Perceived ease of flavored e-cigarette use and e-cigarette use progression among youth never tobacco users

Restrictions of cigarette and e-cigarette flavor and filter ventilation on demand and substitution in the Experimental Tobacco Marketplace

SIGNIFICANCE

Tobacco product design features, including flavors and cigarette filter ventilation, are subject to regulation. This study examined the effects of cigarette and e-cigarette flavors on demand and substitution by preferred cigarette flavor and ventilation in the Experimental Tobacco Marketplace (ETM).

METHODS

In a mixed between-group (usual cigarette flavor and ventilation)/within-subject design (policy conditions), individuals who use tobacco (n=176 cigarette (60.5 % female); n=91 multiple products (26.7 % female)) were recruited using Ipsos and InnovateMR, completed purchasing trials with increasing cigarette prices in the ETM. Participants were exposed to four conditions in a 2×2 factorial design with cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted.

RESULTS

In individuals who exclusively smoke cigarettes: 1) Cigarette menthol restrictions decreased willingness to purchase cigarettes (OR: 0.001; 95 % CI: 0.00002, 0.015) for individuals that prefer menthol cigarettes and increased willingness to purchase NRT (OR: 4.02; 95 % CI: 1.47, 11.0), 2) cigarette menthol restrictions reduced demand for cigarettes in individuals who smoke menthol cigarettes (p<0.001), 3) e-cigarette flavor restrictions reduced the degree of e-cigarette substitution in individuals who smoke menthol cigarettes (p=0.028), and 4) preference for higher cigarette filter ventilation was associated with higher demand for cigarettes (p=0.003) and lowered substitution of smokeless tobacco products (p=0.028). In individuals who use multiple tobacco products, restrictions did not impact product purchasing.

CONCLUSION

Strategies to reduce flavored product sales and increase cessation resource accessibility may improve population health by reducing smoking and increasing NRT use in individuals who use menthol cigarettes.

Young adults' visual attention to features of social media marketing for disposable e-cigarettes and associated perceptions

BACKGROUND AND AIMS

E-cigarette marketing exposure on social media influences perceptions; however, limited knowledge exists regarding marketing features attracting the most visual attention. This study examined visual attention to features of social media marketing for disposable e-cigarettes and related product perceptions.

DESIGN, SETTING AND PARTICIPANTS

Participants viewed 32 disposable marketing post images from social media (Instagram) using computer-based eye-tracking technology to assess standardized attention metrics of marketing features. They then completed a survey assessing positive product perceptions. The study took place in New Jersey, USA, June-September 2022, comprising young adults (aged 18-29) who do not use tobacco (n = 72) or who smoke cigarettes (n = 42).

MEASUREMENTS

We examined associations between 14 marketing features (e.g. product package, personal item, fruit/candy descriptor, social media account) and standardized attention metrics of dwell time (fixation duration) and entry time (time to first fixation). Then, we assessed attention metrics for each feature in relation to positive product perceptions (appeal and positive use expectancy).

FINDINGS

Among all participants, dwell time was the longest for the product descriptor [marginal means (MM) = 1.77; 95% confidence interval (CI) = 1.69, 1.86], social media account (MM = 1.76; 95% CI = 1.67, 1.85) and fruit/candy descriptor features (MM = 1.56; 95% CI = 1.41, 1.70); entry time was the shortest for the social media account (MM = 0.35; 95% CI = 0.26, 0.46), personal item (MM = 0.36; 95% CI = 0.17, 0.56) and human model features (MM = 0.40; 95% CI = 0.08, 0.72). Two use status groups had comparable dwell and entry times, except for the product descriptor feature. Longer dwell time for the product package feature increased positive product perceptions among both use status groups [regression coefficient (β) = 0.44 and 2.61]. Longer dwell time for fruit/candy descriptor (β = 1.80) and price promotion features (β = 4.04) increased positive product perceptions among those who smoke.

CONCLUSIONS

US young adults appear to be particularly visually engaged by disposable e-cigarette marketing that uses social media account features (account profile pictures, information about the products marketed and relevant hashtags) and features enhancing the products' personal relatability. Disposable product packages, fruit/candy descriptors and price promotions may increase the influence of social media marketing among various use status groups.

Using Eye tracking to Examine Young Adults' Visual Attention to E-cigarette Advertising Features and Associated Positive E-cigarette Perceptions

BACKGROUND

Little is known about the influence of e-cigarette marketing features on the antecedents of e-cigarette use.

PURPOSE

Using an eye-tracking experiment, we examined visual attention to common features in e-cigarette ads and its associations with positive e-cigarette perceptions among young adults.

METHODS

Young adults (ages 18-29) who smoke cigarettes (n = 40) or do not use tobacco (n = 71) viewed 30 e-cigarette ads on a computer screen. Eye-tracking technology measured dwell time (fixation duration) and entry time (time to first fixation) for 14 pre-defined ad features. Participants then completed a survey about perceptions of e-cigarettes shown in the ads. We used regression models to examine the associations between ad features and standardized attention metrics among all participants and by tobacco-use status and person-aggregated standardized attention for each ad feature and positive e-cigarette perceptions.

RESULTS

Dwell time was the longest for smoker-targeted claims, positive experience claims, and price promotions. Entry time was the shortest for multiple flavor descriptions, nicotine warnings, and people. Those who do not use tobacco had a longer dwell time for minor sales restrictions and longer entry time for purchasing information than those who smoke. Longer dwell time for multiple flavor descriptions was associated with e-cigarette appeal. A shorter entry time for fruit flavor description was associated with positive e-cigarette-use expectancies.

