"They're sleek, stylish and sexy:" selling e-cigarettes online

OBJECTIVE

We examined the product range, marketing strategies, access and marketing claims made by Australian and New Zealand (NZ) online e-cigarette retailers.

METHODS

Twenty Australian (n=10) and NZ (n=10) e-cigarette retail websites were identified via Google using a combination of keywords nominated by an expert panel and identified via a literature review: 'e-cigarette', 'e-cigs', 'vape', and 'vaping', combined with 'Australia', 'AU', 'New Zealand' and 'NZ' and then examined.

RESULTS

Products were extensive (disposable, pod-based, reusable, replacement parts), 95% (n=19) offered 'Starter Kits,' flavoured e-liquid (n=1,032), most containing nicotine (70%, n=14). Most retailers (85%, n=17) offered price discounts and free delivery. There were unsubstantiated health claims (80%, n=16), cessation claims (65%, n=13) and cost-benefit claims (50%, n=10) promoting e-cigarette use. Most (n=14) website age verification features simply required the purchaser to indicate they were aged 18 years.

CONCLUSIONS

Although e-cigarette regulations are different in Australia and NZ, the online product range, marketing strategies, access and marketing claims were similar and sold e-liquid containing nicotine. The health and cessation e-cigarette marketing claims were outlandish and unsubstantiated.

IMPLICATIONS FOR PUBLIC HEALTH

Most purchasing of e-cigarettes occurs online. Regulations and enforcement to limit access and stop unsubstantiated marketing claims must be a public health priority.

Use of Single, Dual, and Poly Tobacco Products in Korean Adolescents

This study aimed to examine the prevalence of single, dual, and poly use of conventional cigarettes, e-cigarettes, and heated tobacco products among Korean adolescent smokers and identify factors related to dual and poly tobacco product use. Data from 4028 current smokers in the 2019 Korea Youth Behavior Web-based Survey were included. Single users accounted for 53.1%, followed by dual users at 24.8% and poly users at 22.1%. The factors influencing dual and poly tobacco product use included male, living in a metropolitan area, risky alcohol drinking, sexual experience, number of cigarettes smoked, secondhand smoke exposure, and easy-to-buy tobacco products. The findings suggest restricting the use of new types of tobacco products in the high-risk group are required to prevent dual and poly use. Furthermore, it is necessary to provide support like education for new tobacco products and smoking cessation, programs for secondhand smoke prevention, or rigorous marketing regulations for adolescents.

Adolescent's Health Perceptions of E-Cigarettes: A Systematic Review

CONTEXT

E-cigarette use is increasing among adolescents, particularly in high-income countries. This review examines the health perceptions of E-cigarettes among adolescents (aged 12-17 years) residing in the U.S., United Kingdom, Canada, Australia, and New Zealand and their sources of E-cigarette information.

EVIDENCE ACQUISITION

Peer-reviewed literature published in January 2009-April 2019 in MEDLINE, Embase, and ProQuest were systematically reviewed using identified keywords. The search identified 654 references. Studies (n=99) that met the inclusion criteria were subjected to full-text screening. A total of 27 articles were subjected to quality appraisal using the Joanna Briggs Institute's critical appraisal checklists.

EVIDENCE SYNTHESIS

A total of 7 qualitative and 18 quantitative studies were included in the review, and the study characteristics, results, and limitations were extracted. A total of 4 main themes emerged from the study findings: (1) perceived relative harm of E-cigarettes versus that of cigarettes, (2) perceived health effects of E-cigarettes, (3) perceived benefits and safety of E-cigarettes, and (4) sources of E-cigarette information and exposure. Most adolescents perceived E-cigarettes to be less harmful than cigarettes; however, often, their health perceptions of E-cigarettes were conflicting. Sources of exposure to E-cigarette information included friends, family, retail point of sale, TV and online advertising, national agencies, healthcare providers, and from direct experience.

CONCLUSIONS

Findings indicate that adolescents, particularly E-cigarette users, have more favorable perceptions of E-cigarettes than of cigarettes; however, these perceptions are conflicting. Advertising, marketing, and peer and family networks appear to influence adolescents' perceptions. More research is required, particularly in Australia and New Zealand, to better understand adolescents' health perceptions of E-cigarettes and where they source information from so that misperceptions can be addressed through appropriate channels with suitable messaging.

