E-Cigarette Social Norms and Risk Perceptions Among Susceptible Adolescents in a Country That Bans E-Cigarettes

Susceptibility to e-cigarette among high school students: a study based on the ecological model of health behavior

Introduction

Youth e-cigarette (EC) use has rapidly increased in the last few years. It is crucial to identify the susceptible youth and prevent them from EC uptake. This study was conducted to investigate factors that affect youth susceptibility to EC use.

Methods

This study employed a cross-sectional survey design, utilizing multi-center stratified cluster sampling method to select two junior high schools and two senior high schools in Shanghai, Guangzhou, and Chengdu. One-third of classes of each grade in the selected schools were involved in this survey. After obtaining the informed consent of parents, an anonymous and self-administered questionnaire was distributed to students. Questionnaire was designed based on the Ecological Models of Health Behavior. Associations between EC susceptibility and covariates were identified using multivariate logistic regression.

Results

Among 2,270 students who had never vaped, 38.0% were susceptible to ECs. Logistic regression analysis identified factors on different levels affecting the susceptibility. Individual factors included senior high school students (OR = 1.34, 95% CI: 1.08-1.65), sensation seeker (OR = 1.11, 95%CI: 1.08-1.14), poor academic performance (OR = 1.24, 95% CI: 1.01-1.54), ever cigarette user (OR = 2.27, 95% CI: 1.29-4.01), unaware of the second-hand smoke from vaping (OR = 1.56, 95% CI: 1.25-1.96), agreeable with "I do not want to hang around vapers" (OR = 0.79, 95% CI: 0.64-0.97), agreeable with "ECs are more fashionable than cigarette" (OR = 2.50, 95% CI: 1.72-3.62) and favorable attitudes toward vaping (OR = 5.09, 95% CI: 3.78-6.85) were significantly associated with susceptibility to ECs. At interpersonal level, students who believe they would not be punished by parents for vaping increased susceptibility (OR = 1.27, 95% CI:1.01-1.59). At community level, exposure of EC advertising (OR = 1.81, 95% CI:1.46-2.25), exposure to hazard information (OR = 0.76, 95% CI: 0.59-0.97) and seeing vaping in daily life (OR = 2.11, 95% CI: 1.62-2.74), were statistically significantly associated with youth susceptibility to ECs.

Conclusion

EC susceptibility was observed in a substantial proportion of adolescents who had never vaped, influenced by factors on different levels. This research underscores the urgent need for comprehensive intervention strategies to prevent the youth susceptibility to ECs.

Susceptibility to Electronic Cigarette and Consumption Patterns in Adolescents

The use of electronic cigarettes (ECs) is a major problem globally. Susceptibility and curiosity are important factors that develop prior to the onset of substance use, such as ECs, and are therefore considered as predictors. Both factors are used to obtain an extended index of susceptibility (ESIe-c), which allows the identification of adolescents who are at risk of starting to use these devices. The aim of this study was to determine the prevalence of EC consumption and to assess the association of possible predictors with susceptibility to use and experimentation with ECs among adolescents. A cross-sectional study was carried out in 377 adolescents (53.0% female). Participants were compared according to their experimentation with ECs. A total of 45.9% had already used electronic cigarettes, and 20.8% were current users. Among those who had not tried electronic cigarettes, 43.3% had a medium-high susceptibility to EC initiation. Consumption among close friends, receiving offers of consumption and alcohol consumption were associated with initiation. There was an inverse association between a medium susceptibility index electronic cigarette score and the consumption of cigarettes and positive affect; on the other hand, the lack of premeditation was associated with a higher susceptibility index score. Intrapersonal factors and social factors seem to influence the ESIe-c and onset of EC use, respectively. The main conclusion in this study is that susceptibility is influenced by intrapersonal factors such as affectivity and impulsivity through the lack of premeditation, and by social factors such as EC consumption by best friends.

Relationship between electronic cigarette use, dual smoking habits, and psychological distress among youth in Northern Thailand: A cross-sectional study

INTRODUCTION

Amidst the escalating trend of electronic cigarette (e-cigarette) use and dual smoking habits among youth, understanding their potential impact on psychological well-being is imperative. Limited research has explored this relationship, particularly among youth in settings where e-cigarettes are banned. This study investigates the relationship between current e-cigarette and traditional cigarette use patterns and the presence of depression and anxiety symptoms among youth in Thailand.

METHODS

Using a cross-sectional survey encompassing 3424 individuals aged 15-24 years in Northern Thailand from December 2021 to September 2022, we accessed cigarette and e-cigarette usage over the past 30 days alongside depression and anxiety symptoms over the past two weeks. Multivariable logistic regression was employed to analyze the association of these variables, adjusting for sociodemographic factors.

RESULTS

Among the surveyed youths, 10.8% reported cigarette use, 6.2% utilized e-cigarettes, and 3.3% were dual users within the past 30 days. Regarding mental health, 33.96% exhibited moderate-severe to severe depression, while 52.54% experienced anxiety at similar levels. After adjusting for covariates, both current e-cigarette users and dual users exhibited heightened depression symptoms (AOR=1.80; 95% CI: 1.30-2.51, and AOR=2.30; 95% CI: 1.49-3.55, respectively) and only e-cigarette use had increased odds of increased anxiety levels (AOR=1.70; 95% CI: 1.24-2.32) compared to non-users. Notably, current cigarette smokers demonstrated no association with depression but had decreased odds of higher levels of anxiety compared to non-users (AOR=0.73; 95% CI: 0.55-0.96).

CONCLUSIONS

A substantial number of Thai youths are using e-cigarettes and experiencing psychological distress. E-cigarette use is associated with heightened levels of depression and anxiety, whereas cigarette smoking is not associated with depression but is likely to be associated with an increased reporting of anxiety. These contradictory findings highlight the need for comprehensive investigations, especially when e-cigarettes are prohibited.