CONCLUSIONS

Young adults allocated attention differently to various e-cigarette ad features, and such viewing patterns were largely similar by tobacco-use statuses. Multiple or fruit flavors may be the features that contribute to the positive influence of e-cigarette marketing among young adults.

The characteristics and risk factors of e-cigarette use among adolescents in Shanghai: A case-control study

INTRODUCTION

This study was conducted to explore the characteristics and risk factors of e-cigarette use in adolescents, aiming for tobacco control and reducing e-cigarette use in this population.

METHODS

Using 1:1 matching, 88 students from three vocational high schools in Shanghai were recruited to conduct a case (using e-cigarettes) - control (not using e-cigarettes) study. Group interviews and questionnaire surveys were used for this qualitative and quantitative mixed-methods study. The keywords were extracted from the interview data and analyzed by the Colaizzi seven-step method.

RESULTS

The characteristics of adolescents' use of e-cigarettes include young age at first use, consumption of a large amount, as well as smoking in discrete locations in order to hide from adults. The reasons for using e-cigarettes include curiosity and wanting to replace traditional cigarettes. The risk factors of using e-cigarettes include insufficient understanding of the harm of e-cigarettes at the individual level (The positive outcome expectancy points: Z= -3.746, p<0.001; The negative outcome expectancy points: Z= -3.882, p<0.001), peer influence at the interpersonal level (χ²=6.510, p<0.01), and the influence of social and environmental factors such as e-cigarette sales in the stores and WeChat Moments (p<0.05 for all associations).

CONCLUSIONS

Having friends who use e-cigarettes, curiosity and sales exposure about e-cigarettes are important factors affecting the use of e-cigarettes by adolescents. It is necessary to strengthen the publicity of the potential hazards of e-cigarettes and to reduce overall usage by improving relevant laws and regulations.

A Machine Learning Approach Reveals Distinct Predictors of Vaping Dependence for Adolescent Daily and Non-Daily Vapers in the COVID-19 Era

Since 2016, there has been a substantial rise in e-cigarette (vaping) dependence among young people. In this prospective cohort study, we aimed to identify the different predictors of vaping dependence over 3 months among adolescents who were baseline daily and non-daily vapers. We recruited ever-vaping Canadian residents aged 16-25 years on social media platforms and asked them to complete a baseline survey in November 2020. A validated vaping dependence score (0-23) summing up their responses to nine questions was calculated at the 3-month follow-up survey. Separate lasso regression models were developed to identify predictors of higher 3-month vaping dependence score among baseline daily and non-daily vapers. Of the 1172 participants, 643 (54.9%) were daily vapers with a mean age of 19.6 ± 2.6 years and 76.4% (n = 895) of them being female. The two models achieved adequate predictive performance. Place of last vape purchase, number of days a pod lasts, and the frequency of nicotine-containing vaping were the most important predictors for dependence among daily vapers, while race, sexual orientation and reporting treatment for heart disease were the most important predictors in non-daily vapers. These findings have implications for vaping control policies that target adolescents at different stages of vape use.

Price promotion receipt and use progression of any tobacco, cigarettes, e-cigarettes and cigars among US youth between 2016 and 2018

BACKGROUND

Tobacco price promotions may prompt tobacco trials among youth. We assessed whether receiving price promotions for any tobacco, cigarettes, e-cigarettes and cigars was associated with product use progression.

METHODS

The analysis included a nationally representative sample of youth never tobacco users (aged 12-16; n=9405) from wave 4 (2016-2018) of the Population Assessment of Tobacco and Health Study. We assessed past-year receipt of price promotions and use progression (initiation, current use and ever regular use) for any tobacco, cigarettes, e-cigarettes and cigars 1 year later at wave 4.5 (2017-2018). Multivariable logistic regressions were used to examine the associations between receiving price promotions and use progression by product type, controlling for covariates.

RESULTS

At wave 4.5, 9.4% of youth initiated any tobacco (1.8%, 7.8% and 0.9% for cigarettes, e-cigarettes and cigars), and 5.4% received any price promotions (3.8%, 3.1% and 0.9% for cigarettes, e-cigarettes and cigars). Receiving any tobacco price promotions was associated with any tobacco initiation (adjusted OR (AOR)=1.77; 95% CI 1.30 to 2.41), current use (AOR=1.54; 95% CI 1.06 to 2.23) and ever regular use (AOR=1.76; 95% CI 1.04 to 3.10). Receiving e-cigarette price promotions was associated with e-cigarette initiation (AOR=1.78; 95% CI 1.18 to 2.26), current use (AOR=1.88; 95% CI 1.17 to 3.02) and ever regular use (AOR=2.10; 95% CI 1.02 to 4.40). The associations specific to cigarettes and cigars were only found for product initiation.

DISCUSSION

Receiving price promotions for any tobacco and e-cigarettes was respectively associated with the use progression of any tobacco and e-cigarettes. Continuous monitoring of tobacco marketing activities is needed to identify youth-appealing price promotion tactics.

Racial Disparities in Flavored Tobacco Product Use, Curiosity, Susceptibility, and Harm Perception, National Youth Tobacco Survey 2019-2020

Introduction

Studies characterizing differences in youth flavored tobacco product use prevalence, curiosity/susceptibility, and harm perceptions by race and ethnicity are limited. This study comprehensively examines flavored tobacco product use and harm perceptions among U.S. middle and high school students, by race and ethnicity.

