E-cigarette and cigarette purchasing among young adults before and after implementation of California's tobacco 21 policy

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

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

INTRODUCTION

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

AIMS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPLICATIONS

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

Birthdate-based commercial tobacco sales restrictions: will 'tobacco-free generation' policies advance or delay the endgame?

Endgame thinking means transitioning from merely trying to 'control' the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as 'endgame' policies are so-called 'tobacco-free generation' or 'smoke-free generation' policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

Environmental influences on E-cigarette use among young people: A systematic review

E-cigarettes are a popular mode of delivery for nicotine, tobacco and cannabis. The prevalence of vaping among youth is increasing and this review aims to identify features of the neighbourhood environment, e.g., retailers, advertisements, and policies, that are associated with youth vaping. We included 48 studies. Of these, approximately 40% and 60% reported that presence of e-cigarette retailers, and advertisements, was associated with statistically higher odds of e-cigarette use in youth, respectively. Approximately 30% of studies reported that policies affecting e-cigarette availability were associated with statistically lower odds of vaping. Identifying these influential features of the neighbourhood environment will help formulate appropriate policies to reduce e-cigarette use among youth.

Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review

INTRODUCTION

Many jurisdictions have implemented different regulatory strategies to reduce vaping among youth. The objective of this systematic review is to synthesize the evidence of the effectiveness of different regulatory strategies for preventing and reducing nicotine vaping among youth.

METHODS

Five electronic databases were searched from January 1, 2004 to July 17, 2022 for primary studies examining state/provincial or national regulations targeting vaping among youth (aged 12-21 years) in high-income countries. The primary outcome was vaping prevalence. Included studies were qualitatively synthesized through systematic review.

RESULTS

The systematic review included 30 studies. There was insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping. Included studies had moderate-to-serious risks of bias.

DISCUSSION

Although several regulatory interventions have been shown to be effective at reducing vaping among youth, evidence is insufficient to recommend a specific type of regulation. Regulatory authorities could implement various regulations targeting the price, accessibility, and desirability (i.e., flavors and packaging) of E-cigarettes.

Underage sales signage in vape shops: Comparison of stores near and far from California colleges

Objective: Two-thirds of U.S. colleges are near vape shops, where higher rates of underage sales exist. This study examined vape shop compliance with state-mandated age-of-sale signs, the presence of age-of-entry signs and the tobacco industry's "We Card" sign. Participants: Random sample of 614 California vape shops, stratified by distance to community colleges or 4-year universities/colleges; visited June-August, 2019. Methods: Logistic regressions examined whether signage varied by distance to colleges and whether stores sold other tobacco products (OTP). Results: Compliance with the state-mandated age-of-sale sign was 69.4%; vape-only stores were less compliant than vape + OTP (AOR = 0.39, 95% CI = 0.22,0.70). Age-of-entry signs were more common in vape-only (AOR = 1.87, 95% CI = 1.07,3.28) than vape + OTP stores. However, this difference was greater for vape-only stores near community colleges and attenuated for vape-only stores near 4-year universities/colleges. Conclusion: Improved enforcement and retailer education regarding age-of-sale signage are needed, particularly near colleges where greater potential for underage sales presumably exists.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review for the impacts of global approaches to regulating electronic nicotine products

Background

The rapid increase in electronic nicotine product (ENP) use among young people has been a global public health challenge, given the potential harm of ENPs and nicotine dependence. Many countries have recently introduced legislations to regulate ENPs, but the impacts of these policies are poorly understood. This systematic review aims to critically synthesise empirical studies on the effects of global regulations regarding ENPs on the prevalence of use, health outcomes and their determinants, using the 4A marketing mix framework (acceptability, affordability, accessibility and awareness).

Methods

Following the PRISMA guideline, we searched PubMed, Embase, Scopus, Web of Science, Academic Search Complete, Business Source Complete, and APA PsycINFO databases from inception until June 14, 2022 and performed citation searches on the included studies. Reviewed literature was restricted to peer-reviewed, English-language articles. We included all pre-post and quasi-experimental studies that evaluated the impacts of e-cigarette policies on the prevalence of ENP use and other health outcomes. A modified Joanna Briggs Institute (JBI) Critical Appraisal checklist for quasi-experimental studies was used for quality assessment. Due to heterogeneity of the included studies, we conducted a narrative synthesis of evidence.