Factors associated with susceptibility to e-cigarette use among Australian adolescents

BACKGROUND

Preventing uptake of e-cigarette use among adolescents is critical to minimizing vaping-related harms. To inform the development of effective prevention programs and policies, this study explored potential determinants of susceptibility to e-cigarette use among young Australians.

METHODS

A cross-sectional online survey was administered to 12- to 17-year-old Australians who had never smoked nor vaped (N = 973; 53 % women). The survey assessed susceptibility to e-cigarette use (curiosity about use, willingness to use, and intentions to use) and a comprehensive range of potential correlates that included individual, social, and environmental factors. Regression analyses were conducted to identify factors significantly correlated with each of the dependent variables.

RESULTS

Susceptibility to e-cigarette use was observed in 45 % of respondents. Individual factors associated with susceptibility included respondents' (i) overall opinion of e-cigarettes, (ii) attitudes toward e-cigarettes, (iii) affect regulation expectancies, and (iv) quitting perceptions. Significant social factors included both descriptive and injunctive norms, specifically: perceiving that use is ok for people of one's age, approval from important others to use, and having at least one family member or close friend who vapes.

CONCLUSION

Susceptibility to vaping was observed in a substantial proportion of adolescents who have never smoked. Shifting attitudes and social norms around e-cigarette use appears critical to reducing susceptibility. Recommended prevention efforts include the development of communications addressing misperceptions about the benefits of vaping on affect regulation and stricter regulations on e-cigarette advertising to reduce young Australians' exposure to claims that may result in favourable attitudes to e-cigarette use.

Exposure to e-cigarette advertising and young people's use of e-cigarettes: A four-country study

INTRODUCTION

The World Health Organization recommends banning all forms of e-cigarette advertising, promotion, and sponsorship. The aims of the present study were to: 1) examine young people's exposure to e-cigarette advertising across a wide range of media in four diverse countries; and 2) identify any association between the number of different types of media exposures and e-cigarette use.

METHODS

A cross-sectional online survey was administered to approximately 1000 people aged 15-30 years in Australia, China, India, and the United Kingdom (n=4107). The survey assessed demographic characteristics, e-cigarette and tobacco use, numbers of friends and family members who vape, and exposure to multiple forms of e-cigarette advertising (e.g. television, radio, print, and various types of social media). Descriptive analyses were conducted on those who had heard of e-cigarettes (n=3095, significance threshold p<0.001) and a logistic regression analysis was used to identify factors associated with e-cigarette ever use (significance threshold p<0.05).

RESULTS

The majority (85%) of respondents who had heard of e-cigarettes reported being exposed to e-cigarette advertising on at least one type of media, and the average number of types of media to which respondents were exposed was 5 (range: 0-17). The number of media types was significantly associated with ever use of e-cigarettes (OR=1.05; 95% CI: 1.02-1.08, p=0.001).

CONCLUSIONS

Despite advertising restrictions in place in all four countries, large majorities of young people reported being exposed to e-cigarette advertising. Social media and advertising on/around vape shops and other retailers appear to be key exposure locations. Urgent attention is needed to address these forms of exposure given their apparent association with e-cigarette use.

A Survey of Vaping Use, Perceptions, and Access in Adolescents from South-Central Texas Schools

Despite efforts to dissuade major manufacturers and retailers from marketing and selling vape products to adolescents, the practice of vaping continues to increase in this population. Few studies have assessed adolescent perceptions of vaping, access to vaping, and use of vaping, and most rely, at least in part, on inferential conclusions drawn from data on smoking traditional combustible cigarettes. A novel electronic survey was created to assess the use of vapes, perceptions of vaping, and access to vaping among a convenience sample of adolescents (ages 12-20 years) in eleven schools in South-Central Texas from May to August 2021. The students' perceived threat of negative health outcomes due to vaping was calculated based on questions soliciting perceptions of severity (perceived danger) and susceptibility (perceived likelihood of illness). Trends were identified using descriptive and bivariate statistical tests. A total of 267 respondents were included; 26% had tried vaping. A majority (63%) did not believe vaping and smoking were synonymous. Most (70%) thought it was easy to obtain supplies and (76%) vape before and after (88%) or even during (64%) school. Respondents who vaped had a 34% lower perceived threat when compared to respondents who did not vape. In this sample of adolescents from South-Central Texas, one in four reported that they had tried vaping. Easy access to vapes and misperceptions regarding the safety of vaping might create a false sense of security with respect to vaping as an alternative to smoking, particularly among those who reported vaping, and is likely contributing to the increased use of vapes.

Short report: Factors contributing to young people's susceptibility to e-cigarettes in four countries

BACKGROUND

Identifying young people who are susceptible to e-cigarettes is important for developing interventions designed to discourage uptake. Current evidence in a broader range of national contexts is needed given recent surges in youth e-cigarette use in many countries and the constantly evolving nature of vaping products and the promotional strategies used by the industry to increase their appeal.

METHODS

A cross-sectional online survey was administered to around 1000 15-30 year olds in each of four countries: Australia, China, India, and the United Kingdom (total n = 4007). The survey assessed demographic characteristics, e-cigarette and tobacco use, exposure to e-cigarette advertising, and number of friends and family members who vape. Those who had never used e-cigarettes (n = 1589) were assessed for susceptibility (curiosity about e-cigarettes, intentions to use in the next 12 months, and likely use if offered by a friend). Mixed effects logistic regression analysis was used to identify factors associated with susceptibility to e-cigarette use.

RESULTS

Susceptibility to e-cigarette use was apparent among 54% of respondents from Australia, 61% from India, 62% from the UK, and 82% from China. Factors positively associated with susceptibility were tobacco use, exposure to advertising, higher income, and having friends and family members who vape. Factors negatively associated with susceptibility were perceptions of harmfulness and education.