Methods

Data came from the 2019 (N=19,018) and 2020 (N=14,531) National Youth Tobacco Surveys (NYTS). Weighted prevalence estimates of flavored tobacco product use and curiosity, susceptibility, and harm perception are reported by race and ethnicity (non-Hispanic [NH] White, NH Black, Hispanic, or NH Other). t-Tests assessed differences in prevalence by years and racial/ethnic groups.

Results

Among youth with past 30-day tobacco use, use of most flavored tobacco products increased across all racial/ethnic groups; the largest increase was observed among Hispanic youth using other flavored tobacco products (30.3%). The group with the highest susceptibility to future electronic cigarette (e-cigarette) use was Hispanic students (42.3%). Hispanic students had the highest curiosity about and susceptibility to future use of cigarettes and cigars as well.

Conclusions

Increases in the use of and higher susceptibility to other flavored tobacco products, particularly among Hispanic youth, suggest a need for additional changes in environmental conditions and possibly targeted or tailored tobacco control interventions for Hispanic youth.

Implications

Given that flavored tobacco use is prevalent among youth and aggressively marketed more to racial/ethnic minority populations, it is important to understand how susceptibility and perceptions relate to tobacco use. Our results suggest a need for a better understanding of social and environmental factors that drive tobacco use behaviors and perceptions, particularly among Hispanic youth, to address the root causes of these differences and create more equitable tobacco control interventions.

Home e-cigarette rules and youth's vulnerability to initiate and sustain e-cigarette use

Existing studies of the impact of home rules on youth's vulnerability to e-cigarette use were based on cross-sectional data, youth or parent reports alone, as well as youth's perceptions and susceptibility. This study capitalizes on the restricted-use data of the Population Assessment of Tobacco and Health (PATH) Study to examine the longitudinal association between home rules for e-cigarette use and youth's vulnerability including initiation of use and regular use two years later. Secondary analysis was conducted on 1203 parent-youth pairs who participated in both Wave 4 (2016-2018) and Wave 5 (2018-2019) assessment of the PATH Study and while the youth were age 12-16 at Wave 4. Linear and logistic regressions were performed to examine the associations between having a strict home rule for e-cigarette use at Wave 4 and the youth's outcomes including perceived social norms, expectancies, susceptibility, initiation of use, and regular use of e-cigarettes at Wave 5, controlling for parent and youth factors. The results show that having a strict home rule for e-cigarette use was associated with youth's heightened level of perceived injunctive norms (β = 0.22, p < 0.01), higher expectancy of harmfulness (β = 0.28, p < 0.01) and lower odds for regular e-cigarette use (OR = 0.36, p < 0.05). In conclusion, the findings of this study support the potential protective effects of implementing a strict home rule for e-cigarette use. Future intervention efforts may promote parents' awareness of the potential protective effects of a strict home e-cigarette rule on youth's normative belief, harm expectancy, and behavior of e-cigarette use.

Assessing toxicant emissions from e-liquids with DIY additives used in response to a potential flavour ban in e-cigarettes

SIGNIFICANCE

Electronic cigarettes (e-cigarettes) aerosolise liquids that contain nicotine, propylene glycol, glycerol and appealing flavours. In the USA, regulations have limited the availability of flavoured e-cigarettes in pod-based systems, and further tightening is expected. In response, some e-cigarette users may attempt to make their e-liquids (do-it-yourself, DIY). This study examined toxicant emissions from several aerosolised DIY e-liquids.

METHODS

DIY additives were identified by reviewing users' responses to a hypothetical flavour ban, e-cigarette internet forums and DIY mixing internet websites. They include essential oils, cannabidiol, sucralose and ethyl maltol. E-liquids with varying concentrations and combinations of additives and tobacco and menthol flavours were prepared and were used to assess reactive oxygen species (ROS), carbonyl and phenol emissions in machine-generated aerosols.

RESULTS

Data showed that adding DIY additives to unflavoured, menthol-flavoured or tobacco-flavoured e-liquids increases toxicant emissions to levels comparable with those from commercial flavoured e-liquids. Varying additive concentrations in e-liquids did not have a consistently significant effect on the tested emissions, yet increasing power yielded significantly higher ROS, carbonyl and phenol emissions for the same additive concentration. Adding nicotine to DIY e-liquids with sucralose yielded increase in some emissions and decrease in others, with freebase nicotine-containing e-liquid giving higher ROS emissions than that with nicotine salt.

CONCLUSION

This study showed that DIY additives can impact aerosol toxicant emissions from e-cigarettes and should be considered by policymakers when restricting commercially available flavoured e-liquids.

Longitudinal associations between U.S. youth exposure to E-cigarette marketing and E-cigarette use harm perception and behavior change

E-cigarette marketing tactics to reach and appeal to youth are rapidly changing. This study examined to what extent youth e-cigarette marketing exposure was associated with e-cigarette use behavior change one year later, during a time when youth e-cigarette use was starting to surge in the U.S. Using nationally representative longitudinal public-use data from the Population Assessment of Tobacco and Health (PATH) Study, we examined associations between recalled e-cigarette marketing exposure (2016-2018) at Wave (W) 4 and e-cigarette use harm perception and behavior change (ever, current, and regular use) one year later (W4.5; 2017-2018) among W4 never tobacco users (n = 9405). Recall of exposure to e-cigarette marketing through different channels was also examined in multivariable models controlling for socio-demographic factors and established e-cigarette use risk factors. Results show that the most frequently recalled channels of e-cigarette marketing exposure were retail stores (50.3%), television (22.2%), and websites/social media (20.2%). Over one year, 21.2%, 7.8%, 3.4%, and 1.2% of respondents reported reduced harm perceptions, and ever, current, and regular use of e-cigarettes, respectively, at follow-up. Recalled exposure to e-cigarette marketing was associated with reduced e-cigarette harm perception (AOR = 1.20; 95% CI = 1.05-1.37) and ever (AOR = 1.26; 95% CI = 1.01-1.56) and current use (AOR = 1.40; 95% CI = 1.02-1.92) at follow-up. E-cigarette marketing exposure through websites/social media was associated with reduced harm perceptions and all stages of e-cigarette use change, including regular use. Identifying marketing techniques and channels that change youth e-cigarette harm perceptions and influence e-cigarette use progression is essential to inform e-cigarette regulatory policies and prevention campaigns.