Results

Of 3991 unduplicated records screened, 48 (1.2%) met the inclusion criteria, most were from high-income countries in North America and Europe and 26 studies measured self-reported ENPs use. Flavour restrictions significantly decreased youth ENP use and taxation reduced adult use; mixed results were found for the impacts of age restrictions. Indoor vaping restrictions and the European Tobacco Products Directive (TPD) did not seem to reduce ENP use based on existing studies. Changes in determinants such as sales and perceptions corroborated our conclusions. Few studies assessed the impacts of other regulations such as advertising restrictions and retail licensing requirements.

Conclusions

Flavour restrictions and taxes have the strongest evidence to support effective control of ENPs, while others need powerful enforcement and meaningful penalties to ensure their effectiveness. Future research should focus on under-examined policies and differential impacts across sociodemographic characteristics and countries.

Registration

PROSPERO CRD42022337361.

Youth's exposure to and engagement with e-cigarette marketing on social media: a UK focus group study

OBJECTIVE

Electronic-cigarettes (e-cigarette) are promoted creatively through social media and considering the potential influence of social media marketing on young people, we explored young people's exposure to and engagement with social media marketing of e-cigarettes.

DESIGN

Semistructured discussion groups.

SUBJECTS

Twenty focus groups with 82 young people aged 11-16 living in the Central belt of Scotland.

METHODS

Youths were asked about smoking and vaping behaviours, social media use, vaping advertisement exposure and were shown illustrative examples of social media content (eg, images and videos) about different messages, presentations and contextual features. Transcripts were imported into NVivo V.12, coded thematically and analysed.

RESULTS

Youths highlighted a variety of tactics e-cigarette companies use, including influencer or celebrity endorsement, attractive youth flavours, bright colours and emotional appeal to advertise and promote their products directly to young people. Social media influencers who advertise e-cigarettes were described as portraying e-cigarettes as 'cool' and 'fashionable' to entice viewers to try the products. Youths considered that there is a need for more restrictions on social media content to protect youths while also still allowing smokers to purchase them as a cessation device.

CONCLUSIONS

Our study highlights that the e-cigarette industry is using previously employed tactics similar to the tobacco industry to advertise and promote its products on social media. These findings suggest the growing need for governments to work together to develop and implement policies to restrict the advertising and marketing of e-cigarettes on social media.

Rates of Age Verification for Cigarette and E-cigarette Purchases as a Function of State T21 Laws Before and After Implementation of the Federal T21 Law in the United States

INTRODUCTION

In the US, having a 21 minimum legal sales age for tobacco (T21) at the state level may have impacted age verification of cigarette and e-cigarette purchases among U.S. young adults (ages 18-26), before and/or after federal T21 implementation.

AIMS AND METHODS

This study examined this by analyzing data from cigarette and/or e-cigarette users (n = 618 and n = 864) in six metropolitan areas in six states. Participants reported frequency of being age verified ("almost always" vs. less frequently) for cigarette and/or e-cigarette purchases across 3 timepoints (ie, wave 1 [w1]: September-December 2018, w2: September-December 2019, and w3: September-December 2020). Multilevel modeling examined time-varying state T21 status and time (reflecting federal T21 implementation) in relation to age verification of cigarette and e-cigarette purchases, respectively.

RESULTS

The proportions almost always age verified for cigarette purchases in states with T21 versus without were: W1: 38.5% versus 37.7%, w2: 33.0% versus 39.1%, and w3: 45.4% versus 30.6%. For e-cigarettes, the proportions were: W1: 30.6% versus 40.3%, w2: 42.3% versus 50.5%, and w3: 56.0% versus 58.3%. In multilevel modeling, state T21 status was associated with greater likelihood of age verification for e-cigarettes (aOR = 1.67, CI = 1.13 to 2.45), but not for cigarettes. Age verification increased over time for e-cigarettes-both accounting for and not accounting for state T21 status. There were no changes for cigarettes.