CONCLUSION

The results indicate the need across a diverse range of countries for interventions designed to address substantial proportions of young people who are likely to be susceptible to e-cigarette use.

How Does Online e-cigarette Advertisement Promote Youth's e-cigarettes Use? The Mediating Roles of Social Norm and Risk Perceptions

The adoption of the internet, social media, and e-cigarettes are on the rise among U.S. youth. Uses of social media and online platforms increase the probability for youth to encounter e-cigarette advertisements. Departing from this line of reasoning, we examine the underlying mechanisms of how online e-cigarettes exposure promotes youth's e-cigarette use. Drawing on insights from the social construction of risk model, this study looks at how perceived social norms and risk perception mediate the link between online e-cigarette advertisement exposure and e-cigarette use. Youth aged 12-17 from the Public Assessment of Tobacco and Health (PATH) Study Waves 2-4 (2014-2018) were included (N = 6,067). Controlling for demographic and other known risk factors for e-cigarette use, respondents who had been exposed to online e-cigarette ads at Wave 2 perceived higher levels of positive social norms of e-cigarette use at Wave 3 (β = 0.13, p < .001) which was associated with lower e-cigarette risk perception at Wave 3 (β = -0.22, p < .001). Lower e-cigarette risk perception at Wave 3 resulted in a higher likelihood of e-cigarette use at Wave 4 (AOR = 0.51, p < .001). Online e-cigarettes ads exposure at Wave 2 predicted e-cigarette use at Wave 4 (AOR = 1.87, p < .001). The results indicate that norm perception associated with online e-cigarettes ads may twist youth's e-cigarette risk perception that is associated with subsequent usage. Interventions to curb youth's e-cigarette use can target social norms of e-cigarette use and restrict e-cigarette advertisement exposure to youth.

Relationship Between Chronic Lung Disease Diagnosis and Susceptibility to E-Cigarette Use in Adults

BACKGROUND

Electronic cigarettes (e-cigarettes) are known to cause adverse pulmonary effects, yet paradoxically, the prevalence of e-cigarette use has increased among individuals with chronic lung disease. We assessed the relationship between chronic lung disease and the susceptibility to e-cigarette use in adults and determined if specific behavioral, social, and environmental factors influence this relationship.

METHODS

We enrolled adults age ≥ 18 y in Alabama with chronic lung disease from university medical clinics (n = 140) and individuals without chronic lung disease (n = 123, reference group) from January 2020-March 2021. A cross-sectional design was used where we administered questionnaires to collect sociodemographic information and assessed susceptibility to e-cigarette use, exposure to social and environmental factors (ie, advertisements, warning labels, special prices, others' e-cigarette vapors, use of an e-cigarette by others in the home, and visiting a web site or online discussion), and behavioral factors (ie, alcohol and cannabis use). Moderation analyses were conducted to determine if any of these factors would modify the association between chronic lung disease and susceptibility to e-cigarette use.

RESULTS

Susceptibility to e-cigarette use was higher among adults without chronic lung disease than among those with chronic lung disease. Noticing e-cigarette warning labels and visiting a web site or online discussion about e-cigarettes were significantly associated with an increased likelihood of susceptibility to using e-cigarettes in both groups. Exposure to e-cigarette vapor from close contacts, special pricing, living with someone who uses e-cigarettes, and cannabis use were significantly associated with an increased likelihood of susceptibility to e-cigarette use in individuals without chronic lung disease. However, our analyses did not indicate a statistically significant interaction between chronic lung disease and any social, environmental, or behavioral factors on susceptibility to e-cigarette use.

CONCLUSIONS

Individuals without chronic lung disease were more susceptible to e-cigarette use than those with chronic lung disease. Although the prevalence of some behavioral and environmental factors differed among individuals with and without chronic lung disease, these factors did not moderate the association between chronic lung disease and susceptibility to e-cigarette use. Longitudinal investigations are warranted to better test the temporal relationships between chronic lung disease, substance use, social and environmental factors, and the susceptibility to e-cigarette use among individuals with chronic lung disease to identify prevention strategies for this population.

Assessing Adolescent Vaping Norms and Perceptions in a Statewide Multi-Community Project

Background: Adolescent e-cigarette use has increased dramatically in recent years and is quickly becoming a serious public health issue. While studies have identified the influence of social norms on the use of traditional cigarettes, few have examined these factors in the context of e-cigarettes and other vaping devices. Objective: The goal of this study was to examine social norms predictors of past 30-day e-cigarette use among high school students in 10 communities located in Minnesota. Results: In our sample (N = 3,285), students who believe most students in their school vape daily are more likely to have vaped in the past 30 days than those who believe most students vape weekly or less frequently. Further, students were likely to have used e-cigarettes in the past 30 days if they perceived that most students approved of vaping (i.e., they disagreed with the statement that, "vaping is not a good thing for anyone their age to do"). Findings from this study highlight social norms related to perceptions that increase the likelihood of past 30-day e-cigarette use. Conclusions: Results from this study lend themselves to norms-based prevention science strategies that are critical to reducing e-cigarette use among high school students.

Predictors of e-cigarette initiation and use among middle school youth in a low-income predominantly Hispanic community

Introduction

E-cigarette use among middle and high school youth increased from 2. 5 million in 2014 to 9.2 million in 2019, becoming the most common tobacco product used among youth. Hispanic youth, the largest ethnic minority in the United States, have higher rates of tobacco use, including e-cigarettes, than non-Hispanics. Identifying factors that put youth at risk for future e-cigarette use is vital to focusing prevention efforts. Informed by social cognitive theory, this study identifies predictors of e-cigarette uptake among e-cigarette naïve youth in a predominantly low-income Hispanic community.

