exposure With Either Electronic Cigarettes or Heated tobacco Products Did Not Attenuate Acute Lung Injury in an Animal Model

BACKGROUND

To reduce the harmful health effects of combustible cigarette smoke (CS), some (CS) users attempt to substitute CS with electronic cigarettes (ECIG) and/or heated tobacco products (HTP). In this animal study, we evaluated the acute effects of substituting CS consumption with ECIG or HTP thus mimicking the dual users' approach, on the lungs of a mouse model.

METHODS

C57BL/6 mice were divided into Control, ECIG, HTP, CS, ECIG + CS, HTP + CS, and HTP + ECIG groups. Animals were exposed for 3 hours in AM and PM sessions to either air, CS, ECIG, or HTP for seven days. Lung injury was assessed by: wet to dry (W/D) ratio, albumin concentration in bronchoalveolar lavage fluid, expression of IL-1β, IL-6, and TNF-α, histopathology examination, reactive oxygen species (ROS) production, and assessment of cellular apoptosis.

RESULTS

W/D ratio was significantly increased in mice exposed to CS only. Albumin leak and expression of IL-1β, IL-6, and TNF-a were elevated in CS, ECIG + CS, and HTP + CS. Histological examination revealed significant inflammatory cells infiltration, as well as collagen deposit in CS, ECIG + CS, HTP + CS. ROS production was significantly increased in CS, ECIG + CS, HTP + CS. Finally, cell death was also significantly increased in CS, ECIG + CS, and HTP + CS.

CONCLUSION

In this animal model, substituting 50% of daily CS exposure by either ECIG or HTP exposure did not result in significant attenuation of acute lung injury.

Differentiating Reasons for Young Adult E-cigarette Use Using Maximum Difference Choice Models

INTRODUCTION

Understanding the reasons young adults use e-cigarettes (ie, vape)-and whether these motivations vary across groups-is essential for informing tobacco regulatory efforts.

AIMS AND METHODS

An online panel of young adults who vape (n = 230; age = 18-30 years) completed a maximum difference discrete choice task for 15 reasons for vaping. Over 9 choice sets, participants were presented a subset of 5 reasons and selected the most and least important. Hierarchical bayesian analysis estimated the relative importance of each reason. Latent class analysis (LCA) identified groups with similarly ranked reasons for use. Multinomial regression evaluated the association between sample characteristics and class membership.

RESULTS

Overall, relaxation had the highest probability of being the most important reason for use (14.8%), followed by harm reduction (13.2%), and flavors (10.3%). LCA identified five distinct classes, based on top reasons for use: 1. cessation (cigarette cessation [20.2%]; n = 80); 2. dependence (relaxation [20.5%] and unable to quit [19.2%]; n = 21); 3. relaxation (relaxation [20.6%]; n = 66); 4. socializing (socializing [22.2%]; n = 27); and 5. variable (boredom [10.5%] and acceptability [10.2%]; n = 36). Participants who were older, smoked cigarettes, or vaped more frequently were more likely to belong to the cessation class while those who were younger or more e-cigarette dependent were more likely to belong to the dependence class.

CONCLUSIONS

Perceived reasons why young adults vape are highly heterogeneous and dependent on the type of user. Tobacco regulatory efforts targeting distinct types of vapers are needed to minimize the adverse public health impact of vaping without compromising appeal for smoking cessation.

IMPLICATIONS

E-cigarette use remains high among young adults, with flavors, cost, and harm reduction (vs. combustible cigarettes) among the mostly commonly reported reasons for use. Yet, little is known about how relatively important these reasons are to the individual. Leveraging a maximum difference task, young adults' reasons for use were evaluated on a common interval scale and groups sharing similar reasons identified. Smoking cessation, dependence, relaxation, socialization, and boredom were respectively the most important reasons for use among five classes of vapers. E-cigarette regulatory policies should consider the distinct reasons for use as to not compromise their appeal for smoking cessation.

Comparison of a Tobacco-Specific Carcinogen in Tobacco Cigarette, Electronic Cigarette, and Dual Users

BACKGROUND

4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) is known as a lung carcinogen. The objective of this study was to investigate associations of urine NNAL concentrations and smoking status.

METHODS

This was a cross-sectionally designed study based on data from the 2016-2018 Korean National Health and Nutrition Examination Survey. A total of 2,845 participants were classified into past-smoker, electronic cigarette (e-cigar) only, dual-user, and cigarette only smoker groups. All sampling and weight variables were stratified and analysis was conducted accounting for the complex sampling design. Analysis of covariance was used to compare the geometric mean of urine NNAL concentrations and log-transformed urine NNAL level among smoking status with weighted survey design. Post hoc paired comparisons with Bonferroni adjustment was performed according to smoking status.

RESULTS

The estimated geometric mean concentrations of urine NNAL were 1.974 ± 0.091, 14.349 ± 5.218, 89.002 ± 11.444, and 117.597 ± 5.459 pg/mL in past-smoker, e-cigar only, dual-user, and cigarette only smoker groups, respectively. After fully adjusting, log-transformed urine NNAL level was significantly different among groups (P < 0.001). Compared with the past-smoker group, e-cigar only, dual-user, and cigarette only smoker groups showed significantly higher log-transformed urine NNAL concentrations in post hoc test (all P < 0.05).

CONCLUSION

E-cigar only, dual-user, and cigarette only smoker groups showed significantly higher geometric mean concentrations of urine NNAL than the past-smoker group. Conventional cigarette, dual users, and e-cigar users can potentially show harmful health effects from NNAL.

'No-Barriers' tobacco product? Selling smokeless tobacco to women, people of colour and the LGBTQ+ community in the USA

BACKGROUND

In both Sweden and the USA, smokeless tobacco (ST) is legal and used predominantly by men. Starting in the 1970s, US tobacco companies attempted to expand the ST market to women, African Americans, Hispanic Americans and lesbian, gay, bisexual, transgender, queer and other sexual orientation (LGBTQ+) people.

DESIGN

We analysed industry documents from the Truth Tobacco Industry Documents Library triangulating findings with recent ST advertising and publicly available literature.

FINDINGS

We found tobacco companies used design innovations such as pouched moist snuff, snus and dissolvable products to expand the market. In addition, diverse advertising campaigns targeted women, people of colour (Hispanic, African American) and LGBTQ+ communities with identity-targeted messages emphasising novelty, convenience, cleanliness and use in smoke-free environments. However, stereotypes of ST users as rural white males endured, perpetuated by continued marketing aimed at this customer base, which created cognitive dissonance and stymied marketer's hopes that pouch products would 'democratize' ST.

CONCLUSION

These failed campaigns suggest novel products such as nicotine pouch products may provide a 'clean slate' to similarly target women and other low-ST-using groups. Based on this history, the risk of new tobacco and nicotine products to increase health disparities should be closely monitored.

Longitudinal transitions in tobacco use in youth and young adults: A latent transition analysis of the population assessment of tobacco and health study from Wave 1 to 5

BACKGROUND

Tobacco use by youth and young adults can lead to significant long-term health problems. We aim to understand transitions in tobacco use patterns among these groups and the factors that affect transition patterns.

METHODS

Using the five waves of data from the nationally representative Population Assessment of Tobacco and Health (PATH) Study (2013-2019), we conducted latent class analysis and latent transition analysis to understand tobacco use classes and the longitudinal transitions between classes. We also adjusted for covariates, including demographics, individual behaviors, household environment, and psychosocial factors, to capture their effects on class transition probabilities.

RESULTS

Three tobacco use behaviors were identified: non-current user (C1), moderate e-cigarette user (C2), and poly-tobacco user (C3). At baseline (Wave 1), 94.4% of participants were classified as C1, 3.2% as C2, and 2.4% as C3, and the distribution shifted towards C2 and C3 over time. Progression to the next class represented the most common transitions (14.1% C2 to C3, 10.7% C1 to C2), while the direct progression from C1 to C3 was rare (0.6%). Being male, White, adult, living in smoking-allowed households, past-year alcohol use, drug use, internalizing problems, and social media follower of tobacco brands were associated with a faster progression to poly-tobacco use.

CONCLUSIONS

The transition patterns implied that e-cigarette use might be an intermediate progression from non-current use into poly-tobacco use. Individual behaviors, household environment, and psychosocial factors are associated with elevated risks of progression. The findings may inform tobacco prevention and cessation policies among youth and young adults.

Nicotine Dependence among Current Cigarette Smokers Who Use E-Cigarettes and Cannabis

BACKGROUND

Co-use of tobacco and cannabis and dual use of cigarettes and e-cigarettes are very common among young adults. However, it is unclear whether co-use of cigarettes, e-cigarettes, and/or cannabis is associated with higher levels of nicotine dependence than cigarette-only use. We investigated the relationship between cigarette/nicotine dependence and co-use of tobacco and cannabis among 4 groups of cigarette smokers aged 18-35: cigarette-only smokers, cigarette-e-cigarette (CIG-ECIG) co-users, cigarette-cannabis (CIG-CAN) co-users, and cigarette-e-cigarette-cannabis (CIG-ECIG-CAN) co-users.