Substance use among adult marijuana and nicotine e-cigarette or vaping product users, 2020

INTRODUCTION

Co-use of marijuana and tobacco/nicotine have unknown impacts on addiction and health. There are limited data on the extent to which adults are co-using tetrahydrocannabinol (THC)- and nicotine-containing products, in any of their various modes. This study describes adult use of THC- and nicotine-containing products among electronic vaping product (EVP) users.

METHODS

Data on marijuana and tobacco use were collected from February 25-29, 2020 through an online survey of adults aged ≥18 years who reported using THC- and nicotine-containing electronic vaping products (EVPs) in the past 3 months (n = 3,980). Survey respondents from 18 states participated in the U.S. YouGov panel, a proprietary opt-in internet panel survey of 1.8 million U.S. residents.

RESULTS

Among those who reported using nicotine and THC-containing EVPs in the past 3 months, 90.1% of respondents reported smoking marijuana in the past 3 months; 82.7% reported smoking as the most frequent mode of marijuana use. Almost 63% of EVP users reported smoking cigarettes; 55.6% reported smoking for over 8 years, while 7.7% had been smoking cigarettes for under a year.

CONCLUSIONS

In this study, respondents reported cigarette smoking and marijuana smoking in addition to using marijuana- and nicotine- containing EVPs. Considering the unknown health effects of co-use of tobacco and THC-containing products, the finding that adults are vaping THC and nicotine alongside traditional modes of marijuana and tobacco use of these substances warrants further investigation.

IMPLICATIONS

Findings from this study provide evidence that adults who use nicotine and THC EVPs are also using a variety of other THC-containing and tobacco-containing products. This indicates the importance of continued surveillance to assess trends of polysubstance EVP and multi-modal marijuana and tobacco use. Monitoring various modes of marijuana and tobacco use may inform policies, prevention education, communication, and cessation tools.

Real-Time Context of Tobacco Marketing Exposure and Community Vulnerability-An Ecological Momentary Assessment Among Young Adults

BACKGROUND

Exposure to tobacco product marketing increases tobacco use among young adults, especially those from vulnerable communities (VCs).

PURPOSE

This study examined real-time tobacco marketing exposure among young adults from vulnerable and non-vulnerable communities using Ecological Momentary Assessment (EMA).

METHODS

This study used EMA data to assess context (e.g., location and activity) of tobacco marketing exposure using four text-messaging surveys per day over 2 weeks. Young adult non-current tobacco users living in Washington, D.C. (n = 146; ages 18-24) recorded 5,285 surveys, including 20 participants (13.2%) from VCs with high proportions of lower income and racial/ethnic minorities, and high smoking rates. Unadjusted and adjusted multilevel logistic regressions were used to assess the associations between exposure to any and flavored tobacco marketing, VC residence, and real-time context.

RESULTS

Fifty-nine participants (40.4%) reported at least one tobacco marketing exposure and recorded 94 exposure moments. In adjusted models, odds of exposure were higher among VC residents (AOR = 2.6, 95% CI = 1.2-5.4), in the presence of anyone using tobacco versus no use (AOR = 4.0, 95% CI = 2.4-6.7), at store/retail (AOR = 17.0, 95% CI = 6.4-44.8), or outside/in transit (AOR = 4.1, 95% CI = 2.1-7.8) versus at home. VC residence (AOR = 7.2, 95% CI = 2.3-22.2) was the strongest predictor of flavored tobacco marketing exposure among all covariates examined.

CONCLUSIONS

Young adults are predominantly exposed to tobacco marketing in their daily lives through retail advertisements. Young adults from VCs are at increased risks of seeing any tobacco and especially flavored tobacco marketing. Policies that curtail tobacco retailer density and advertisement displays may reduce overall and differential tobacco marketing exposure.

Youth use of e-liquid flavours-a systematic review exploring patterns of use of e-liquid flavours and associations with continued vaping, tobacco smoking uptake or cessation

BACKGROUND AND AIMS

There is concern that young people may be attracted to e-liquid flavours, prompting long-term vaping in naive users and potentially subsequent tobacco smoking. We aimed to review the use of e-liquid flavours by young people and describe associations with uptake or cessation of both regular vaping and tobacco smoking, adverse effects and subjective experiences.

DESIGN

Systematic review, including interventional, observational and qualitative studies reporting on the use of e-cigarette flavours by young people (aged < 18 years).

SETTING

Studies published in English language from any country or cultural setting.

PARTICIPANTS

Young people and their carers (aged < 18 years).

MEASUREMENTS

A meta-analysis was not possible due to substantial heterogeneity, inconsistency in reporting of flavour categorizations and non-interventional study designs; thus, we narratively report findings.

