Trends and Substance Use Associations With E-Cigarette Use in US Adolescents

"I've lost my children to vaping": A frame analysis of the Australian media's construction of the "Youth vaping crisis"

BACKGROUND

Youth vaping has become an issue of extreme concern in the Australian public and political discourse, recently culminating in the announcement of further restrictions on the sale and use of nicotine vaping products (NVPs) by the Federal Government. We examine how youth vaping has been framed in the Australian news media in the six months leading up to the announcement of these new measures in May 2023.

METHODS

Drawing a sample from the Factiva database, we conducted a frame analysis on articles published during this six month period, identifying media framings that included the necessary components of a distinct Problem Definition, Causal Attribution, Moral Evaluation, and Treatment Recommendation.

RESULTS

We identified 123 relevant articles, and four dominant framings being applied. Most common was that of A Failure of Control, followed by A Poisonous Epidemic, A Health Behaviour Needing Regulation, and A Moral Failure.

CONCLUSION

These findings are discussed in the context of moral panic theory and how framings are constructed by the media in collaboration with policy actors to support particular policy measures.

Longitudinal associations of e-cigarette use with cigarette, marijuana, and other drug use initiation among US adolescents and young adults: Findings from the population assessment of tobacco and health study (Waves 1-6)

INTRODUCTION

Research examining prospective links of e-cigarette use with cigarette, marijuana, and other substance use has been limited largely to 1-2-year follow-up periods and focused on younger adolescents. This study examined longitudinal associations of e-cigarette use with cigarette, marijuana, and other substance use initiation among U.S. adolescents and young adults (AYAs) across an eight-year period.

METHODS

Adolescent (ages 12-17) and young adult (ages 18-25) data from waves 1-6 of the nationally representative Population Assessment of Tobacco and Health study (2013-2021) were used. Discrete time survival models with time-varying weights were employed to examine the risk of cigarette, marijuana, and other drug use initiation over an eight-year follow-up period among AYAs with no lifetime use of e-cigarettes/other tobacco, lifetime but no past 30-day use of e-cigarettes/other tobacco, past 30-day e-cigarettes only, other tobacco use only, or past 30-day e-cigarette/other tobacco use. We compare our time-varying weighting approach to a traditional time-invariant/complete case weighting approach.

RESULTS

Across six follow-up waves, all three past 30-day nicotine/tobacco use groups, including e-cigarettes only, had greater risk for cigarette, marijuana, and other drug use initiation relative to those not using nicotine/tobacco. The three past 30-day nicotine/tobacco use groups did not differ from each other in risk for marijuana use initiation. Associations were smaller in magnitude for young adults compared to adolescents, but significant for both age groups.

CONCLUSIONS

Substance use initiation risks persist beyond 1-2 years for U.S. AYAs using e-cigarettes. Prevention strategies to reduce AYA e-cigarette use are needed to reduce cancer-related risk.

Adolescent Perspectives on the Pharmacy-Based T-EVER (Teen E-Cigarette and Vaping Educational Resource) and Its Potential Impact on Youth Vaping

BACKGROUND

While public health efforts have made tobacco smoking near obsolete among adolescents, vaping products are quickly taking their place. With the negative health consequences looming ahead of young vapers, there is a desperate need to curb youth vaping. Adolescents want to be actively engaged in their health which creates space to educate on vaping in this population segment.

METHODS

From January to May 2023, 35 adolescents aged 11-18 participated in interviews to assess the investigator-developed Teen E-cigarette and Vaping Educational Resource (T-EVER). All the interviews were recorded and transcribed for independent analysis by two study team members.

RESULTS

The participants liked the T-EVER, indicating they were engaged in the content. However, some participants wanted more information. The participants wanted health professionals to educate them on vaping but were worried about the potential barriers facing the implementation in community pharmacy settings.

CONCLUSIONS

Adolescents want to learn about vaping, but there are limited opportunities to do so. The T-EVER is designed to educate youth about vaping. This tool was well received and has the potential to be used by pharmacists as a vaping prevention and cessation intervention. More research is required to discern the true scope of the pharmacist's role in using an educational tool to address adolescent vaping.

Avoidance biases for vaping stimuli among college students with electronic-cigarette use

Previous research has suggested that individuals who smoke demonstrate a behavioral tendency to approach rather than avoid smoking-related stimuli (i.e., approach bias). This study assessed whether 149 undergraduates with varying levels of e-cigarette use demonstrated an approach bias for vaping-related stimuli on an Approach-Avoidance Task (AAT). In contrast to our hypotheses, participants with e-cigarette use demonstrated a significant avoidance bias to vaping-related stimuli, and this effect appeared to be primarily driven by female e-cigarette users. Further, we found that more severe e-cigarette use was associated with numerous adverse outcomes, including reduced quality of life and increased vaping cravings, depressive symptoms, perceived stress, and cannabis use severity. Overall, our findings elucidate various negative impacts of e-cigarette use and suggest a potential role for sex differences in approach-avoidance tendencies toward vaping-related stimuli among young adults.

An ecological examination of early adolescent e-cigarette use: A machine learning approach to understanding a health epidemic

E-cigarette use among adolescents is a national health epidemic spreading faster than researchers can amass evidence for risk and protective factors and long-term consequences associated with use. New technologies, such as machine learning, may assist prevention programs in identifying at risk youth and potential targets for intervention before adolescents enter developmental periods where e-cigarette use escalates. The present study utilized machine learning algorithms to explore a wide array of individual and socioecological variables in relation to patterns of lifetime e-cigarette use during early adolescence (i.e., exclusive, or with tobacco cigarettes). Extant data was used from 14,346 middle school students (Mage = 12.5, SD = 1.1; 6th and 8th grades) who participated in the Utah Prevention Needs Assessment. Students self-reported their substance use behaviors and related risk and protective factors. Machine learning algorithms examined 112 individual and socioecological factors as potential classifiers of lifetime e-cigarette use outcomes. The elastic net algorithm achieved outstanding classification for lifetime exclusive (AUC = .926) and dual use (AUC = .944) on a validation test set. Six high value classifiers were identified that varied in importance by outcome: Lifetime alcohol or marijuana use, perception of e-cigarette availability and risk, school suspension(s), and perceived risk of smoking marijuana regularly. Specific classifiers were important for lifetime exclusive (parent's attitudes regarding student vaping, best friend[s] tried alcohol or marijuana) and dual use (best friend[s] smoked cigarettes, lifetime inhalant use). Our findings provide specific targets for the adaptation of existing substance use prevention programs to address early adolescent e-cigarette use.

