Looks like smoking, is it smoking?: children's perceptions of cigarette-like nicotine delivery systems, smoking and cessation

Family Socioeconomic Position and Lung Cancer Risk: A Meta-Analysis and a Mendelian Randomization Study

Background

Family socioeconomic position (SEP) in childhood is an important factor to predict some chronic diseases. However, the association between family SEP in childhood and the risk of lung cancer is not clear.

Methods

A systematic search was performed to explore their relationship. We selected education level, socioeconomic positions of parents and childhood housing conditions to represent an individual family SEP. Hazard ratios (HRs) of lung cancer specific-mortality were synthesized using a random effects model. Two-sample Mendelian randomization (MR) was carried out with summary data from published genome-wide association studies of SEP to assess the possible causal relationship of SEP and risk of lung cancer.

Results

Through meta-analysis of 13 studies, we observed that to compared with the better SEP, the poorer SEP in the childhood was associated with the increased lung cancer risk in the adulthood (HR: 1.25, 95% CI: 1.10 to 1.43). In addition, the dose-response analysis revealed a positive correlation between the poorer SEP and increased lung cancer risk. Same conclusion was reached in MR [(education level) OR 0.50, 95% CI: 0.39 to 0.63; P < 0.001].

Conclusion

This study indicates that poor family socioeconomic position in childhood is causally correlated with lung cancer risk in adulthood.

Systematic Review Registration

identifier: 159082.

The emerging norms of e-cigarette use among adolescents: A meta-ethnography of qualitative evidence

While qualitative research has indicated that adolescents' motivation for e-cigarette use is different than adults', this body of literature has not yet been brought together and synthesised. We reviewed qualitative evidence on perceptions and uses of e-cigarettes in order to explore the emerging norms of vaping among adolescents. We searched five databases for qualitative research in October 2019 with no restrictions on date of publication or data collection. We identified fifteen papers from thirteen studies. Using a meta-ethnographic approach, we identified a spectrum of descriptive and injunctive norms of vaping across the themes of addiction; perceptions of comparative harm; parental perceptions and peer perceptions. We found addiction and perceptions of comparative harm to reflect descriptive norms, while we found clearer evidence explaining the use and non-use of e-cigarettes through parental and peer approval of vaping. However, these norms were fluid, diverse and sometimes contradictory. This review provides a resource for researchers, policymakers and practitioners to better understand the ways that emerging norms could be influenced through policy and practice.

Responsibility, normalisation and negotiations of harm: E-cigarette users' opinions and experiences of vaping around children

BACKGROUND

Concern about youth uptake of vaping is widespread. Regulation and education campaigns aim to protect children from initiating use, yet it is likely that children will be primarily influenced by the behaviour of people in their immediate environment. This is the first known study exploring e-cigarette users' views and reported experiences of vaping around children.

METHODS

Following informed consent, semi-structured qualitative interviews were conducted with 40 adults who had attempted to give up smoking by vaping. Participants were recruited from England as part of a wider study into e-cigarette use trajectories and smoking relapse (ECtra study). Data were extracted from 28 interviews where participants had spontaneously discussed vaping around children. Extracted data were analysed thematically and situated in previous analysis of vaping identity which distinguished between recreational and medicinal vapers.

RESULTS

Vaping behaviour around children was in part a habituated replication of smoking norms but also guided by broad vaping identity; recreational users were more permissive and medicinal users more secretive. Vaping in the home appeared to be determined by caregivers' need to reconcile vaping behaviour so that it was congruent with parental identity as a responsible caregiver. Participant perspectives reflected existing moral discourses applied to e-cigarettes around the use of "harm reduction for smokers" and "potential for youth harm".

CONCLUSION

Vaping is likely to be role modelled within the community and home despite attempts by e-cigarette users to conceal the behaviour. The ambivalent contextualisation of e-cigarettes means that e-cigarette users may lack a clear narrative to draw on when discussing vaping with children. Public health guidance for vaping around children could be helpful, but to be most effective, should take into consideration users' vaping identity.

E-cigarettes: How can they help smokers quit without addicting a new generation?

The dramatic increase in youth use of electronic nicotine delivery systems (ENDS; e.g., e-cigarettes) in the United States has focused regulatory efforts to address this concern while still encouraging smokers to switch completely to lower risk products or quit all tobacco product use. Increases in the minimum age for purchase of all tobacco products and changes in enforcement policy for ENDS have been recently enacted in an effort to address the youth vaping epidemic. Since all ENDS marketed after February 15, 2007 will be required to meet the "appropriate for the protection of public health" standard for marketing authorization of new products, ENDS manufacturers will have to demonstrate, in part, that their products help lessen the adverse impact on youth use. Some, such as disallowing flavors other than tobacco or menthol or limiting nicotine delivery, may help reduce youth use but could also inhibit smokers from quitting smoking. Other approaches, including reducing the high-tech appearance and discreteness of ENDS, discontinuing use of coupons and two-for-one type price incentives for ENDS, limiting retail sales of these products to adult-only facilities, and incorporating technological innovations such as biometrics or geofencing into ENDS, may help manufacturers demonstrate that marketing of their products would help reduce youth use of ENDS and lessen the epidemic, while still assuring adult smokers have access to products that encourage discontinuing combusted product use.

