Changes in Flavor Preference in a Cohort of Long-Term Electronic Cigarette Users

Selecting an e-cigarette for use in smoking cessation interventions and healthcare services: findings from patient and public consultation for the COSTED trial

OBJECTIVES

The Cessation of Smoking Trial in the Emergency Department (COSTED) trial aims to ascertain whether brief advice, the provision of an e-cigarette starter kit and referral to stop smoking services (SSS), increases smoking cessation in people attending the emergency department. Patient and public involvement (PPI) and scoping work were undertaken to select an appropriate e-cigarette for the trial.

DESIGN AND SETTING

PPI consultation and feasibility scoping about potential devices with a professional and lay panel, all based in England. Consultation was via email, telephone or video interview. This work took place between April and July 2021, prior to recruitment commencing for the COSTED trial.

PARTICIPANTS

A professional panel (n=7) including representatives from academia, SSS and the independent vaping industry, and a PPI lay panel (n=3) who smoke or vape.

RESULTS

The professional panel recommended a shortlist of devices which were tested by the PPI lay panel. Key criteria for selecting an appropriate e-cigarette for smoking cessation intervention include satisfaction, usability, affordability and availability. Simplicity of use was highlighted by the PPI lay panel, who found refillable devices complex, and availability of consumables was highlighted as more important than price by both panels. The pod device selected for inclusion was rated highly for satisfaction and usability and had mid-price range and consumables which were widely available.

CONCLUSIONS

To select the most appropriate device for the COSTED trial, each criterion required assessment to ensure the best fit to the intervention context and needs of the target population. There is a need for guidance to help enable decision-making about choice of vape products, tailored to service users' needs. We propose a bespoke checklist template, based on our findings, to assist with this process. This has applicability to the recent government announcement of a 'Swap to Stop' programme, offering a vaping starter kit to smokers across England, allowing services flexibility to shape their own programmes and models of delivery.

TRIAL REGISTRATION NUMBER

Clinical trial number NCT04854616; pre-results.

Analysis of e-cigarette warning letters issued by the Food and Drug Administration in 2020 and 2021

PURPOSE

This study analyses the Food and Drug Administration (FDA) warning letters sent to e-cigarette companies from 1 January 2020 to 9 September 2021. Study results can inform regulation of e-cigarettes.

METHODOLOGY

Warning letters retrieved from FDA's website were coded for company type (retailer, manufacturer or distributor), location (domestic or international), infractions listed (PMTA (premarket tobacco product application), selling to minors, advertising to youth or packaging violation/mislabelling), product type (e-liquid, device or both), flavour (fruit, candy, tobacco, menthol/mint, concept flavour) and consequence (civil money penalties, product seizure and injunction, product detention and refusal of entry to the USA, no-tobacco-sales order, criminal prosecution).

RESULTS

Of 303 coded letters (126 from 2020 and 177 from 2021), 97.4% were sent to small online retailers. Overall, 94.1% of the companies cited were located within the USA, 75.2% of the infractions were identified by reviewing a company's website and 70.5% were PMTA violations. In 2020, 55.6% of infractions were PMTA violations; in 2021, nearly all infractions were PMTA violations. The letters cited 880 products; 92.2% of which were e-liquid products, with 32.4% fruit and 31.1% concept flavours.

DISCUSSION

Warning letters targeted small online retailers rather than large e-cigarette brands or products most used by youth: pod mods and disposables. The focus of these enforcement actions comprises a small share of the market and the impact on use was likely minimal. With PMTA decisions pending for the largest brands of e-cigarettes, the FDA should use its enforcement powers to target manufacturers, distributors and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.

An 8-year longitudinal study of long-term, continuous users of electronic cigarettes

BACKGROUND AND AIMS

E-cigarettes have been available for over 15 years, but relatively little is known about long-term users. Our aim was to describe change over time in behaviours, attitudes and dependence in long-term users.

DESIGN AND PARTICIPANTS

A longitudinal study of 375 e-cigarette users enrolled on the Internet in 2012-2016 and surveyed again in 2021 (8 years later on average), who continuously used e-cigarettes in the interval.

FINDINGS

Fewer people in 2021 (11 %) than at baseline (33 %) had smoked tobacco in the past 31 days. Participants switched from second-generation models at baseline (e.g. Ego) to box mods in 2021 (e.g. iStick), they used larger refill bottles, they used home-made e-liquids twice as often, they used tobacco flavours less often and the nicotine concentration in e-liquids decreased from 12 to 6 mg/mL. There was no change over time in the time to the first e-cigarette puff of the day, but an e-cigarette dependence score of 0-100 decreased from 75 to 60, the frequency and strength of urges to vape decreased (from 31 % to 18 % of "strong" urges) and the proportion of people who said they would be likely to succeed if they tried to stop vaping increased. Compared to baseline, fewer people in 2021 reported vaping to cope with cravings or other smoking cessation symptoms, and fewer people reported vaping to quit smoking, to avoid relapse into smoking, or to reduce their tobacco consumption (p < 0.001 for all differences).

CONCLUSIONS

In long-term, continuous users, over a period of 8 years, substantial changes were observed in the models of e-cigarettes used, in the flavours and strength of e-liquids, and in the reasons for vaping. Their level of nicotine dependence tended to decrease over time. These users were satisfied with e-cigarettes and vaped mostly because they felt that vaping was less dangerous than smoking, and for enjoyment.