Methods

1,249 students (6-8th grades) from two middle schools in El Paso, Texas consented to participate in this longitudinal survey during the 2016-2017 school year. The study sample for analysis was restricted to e-cigarette naïve students (n = 862). Outcome measures were e-cigarette initiation and current use at follow-up. Logistic regression models tested six hypotheses about predictors of e-cigarette initiation and current use: (1) intention, (2) outcome expectations, (3) knowledge, (4) friendship network exposure, (5) normative beliefs, and (6) social acceptability.

Results

Among e-cigarette naïve students at baseline, 8% (n = 71) reported initiation at follow-up; of these, 3% (n = 23) reported current use. Significant predictors of initiation were intention (AOR = 2.46; 95% CI 1.69-3.59; p < 0.001), outcome expectations (AOR = 1.73; 95% CI 1.14-2.61; p = 0.009), friendship network exposure (AOR = 1.53; 95% CI 1.11-2.11; p =0.01), normative beliefs (AOR = 2.12; 95% CI 1.47-3.08; p < 0.001), and social acceptability (AOR = 1.91; 95% CI 1.28-2.85; p = 0.002). Significant predictors of current use were intention (AOR = 1.98; 95% CI 1.07-3.69; p = 0.03) and friendship network exposure (AOR = 1.69; 95% CI 1.06-2.70; p = 0.03).

Conclusions

With the increasing popularity of e-cigarettes, age appropriate and culturally sensitive prevention strategies tailored at altering these predictive factors are essential in preventing future e-cigarette use.

The personality and cognitive traits associated with adolescents' sensitivity to social norms

Little is known about the personality and cognitive traits that shape adolescents' sensitivity to social norms. Further, few studies have harnessed novel empirical tools to elicit sensitivity to social norms among adolescent populations. This paper examines the association between sensitivity to norms and various personality and cognitive traits using an incentivised rule-following task grounded in Game Theory. Cross-sectional data were obtained from 1274 adolescents. Self-administered questionnaires were used to measure personality traits as well as other psychosocial characteristics. Incentivised rule-following experiments gauged sensitivity to social norms. A series of multilevel mixed effects ordered logistic regression models were employed to assess the association between sensitivity to norms and the personality and cognitive traits. The results highlighted statistically significant univariate associations between the personality and cognitive traits and sensitivity to norms. However, in the multivariate adjusted model, the only factor associated with sensitivity to norms was gender. The gender-stratified analyses revealed differences in the personality and cognitive traits associated with sensitivity to norms across genders. For males need to belong was significantly negatively associated with sensitivity to norms in the multivariate model. By comparison, emotional stability was negatively associated with sensitivity to norms for females. This study reinforced the findings from an earlier study and suggested female adolescents had higher levels of sensitivity to norms. The results indicated no consistent pattern between sensitivity to norms and the personality and cognitive traits. Our findings provide a basis for further empirical research on a relatively nascent construct, and bring a fresh perspective to the question of norm-following preferences among this age group.

Social connections influencing e-cigarette use and intentions in Australia: a survey

Social factors play a role in e-cigarette uptake, but Australian evidence is limited. This study evaluated associations between social factors and e-cigarette intention and use.

Australian participants surveyed between March 2019 and July 2019 using a cross-sectional survey design, measuring e-cigarette intentions and use, and factors including smoking status and social acceptability.

Of 243 respondents, 185 were included in the final analysis, measuring e-cigarette intention and use, and factors including smoking status and social acceptability. Of 185 participants, daily, occasional, and ex-smokers (123 participants) were more likely to have used e-cigarettes (OR = 9.33; 95% CI 4.63-18.80) or intend to use e-cigarettes (OR = 4.86; 95% CI 2.32-10.21), relative to nonsmokers (62 participants). Participants reporting acceptability among people they study or work with (70 participants) were more likely to have used e-cigarettes relative to the reference group (OR = 16.76; 95% CI 3.70-75.83; p = 0.001) and were more likely report intending to use e-cigarettes relative to the reference group (OR = 3.40; 95%CI 1.58-7.30; p = 0.002).

With caveats related to the survey participant composition, the results suggest that places of work or study may be an appropriate place to consider interventions aimed at reducing e-cigarette uptake among nonsmokers.

Adolescents’ Perceptions of Substance Use Harms are Contingent on Mode of Administration and Type of Substance

Early vaping research often did not differentiate between substances vaped. The present study investigates risk perceptions for vaped nicotine and vaped cannabis. A school-based census of 9th and 11th graders yielded 431 responses to the California Healthy Kids Survey. Differences in harm perceptions were evaluated using multilevel mixed-effects models. Students were more likely to report nicotine vaping as great-moderate risk in comparison to cannabis vaping. Additionally, vaped cannabis was viewed as riskier than traditional administration. These results indicate that differences in harm perceptions may need to be addressed when targeting specific classes of substance use in investigations and interventions.

Factors Associated with E-Cigarette Escalation among High School Students: A Review of the Literature

BACKGROUND

E-cigarette use has been identified as a behaviour of concern among adolescents, and ever and daily use among this population has increased recently. The purpose of this review was to summarize the relevant studies investigating the frequency and intensity of e-cigarette use in adolescents and the factors associated with these patterns of use.

METHODS

A scoping search of two databases was conducted to identify longitudinal studies examining escalating e-cigarette use among adolescents. Escalating e-cigarette use could refer to an increasing frequency or intensity of use over time. Articles were screened for relevance. Studies that met inclusion criteria were included for synthesis.

RESULTS

Five articles were included for synthesis. All five articles were longitudinal studies taking place in the United States between 2013 and 2017. Age, gender, cost of e-cigarettes, use of cigarettes, polysubstance use, and e-liquid nicotine concentration were associated with escalation of e-cigarette use.