METHODS

Data were from a 2018 cross-sectional survey based on a national convenience sample of smokers aged 18-35 (n = 315). Cigarette/nicotine dependence was measured by the Fagerstrom Test of Nicotine Dependence (FTND) and e-cigarette dependence was measured by the Penn State E-cigarette Dependence Index. Bivariate analyses examined sociodemographic and tobacco/other substance use characteristics by co-use status and multivariable linear regression assessed the relationship between co-use and nicotine dependence.

RESULTS

In the sample, 27.6% were cigarette-only smokers, 24.8% were CIG-ECIG, 27.6% were CIG-CAN, and 20.0% were CIG-ECIG-CAN co-users. Significant differences were observed in sociodemographic and tobacco/other substance use characteristics by co-use status. E-cigarette co-users had low e-cigarette dependence, but moderate FTND scores. In adjusted analyses, only CIG-ECIG co-use was associated with higher FTND scores compared to cigarette-only smoking. However, CIG-ECIG and CIG-ECIG-CAN co-use were associated with higher FTND scores compared to CIG-CAN co-use.

CONCLUSIONS

Co-use of cigarettes and e-cigarettes was associated with greater nicotine dependence among smokers aged 18-35. Additional research is needed to understand the underlying mechanisms of these relationships and inform prevention efforts.

A Longitudinal Analysis of Respiratory Illness and Tobacco Use Transitions

INTRODUCTION

Among individuals with chronic respiratory conditions, transitions between patterns of tobacco product use are not well understood. This study examines how transitions, including quitting altogether, differ over time between those who do and do not have chronic respiratory conditions.

METHODS

Data from youth and adult participants of the longitudinal Population Assessment of Tobacco and Health Study (2013-2018) were analyzed. Youth aged 12-17 years were included if they had aged into the adult sample by Wave 4. Stratified polytomous regression models built under a first-order Markov assumption modeled the probability of transitioning between different states/patterns of tobacco product use (exclusive current E-cigarette use, exclusive current combustible tobacco product use, current dual use of combustible products and E-cigarettes, and no current tobacco product use) at each wave. Marginal transition probabilities were computed as a function of ever or past-year diagnosis of a respiratory condition (separately for asthma and a composite variable representing chronic bronchitis, emphysema, and/or chronic obstructive pulmonary disease). Analyses were conducted in 2020-2021.

RESULTS

Most individuals, regardless of respiratory condition, maintained the same pattern of tobacco use between waves. Exclusive combustible tobacco product users, including those with or without a respiratory condition, were not likely to become exclusive E-cigarette users or to quit using tobacco entirely.

CONCLUSIONS

Although combustible tobacco use negatively impacts the management and prognosis of respiratory illnesses, combustible tobacco users who were recently diagnosed with a chronic respiratory condition were not likely to quit using tobacco. Efforts to encourage and support cessation in this medically vulnerable population should be increased.

Biomarkers of Electronic Nicotine Delivery Systems (ENDS) Use

This perspective summarizes available evidence on biomarkers of exposure in electronic nicotine delivery system (ENDS) users to aid the overall assessment of the health consequences of using ENDS. Identification of novel biomarkers of exposure specific to ENDS use remains challenging because chemicals emitted from ENDS devices have many familiar sources. The biomarker levels of many tobacco-related toxicants measured in biological samples collected from ENDS users did not differ significantly from non-users, except for nicotine metabolites and a small number of biomarkers of exposure to volatile organic compounds and tobacco-specific tobacco nitrosamines. Several studies have shown that while exposed to nicotine, long-term exclusive ENDS users showed significantly lower levels of toxicant biomarkers than cigarette smokers. Studies have also shown that concurrent users of ENDS and combustible cigarettes ('dual users') are not reducing overall exposure to harmful toxicants compared to exclusive cigarette smokers. Because of an absence of validated ENDS-specific biomarkers, we recommend combining several biomarkers to differentiate tobacco product user groups in population-based studies and monitor ENDS compliance in randomized controlled trials. Using a panel of biomarkers would provide a better understanding of health effects related to ENDS use.

Reasons for Use of Electronic Cigarettes, Cigars, and Hookah in Pregnant Women in Rhode Island: A Preliminary Study

BACKGROUND

The current study examined reasons pregnant women in Rhode Island use non-cigarette nicotine/tobacco products during and prior to pregnancy.

METHODS

Of the 124 pregnant women in Rhode Island enrolled in the study, 91% self-reported ever using e- cigarettes, hookah or cigars, and reasons for their use. We compared responses between participants who used these products during pregnancy (prenatal) and those who used prior to pregnancy (lifetime) for each product separately.

RESULTS

Participants reported using e-cigarettes as a cessation aid, hookah for entertainment, and cigars as a vehicle for marijuana consumption as primary reasons for use. There were no significant differences in reasons for using hookah or cigars between prenatal and lifetime users, but prenatal e-cigarette users were more likely to report affordability as a reason for use compared to lifetime e-cigarette users.

CONCLUSIONS

Differential reasons for use by tobacco product may have implications for targeted interventions in pregnant people in Rhode Island.

Changes in Dependence Over One Year among US Adults Who Smoke Cigarettes and Switched Completely or Partially to Use of the JUUL-Brand Electronic Nicotine Delivery System

Background

Electronic nicotine delivery systems (ENDS) are substitute sources of nicotine for adults who smoke cigarettes. Understanding changes in dependence as people switch from cigarettes to ENDS is relevant to public health. This study assessed changes in dependence among adults who switched completely or partially (dual users) from cigarettes to JUUL-brand ENDS over 12 months.

Methods

US adults who smoke and purchased a JUUL Starter Kit (n = 17,619) completed a baseline assessment and were invited to 1-, 2-, 3-, 6-, 9- and 12-month follow-ups. Dependence on cigarettes at baseline and on JUUL at follow-ups was assessed with the Tobacco Dependence Index (TDI; Range 1-5). Analyses estimated the minimal important difference (MID) for the scale, compared JUUL dependence to baseline cigarette dependence and assessed changes in JUUL dependence over 1-year, including among those using JUUL at all follow-ups.

Results

Participants who switched at month 2 had month 1 JUUL TDI scores 0.24 points greater than those who continued smoking (p<0.001); thus MID=0.24. Among both switchers and dual users overall, dependence on JUUL 1 and 12 months later was lower than baseline dependence on cigarettes (ps<0.001); participants who smoked every day showed more consistent and larger reductions. Among participants who persistently used JUUL without smoking, dependence increased 0.01 points per month (p<0.001), but was leveling off over time.

Conclusions

Dependence on JUUL was lower than baseline cigarette dependence. Increases in JUUL dependence were small over 12 months of continual JUUL use. These data indicate that ENDS, including JUUL, have lower dependence potential than cigarettes.

Social Network Ties and Responses to COVID-19 Among E-Cigarette Users

Social networks can enhance behavioral changes or entrench existing patterns of behavior. We aimed to identify how network ties to other e-cigarette users shaped responses to the pandemic and e-cigarette considerations. A national U.S. survey of 562 e-cigarette users was conducted during April 2020. Participants self-reported network ties to other e-cigarette users and pandemic outcomes: receiving expressions of concern about vaping, risk for a bad COVID outcome, changes in e-cigarette risk perceptions, and considerations of quitting. Each additional e-cigarette user tie was associated with a 0.014 unit increase in expressions of concern (p < 0.001), a 0.034 unit increase in perceived risk of a bad outcome (p < 0.05), and 3.9% higher odds of quit considerations (OR = 1.039; p < 0.01). Family ties to e-cigarette users were particularly important. Additional e-cigarette users within a network shaped risk perceptions in response to COVID-19. Network ties to other e-cigarette users have implications for cessation or reduction of e-cigarette use.

Exposure-response analysis of the association of maternal smoking and use of electronic cigarettes (vaping) in relation to preterm birth and small-for-gestational-age in a national US sample, 2016-2018

Introduction

The US experienced a surge in use of e-cigarettes. Smoking women may consider e-cigarettes during pregnancy as an alternative to smoking. E-cigarettes typically contain nicotine, an established cause of reduction in fetal growth in animal studies.

Methods

This cohort study included 99,201 mothers who delivered live singletons in 2016-2018 from the Pregnancy Risk Assessment Monitoring System. We created exposure categories based on self-reported number of cigarettes smoked per day and vaping frequency and evaluated their associations with preterm birth and small-for-gestational-age (SGA) birth (two established cigarette smoking-related risks).

