Electronic nicotine delivery systems: a policy statement from the American Association for Cancer Research and the American Society of Clinical Oncology

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

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

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

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

Risk and safety profile of electronic nicotine delivery systems (ENDS): an umbrella review to inform ENDS health communication strategies

OBJECTIVES

This umbrella review aims to summarise the evidence about electronic nicotine delivery systems' (ENDS) risk and safety health profile to inform ENDS health communication strategies.

DATA SOURCES AND STUDY SELECTION

Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4.

DATA EXTRACTION

Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine's Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive.

DATA SYNTHESIS

We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes.

CONCLUSIONS

As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided.

PROSPERO REGISTRATION NUMBER

CRD42021241630.

Use of electronic nicotine delivery systems (ENDS) among U.S. women of reproductive age: Prevalence, reported reasons for use, and toxin exposure

Given the rapidly expanding marketplace for Electronic Nicotine Delivery Systems (ENDS), it is important to monitor patterns of use, particularly among vulnerable populations. This study examined ENDS prevalence, reasons for use (i.e., to help quit smoking and for appealing flavors), and toxin exposure among U.S. women of reproductive age using data from the Population Assessment of Tobacco and Health (PATH) Study (2013-17). Exclusive ENDS users, dual users of ENDS and cigarettes, and exclusive cigarette smokers were compared within and between pregnant and not-pregnant women. Among pregnant women, prevalence of exclusive ENDS and dual use was similar (0.8%; 95%CI = 0.4-1.2% vs. 1.4%; 95%CI = 0.9-2.0%, respectively), but exclusive ENDS use was less prevalent than dual use among not-pregnant women (1.1%; 95%CI = 0.9-1.4% vs. 3.7%; 95%CI = 3.3-4.0%, respectively). Most women reported ENDs were used to help quit smoking (66.5-90.0%) and for appealing flavors (57.6-87.4%), and endorsement rates did not differ by use pattern or pregnancy status. Except for metals, toxin exposure was substantially lower for exclusive ENDS users relative to dual users and exclusive cigarette smokers regardless of pregnancy status. Pregnant and not-pregnant U.S. women regularly report using ENDS for help with quitting smoking and for appealing flavors. Although no type or pattern of tobacco/nicotine use is safe, especially during pregnancy, using ENDS exclusively is consistent with lower overall toxin exposure for pregnant and not-pregnant women. This study advances understanding of ENDS use and toxin exposure in women of reproductive age, a population highly vulnerable to the effects of nicotine/tobacco consumption.

Assessing Electronic Nicotine Delivery Systems Use at NCI-Designated Cancer Centers in the Cancer Moonshot-funded Cancer Center Cessation Initiative

Assessing tobacco product use and delivering tobacco dependence treatment is an essential part of cancer care; however, little is known about electronic nicotine delivery systems (ENDS) or e-cigarette use assessment in cancer treatment settings. Given the importance of tailoring tobacco treatment, it is critical to understand how ENDS use is assessed in the electronic health record (EHR) in cancer care settings. Two questionnaires were completed by tobacco treatment program leads at 42 NCI-Designated Cancer Centers in the Cancer Center Cessation Initiative (January 1 to June 30 and July 1 to December 31, 2019). Items assessed how often smoking status and ENDS use were recorded in the EHR. An open-ended item recorded the text and response categories of each center's ENDS assessment question. All 42 centers assessed smoking status at both time periods. Twenty-five centers (59.5%) assessed ENDS use in the first half of 2019, increasing to 30 (71.4%) in the last half of 2019. By the end of 2019, 17 centers assessed smoking status at every patient visit while six assessed ENDS use at every visit. A checkbox/drop-down menu rather than scripted text was used at 30 centers (73.2%) for assessing smoking status and at 18 centers (42.9%) for assessing ENDS use. Our findings underscore the gap in systematic ENDS use screening in cancer treatment settings. Requiring ENDS use measures in the EHR as part of quality measures and providing scripted text scripts to providers may increase rates of ENDS use assessment at more cancer centers. PREVENTION RELEVANCE: This study identifies a gap in the systematic assessment of ENDS use among patients seen at 42 NCI-Designated cancer centers. Requiring the systematic assessment of both ENDS use and use of other tobacco products can inform evidence-based treatment of tobacco dependence and lead to improved cancer treatment outcomes.

Optimization of aqueous aerosol extract (AqE) generation from e-cigarettes and tobacco heating products for in vitro cytotoxicity testing

Electronic cigarettes (e-cigarettes) and tobacco heating products (THPs) have reduced yields of toxicants and have recently emerged as a potentially safer alternative to combustible cigarettes. To understand if reduced toxicant exposure is associated with reductions in biological responses, there is a need for high-quality pre-clinical in vitro studies. Here, we investigated the cytotoxic response of human umbilical vein endothelial cells to conventional cigarette aqueous aerosol extracts (AqE) and highly concentrated AqEs from e-cigarettes (two generations of atomisers) and THPs (two variants). All AqE samples were generated by a standardized methodology and characterized for nicotine, propylene glycol and vegetable glycerol. The cigarette AqE caused a maximum 100 ± 0.00 % reduction in cell viability at 35 % dose (2.80 puffs) as opposed to 96.63 ± 2.73 % at 50 % (20 puffs) and 99.85 ± 0.23 % at 75 % (30 puffs) for the two THP variants (glo Bright Tobacco, glo Rich Tobacco), and 99.07 ± 1.61 % at the neat ePen2.0 e-cigarette (200 puffs). The AqE of the remaining e-cigarettes either resulted in an incomplete dose-response or did not elicit any response. The methods utilized were suitably sensitive to not only differentiate between cigarette, THP and e-cigarette aerosols but also to distinguish between products within each product category.

Collecting e-cigarette aerosols for in vitro applications: A survey of the biomedical literature and opportunities to increase the value of submerged cell culture-based assessments

Electronic nicotine delivery systems (ENDS) are being developed as potentially reduced‐risk alternatives to the continued use of combustible tobacco products. Because of the widespread uptake of ENDS—in particular, e‐cigarettes—the biological effects, including the toxic potential, of their aerosols are under investigation. Preclinically, collection of such aerosols is a prerequisite for testing in submerged cell culture‐based in vitro assays; however, despite the growth in this research area, there is no apparent standardized collection method for this application. To this end, through an Institute for in vitro Sciences, Inc. workshop initiative, we surveyed the biomedical literature catalogued in PubMed® to map the types of methods hitherto used and reported publicly. From the 47 relevant publications retrieved, we identified seven distinct collection methods. Bubble‐through (with aqueous solvents) and Cambridge filter pad (CFP) (with polar solvents) collection were the most frequently cited methods (57% and 18%, respectively), while the five others (CFP + bubble‐through; condensation; cotton filters; settle‐upon; settle‐upon + dry) were cited less often (2–10%). Critically, the collected aerosol fractions were generally found to be only minimally characterized chemically, if at all. Furthermore, there was large heterogeneity among other experimental parameters (e.g., vaping regimen). Consequently, we recommend that more comprehensive research be conducted to identify the method(s) that produce the fraction(s) most representative of the native aerosol. We also endorse standardization of the aerosol generation process. These should be regarded as opportunities for increasing the value of in vitro assessments in relation to predicting effects on human health.