Patterns of flavored e-cigarette use among adult vapers in the USA: an online cross-sectional survey of 69,233 participants

BACKGROUND

Flavored e-cigarettes remain a controversial topic with regulators planning or already implementing restrictions worldwide. In this study, we examined patterns of flavor use in e-cigarettes among a convenience sample of US adult vapers.

METHODS

Participants aged ≥ 18 years who reported ever using an e-cigarette were included in the study (N = 69,233) and responded to an online questionnaire. Their smoking status was recorded as well as patterns of flavor use at e-cigarette use initiation, at the time of the survey and at the time of smoking cessation (for participants who used to smoke and were using e-cigarettes at the time of quitting).

RESULTS

The most popular flavors at e-cigarette use initiation were fruit (82.8%), followed by dessert/pastry/bakery (68.6%) and candy/chocolate/sweet (52.2%). Slightly higher prevalence of using fruit and dessert/pastry/bakery flavors was observed in those who never smoked compared to those who were currently and formerly smoking. Tobacco flavors were used by 20.8% of the participants and was by far the least prevalent among participants who never smoked. Similar patterns were observed with participants' choices at the time of the survey, but tobacco flavor use was substantially reduced (7.7%). Only 2.1% reported tobacco as the single most often used flavor. The most prevalent flavor at the time of quitting smoking was again fruit (83.3%), followed by dessert/pastry/bakery (68.0%) and candy/chocolate/sweet (44.5%). These flavors were considered the most helpful for quitting smoking. Tobacco flavor use at the time of smoking cessation was reported by 15.0%, while 9.3% considered it helpful for quitting smoking.

CONCLUSION

Non-tobacco flavors were popular among the US adult vapers who participated in the study, and were popular choices at the time of quitting smoking for those who formerly smoked. Tobacco flavor use prevalence was low and was further reduced over time. Regulators should consider the flavor choice of adult consumers, especially those who quit smoking, when preparing legislation on flavored e-cigarettes.

Electronic Nicotine Delivery System flavor use over time by age group in the US: A longitudinal analysis

INTRODUCTION

The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019.

METHODS

Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed.

RESULTS

The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves.

CONCLUSIONS

Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

E-cigarette Use Patterns, Flavors, and Device Characteristics Associated With Quitting Smoking Among a U.S. sample of Adults Using E-cigarettes in a Smoking Cessation Attempt

INTRODUCTION

Many adults who smoke cigarettes use e-cigarettes to try to quit smoking; however, some are not successful. Identifying factors that are associated with successfully quitting smoking using e-cigarettes is important for maximizing cigarette cessation.

AIMS AND METHODS

Online survey data were collected in 2021 from 857 adults in the United States who reported using e-cigarettes in a recent attempt to quit smoking. Survey items assessed patterns of e-cigarette use and device characteristics (flavors, device, and nicotine) used when trying to quit smoking. Multivariable linear regression models examined characteristics associated with the longest duration of smoking abstinence when using e-cigarettes to try to quit.

RESULTS

The average duration of smoking abstinence when using e-cigarettes during a quit attempt was 65 days (SD = 104). In the multivariable model, greater frequency of e-cigarette use when quitting and abruptly switching to e-cigarettes from cigarettes (vs. gradually reducing) were significantly associated with longer durations of abstinence (p < .001). Preference for non-tobacco (relative to tobacco) flavors and nicotine concentration were not associated with duration of abstinence, although preference for rechargeable pod and mod device types (vs. cig-a-likes) was associated with longer durations of abstinence.

CONCLUSIONS

Patterns of e-cigarette use were related to abstinence duration, which may provide guidance for adults who are using e-cigarettes to quit smoking to encourage complete substitution and maximize smoking cessation. Findings indicate that non-tobacco e-cigarette flavors and nicotine strength are not related to longer durations of cessation success for adults, which may inform tobacco regulatory policies limiting these constituents to protect public health.

IMPLICATIONS

This study provides important new information about the characteristics of e-cigarettes used during an attempt to quit smoking among adults across the United States and identifies factors associated with quitting success. Patterns of e-cigarette use were associated with longer durations of abstinence. In contrast, few e-cigarette characteristics were associated with abstinence. Although preference for some pod and mod device types was associated with longer abstinence duration compared to earlier cig-a-like devices, preference for non-tobacco (vs. tobacco) flavor and nicotine concentration were not associated with abstinence. Findings may help inform guidance for adults using e-cigarettes to quit smoking and support tobacco regulatory policies.

Pro-inflammatory effects of aerosols from e-cigarette-derived flavoring chemicals on murine macrophages

Macrophages treated with the flavoring chemicals found in flavored electronic cigarettes have been shown to induce an inflammatory response, however, limited data are available on the effect of aerosol exposure to these chemicals. We hypothesized that aerosol exposure to flavoring chemicals found in commercially available flavored e-liquids would result in an increase in pro-inflammatory cytokines in macrophages. Raw264.7 macrophage cell lines were exposed to a low and high dose of propylene glycol/vegetable glycerin (PG/VG) with almond flavoring benzaldehyde (280 μg/ml and 2.1 mg/ml), PG/VG with spicy/clove flavoring eugenol (3.5 mg/ml and 12 mg/ml), or PG/VG with apple flavoring hexyl acetate (500 μg/ml and 2.5 mg/ml). Exposure to PG/VG with 2.1 mg/ml benzaldehyde resulted in a significant increase in KC levels compared to air and PG/VG exposed cells. Exposure to PG/VG with both doses of hexyl acetate resulted in a significant increase in KC and IL-6 levels compared to air exposed cells. Exposure to PG/VG with both doses of eugenol resulted in a significant increase in KC and IL-6 levels compared to air and PG/VG exposed cells. These data indicate the ability of aerosol exposure to e-cigarette flavoring chemicals to significantly increase pro-inflammatory cytokine release in macrophages.