Results

Dual users in late pregnancy were a heterogeneous group: 29% lightly smoked and occasionally vaped; 19% lightly smoked and frequently vaped; 36% heavily smoked and occasionally vaped; and 15% heavily smoked and frequently vaped. While dual users who heavily smoked and occasionally vaped had the highest adjusted OR for SGA (3.4, 95% CI 2.0, 5.7), all the dual users had, on average, about twice the odds of having SGA than non-users. While the risks of preterm birth were higher among sole light smokers (adjusted OR 1.3, 95% CI 1.1, 1.5) and sole heavy smokers (adjusted OR 1.5. 95% CI 1.2, 1.8) than non-users, the adjusted odds of preterm birth for dual users were not noticeably higher than those of non-users.

Conclusion

Relative to non-users, both smoking and vaping during pregnancy appear to increase risk of SGA, but excess risk of preterm birth appears to be primarily attributable to smoking alone. Higher levels of exposure tended to confer more risk.

E-cigarette and tobacco product use among NYS youth before and after a state-wide vaping flavour restriction policy, 2020-2021

Significance

Reducing youth e-cigarette use is a New York State (NYS) public health priority. In May 2020, a state-wide restriction on flavoured e-cigarettes, except tobacco flavour, was passed. This study examines changes in nicotine product use behaviour among youth around the time of the state-wide vaping flavour restriction.

Methods

NYS data from the US International Tobacco Control Policy Evaluation Project Youth Tobacco and E-cigarette Tobacco and Vaping Survey were analysed cross-sectionally from February 2020 (n=955), August 2020 (n=946), February 2021 (n=1030) and August 2021 (n=753). Online surveys were conducted among youth 16–19 years. Weighted descriptive statistics and regression models were used to describe changes in nicotine product use behaviour. Models were adjusted for age, sex, race/ethnicity and perceived family socioeconomic status.

Results

Significant decreases in past 30-day e-cigarette use (20%–11%), cigarette (7%-4%), and dual use of e-cigarettes and cigarettes (5%–2%) were observed over the 2-year period in NYS. Over 95% of vapers still reported using a non-tobacco-flavoured e-cigarette following the restriction, with fruit-flavoured being the most popular at each time point.

Conclusions

Nearly all NYS youth continued to vape flavours that were restricted in NYS. While youth past 30-day vaping prevalence decreased significantly from 2020 to 2021, increased flavour restriction compliance could result in an even greater decrease. Continuous monitoring is important to better understand perceptions, use patterns and access at the individual level, retail level and population level to inform future enforcement and restrictions.

Effects of Vaping Prevention Messages on Electronic Vapor Product Beliefs, Perceived Harms, and Behavioral Intentions among Young Adults: A Randomized Controlled Trial

Youth have been the focus of electronic vapor product (EVP) prevention efforts though young adults had similar increases in current EVP use from 2015-2019. This study tested messages to reduce EVP use in young adults. Eight messages on vaping related harms and addictiveness combined with themes on social use and flavors were selected for inclusion in an online randomized controlled trial. Vermont young adults aged 18-24 (n = 569) were randomized to view the eight vaping prevention messages (n = 295) or eight messages on sun safety (n = 274). After completing baseline measures, participants viewed study messages and completed measures on message perceptions and perceived message effectiveness (PME), EVP-related beliefs, and EVP-related harm perceptions. Participants completed EVP-related beliefs and harm perception measures again at 1-month follow-up, as well as measures on tobacco and EVP-related behavioral intentions and behavior (ever and past 30-day use). Intervention participants reported positive impacts on vaping-related message responses. However, findings suggested no effect of vaping prevention messages on EVP-related beliefs, harm perceptions, or behaviors in the full sample. Exploratory analyses in the intervention condition showed that greater PME was associated with lower odds to intent to try cigarettes in the next year at follow-up.

The Impact of Current Tobacco Product Use Definitions on Estimates of Transitions Between Cigarette and ENDS Use

INTRODUCTION

Definitions of current tobacco and nicotine delivery product use vary and depend on frequency of use, established-use criteria, and the product type. Previous research has not considered how transition rates between current use of different products depend on the current use definition.

AIMS AND METHODS

We applied a multistate transition model to data on U.S. adults from waves 1-4 (2013-2017) of the Population Assessment of Tobacco and Health (PATH) study. We estimated transition rates between never, non-current, cigarette, electronic nicotine delivery systems (ENDS), and dual use states with and without established-use criteria (has smoked 100+ cigarettes in their lifetime; ever fairly regularly used ENDS) and different frequency thresholds (1+, 10+, 20+, and 30 days of the past 30 days). We considered use below a frequency threshold as either non-current use or a distinct, infrequent use category.

RESULTS

When treating use below a frequency threshold as non-current use, transition probability estimates were largely robust to the choice of use frequency threshold, although sole ENDS users were more likely to transition to non-current use or dual use as the current use threshold increased. Removing the established-use criterion for ENDS reduced the estimates of sole ENDS and dual users staying in their use state. When treating infrequent use as a separate category, transition probability estimates were dependent on the use frequency threshold, particularly transitions among the dual use states.

CONCLUSIONS

Product use definitions have important implications for assessing product use transitions and thus the public health implications of cigarette and ENDS control strategies.

IMPLICATIONS

How we define "current use" of tobacco and nicotine delivery products changes our estimates of how individuals transition to, between, and from different patterns of use. We show that the robustness of transition estimates to whether or not non-established users are included as current users and to different frequency-of-use threshold depends in part on whether low-frequency users are categorized as non-current users or as a distinct category. Our results emphasize the importance of intentional definitions of product use that reflect the larger goals of public health and tobacco control.

Tobacco use profiles by respiratory disorder status for adults in the wave 1-wave 4 population assessment of tobacco and health (PATH) study

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Exclusive ENDS use is associated with a prior COPD diagnosis.

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Dual ENDS/cigarette use is associated with prior diagnoses of COPD and bronchitis.

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Analyses adjusted for behavioral health symptoms and other respiratory disorders.

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Complete tobacco cessation is most beneficial in reducing respiratory complications.

Limited evidence exists on the association between electronic nicotine delivery systems (ENDS) and chronic respiratory disorders. This study examines the association of combustible tobacco and ENDS use with chronic respiratory disorders among US adults. Public-use data from the Population Assessment of Tobacco and Health (PATH) Study Wave 1 (2013–2014), Wave 2 (2014–2015), Wave 3 (2015–2016), and Wave 4 (2016–2018) were pooled. Analyses focused on adults with W1–W4 respiratory disorder data and current tobacco use at W4, as well as youth entering the adult cohort at W2 through W4 (N = 26,072). We fit weighted multivariable logistic regression models for each respiratory outcome (asthma, COPD, bronchitis) using W4 longitudinal weights. Cigarette smokers (adjusted odds ratio [AOR] = 0.8, 95 % CI 0.7–0.9) were less likely to report an asthma diagnosis (p = 0.013). In contrast, ENDS users (AOR = 6.5, 95 % CI 3.7–11.5), cigarette smokers (AOR = 6.1, 95 % CI 4.0–9.1), dual users of cigarettes and ENDS (AOR = 5.4, 95 % CI 3.4–8.7), current users of non-cigarette combustible, smokeless, and polytobacco products (AOR = 4.4, 95 % CI 3.1–6.4), and former users of any product (AOR = 3.0, 95 % CI 1.9–4.7) had significantly elevated odds of reporting a diagnosis of COPD (p < 0.001). Similar patterns to COPD were observed for bronchitis (p < 0.001). Current and former tobacco use, including ENDS, were significantly associated with prevalence of self-reported COPD and bronchitis after controlling for demographic and psychosocial confounders.

Determinants of E-Cigarette and Cigarette Use among Youth and Young Adults in Poland-PolNicoYouth Study

Teen use of tobacco-related products is a significant public health concern. This study evaluated the predictors of e-cigarette use among secondary school students who were never cigarette smokers and ever cigarette smokers in Poland.

METHODS

This study examined a sample of Polish youths aged 13-19 (n = 19,241) attending 200 schools, 12 on average in each county. The study was a part of the National Health Program in Poland for 2016-2020. Logistic regression and multivariable logistic regression models were used to calculate crude and adjusted odds ratios.

RESULTS

Of all participants, 32.5% were ever cigarette users. Among the never cigarette users, 13.6% were deemed susceptible to e-cigarette use. Among the ever cigarette users, 60.6% were deemed susceptible to e-cigarette use. Of those susceptible to e-cigarette use, 68.2% were among the 32.5% ever cigarette users. The profile of e-cigarette use among never e-cigarette users also included: pocket money available per month (more than 150 PLN) (OR = 1.7; p = 0.001), 16-17 years old (OR = 1.9; p = 0.001), parental tobacco smoking and e-cigarette usage (OR = 2.0; p = 0.01 and OR = 1.7; p = 0.001 respectively), maternal secondary education (OR = 1.1; p = 0.04), and living in big cities >500,000 inhabitants (OR = 1.4; p = 0.04). E-cigarette users among ever cigarette users were similar to never cigarette users in their opinion that e-cigarette use is less harmful than traditional smoking (OR = 1.6; p = 0.0012) and living with both parents smoking cigarettes (OR = 1.3; p = 0.02). Additionally, the determinants were: female gender (OR = 1.5; p = 0.009) in the age group less than 15 years of age (OR = 1.3; p = 0.007).