FINDINGS

In total, 58 studies were included. The quality of the evidence was extremely low. Most (n = 39) studies were cross-sectional survey designs. In total, 11 longitudinal cohort studies assessed trajectories; eight qualitative studies reported on user experiences. Studies reported views and experiences of a total of 512 874 young people. Both cross-sectional and longitudinal studies suggested that flavours are important for initiation and continuation of vaping. Qualitative evidence shows interest and enjoyment in flavours. There was judged to be insufficient evidence that use of e-liquid flavours specifically is associated with uptake of smoking. No studies found clear associations between flavours and cessation in this population. We found no included reports of adverse effects of flavours.

CONCLUSIONS

Flavours may be an important motivator for e-cigarette uptake, but the role of flavours in tobacco smoking uptake or cessation is unclear. The quality of the evidence on use of e-cigarette flavours by young people is low overall.

Analytical methods for the identification of micro/nano metals in e-cigarette emission samples: a review

In this review, numerous analytical methods to quantify the heavy and trace elements emitted from electronic cigarettes, cigarettes liquid and atomizer. The selection of a method was dependent upon the purpose, e.g., quantification or identification of elements only. The introductory part of this review focuses on describing the importance of setting up an electronic cigarettes- associated safety profile. The review dealt with studies that assessed elements in sizes ranging from nano to micro. The formation of different degradation chemical substances as well as impurity trends can be indicated through chemical investigation of metals in electronic cigarettes. Some studies have been covered that show the uses and benefits of. It is noticeable from all the collected sources that the minerals emitted from the smoke of e- cigs do not constitute any significant damage, as the percentage is very small, with the exception of minerals that may be emitted from the components of the device after heating it if the components of the e- cig are of poor specifications, except in the case of long-term accumulation. For this reason, an electronic cigarette can help smokers to quit smoking tobacco and replace it with electronic cigarettes smoke with distinctive flavors.

#FlavorsSaveLives: An Analysis of Twitter Posts Opposing Flavored E-cigarette Bans

BACKGROUND

Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. People took to Twitter to voice their opposition, referencing the phrase "Flavors Save Lives." This study documented the emerging themes pertaining to "Flavors Saves Lives" over a 12-month period.

METHODS

The study period was from May 1, 2019, to May 1, 2020. A stratified sampling procedure supplied 2500 tweets for analysis. Posts were classified by one or more of the following themes: (1) Political Referendum; (2) Institutional Distrust; (3) Individual Rights; (4) Misinformation; (5) THC Vaping is the Real Problem; (6) Smoking Cessation; (7) Adult Use; and (8) Not a Bot. The temporal pattern of tweets over the year was examined.

RESULTS

Political Referendum (76.5%) and Institutional Distrust (31.3%) were the most prominent themes, followed by Not a Bot (11.0%), Individual Rights (10.4%), Adult Use (8.0%), Smoking Cessation (6.6%), Misinformation (5.9%), and THC Vaping is the Real Problem (3.5%). Total tweet frequencies increased in September 2019 and peaked in November 2019 before returning to relatively low numbers. Political Referendum and Institutional Distrust were consistently the most prevalent themes over time.

CONCLUSION

Twitter posts with the phrase "Flavors Save Lives" commonly discussed voting against political incumbents and mentioned distrust of government representatives. Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans. These data may be valuable for designing tobacco control information campaigns in the future.

IMPLICATIONS

(a) Starting in 2019 policies restricting the availability of flavored e-cigarette products were proposed or implemented in the United States to curb vaping by youth. (b) This study content analyzed Twitter posts with the phrase "Flavors Save Lives" from a 12-month period to understand opposition to flavor restrictions. (c) Twitter posts commonly discussed voting against political incumbents and mentioned distrust of government representatives. (d) Findings demonstrated the possibility of near real-time Twitter monitoring of public opposition to flavor bans, and contribute to a more comprehensive assessment of different sub-population's responses to current and proposed tobacco control information policies.

Do JUUL and e-cigarette flavours change risk perceptions of adolescents? Evidence from a national survey

INTRODUCTION

Use of JUULs and e-cigarettes is growing rapidly, particularly among adolescents. Research suggests that flavours may increase the appeal of these products, but little is known about how flavours influence perception. We examined whether youth perceptions about the health risks of JUULs and e-cigarettes vary with flavours.

METHODS

We conducted a national survey in 2018 of 1610 high-school students aged 14-18 who had ever heard of either JUULs or e-cigarettes. Respondents were asked to rate the lung cancer risk, the harm of second-hand vapour, potential for addiction and healthiness of differently flavoured JUUL and e-cigarette products. We investigated the relationship among flavour, risk perception and socio-demographic information.

RESULTS

We found that risk perceptions for both JUULs and e-cigarettes differ significantly by flavour type. Youths perceive fruit flavours to be less likely to lead to lung cancer (-0.909 (0.065)), have harmful second-hand vapour (-0.933 (0.060)) and be more addictive (1.104 (0.094)) relative to tobacco flavours. Candy, menthol/mint and alcohol flavours show similar patterns of risk association, although the magnitude is slightly smaller than for fruit flavours.

CONCLUSIONS

Youths believe that flavours are related to the health risks of both JUULs and e-cigarettes despite the fact that these differences in risk by flavour have not been scientifically or systematically established. A policy concern is that misperceptions based on flavour may result in increased vaping by youths. The findings from this study support the assertion that banning fruit, menthol or mint and sweet flavours could reduce the appeal of JUULs and e-cigarettes to youth, with concomitant health protections.

Social media's influence on e-cigarette use onset and escalation among young adults: What beliefs mediate the effects?