Evidence from an fMRI study that dessert-flavored e-cigarettes engage taste-related, but not smoking-related, brain circuitry for female daily smokers

Regulations limiting the sale of flavored e-cigarette products are controversial for their potential to interfere with e-cigarette use as a cessation aid in addition to curbing youth use. Limited research suggests that flavor might enhance the addictive potential of e-cigarettes; however, the acute effects of flavored aerosols on brain function among humans have not been assessed. The present study aimed to isolate and compare the neural substrates of flavored and unflavored e-cigarette aerosols on brain function among nine female daily smokers. Participants inhaled aerosolized e-liquid with 36 mg/mL of nicotine with and without a strawberry-vanilla flavor while undergoing functional magnetic resonance imaging. We used general linear modeling to compare whole-brain mean neural activation and seed-to-voxel task-based functional connectivity between the flavored and unflavored inhalation runs. Contrary to our hypothesis, the flavored aerosol was associated with weaker activation than the unflavored aerosol in the brain stem and bilateral parietal-temporal-occipital region of the cortex. Instead, the flavor engaged taste-related brain regions while suppressing activation of the neural circuits typically engaged during smoking and nicotine administration. Alternatively, functional connectivity between subcortical dopaminergic brain seeds and cortical brain regions involved in motivation and reward salience were stronger during the flavored compared to unflavored aerosol run. The findings suggest that fruity and dessert-flavored e-cigarettes may dampen the reward experience of aerosol inhalation for smokers who initiate e-cigarette use by inhibiting activation of dopaminergic brain circuits. These preliminary findings may have implications for understanding how regulations on flavored e-cigarettes might impact their use as cessation aids. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Electronic nicotine delivery systems (ENDS) flavours and devices used by adults before and after the 2020 US FDA ENDS enforcement priority: findings from the 2018 and 2020 US ITC Smoking and Vaping Surveys

Background

In February 2020, the US Food and Drug Administration (FDA) prioritised enforcement efforts against flavoured prefilled cartridge/pod electronic nicotine delivery systems (ENDS), with the exception of tobacco and menthol. This study examined changes between prepriority enforcement (2018) and early postenforcement (February–June 2020) among adults on: ENDS flavours and devices used most often; location of last purchase of fruit/other-flavoured cartridges (covered under the enforcement priority); and smoking and vaping.

Methods

Prevalence estimates came from 1608 adult frequent (≥weekly) ENDS users (current smokers (n=1072), ex-smokers (n=536)) who participated in the 2018 and/or 2020 US ITC Smoking and Vaping Surveys. Transitions between flavours/devices and changes in smoking/vaping were assessed among baseline respondents who were followed up in 2020 (n=360). Respondents self-reported the ENDS device (disposable, cartridge/pod or tank) and the flavor that they used most often: (1) tobacco flavors (tobacco/tobacco-menthol mix) or unflavored; (2) menthol/mint; (3) fruit/other flavors.

Results

Compared to 2018, in the first 5 months of the 2020 enforcement priority, there were significant increases in the prevalence of fruit/other-flavoured cartridges (7.9% to 12.4%,p=0.026) and menthol/mint cartridges (7.1% to 13.0%, p<0.01) and decreases in tobacco-flavoured tanks (15.5% to 10.0%,p=0.002) and fruit/other-flavoured tanks (38.7% to 33.6%,p=0.038). Fewer than 10% of adults used disposables in 2018 and 2020. Among the cohort sample, the most pronounced transitions between flavours/devices occurred among those who used flavoured cartridges covered under the enforcement priority (54.6% switched to a flavour and/or device excluded from enforcement). There was an increase in purchasing fruit/other-flavoured cartridges online and a decrease in retail locations except for vape shops. Overall, there were few changes in smoking and vaping behaviours.

Conclusions

Between 2018 and the early phase of the FDA’s 2020 enforcement priority, prevalence of menthol/mint and fruit/other-flavoured cartridges increased among adults. Half of vapers using cartridge flavours covered in the enforcement switched to other flavours and/or devices that were exempt, with the exception of disposables. The extent to which more comprehensive restrictions may be problematic for adults who prefer a range of ENDS flavours remains uncertain.

Expanding the E-Liquid Flavor Wheel: Classification of Emerging E-Liquid Flavors in Online Vape Shops

INTRODUCTION

Electronic cigarettes are the most popular tobacco product among U.S. youth, and over 80% of current youth users of e-cigarettes use flavored e-cigarettes, with fruit, mint/menthol, and candy/sweets being the most popular flavors. A number of new e-liquid flavors are currently emerging in the online e-cigarette market. Menthol and other flavored e-cigarettes could incentivize combustible tobacco smokers to transition to e-cigarette use.

METHODS

From February to May 2021, we scraped data of over 14,000 e-liquid products, including detailed descriptions of their flavors, from five national online vape shops. Building upon the existing e-liquid flavor wheel, we expanded the semantic databases (i.e., key terms) to identify flavors using WordNet-a major database for keyword matching and group discussion. Using the enriched databases, we classified 14,000+ e-liquid products into the following 11 main flavor categories: "fruit", "dessert/candy/sweets", "coffee/tea", "alcohol", "other beverages", "tobacco", "mint/menthol", "nuts", "spices/pepper", "other flavors", and "unspecified flavor".