CONCLUSIONS

A paucity of information exists regarding the escalation of e-cigarette use among adolescents. Given the changing popularity of devices, additional updated evidence is needed to understand the factors associated with the escalation of e-cigarette use among adolescents, which can be used to inform local and national programs and policies.

Use patterns of cigarettes and alternative tobacco products and socioeconomic correlates in Hong Kong secondary school students

Smoking is a major cause of health inequities. However, sociodemographic differences in adolescent tobacco use are unclear. In a territory-wide school-based anonymous survey in 2018/19, we investigated tobacco use and sociodemographic correlates in 33,991 students (mean age 14.8 ± 1.9 years) in Hong Kong. Tobacco use prevalence and current-ever use ratios by sociodemographic factors were calculated. Generalised linear mixed models were used in association analyses. Current use was highest for cigarettes (3.2%), closely followed by alternative tobacco products (3.0%). Current-ever use ratios were highest for heated tobacco products (HTPs, 0.60), followed by nicotine e-cigarettes (0.52), waterpipe (0.51), and cigarettes (0.35). Use prevalence and current-ever use ratios of all products showed curvilinear relations with perceived family affluence (P values < 0.01), being highest in the richest families. Tobacco use was also associated with more senior grades, the lowest parental education, and boys, but current-ever use ratios of HTPs and waterpipe were higher in girls (P values < 0.05). The results suggested that adolescent ever users of nicotine-containing alternative tobacco products were more likely to keep using them than cigarettes, and the richest adolescents were at the highest risks of tobacco use. Diverse tobacco control measures are needed to improve health equity, especially on alternative tobacco products.

Social media and E-cigarette use among US youth: Longitudinal evidence on the role of online advertisement exposure and risk perception

OBJECTIVES

Previous studies revealed a link between social media use and e-cigarette use among U.S. youth, but less is known about the mechanisms through which they interconnect. This study examined how social media and e-cigarette use are connected through online advertisement exposure and risk perception of e-cigarettes among U.S. youth.

METHODS

Youth aged 12-17 from the Public Assessment of Tobacco and Health (PATH) Study Waves 2-4 (2014-2018) were included (N = 6,208). This study integrated the incidental exposure framework and the risk perception framework to guide study conceptualization and variable selection. Generalized structural equation modeling was performed to investigate the sequential mediation relationship between social media and e-cigarette use through online e-cigarette advertisement exposure and risk perception of e-cigarette use.

RESULTS

Youth respondents with more social media use were more likely to be exposed to e-cigarette advertisement at Wave 2 (OR = 1.13, p < 0.001), which led to lower e-cigarette risk perception at Wave 3 (β = -0.07, p < 0.001). Higher e-cigarette risk perception at Wave 3 resulted in lower likelihood of e-cigarette use at Wave 4 (OR = 0.57, p < 0.001). High social media use at Wave 2 was directly associated with high likelihood of e-cigarette use at Wave 4 (OR = 1.11, p < 0.001).

CONCLUSIONS

The results indicate that social media use is associated with increased e-cigarette use through online e-cigarette advertisement exposure and subsequently decreased e-cigarette risk perception among U.S. youth. Our findings underscore the importance of regulating online e-cigarette advertisement, with the emphasis of avoiding information that could twist youth's risk perception of e-cigarettes, which may in turn curtail youth e-cigarette use.

Vaping identity in adolescent e-cigarette users: A comparison of norms, attitudes, and behaviors

INTRODUCTION

Using the tenets underlying social identity theory and the theory of planned behavior, the current study compared the perceptions, attitudes, and behaviors of e-cigarette users that reported vaping as self-defining ("vapers") compared to users that denied vaping was central to their identity ("non-vapers").

METHOD

Secondary analyses of data from the 2017-2018 California Student Tobacco Survey were utilized. A weighted, multivariable regression model (N = 82,217) compared the demographic characteristics, beliefs, and behaviors of vapers and non-vapers. A path analytic model examined whether norms and attitudes mediated the relationship between vaper identity and use behavior.

RESULTS

Self-identified sexual and/or gender minority youth were more likely to identify as vapers compared to heterosexual and cisgender respondents. Youth that identified as vapers viewed e-cigarette use as more normative, held more favorable attitudes (i.e., lower harm beliefs), used e-cigarettes more frequently and in greater quantities, were more likely to use fruit and mint flavored e-cigarettes, and were more likely to acquire e-cigarettes from commercial sellers (i.e., vape/tobacco shops; all p < 0.05). Additionally, descriptive norms and attitudes mediated the relationship between vaper identity and use frequency/quantity.

CONCLUSIONS

Differences in e-cigarette beliefs and behaviors were found for youth e-cigarette users that perceived vaping as self-defining versus those that did not view vaping as part of their self-concept. Future studies are needed to examine causal directionality between identity, norms, attitudes, and behavior. Tobacco control efforts might use these findings to further denormalize vaping using evidence-based media campaigns and policy implementation.

Adolescent Susceptibility to E-Cigarettes: An Update From the 2018 National Youth Tobacco Survey

PURPOSE

Examine correlates of e-cigarette susceptibility among adolescents.

DESIGN

Secondary data analyses using the 2018 National Youth Tobacco Survey, excluding participants under 12 and over 17.

SETTING

United States middle and high schools.

SUBJECTS

Never e-cigarette users (n = 12,439) ages 12-17.

MEASURES

Relationships between e-cigarette susceptibility and age, sex, race/ethnicity, ever tobacco use, perceived ease of purchasing tobacco products, perceived harm, relative addictiveness, household use of e-cigarettes/tobacco were examined.

ANALYSIS

Odds of susceptibility were modeled with weighted multivariable logistic regressions.