As an extension of a previous cross-sectional study, this study employed prospective data to test positive outcome expectancy beliefs as mediators of social media's influence on e-cigarette use progression among young adults. Self-report data were collected from 2327 young adult college students (Mean age = 21.2; SD = 2.1; 54% women) between 2017 and 2019, every 6-month, at 3 time-points. Structural equation modeling was used to test the mediational models. Among baseline never e-cigarette users, higher affect regulation expectancies-e.g., beliefs that e-cigarette use results in feeling good, reduced boredom and stress-mediated the effects of higher baseline social media e-cigarette exposure on e-cigarette use onset one year later. Among baseline lifetime e-cigarette users, higher positive sensory, positive "smoking" experience, and affect regulation expectancy beliefs mediated the effects of higher social media e-cigarette exposure at baseline on increased current e-cigarette use one year later. E-cigarette content on social media may persuade young adults to try e-cigarettes by imparting the sense that e-cigarettes make one feel good and help reduce stress. E-cigarette content on social media that promote e-cigarette flavors and e-cigarettes as cleaner and a socially more acceptable alternative to cigarettes may work to escalate e-cigarette use among experimenters. Efforts to prevent e-cigarette use onset and escalation may need to target the outcome expectancy beliefs influenced by social media.

Flavor-Toxicant Correlation in E-cigarettes: A Meta-Analysis

Flavors in electronic cigarette (ECIG) liquids may increase ECIG aerosol toxicity via intact distillation or chemical transformation. For this report, we performed a meta-analysis of the literature to categorize the compounds found in flavored ECIG liquids into a few chemical classes and to predict their possible chemical transformations upon ECIG liquid aerosolization. This analysis allowed us to propose specific correlations between flavoring chemicals and aerosol toxicants. A literature search was conducted in November 2019 using PubMed. Keywords included terms related to ECIGs and flavors. Studies were included if they reported chemical ingredients of flavored liquids and clearly stated the commercial names of these liquids. The obtained data were visualized on a network diagram to show the common chemical compounds identified in flavored ECIG liquids and categorize them into different chemical classes. The systematic literature review included a total of 11 articles. Analysis of the data reported gave a total of 189 flavored liquids and 173 distinct chemical compounds that were categorized into 22 chemical classes according to their functional groups. The subsequent prediction of chemical transformations of these functional groups highlighted the possible correlation of flavor compounds to aerosol toxicants.

Young adult e-cigarette use: A latent class analysis of device and flavor use, 2018-2019

OBJECTIVE

The myriad of e-cigarette devices and flavors used by young adults (YAs) complicates identification of the particular e-cigarette products that are associated with more frequent tobacco use and merit consideration for regulation. The current study used latent class analysis to identify distinct patterns of e-cigarette device and flavor use and evaluate their association with vaping and smoking frequency.

METHODS

Cross-sectional survey data (2018-2019) from a Southern California cohort were analyzed. YAs reporting past 30-day nicotine vaping (N = 550; M age = 19.2 years) self-reported e-cigarette device type/brand and flavor. Six device (e-cig/vape pen, mech mod, box mod, JUUL, non-JUUL pod, disposable) and three flavor (tobacco, mint/menthol, sweet/fruit) indicators were included in a latent class analysis. Past 30-day nicotine vaping and cigarette smoking frequency were assessed as correlates of device and flavor class membership.

RESULTS

Three classes were identified: Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (prevalance:47%); Non-JUUL-Sweet/Fruit Flavor Users (28%); and Poly-Device-Poly-Flavor Users (25%). Greater frequency of vaping and smoking were associated with higher odds of belonging to the Poly-Device-Poly-Flavor Users class vs. the Any Pod-Mint/Menthol or Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.36[1.16, 1.59], p < .001; smoking: aOR[95%CI] = 1.25[1.02, 1.54], p = .03) and Non-JUUL-Sweet/Fruit Flavor Users (vaping: aOR[95%CI] = 1.30[1.10, 1.53], p < .01; smoking: aOR[95%CI] = 1.42[1.07, 1.88], p = .02) classes.

CONCLUSIONS

Although YAs that predominately used pod devices alongside non-tobacco flavors were most common, YAs characterized by a proclivity toward using many different devices and flavors were appreciably prevalent and smoked and vaped more frequently. Regulations targeting a wide spectrum of vaping products may be optimal in protecting YA health.

Cell-specific toxicity of short-term JUUL aerosol exposure to human bronchial epithelial cells and murine macrophages exposed at the air-liquid interface

Backgroud

JUUL, an electronic nicotine delivery system (ENDS), which first appeared on the US market in 2015, controled more than 75% of the US ENDS sales in 2018. JUUL-type devices are currently the most commonly used form of ENDS among youth in the US. In contrast to free-base nicotine contained in cigarettes and other ENDS, JUUL contains high levels of nicotine salt (35 or 59 mg/mL), whose cellular and molecular effects on lung cells are largely unknown. In the present study, we evaluated the in vitro toxicity of JUUL crème brûlée-flavored aerosols on 2 types of human bronchial epithelial cell lines (BEAS-2B, H292) and a murine macrophage cell line (RAW 264.7).

Methods

Human lung epithelial cells and murine macrophages were exposed to JUUL crème brûlée-flavored aerosols at the air–liquid interface (ALI) for 1-h followed by a 24-h recovery period. Membrane integrity, cytotoxicity, extracellular release of nitrogen species and reactive oxygen species, cellular morphology and gene expression were assessed.