Prevalence and correlates of past 30-day dual-vaping of nicotine and cannabis among adolescents in five New England states

SIGNIFICANCE

Adolescent vaping behavior includes vaping of multiple substances, including both nicotine and cannabis (dual-vaping). This study describes the prevalence and the sociodemographic correlates of past 30-day dual-vaping.

METHODS

We recruited adolescents ages 13-17 from five New England states (Massachusetts, Connecticut, Rhode Island, Vermont, New Hampshire) through the Prodege online survey panel from April 2021 to August 2022. Dual-vaping was defined as vaping both nicotine and cannabis (THC and/or CBD) in the past 30-days. We analyzed the prevalence of sole-nicotine, sole-cannabis, and dual-vaping of nicotine and cannabis and used multinomial logistic regression to examine associations between sociodemographic factors and sole- and dual-vaping of nicotine and cannabis.

RESULTS

The analytic sample included 2013 observations from 1858 participants (mean age 15.1 years, 46.2% female, 74.1% White, 82.2% heterosexual). Among these observations, 5.6% reported past 30-day sole-nicotine vaping, 5.5% reported sole-cannabis vaping, and 7.3% had dual-vaped. Correlates for higher odds of past 30-day dual-vaping included total social media sites used and household tobacco use, in contrast with sole-cannabis vaping, which included older age and self-reported depression (all p's <0.05).

DISCUSSION

Adolescent past 30-day dual-vaping of nicotine and cannabis was more prevalent than past 30-day sole-vaping of either nicotine or cannabis alone. Future studies should continue to collect detailed data on the type of substances, besides nicotine, that adolescents are vaping.

Correlates of adolescent sole-, dual- and poly-use of cannabis, vaped nicotine, and combusted tobacco

BACKGROUND

Compared to single substance use, adolescents' use of multiple substances is associated with more severe dependence, cessation outcomes, and health risks. This study examined correlates of use and co-use of e-cigarettes, combusted tobacco, and cannabis among high school-aged (9th-12th grade, approximately aged 14-18) adolescents.

METHODS

We analyzed the 2019 Massachusetts Youth Health Survey (MYHS) data to calculate the weighted means of any past 30-day sole-use of e-cigarettes, sole-use of combusted tobacco, sole-use of cannabis, dual-use of two of the above substances, and poly-use of all three substances. We then used weighted multinomial logistic regression to examine the associations between demographic, social and behavioral factors and sole-, dual-, and poly-use (vs. no use) of these substances.

RESULTS

Among N = 1614 respondents, any past 30-day dual-use of e-cigarettes and cannabis was the most prevalent (17.2%, SE: 1.3%). Sole-use of combusted tobacco was less than 1%, whereas 4.5% (SE: 0.7%) of respondents reported poly-use of e-cigarettes, cannabis, and combusted tobacco. Lower academic grades and self-reported depression (1 item on persistent feelings of sadness or hopelessness) were associated with increased odds of dual-use of e-cigarettes and cannabis and poly-use (vs. sole-use of any substance). Adolescents who self-reported having "any long-term emotional problems or learning disabilities" had greater odds of poly-use.

CONCLUSION

Different sets of correlates were associated with sole-, dual-, and poly-use, suggesting that certain adolescents may be more vulnerable than others to multiple substance use. Future research should examine potentially modifiable upstream influences, such as the home environment and socioeconomic factors that may affect the relationship between adolescent mental health, school performance, and multiple addictive substance use.

Electronic Nicotine Delivery Systems and E-Liquid Modifications to Vape Cannabis Depicted in Online Videos

Importance

Electronic nicotine delivery systems (ENDS) were created to vape nicotine e-liquids; however, social media demonstrates increased ENDS modifications to vape cannabis. Analysis of social media content helps with understanding ENDS modifications for cannabis use, overlapping markets for ENDS and cannabis, and the need for additional regulation.

Objective

To analyze online videos for use, modification, and marketing of ENDS to vape cannabis.

Design, Setting, and Participants

In this qualitative study, 10 searches were performed on YouTube on July 14, 2022, using different combinations of relevant search terms to identify videos depicting modifications to ENDS and e-liquids to vape cannabis. The first 40 videos from each search (400 videos total, 152 without duplicates) were extracted, of which 59 included depiction or discussion of cannabis vaping content. Content analysis of videos included iterative development of codes, consensus building across team members, and reliability checks.

Main Outcomes and Measures

Metadata (ie, video length, number of likes, comments, and views) were extracted for included videos. Coding was performed for uploader type, modifications to ENDS and e-liquids, devices used, cannabis products vaped, age restriction, purchasing links, health claims, and discussion of warning messages and cannabis regulations.