CONCLUSIONS

State T21 status and time correlated with age verification for e-cigarettes, but not cigarettes. These self-reported age verification data contribute to evidence from compliance checks, indicating that retailers require additional prompts and enforcement to enhance compliance with T21 laws.

IMPLICATIONS

Current findings suggest that variations in regulations and gaps in enforcement may hinder the potential impact of increasing the minimum legal sales age, which ultimately may undermine the promise of such policies, specifically with regard to preventing tobacco use among the underage. Therefore, it is crucial to monitor retailer compliance with T21 laws and evaluate their efficacy to increase ID checks, minimize illegal sales, and curb underage use of tobacco. Relatedly, particular attention to enforcement efforts that may promote compliance is warranted.

Associations between e-cigarette policies and adolescent use and access to e-cigarettes

Background

Tobacco control policies have been adapted to address rising levels of adolescent e-cigarette use. Despite new restrictions, adolescents are continuing to access e-cigarettes.

Methods

We linked 2015-2019 Youth Risk Behavior Survey data on 503,154 14-18-year-olds from 40 states with state-level e-cigarette minimum legal sales age (MLSA) laws, taxes, and smoke-free legislation. Using two-way fixed effects probit regression models, we first examined the associations between these statewide e-cigarette policies and adolescent use and, second, with access to e-cigarettes. We subsequently tested interactions between age and each policy and present average marginal effects as percentage point (pp) changes.

Results

While MLSA laws for e-cigarettes were associated with slight increases in e-cigarette use (2.72 pp; 1.29, 4.15), associations were no longer significant after at least 1-year post-implementation. MLSA laws were also associated with decreases in e-cigarette purchases in stores (-9.50 pp; -18.21, -0.79) and increases in acquiring them from someone else (13.26 pp; 4.10, 22.42), particularly among 18-year-olds. E-cigarette taxes were associated with decreases in use (-9.18 pp; -11.63, -6.73), but there were limited associations with e-cigarette access. While smoke-free legislation prohibiting e-cigarettes was associated with slight increases in use (1.87 pp; 0.23, 3.50), after at least 1-year post-implementation, they were associated with decreases in use. Smoke-free legislation was also associated with decreases in purchases in stores by 14-year-olds, but increases in online purchases by 18-year-olds.

Conclusion

Understanding the immediate and longer-term consequences of e-cigarette policies is essential to influence adolescent e-cigarette use. Adolescents will continue acquiring e-cigarettes across varying sources if measures are not taken to address access alongside policies aimed at reducing use.

Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021

BACKGROUND

Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

METHODS

Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

RESULTS

Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

CONCLUSIONS

Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

COVID-19 Restrictions and Adolescent Cigarette and E-cigarette Use in California

INTRODUCTION

Shelter-in-place orders altered facilitators and barriers to tobacco use (e.g., outlet closures, restricted social gatherings). This study examined whether the duration of time in shelter in place and compliance with different shelter-in-place orders influenced adolescent cigarette and E-cigarette use and how the use may differ by demographic characteristics.

METHODS

Shelter-in-place policy data obtained from government websites were merged with cross-sectional 2020 survey data on adolescents in California. Treatment variables included the proportion of time in shelter in place and self-reported compliance with shelter-in-place orders (for essential businesses and retail spaces and social and outdoor contexts). Multilevel logit models for dichotomous past 6-month cigarette and E-cigarette use and multilevel negative binomial regression models for past 6-month frequency of use were used. Moderation analyses were conducted on demographic measures. The sample included 1,196 adolescents (mean age=15.8 years, age range=13-19 years, 49.2% female, 50.0% White). Analyses were conducted in 2022.

RESULTS

No associations were found between the proportion of time in shelter in place and outcomes. Shelter-in-place compliance with essential business and retail space orders was associated with lower odds of using cigarettes and E-cigarettes in the past 6 months. Compliance with social and outdoor context-related orders were associated with lower odds of using E-cigarettes and fewer days using cigarettes and E-cigarettes. Being aged ≥18 years moderated the associations between essential business/retail space and social/outdoor context-related shelter-in-place compliance orders and past 6-month frequency of cigarette smoking.