RESULTS

Thirty-five percent (unweighted n = 4,436) of adolescents were susceptible to e-cigarettes. Adolescents who were female (aOR = 1.2), Hispanic (aOR = 1.3), perceived e-cigarettes as anything less than "a lot of harm" (aOR = 2.2-4.9) and "easy" to purchase (aOR = 1.4), had ever used combustible tobacco (aOR = 2.9), or reported household use of e-cigarettes (aOR = 1.5) were susceptible. Non-Hispanic black respondents (vs. non-Hispanic white; aOR = 0.72) had significantly lower odds of susceptibility to e-cigarettes.

CONCLUSION

In the 2018 NYTS adolescent sample, perceptions of harm and ease of tobacco product purchase appear to be significantly related to higher odds of e-cigarette susceptibility, in addition to other demographic factors. Longitudinal data, particularly cohort data following adolescents from susceptible to actual or no use, are needed to assess predictors of e-cigarette use initiation.

E-cigarette use susceptibility among youth in Mexico: The roles of remote acculturation, parenting behaviors, and internet use frequency

INTRODUCTION

Adolescent electronic cigarette (e-cigarette) use is increasing worldwide, raising concerns about its impact on youth development. Remote acculturation may influence the e-cigarette use cognitions of youth in Mexico by influencing their media use, thereby contributing to their e-cigarette use susceptibility. This study examined whether remote acculturation was associated with youth internet use frequency, and whether youth internet use frequency, in turn, was associated with youth e-cigarette use susceptibility. Because parenting behaviors can relate with lower tobacco and media use (e.g., internet use), this study also examined the associations of parental media restrictions and mother's parenting practices with youth internet use frequency and e-cigarette use susceptibility.

METHODS

Data came from a school-based survey with middle school students in Mexico who had never tried e-cigarettes (N = 6004; 52.6% female; Mage = 13.07 years). Students completed measures of remote acculturation, parental media restrictions, mother's parenting practices, internet use, and e-cigarette use susceptibility.

RESULTS

Structural equation analyses suggest that U.S. American cultural orientation may increase youth e-cigarette use risk by way of higher youth internet use. Mexican cultural orientation and parental media restrictions may reduce youth e-cigarette use risk by way of lower youth internet use.

CONCLUSIONS

Preventive interventions to reduce Mexican youths' intention to try e-cigarettes could benefit from efforts to reduce youth internet use and from media literacy interventions that inform parents and youth about the influence of internet use on youth e-cigarette use.

Factors associated with smoking susceptibility among high school students in western Spain

The Expanded Susceptibility to Smoking Index (ESSI) is based on the combination of susceptibility to smoking and curiosity about smoking. The ESSI can identify young people who are at risk of starting to smoke cigarettes and related products. The objective of this study was to analyse the ESSI results and to examine factors associated with ESSI scores in students between 12 and 16 years of age. Sociodemographic, social/environmental and personal variables were analysed, and the ESSI value was determined for non-smoking students recruited from three schools in western Spain. Regression models were used to examine the factors associated with smoking for the entire sample and the factors associated with ESSI scores in the non-smoking population. Of the 377 participants who were analysed, 20.4% were smokers. Among the non-smokers, 53.5% and 55.3% presented medium-high ESSI scores for cigarettes and e-cigarettes, respectively, and 39.8% presented medium-high ESSI scores for hookah use. A higher ESSI score was associated with greater exposure to people smoking in the home, having more friends who smoke, alcohol consumption, and a higher impulsivity scale score. These findings reinforce the importance of reducing peer pressure and suggest the important role of resolve under conditions of positive affect on reducing impulsivity. Approaches based on self-efficacy could be addressed in preventive programmes developed in educational settings.

Electronic Vaping Product Use among Young Adults Who Receive Care at a Major Medical Institution

Background: National estimates of electronic vaping product (EVP) use exist, but little is known about young adult EVP users who interact with the healthcare setting. Methods: Cross-sectional survey of 18-25 year olds receiving care in our ambulatory medical practice. Population differences were evaluated with the chi square test reporting unadjusted odds ratios (ORs). Results: Response rate was 16.6% (n = 1,017/6,119). The prevalence of ever EVP use was 46.0% of whom 13.9% used every day. Each additional day of alcohol use (past 30 days) was associated with increased odds of being an EVP user (OR = 1.06, 95% CI 1.02-1.09), and cannabis use (past 30 days) was associated with a higher odds of being an EVP user compared to non-cannabis users (OR = 40.0, 95% CI 17.4 - 111.8). Observing a biological parent (OR = 2.89, 95% CI 1.98-4.24), step parent (OR = 2.03, 95% CI 1.02-4.19) and full sibling (OR = 2.31, 95% CI 1.78-3.00) using inhaled substances (past 30 days) was associated with increased odds of being an ever EVP user. Ever EVP users had lower odds than never users to report that EVPs with nicotine are "a little" or "a lot" more harmful than smoking "regular" tobacco cigarettes (OR = 0.53, 95% CI 0.37 - 0.76). Conclusion: Our survey is limited by a low response rate but confirms observed associations between EVP use and substance use and social influences. Our data also suggest that professionals should regularly screen for EVP use among young people, especially those with exposure to family members who used inhaled substances.