Results

Of the 59 videos analyzed, 34 (58%) included tetrahydrocannabinol; 33 (56%), cannabidiol; and 8 (14%), both. A total of 21 videos (36%) were age-restricted, while 25 (42%) included purchasing links for cannabis products, 20 (34%) for ENDS, and 7 (12%) for nicotine e-liquids. Twenty-six videos (44%) made claims about health benefits of vaping cannabis. Forty-one videos (69%) demonstrated vaping manufacturer-made cannabis products (eg, cannabis concentrates) with no modifications needed. Eighteen videos (31%) depicted modifications to e-liquids or ENDS for cannabis use. The most frequent modification was mixing e-liquids with cannabis products to be compatible with ENDS. The most frequently reported reason for modifications was to vape cannabis in public by using the same devices used for nicotine.

Conclusions and Relevance

This qualitative study of online videos found high frequencies of statements about health benefits from vaping cannabis, frequent purchasing links, and inadequate age restrictions. Exposure to such content on social media platforms may increase risk of cannabis vaping among youth. Use of the same devices for multiple substances may also enable dual use and complicate the US Food and Drug Administration's regulation of ENDS.

A randomized controlled trial of varenicline and brief behavioral counseling delivered by lay counselors for adolescent vaping cessation: Study protocol

Background

Approximately one-fifth of high-school seniors and college students currently vape nicotine. Adolescents express a desire to quit vaping, and case reports have shown promise for e-cigarette tapering with dual behavioral and pharmacologic therapies. However, there are no published clinical trials to date that test these intervention approaches for adolescent nicotine vaping cessation. In this three-arm randomized, placebo-controlled, parallel-group study, we aim to assess the efficacy of varenicline in combination with brief behavioral counseling and texting support on vaping cessation in adolescents dependent on vaped nicotine.

Methods

The study will enroll 300 individuals between the ages of 16–25 with daily or near-daily nicotine vaping who reside in the Greater Boston area. Participants will be randomly assigned in a 1:1:1 ratio in blocks of six to one of the three arms: (1) a 12-week course of varenicline titrated to 1 mg bid, brief behavioral counseling delivered by a lay counselor, and an introduction to This is Quitting (TIQ) texting support created by the Truth Initiative; (2) a 12-week course of placebo, brief behavioral counseling, and TIQ; and (3) 12 weeks of enhanced usual care, consisting of advice to quit and an introduction to TIQ. The primary outcome will be biochemically verified continuous vaping abstinence at the end of the treatment (week 12). Secondary outcomes include continuous abstinence at follow-up (week 24), 7-day point prevalence abstinence at weeks 12 and 24, safety and tolerability of varenicline in an adolescent vaping population, as well as change in mood and nicotine withdrawal symptoms across the intervention period. Exploratory outcomes include change in comorbid substance use behaviors and nicotine dependence. Analysis will be intent-to-treat, with multiple imputation sensitivity analyses for participants with missing or incomplete outcome data.

Discussion

This is the first study to evaluate varenicline in combination with a novel, brief, lay counselor delivered vaping cessation program for adolescents who vape nicotine. Results will inform clinicians on the effectiveness and acceptability of this promising, but not yet tested intervention.

Clinical trial registration: ClinicalTrials.gov, identifier NCT05367492.

Electronic Cigarette Use Intentions Mediate the Association between Low Self-Control and Future Use by Internalizing Symptoms

Background: Adolescent electronic (e-)cigarette use intentions are related to initiation. Low self-control is also a risk factor for early stages of substance use. Yet, the impact of low self-control on use through intentions may vary across individuals; depression and anxiety may affect this association. Methods: A sample of 200 adolescents who completed waves 1 and 2 of an ongoing longitudinal study were assessed. We hypothesized that high internalizing symptoms would moderate the indirect effect of low self-control on actual e-cigarette use through e-cigarette use intentions. Results: The mediation pathway was significant at high levels of internalizing symptoms, but not at low or moderate levels. Conclusion: Specifically, those with low self-control and high internalizing symptomatology endorsed the highest e-cigarette use intentions and were more likely to subsequently use e-cigarettes. Youth low in self-control and high in depression and anxiety might be at increased risk to initiate e-cigarette use compared to youth high in self-control and high in internalizing symptomatology.

La protection des enfants et des adolescents contre les risques du vapotage

Le vapotage chez les jeunes comporte des risques importants pour la santé et la sécurité des enfants et des adolescents canadiens. Le présent document de principes fournit de l'information générale sur le vapotage et les produits et dispositifs qui y sont liés, traite des méfaits à court et à long terme associés à leur utilisation et propose des stratégies de prévention et d'abandon pour les jeunes vapoteurs ou ceux qui sont à risque de commencer à vapoter. Le vapotage chez les jeunes est associé à un risque accru d'usage de tabac et de substances psychoactives, de troubles de santé mentale, de pneumopathie, de cardiopathie et de blessures accidentelles. Le vapotage ne doit pas servir d'outil d'abandon du tabac chez les jeunes, en raison de son manque d'efficacité et des données probantes sur les méfaits qu'il occasionne. De nombreuses stratégies préventives et thérapeutiques utilisées pour l'abandon du tabac, y compris les stratégies comportementales et pharmacologiques, peuvent être adaptées pour aider les jeunes à arrêter de vapoter. Des recommandations sont formulées pour les intervenants communautaires et les décideurs.

Protecting children and adolescents against the risks of vaping

Youth vaping presents significant risks for the health and safety of Canadian children and adolescents. This statement provides background information about vaping, vaping products, and related devices, discusses the short- and long-term harms known to be associated with their use, and offers prevention and cessation strategies for youth who vape or are at risk for starting. Youth vaping is associated with increased risk for tobacco and other substance use, mental health problems, pulmonary and cardiovascular disease, and unintentional injuries. Vaping should not be used as a smoking cessation tool for youth, due to lack of effectiveness and evidence of harm. Many preventive and treatment strategies used for tobacco cessation, including behavioural and pharmacological options, can be adapted to help youth quit vaping. Recommendations for community stakeholders and policy makers are included.