CONCLUSIONS

Findings support tailored interventions for less compliant and older adolescents for future pandemic mitigation measures.

Neighborhood Characteristics and the Burden of E-Cigarette, or Vaping, Product Use-Associated Lung Injury: An Ecological Comparison Study

Purpose: E-cigarette, or vaping, product use-associated lung injury (EVALI) is a severe consequence of vaping first described in 2019. Investigating associations between neighborhood-level characteristics and EVALI cases is an important step in identifying at-risk communities to implement future targeted prevention programs. Methods: We retrospectively identified 41 adolescents <19 years hospitalized for treatment for EVALI at Children's Medical Center Dallas from December 2018 to June 2021. Patient ZIP codes were extracted from the electronic medical record and were compared with Dallas area ZIP codes containing no EVALI cases. Socioeconomic status (SES) characteristics were obtained from the 2019 American Community Survey, and they were mapped for ZIP codes using ESRI ArcMap geospatial processing software. A parallel analysis was conducted utilizing data of adolescents hospitalized with appendicitis. Results: Ninety-five percent of our cohort used tetrahydrocannabinol-containing products, and 66% obtained their vaping products from informal sources. EVALI cases were less likely to reside in higher SES ZIP codes as measured by the proportion of the population with at least a high school education (odds ratio [OR]: 0.95, 95% confidence interval [CI]: 0.92-0.99), access to broadband access (OR: 0.95, 95% CI: 0.91-0.99), and private health insurance (OR: 0.97, 95% CI: 0.95-0.99). Alternatively, they were more likely to reside in lower SES ZIP codes as measured by proportion of the population without any health insurance (OR: 1.07, 95% CI: 1.01-1.12). No neighborhood level low SES characteristics were associated with appendicitis hospitalizations. Conclusions: Although small in magnitude, EVALI cases were associated with lower SES ZIP codes but not with vape shop density.

Underage E-Cigarette Purchasing and Vaping Progression Among Young Adults

PURPOSE

Despite laws prohibiting sale of e-cigarettes to individuals aged less than 21 years, many underage young adults purchase e-cigarettes from retail stores, which may increase likelihood of continued use due to a greater access to vaping products and exposure to point-of-sale marketing.

METHODS

Data are from a prospective cohort of young adults aged 18-20 years in Los Angeles who had ever used e-cigarettes at baseline (N = 1,029). We evaluated the association of underage e-cigarette purchasing behavior (owned and purchased vs. owned but never purchased vs. never owned an e-cigarette) with subsequent vaping frequency, intensity, and dependence symptoms one year later, adjusting for vaping behaviors prior to baseline; additional models evaluated whether associations differed by purchase location or product type.

RESULTS

At baseline, 332 (32%) had purchased e-cigarettes while underage, 227 (22%) owned but never purchased e-cigarettes themselves, and 470 (46%) never owned an e-cigarette. Compared to never owning e-cigarettes, those who had purchased their own e-cigarettes vaped more days in the past month (rate ratio [RR] = 2.97; 95% confidence interval [CI]: 2.15-4.09), had more vaping episodes per day (RR: 2.58; 95% CI: 2.12-3.14), vaped more puffs per vaping episode (RR: 1.90; 95% CI: 1.61-2.23), and had greater odds of dependence (odds ratio: 3.68; 95% CI: 2.51-5.40); elevated estimates were also observed for those who owned but never purchased e-cigarettes (vs. never owned). Vaping dependence was greatest among participants who purchased JUULs or other pod-mods.

DISCUSSION

Participants who purchased e-cigarettes underage subsequently vaped more intensely and had greater vaping dependence. Regulations that reduce underage retail access to e-cigarettes may help prevent vaping progression among those most at risk of dependence.