E-cigarettes and health risks: more to the flavor than just the name

The growing interest in regulating flavored E-liquids must incorporate understanding of the "flavoring profile" of each E-liquid-which flavorings (flavoring chemicals) are present and at what concentrations not just focusing on the flavor on the label. We investigated the flavoring profile of 10 different flavored E-liquids. We assessed bronchial epithelial cell viability and apoptosis, phagocytosis of bacteria and apoptotic cells by macrophages after exposure to E-cigarette vapor extract (EVE). We validated our data in normal human bronchial epithelial cells (NHBE) and alveolar macrophages (AM) from healthy donors. We also assessed cytokine release and validated in the saliva from E-cigarette users. Increased necrosis/apoptosis (16.1-64.5% apoptosis) in 16HBE cells was flavor dependent, and NHBEs showed an increased susceptibility to flavors. In THP-1 differentiated macrophages phagocytosis was also flavor dependent, with AM also showing increased susceptibility to flavors. Further, Banana and Chocolate were shown to reduce surface expression of phagocytic target recognition receptors on alveolar macrophages. Banana and Chocolate increased IL-8 secretion by NHBE, whereas all 4 flavors reduced AM IL-1β secretion, which was also reduced in the saliva of E-cigarette users compared with healthy controls. Flavorant profiles of E-liquids varied from simple 2 compound mixtures to complex mixtures containing over a dozen flavorants. E-liquids with high benzene content, complex flavoring profiles, high chemical concentration had the greatest impacts. The Flavorant profile of E-liquids is key to disruption of the airway status quo by increasing bronchial epithelial cell apoptosis, causing alveolar macrophage phagocytic dysfunction, and altering airway cytokines.

Perception of Harms and Benefits of Electronic Cigarettes Among Adult Malaysian Men: A Comparison by Electronic Cigarette Use and Smoking Status

Little is known about the perceptions of harm and benefit associated with the use of e-cigarettes in Malaysia. This was a cross-sectional analysis of a nationally representative sample comprising 1987 males (≥18 years of age). Current, former, and never users of conventional cigarettes and/or e-cigarettes participated in a questionnaire study conducted via face-to-face interviews. The relationship between participant characteristics and perceptions of harm and benefit of e-cigarettes were determined with multivariable logistic regression. There were 950 current, 377 former, and 660 never users of e-cigarettes. Government employees (odds ratio [OR] = 1.85, 95% confidence interval [CI] = 1.29-2.66, P = .001), private sector employees (OR = 1.67, 95% CI = 1.27-2.18, P = .001), and the self-employed people (OR = 1.68, 95% CI = 1.31-2.17, P = .001) were more likely to perceive e-cigarettes as more harmful than conventional cigarettes compared with respondents who were not wage earners. All current users in the form of e-cigarette users (OR = 7.87, 95% CI = 3.23-19.18), conventional cigarette smokers (OR = 1.80, 95% CI = 1.39-2.33), and dual users (OR = 8.59, 95% CI = 4.76-15.52) were more likely to perceive e-cigarettes as useful in quitting conventional cigarette smoking compared with former and never users. Our findings constitute an important snapshot into the perceptions of e-cigarette harms and benefits, which could inform targeted public health messaging strategies.

The Messages Presented in Electronic Cigarette-Related Social Media Promotions and Discussion: Scoping Review

BACKGROUND

There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long-term health consequences. As smoking rates continue to drop or plateau in many well-developed countries, transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence indicates e-cigarettes are being marketed on social media as a harm reduction alternative, with retailers and manufacturers utilizing marketing techniques historically used by the tobacco industry.

OBJECTIVE

This study aimed to identify and describe the messages presented in e-cigarette-related social media (Twitter, YouTube, Instagram, and Pinterest) promotions and discussions and identify future directions for research, surveillance, and regulation.

METHODS

Data sources included MEDLINE, Scopus, ProQuest, Informit, the Journal of Medical Internet Research, and Google Scholar. Included studies were published in English between 2007 and 2017, analyzed content captured from e-cigarette-related social media promotions or discussions, and reported results for e-cigarettes separately from other forms of tobacco and nicotine delivery. Database search ceased in October 2017. Initial searches identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full-text articles to determine eligibility and identified 25 studies for inclusion. This process was undertaken with the assistance of the Web-based screening and data extraction tool-Covidence. The review was registered with the Joanna Briggs Institute (JBI) Systematic Reviews database and followed the methodology for JBI Scoping Reviews.

RESULTS

Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavoring and highlighting the public performance of vaping. Discussion and promotion of these devices appear to be predominantly occurring among the general public and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media.

CONCLUSIONS

The social media landscape is dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly, real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals.

Juggling Two Balls-Smoking (Re)Normalization and Harm Reduction: E-Cigarettes-Facts and Misconceptions in Taiwan

The increasing popularity of e-cigarettes, especially among adolescents, has alarmed health advocates and government officials, dominating the tobacco control narrative in the past few years. According to the Global Youth Tobacco Survey, the percentage of Taiwanese teenagers reporting use of e-cigarettes in the past 30 days rose from 2.01% (95% confidence interval [CI] = 1.82% to 2.23%) in 2014 to 3.54% (95% CI = 3.30% to 3.80%) in 2017. However, during the same period, prevalence of cigarettes declined from 11.51% (95% CI = 9.84% to 13.42%) to 8.26% (95% CI = 7.80% to 8.76%) among senior high school students, and from 5.00% (95% CI = 4.36% to 5.74%) to 2.66% (95% CI = 2.38% to 2.96%) among junior high school students, with figures for both groups reaching historical lows. This trend is similar to population-level trends observed in both the United Kingdom and the United States, but only future long-term studies will be able to clarify if it is consistent or not with the fears that e-cigarette may act as a "gateway" to cigarette smoking renormalization.