CONCLUSIONS

The major determinant of e-cigarette use in this population was prior smoking. Additionally, the results revealed that fairly obvious predictors such as parental smoking and a belief in the less harmfulness of e-cigarette use are important determinants for smoking among never or ever e-cigarette users.

E-cigarette Transitions Among US Youth and Adults: Results from the Population Assessment of Tobacco and Health Study (2013-2018)

Currently, the debate surrounding the regulation of e-cigarettes focuses mainly on the size of e-cigarettes' potentially beneficial effects (i.e., adult cessation) versus their unwarranted effects (i.e., initiation among tobacco-naïve adolescents). Therefore, we investigated the relative scale of e-cigarette use transitions in the United States. We reported cross-sectional weighted prevalence estimates of past-month e-cigarette use by ever cigarette use from Waves 1-4 of the Population Assessment of Tobacco and Health study (2013-2018) among youth (12-17 years) and adults (≥ 18 years). We also examined past-month e-cigarette mono and dual transitions related to cigarette smoking and reported the longitudinal weighted prevalence across waves. Among youth new e-cigarette users, the proportion of never-cigarette smokers increased from 24.1 in Wave 1 (n = 418) to 51.4% in Wave 4 (n = 310) (p < 0.0001 for trend). Of youth past-month e-cigarette mono-users in Wave 1 (n = 151), 15.2% transitioned to cigarette mono-use and 8.2% dual-use at Wave 2 or 3 or 4, compared to 60.2% no tobacco use and 16.4% e-cigarette mono-use. Among young adult past-month dual-users (18-24 years; n = 684), 22.6% transitioned to no tobacco use, 60.1% continued cigarette use, 11.4% dual use, and 5.9% e-cigarette mono-use. Among adult dual-users ≥ 25 years old (n = 1560), 13.6% transitioned to no tobacco use, 71.3% cigarette mono-use, 9.0% dual-use, and 6.1% e-cigarette mono-use. Transition to cigarette mono-use and continued dual-use were common among adult past-month e-cigarette users, while e-cigarette initiation was common among youth never-cigarette smokers. These findings contrast with data from other countries showing limited evidence of e-cigarette initiation among youth never cigarette smokers. Both e-cigarette and cigarette use should be addressed in youth and adults, given the potential for dual use in both populations.

Geographic isolation predicts tobacco product use among youth: A latent class analysis

PURPOSE

The purpose of the current study was to evaluate associations between geographic rurality and tobacco use patterns among adolescents.

METHODS

High school students (N = 566) from north-central Appalachia reported on their lifetime and/or current use of cigarettes, electronic cigarettes (ECIGs), cigars, and smokeless tobacco. Geographic rurality was measured via the Isolation scale, whereby residential ZIP Codes determined the degree to which respondents have access to health-related resources. Latent class analysis (LCA) was used to identify discrete classes of adolescent tobacco users based on their use of tobacco products. Then, associations between participants' geographic rurality and class membership were evaluated using a series of multinomial logistic regressions.

FINDINGS

LCA classified participants as Nonusers, Current ECIG Users, Cigarette/ECIG Experimenters, and Polytobacco Users. Individuals with higher Isolation scores were more likely to be Polytobacco Users and Cigarette/ECIG Experimenters than Nonusers, and were more likely to be Polytobacco Users than Current ECIG Users.

CONCLUSIONS

The continuous Isolation scale used in the present study predicted polytobacco use patterns among adolescents in a manner that is consistent with, while simultaneously expanding upon, prior work. Tobacco control practices and policies should be viewed through a lens that considers the unique needs of geographically isolated areas.

Preferred flavors and tobacco use patterns in adult dual users of cigarettes and ENDS

OBJECTIVES

This study examined how adult dual users of cigarettes and electronic nicotine delivery system (ENDS) flavor preference varied by demographics, tobacco history, motives, and expectancies for ENDS, and how ENDS flavor preference was associated with changes in cigarette and ENDS use over 12 months.

METHODS

Data come from the baseline and 12-month waves of an observational study of adult dual cigarette and ENDS users (N = 406). Flavor preferences were grouped into 4 categories: tobacco (12.6%), menthol/mint (34.7%), sweet (44.8%), and other (7.9%).

RESULTS

Users of sweet-flavored ENDS were significantly younger than those who used tobacco- or menthol flavors. Black dual users were significantly more likely than other racial groups to use menthol and less likely to use sweet flavors. Dual users who preferred sweet flavors smoked cigarettes on fewer days than those who preferred tobacco and menthol flavors, were less cigarette dependent, more strongly endorsed boredom reduction expectancies and motives related to taste and sensory experience and were more likely to stop smoking by 12 months.

CONCLUSIONS

Dual users of cigarettes and ENDS who preferred sweet flavored ENDS differed in demographics, tobacco history, motives, expectancies, and smoking changes. Findings have implications for interventions and regulations.

Associations of e-cigarette industry beliefs and e-cigarette use and susceptibility among youth and young adults in the United States

BACKGROUND

Anti-industry sentiments are protective against smoking, but the relationship between industry beliefs and e-cigarette use remains unknown.

METHODS

A nationally representative survey of U.S. youth and young adults in Fall 2019 (n = 9554) assessed knowledge that e-cigarette and cigarette companies are the same, belief that e-cigarette companies lie about harm, and belief that tobacco companies want young people to vape. Weighted multivariate logistic regression models estimated odds of current use and susceptibility to use (among ever and never users) by industry knowledge and beliefs. Additional models assess association between industry knowledge and industry beliefs. All models controlled for harm perceptions, friend use, sensation seeking, combustible use, and demographic characteristics.

RESULTS

Disagreement that companies lie about harm (adjusted odds ratio (aOR)= 1.94, 95% CI: 1.43-2.63) and companies want young people to vape (aOR=1.72, 95% CI: 1.36-2.17) was associated with increased odds of current use. Belief that e-cigarette and cigarette companies were different entities was associated with increased odds of current use (aOR=1.45, 95% CI: 1.12-1.88). Disagreement or not knowing that companies are the same was associated with lower odds of believing companies lie about harm (disagreement aOR=0.37, 95% CI: 0.27-0.52; don't know aOR=0.47, 95% CI: 0.35-0.65) and belief that companies want young people to vape (disagreement aOR=0.36, 95% CI: 0.28-0.46; don't know aOR=0.54, 95% CI: 0.42-0.68).

CONCLUSION

Similar to cigarettes, e-cigarette industry beliefs were associated with current use among young people. Highlighting e-cigarettes' connection to Big Tobacco may be an important strategy to prevent youth and young adult e-cigarette use.

Association between electronic nicotine delivery systems (ENDS) device and E-liquid alterations and flavor use with clinical and EVALI-like symptoms

Studies reporting clinical symptoms related to electronic nicotine delivery systems (ENDS) usage, especially types of devices and e-liquids, are sparse. The sample included 1,432 current ENDS users, ages 18-64, from a nationwide online survey conducted in 2016. ENDS use included device types, nicotine content, flavors, and e-liquid used. Outcomes included any e-cigarette, or vaping, product use-associated lung injury (EVALI)-like symptoms (e.g., cough, shortness of breath, nausea) as well as any clinical symptoms. Of the sample, 50% were female, 23% non-Hispanic (NH) White, 23% NH Black, 54% Hispanic, 18% aged 18-24, 17% LGBTQ, 41% with <$50 K income, 55% 1 + any symptoms, and 33% 1 + any EVALI-like symptoms. Cough and nausea were most prevalent among EVALI-like symptoms (27% and 7.3%, respectively). The proportion having any EVALI-like symptoms was higher in the following groups: younger, Hispanic, current smokers, and current other product users. With multiple adjustments, participants who used refillable devices, varied nicotine content, used flavored products, or made their own e-liquids were more likely to have clinical symptoms than their counterparts. For example, the odds (95% CI) of having 1 + EVALI-like symptoms in participants who used refillable devices with e-liquid pour or e-liquid cartridge replacement were 1.70 (1.13, 2.56) and 1.95 (1.27, 2.99), respectively, compared to the non-refillable group. Use of products (devices and e-liquids) that can be altered and flavored products are associated with higher odds of having clinical symptoms, including EVALI-like symptoms.