Young Adults' Electronic Cigarette Use and Perceptions of Risk

In the United States, 18.6% of college students between 19-and 22-years old report e-cigarette use in the last 30 days. Information regarding e-cigarette use and perceptions in this age group may assist in understanding how to decrease initiation of e-cigarettes in a population that may otherwise not use nicotine. The purpose of this survey was to determine current e-cigarette use and how e-cigarette use history relates to a college student's perceptions of health risks associated with e-cigarettes. A 33-item questionnaire was sent to students at a Midwestern university in Fall 2018. Overall, 3754 students completed the questionnaire. More than half of the respondents (55.2%) had used e-cigarettes and 23.2% identified as current users of e-cigarettes. Current e-cigarette users were more likely to agree that e-cigarettes are a safe and effective option to quit smoking, while never users were more likely to disagree (safe P < .001, effective P < .001). Current users were less likely to agree that e-cigarettes may harm a person's overall health than never users (P < .001). Young adults continue to be frequent users of e-cigarettes. There are significant differences in perceptions of e-cigarettes associated with use history. Additional research is needed to see how perceptions and use of e-cigarettes have changed considering lung injury reports and increased regulations in the U.S.

Flavored Tobacco Sales Restrictions and Teen E-cigarette Use: Quasi-experimental Evidence From California

INTRODUCTION

Flavored tobacco sales restrictions (FTSRs) are implemented to reduce access to flavored tobacco products. We examined the association between seven cities with local FTSRs implemented in 2018/2019 and e-cigarette use among high school students in the California Bay Area.

AIMS AND METHODS

We analyzed data from the California Healthy Kids Survey using a difference-in-differences (D-I-D) strategy. We compared pre- and post-policy changes one year after implementation in current and ever e-cigarette use among students attending school in a city with a FTSR (exposed) (n = 20 832) versus without (unexposed) (n = 66 126). Other outcomes included ever marijuana use in an e-cigarette and ease of access to e-cigarettes.

RESULTS

Pre- to post-policy, the adjusted odds of current and ever e-cigarette use did not significantly change among students exposed and unexposed to a FTSR. In the adjusted D-I-D analysis, the odds of current (aOR: 1.25, 95% CI: 0.95, 1.65) and ever e-cigarette use (aOR: 1.06, 95% CI: 0.89, 1.26) did not significantly change by exposure group. However, one year post-implementation, the odds of ease of access to e-cigarettes significantly increased among exposed (aOR: 1.57, 95% CI: 1.27, 1.95) and unexposed students (aOR: 1.54, 95% CI: 1.39, 1.70). Similarly, the odds of ever using marijuana in an e-cigarette significantly increased among exposed (aOR: 1.35, 95% CI: 1.19, 1.53) and unexposed students (aOR: 1.29, 95% CI: 1.20, 1.39).

CONCLUSIONS

Local FTSRs in the California Bay Area were not associated with a change in e-cigarette use one year post-implementation. Increased ease of access and marijuana use may be explanatory factors.

IMPLICATIONS

FTSRs were not associated with a decrease in current or ever e-cigarette use among high school students in the California Bay Area one-year post-implementation. Potential explanatory factors are that ease of access to e-cigarettes and using marijuana in an e-cigarette increased. More research is needed to understand the influence of these factors on youth access and behaviors. To address the youth e-cigarette epidemic, a comprehensive approach is needed, including policies, media campaigns, education programs, and cessation tools targeted to youth.

Evaluation of Risk Perception of Smoking after the Implementation of California's Tobacco 21 Law

Decreasing smoking initiation remains a public health priority. In 2016, California, in the United States, enacted the Tobacco 21 law, which raised the minimum age for the purchase of tobacco products from age 18 to age 21. This paper evaluates whether the enactment and implementation of the Tobacco 21 law changed how young adults perceive the risk(s) of smoking. Data were drawn from a cohort of emerging adults (n = 575) in California who were non-daily smokers at enrollment and followed quarterly for 3 years. Data were collected during 2015-2019. Piecewise multilevel regression models were used to test for changes in smoking status and perceived risks of cigarettes after Tobacco 21 enforcement began. Findings indicated that the prevalence of current smoking and perceived risks of smoking both declined following Tobacco 21 implementation (ps < 0.001). Post-hoc analyses suggested that post-implementation changes in perceived risk occurred primarily among ongoing smokers. Findings suggest that Tobacco 21 and associated public health measures have been effective, but additional research is needed to disentangle the effects of specific components. Understanding the impact and efficacy of tobacco laws provides great social value to research and implement policies that create intervention(s) on reducing tobacco use initiation.