Collection of e‐cigarette aerosols is a prerequisite to enable testing in submerged culture‐based in vitro assays; however, there is no standardized method for this. Thus, we surveyed the biomedical literature to map the types of published methods. Bubble‐through and Cambridge filter pad methods were most common, although there was heterogeneity among other parameters, and moreover, the resulting fractions were only minimally characterized. Comprehensive research is required to identify the method(s) that produce the fraction(s) most representative of the native aerosol.

Interventions to prevent periodontal disease in tobacco-, alcohol-, and drug-dependent individuals

Substance abuse affects more than one sixth of the world's population. More importantly, the nature of the abuse and the type of addictive substances available to individuals is increasing exponentially. All substances with abusive potential impact both the human immuno-inflammatory system and oral microbial communities, and therefore play a critical role in the etiopathogenesis of periodontal diseases. Evidence strongly supports the efficacy of professionally delivered cessation counseling. Dentists, dental therapists, and hygienists are ideally placed to deliver this therapy, and to spearhead efforts to provide behavioral and pharmacologic support for cessation. The purpose of this review is to examine the biologic mechanisms underlying their role in disease causation, to understand the pharmacologic and behavioral basis for their habituation, and to investigate the efficacy of population-based and personalized interventions in prevention of periodontal disease.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams.

Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations.

Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes.

Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.

Use of Anticancer Platinum Compounds in Combination Therapies and Challenges in Drug Delivery

As one of the leading and most important metal-based drugs, platinum-based pharmaceuticals are widely used in the treatment of solid malignancies. Despite significant side effects and acquired drug resistance have limited their clinical applications, platinum has shown strong inhibitory effects for a wide assortment of tumors. Drug delivery systems using emerging technologies such as liposomes, dendrimers, polymers, nanotubes and other nanocompositions, all show promise for the safe delivery of platinum-based compounds. Due to the specificity of nano-formulations; unwanted side-effects and drug resistance can be largely averted. In addition, combinational therapy has been shown to be an effective way to improve the efficacy of platinum based anti-tumor drugs. This review first introduces drug delivery systems used for platinum and combinational therapeutic delivery. Then we highlight some of the recent advances in the field of drug delivery for combinational therapy; specifically progress in leveraging the cytotoxic nature of platinum-based drugs, the combinational effect of other drugs with platinum, while evaluating the drug targeting, side effect reducing and sitespecific nature of nanotechnology-based delivery platforms.

Electronic cigarette liquid substances propylene glycol and vegetable glycerin induce an inflammatory response in gingival epithelial cells

Information on the effects of propylene glycol (PG) and vegetable glycerin (VG) and on cytotoxicity and subsequent activation of the biological mediators is limited in periodontal diseases. This study analyzes the effect of unflavored PG/VG alone or in combination with nicotine on gingival epithelial cells. The cells were exposed to different PG/VG (± nicotine) concentrations for 24 h and cytotoxicity was evaluated by calorimetric 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromid assay. The expressions of interleukin (IL)-6, IL-8, and matrix metalloproteinases (MMPs)-9 were measured using an enzyme-linked immunosorbent assay and a western blotting. Stimulation with PG/VG mixtures reduced cell viability compared to nonexposed controls (p < 0.05). Adding PG/VG increased the levels of IL-6, IL-8, and MMP-9, and the amount of PG had more biological impact compared to the VG amount. The nicotine augmented this effect compared to its nicotine-free counterparts. In western blotting result, MMP-9 was clearly activated in almost all samples. These findings suggest that the main constituents PG/VG are cytotoxic and able to induce biological response in gingival cells in vitro. Despite being advertised as less harmful than conventional cigarettes, electronic cigarette liquid pose certain risks on periodontal cells. Awareness about the effects of electronic cigarettes on periodontal diseases must be increased.

Cessation outcomes in adult dual users of e-cigarettes and cigarettes: the Population Assessment of Tobacco and Health cohort study, USA, 2013-2016

OBJECTIVES

We examined the transitions of adult dual e-cigarette/cigarette users in the USA in relation to nicotine dependence (ND) symptoms, interest in quitting, and history of cardiovascular disease (CVD).

METHODS

We used the Population Assessment of Tobacco and Health study Waves 1 and 3 (2013-2016) in a longitudinal analysis of adults (≥ 18 years). Dual past-month users of e-cigarettes/cigarettes were identified from Wave 1 and followed for tobacco use transitions 2 years later (Wave 3).

RESULTS

Among 1870 adult dual users at Wave 1, 25.7% (95% CI 23.5-28.2) were dual users 2 years later, 12.1% (95% CI 10.6-13.7) reported no past-month tobacco use, 7.0% (95% CI 5.6-8.9) e-cigarette mono-use, and 55.2% (95% CI 52.4-58.0) cigarette mono-use. In the regression analysis, greater ND severity was associated with decreased relative risk of no past-month tobacco use (RRR 0.29; 95% CI 0.12-0.71). Interest in quitting and CVD factors were not associated with no past-month tobacco or e-cigarette mono-use.

CONCLUSIONS

Dual users who are nicotine dependent are less likely to transition to cessation. To quit cigarette use, other cessation resources may be necessary to support the needs of cigarette smokers who use e-cigarettes, particularly those at risk of continuing cigarette smoking or those with smoking-related illnesses.

Insights on electronic cigarette products from reviews on the Reddit forum

INTRODUCTION

E-cigarette devices and their component parts are continuously evolving. Little is known about the product design features that may increase the appeal of e-cigarette use, ultimately affecting continuation of use. Product reviews have been described as useful in helping to forecast the popularity of products, and online reviews have become an important channel of product information. This study analyzed e-cigarette product reviews to attempt to arrive at a greater understanding of the features of e-cigarette products that may make them appealing to current users.

METHODS

Data included 248 product reviews found on a popular e-cigarette-related discussion site of Reddit from 10 April 2017 to 12 November 2018. For this study, we examined the sub-sections relating to the positive features (PFs) and negative features (NFs) of the product, found in each review. Common themes were identified and coded.