RESULTS

We find that the most prominent flavor sold in the five online vape shop in 2021 was fruit flavored products, followed by dessert/candy/other sweets. Online vendors often label a product with several flavor profiles, such as fruit and menthol.

CONCLUSIONS

Given that online stores market products with multiple flavor profiles and most of their products contain fruit flavor, the FDA may have issued marketing denial orders to some of these products. It is important to further examine how online stores respond to the FDA flavor restrictions (e.g., compliance or non-compliance).

Associations Between E-cigarette Use and E-cigarette Flavors With Cigarette Smoking Quit Attempts and Quit Success: Evidence From a U.S. Large, Nationally Representative 2018-2019 Survey

INTRODUCTION

Although many studies have examined the association between e-cigarette use and smoking cessation, fewer have considered the impact of e-cigarette flavors on cessation outcomes. This study extends previous studies by examining the effects of e-cigarette use and e-cigarette flavors on quit attempts and quit success of smoking.

AIMS AND METHODS

We used data from the 2018-2019 Tobacco Use Supplement-Current Population Survey (TUS-CPS) survey. Multivariate logistic regression analyses were used to investigate the associations between flavored e-cigarette use with quit attempts and quit success of smoking among individuals who smoked 12 months ago. Two current e-cigarette use definitions were used in these logistic regression analyses; currently use every day or some days versus 20+ days in the past 30 days.

RESULTS

Compared to those not using e-cigarettes, current every day or someday e-cigarette use with all nontobacco flavors had an adjusted odds ratio (AOR) of 2.9 (95% CI: 2.4 to 3.5) for quit attempts and 1.7 (95% CI: 1.3 to 2.2) for quit success. 20+ days e-cigarette use with flavors had stronger associations with quit attempts (AOR = 4.2, 95% CI: 3.1 to 5.5) and quit success (AOR = 4.0, 95% CI: 2.9 to 5.4). E-cigarette users with nontobacco flavors were more likely to succeed in quitting compared to those exclusively using non-flavored or tobacco-flavored e-cigarettes. Menthol or mint flavor users had slightly higher odds of quit attempts and success than users of other nontobacco flavors.

CONCLUSIONS

E-cigarette use is positively associated with both making smoking quit attempts and quit success. Those using flavored e-cigarettes, particularly menthol or mint, are more likely to quit successfully.

IMPLICATIONS

E-cigarette use is positively associated with both making a quit attempt and quit success, and those using flavored e-cigarettes are more likely to successfully quit smoking, with no statistically significant differences between the use of menthol or mint-flavored e-cigarettes versus the use of other nontobacco flavored products. This suggests that the potential for e-cigarettes to help people who currently smoke quit could be maintained with the availability of menthol or mint-flavored e-cigarettes, even if other nontobacco flavored products, which are associated with e-cigarette use among youth, were removed from the market.

A Proposed Policy Agenda For Electronic Cigarettes In The US: Product, Price, Place, And Promotion

Growth in the market for electronic cigarettes (e-cigarettes) raises complex questions about the devices' public health implications and, hence, challenging policy issues. We propose a policy agenda addressing concerns about preventing youth uptake of e-cigarettes and the desire to realize the potential of e-cigarettes to increase adult cigarette smoking cessation. We organize interventions according to the "four Ps" of marketing: product, price, place, and promotion. Policies include decreasing the addictiveness of combusted tobacco products while ensuring the availability of consumer-acceptable reduced-risk nicotine products, imposing large taxes on combustible products and smaller taxes on e-cigarettes, limiting the sale of all tobacco and (nonmedicinal) nicotine products to adult-only retailers, and developing communications that accurately portray e-cigarettes' risks to youth and benefits for inveterate adult smokers. All members of the public health community should unite to pursue a shared commitment to the principle that both youth and adults deserve a future free of tobacco-related disease.

The Role of Nicotine and Flavor in the Abuse Potential and Appeal of Electronic Cigarettes for Adult Current and Former Cigarette and Electronic Cigarette Users: A Systematic Review

INTRODUCTION

Many adult cigarette smokers use electronic cigarettes (e-cigarettes) to cut down on or quit smoking cigarettes. E-cigarettes with higher abuse potential and appeal might facilitate complete switching. E-liquid nicotine concentration and flavor are two of the characteristics that may affect the abuse potential and appeal of e-cigarettes. The objective of this systematic review was to compile results from survey, animal, human laboratory, and clinical studies to understand the possible effects of nicotine concentration and flavor on abuse potential and appeal of e-cigarettes in adult current and former cigarette and e-cigarette users.

AIMS AND METHODS

A comprehensive literature search was conducted in Ovid Medline and PsycINFO followed by citation tracking in Web of Science Core Collection. Peer-reviewed studies published in English between 2007 and August 2020 were selected that analyzed differences between e-liquid nicotine concentration and/or flavors, had outcome measures related to abuse potential and/or appeal, and included adult humans (18+) or animals. A total of 1624 studies were identified and screened. A qualitative synthesis of results was performed.

RESULTS

Results from 104 studies included in this review suggest that higher nicotine concentration and access to a variety of flavors are likely to be associated with higher abuse potential and appeal of e-cigarettes for adult current and former cigarette and e-cigarette users.

CONCLUSIONS

Higher nicotine concentrations and the availability of a variety of flavors in e-cigarettes might facilitate complete substitution for cigarettes. Future e-cigarette regulations should take into account their impact on smokers, for whom e-cigarettes may be a cessation tool or reduced-harm alternative.