Using place-based characteristics to inform FDA tobacco sales inspections: results from a multilevel propensity score model

BACKGROUND

Conducting routine inspections for compliance with age-of-sale laws is essential to reducing underage access to tobacco. We seek to develop a multilevel propensity score model (PSM) to predict retail violation of sales to minors (RVSM).

METHODS

The Food and Drug Administration compliance check of tobacco retailers with minor-involved inspections from 2015 to 2019 (n=683 741) was linked with multilevel data for demographics and policies. Generalised estimating equation was used to develop the PSM using 2015-2016 data to predict the 2017 RVSM. The prediction accuracy of the PSM was validated by contrasting PSM deciles against 2018-2019 actual violation data.

RESULTS

In 2017, 44.3% of 26 150 zip codes with ≥1 tobacco retailer had 0 FDA underage sales inspections, 11.0% had 1 inspection, 13.5% had 2-3, 15.3% had 4-9, and 15.9% had 10 or more. The likelihood of having an RVSM in 2017 was higher in zip codes with a lower number of inspections (adjusted OR (aOR)=0.988, 95% CI (0.987 to 0.990)) and penalties (aOR=0.97, 95% CI (0.95 to 0.99)) and a higher number of violations (aOR=1.07, 95% CI (1.06 to 1.08)) in the previous 2 years. Urbanicity, socioeconomic status, smoking prevalence and tobacco control policies at multilevels also predicted retail violations. Prediction accuracy was validated with zip codes with the highest 10% of the PSM 3.4 times more likely to have retail violations in 2019 than zip codes in the bottom decile.

CONCLUSION

The multilevel PSM predicts the RVSM with a good rank order of retail violations. The model-based approach can be used to identify hot spots of retail violations and improve the sampling plan for future inspections.

A Rapid Evaluation of the US Federal Tobacco 21 (T21) Law and Lessons From Statewide T21 Policies: Findings From Population-Level Surveys

BACKGROUND

On December 20, 2019, the minimum age for purchasing tobacco in the US was raised nationally to 21 years. We evaluated this law (Tobacco 21 [T21]) 1 year after implementation. We also compared states with versus without T21 policies during 2019 to explore potential equity impacts of T21 policies.

METHODS

We examined shifts in tobacco access among 6th through 12th graders using the National Youth Tobacco Survey. To explore equity of state T21 policies among youths and young adults, the associations with tobacco use were explored separately for race and ethnicity by using data from the 2019 Behavioral Risk Factor Surveillance System (for persons aged 18 to 20 years) and the 2019 Youth Risk Behavior Survey (for high school students).

RESULTS

The overall percentage of 6th to 12th graders perceiving that it was easy to buy tobacco products from a store decreased from 2019 (67.2%) to 2020 (58.9%). However, only 17.0% of students who attempted buying cigarettes in 2020 were unsuccessful because of their age. In the 2019 BRFSS, those aged 18 to 20 years living in a state with T21 policies had a lower likelihood of being a current cigarette smoker (adjusted prevalence ratio [APR], 0.58) or smoking cigarettes daily (APR, 0.41). Similar significant associations were seen when analyses were restricted to only non-Hispanic White participants but not for participants who were non-Hispanic Black, non-Hispanic Asian, Hispanic, or of other races or ethnicities. Consistent findings were seen among high school students.

CONCLUSION

Greater compliance with the federal T21 law is needed as most youth who attempted buying cigarettes in 2020 were successful. Comparative analysis of states with versus states without statewide T21 policies in 2019 suggest the policies were differentially more protective of non-Hispanic White participants than other participants. Equitable and intensified enforcement of T21 policies can benefit public health.

Puff bars: a dangerous trend in adolescent disposable e-cigarette use

PURPOSE OF REVIEW

Puff Bars, a brand of disposable e-cigarettes, have skyrocketed in popularity recently, presenting significant health and safety risks to adolescents. Puff Bars and other disposable e-cigarette products are attractive to children and teenagers because of their vibrant colors and flavors, low cost, and ease of access. This review examines the rise in Puff Bar popularity, describes notable health and safety concerns, and provides advice for parents and pediatricians in identifying and preventing adolescent Puff Bar use.