RESULTS

There were 2929 comments on PFs (average 12 per product), and 1003 on NFs (average 4 per product). Commonly found in the reviews were the ten themes: build quality, color, tip model, battery quality, price, screw quality, power mode performance, coil performance, temperature control performance, and tank quality.

CONCLUSIONS

Findings suggest e-cigarette users expect well-made devices and have developed ways to discriminate between products that perform well from those that do not. Findings suggest that the control of price and design features of e-cigarette products (e.g. color, size, voltage, wattage, coils) warrants consideration for future research and policies addressing e-cigarette use.

Longitudinal transitions of exclusive and polytobacco electronic nicotine delivery systems (ENDS) use among youth, young adults and adults in the USA: findings from the PATH Study Waves 1-3 (2013-2016)

OBJECTIVE

Electronic nicotine delivery systems (ENDS; including e-cigarettes) are rapidly evolving in the US marketplace. This study reports cross-sectional prevalence and longitudinal pathways of ENDS use across 3 years, among US youth (12-17 years), young adults (18-24 years) and adults 25+ (25 years and older).

DESIGN

Data were from the first three waves (2013-2016) of the Population Assessment of Tobacco and Health Study, a nationally representative, longitudinal cohort study of US youth and adults. Respondents with data at all three waves (youth, n=11 046; young adults, n=6478; adults 25+, n=17 188) were included in longitudinal analyses.

RESULTS

Weighted cross-sectional ever use of ENDS increased at each wave. Across all three waves, young adults had the highest percentages of past 12-month, past 30-day (P30D) and daily P30D ENDS use compared with youth and adults 25+. Only about a quarter of users had persistent P30D ENDS use at each wave. Most ENDS users were polytobacco users. Exclusive Wave 1 ENDS users had a higher proportion of subsequent discontinued any tobacco use compared with polytobacco ENDS users who also used cigarettes.

CONCLUSIONS

ENDS use is most common among young adults compared with youth and adults 25+. However, continued use of ENDS over 2 years is not common for any age group. Health education efforts to reduce the appeal and availability of ENDS products might focus on reducing ENDS experimentation, and on reaching the smaller subgroups of daily ENDS users to better understand their reasons for use.

e-Cigarettes for smoking cessation: Do they deliver?

WHAT IS KNOWN AND OBJECTIVE

Electronic nicotine delivery systems (ENDS) are battery-powered devices that allow nicotine and/or other substances to be inhaled in aerosolized form. e-Cigarettes (electronic cigarettes), the most commonly used ENDS, have been proposed to be smoking cessation aids. However, despite the rapid surge in their popularity, little is known about long-term health consequences of e-cigarette usage. We assess published data to see if they deliver what they promise.

COMMENT

e-Cigarettes may contain uncertain quantities of various ingredients, and evidence of adulteration has been identified. Flavouring agents can alter the pharmacokinetics of nicotine and have uncertain impact on the nature of e-cigarette use (eg ab initio use vs smoking cessation).

WHAT IS NEW AND CONCLUSION

Although e-cigarettes have been proposed to be a safe approach to encouraging smoking cessation, there are inconsistencies in available data. And further data are needed regarding long-term implications of primary and secondary exposure to e-cigarette products.

Perceived health risks of electronic nicotine delivery systems (ENDS) users: The role of cigarette smoking status

INTRODUCTION

Use of electronic nicotine delivery systems (ENDS) has increased markedly. We examined how current ENDS users differ in perceptions of tobacco and ENDS-related health risks as a function of cigarette smoking status.

METHODS

We classified 1329 current ENDS users completing a national online survey based on cigarette smoking status, and employed linear and logistic regression to assess group differences in perceptions of tobacco-related health risks.

RESULTS

The sample consisted of 38% Current Cigarette Smokers, 40% Former Cigarette Smokers, and 22% Non-Smokers. Our targeted recruitment strategy yielded a balance of key descriptive variables across participants. Significant differences were observed in race, employment and marital status across cigarette smoking status, but not in gender, education, income, or sexual orientation. Participants reported considerable perceived knowledge about health risks associated with tobacco use, but less regarding ENDS use. Current Smokers rated ENDS use as riskier than Non-Smokers, and considered cigarette use less risky for both users and bystanders. Current Smokers were more likely to perceive cardiovascular diseases, diabetes and cancer as the health risks associated with ENDS use. Former Smokers were more likely to perceive such risks with traditional tobacco use. Further, regardless of smoking status, perceived knowledge about the health risks of tobacco or ENDS use was positively associated with perceived likelihood of high risks of cardiovascular diseases and cancer.

CONCLUSIONS

Among current ENDS users, there were significant differences in perceived health risks based on cigarette smoking history. Improved health messaging can be achieved when cigarette smoking status is taken into account.

The effects of e-cigarette minimum legal sale age laws on youth substance use

We use difference-in-differences models and individual-level data from the national and state Youth Risk Behavior Surveillance System from 2005 to 2015 to examine the effects of e-cigarette minimum legal sale age (MLSA) laws on youth cigarette smoking, alcohol consumption, and marijuana use. Our results suggest that these laws increased youth smoking participation by about one percentage point and approximately half of the increased smoking participation could be attributed to smoking initiation. We find little evidence of higher cigarette smoking persisting beyond the point at which youth age out of the laws. Our results also show little effect of the laws on youth drinking, binge drinking, and marijuana use. Taking these together, our findings suggest a possible unintended effect of e-cigarette MLSA laws-rising cigarette use in the short term while youth are restricted from purchasing e-cigarettes.

Prevalence and correlates of dual tobacco use in cancer survivors

PURPOSE

Tobacco use in cancer survivors remains a significant problem, however, the use of non-cigarette tobacco products (NCTPs) in this population is less understood. This study examined prevalence and correlates of tobacco use among cancer survivors who were never, current, and former cigarette users. Tobacco-related behaviors and quitting attitudes were compared between survivors dually using cigarettes and electronic cigarettes (ECs) and cigarette-only users.

METHODS

In this cross-sectional study, patients at Mid-South cancer centers (n = 629; 50.4% never, 17.8% current, and 31.8% former cigarette users) responded to an anonymous questionnaire about tobacco-related behaviors and quitting attitudes.

RESULTS

Among current cigarette users, 27.7% reported using two or more tobacco products. Most commonly, 15.2% of cigarettes users were using ECs. Compared to cigarette only use, dual use of tobacco products was associated with male gender (p < 0.0001), being single (p = 0.009), and a lung cancer diagnosis (p < 0.0001). Dual users of cigarettes and ECs were more likely to report a readiness to quit cigarettes within 6 months (p = 0.0317) and that a physician recommended ECs as a quit resource (p = 0.0361) compared to cigarette-only users.