Electronic Cigarette Refill Liquids: Nicotine Content, Presence of Child-Resistant Packaging, and in-Shop Compounding

PURPOSE

To expand on our 2015 study of the nicotine content accuracy of e-liquids, including salts, and the presence of child-resistant packaging. We also describe compounding in shop (CIS).

DESIGN AND METHODS

We analyzed samples from 35 shops. CIS processing was observed. Descriptive statistics summarized the data, and inference was performed.

RESULTS

Actual nicotine content was significantly less than the identified content, on average, with a mean percent deviation 34.0% below the identified content. Only 3.8% of the samples' actual nicotine content was within 10% of the identified content; the maximum deviation was 213.2%. Of eight uniquely packaged samples, including designs resembling pop cans, ice cream cones, etc., the mean percent deviation was -39.6%; none were within 10% of the identified content. Eight shops compounded samples. After removing outlier values, significant differences were found in the percent deviations between the CIS and non-CIS free-base samples. A significantly higher percentage of CIS samples had nicotine content > 10% above the identified content, and none were within 10%. One shop visually estimated the nicotine quantities to add, e-liquids were not always relabeled to reflect new nicotine levels, and protective materials were not always worn during compounding. Child-resistant packaging was not present for one third of the samples.

CONCLUSIONS

Labeling of nicotine content in e-liquids remains inaccurate, child-resistant packaging is inconsistent, and CIS is problematic. Effective e-liquid regulation is needed to protect public health.

PRACTICE IMPLICATIONS

Nurses should educate families about the serious health risks of e-liquids and advocate for increased e-liquid regulations.

Adolescent E-Cigarette Onset and Escalation: Associations With Internalizing and Externalizing Symptoms

PURPOSE

We sought to evaluate if internalizing symptoms (i.e., anxiety and depression) and/or externalizing symptoms (i.e., impulsivity, sensation seeking, and substance use) were risk factors for the onset of 30-day e-cigarette use and escalation in the number of days used across the following 30 months among adolescents.

METHODS

Adolescents (N = 1,808) from public high schools outside Philadelphia, PA, completed in-classroom surveys at wave 1 (fall 2016, beginning of ninth grade) and at 6-month intervals for the following 30 months (spring 2019, end of 11th grade).

RESULTS

A two-part latent growth curve model of e-cigarette use revealed significant positive associations between externalizing factors, past 30-day e-cigarette use, and the number of days of e-cigarette use only at wave 1 (p values <.05). Cigarette smoking was associated with a slowing in the rate of onset of 30-day e-cigarette use across the 30-month follow-up (β = -.24, z = -2.41, p = .02). Depression was associated with an increased rate of escalation in the number of days of e-cigarette use across the following 30 months (β = .01, z = 2.52, p = .01), whereas anxiety was associated with a decreased rate (β = -.72, z = -2.36, p = .02).

CONCLUSIONS

The findings highlight two groups of adolescents at risk for e-cigarette use: adolescents whose e-cigarette use reflects a higher-risk profile with early e-cigarette onset, and adolescents who have a lower-risk profile, at least initially, with later e-cigarette use onset. The timing and content of prevention efforts should be tailored to each group.

Bidirectional associations between e-cigarette use and alcohol use across adolescence

INTRODUCTION

Evidence on prospective bidirectional associations between e-cigarette and alcohol use among adolescents can inform prevention and policy but is largely absent from the literature.

METHODS

Data were drawn from a prospective cohort of students attending 10 Los Angeles high schools (N = 3396; baseline mean age = 14.1, SD = 0.4). Students completed surveys every 6-months from 2013 to 2017; 8 total waves. Analyses were restricted to (a) individuals who were never users of alcohol (N = 2394) or (b) individuals who were never users of e-cigarettes (N = 2704) at baseline. Repeated-measures, generalized linear mixed models were used to estimate the adjusted odds of past 6-month alcohol and e-cigarette initiation, in separate models.

RESULTS

Among alcohol never-users at baseline, 15.7 % (N = 375) initiated alcohol use over the study period. Compared to never-users of e-cigarettes, those who reported use of e-cigarettes had 3.5 times the odds of subsequently initiating alcohol use in the following wave (OR = 3.54; 95 % CI: 2.81, 4.47). Stronger associations were observed for males (OR = 4.94; 95 % CI: 3.78, 6.45) than for females (OR = 3.21; 95 % CI: 2.33, 4.41; p_interaction = 0.04). Among e-cigarette never-users at baseline, 26.3 % (N = 709) initiated e-cigarette use over the study period. Compared to never-users of alcohol, those who reported use of alcohol had 3.2 times the odds of subsequently initiating e-cigarette use in the following wave (OR = 3.23; 95 % CI: 2.68, 3.89). This association did not differ by gender.

CONCLUSIONS

E-cigarette and alcohol use can be markers to identify youth at risk for future alcohol and e-cigarette use, respectively. Research examining mechanisms underlying these associations is needed to infer causality.

The Future of Substance Abuse Now: Relationships among Adolescent Use of Vaping Devices, Marijuana, and Synthetic Cannabinoids

Background: Substances that can be vaped include nicotine, marijuana, cocaine, heroin, and a range of synthetic drugs called new psychoactive substances (NPS). Due to the rising popularity of vaping among adolescents, it is crucial to understand the relationships between vaping and illicit drug use. Objectives: This paper examined the prevalence and trends of using vaping devices, marijuana vaping, marijuana products, synthetic cannabinoids and mist contents among youth. Methods: The study utilized 5 sets of public cross-sectional national data from the "Monitoring the Future" surveys during 2014-2018. It employed logistic regression to analyze the data. Results: There was an increase from 10.5% in 2017 to 20.8% in 2018 for the past 30-day use of vaping devices among 12^th graders. Furthermore, there was an increase from 21.6% in 2017 to 34.5% in 2018 for the past 12-month use of marijuana via vaping device among 12^th-grade marijuana users. Additionally, there were significant associations between vaping device use and marijuana vaping, between vaping device use and marijuana use, between vaping device use and synthetic cannabinoids use, and between marijuana use and synthetic cannabinoids use from 2016 to 2018. Conclusions: Vaping emerged as another major route of marijuana administration among youth. Adolescent marijuana users had higher odds of using synthetic cannabinoids. This finding highlighted the importance of understanding what adolescent substance consumption pattern would be where marijuana was legalized. It also supported the hypothesis that vaping devices use correlates with, or is associated with, marijuana and synthetic cannabinoids use.