IMPLICATIONS

E-cigarettes may provide a reduced-harm alternative to cigarettes for smokers unwilling/unable to quit or serve as a path for quitting all nicotine products. Higher nicotine concentrations and flavor variety are associated with higher abuse potential and appeal of e-cigarettes. Higher abuse potential and appeal products may help facilitate complete switching from cigarettes to e-cigarettes. Regulation of nicotine concentration and flavors aimed at decreasing naïve uptake may inadvertently decrease uptake and complete switching among smokers, reducing the harm reduction potential of e-cigarettes. Evidence-based effects of regulating nicotine concentration and flavors must be considered for the population as a whole, including smokers.

Chemosensory Contributions of E-Cigarette Additives on Nicotine Use

While rates of smoking combustible cigarettes in the United States have trended down in recent years, use of electronic cigarettes (e-cigarettes) has dramatically increased, especially among adolescents. The vast majority of e-cigarette users consume "flavored" products that contain a variety of chemosensory-rich additives, and recent literature suggests that these additives have led to the current "teen vaping epidemic." This review, covering research from both human and rodent models, provides a comprehensive overview of the sensory implications of e-cigarette additives and what is currently known about their impact on nicotine use. In doing so, we specifically address the oronasal sensory contributions of e-cigarette additives. Finally, we summarize the existing gaps in the field and highlight future directions needed to better understand the powerful influence of these additives on nicotine use.

Balancing Consideration of the Risks and Benefits of E-Cigarettes

The topic of e-cigarettes is controversial. Opponents focus on e-cigarettes' risks for young people, while supporters emphasize the potential for e-cigarettes to assist smokers in quitting smoking. Most US health organizations, media coverage, and policymakers have focused primarily on risks to youths. Because of their messaging, much of the public-including most smokers-now consider e-cigarette use as dangerous as or more dangerous than smoking. By contrast, the National Academies of Science, Engineering, and Medicine concluded that e-cigarette use is likely far less hazardous than smoking. Policies intended to reduce adolescent vaping may also reduce adult smokers' use of e-cigarettes in quit attempts. Because evidence indicates that e-cigarette use can increase the odds of quitting smoking, many scientists, including this essay's authors, encourage the health community, media, and policymakers to more carefully weigh vaping's potential to reduce adult smoking-attributable mortality. We review the health risks of e-cigarette use, the likelihood that vaping increases smoking cessation, concerns about youth vaping, and the need to balance valid concerns about risks to youths with the potential benefits of increasing adult smoking cessation.

Vaping-Related Adverse Events and Perceived Health Improvements: A Cross-Sectional Survey among Daily E-Cigarette Users

Web-based samples of e-cigarette users commonly report significant vaping-related health improvements (HIs) and mild adverse events (AEs). This cross-sectional study with in-person interviewing data collection examined self-reported AEs and perceived HIs among Hungarian adult current daily exclusive e-cigarette (n = 65) and dual users (n = 127), and former daily e-cigarette users (n = 91) in 2018. Logistic regression was used to evaluate associations between reporting any AEs/HIs, vaping status, and covariates. More former users (52.7%) reported AEs than current users (39.6%; p = 0.038). Exclusive and dual daily users reported similar rates of AEs (44.6% and 37.0%, respectively; p = 0.308). More current users (46.9%) experienced HIs than former users (35.2%; p = 0.064). Exclusive daily users were more likely to report HIs than dual users (63.1% versus 38.6%; p = 0.001). Former user status and smoking cessation/reduction reasons increased the odds of reporting AEs, whereas nicotine-containing e-liquid use and older age decreased the odds of reporting AEs. Exclusive vaper status, using advanced generation devices, and smoking cessation/reduction reasons increased the odds of experiencing HIs. This study, which used a traditional data collection methodology, found a higher rate of AEs and a lower rate of HIs compared to web-based surveys. Our results highlight that experiencing AEs and HIs is affected by users’ characteristics, in addition to the device and e-liquid type.

Choice and Variety-Seeking of E-liquids and Flavor Categories by New Zealand Smokers Using an Electronic Cigarette: A Longitudinal Study

BACKGROUND

Little is currently known about how e-liquid flavor use evolves among electronic cigarette users. We describe patterns of e-liquid and flavor category use, and variety-seeking, among New Zealand adult smokers attempting to transition from smoking to e-cigarettes.

METHODS

Data were collected in 2018-19, using a longitudinal design comprising up to five in-depth interviews over a 12-20 week period. Participants (n = 32) were current smokers aged ≥18 years, who were not currently using an e-cigarette once a week or more often, and were willing to use an e-cigarette in an attempt to stop smoking. We purchased participants a starter e-cigarette of their choice; they supplied their own e-liquids throughout the study. We extracted e-liquid use data from the verbatim interview transcripts, categorized these into flavor categories, and then explored these data for the whole sample, and by flavor category purchased at intake.

RESULTS

Most participants (n = 12) selected a tobacco flavored e-liquid at intake; fruit (n = 7), mint/menthol (n = 6), and dessert/sweets and non-alcoholic beverage (both n = 5) were also popular. Most participants were still using their initially chosen flavor category at study exit, however, many described variety-seeking behaviors, which typically occurred during the first 12 weeks of enrolment.

CONCLUSION

Most participants did not follow a straightforward e-liquid or flavor category pathway. Evidence of a variety-seeking continuum, typically occurring within the first 12 weeks, suggests possible opportunities at specialist e-cigarette stores to couple e-liquid purchasing occasions with cessation advice.