Electronic nicotine delivery system (ENDS) use patterns and its associations with cigarette smoking and nicotine addiction among Asian Americans: Findings from the national adult tobacco survey (NATS) 2013-2014

This study examined the ENDS use and their associations with conventional cigarette smoking and nicotine addiction among Asian Americans (AAs). The study sample was restricted to Non-Hispanic AAs (n = 1,956) using the National Adult Tobacco Survey (NATS) 2013-2014. Chi-square tests and logistic regressions were employed. AAs who ever used ENDS reported they were more likely to smoke conventional cigarettes, smoke ≤100 cigarettes in a lifetime, and felt more difficulty concentrating without using tobacco than those who never used END. Study findings indicate that ENDS use may be associated with conventional cigarette smoking and may lead to nicotine addiction among AAs.

E-cigarettes use among university students in Jordan: Perception and related knowledge

The use of e-cigarettes has been increasing in popularity among people, especially young adults. Assessing young individuals’ perceptions of e-cigarettes can help to identify factors that may influence their decision to use e-cigarettes. To examine prevalence, perceptions, and knowledge of e-cigarettes among university students in Jordan, an observational cross-sectional study using an online self-administered questionnaire was conducted among students from public and private universities between October 2020 and January 2021. A total of 1259 university students completed the questionnaire. Approximately, 11% of participants reported e-cigarettes use. Among users, 26.5% used it for the purpose of smoking cessation, while 22% of them used it out of curiosity, and 20.5% used it as they believed it is less harmful than other tobacco products. Multivariate analysis showed that conventional cigarette smokers were independently associated with a better knowledge about e-cigarettes (OR = 1.496, 95CI% = 1.018–2.197, p-value = 0.040). In addition, medical students showed a significantly better knowledge compared to non-medical students (OR = 1.710, 95CI% = 1.326–2.204, p-value = <0.001). In Jordan, e-cigarettes use is less popular compared to other countries. Nonetheless, educational interventions are needed to correct misconceptions about e-cigarettes among young adults.

Age of e-cigarette initiation in USA young adults: Findings from the Population Assessment of Tobacco and Health (PATH) study (2013-2017)

INTRODUCTION

There is a lack of research prospectively estimating the age of e-cigarette initiation in U.S. young adults.

METHODS

Secondary analysis of PATH young adults across 2013-2017 (waves 1-4) were conducted. We prospectively estimated age of initiation of: ever, past 30-day, and fairly regular e-cigarette use using weighted interval-censoring survival analyses. Interval-censoring Cox proportional hazard models adjusting for sex, race/ethnicity, and previous use of six other tobacco products (cigarettes, traditional cigars, filtered cigars, cigarillos, hookah, and smokeless tobacco) were fitted for each of the three e-cigarette initiation outcomes.

RESULTS

Among never e-cigarette users, by age 21, 16.8% reported ever use, 7.2% reported past 30-day use, and 2.3% reported fairly regular e-cigarette use. Males had increased risk of initiating ever, past 30-day, and fairly regular e-cigarette use at earlier ages compared to females. Hispanic young adults had increased risk of initiating ever and past 30-day e-cigarette use at earlier ages compared to Non-Hispanic White young adults. Previous use of other tobacco products before e-cigarette initiation increased the risk of an earlier age of e-cigarette initiation.

CONCLUSION

Prevention and education campaigns should focus on young adults in order to alleviate the public health burden of initiating e-cigarette use at earlier ages.

Health Conditions, Substance Use, Physical Activity, and Quality of Life in Current and Former Baseball Players

Background:

A comprehensive understanding of lifestyle (health conditions and substance use), health-related quality of life (HRQoL), flourishing (holistic representation of health), and physical activity can inform stakeholders (players, coaches, and clinicians) and help improve long-term health across the life span.

Purpose:

To describe health conditions (comorbidities or diagnoses), substance use, physical activity, HRQoL, and flourishing in current and former collegiate and professional baseball players and to assess the relationship between playing position and HRQoL/flourishing in former baseball players.

Study Design:

Descriptive epidemiology study.

Methods:

Eligible participants were those ≥18 years old with ≥1 season of collegiate or professional baseball experience. Participants completed a survey on health conditions (asthma, diabetes, hypertension, hypercholesterolemia, and depression), substance use (tobacco, alcohol, and energy drinks), physical activity (International Physical Activity Questionnaire–Short Form), HRQoL (Veterans Rand 12-Item Health Survey [VR-12] physical and mental component scores), and flourishing (Flourishing Scale). Adjusted multivariable regressions were performed for HRQoL and flourishing.

Results:

Overall, 260 baseball players opened the survey, and 214 (current players, 97; former players, 117) participated for an 82% response rate. Of the former players, 32% had hypertension or hypercholesterolemia. In addition, 26% of current players had used smokeless tobacco (median, 3 years; interquartile range [IQR], 1-5 years) as compared with 34% of former players (median, 15 years; IQR, 5-25 years). In addition, 14% of current players had used electronic cigarettes (median, 2 years; IQR, 0-4 years) as opposed to 3% of former (median, 3 years; IQR, 2-4 years). Energy drinks were consumed by 31% and 14%, respectively, of current and former players on at least a weekly basis. Current baseball players performed 8667 metabolic equivalents per week of physical activity as opposed to 3931 in former players. Pitching was associated with worse VR-12 Mental Component Scores (–5.0; 95% confidence interval, –9.0 to –1.0). Playing position was not related to VR-12 Physical Component Scores or flourishing in former baseball players.

Conclusion:

The similar smokeless tobacco prevalence between current and former baseball players suggests that they may start using tobacco products during baseball participation and continue after retirement. Similar reported HRQoL as compared with the general US population and high flourishing and physical activity levels suggest that baseball players may present with good musculoskeletal and psychological health.

Systemic biomarkers of exposure associated with ENDS use: a scoping review

OBJECTIVE

This scoping review provides an overview of the existing literature on biomarkers of exposure from electronic nicotine delivery systems (ENDS) use and identifies gaps in existing knowledge.

DATA SOURCES

We searched two international databases (PubMed and Web of Science) to identify relevant studies published from August 2013 to February 2021.

DATA SELECTION

Studies were included if they assessed and compared biomarkers of exposure between exclusive ENDS users, non-users, exclusive cigarette smokers, dual users of ENDS and cigarettes or cigarette smokers who switch to ENDS.

DATA EXTRACTION AND SYNTHESIS

Of the 5074 studies identified, 188 studies met criteria and were selected for full-text screening. Of these, 27 studies were selected for inclusion and data extraction.

CONCLUSIONS

Consistent, although limited, evidence shows that exclusive ENDS users have elevated levels of biomarkers of certain volatile organic compounds (VOCs; eg, acrylamide and acrylonitrile), metals (eg, cadmium and selenium) and propylene glycol compared with non-users; however, evidence for biomarkers of other toxicants (eg, acrolein, benzene and chromium) is mixed. Biomarkers of most VOCs are lower in ENDS users compared with cigarette smokers, and cigarette smokers who switch to ENDS consistently show reductions in VOC biomarkers. Evidence comparing metal exposures from exclusive ENDS use, cigarette smoking and dual use is mixed and depends on the metal. ENDS and e-liquid characteristics as well as use patterns may be associated with elevated exposure to VOCs and metals. Additional rigorous, controlled studies can assess biomarker exposures from ENDS use and inform the overall risk-benefit of ENDS use for different user populations.

Characterizing heated tobacco product use among adult cigarette smokers and nicotine vaping product users in the 2018 ITC Four Country Smoking & Vaping Survey

INTRODUCTION

Heated tobacco products (HTP) have diversified global tobacco markets, and user characteristics remain understudied. This study evaluated sociodemographic characteristics, nicotine-related perceptions and behaviors of current HTP users within a sample of adult (18+ years) nicotine users across four countries.

METHODS

Data were from current smokers or nicotine vaping product (NVP; known as "e-cigarettes") users from Canada, England, the United States and Australia (n=11,421) who participated in the 2018 ITC Four Country Smoking and Vaping Survey. Current (at-least-monthly) HTP users were characterized (n=441), and weighted multivariable logistic regressions examined correlates of HTP use.

RESULTS

Compared to non-users, current HTP users were younger (mean age: 44.4 vs 31.0 years; p<0.001) and had higher socioeconomic status (p<0.001). A majority of current HTP users used HTPs non-daily (daily: 40.3% vs non-daily: 59.7%). Most HTP users concurrently used both cigarettes and NVPs (90.5%). Among concurrent cigarette-HTP-NVP users, 36.2% used all three products daily. Use of other combusted tobacco products (cigars, cigarillos, pipe, waterpipe/hookah), cannabis, and binge drinking were each associated with current HTP use. HTP use was more common among smokers intending to quit within 6 months or reporting a quit attempt in the past 18 months, and vapers who had experienced negative side effects.

CONCLUSION

HTP users in this sample tended to be younger and more affluent. Most reported concurrent use of multiple nicotine products and other substances. Those cigarette smokers who used HTPs appeared more interested in smoking cessation, while some characteristics of concurrent HTP-NVP users were suggestive of dissatisfaction with NVPs.