RECENT FINDINGS

Puff Bars have increased in popularity as their product design evaded strict regulations imposed on alternate e-cigarette products, such as Juul. In addition, Puff Bars' sweet and fruit flavors and marketing on social media have made their use pervasive among youth. Puff Bar use can lead to increased risk of e-cigarette product use-associated lung injury (EVALI) and potential exposure to carcinogens. Furthermore, the developmental risks of nicotine use during adolescence include negative effects on cognitive function and detriments to short-term memory.

SUMMARY

Puff Bars present a significant danger to adolescents, and it is imperative that parents and pediatricians are aware of the health risks involved with vaping. Pediatricians should explore e-cigarette use during patient visits, and parents must communicate these dangers to their children and be able to identify these products to regulate their use.

Tobacco 21 laws may reduce smoking and tobacco-related health disparities among youth in the U.S

The goal of our study is to understand the impact of Tobacco 21 (T21) laws on youth smoking and health equity. We conducted modified Poisson regression models using 2014-2019 Monitoring the Future data to measure the impact of attending school in a county 100% covered by a T21 law versus counties with <100% T21 coverage on past 30-day smoking participation (n = 262,632), first cigarette smoking initiation (n = 189,698), and daily smoking initiation among 8th, 10th, and 12th graders (n = 214,496), separately. Additive interactions were tested between T21 coverage and sex, race/ethnicity, parental education, and college plans. T21 coverage was associated with a lower likelihood of smoking participation among 12th graders. T21 coverage was most strongly associated with a lower likelihood of smoking participation among: Hispanic and NH (Non-Hispanic) Other/Multiracial individuals; respondents with parents who had less than a college education; and respondents who were not definitely planning on attending college. T21 laws were associated with a lower likelihood of smoking participation among 12th graders. T21 policies were most impactful for individuals disproportionately impacted by tobacco, indicating T21 laws might help reduce tobacco-related health disparities.

Current state of unhealthy living characteristics in Black/African American and Latino populations: Tobacco use

Over the past six decades, the United States has significantly improved tobacco-related health outcomes through mass efforts in policies, research, and behavioral and clinical interventions. Disparities persist, however, among communities of color who continue to suffer disproportionate rates of cardiovascular disease and other tobacco-related morbidity and mortality. In this review, we synthesize and discuss the tobacco use lifecycle across the lifespan, with special attention paid to socioecological determinants of tobacco-use behavior among Blacks and Latinos. This review summarizes the permeability of tobacco use and tobacco-related determinants across multiple levels of influence, from the individual to the societal, and highlights gaps in the tobacco control and prevention landscape. Given its continued evolution and impact on socially disadvantaged communities, we conclude with recommendations for improving current tobacco research and treatment and prevention efforts.

Electronic cigarette knowledge, attitudes and use among students at a university in Hangzhou, China

INTRODUCTION

Electronic cigarettes are increasingly popular worldwide, especially among youth. There is growing evidence of the negative health consequences of vaping. Our objective was to assess university students’ knowledge and attitudes regarding electronic cigarettes (e-cigarettes), their use, as well as the associated influencing factors for their use.

METHODS

The study involved an online cross-sectional survey conducted between November 2019 and March 2020 in a university in Hangzhou, China. A total of 563 students completed the questionnaire. Descriptive statistics were used to assess characteristics, knowledge, and attitudes; t-tests, χ²-tests and logistic regression models were used to identify factors associated with ever e-cigarette use.

RESULTS

In all, 59.9% of respondents were female and the average age was 20.38 years (SD=1.32). Only 42.6% of the respondents thought that e-cigarettes contain nicotine, 31.1% thought e-cigarettes are tobacco products, and 8.2% of the students reported being ever e-cigarettes users. In regard to attitude, the average score of the students in the Safety dimension was 3.34 (SD=0.64), followed by the Restriction dimension (Mean=2.66, SD=0.83). Correlates of ever use included regions, friends’ and roommates’ ever e-cigarette use, and higher attitude score in the Supervision dimension.

CONCLUSIONS

The university students’ level of knowledge regarding e-cigarettes was not high, and their attitudes regarding e-cigarettes were not that supportive. Students’ ever use of e-cigarettes at a university in Hangzhou was higher than for university students in other cities in China, but lower than for those in foreign countries.