Welsh Primary Schoolchildren's Perceptions of Electronic Cigarettes: A Mixed Methods Study

There are concerns that the growing popularity of e-cigarettes promotes experimentation among children. Given the influence of the early years on attitude and habit formation, better understanding of how younger children perceive vaping before experimentation begins is needed, to prevent uptake and inform tobacco control strategies. We explored Welsh primary schoolchildren’s (aged 7–11) awareness of e-cigarettes relative to tobacco smoking, their understanding of the perceived risks and benefits and their intentions and beliefs about vaping. Data was collected using a mix of methods in June and July 2017 from 8 purposively selected primary schools across Wales. Four hundred and ninety-five children (52% female) aged 7 years (n = 165), 9 years (n = 185) and 11 years (n = 145) completed a class-administered booklet encompassing a draw and write exercise and survey. Ninety-six children participated in 24 peer discussion groups comprised of 2 boys and 2 girls from each year group. Data were analysed independently and findings triangulated. Survey analyses used frequencies, descriptive statistics and chi-squared tests. Content analysis was undertaken on the draw and write data and peer discussion groups were analysed thematically. Study findings highlight that primary schoolchildren have general awareness of e-cigarettes. Vaping was perceived to be healthier than smoking and there was some recognition that e-cigarettes were used for smoking cessation. Understanding of any health harms was limited. Few children intended to smoke or vape in the future but almost half thought it was okay for grownups. Children’s perceptions were influenced by exposure through family and friends. Findings suggest a need for e-cigarette education in primary schools, to highlight the associated risks of e-cigarette experimentation including the potential for tobacco initiation.

Exposure to secondhand aerosol of electronic cigarettes in indoor settings in 12 European countries: data from the TackSHS survey

INTRODUCTION

Exposure to secondhand aerosol from e-cigarette (SHA) may pose harmful effects to bystanders. This study aims to investigate the prevalence, duration and determinants of SHA exposure in various indoor settings in 12 European countries.

METHODS

In 2017-2018, we conducted a cross-sectional study, the TackSHS survey, on a representative sample of the population aged ≥15 years in 12 European countries (Bulgaria, England, France, Germany, Greece, Ireland, Italy, Latvia, Poland, Portugal, Romania and Spain). We described the prevalence and duration of exposure to SHA in several indoor settings among 11 604 e-cigarette non-users. Individual-level and country-level characteristics associated with SHA exposure were also explored using multilevel logistic regression analyses.

RESULTS

Overall, 16.0% of e-cigarette non-users were exposed to SHA in any indoor setting at least weekly, ranging from 4.3% in Spain to 29.6% in England. The median duration of SHA exposure among those who were exposed was 43 min/day. 'Other indoor settings' (eg, bar and restaurant) was reported as the place where most of e-cigarette non-users were exposed (8.3%), followed by workplace/educational venues (6.4%), home (5.8%), public transportation (3.5%) and private transportation (2.7%). SHA exposure was more likely to occur in certain groups of non-users: men, younger age groups, those with higher level of education, e-cigarette past users, current smokers, those perceiving SHA harmless and living in countries with a higher e-cigarette use prevalence.

CONCLUSIONS

We found inequalities of SHA exposure across and within European countries. Governments should consider extending their tobacco smoke-free legislation to e-cigarettes to protect bystanders, particularly vulnerable populations such as young people.

TRIAL REGISTRATION NUMBER

NCT02928536.

Associations of Socioeconomic Status, Parental Smoking and Parental E-Cigarette Use with 10-11-Year-Old Children's Perceptions of Tobacco Cigarettes and E-Cigarettes: Cross Sectional Analysis of the CHETS Wales 3 Survey

BACKGROUND

This study examines primary schoolchildren's perceptions of e-cigarettes and tobacco cigarettes, and associations with parental smoking, vaping and socioeconomic status.

METHODS

Survey of 2218 10-11-year-old children in 73 schools in Wales.