IMPLICATIONS

Variety-seeking behavior was common and typically reported within the first 12 weeks of participants' e-cigarette-assisted attempt to transition away from smoking. Policies allowing diverse e-liquid flavors at specialist stores only could support users' variety-seeking and potentially create opportunities to couple e-liquid purchasing occasions with cessation advice during the first months of a transition attempt.

Patterns of E-cigarette Use and Subsequent Cigarette Smoking Cessation Over 2 Years (2013/2014-2015/2016) in the Population Assessment of Tobacco and Health Study

INTRODUCTION

Understanding the population impact of e-cigarettes requires determining their effect on cigarette smoking cessation.

METHODS

Using the US Population Assessment of Tobacco and Health cohort, we examined smoking cessation among adult current cigarette smokers at Wave 1 with follow-up data at Waves 2 and 3 (n = 9724).

RESULTS

By Wave 3 (2015/2016), 17.3% of smokers had quit smoking. Smokers using e-cigarettes daily or who increased to daily use over the three waves were two to four times more likely to have quit in the short term (<1 year) and long term (1+ years) compared with never e-cigarette users (p < .001). E-cigarette use in the last quit attempt was associated with a higher likelihood of short-term (<1 year) quitting at Wave 3 (adjusted relative risk ratio: 1.33; 95% confidence interval: 1.04, 1.71) compared with smokers who did not use an e-cigarette in their last quit attempt. Noncurrent (no use in any wave) e-cigarette users and users who were unstable in use frequency were 33% and 47% less likely to quit in the short-term, respectively (p < .001). Flavored (vs nonflavored) and using a rechargeable (vs disposable) e-cigarette device was associated with an increased likelihood of both short- and long-term quitting.

CONCLUSION

Smoking cessation was more likely among frequent e-cigarette users, users of e-cigarettes in last quit attempt, and users of flavored and rechargeable devices. Less frequent, unstable, past, or never e-cigarette users were less likely to quit smoking. Monitoring the relationship between patterns of e-cigarette and cigarette use is complex but critical for gauging the potential of e-cigarettes as a harm reduction tool.

IMPLICATIONS

This study suggests that consistent and frequent e-cigarette use over time is associated with cigarette smoking cessation among adults in the United States. In addition, findings suggest that flavored e-cigarette use and use of rechargeable e-cigarette devices can facilitate smoking cessation. These results underscore the importance of carefully defining and characterizing e-cigarette exposure patterns, potential confounders, and use of e-cigarettes to quit smoking, as well as variations in length of the smoking cessation.

The impact of flavored ENDS use among adolescents on daily use occasions and number of puffs, and next day intentions and willingness to vape

BACKGROUND

The FDA's policies restricting sale of sweet flavored cartridge-based and disposable electronic nicotine delivery systems (ENDS) comprise important steps toward curbing adolescent ENDS use. However, additional evidence is needed about the contribution of specific flavors to adolescents' ENDS use. This study investigated the effects of flavor use on same day vaping behaviors, and next day intentions and willingness.

METHODS

We collected ecological momentary assessments (EMA) from 50 adolescent past two-week vapers (ages 14-17) over 14 days. Daily EMA data were collected on vaping occasions, total puffs, vaping intentions, vaping willingness, and flavor used.

RESULTS

On average, data were obtained on 13.4 days per participant (670 observations). Participants vaped flavors on 87% of days (fruit = 55%; mint = 30%; tobacco = 6%; menthol = 5%, and candy, sweets, or chocolate = 5%). On days when participants vaped fruit flavors, they took more puffs (r = 0.13, p = .030). On days when they vaped tobacco flavor, they reported more vaping occasions (r = 0.20, p = .005) and more puffs (r = 0.15, p = .033). On days when they vaped because of flavor appeal, they reported more vaping occasions (r = 0.19, p = .001) and more puffs (r = 0.24, p < .001). On days when they vaped menthol flavor, they were less likely to report willingness to vape the next day (r = -0.14, p = .042). Adolescents who reported vaping due to flavor appeal were more likely to report intentions (OR = 5.63, p = .035) and willingness to vape the next day (r = 0.23, p < .001) CONCLUSION: These findings provide additional support for policies restricting the sale of flavored ENDS products to adolescents.

Analysis of on-pack messages for e-liquids: a discrete choice study

BACKGROUND

Policymakers wishing to encourage smokers unable to quit to switch to using electronic nicotine delivery systems (ENDS) also need to consider how to deter ENDS use among non-smokers. We examined whether reduced-risk messages could increase ENDS' appeal among smokers and if increased-risk messages could decrease appeal among susceptible non-smokers, occasional and former smokers.

METHODOLOGY

An online discrete choice experiment tested three attributes: information message, nicotine content (0 mg or 3 mg) and flavour (tobacco, menthol or fruit). The sample comprised 352 current smokers, 118 occasional and former smokers, and 216 ENDS-susceptible never smokers. Smokers viewed reduced-risk messages that encouraged switching to ENDS, while other groups viewed increased-risk messages that discouraged ENDS use. All groups saw a typical addiction warning. We analysed the data by estimating multinomial logit regression and adjusted latent class analysis models.

RESULTS

Relative to no message, reduced risk-messages increased the appeal of ENDS uptake among one class of smokers (33.5%) but decreased appeal among other smokers. However, among all smokers, reduced-risk messages increased preference more than a dissuasive addiction warning. By contrast, among occasional or former smokers, and susceptible non-smokers, all information messages discouraging ENDS use, including an addiction warning, decreased preference relative to no message.