IMPLICATIONS

Few studies have scrutinized characteristics of HTP early-adopters in emerging markets. Our results indicate that in 2018, characteristics of established nicotine users who adopted HTP use in four high-income Western countries mirror those of HTP users in East Asian markets (South Korea and Japan) where HTPs are popular. HTP users reported high levels of concurrent use of non-cigarette combusted tobacco products (e.g., cigars, pipe tobacco). These findings point to the need for future longitudinal studies of HTP use given the implications of those use patterns on the harm reduction potential of HTPs. HTP user characteristics may yield important information to consider in regulation of these products.

Factors associated with past-year attempts to quit e-cigarettes among current users: Findings from the Population Assessment of Tobacco and Health Wave 4 (2017-2018)

Over 10 million adults report use of electronic nicotine delivery systems (ENDS), with approximately 3.6 million reporting daily use. Even as the popularity of ENDS has increased, both as an available nicotine delivery system and an alternative to combustible cigarette smoking, few studies to date have examined ENDS cessation interest and related behaviors among ENDS users. The current study aimed to describe past year attempts to quit ENDS among current users and to investigate ENDS use / user characteristics associated with unsuccessful attempts to quit in the past year among adult, current, established ENDS users using data from the Population Assessment of Tobacco and Health (PATH) Study Wave 4. Over 10 % of ENDS users reported an attempt to quit completely in the past year, and 60 % indicated future intention to quit completely. Higher nicotine dependence, lower-frequency ENDS use, and higher interest in quitting were associated with past year attempts to quit ENDS. The current study adds support to claims that many ENDS users plan to quit using ENDS someday and highlights the need for continued research on ENDS cessation.

Factors Associated with Cigarette, E-Cigarette, and Dual Use among South Korean Adolescents

Dual use of e-cigarettes and cigarettes has become common among Korean adolescents but has decreased among adults. Dual use refers to using two tobacco products; however, in this study, it is defined as using both e-cigarettes and cigarettes. We assessed the prevalence of dual use among Korean adolescents and its relationship with socio-demographic, smoking-related characteristics, and other risk behaviors. The 2019 Korea Youth Risk Behavior Survey’s data on 57,303 adolescents were analyzed using logistic regression. Overall, 13.8% had recently (in the past 30 days), used some type of cigarette, 3.3% were dual users, 3.4% exclusively smoked conventional cigarettes, and 0.6% exclusively vaped e-cigarettes. After adjusting for socio-demographic and psychological factors, substance use, smoking initiation by 13 years, secondhand smoke in school and public, and amount of cigarette consumption proved significant for all cigarette user types. Dual use was strongly associated with younger age (≤15 years), cigarette smoking initiation before 13 years, secondhand smoke exposure at school, and heavy cigarette smoking. Limited smoking cessation attempts, secondhand smoke exposure in public, and ease of cigarette purchases decrease the odds of adolescents becoming dual users. Thus, surveillance and enforcement of the juvenile protection measures need updating to prevent a shift into dual use.

Prevalence of Flavored e-Cigarette Use Among Subpopulations of Adults in the United States

BACKGROUND

Evidence of US adult flavored e-cigarette use prevalence stratified by age, smoking status, and purpose for vaping (ie, quitting smoking, to use when or where smoking is not allowed) can inform policies that reduce the tobacco-related cancer burden.

METHODS

Current flavored e-cigarette use (use 1 or more nontobacco flavors) prevalence estimates were compared across subpopulation groups using 2-sided statistical significance tests in the July 2018 Current Population Survey Tobacco Use Supplement, a nationally representative cross-sectional adult survey (n = 46 759).

RESULTS

Current flavored e-cigarette use was reported by 1.6% (95% confidence interval [CI] = 1.47% to 1.69%) of all respondents. Among current vapers, the percentage of those who used flavored e-cigarettes was higher for adults aged 18-24 years (89.6%), 25-34 years (86.7%), and 35-44 years (76.0%) than for adults aged 45 years and older (60.4%, Ps < .001); was higher in never smokers (89.8%) than current (72.9%), long-term former (73.9%), and recent former (80.4%) smokers (Ps ≤ .009); was higher in smokers who reportedly did (78.9%) vs did not (71.1%) use e-cigarettes to vape where or when smoking is not allowed (P = .005); and did not differ between smokers who reportedly did (75.0%) vs did not (73.9%) vape to quit smoking (P = .71). Individuals who vaped to quit smoking and currently used flavored e-cigarettes constituted 0.9% (95% CI = 0.82% to 0.99%) of all adults (weighted N = 2 251 000, 95% CI = 2 046 000 to 2 476 000) and 57.2% of current flavored e-cigarette users.

CONCLUSIONS

Flavored e-cigarette use prevalence was low among US adults overall but common for current vapers. Flavored e-cigarette use was disproportionately prevalent among never smokers and other subpopulations that might experience harm from vaping.

Effectiveness of ENDS, NRT and medication for smoking cessation among cigarette-only users: a longitudinal analysis of PATH Study wave 3 (2015-2016) and 4 (2016-2017), adult data

BACKGROUND

Research is inconclusive on the effectiveness of electronic nicotine delivery systems (ENDS) as cigarette cessation aids compared with nicotine replacement therapy (NRT) or non-NRT medication. This study compared the cigarette cessation rates for ENDS, NRT and non-NRT medication.

METHOD

Population Assessment of Tobacco and Health Study wave 3 cigarette-only users who used ENDS, NRT or non-NRT medication (varenicline and bupropion) to quit smoking between wave 3 and 4 were included. 'Cessation' was defined as being a former cigarette smoker in wave 4. χ², logistic regression, and a sensitivity analysis with Bayes factor assessed the association between quitting smoking and method used.

RESULTS

Among 6794 cigarette-only users, 532 used ENDS (n=75), NRT (n=289), non-NRT medication (n=68), or a combination of NRT and non-NRT medication (n=100) to quit smoking between wave 3 and 4. The percentages of quitting smoking among those who used ENDS, NRT, non-NRT medication, and a combination of NRT and non-NRT medication were 16.2% (n=14), 16.1% (n=47), 17.7% (n=13), and 14.8% (n=12), respectively (p=0.97). None of the cigarette-only users who used ENDS to quit smoking became ENDS-only users in wave 4; 37.6% became dual users of ENDS and cigarettes.

CONCLUSION

No differences were found when cessation rates of ENDS, NRT or non-NRT medication were compared. Given uncertainty about the long-term health effect of ENDS and the likelihood of becoming dual users, people who smoke and need assistance quitting should be encouraged to use current Food and Drug Administration-approved cessation methods until more effective methods are developed.

Characterising vaping products in the United Kingdom: an analysis of Tobacco Products Directive notification data

AIMS

To analyse content and emission data submitted by manufacturers for nicotine-containing vaping products in the United Kingdom (UK) in accordance with the European Union Tobacco Products Directive.

DESIGN

Analysis of ingredient and emission data reported for all e-liquid-containing e-cigarettes, cartridges or refill containers notified to the Medicines and Healthcare Regulatory Agency (MHRA) from November 2016 to October 2017.

SETTING

United Kingdom CASES: A total of 40 785 e-liquid containing products.

MEASUREMENTS

The average number of ingredients per product, nicotine concentrations, frequency of occurrence ingredients and frequency and levels of chemical emissions.

FINDINGS

Reports were not standardised in relation to units of measurement or constituent nomenclature. Products listed an average of 17 ingredients and 3.3% were reported not to contain nicotine. A total of 59% of products contained <12 mg nicotine per mL, and <1% were reported to have nicotine concentrations above the legal limit of 20 mg/mL. Over 1500 ingredients were reported, and other than nicotine the most commonly reported non-flavour ingredients were propylene glycol (97% of products) and glycerol (71%). The most common flavour ingredients were ethyl butyrate (42%), vanillin (35%) and ethyl maltol (33%). The most frequently reported chemical emissions were nicotine (65%), formaldehyde (48%) and acetaldehyde (40%). The reporting of the concentration of emissions was not standardised; emissions were reported in a format allowing analysis of median estimated concentration for between 13% and 100% of products for each reported emission. Most of the frequently reported emissions, other than nicotine, were present in median estimated concentrations below 1 μg/L of inspired air, and with the exception of nicotine, acrolein and diacetyl, at median levels below European Chemicals Agency Long Term Exposure and United States (US) Department of Labor Occupational Safety and Health Administration (OSHA) limits, where these were available.

CONCLUSIONS

An analysis of reports to the United Kingdom's Medicines and Healthcare products Regulatory Agency by manufacturers of vaping products shows that (i) these products have a large range of ingredients and emissions, (ii) the reporting system is unstandardized in terms of reporting requirements, and (iii) for quantified emissions, median levels are for the most part below published safe limits for ambient air.

Reasons for individual and concurrent use of vaped nicotine and cannabis: their similarities, differences, and association with product use

BACKGROUND

Understanding similarities, differences, and associations between reasons people vape nicotine and cannabis may be important for identifying underlying contributors to their co-use.