Changes from 2017 to 2018 in e-cigarette use and in ever marijuana use with e-cigarettes among US adolescents: analysis of the National Youth Tobacco Survey

AIMS

To examine changes from 2017 to 2018 in e-cigarette use and ever marijuana use with e-cigarettes among US adolescents.

DESIGN

Analysis of data from the 2017 and 2018 National Youth Tobacco Survey (NYTS), cross-sectional surveys of US middle school (grades 6-8) and high school (grades 9-12) students.

SETTING

United States.

PARTICIPANTS

US adolescent population from middle school, with mean age = 12.7 [standard deviation (SD) = 1.0] years, and high school, with mean age = 16.1 (SD = 1.3) years.

MEASUREMENTS

Analysis of e-cigarette use and ever use of marijuana with e-cigarettes according to frequency of use and smoking status, comparing 2017 with 2018. Frequent smoking and e-cigarette use was defined as use for ≥ 20 of the past 30 days.

FINDINGS

Past 30 days e-cigarette use was reported by 33.1% [95% confidence interval (CI) = 29.1-37.4%] of ever/no past 30 days smokers, 68.6% (95% CI = 64.1-72.7%) of past 30 days smokers and 7.2% (95% CI = 6.3-8.2%) of never smokers in 2018 and by 19.3% (95% CI = 16.1-23.1%), 53.0% (95% CI = 46.9-58.9%) and 3.3% (95% CI = 2.7-4.4%) in 2017, respectively (all P < 0.001). Prevalence of past 30 days e-cigarette use was higher among frequent smokers (69.8%, 95% CI = 62.3-76.5% in 2018; 53.8%, 95% CI = 44.1-63.2% in 2017, P < 0.001) and lower among never smokers. Most of the latter were infrequent users, while frequent and daily e-cigarette use was 18- and 24-fold lower compared with ever smokers, respectively. Approximately half of past 30 days and 70% of frequent e-cigarette users reported ever marijuana use with e-cigarettes in both years. Past 30 days smokers were more likely to report past 30 days e-cigarette use [odds ratio (OR) = 15.79, 95% CI = 12.58-19.83 in 2018; OR = 16.11, 95% CI = 12.44-20.86 in 2017) compared with adolescents reporting no past 30 days smoking.

CONCLUSIONS

Among US adolescents, e-cigarette use increased in all smoking groups in 2018 compared with 2017. Frequent and daily e-cigarette use was far lower in never-smokers compared with ever-smokers. High prevalence of ever marijuana use with e-cigarettes was observed.

Substance Use among Exclusive Electronic Cigarette Users and Dual Combustible Cigarette Users: Extending Work to Adult Users

BACKGROUND

Electronic cigarettes (e-cigarettes) have become increasingly popular in recent years. Existing evidence indicates e-cigarettes used in isolation are less harmful than combustible cigarettes, yet emerging work has demonstrated that adults use e-cigarettes largely in combination with combustible cigarettes (i.e. dual use). Despite this data, little is understood about how exclusive and dual e-cigarette users may differ across behavioral outcomes, such as substance use dependence and behaviors among adults.

OBJECTIVES

Thus, the current project examined differences in e-cigarette dependence, problematic alcohol use, cannabis use, and nonmedical prescription opioid use (e.g. methadone and oxycodone) across both exclusive and dual e-cigarette adult users.

RESULTS

Participants included 531 (53.6% female; M_age = 35.29 years, SD = 10.44) adults with past-month e-cigarette use. Dual users reported greater e-cigarette dependence, alcohol use, current cannabis use, and endorsement of nonprescription opioid use. Conclusions/Importance: Importantly, this work suggests that adults who use both combustible and e-cigarettes may constitute a group more vulnerable to experiencing problematic substance use and more severe e-cigarette dependence than exclusive e-cigarette users.

Vaping and e-cigarette use. Mysterious lung manifestations and an epidemic

Electronic (e)-cigarette use and the practice of vaping has rapidly expanded both in adult smokers and previously nicotine naïve youths. Research has focused on harm reduction in adults using e-cigarettes to stop or reduce traditional cigarette use, but the short and long-term safety of these products has not been established. Vaping has more recently been associated with a growing list of pulmonary complications with the most urgent being the e-cigarette or vaping product use-associated lung injury (EVALI) epidemic. This review details the inhalant toxicology of vaping products, the described lung diseases associated with vaping with a focus on EVALI, and the predicted long-term consequences of e-cigarette use, including increased asthma severity.

What is the face of new nicotine users? 2012-2018 e-cigarettes and tobacco use among young students in Italy

BACKGROUND

With increased use of electronic-nicotine delivery devices (e-cigarettes) and non-cigarettes tobacco products (heated tobacco products, shisha, moist snuff/snus) among adolescents, the percentage of Italian students who use nicotine products is at its highest level of the past ten years, even though prevention and anti-smoking policies have produced tangible results in decreasing tobacco smoking prevalence. This cross-sectional study examined trends in exclusive and dual smoking, identified new poly-consumption patterns and profiled old and new nicotine users.