Results

Crème brûlée-flavored aerosol contained elevated concentrations of benzoic acid (86.9 μg/puff), a well-established respiratory irritant. In BEAS-2B cells, crème brûlée-flavored aerosol decreased cell viability (≥ 50%) and increased nitric oxide (NO) production (≥ 30%), as well as iNOS gene expression. Crème brûlée-flavored aerosol did not affect the viability of either H292 cells or RAW macrophages, but increased the production of reactive oxygen species (ROS) by ≥ 20% in both cell types. While crème brûlée-flavored aerosol did not alter NO levels in H292 cells, RAW macrophages exposed to crème brûlée-flavored aerosol displayed decreased NO (≥ 50%) and down-regulation of the iNOS gene, possibly due to increased ROS. Additionally, crème brûlée-flavored aerosol dysregulated the expression of several genes related to biotransformation, inflammation and airway remodeling, including CYP1A1, IL-6, and MMP12 in all 3 cell lines.

Conclusion

Our results indicate that crème brûlée-flavored aerosol causes cell-specific toxicity to lung cells. This study contributes to providing scientific evidence towards regulation of nicotine salt-based products.

Electronic cigarette and moist snuff product characteristics independently associated with youth tobacco product perceptions

INTRODUCTION

Tobacco product characteristics convey product attributes to potential users. This study aimed to assess independent contributions of specific e-cigarette and smokeless tobacco product characteristics to adolescents' perceptions about these products.

METHODS

In 2019-2020, students (N=1003) attending a convenience sample of 7 high schools in California (USA) were individually randomized to one of two discrete choice experiments, featuring either electronic cigarettes (e-cigarettes) or moist snuff. Participants were presented like-product pairs of randomlygenerated hypothetical tobacco products differing in device type, flavor, vapor cloud, and nicotine amount (for e-cigarettes) or differing in brand, flavor, cut, and price (for moist snuff). Within pairs, participants were asked about which product they were more curious, was more dangerous, would give a greater 'buzz,' and would be easier to use. Conditional logistic regression was used to quantify independent associations of product characteristics to participants' choices.

RESULTS

Each e-cigarette and moist snuff characteristic was independently associated with multiple product perceptions. All non-tobacco flavors were associated with more curiosity and perceived ease-of-use but lower perceived danger. Tank and pod-type e-cigarettes were viewed as easier to use and garnered more curiosity than 'cigalike' or 'drip-mod' devices. Smaller vapor cloud e-cigarettes and lower-price moist snuff were viewed as less dangerous, less buzz-inducing, and easier to use. Product ever users held stronger perceptions than never users about device type (e-cigarettes) and brands (moist snuff), while product naïve participants more strongly associated flavor with danger and buzz.

CONCLUSIONS

Tobacco product characteristics convey product attributes to adolescents that may increase appeal. Restricting specific characteristics, including flavors, could reduce positive perceptions of these products among youth.

Electronic-Cigarette Vehicles and Flavoring Affect Lung Function and Immune Responses in a Murine Model

The use of electronic nicotine delivery systems (ENDS), also known as electronic-cigarettes (e-cigs), has raised serious public health concerns, especially in light of the 2019 outbreak of e-cig or vaping product use-associated acute lung injury (EVALI). While these cases have mostly been linked to ENDS that contain vitamin E acetate, there is limited research that has focused on the chronic pulmonary effects of the delivery vehicles (i.e., without nicotine and flavoring). Thus, we investigated lung function and immune responses in a mouse model following exposure to the nearly ubiquitous e-cig delivery vehicles, vegetable glycerin (VG) and propylene glycol (PG), used with a specific 70%/30% ratio, with or without vanilla flavoring. We hypothesized that mice exposed sub-acutely to these e-cig aerosols would exhibit lung inflammation and altered lung function. Adult female C57BL/6 mice (n = 11-12 per group) were exposed to filtered air, 70%/30% VG/PG, or 70%/30% VG/PG with a French vanilla flavoring for 2 h a day for 6 weeks. Prior to sacrifice, lung function was assessed. At sacrifice, broncho-alveolar lavage fluid and lung tissue were collected for lipid mediator analysis, flow cytometry, histopathology, and gene expression analyses. Exposures to VG/PG + vanilla e-cig aerosol increased lung tidal and minute volumes and tissue damping. Immunophenotyping of lung immune cells revealed an increased number of dendritic cells, CD4+ T cells, and CD19+ B cells in the VG/PG-exposed group compared to air, irrespective of the presence of vanilla flavoring. Quantification of bioactive lung lipids demonstrated a >3-fold increase of 2-arachidonoylglycerol (2-AG), an anti-inflammatory mediator, and a 2-fold increase of 12-hydroxyeicosatetraenoic acid (12-HETE), another inflammatory mediator, following VG/PG exposure, with or without vanilla flavoring. This suggests that e-cig aerosol vehicles may affect immunoregulatory molecules. We also found that the two e-cig aerosols dysregulated the expression of lung genes. Ingenuity Pathway Analysis revealed that the gene networks that are dysregulated by the VG/PG e-cig aerosol are associated with metabolism of cellular proteins and lipids. Overall, our findings demonstrate that VG and PG, the main constituents of e-liquid formulations, when aerosolized through an e-cig device, are not harmless to the lungs, since they disrupt immune homeostasis.