METHODS

A cross-sectional survey of 112 co-users of vaped nicotine and cannabis was conducted in 2020. A convenience sample of participants was recruited for the survey using Amazon Mechanical Turk. Participants responded to questions about their reasons for individual nicotine and cannabis product use and co-use and rated their level of agreement using numerical scales. Mean ratings for each reason for use subscale were examined across all participants and compared using paired samples t tests. Associations between reasons for use ratings and product consumption behaviors were examined using linear and logistic regression analyses.

RESULTS

Cannabis vaping and smoking exhibited similar mean ratings for user experience and product/substance-related reasons for use. Mean ratings for reasons related to product utility were similar for cannabis vaping and nicotine vaping. Mean ratings for utility-related reasons for use were higher for cannabis vaping than cannabis smoking (mean (SD), 3.6 (± 1.0) vs. 2.6 (± 1.2), p < 0.0001). On average, harm reduction-related reasons for use were rated higher for nicotine vaping than cannabis vaping (2.4 (± 1.6) vs. 1.8 (± 1.4), p < 0.0001). Regression models showed higher average ratings for utility-related (b = 0.32; 95% CI, 0.03-0.60) and harm reduction-related (b = 0.21; 95% CI, 0.04-0.37) reasons for nicotine vaping were associated with more frequent nicotine vaping (both p < 0.05). Higher average ratings for instrumentality-related reasons for co-use corresponded with more frequent monthly nicotine vaping (b = 0.26; 95% CI, 0.08-0.44) and higher odds of ever chasing cannabis with nicotine (aOR, 3.06; 95% CI, 1.29-7.30).

CONCLUSIONS

Vaping serves purposes that differ by substance; nicotine vaping was more closely related to reducing tobacco smoking-related harms, and cannabis vaping was more closely related to circumventing social problems posed by cannabis smoking. Lifetime sequential co-use practices and more frequent nicotine vaping were associated with enhancing the intoxicating effects of cannabis. While replication of these findings using non convenience-based sampling approaches is warranted, results underscore the need to consider shared and unique aspects of nicotine and cannabis vaping, as well as cross-substance interactions between nicotine and cannabis.

Regulatory approaches and implementation of minimally addictive combusted products

INTRODUCTION

A joint meeting was held by the World Health Organization (WHO) and the Convention Secretariat of the WHO Framework Convention on Tobacco Control to examine the potential effects of a regulatory policy to reduce nicotine in cigarettes to minimally addictive levels. This paper reviews the feasibility of and approaches to implementing a nicotine product standard.

METHODS

Prior WHO reports on this topic were consulted and a systematic review of the scientific literature was conducted. The paper was reviewed by the participants at the aforementioned meeting and their feedback was incorporated.

RESULTS

The nicotine dose most likely to consistently reduce smoking behavior and dependence is < 0.4 mg nicotine/g tobacco. An immediate rather than a gradual nicotine reduction approach appears to be more beneficial. Smokers are likely to seek nicotine from alternate sources (e.g., nicotine replacement therapies, e-cigarettes) or potentially, the illegal market. As such, the availability of alternative products, as well as strong policies against illegal markets, can potentially mitigate unintended consequences. An effective reduced nicotine regulation must be imbedded in a comprehensive and strong tobacco control program that includes public education and surveillance. Barriers and challenges to implementing a nicotine product standard exist, particularly in low-capacity countries.

CONCLUSION

Not all countries will have the capacity to implement a regulation to reduce nicotine in cigarettes (and preferably other combusted tobacco products) to minimally addictive levels. However, for the countries that choose to implement it, such a policy could potentially dramatically reduce the burden of tobacco use.

A comparison of tobacco product prevalence by different frequency of use thresholds across three US surveys

BACKGROUND

With the increasing changes in tobacco use patterns, "current use" definition and the survey used may have important implications for monitoring population use trends.

METHODS

Using three US surveys (2014/15 TUS-CPS, NHIS and PATH), we compared the adult (age 18+) prevalence of four product groups (cigarettes, other combustibles, smokeless tobacco, and e-cigarettes) based on three past 30-day frequency of use thresholds: 1+, 10+, and 25+ days. We also examined mutually exclusive single, dual, and polytobacco users as a percentage of total users for each product group.

RESULTS

Regardless of threshold or product, the prevalence was higher in PATH followed by NHIS and TUS-CPS, in some cases by large percentages. The differences in cigarette and smokeless tobacco use prevalence in going from the 1+ to 10+ days and to the 25+ days threshold were minimal. Applying different frequency thresholds had the largest impact on other combustibles prevalence, with a 60% reduction with the 10+ days threshold and a 80% reduction with the 25+ days threshold, compared to the 1+ days threshold, followed by e-cigarettes with 40 and 60% reductions, respectively. The proportion of dual and polytobacco users decreased considerably when using the 10+ vs. the 1+ days threshold and polytobacco use was almost non-existent with the 25+ days threshold.

CONCLUSION

The estimated prevalence of each tobacco product use depends largely on the survey and frequency of use threshold adopted. The choice of survey and frequency threshold merits serious consideration when monitoring patterns of tobacco use.

Tobacco Use Prevalence and Transitions From 2013 to 2018 Among Adults With a History of Cardiovascular Disease

Background Although tobacco product use and transitions have been characterized in the general population, few studies have focused on individuals with established cardiovascular disease (CVD) in a population-based sample. Methods and Results We examined tobacco use prevalence and longitudinal patterns of tobacco product transitions in adults (≥18 years) of the nationally representative PATH (Population Assessment of Tobacco and Health) study, from 2013 to 2014 (Wave 1) through 2016 to 2018 (Wave 4). Prevalent CVD was classified through self-report of having had a heart attack, heart failure, stroke, or other heart condition. Factors associated with tobacco product use and transitions were investigated using survey logistic regression. We examined 2615 participants with self-reported CVD at Wave 1. Overall, 28.9% reported current tobacco use, equating to ≈6.2 million adults in the United States with prevalent CVD and current tobacco use. Among adults with CVD who are current tobacco users, the most commonly used product was cigarettes (82.8%), followed by any type of cigar (23.7%), and e-cigarette use (23.3%). E-cigarette use without concurrent cigarette use among participants with prevalent CVD was uncommon (1.1%). Factors associated with tobacco use were younger age, male sex, had lower education level, and lack of knowledge about the association between smoking and CVD. Men with prevalent CVD were less likely to use e-cigarettes compared with women (odds ratio [OR], 0.7; 95% CI, 0.5-0.9). Among cigarette users with CVD, transition rates between Waves 1 and 4 demonstrated <5% decrease in cigarette, with a 0.5% increase in e-cigarette use. Only ≈10% were in formal tobacco cessation programs. Conclusions Despite known harmful cardiovascular effects, over one fourth of adults with prevalent CVD use tobacco products and few quit smoking over the 4 waves of the PATH data set.

The role of affective urgency and emotion regulation in vaping susceptibility

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Both positive and negative urgency are correlated with emotion dysregulation.

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Emotion dysregulation mediated the effect of negative urgency but not positive urgency on a measure of vaping susceptibility.

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Measures to prevent e-cigarette use should target individuals with high negative urgency and focus on building emotion regulation skills.

Introduction

The prevalence of E-cigarette use is increasing along with concerns about the negative health effects of their use. Understanding the psychological constructs associated with susceptibility to beginning regular e-cigarette use may be helpful for prevention efforts. Factors such as emotion regulation (ER) and impulsivity, specifically urgency, have been significantly correlated with patterns of drug addiction in the past. With few prior studies linking ER and impulsivity factors with e-cigarette susceptibility, the present study aims to assess their relationship in predicting e-cigarette susceptibility in university never-smokers.

Method

Two hundred and twenty-five students were surveyed online using a questionnaire measuring difficulties in ER, impulsivity, and e-cigarette susceptibility. Path analysis was used to understand the relationship between positive and negative urgency and ER in predicting susceptibility to use.

Results

Results indicated that negative urgency was mediated by difficulties in ER to predict susceptibility while positive urgency was not significantly related to susceptibility.

Conclusion

The results of this study offer insights into the role affective traits contribute to susceptibility to e-cigarettes, potentially improving future addiction prevention research.