CONCLUSIONS

Results suggest that using more than one tobacco product is common among cancer survivor cigarette users. Dual use of cigarettes and ECs was associated with an increased readiness for cigarette cessation and a physician recommendation of ECs. Targeting potential dual use of tobacco products, particularly cigarettes and ECs, might be beneficial for cigarette cessation among cancer survivors.

Electronic nicotine delivery systems: Oral health implications and oral cancer risk

There is a paucity of evidence surrounding the potential detrimental effects of electronic nicotine delivery systems (ENDS) for both systemic and oral health. The effects of conventional cigarettes on the development of oral cancer are well known; however, the role of ENDS in oral carcinogenesis is yet to be elucidated. Furthermore, the exponential rise of the use of ENDS by the general public means that dental healthcare providers are more likely to encounter questions on their safety in the oral cavity, and on their effectiveness as a smoking cessation aid. Herein, we review the most up to date literature on the systemic and oral health complications of ENDS. Moreover, evidence-based recommendations on the use of ENDS as a smoking cessation tool within the dental setting are discussed.

Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use

BACKGROUND AND PURPOSE

This study assessed pharmacy students' self-rated ability to provide cessation counseling for e-cigarette use and traditional cigarette smoking.

EDUCATIONAL ACTIVITY AND SETTING

A cross-sectional study was conducted in spring 2014 at The University of Texas at Austin. Participants included first through fourth year (P1-P4) doctor of pharmacy (PharmD) students. Perceived confidence and knowledge to counsel on cigarette smoking cessation and e-cigarette cessation were self-rated and based on the Ask-Advise-Assess-Assist-and Arrange (5 A's) follow-up model as well as general counseling skills for recreational nicotine product use cessation. Comparisons were made between students' confidence to counsel patients on traditional cigarette smoking cessation and e-cigarette cessation and by class level.

FINDINGS

Compared to cigarette smoking cessation counseling, students were less confident in their ability to counsel on e-cigarette cessation using the 5 A's model and general counseling skills. Students perceived themselves to be less knowledgeable about the harmful effects of e-cigarettes, pharmacists' role in counseling on e-cigarette cessation, and how patients can benefit from e-cigarette cessation counseling. A higher proportion of students reported having no training on e-cigarette cessation compared to cigarette smoking cessation (59% vs 9%).

SUMMARY

Targeted training on how to counsel patients on e-cigarette cessation should be included in pharmacy curricula. Such training is expected to increase the confidence of pharmacists-in-training to address the needs of patients who use e-cigarettes.

Weighing the Risks and Benefits of Electronic Cigarette Use in High-Risk Populations

This article reviews the current evidence on electronic cigarette (e-cigarette) safety and efficacy for smoking cessation, with a focus on smokers with cardiovascular disease, pulmonary disease, or serious mental illness. In the United States, adult smokers use e-cigarettes primarily to quit or reduce cigarette smoking. An understanding of the potential risks and benefits of e-cigarette use may help clinicians counsel smokers about the potential impact of e-cigarettes on health.

Electronic cigarette use among patients with cancer: Reasons for use, beliefs, and patient-provider communication

OBJECTIVE

Smoking tobacco cigarettes after a cancer diagnosis increases risk for several serious adverse outcomes. Thus, patients can significantly benefit from quitting smoking. Electronic cigarettes are an increasingly popular cessation method. Providers routinely ask about combustible cigarette use, yet little is known about use and communication surrounding e-cigarettes among patients with cancer. This study aims to describe patterns, beliefs, and communication with oncology providers about e-cigarette use of patients with cancer.

METHODS

Patients with cancer (N = 121) who currently used e-cigarettes were surveyed in a cross-sectional study about their patterns and reasons for use, beliefs, and perceptions of risk for e-cigarettes, combustible cigarettes, and nicotine replacement therapies. Patient perspectives on provider communication regarding e-cigarettes were also assessed.

RESULTS

Most participants identified smoking cessation as the reason for initiating (81%) and continuing (60%) e-cigarette use. However, 51% of patients reported current dual use of combustible cigarettes and e-cigarettes, and most patients reported never having discussed their use of e-cigarettes with their oncology provider (72%). Patients characterized e-cigarettes as less addictive, less expensive, less stigmatizing, and less likely to impact cancer treatment than combustible cigarettes (Ps < .05), and more satisfying, more useful for quitting smoking, and more effective at reducing cancer-related stress than nicotine replacement therapies (Ps < .05).

CONCLUSIONS

Patients with cancer who use e-cigarettes have positive attitudes toward these devices and use them to aid in smoking cessation. This study also highlights the need for improved patient-provider communication on the safety and efficacy of e-cigarettes for smoking cessation.

E-cigarette use and quantity of cigarette smoking among adolescent cigarette smokers: A finite mixture model analysis

BACKGROUND

E-cigarette use is popular among adolescents and youth, but its long-term public health implications remain largely unknown. Much of the literature has focused on understanding the relationship between e-cigarette use and youth cigarette initiation. However, very little is known about e-cigarette use and cigarette quantity among those who continue to smoke cigarettes. The objective of the present study was to examine the association between current e-cigarette use and quantity of cigarette smoking.

METHODS

Cross-sectional data on current smokers were drawn from the 2014-2015 Canadian Student Tobacco, Alcohol and Drugs Survey among high school students (n = 1411). A finite mixture model (FMM) was employed to account for unobserved heterogeneity due to clusters of finite sub-populations.

RESULTS

Current e-cigarette users reported smoking more conventional cigarettes in the past week compared to non-e-cigarette users (t [1409] = 4.7998; p < 0.001 in unadjusted analysis). Results from a finite mixture regression showed that current e-cigarette use was significantly associated with the number of cigarettes smoked in the past week, but only among light smokers (IRR = 1.40; CI = 1.05-1.85). However, additional analyses found that the association between e-cigarette use and quantity of cigarette smoked varied by individual smoking pattern. An FMM with a group or class modelling using individual smoking pattern showed a weaker association between e-cigarette use and quantity of cigarette smoking.

CONCLUSION

Findings of this study suggest that the significant association between e-cigarette use and quantity of cigarette smoking may be driven by patterns of use among experimental or beginner smokers.

Prevalence, Reasons for Use, and Risk Perception of Electronic Cigarettes Among Post-Acute Coronary Syndrome Smokers

PURPOSE

The use of electronic cigarettes (e-cigarettes) has risen dramatically in recent years. However, there are currently no published data on the use of e-cigarettes among cardiac patients. The current study reports on the prevalence, reasons for use, and perceived risks of e-cigarettes among patients with post-acute coronary syndrome (ACS). The relationship between e-cigarette use and post-ACS tobacco smoking cessation is also explored.