METHODS

We used the annual cross-sectional ESPAD® Italia survey which sampled students (aged 15-19), currently used for surveillance and monitoring of at risk population, between 2012 and 2018 (N = 170,974) to describe Italian trends in exclusive cigarette, exclusive vaping, and dual cigarette and vaping use. . For the 2018 sample, patterns of poly-consumption were described, and a multinomial logistic regression (N = 15,732) estimated characteristics associated with exclusive and dual cigarette and vaping use.

RESULTS

The lifetime prevalence of cigarette smokers slightly decreased from 60.9% in 2012 to 56.9% in 2018, whereas the proportion of vaping users substantially increased from 32.9% in 2013 to 52.0% in 2018. Combining cigarette and vaping use, these trends result in an increase in the lifetime prevalence of any use from 60.8% in 2013 to 66.2% in 2018. Three out of every 10 minors have experienced smoking and/or vaping, and younger students were more prone to be dual users. Overall, current vapers were generally less prone to risky behaviours.

CONCLUSION

In contrast to a slight decrease in cigarette smoking, the prevalence of Italian students approaching old and/or new smoking habits in their lifetime is substantially increasing. The popularity of alternative nicotine-based products, particularly e-cigarettes, has increased among teenagers, resulting in a summation of usage patterns rather than a compensation, and attracting a novel slice of young users. The lack of regulation within current drug policy to limit the access to such licit psychoactive substance use, is urgently needed to avoid a future nicotine addicted population.

Systematic Review of Electronic Cigarette Use (Vaping) and Mental Health Comorbidity Among Adolescents and Young Adults

Introduction

The prevalence of electronic cigarette (EC) use has risen dramatically among adolescents and young adults (AYA, ages 12–26) over the past decade. Despite extensive established relationships between combustible cigarette use and mental health problems, the mental health comorbidities of EC use remain unclear.

Aims and Methods

To provide a systematic review of existing literature on mental health comorbidities of EC use among AYA. Database searches using search terms related to EC, AYA, and mental health identified 1168 unique articles, 87 of which prompted full-text screening. Multiple authors extracted data, applied the Effective Public Health Practice Project Quality Assessment Tool to evaluate the evidence, and synthesized findings.

Results

Forty articles met eligibility criteria (n = 24 predominantly adolescent and 16 predominantly young adult). Analyses yielded three main categories of focus: internalizing disorders (including depression, anxiety, suicidality, eating disorders, post-traumatic stress disorder), externalizing disorders (attention-deficit/hyperactivity disorder and conduct disorder), and transdiagnostic concepts (impulsivity and perceived stress). Significant methodological limitations were noted.

Conclusions

Youth EC use is associated with greater mental health problems (compared with nonuse) across several domains, particularly among adolescents. Because many existing studies are cross-sectional, directionality remains uncertain. Well-designed longitudinal studies to investigate long-term mental health sequelae of EC use remain needed.

Implications

Forty recent studies demonstrate a variety of mental health comorbidities with AYA EC use, particularly among adolescents. Mental health comorbidities of EC use generally parallel those of combustible cigarette use, with a few exceptions. Future EC prevention and treatment strategies may be enhanced by addressing mental health.

The Vaping Teenager: Understanding the Psychographics and Interests of Adolescent Vape Users to Inform Health Communication Campaigns

Background:

Adolescent vaping continues to rise, yet little is known about teen vape users beyond demographics. Effective intervention requires a deeper understanding of the psychographics and interests of adolescent vape users to facilitate targeted communication campaigns.

Methods:

We analyzed the 2017-2018 weighted cross-sectional online survey data from Virginia high school students (N = 1594) to identify and describe subgroups of adolescents who vaped. Participants reported 30-day vape use, identification with 5 peer crowds (Alternative, Country, Hip Hop, Mainstream, Popular), social prioritization, agreement with personal values statements, social media and smartphone use, and television and event preferences. We compared vaping rates and frequency by peer crowd using a chi-square analysis with follow-up testing to identify higher-risk crowds and confirmed associations using binary and multinomial logistic regression models with peer crowd scores predicting vaping, controlling for demographics. We then used chi-square and t tests to describe the psychographics, media use, and interests of higher-risk peer crowds and current vape users within those crowds.

Results:

Any current vaping was the highest among those with Hip Hop peer crowd identification (25.4%), then Popular (21.3%). Stronger peer crowd identification was associated with increased odds of any current vaping for both crowds, vaping on 1 to 19 days for both crowds, and vaping on 20 to 30 days for Hip Hop only. Compared with other peer crowds and non-users, Hip Hop and Popular youth and current vape users reported greater social prioritization and agreement with values related to being social and fashionable. Hip Hop and Popular youth and current vape users reported heavy Instagram and Snapchat use, as well as unique television show and event preferences.

Conclusions:

Hip Hop and Popular adolescents are most likely to vape and should be priority audiences for vaping prevention campaigns. Findings should guide the development of targeted health communication campaigns delivered via carefully designed media strategies.

A review of toxic effects of electronic cigarettes/vaping in adolescents and young adults

In this review, we examine the known and suspected toxicity of electronic cigarettes (e-cigarettes) in adolescents and young adults, to improve awareness of risks and identification of complications of their use. The use of e-cigarettes, or "vaping," is exploding among the pediatric population. E-cigarettes heat a solution containing a psychoactive compound, most commonly nicotine or tetrahydrocannabinol (THC), along with flavorings and other additives to a vapor, which users inhale. Since their introduction in the early 2000s, e-cigarette use is now prolific among youth, per the Monitoring the Future survey, with over 40% of high school seniors reporting use within the past year. Adolescents are vulnerable to the risks of e-cigarettes, as they are targeted as new consumers with advertisements and flavoring compounds, and are not utilizing them as a means to smoking cessation. The pulmonary risks of vaping are rapidly emerging, with the most immediately alarming being the condition electronic-cigarette/vaping associated lung injury (EVALI). Additionally, there have been more recent studies showing extrapulmonary effects including cardiovascular, immunologic and neuro-developmental effects. Many of these effects are likely dose-dependent. Public health efforts are urgently needed to decrease or eliminate new e-cigarette initiation, and support should be established to assist current e-cigarette users with cessation. We strongly advocate for the elimination of e-cigarette flavorings and advertising directed at adolescents, and call for physicians to be cognizant of this expanding epidemic.