Convenience Store Access and E-cigarette Advertising Exposure Is Associated With Future E-cigarette Initiation Among Tobacco-Naïve Youth in the PATH Study (2013-2016)

PURPOSE

The association between e-cigarette marketing exposure and youth e-cigarette initiation is not well understood. This study examines whether convenience store access, exposure to retail e-cigarette marketing, and having a favorite e-cigarette ad before e-cigarette use is associated with susceptibility to use and future e-cigarette initiation in a national longitudinal study of youth.

METHODS

A nationally representative longitudinal cohort of youth in the Population Assessment of Tobacco and Health study (12-17 years) was followed up over three waves of annual data collection (2013-2016). Tobacco-naïve (wave 1) and e-cigarette-naïve (wave 2) youth (n = 6,470) were included. Marketing exposure at wave 2 was examined in association with e-cigarette susceptibility (wave 2) and e-cigarette initiation (wave 3) using adjusted logistic regression models. Analysis occurred in 2019.

RESULTS

Youth visiting convenience stores at least weekly (vs. never) had 1.51 times the odds of e-cigarette susceptibility (95% confidence interval [CI]: 1.25, 1.81) and 1.79 times the odds of e-cigarette initiation (95% CI: 1.29, 2.48). Noticing a retail e-cigarette ad (vs. not noticing) was associated with e-cigarette susceptibility (adjusted odds ratio [AOR] 1.36, 95% CI: 1.18, 1.57), but not initiation. Youth reporting a favorite branded e-cigarette ad had greater odds of both susceptibility (AOR 1.31, 95% CI, 1.10, 1.56) and e-cigarette initiation (AOR 1.60, 95% CI: 1.18, 2.17) compared to youth without a favorite ad.

CONCLUSIONS

Tobacco-naïve youth with frequent convenience store access and exposure to e-cigarette marketing were at greater risk of e-cigarette susceptibility and progression to e-cigarette initiation over a 2-year period. Policies to restrict retailer locations and e-cigarette marketing could enhance youth e-cigarette use prevention efforts.

Youth and Young Adult Convenience Store Behaviors: Findings From Intercept Surveys

INTRODUCTION

To inform tobacco policy and prevention efforts, we examined youth and young adult behaviors at gas-station-convenience stores and whether these behaviors varied by demographics or tobacco use.

AIMS AND METHODS

Between June and July 2017, we conducted 990 intercept surveys at convenience stores in North Carolina among 16- to 25-year olds who were susceptible to or used tobacco. We used logistic regression to examine whether demographics or tobacco use predicted pumping gas, entering the store, or purchasing tobacco, gas, food, lottery tickets, or other items inside the store.

RESULTS

Most participants (85.3%) reported ever using tobacco. Most visited that store at least once per week (40.3%) or once within the past month (41.2%). Just over half (55.0%) reported pumping gas at the store. Of those who went or planned to go inside (68.8%), 43.2% purchased food, 39.2% purchased gas, 33.1% purchased tobacco, and 6.8% purchased lottery tickets. Those who were aged 21-25, visited the store two to three times a week, and went inside already were more likely to purchase tobacco (all p < .05). Past 30-day cigarette, cigar, smokeless, and other tobacco uses were positively associated with purchasing tobacco (all p < .05).

CONCLUSIONS

Our sample of young people who were susceptible to or ever used tobacco regularly visited gas-station-convenience stores, and one-third purchased or planned to purchase tobacco during their visit. Convenience stores appear to be an important access point for young people. Practitioners and policy makers should consider a comprehensive set of strategies to reduce access among youth and young adults.

IMPLICATIONS

We conducted 990 intercept surveys among youth and young adults at gas-station-convenience stores. Among our sample of those who had ever used tobacco or were susceptible to use, most visited the store frequently and one-third purchased tobacco, particularly those who used cigarettes and cigars. Tobacco companies heavily market in convenience stores, and our results show tobacco is a product often purchased by susceptible young adults. Practitioners and policy makers should consider prioritizing efforts at convenience stores to reduce product purchase and use.