METHODS

Participants were drawn from a randomized trial of smoking cessation treatments following hospitalization for ACS. The current study focused on 49 participants who completed e-cigarette questions at 24 weeks post-ACS.

RESULTS

Of the 49 of participants, 51.0% reported ever use of an e-cigarette and 26.5% reported using an e-cigarette at some time during the 24 weeks post-ACS. Ever use and post-ACS use were both significantly associated with lower rates of abstinence from tobacco cigarettes. Participants perceived e-cigarettes as less harmful to cardiac health than tobacco use and Chantix (varenicline), and similarly harmful as nicotine replacement therapy. Participant perceived likelihood of experiencing a heart attack in the next year was 34.6% if they were to regularly use only e-cigarettes, significantly lower than the perceived risk of recurrence if they were to regularly smoke only tobacco cigarettes (56.2%) and significantly higher than the perceived risk of recurrence if they were to use no nicotine (15.2%).

CONCLUSIONS

A significant minority of patients are using e-cigarettes post-ACS. Providers should be prepared to discuss potential discrepancies between patient beliefs about the safety of e-cigarettes and the current state of the science.

Susceptibility to cigarette smoking among middle and high school e-cigarette users in Canada

There is a growing concern that the historic reductions in tobacco consumption witnessed in the past decades may be undermined by the rapid increase in e-cigarette use. This study examined the association between e-cigarette use and future intention to smoke cigarettes among middle and high school students who had never smoked cigarettes. Data were drawn from the 2014-2015 Canadian Student Tobacco, Alcohol and Drugs Survey (n=25,637). A multivariable logistic regression model was used to examine the association between e-cigarette use and susceptibility to cigarette smoking. In addition, an inverse probability of treatment weighted regression adjustment method (doubly robust estimator), which models both the susceptibility to smoking and the probability of e-cigarette use, was conducted. About 10% of the students had ever tried an e-cigarette. There were higher rates of ever e-cigarette use among students in grades 10-12 (12.5%) than those in grades 7-9 (7.3%). Students who had ever tried an e-cigarette had higher odds of susceptibility to cigarette smoking (adjusted odds ratio=2.16, 95% confidence interval=1.80-2.58) compared to those that had never tried an e-cigarette. Current use of an e-cigarette was associated with higher odds of smoking susceptibility (adjusted odds ratio=2.02, 95% confidence interval=1.43-2.84). Similar results were obtained from the doubly robust estimation. Among students who had never smoked cigarettes, e-cigarette use was associated with a higher susceptibility to cigarette smoking.

A Review of Pulmonary Toxicity of Electronic Cigarettes in the Context of Smoking: A Focus on Inflammation

The use of electronic cigarettes (e-cigs) is increasing rapidly, but their effects on lung toxicity are largely unknown. Smoking is a well-established cause of lung cancer and respiratory disease, in part through inflammation. It is plausible that e-cig use might affect similar inflammatory pathways. E-cigs are used by some smokers as an aid for quitting or smoking reduction, and by never smokers (e.g., adolescents and young adults). The relative effects for impacting disease risk may differ for these groups. Cell culture and experimental animal data indicate that e-cigs have the potential for inducing inflammation, albeit much less than smoking. Human studies show that e-cig use in smokers is associated with substantial reductions in blood or urinary biomarkers of tobacco toxicants when completely switching and somewhat for dual use. However, the extent to which these biomarkers are surrogates for potential lung toxicity remains unclear. The FDA now has regulatory authority over e-cigs and can regulate product and e-liquid design features, such as nicotine content and delivery, voltage, e-liquid formulations, and flavors. All of these factors may impact pulmonary toxicity. This review summarizes current data on pulmonary inflammation related to both smoking and e-cig use, with a focus on human lung biomarkers. Cancer Epidemiol Biomarkers Prev; 26(8); 1175-91. ©2017 AACR.

Practice Patterns and Perceptions of Chest Health Care Providers on Electronic Cigarette Use: An In-Depth Discussion and Report of Survey Results

Introduction

The emergence of electronic cigarettes (ECs) has become a growing phenomenon that has sharply split opinion among the public health community, physicians, and lawmakers.

Aims

We sought to determine chest physician perceptions regarding ECs.

Methods

We conducted a web-based survey of 18,000 American College of Chest Physician (CHEST) members to determine healthcare provider experiences with EC users and to characterize provider perceptions regarding ECs.

Results/Findings

There were 994 respondents. 88% reported that patients had asked their opinion of ECs, and 31% reported EC use among at least 10% of their patients. More disagreed than agreed (41% vs. 21%) that patients could improve their health by switching from tobacco smoking to daily EC use. Respondents were split on whether ECs promote tobacco cessation (32% agree vs. 33% disagree).

Conclusions

Current perceptions of ECs are variable among providers. More than 1/3 of respondents felt that EC's could be used for smoking cessation for smokers who failed prior quit attempts with approved therapies. However, many respondents were not convinced that ECs will reduce harms from tobacco use. There is an urgent need to generate additional high quality scientific data regarding ECs to inform chest physicians, health professionals and the general public.

A Content Analysis of Unique Selling Propositions of Tobacco Print Ads

OBJECTIVES

We describe the unique selling propositions (USPs) (propositions used to convince customers to use a particular brand/product by focusing on the unique benefit) of print tobacco ads.

METHODS

A qualitative content analysis was conducted of print tobacco ads (N = 171) selected from August 2012 to August 2013 for cigarettes, moist snuff, e-cigarettes, cigars, and snus to determine the content and themes of USPs for tobacco ads.

RESULTS

Cigarette ad USP themes focused on portraying the product as attractive; moist snuff ads focused on portraying product as masculine; cigar ads focused on selling a "high end product;" and new and emerging tobacco products (e-cigarette, snus) focused on directly comparing these products to cigarettes.

CONCLUSIONS

Whereas traditional tobacco product ads used USPs focused on themes of enjoyment and pleasure (eg, attractive for cigarettes, "high end product" for cigars), new and emerging tobacco product ads offered the unique benefit (USP) of their product being a better and "safer" alternative to traditional tobacco products. Snuff's USPs focused nearly exclusively on the masculinity of their products. Our results provide targets for potential tobacco regulatory actions that could be implemented to reduce demand for tobacco products by reducing their perceived unique benefits.

The Application of a Decision-Theoretic Model to Estimate the Public Health Impact of Vaporized Nicotine Product Initiation in the United States

INTRODUCTION

The public health impact of vaporized nicotine products (VNPs) such as e-cigarettes is unknown at this time. VNP uptake may encourage or deflect progression to cigarette smoking in those who would not have otherwise smoked, thereby undermining or accelerating reductions in smoking prevalence seen in recent years.