Cannabis vaping: Understanding the health risks of a rapidly emerging trend

The rapid emergence of youth vaping has completely changed the landscape of adolescent substance use in Canada and has become a pressing public health issue of our time. While nicotine remains the most common substance encountered in vaping devices, cannabis vaping is now reported by one-third of youth who vape. Though cannabis vaping is thought to generate fewer toxic emissions than cannabis smoking, it has been associated with several cases of acute lung injury and often involves high-potency forms of cannabis, exposing youth to several acute and long-term health risks. The low perceived riskiness of cannabis as a substance and of vaping as a mode of consumption may bring a false sense of security and be particularly appealing for youth who may be looking for a 'healthier way' to use substances. While research is still lacking on how best to support youth who may have already initiated cannabis vaping, concerted efforts among paediatric providers, public health experts, schools, communities, and families are urgently needed to limit the spread of cannabis vaping among Canadian youth.

Peers, Perceptions, and E-Cigarettes: A Social Learning Approach to Explaining E-Cigarette Use Among Youth

This study uses social learning theory to examine whether differential associations with e-cigarette-using peers is related to personal e-cigarette use among youth, and the extent to which this relationship is explained by personal risk perceptions of e-cigarettes. Moreover, this study tests whether the mediation process is moderated by type of e-cigarette user. This study uses a sample of high school seniors from the 2016 Monitoring the Future Study ( N = 2,100), and a subsample of e-cigarette users ( n = 523). Analyses are carried out using OLS and logistic regression. Findings demonstrate that higher levels of peer e-cigarette use are related to higher odds of personal e-cigarette use, but that risk perceptions of e-cigarettes only explain a modest portion of that relationship (about 10%). Furthermore, the mediation process does not appear to vary by type of e-cigarette user. Future directions and policy implications are discussed.

Exposure to adverse childhood experiences and early initiation of electronic vapor product use among middle school students in Nevada

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1 in 5 middle school students had used EVPs and 5.1% initiated before age 11.

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A strong graded relationship between cumulative ACEs and early initiation of EVPs was observed.

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Hispanic, rural, and military family students were also at risk for early initiation of EVPs.

Introduction

The use of electronic vapor products (EVPs) among youth has increased significantly in recent years, yet little is known about factors associated with initiation of EVPs during early adolescence. The purpose of this study was to explore the relationship between chronic exposure to adverse childhood experiences (ACEs) and early initiation of EVPs in a representative sample of middle school students.

Methods

5,464 students from 113 middle schools (grades 6–8) completed the Nevada Youth Risk Behavior Survey (YRBS) in the spring of 2017. Six abuse and household dysfunction measures were used to calculate a cumulative ACE score (range 0–6). Initiation of EVPs (e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens) before age 11 was considered early initiation. Weighted logistic regression was used to assess the relationship between cumulative ACE exposure and early initiation of EVPs after controlling for sex, age, race/ethnicity, rurality, free or reduced lunch status, and military family involvement.

Results

Nearly 1 in 5 middle school students (18.6%) reported using EVPs, 6.7% had used EVPs during the past 30 days, and 5.1% started using EVPs before age 11. After controlling for sociodemographics, a strong graded relationship between cumulative ACE exposure and early initiation of EVPs was observed: 1 ACE (AOR = 1.60; 95% CI = 0.99–2.59), 2 ACEs (AOR = 2.29; 95% CI = 1.33–3.93), and 3–6 ACEs (AOR = 3.43, 95% CI = 2.20–5.36) compared to no ACEs.

Conclusions

Screening for ACEs in school-based settings may be a feasible approach for identifying students who may be at-risk for early initiation of EVPs.

Cannabis legalization, tobacco prevention policies, and Cannabis use in E-cigarettes among youth

BACKGROUND

E-cigarettes are the most popular tobacco product among youth. As more states adopt cannabis legalization policies, youth cannabis use in e-cigarettes is a mounting concern.

METHODS

Data were from the 2016 and 2017 National Youth Tobacco Survey, a nationally-representative repeated cross-sectional survey administered to US middle and high school students. Ever use groups were categorized into e-cigarette ever users, cannabis in e-cigarette ever users, other tobacco ever users, and never users. Weighted multinomial logistic regression compared ever use groups, while controlling for state-level cannabis legalization and tobacco prevention polices, tobacco perceptions and exposures, and sociodemographic variables. Weighted prevalence of ever and current, or past 30 day, tobacco product use was determined by ever use groups.

RESULTS

Compared to e-cigarette ever users, cannabis in e-cigarette ever users increased (Adjusted Relative Risk Ratio (ARRR) = 1.65; p < 0.01) from 2016 to 2017. Medical-only and medical and recreational cannabis laws, and no e-cigarette minimum legal sales age (MLSA) and increased e-cigarette MLSA at 19 or 21 were positively associated with cannabis in e-cigarette ever users (ARRR = 1.34-1.85; p < 0.01, each). Ever and current use of all individual tobacco products was highest among cannabis in e-cigarette ever users compared to e-cigarette and other tobacco ever users.

CONCLUSIONS

Cannabis use in e-cigarettes has increased among youth, and these trends will likely continue as e-cigarettes continue to gain popularity and cannabis legalization policies proliferate. Targeted tobacco and cannabis prevention strategies are needed for youth, especially in states that have implemented cannabis 'medical and recreational laws.