Applying the Population Health Standard to the Regulation of Electronic Nicotine Delivery Systems

Regulatory authorities have devoted increasing attention and resources to a range of issues surrounding the regulation of novel nicotine and tobacco products. This review highlights the inherent complexity of evaluating prospective policies that pertain to products that heat solutions containing nicotine, but not tobacco leaf, sometimes referred to as electronic nicotine delivery systems (ENDS). The US Food and Drug Administration (FDA) is compelled to incorporate a set of public health criteria in their decision making, collectively referred to as the Population Health Standard. Adherence to this standard is necessary to estimate the impact of prospective ENDS policy decisions on net population harm associated with nontherapeutic nicotine products. For policies that are expected to decrease or increase ENDS use, application of the Population Health Standard requires a comprehensive assessment of the status quo impact of ENDS use on population health. Accordingly, this review first assesses the state of the evidence on the direct harms of ENDS and the indirect effects of ENDS use on smoking, particularly rates of initiation and cessation. After that, the example of flavor restrictions is used to demonstrate the further considerations that are involved in applying the Population Health Standard to a prospective ENDS policy. Implications: This narrative review aims to inform regulatory considerations about ENDS through the prism of the Population Health Standard. More specifically, this review (1) describes and explains the importance of this approach; (2) provides guidance on evaluating the state of the evidence linking ENDS to the net population harm associated with nontherapeutic nicotine products; and (3) illustrates how this framework can inform policymaking using the example of flavor restrictions.

Exposure to Nicotine and Toxicants Among Dual Users of Tobacco Cigarettes and E-Cigarettes: Population Assessment of Tobacco and Health (PATH) Study, 2013-2014

INTRODUCTION

Concurrent use of tobacco cigarettes and e-cigarettes ("dual use") is common among tobacco users. Little is known about differences in demographics and toxicant exposure among subsets of dual users.

AIMS AND METHODS

We analyzed data from adult dual users (current every/some day users of tobacco cigarettes and e-cigarettes, n = 792) included in the PATH Study Wave 1 (2013-2014) and provided urine samples. Samples were analyzed for biomarkers of exposure to nicotine and selected toxicants (tobacco-specific nitrosamine NNK [NNAL], lead, cadmium, naphthalene [2-naphthol], pyrene [1-hydroxypyrene], acrylonitrile [CYMA], acrolein [CEMA], and acrylamide [AAMA]). Subsets of dual users were compared on demographic, behavioral, and biomarker measures to exclusive cigarette smokers (n = 2411) and exclusive e-cigarette users (n = 247).

RESULTS

Most dual users were predominant cigarette smokers (70%), followed by daily dual users (13%), non-daily concurrent dual users (10%), and predominant vapers (7%). Dual users who smoked daily showed significantly higher biomarker concentrations compared with those who did not smoke daily. Patterns of e-cigarette use had little effect on toxicant exposure. Dual users with high toxicant exposure were generally older, female, and smoked more cigarettes per day. Dual users who had low levels of biomarkers of exposure were generally younger, male, and smoked non-daily.

CONCLUSIONS

In 2013-2014, most dual users smoked cigarettes daily and used e-cigarettes occasionally. Cigarette smoking appears to be the primary driver of toxicant exposure among dual users, with little-to-no effect of e-cigarette use on biomarker levels. Results reinforce the need for dual users to stop smoking tobacco cigarettes to reduce toxicant exposure.

IMPLICATIONS

With considerable dual use of tobacco cigarettes and e-cigarettes in the United States, it is important to understand differences in toxicant exposure among subsets of dual users, and how these differences align with user demographics. Findings suggest most dual users smoke daily and use e-cigarettes intermittently. Low exposure to toxicants was most common among younger users, males, and intermittent smokers; high exposure to toxicants was most common among older users, females, and heavier cigarette smokers. Results underscore the heterogeneity occurring within dual users, and the need to quit smoking cigarettes completely in order to reduce toxicant exposure.

Patterns of E-cigarette Use and Subsequent Cigarette Smoking Cessation Over 2 Years (2013/2014-2015/2016) in the Population Assessment of Tobacco and Health Study

INTRODUCTION

Understanding the population impact of e-cigarettes requires determining their effect on cigarette smoking cessation.

METHODS

Using the US Population Assessment of Tobacco and Health cohort, we examined smoking cessation among adult current cigarette smokers at Wave 1 with follow-up data at Waves 2 and 3 (n = 9724).

RESULTS

By Wave 3 (2015/2016), 17.3% of smokers had quit smoking. Smokers using e-cigarettes daily or who increased to daily use over the three waves were two to four times more likely to have quit in the short term (<1 year) and long term (1+ years) compared with never e-cigarette users (p < .001). E-cigarette use in the last quit attempt was associated with a higher likelihood of short-term (<1 year) quitting at Wave 3 (adjusted relative risk ratio: 1.33; 95% confidence interval: 1.04, 1.71) compared with smokers who did not use an e-cigarette in their last quit attempt. Noncurrent (no use in any wave) e-cigarette users and users who were unstable in use frequency were 33% and 47% less likely to quit in the short-term, respectively (p < .001). Flavored (vs nonflavored) and using a rechargeable (vs disposable) e-cigarette device was associated with an increased likelihood of both short- and long-term quitting.

CONCLUSION

Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices. Less frequent, unstable, past, or never e-cigarette users were less likely to quit smoking. Monitoring the relationship between patterns of e-cigarette and cigarette use is complex but critical for gauging the potential of e-cigarettes as a harm reduction tool.

IMPLICATIONS

This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the United States. In addition, findings suggest that flavored e-cigarette use and use of rechargeable e-cigarette devices can facilitate smoking cessation. These results underscore the importance of carefully defining and characterizing e-cigarette exposure patterns, potential confounders, and use of e-cigarettes to quit smoking, as well as variations in length of the smoking cessation.

Toxicology of flavoring- and cannabis-containing e-liquids used in electronic delivery systems

Electronic cigarettes (e-cigarettes) were introduced in the United States in 2007 and by 2014 they were the most popular tobacco product amongst youth and had overtaken use of regular tobacco cigarettes. E-cigarettes are used to aerosolize a liquid (e-liquid) that the user inhales. Flavorings in e-liquids is a primary reason for youth to initiate use of e-cigarettes. Evidence is growing in the scientific literature that inhalation of some flavorings is not without risk of harm. In this review, 67 original articles (primarily cellular in vitro) on the toxicity of flavored e-liquids were identified in the PubMed and Scopus databases and evaluated critically. At least 65 individual flavoring ingredients in e-liquids or aerosols from e-cigarettes induced toxicity in the respiratory tract, cardiovascular and circulatory systems, skeletal system, and skin. Cinnamaldehyde was most frequently reported to be cytotoxic, followed by vanillin, menthol, ethyl maltol, ethyl vanillin, benzaldehyde and linalool. Additionally, modern e-cigarettes can be modified to aerosolize cannabis as dried plant material or a concentrated extract. The U.S. experienced an outbreak of lung injuries, termed e-cigarette, or vaping, product use-associated lung injury (EVALI) that began in 2019; among 2,022 hospitalized patients who had data on substance use (as of January 14, 2020), 82% reported using a delta-9-tetrahydrocannabinol (main psychoactive component in cannabis) containing e-cigarette, or vaping, product. Our literature search identified 33 articles related to EVALI. Vitamin E acetate, a diluent and thickening agent in cannabis-based products, was strongly linked to the EVALI outbreak in epidemiologic and laboratory studies; however, e-liquid chemistry is highly complex, and more than one mechanism of lung injury, ingredient, or thermal breakdown product may be responsible for toxicity. More research is needed, particularly with regard to e-cigarettes (generation, power settings, etc.), e-liquids (composition, bulk or vaped form), modeled systems (cell type, culture type, and dosimetry metrics), biological monitoring, secondhand exposures and contact with residues that contain nicotine and flavorings, and causative agents and mechanisms of EVALI toxicity.

Cross-Sectional Associations of Smoking and E-cigarette Use with Self-Reported Diagnosed Hypertension: Findings from Wave 3 of the Population Assessment of Tobacco and Health Study

Following their introduction a decade ago, electronic cigarettes (e-cigarettes) have grown in popularity. Given their novelty, knowledge of the health consequences of e-cigarette use remains limited. Epidemiologic studies have not comprehensively explored associations between e-cigarette use and hypertension, a highly prevalent health condition and major contributor to cardiovascular disease burden. In this study, cross-sectional associations of cigarette smoking and e-cigarette use (vaping) with self-reported diagnosed hypertension were evaluated among 19,147 18-55 year old respondents in Wave 3 (2015-2016) of the Population Assessment of Tobacco and Health Study. Multivariable analyses first modeled smoking and vaping as separate 2-category variables, then as a 6-category composite variable accounting for former smoking. After adjusting for potential confounders, current vaping (aOR = 1.31; 95%CI: 1.05-1.63) and current smoking (aOR = 1.27; 95%CI: 1.10-1.47) were both associated with higher odds of hypertension. In analyses modeling smoking and vaping compositely, respondents who were concurrently smoking and vaping had the highest odds of hypertension (aOR = 1.77; 95%CI: 1.32-2.39 [referent: never smokers]). These results differ somewhat from prior epidemiologic studies of vaping and respiratory outcomes, which consistently report smaller point estimates for current vaping than for current smoking. Our findings reinforce the uncertainty surrounding long-term health consequences of vaping, as well as highlight important distinctions between respiratory and cardiovascular outcomes when considering the harm reduction potential of e-cigarettes.