METHODS

The public health impact of VNP use are modeled in terms of how it alters smoking patterns among those who would have otherwise smoked cigarettes and among those who would not have otherwise smoked cigarettes in the absence of VNPs. The model incorporates transitions from trial to established VNP use, transitions to exclusive VNP and dual use, and the effects of cessation at later ages. Public health impact on deaths and life years lost is estimated for a recent birth cohort incorporating evidence-informed parameter estimates.

RESULTS

Based on current use patterns and conservative assumptions, we project a reduction of 21% in smoking-attributable deaths and of 20% in life years lost as a result of VNP use by the 1997 US birth cohort compared to a scenario without VNPs. In sensitivity analysis, health gains from VNP use are especially sensitive to VNP risks and VNP use rates among those likely to smoke cigarettes.

CONCLUSIONS

Under most plausible scenarios, VNP use generally has a positive public health impact. However, very high VNP use rates could result in net harms. More accurate projections of VNP impacts will require better longitudinal measures of transitions into and out of VNP, cigarette and dual use.

IMPLICATIONS

Previous models of VNP use do not incorporate whether youth and young adults initiating VNP would have been likely to have been a smoker in the absence of VNPs. This study provides a decision-theoretic model of VNP use in a young cohort that incorporates tendencies toward smoking and shows that, under most plausible scenarios, VNP use yields public health gains. The model makes explicit the type of surveillance information needed to better estimate the effect of new products and thereby inform public policy.

Documenting the emergence of electronic nicotine delivery systems as a disruptive technology in nicotine and tobacco science

BACKGROUND

The emergence of electronic nicotine delivery systems (ENDS, or "e-cigarettes") has resulted in nicotine and tobacco scientists committing increased resources to studying these products. Despite this surge of research on various topics related to e-cigarettes, it is important to characterize the evolving e-cigarette research landscape as a way to identify important future research directions. The purpose of this review was to broadly categorize published scholarly work on e-cigarettes using a structured, multi-level coding scheme.

METHODS

A systematic literature search was conducted to collect articles on e-cigarettes that were published in peer-reviewed journals from 2006 through 2014. Studies were classified through 3 coding waves. Articles were first divided into research reports, literature reviews and opinions/editorials. Research reports were further categorized to determine the proportion of these studies using human participants. Finally, human studies were classified based on their methodologies: descriptive, predictive, explanatory, and intervention.

RESULTS

Research reports (n=224) and opinions/editorials (n=248) were published at similar rates during this time period. All types of articles showed exponential rates of increase in more recent years. 76.4% of human research studies were descriptive in nature, with very little research employing experimental (6.8%) or intervention-based methodologies (5.4%).

CONCLUSIONS

This review reinforces the idea that e-cigarettes are a disruptive technology exerting substantial influence on nicotine and tobacco science. This review also suggests that opinions on e-cigarettes may be outpacing our scientific understanding of these devices. Our findings highlight the need for more e-cigarette research involving experimental, intervention, and longitudinal designs.

Reduced nicotine content cigarettes and use of alternative nicotine products: exploratory trial

AIMS

To compare the use of alternative nicotine products, smoking behavior and tobacco biomarker exposure in smokers unwilling to quit who were assigned randomly to normal nicotine content (NNC) cigarettes or very low nicotine content (VLNC) cigarettes.

DESIGN

Randomized, parallel-arm 8-week study with assignment to VLNC (VLNC 1, n = 53) or NNC (NNC, n = 27) with access to non-cigarette combusted and non-combusted tobacco/nicotine products or to VLNC with access to only non-combusted products (VLNC2, n = 56).

SETTING

Clinics in Minnesota, USA.

PARTICIPANTS

Smokers uninterested in quitting smoking with a mean [± standard deviation (SD)] age of 44 (± 14) years and smoking 16 (± seven) cigarettes/day; 51% female, 72% white.

MEASUREMENTS

During the experimental period, the measures taken included: rate of alternative products used, amount of and abstinence from combusted tobacco used and tobacco exposure biomarkers.

FINDINGS

There were higher rates of non-combusted alternative tobacco/nicotine product use in both VLNC conditions versus the NNC condition [rate ratio (RR) = 2.18, 95% confidence interval (CI) = 1.94, 2.46 and RR = 1.64, 95% CI = 1.46, 1.85, respectively] and in VLNC1 versus VLNC2 condition (RR = 1.33, 95% CI = 1.23, 1.44), accompanied by reduced biomarkers of exposure primarily in VLNC2 condition compared to NNC condition (Ps < 0.05). Fewer combusted products were smoked at almost all visits (Ps ≤ 0.02) and there were higher rates of abstinence for both VLNC conditions compared with the NNC condition (VLNC1 versus NNC: RR = 9.96, 95% CI = 5.01, 19.81; VLNC2 versus NNC: RR = 11.23, 95% CI = 5.74, 21.97).

CONCLUSION

The offer of, and instructions to use, reduced nicotine content cigarettes during an 8-week period led to greater use of alternative tobacco/nicotine products compared with continued use of normal nicotine cigarettes and also reductions in smoking rates.

Use of Electronic Cigarettes Among Cancer Survivors in the U.S

INTRODUCTION

The population-level patterns of electronic cigarette (e-cigarette) use among cancer survivors in the U.S. are unknown. The objective of this study was to examine the prevalence and correlates of e-cigarette use among cancer survivors in a nationally representative sample.

METHODS

A cross-sectional analysis was conducted of the 2014 National Health Interview Survey of the U.S. non-institutionalized civilian population. The main study outcomes were the prevalence and correlates of ever and current e-cigarette use among adults with self-reported history of cancer, excluding non-melanoma skin cancer (N=2,695). Multivariable logistic regression analyses examined whether e-cigarette use differed by cigarette smoking status and demographic subgroups. The analyses were performed in 2015.

RESULTS

The prevalence of e-cigarette use among adult cancer survivors was lower than the general population: 2.8% of cancer survivors reported currently using e-cigarettes and an additional 6.3% had previously used e-cigarettes but were not currently using them. Use of e-cigarettes was most common among cancer survivors who currently smoked cigarettes: 34.3% of current smokers were ever e-cigarette users and 15.6% were current e-cigarette users, compared with former smokers (2.7% ever and 1.4% current e-cigarette users) and never smokers (small sample/estimates unavailable).

CONCLUSIONS

E-cigarettes are not part of current evidence-based smoking-cessation strategies. However, the finding that cancer survivors who currently smoke cigarettes are more likely to use e-cigarettes highlights the importance of addressing e-cigarette use in patient-provider communications around tobacco cessation.