Teen vaping: There is no vapour without fire

E-cigarettes have become the most important source of nicotine exposure among adolescents. While e-cigarettes may have the potential to help some adults quit smoking, there is a lack of reliable evidence that this would apply to adolescents. On the contrary, e-cigarette use is associated with subsequent use of cigarettes and other tobacco products in teens and is also associated with increased use of alcohol, marijuana, and other drugs. Research on the health effects of e-cigarettes is rapidly emerging suggesting that they carry several acute and long-term risks, particularly for adolescents' still-developing bodies and brains. While several strategies to help youth quit smoking exist, much less is known about effective clinical interventions for adolescents presenting with an addiction to nicotine consumed through e-cigarettes. We discuss the latest research on e-cigarettes with a focus on health effects in youth and propose potential avenues for concerted action among paediatric providers and decision makers.

Association Between Electronic Cigarette Use and Marijuana Use Among Adolescents and Young Adults: A Systematic Review and Meta-analysis

IMPORTANCE

Use of electronic cigarettes (often called e-cigarettes) has increased considerably among young people in the past 5 years. Use of e-cigarettes has been associated with higher rates of marijuana use, which is associated with several adverse health outcomes in youth.

OBJECTIVE

To characterize and quantify the association between e-cigarette and marijuana use among youth using a meta-analysis.

DATA SOURCES

PubMed, Embase, and Web of Science & ProQuest Dissertations and Theses were searched from inception to October 2018. A gray-literature search was also conducted on conference abstracts, government reports, and other sources.

STUDY SELECTION

Included studies compared rates of marijuana use among youth aged 10 to 24 years who had used e-cigarettes vs those who had not used e-cigarettes. Two reviewers independently assessed studies for inclusion; disagreements were discussed with a third reviewer and resolved by consensus.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by 2 independent reviewers following Meta-analyses of Observational Studies in Epidemiology (MOOSE) reporting guidelines and pooled using a random-effects analysis. The Newcastle-Ottawa Scale was used to assess data quality and validity of individual studies.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios (AORs) of self-reported past or current marijuana use by youth with vs without past or current e-cigarette use.

RESULTS

Twenty-one of 835 initially identified studies (2.5%) met selection criteria. The meta-analysis included 3 longitudinal and 18 cross-sectional studies that included 128 227 participants. Odds of marijuana use were higher in youth who had an e-cigarette use history vs those who did not (AOR, 3.47 [95% CI, 2.63-4.59]; I2, 94%). Odds of marijuana use were significantly increased in youth who used e-cigarettes in both longitudinal studies (3 studies; AOR, 2.43 [95% CI, 1.51-3.90]; I2, 74%) and cross-sectional studies (18 studies; AOR, 3.70 [95% CI, 2.76-4.96]; I2, 94%). Odds of using marijuana in youth with e-cigarette use were higher in adolescents aged 12 to 17 years (AOR, 4.29 [95% CI, 3.14-5.87]; I2, 94%) than young adults aged 18 to 24 years (AOR, 2.30 [95% CI, 1.40-3.79]; I2, 91%).

CONCLUSIONS AND RELEVANCE

This meta-analysis found a significant increase in the odds of past or current and subsequent marijuana use in adolescents and young adults who used e-cigarettes. These findings highlight the importance of addressing the rapid increases in e-cigarette use among youths as a means to help limit marijuana use in this population.

Association of alcohol and drug use with use of electronic cigarettes and heat-not-burn tobacco products among Korean adolescents

Background

The tobacco industry has aggressively introduced new and diverse products in the market, including electronic cigarettes (e-cigarettes) and heat-not-burn (HNB) tobacco products, to which adolescents are readily susceptible. Conventional cigarettes have a well-established relationship with adolescent risky behaviors such as alcohol and drug use; however, no studies exist on the association between alcohol consumption and use of e-cigarettes or HNB tobacco products among Korean adolescents. This study evaluated alcohol-related behaviors and drug use in relation to whether a Korean nationally representative adolescent sample had ever used e-cigarettes and HNB tobacco products.

Methods

Data from the 2018 Korean Youth Risk Behavior Web-based Survey were analyzed. The final study sample comprised 60,040 adolescents. Chi-square and logistic regression were used to examine whether the ever having used e-cigarettes and HNB tobacco products was associated with alcohol-related behaviors and drug use. P-values for trends were calculated to examine the dose-response relationship for each variable.

Results

Respondents with higher drinking frequency, drinking quantity, alcohol intoxication, alcohol availability, and drug use were more likely to report having used e-cigarettes and HNB tobacco products, thus implying a significant relationship between substance use and novel tobacco product (P < .001).

Conclusions

Our findings suggest that at-risk adolescents who are engaged in other forms of risk-taking behaviors are prone to attract the experimentation with e-cigarettes or HNB tobacco products. Thus, smoking cessation programs related to substance use should be implemented, and there is an urgent need to monitor and regulate these products effectively.

Understanding the implications of the "vaping epidemic" among adolescents and young adults: A call for action

In the past 5 years, the use of nicotine delivered through electronic cigarettes ("e-cigarettes") has sky-rocketed among adolescents and young adults. E-cigarettes, with their high nicotine content, appealing flavors, low costs, wide availability, and discreet designs threaten 5 decades of progress in the fight against tobacco use. Aside from the increased risk of subsequent use of traditional cigarettes, marijuana, opioids, and other illicit drugs, building evidence indicates that e-cigarette use also exposes youth to several acute and long-term health risks that greatly outweigh the as-yet unfounded potential benefits from the use of e-cigarettes as a smoking reduction or cessation tool in this age group. We discuss some of the latest research on e-cigarettes, highlighting risks and harms associated with their use in adolescents and young adults, and suggest opportunities for action, including the enforcement of age, sales and marketing limitations, and concerted research and public health efforts to help curb what has become a new nicotine epidemic among youth.