CONCLUSIONS

On-pack relative-risk messages about ENDS could make transition more attractive to smokers while increased-risk messages could deter ENDS uptake among susceptible non-smokers, occasional and former smokers. Communicating diverse messages via discrete channels could recognise heterogeneity among and between smokers and non-smokers.

The Association of E-cigarette Flavors With Satisfaction, Enjoyment, and Trying to Quit or Stay Abstinent From Smoking Among Regular Adult Vapers From Canada and the United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey

Aims

This study examined whether nontobacco flavors are more commonly used by vapers (e-cigarette users) compared with tobacco flavor, described which flavors are most popular, and tested whether flavors are associated with: vaping satisfaction relative to smoking, level of enjoyment with vaping, reasons for using e-cigarettes, and making an attempt to quit smoking by smokers.

Methods

This cross-sectional study included 1603 adults from Canada and the United States who vaped at least weekly, and were either current smokers (concurrent users) or former smokers (exclusive vapers). Respondents were categorized into one of seven flavors they used most in the last month: tobacco, tobacco–menthol, unflavored, or one of the nontobacco flavors: menthol/mint, fruit, candy, or “other” (eg, coffee).

Results

Vapers use a wide range of flavors, with 63.1% using a nontobacco flavor. The most common flavor categories were fruit (29.4%) and tobacco (28.7%), followed by mint/menthol (14.4%) and candy (13.5%). Vapers using candy (41.0%, p < .0001) or fruit flavors (26.0%, p = .01) found vaping more satisfying (compared with smoking) than vapers using tobacco flavor (15.5%) and rated vaping as very/extremely enjoyable (fruit: 50.9%; candy: 60.9%) than those using tobacco flavor (39.4%). Among concurrent users, those using fruit (74.6%, p = .04) or candy flavors (81.1%, p = .003) were more likely than tobacco flavor users (63.5%) to vape in order to quit smoking. Flavor category was not associated with the likelihood of a quit attempt (p = .46). Among exclusive vapers, tobacco and nontobacco flavors were popular; however, those using tobacco (99.0%) were more likely than those using candy (72.8%, p = .002) or unflavored (42.5%, p = .005) to vape in order to stay quit.

Conclusions

A majority of regular vapers in Canada and the US use nontobacco flavors. Greater satisfaction and enjoyment with vaping are higher among fruit and candy flavor users. While it does not appear that certain flavors are associated with a greater propensity to attempt to quit smoking among concurrent users, nontobacco flavors are popular among former smokers who are exclusively vaping. Future research should determine the likely impact of flavor bans on those who are vaping to quit smoking or to stay quit.

Implications

Recent concerns about the attractiveness of e-cigarette flavors among youth have resulted in flavor restrictions in some jurisdictions of the United States and Canada. However, little is known about the possible consequences for current and former smokers if they no longer have access to their preferred flavors. This study shows that a variety of nontobacco flavors, especially fruit, are popular among adult vapers, particularly among those who have quit smoking and are now exclusively vaping. Limiting access to flavors may therefore reduce the appeal of e-cigarettes among adults who are trying to quit smoking or stay quit.

Dependence and Use Characteristics of Adult JUUL Electronic Cigarette Users

JUUL is a popular electronic cigarette (e-cig) that is capable of delivering nicotine similarly to a cigarette. While known to deliver high doses of nicotine, there is little systematic evidence to show how the nicotine delivery of JUUL translates to user dependence. Purpose: The purpose of the study was to evaluate self-reported dependence of JUUL users and examine the relationship of dependence to user behaviors. Methods: Current JUUL users were recruited via Amazon Mechanical Turk to complete an online survey about their use of JUUL. Participants were asked to complete the Penn State Electronic Cigarette Dependence Index (PSECDI) and to answer questions about their use patterns and other tobacco use. Means and frequencies were used to describe the sample. A linear regression model was used to predict user dependence. Results: Participants (n = 76) were 65.4% male with a mean age of 31.9 (SD = 8.3) years. The mean PSECDI score was 7.8 (SD = 4.2) and ranged from no (15.8%) to high (14.5%) dependence. Overall predictors of a greater PSECDI score included reporting ever stealth vaping (β = 2.8, p < .01) and reporting greater use days in the past 30 (β = 3.5, p < .01). Conclusions: On average, JUUL users reported low to medium nicotine dependence on the PSECDI. JUUL user dependence may be more similar to e-cig user dependence than cigarette smoker dependence. These preliminary findings should be followed up in studies of larger samples of Juul users, collecting multiple measures of dependence, as well as biomarkers of nicotine intake (e.g. cotinine).

Content Analysis of U.S. Newspaper Coverage of Causes and Solutions to Vaping-Associated Lung Injury

In 2019, an outbreak of vaping-associated lung injury (also known as "EVALI") spread throughout the U.S., linked to use of illicit THC cartridges. This paper examines U.S. newspaper coverage on the causes and solutions to EVALI. Methods: A content analysis of 417 articles from April to December 2019 from two national newspapers, one regional newspaper, and the Associated Press was conducted. Articles were coded for information about EVALI causes, mentions of the brand Dank Vapes, calls for individuals take a specific action to prevent harm, and mentions of policy actions to address vaping. Mentions of increasing youth vaping and JUUL were also coded. Results: Most articles (77%) provided an update on the number of EVALI cases and/or deaths. Fewer described EVALI symptoms (20%) or mentioned vaping cessation resources available to the public (2%). Almost half of articles also mentioned youth vaping as a concern (49%). Dank Vapes was mentioned rarely (4%) compared to JUUL (39%). After CDC recommendations changed to no longer recommend avoiding all vaping products, news articles became significantly less likely to mention nicotine products as a cause of EVALI or suggest that individuals cease all vaping. While policy was generally not articulated as a solution to EVALI, banning or limiting flavored nicotine vaping products were the most common policy actions mentioned. Conclusions/Importance: The discussions of causes of and solutions to EVALI were often intertwined with coverage of youth vaping, potentially failing to convey a clear sense of how the public should respond to the EVALI outbreak.