Vaping on Instagram: cloud chasing, hand checks and product placement

INTRODUCTION

This study documented images posted on Instagram of electronic cigarettes (e-cigarette) and vaping (activity associated with e-cigarette use). Although e-cigarettes have been studied on Twitter, few studies have focused on Instagram, despite having 500 million users. Instagram's emphasis on images warranted investigation of e-cigarettes, as past tobacco industry strategies demonstrated that images could be used to mislead in advertisements, or normalise tobacco-related behaviours. Findings should prove informative to tobacco control policies in the future.

METHODS

3 months of publicly available data were collected from Instagram, including images and associated metadata (n=2208). Themes of images were classified as (1) activity, for example, a person blowing vapour; (2) product, for example, a personal photo of an e-cigarette device; (3) advertisement; (4) text, for example, 'meme' or image containing mostly text and (5) other. User endorsement (likes) of each type of image was recorded. Caption text was analysed to explore different trends in vaping and e-cigarette-related text.

RESULTS

Analyses found that advertisement-themed images were most common (29%), followed by product (28%), and activity (18%). Likes were more likely to accompany activity and product-themed images compared with advertisement or text-themed images (p<0.01). Vaping-related text greatly outnumbered e-cigarette-related text in the image captions.

CONCLUSIONS

Instagram affords its users the ability to post images of e-cigarette-related behaviours and gives advertisers the opportunity to display their product. Future research should incorporate novel data streams to improve public health surveillance, survey development and educational campaigns.

Society of Behavioral Medicine's (SBM) position on emerging policy issues regarding electronic nicotine delivery systems (ENDS): A need for regulation

Electronic nicotine delivery systems (ENDS), commonly known as electronic cigarettes (or e-cigarettes), are widely available in the USA, yet almost entirely unregulated on a national level. Researchers are currently gathering data to understand the individual and public health effects of ENDS, as well as the role that ENDS may play in tobacco treatment. Given these uncertainties, regulatory efforts should be aimed at understanding and minimizing any potential harms of ENDS. The Society of Behavioral Medicine (SBM) supports stronger regulation of ENDS, incorporation of ENDS into clean air policies, and special consideration of safety standards to protect vulnerable populations. SBM also supports research on ENDS to guide policy decisions.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

IMPLICATIONS

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

Strategies to promote smoking cessation among adolescents

In recent years, youth have been exposed to a broader spectrum of tobacco products including smokeless tobacco, hookah (water pipe) and e-cigarettes. Despite active local, provincial/territorial and national prevention strategies and legislated controls, thousands of teenagers develop an addiction to tobacco products each year. Current and available smoking cessation interventions for youth have the potential to help teens stop smoking and, as a result, greatly reduce Canada's health burden in the future. Paediatricians and health care professionals can play a key role in helping teens make informed decisions related to tobacco consumption and cessation. This practice point presents the evidence and rationales for smoking cessation interventions which have been studied in youth specifically, such as individual counselling, psychological support, nicotine replacement therapy, bupropion and varenicline. Interventions for which limited or conflicting data exist are also discussed.

Temporal Changes in the Correlates of U.S. Adolescent Electronic Cigarette Use and Utilization in Tobacco Cessation, 2011 to 2013

OBJECTIVE

To examine temporal changes in the correlates of experimental and current e-cigarette use and associations with tobacco quit attempts.

METHOD

Repeated cross-sectional analyses of data from the 2011 ( n = 17,741), 2012 ( n = 23,194), and 2013 ( n = 16,858) National Youth Tobacco Surveys-a nationally representative sample of U.S. middle and high school students. Respondents were asked about lifetime and past-month e-cigarette use, conventional cigarette use, and number of quit attempts made in the prior year among current smokers.

RESULTS

Multinomial logistic regression models indicate higher odds of experimental or current e-cigarette use versus abstinence in the 2012 and 2013 survey years (vs. 2011). Respondents in the 2013 survey were more likely to use e-cigarettes in 2012, and they were significantly more likely to be current versus experimental users. Temporal increases in past-month e-cigarette use were uneven across demographic subgroups. Among current smokers of conventional cigarettes, fully adjusted models show that across all survey years the probability of past-month e-cigarette use was not significantly different for those who attempted to quit using tobacco in the past year from those who did not.

CONCLUSIONS

Adolescent e-cigarette use has become more common between 2011 and 2013 and shows signs of becoming increasingly characterized by current rather than experimental use. Temporal patterns suggest that recent population increases were initially driven by select subgroups (e.g., Whites), with other subgroups contributing to the increase more recently (e.g., Black). Tobacco cessation has remained unrelated to current e-cigarette use over time, suggesting that e-cigarette use may be contributing to increased nicotine use.

The changing tobacco landscape: What dental professionals need to know

BACKGROUND

Tobacco products in the United States and the patterns of tobacco use are changing. Although cigarette smoking prevalence has declined, dental professionals are likely to encounter substantial numbers of patients who have tried and are continuing to use new and alternative tobacco products, including cigars, water pipes (hookahs), and electronic cigarettes, as well as conventional and new smokeless tobacco products.

METHODS

The authors reviewed conventional and new tobacco products in the United States, their adverse oral and systemic health effects, and their prevalence of use.

RESULTS

Tobacco products other than cigarettes account for a substantial portion of tobacco use. For this reason, tobacco-use prevention and cessation counseling provided by dental health care professionals must address all tobacco products, including cigarettes, cigars, water pipes, and electronic cigarettes, as well as conventional and new smokeless tobacco products. Cigarette smoking and smokeless tobacco use are associated with immediate and long-term adverse health effects, including nicotine addiction, oral and systemic disease, and death. Novel products may attract new tobacco users, potentially leading to addiction that results in enduring tobacco product use and associated adverse health effects.

CONCLUSIONS

This critical review of conventional, new, and emerging tobacco products presents information that dental professionals can use in providing tobacco-related counseling to patients who use or who are at risk for using tobacco products.

PRACTICAL IMPLICATIONS

It is essential that dental professionals are knowledgeable about tobacco products and are able to answer patients' questions and provide them with evidence-based tobacco-related counseling. This information may prevent patients from initiating use or help reduce or cease use to avoid immediate and long-term adverse health effects, including nicotine addiction, oral and systemic disease, and death.

The E-cigarette Social Environment, E-cigarette Use, and Susceptibility to Cigarette Smoking

PURPOSE

One concern regarding the recent increase in adolescent e-cigarette use is the possibility that electronic (e-) cigarettes may be used by those who might not otherwise have used cigarettes, and that dual use, or transition to cigarette use alone, may follow.

METHODS

Questionnaire data were obtained in 2014 from 11th/12th grade students attending schools in 12 communities included in the Southern California Children's Health Study. We evaluated the cross-sectional association between e-cigarette use, the social environment (family and friends' use and approval of e-cigarettes and cigarettes), and susceptibility to future cigarette use among never cigarette smokers (N = 1,694), using previously validated measures based on reported absence of a definitive commitment not to smoke.