Changes in Recall to E-Cigarette Advertisement Exposure among Florida Youth, 2016-2019

The Centers for Disease Control and Prevention reported increases in exposure to e-cigarette ads among US middle and high school students from 2014-2016. This study examines changes in exposure to e-cigarette ads by source among youth in Florida. Methods: We analyzed Florida Youth Tobacco Survey (FYTS) data from 2016-2019 (n = 149,407). We calculated the weighted prevalence of exposure to ads by source (on radio, TV, internet, billboards/outdoor signs, or magazines/newspapers) across years and tested differences in prevalence from 2016-2019. We used logistic regression to examine the changes from 2016-2019 and further conducted multivariable logistic regression to examine the likelihood of past-30-day e-cigarette ad recall as a function of sociodemographics, tobacco use among family members, and current use of tobacco products. Results: Exposure to any type of e-cigarette ads decreased significantly from 2016 (weighted, 55.4%, 95% CI = 54.7, 56.1) to 2018 (47.3%, 95% CI = 46.6, 48.1), but rebounded in 2019 (57.0%, 95% CI = 55.7, 58.4). In multivariable logistic models, the following correlates were consistently associated with higher past-30-day exposure to any source of e-cigarette ads: survey year of 2019 (vs. 2016), being a high school (vs. middle school) student, female (vs. male), current use of e-cigarettes, current other tobacco use, and having a family member who uses tobacco. Conclusion: These findings suggest the need for continued surveillance of e-cigarette marketing practices and policies to prevent youth exposure to e-cigarette ads.

It's Not All Smoke and Mirrors: The Role of Social Norms, Alcohol Use, and Pandemic Partying in e-Cigarette Use During COVID-19

E-cigarette use among college students is increasing. In the era of COVID-19, such usage is especially dangerous given that the virus can be deadly for those with impaired respiratory systems. A small but growing body of research suggests that social norms may predict e-cigarette use. However, one's perception of e-cigarette use behaviors (descriptive norms) and approval by peers (injunctive norms) have yet to be studied in college students. The overarching purpose of this study is to determine whether descriptive and injunctive norms for e-cigarette use contribute unique variance to past 30-day e-cigarette use. Methods: Using a sample of 191 students (138 women) surveyed from introductory-level courses at a university in the northeastern United States, we explored the relationships between student demographic characteristics, alcohol use, binge drinking, COVID-19 non-compliant party attendance on and off campus, and social norms with past 30-day e-cigarette use using sequential regression. Two models were utilized to determine if descriptive and injunctive e-cigarette use norms predicted e-cigarette use after controlling for demographic characteristics in the social norms model, and above and beyond demographics and COVID-19 noncompliant party attendance, alcohol use, and binge drinking in the party behaviors model. Results: The results demonstrated that descriptive and injunctive norms for e-cigarette use significantly predicted e-cigarette use in both models, controlling for all covariates. Conclusions/Importance: Findings highlight the importance of social norms in predicting e-cigarette use during the COVID-19 pandemic, identifying areas for prevention and intervention for public health officials and higher education administrators.

Youth vaping and smoking and parental vaping: a panel survey

BACKGROUND

Concerns remain about potential negative impacts of e-cigarettes including possibilities that: youth e-cigarette use (vaping) increases risk of youth smoking; and vaping by parents may have impacts on their children's vaping and smoking behaviour.

METHODS

With panel data from 3291 youth aged 10-15 years from the 7th wave of the UK Understanding Society Survey (2015-2017), we estimated effects of youth vaping on youth smoking (ever, current and past year initiation), and of parental vaping on youth smoking and vaping, and examined whether the latter differed by parental smoking status. Propensity weighting was used to adjust for measured confounders and estimate average effects of vaping for all youth, and among youth who vaped. E-values were calculated to assess the strength of unmeasured confounding influences needed to negate our estimates.

RESULTS

Associations between youth vaping and youth smoking were attenuated considerably by adjustment for measured confounders. Estimated average effects of youth vaping on youth smoking were stronger for all youth (e.g. OR for smoking initiation: 32.5; 95% CI: 9.8-107.1) than among youth who vaped (OR: 4.4; 0.6-30.9). Relatively strong unmeasured confounding would be needed to explain these effects. Associations between parental vaping and youth vaping were explained by measured confounders. Estimates indicated effects of parental vaping on youth smoking, especially for youth with ex-smoking parents (e.g. OR for smoking initiation: 11.3; 2.7-46.4) rather than youth with currently smoking parents (OR: 1.0; 0.2-6.4), but these could be explained by relatively weak unmeasured confounding.

CONCLUSIONS

While measured confounding accounted for much of the associations between youth vaping and youth smoking, indicating support for underlying propensities, our estimates suggested residual effects that could only be explained away by considerable unmeasured confounding or by smoking leading to vaping. Estimated effects of youth vaping on youth smoking were stronger among the general youth population than among the small group of youth who actually vaped. Associations of parental vaping with youth smoking and vaping were either explained by measured confounding or could be relatively easily explained by unmeasured confounding.

Social norms for e-cigarettes and smoking: associations with initiation of e-cigarette use, intentions to quit smoking and quit attempts: findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

Social norms have received little attention in relation to electronic cigarettes (EC). The current study examine social norms for EC use and smoking tobacco, and their associations with (i) initiation of EC use, (ii) intention to quit smoking and (iii) attempts to quit smoking.

METHODS

Cross-sectional and longitudinal data analysis from Waves 1 and 2 of the ITC 6 European Country Survey and corresponding waves from England (the ITC Four Country Smoking and Vaping Survey). Current smokers at baseline, who heard of ECs and provided data at both waves were included (n = 3702). Complex samples logistic regression examined associations between the outcomes and descriptive (seeing EC use in public, close friends using ECs/smoking) and injunctive (public approves of ECs/smoking) norms, adjusting for country, demographics, EC use and heaviness of smoking.

RESULTS

In longitudinal analyses, seeing EC use in public at least some days was the only social norm that predicted initiation of EC use between waves (OR = 1.66, 95%CI = 1.08-2.56). In the cross-sectional analysis, having an intention to quit was associated with seeing EC use in public (OR = 1.37, 95%CI = 1.04-1.81) and reporting fewer than three close friends smoke (OR = 0.59, 95%CI = 0.44-0.80). There was no association between any social norm and making a quit attempt between waves.

CONCLUSIONS

Initiation of EC use is predicted by seeing EC use in public, which was also associated with greater intention to quit smoking. Friends' smoking was associated with lower intention to quit. These findings may allay concerns that increased visibility of ECs is renormalizing smoking amongst current smokers.