Effects of Electronic Cigarettes on Indoor Air Quality and Health

With the rapid increase in electronic cigarette (e-cig) users worldwide, secondhand exposure to e-cig aerosols has become a serious public health concern. We summarize the evidence on the effects of e-cigs on indoor air quality, chemical compositions of mainstream and secondhand e-cig aerosols, and associated respiratory and cardiovascular effects. The use of e-cigs in indoor environments leads to high levels of fine and ultrafine particles similar to tobacco cigarettes (t-cigs). Concentrations of chemical compounds in e-cig aerosols are generally lower than those in t-cig smoke, but a substantial amount of vaporized propylene glycol, vegetable glycerin, nicotine, and toxic substances, such as aldehydes and heavy metals, has been reported. Exposures to mainstream e-cig aerosols have biologic effects but only limited evidence shows adverse respiratory and cardiovascular effects in humans. Long-term studies are needed to better understand the dosimetry and health effects of exposures to secondhand e-cig aerosols.

Effects of Electronic Cigarettes on Indoor Air Quality and Health

With the rapid increase in electronic cigarette (e-cig) users worldwide, secondhand exposure to e-cig aerosols has become a serious public health concern. We summarize the evidence on the effects of e-cigs on indoor air quality, chemical compositions of mainstream and secondhand e-cig aerosols, and associated respiratory and cardiovascular effects. The use of e-cigs in indoor environments leads to high levels of fine and ultrafine particles similar to tobacco cigarettes (t-cigs). Concentrations of chemical compounds in e-cig aerosols are generally lower than those in t-cig smoke, but a substantial amount of vaporized propylene glycol, vegetable glycerin, nicotine, and toxic substances, such as aldehydes and heavy metals, has been reported. Exposures to mainstream e-cig aerosols have biologic effects but only limited evidence shows adverse respiratory and cardiovascular effects in humans. Long-term studies are needed to better understand the dosimetry and health effects of exposures to secondhand e-cig aerosols.

Prevalence and Reasons for Use of Flavored Cigars and ENDS among US Youth and Adults: Estimates from Wave 4 of the PATH Study, 2016-2017

Objectives: In this study, we present updated estimates of use prevalence, flavor use, and flavors as a reason for use among US cigar and electronic nicotine delivery system (ENDS) users. Methods: Data come from Wave 4 of the Population Assessment of Tobacco and Health (PATH) Study and were collected between December 2016 and early January 2018. Results are presented for youth (12-17 years), young adults (18-24 years), and adults (25+ years). Results: Approximately half (50.7%) of young adults reported having ever used an ENDS product with 83.7% reporting that their first ENDS product was flavored. Flavor use was particularly high among current (past 30-day) ENDS users at 97.0% among youth, 96.8% among young adults, and 81.2% among adults. For cigars, cigarillos were the most commonly used type among youth and young adults. Flavor use was highest among current cigarillo and filtered cigar users, with close to half of current users reporting flavor use across age groups. Conclusions: Flavored product use is common among ENDS and cigar users.

E-Liquid Flavor Preferences and Individual Factors Related to Vaping: A Survey among Dutch Never-Users, Smokers, Dual Users, and Exclusive Vapers

Appealing product characteristics, such as flavors, may stimulate e-cigarette use. While switching to e-cigarettes may reduce harm for smokers, concerns exist about e-cigarette use among never-smokers. The role of flavors in the decision to switch to or refrain from vaping is unclear. This study used a bottom-up approach to investigate the relation between flavor preferences and individual factors related to vaping between various user groups. A cross-sectional survey was conducted among never-users (n = 407), smokers (n = 138), dual users (n = 122), and exclusive vapers (n = 61) in the Netherlands. Demographics, attractiveness of product characteristics, flavor preferences, and individual factors related to vaping (knowledge, trust, perceived susceptibility, attitude, social influence, deliberation, and intention) were assessed. The availability of different flavors was the most attractive characteristic of e-cigarettes. Dual users and exclusive vapers had most often used tobacco and menthol/mint flavors when they first started vaping. Compared to dual users, exclusive vapers currently used more fruit and sweet flavors. Never-users who were interested in trying an e-liquid flavor had more knowledge about and a more positive attitude towards e-cigarettes. Smokers who were interested in trying a flavor had a more positive attitude towards e-cigarettes and experienced the social influence towards not using e-cigarettes as less strong than those who did not want to try any flavor. Hence, individual factors related to vaping differed depending on whether never-users and smokers wanted to try an e-liquid flavor. This means that flavors may moderate differences found in individual factors related to vaping, or vice versa.

A Combination of Factors Related to Smoking Behavior, Attractive Product Characteristics, and Socio-Cognitive Factors are Important to Distinguish a Dual User from an Exclusive E-Cigarette User

Although total cessation of nicotine and tobacco products would be most beneficial to improve public health, exclusive e-cigarette use has potential health benefits for smokers compared to cigarette smoking. This study investigated differences between dual users and exclusive e-cigarette users provide information to optimize health communication about smoking and vaping. A cross-sectional survey (n = 116) among 80 current, adult dual users and 36 current, adult-exclusive e-cigarette users was conducted in the Netherlands. The questionnaire assessed four clusters of factors: (1) Past and current smoking and vaping behavior, (2) product characteristics used, (3) attractiveness and reasons related to cigarettes and e-cigarettes, and (4) socio-cognitive factors regarding smoking, vaping, and not smoking or vaping. We used random forest-a machine learning algorithm-to identify distinguishing features between dual users and e-cigarette users. We are able to discern a dual user from an exclusive e-cigarette user with 86.2% accuracy based on seven factors: Social ties with other smokers, quantity of tobacco cigarettes smoked in the past (e-cigarette users) or currently (dual users), self-efficacy to not vape and smoke, unattractiveness of cigarettes, attitude towards e-cigarettes, barriers: accessibility of e-cigarettes, and intention to quit vaping (A). This combination of features provides information on how to improve health communication about smoking and vaping.