Response to Flavored Cartridge/Pod-Based Product Ban among Adult JUUL Users: "You Get Nicotine However You Can Get It"

In order to curb increasing youth electronic cigarette (e-cig) use, the United States Food and Drug Administration (FDA) banned the sale of flavored cartridge/pod-based products in February 2020. This mixed-methods study aimed to evaluate the impact of the FDA ban on adult JUUL users. The samples of current adult JUUL users were surveyed via Amazon Mechanical Turk at three time-points n = 76 (Sample 1); n = 128 (Sample 2); n = 86 (Sample 3) before and after the FDA flavored/pod ban. The participants were asked to report the JUUL flavored pod used most often and answer questions on purchasing generic pods or refilling (Quantitative). JUUL users were then interviewed in order to explore their perceptions and behaviors related to the FDA ban of flavored cartridge/pod-based products (Qualitative; n = 16). Quantitative data analysis evaluated the differences in variables by time-point. Qualitative data were coded into themes while using the constant comparative method. We found a significant decrease in the use of mint pods (43.4%, 22.7%, 16.3%) (p < 0.01), while there was a significant increase in the use of menthol pods (6.6%, 26.6%, 37.2%) (p < 0.01). Themes that emerged from the qualitative data included switching from mint to menthol pods, refilling pods, and switching to other products that are available in the desired flavors, such as generic pods or disposable e-cigs. Future research is needed in order to evaluate the impact of these behaviors on public health.

Current Perspectives on Characteristics, Compositions, and Toxicological Effects of E-Cigarettes Containing Tobacco and Menthol/Mint Flavors

Electronic nicotine delivery systems/devices (ENDS) such as electronic cigarettes (e-cigarettes) have been made available globally, with the intent to reduce tobacco smoking. To make these products more appealing to young adults, many brands have added flavoring agents. However, these flavoring agents are shown to progressively result in lung toxicity when inhaled via e-cigarettes. While recent federal regulations have banned the sale of flavored e-cigarettes other than tobacco or menthol flavors, concerns have been raised about the health effects of even these flavors. In this review, we evaluate the current toxicological data with regard to effects upon exposure in animal models and in vitro cell culture for these popular flavorants. We have tabulated the current e-cigarette products containing these most common flavors (menthol, mint, and tobacco) in the market. We have also indicated the prevalence of tobacco and menthol-flavor use among e-cigarette users and highlighted the possible challenges and benefits that will result from new federal regulations.

Flavor Inconsistencies between Flavored Tobacco Products among US Adults

Objective: Banning flavors in some tobacco products, while allowing them in others, may shift consumer preferences towards products in which flavors are still allowed. In this study, we examine flavor popularity and inconsistencies in flavor preference across non-cigarette tobacco products among US adults. Methods: We used data from the Population Assessment of Tobacco and Health Study Wave 3 to assess the prevalence of flavor preference for users of non-cigarette tobacco products (N = 9037), as well as flavor inconsistencies between products among polyusers (N = 3183). Results: Most users of flavored tobacco products reported using one flavor category per product. Fruit and tobacco were among the most commonly used flavor categories of ENDS, hookah, traditional cigars, and cigarillo/filtered cigars. Menthol/mint was the most common flavor among snus/smokeless users. Polyusers of ENDS and traditional cigars had the largest inconsistency, where about 68%-76% used different flavors across products. Conversely, polyusers of traditional cigars and cigarillos/filtered cigars had the lowest inconsistency (25%-28%). Conclusions: Flavor preferences differed according to product, suggesting that consumers are not likely to switch across products to maintain a flavor preference. Future research should assess flavor preferences prospectively to improve understanding of the potential benefits of flavor bans.

Pod-based menthol and tobacco flavored e-cigarettes cause mitochondrial dysfunction in lung epithelial cells

Current FDA regulations have resulted in a ban of flavored e-cigarette pods, with only menthol and tobacco flavored pods being exempted. Previous work using menthol and tobacco-flavored e-cigarettes have been shown to induce mitochondrial reactive oxygen species. We hypothesized that exposure to pod-based JUUL Menthol and Virginia Tobacco aerosols will alter mitochondrial respiration and electron transport chain protein levels. We determined mitochondrial respiration by using a Seahorse technique and electron transport chain complexes by total OXPHOS antibodies after exposing lung epithelial cells, Beas-2b, to pod-based Menthol and Virginia Tobacco flavored aerosols. Menthol pod exposure resulted in an immediate increase in proton leak and decrease in coupling efficiency, as well as a decrease in complex I, II, and IV. Menthol pod exposure twenty-four hour post-exposure resulted in a decrease in basal respiration, maximal respiration, and spare capacity, as well as a decrease in complex I. Tobacco pod exposure resulted in no significant alterations to mitochondrial respiration, but immediately post final exposure resulted in a significant increase in complex I, IV, and V. Our results indicate that exposure to Menthol flavored e-cigarette pods cause mitochondrial dysfunction in lung epithelial cells.