Adult Smokers' Awareness and Interest in Trying Heated Tobacco Products: Perspectives from Mexico, where HTPs and E-Cigarettes Are Banned

BACKGROUND

We evaluated smokers' perceptions of heated tobacco products (HTPs) in Mexico, where industry publically lobbied to introduce HTPs into this country that banned both HTPs and e-cigarettes.

METHODS

Online surveys (November 2018 to July 2019) were analyzed from adults who only smoked cigarettes (n = 2091) or who smoked and used e-cigarettes ("dual users"n = 1128). Logistic models regressed HTP awareness, interest to trying HTPs, and having seen HTPs for sale (only among aware participants) on sociodemographics and tobacco-related variables.

RESULTS

Of the 17.1% who were aware of HTPs, 52.7% reported having seen HTPs for sale. Of all respondents, 75% were somewhat or very interested in trying HTPs. Compared to their counterparts, more frequent smokers, dual users, those exposed to online e-cigarette ads, and those with friends who used e-cigarettes were both more aware of and interested in trying HTPs. Greater awareness was also associated with higher education, recent attempts to quit, receipt of email e-cigarette ads, and smoking among friends and family. Seeing HTPs for sale was higher for those who recently attempted to quit, were exposed to e-cigarette ads online or by email, or had friends who used e-cigarettes.

CONCLUSION

Interest in HTPs is high among smokers in Mexico, which already has a large black market for illegal e-cigarettes. HTPs use should be monitored in this context, especially given the public health impacts of HTPs are unclear.

Social norms towards smoking and vaping and associations with product use among youth in England, Canada, and the US

BACKGROUND

This study assesses differences in social norms towards smoking and vaping among youth across countries (England, Canada, US) and smoking and vaping status.

METHODS

Data are from the 2017 ITC Youth Tobacco and Vaping Survey, among youth age 16-19 in England (N = 3444), Canada (N = 3327), and US (N = 3509). Prevalence of friend smoking, friend vaping, peer approval of smoking, and peer approval of vaping were estimated. Adjusted logistic regression models were estimated for each norm to assess associations with country, smoking status, and vaping status, adjusting for sociodemographics, alcohol use, and marijuana use.

RESULTS

47% and 52% reported friend smoking and vaping respectively. Perceived peer approval of vaping (44%) was almost double that of smoking (23%). Compared with England, fewer Canadian and US youth reported friend smoking (Canada: AOR = 0.71 [95% CI = 0.62-0.82]; US: AOR = 0.54 [0.47-0.62]) and peer approval of smoking (Canada: AOR = 0.74 [0.63-0.87]; US: AOR = 0.78 [0.67-0.91]), yet more reported peer approval of vaping (Canada: AOR = 1.23 [1.08-1.41]; US: AOR = 1.30 [1.14-1.48]). More Canadian than English youth reported friend vaping (AOR = 1.17 [1.02-1.36]). Friend smoking, peer approval of smoking, and friend vaping were more common among smokers and vapers (all p < .02). Peer approval of vaping was more common among vapers but less common among smokers (all p < .044).

CONCLUSIONS

Youth had more positive vaping than smoking norms. English youth reported the most pro-smoking but least pro-vaping norms in adjusted models; this was unexpected given country differences in regulatory environments. Norms towards both products were associated with use, with some evidence of cross-product associations between norms and behaviours.

Perceptions and use of e-cigarettes among young adults in Hong Kong

Background

Little is known about the risk and addiction perceptions of e-cigarettes among Asian populations. We examined e-cigarette perceptions among young adults in Hong Kong and the association between the perceptions and e-cigarette use patterns.

Methods

An online survey was administered to a convenience sample of Hong Kong residents aged 18–35 (N = 1186). Measures of e-cigarette perceptions included perceived harm and addictiveness of e-cigarettes, perceived harm of secondhand e-cigarette aerosol, and perceived popularity of e-cigarette use among peers. Separate multinomial logistic regression models were conducted to examine the associations between the four perceptions and former and current use of e-cigarettes relative to never use, controlling for demographics and current cigarette smoking status. Interactions of e-cigarette perceptions and current cigarette smoking were assessed in all models. Among current e-cigarette users, bivariate exact logistic regression models were used to examine the relationships between each of the perceptions and frequent e-cigarette use (≥3 days in past 30-day vs. 1–2 days). Among participants who had never used e-cigarettes, separate multivariable logistic regression models were conducted to examine the associations between e-cigarette perceptions and susceptibility to e-cigarette use.

Results

Overall, 97.2% of participants were aware of e-cigarettes, and 16.1% had tried e-cigarettes (11.3% former users; 4.8% current users). Young adults perceived e-cigarettes (and aerosol) as less harmful, less addictive, and less popular than cigarettes. Current cigarette smokers reported significantly lower perceived harmfulness and addictiveness of e-cigarettes, lower perceived harmfulness of e-cigarette aerosol, and higher perceived popularity than nonsmokers. The lower degree of harm and addiction perceptions, and higher levels of popularity perceptions were associated with greater odds of e-cigarette use, and these relationships were generally stronger among nonsmokers compared to current cigarette smokers. E-cigarette perceptions were not associated with frequent e-cigarette use. Perceiving e-cigarettes (and aerosol) as less harmful and less addictive were associated with greater susceptibility to e-cigarette use. Compared to nonsmokers, current smokers were more likely to report e-cigarette use and susceptibility.

Conclusions

Continued monitoring of e-cigarette use and perceptions is needed. Educational programs should emphasize the potential harmful and addictive properties of e-cigarettes and the risks of secondhand exposure to e-cigarette aerosol.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7464-z) contains supplementary material, which is available to authorized users.