RESULTS

Overall, 36% reported that a parent figure smoked compared to 21% for vaping, with parental smoking lower in affluent families (OR = 0.72; 95% CI = 0.68 to 0.76). Overall, 1% had tried a cigarette, while 5% had tried an e-cigarette. Most said they would not smoke or vape in 2 years' time; susceptibility to vaping (20%) was higher than smoking (12%). Exposure to and perceptions of tobacco cigarettes were more positive for children of smokers. Having a parent who vaped was associated with exposure to and positive perceptions of e-cigarettes, but not smoking. Most children perceived e-cigarettes as used by adults to stop smoking (64%). Susceptibility to smoking (OR = 0.57; 95% CI = 0.41 to 0.79) and vaping (OR = 0.78; 95% CI = 0.62 to 0.99) were lower among children who perceived e-cigarettes as cessation aids.

CONCLUSIONS

Parental smoking continues to be concentrated in poorer families. This study provides no evidence that parental vaping in the absence of smoking is associated with more positive perceptions of tobacco cigarettes. Communicating to children the role of e-cigarettes as cessation devices for smokers may help to limit their appeal to young people.

Perceptions and Reasons Regarding E-Cigarette Use among Users and Non-Users: A Narrative Literature Review

This paper aims to provide an in-depth understanding of the attractiveness of e-cigarettes for several different groups. For this purpose, perceptions of and reasons for e-cigarette use were systematically reviewed as reported by e-cigarette users, cigarette smokers, dual users, and non-users, among both adults and youth. MEDLINE^® and Scopus were used to search for relevant articles, and references of included studies were also investigated. Two reviewers screened all titles and abstracts independently, blinded to authors and journal titles (Cohen’s Kappa = 0.83), resulting in 72 eligible articles. Risk perceptions, perceived benefits, and reasons for e-cigarette use were categorized in themes and sub-themes. Risk perceptions included harmfulness in general, and specific health risks. Perceived benefits included improved taste and smell, and safety for bystanders. Reasons for use included (health) benefits, curiosity, smoking cessation, and friends using e-cigarettes. The findings highlight that there is a variety of perceptions and reasons mentioned by adult and youth e-cigarette users, cigarette smokers, dual users, and non-users. As such, this overview provides valuable information for scientists, public health professionals, behavior change experts, and regulators to improve future research, risk communication, and possibilities to effectively regulate e-cigarettes.

Government and public health responses to e-cigarettes in New Zealand: vapers' perspectives

BACKGROUND

The New Zealand (NZ) government is to lift the ban on the sale of nicotine for use in electronic cigarettes (e-cigarettes).

METHODS

Using a naturalistic approach, we sought to understand how the current law was experienced by e-cigarette users (vapers). Twenty-nine vapers were interviewed by telephone, between May and September 2016, using a semi-structured interview schedule. Open-ended questions covered: initiating vaping, the experience of stopping smoking, technical problems encountered, reasons for vaping, acceptability of vaping, addiction to vaping and advice given to smokers about vaping. The audio recordings were transcribed and then independently coded using a general inductive thematic analysis.

RESULTS

This paper presents the main theme which was that vapers employed a range of reactionary strategies to the ban on the sale of nicotine e-liquid in NZ. These included lobbying government, spreading the word, establishing vaper support groups, helping people stop smoking by switching to vaping and advocating for e-cigarettes to be incorporated into smoking cessation practice.

CONCLUSIONS

Vapers' experience and observations form a popular or lay epidemiology--one that identified that e-cigarettes were helping people stop smoking and could thus deliver public health benefits. Public health researchers and workers, and government fears about vaping, and proposals to strengthen restrictions contributed to the growth of the vaper community who reacted by forming self-help groups and providing alternative cessation support to smokers. For a significant switch from smoking to vaping to occur, the health sector needs to have a change of attitude towards vaping that is positive, and the public needs evidence-based information on vaping. A first step could be for the health sector to collaborate with the vaping community to reorient current tobacco control and cessation practice to encourage smokers to switch to less harmful smoke-free alternatives to smoking.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Teenage perceptions of electronic cigarettes in Scottish tobacco-education school interventions: co-production and innovative engagement through a pop-up radio project

AIMS

This article thematically analyses spontaneous responses of teenagers and explores their perceptions of electronic cigarettes (e-cigarettes) with a focus on smoking cessation from data collected for research exploring Scottish secondary school students' recall of key messages from tobacco-education interventions and any influence on perceptions and behaviours.

METHODS

E-cigarettes were not included in the research design as they did not feature in interventions. However, in discussions in all participating schools, e-cigarettes were raised by students unprompted by researchers. Seven of 19 publicly funded schools in the region opted to participate. Groups of 13- to 16-year-olds were purposely selected to include a range of aptitudes, non-smokers, smokers, males and females. A total of 182 pupils took part. Data were generated through three co-produced classroom radio tasks with pupils (radio quiz, sitcom, factual interviewing), delivered by a researcher and professional broadcast team. All pupils were briefly interviewed by a researcher. Activities were recorded and transcribed verbatim and the researcher discussed emerging findings with the broadcast team. Data were analysed using NVivo and transcripts making reference to e-cigarettes examined further using inductive thematic analysis.