RESULTS

Among adolescents who had never used cigarettes, 31.8% of past e-cigarette users and 34.6% of current (past 30-day) e-cigarette users indicated susceptibility to cigarette use, compared with 21.0% of never e-cigarette users. The odds of indicating susceptibility to cigarette use were two times higher for current e-cigarette users compared with never users (odds ratio = 1.97; 95% confidence interval: 1.21-3.22). A social environment favorable to e-cigarettes (friends' use of and positive attitudes toward the use of e-cigarettes) was also associated with greater likelihood of susceptibility to cigarette use, independent of an individual's e-cigarette use.

CONCLUSIONS

E-cigarette use in adolescence, and a pro-e-cigarette social environment, may put adolescents at risk for future use of cigarettes. E-cigarettes may contribute to subsequent cigarette use via nicotine addiction or social normalization of smoking behaviors.

The influence of electronic cigarette age purchasing restrictions on adolescent tobacco and marijuana use

OBJECTIVE

In the United States, many states have established minimum legal purchase ages for electronic nicotine delivery systems (ENDS) to ban adolescent purchases, but these policies may also affect other related substance use. We explore whether ENDS are substitutes or complements for cigarettes, cigars, smokeless tobacco, and marijuana among adolescents by using variation in state-level implementation of ENDS age purchasing restrictions.

METHODS

We linked data on ENDS age purchasing restrictions to state- and year-specific rates of adolescent tobacco and marijuana use in 2007-2013 from the Youth Risk Behavior Surveillance System. This data provides a nationally representative sample of adolescents who attend public and private schools. We performed a fixed effect regression analysis exploring the influence of ENDS age purchasing restrictions on outcomes of tobacco use and marijuana use, controlling for state and year fixed characteristics, age-race cohorts, cigarette excise taxes, and cigarette indoor use restrictions.

RESULTS

For cigarette use, we separate our results into cigarette use frequency. We found causal evidence that ENDS age purchasing restrictions increased adolescent regular cigarette use by 0.8 percentage points. ENDS age purchasing restrictions were not associated with cigar use, smokeless tobacco use, or marijuana use.

CONCLUSIONS

We document a concerning trend of cigarette smoking among adolescents increasing when ENDS become more difficult to purchase.

Research Priorities, Measures, and Recommendations for Assessment of Tobacco Use in Clinical Cancer Research

There is strong evidence that cigarette smoking causes adverse outcomes in people with cancer. However, more research is needed regarding those effects and the effects of alternative tobacco products and of secondhand smoke, the effects of cessation (before diagnosis, during treatment, or during survivorship), the biologic mechanisms, and optimal strategies for tobacco dependence treatment in oncology. Fundamentally, tobacco is an important source of variation in clinical treatment trials. Nevertheless, tobacco use assessment has not been uniform in clinical trials. Progress has been impeded by a lack of consensus regarding tobacco use assessment suitable for cancer patients. The NCI-AACR Cancer Patient Tobacco Use Assessment Task Force identified priority research areas and developed recommendations for assessment items and timing of assessment in cancer research. A cognitive interview study was conducted with 30 cancer patients at the NIH Clinical Center to evaluate and improve the measurement items. The resulting Cancer Patient Tobacco Use Questionnaire (C-TUQ) includes "Core" items for minimal assessment of tobacco use at initial and follow-up time points, and an "Extension" set. Domains include the following: cigarette and other tobacco use status, intensity, and past use; use relative to cancer diagnosis and treatment; cessation approaches and history; and secondhand smoke exposure. The Task Force recommends that assessment occur at study entry and, at a minimum, at the end of protocol therapy in clinical trials. Broad adoption of the recommended measures and timing protocol, and pursuit of the recommended research priorities, will help us to achieve a clearer understanding of the significance of tobacco use and cessation for cancer patients.

The perceived effects of electronic cigarettes on health by adult users: A state of the science systematic literature review

BACKGROUND AND PURPOSE

There is a lack of research on perceived health effects of electronic cigarettes by adult users. Because more people are choosing electronic cigarettes (e-cigarettes) in addition to, or instead of traditional cigarettes, it is important for the nurse practitioner (NP) to understand why.

METHODS

A comprehensive literature search was conducted using four scholarly databases. The search strategy utilized remained consistent. Qualitative, quantitative, observational studies and meta-analyses were considered for review. Of the 52 articles preliminarily retrieved, 9 met inclusion criteria and were analyzed.

CONCLUSIONS

The majority of e-cigarette users perceive they are less harmful to health than traditional cigarettes. One reason for use is smoking cessation. Current guidelines recommend against promoting e-cigarette use. More research is needed on the long-term health effects of e-cigarettes as well as regulatory statements to guide future healthcare practice.

IMPLICATIONS FOR PRACTICE

As prevalence of e-cigarette use increases, it is important for NPs to understand the perceived effects on health by adults who use them and, specifically, how these perceptions motivate use. Armed with this information, the NP can communicate with patients about e-cigarettes, confidently recommend against their use, and begin discussions about reliable smoking cessation tools and resources that will help patients achieve their goals.

E-cigarette use in adults: a qualitative study of users' perceptions and future use intentions

BACKGROUND

There has been an exponential increase in the prevalence of e-cigarette use, particularly among youth. However, adult use is also rising, and there have been relatively few qualitative studies with adult users to understand their reasons for use and future use intentions. Such information is needed to inform both prevention and cessation approaches.

METHOD

Thirty-one e-cigarette users participated in one of several focus groups assessing the appeal of e-cigarettes as well as comparisons to combustible cigarettes and approved smoking cessation aids. We also obtained perspectives on future use intentions and interest in e-cigarette cessation interventions. Verbatim transcripts were analyzed using the constant comparative method.

RESULTS

Participants reported several aspects of e-cigarette appeal as compared to approved cessation treatment options. These included similarities to combustible cigarettes, fewer side effects, and control of e-cigarettes to suit personal preferences. Participants were split on whether they preferred flavors that mimicked or contrasted with their combustible cigarettes (i.e., tobacco vs. alternative flavors, such as candy). Some participants who were unmotivated to quit smoking reported an unanticipated disinterest in continuing use of combustible cigarettes shortly after initiating e-cigarettes. Despite strong interest in reducing nicotine dosage, the majority did not intend to fully discontinue e-cigarettes.

CONCLUSIONS

Understanding e-cigarette users' perspectives can inform policy and treatment development. Regulatory and policy initiatives will need to balance the appealing characteristics of e-cigarettes with the potential for negative public health outcomes.