RESULTS

Key themes of their impressions of e-cigarettes were easy availability and price; advertising; the products being safer or healthier, addiction and nicotine; acceptability and experiences of use; and variety of flavours.

CONCLUSIONS

This was a qualitative study in one region, and perception of e-cigarettes was not an a priori topic. However, it provides insights into youth perceptions of e-cigarettes. How they discerned e-cigarettes reflects their marketing environment. The relative harmlessness of nicotine, affordability of e-cigarettes, coolness of vaping, absence of second-hand harms and availability of innovative products are all key marketing features. Conflicting messages on safety, efficacy, potential 'gateway' to smoking and nicotine may be contributing to teenagers' confusion. The allure of 'youthful cool' to vaping offers no public health gain, so children should be protected from misleading promotion. Consistent tobacco-education initiatives need to account for this popular trend.

Opinions about electronic cigarette use in smoke-free areas among U.S. Adults, 2012

INTRODUCTION

In the United States, electronic cigarettes (e-cigarettes) are currently unregulated, extensively marketed, and experiencing a rapid increase in use. The purpose of this study was to examine the opinions of U.S. adults about e-cigarette use in smoke-free public areas.

METHODS

Data were obtained from the online HealthStyle survey administered to a probability sample of a nationally representative online panel. The study included 4,043U.S. adults, aged 18 years or older who responded to this question, "Do you think e-cigarette should be allowed to be used in public areas where tobacco smoking is prohibited?" Multinomial logistic regression analyses were used to examine opinions on e-cigarette use in smoke-free areas by sex, age, race/ethnicity, household income, education, census region, and cigarette smoking status and e-cigarette awareness and ever use.

RESULTS

Overall, about 40% of adults were uncertain whether e-cigarettes should be allowed in smoke-free areas, 37% opposed, while 23% favored their use in smoke-free public places. Multinomial logistic regression analyses showed that adults who were aware, ever used e-cigarettes, and current cigarette smokers were more likely to express an "in favor" opinion than adults who expressed an uncertain opinion (don't know).

CONCLUSION

Over 75% of U.S. adults reported uncertainty or disapproval of the use of e-cigarettes in smoke-free areas. Current cigarette smokers, adults aware or have ever used e-cigarettes were more supportive to exempting e-cigarettes from smoking restrictions. With impending regulation and the changing e-cigarette landscape, continued monitoring and research on public opinions about e-cigarette use in smoke-free places are needed.

E-cigarettes: online survey of UK smoking cessation practitioners

BACKGROUND

Use of e-cigarettes (inhalable vapour producing battery powered devices that aim to simulate tobacco cigarettes), is rising in a number of countries, but as yet none of these products are regulated as medicinal devices or available as smoking cessation treatments. Smokers seeking support from health professionals to stop smoking are interested in e-cigarettes and may be buying them to aid a quit attempt. Determining what smokers are asking, and what health professionals think about these products may have implications for smoking treatment services in a number of countries.

METHODS

Stop smoking service advisors, managers and commissioners in the United Kingdom were asked to take part in two surveys on e-cigarettes. Data was analysed from 587 practitioners who completed a survey in 2011 and 705 practitioners who completed a repeat survey in 2013. Responses to multiple choice questions and free text comments were analysed.

RESULTS

Responding practitioners reported that interest in, and use of, e-cigarettes is growing among adults seeking help to stop smoking in the UK. In 2013 91% of respondents reported that interest in e-cigarettes had grown in the past year and whilst in 2011, 2% of respondents reported a 'quarter to a half' of their clients saying that they were regularly using e-cigarettes, by 2013 this had increased to 23.5% (p < .001). Responding practitioners' views towards e-cigarettes became more positive between the first and second surveys (15% strongly agreed/agreed in 2011 that 'e-cigarettes are a good thing' rising to 26% in 2013). However, they continued to have concerns about the products. In particular, analysis of free text responses suggested practitioners were unsure about safety or efficacy for smoking cessation, and were worried that smokers may become dependent on the products. Practitioners were also aware of the potential of e-cigarettes to undermine smokers' willingness to use evidence-based methods to stop, and to challenge policies aiming to denormalise tobacco smoking.

CONCLUSIONS

Health professionals are asking for reliable and accurate information on e-cigarettes to convey to smokers who want to quit. Randomized controlled trials and ongoing surveillance of e-cigarette use and its consequences for smoking cessation rates and smoking treatment services are required.