Electronic Nicotine Delivery Systems

Factors that influence cannabis vaping habits of college students: A qualitative study

Objective: The purpose of this study is to examine the attitudes and perceptions of college undergraduates regarding cannabis vaping. Participants: Twenty-one, predominantly male (71.4%; Mage = 22, SD = 2.09), undergraduate college students who reported vaping cannabis in the past 30 days. Methods: Participants were interviewed to determine their attitudes and perceptions regarding cannabis vaping. Findings: Thematic analysis uncovered six primary themes and eighteen subthemes. Main themes included (1) Convenience, (2) Discreetness, (3) Mood-Altering Experience, (4) Social Acceptability, (5) Health and Safety, and (6) COVID-19 Pandemic Impact. Conclusion: College students who use cannabis tend to both vape and use combustible methods, depending upon social and physical environment. This population tends to vaporize cannabis for its perceived mood-altering properties. Additional research is needed to further examine the behaviors and attitudes surrounding cannabis vaping among college undergraduates, as well as the development of interventions specific to this demographic.

Sensitivity of Mouse Lung Nuclear Receptors to Electronic Cigarette Aerosols and Influence of Sex Differences: A Pilot Study

The emerging concern about chemicals in electronic cigarettes, even those without nicotine, demands the development of advanced criteria for their exposure and risk assessment. This study aims to highlight the sensitivity of lung nuclear receptors (NRs) to electronic cigarette e-liquids, independent of nicotine presence, and the influence of the sex variable on these effects. Adult male and female C57BL/6J mice were exposed to electronic cigarettes with 0%, 3%, and 6% nicotine daily (70 mL, 3.3 s, 1 puff per min/30 min) for 14 days, using the inExpose full body chamber (SCIREQ). Following exposure, lung tissues were harvested, and RNA extracted. The expression of 84 NRs was determined using the RT2 profiler mRNA array (Qiagen). Results exhibit a high sensitivity to e-liquid exposure irrespective of the presence of nicotine, with differential expression of NRs, including one (females) and twenty-four (males) in 0% nicotine groups compared to non-exposed control mice. However, nicotine-dependent results were also significant with seven NRs (females), fifty-three NRs (males) in 3% and twenty-three NRs (female) twenty-nine NRs (male) in 6% nicotine groups, compared to 0% nicotine mice. Sex-specific changes were significant, but sex-related differences were not observed. The study provides a strong rationale for further investigation.

Food insecurity and use of electronic vapor products among high school students

Background: Studies have shown that food insecurity is associated with electronic vapor products (EVP) use in adults; however, an understanding of this relationship in adolescents is needed to inform prevention efforts in this age group. Aim: Examine the relationship of food insecurity with EVP use patterns, frequency and source of acquisition in high school students. Methods: This cross-sectional study used Youth Risk Behavior Survey (YRBS) 2019 data from states that incorporated the YRBS' optional food insecurity question. The data included 42,154 high school students with complete information on food insecurity and two EVP-related questions. Responses to EVP-related questions identified "ever users," "current users," "former users," "current dual EVP-cigarette users," and assessed "frequency of EVP use among current users" and "source of EVP acquisition." Logistic regression examined associations of food insecurity with EVP-related outcomes. Results: The proportion of high school students who ever used EVP was 48.3% and the proportion of food-insecure students was about 12%. Food security status significantly differed by race/ethnicity of students, such that the proportion of food insecure students classified as "non-Hispanic White" was lower than the proportion of food secure students classified as "non-Hispanic White." Food insecurity was significantly associated with greater odds of ever EVP use (odds ratio (OR) = 1.75; 95% confidence interval (CI) = (1.55, 1.96)), current EVP use (OR = 2.07; 95% CI = (1.80, 2.37); using never users as reference category) and current dual use of EVP and cigarettes (OR = 2.91; 95% CI = (2.38, 3.55)). Food insecurity also was associated with greater odds of current EVP use (OR = 1.54; 95% CI = (1.28, 1.84)) when former users were used as reference category. In current users, food insecurity was related to greater odds of daily EVP use (OR = 1.40; 95% CI = (1.14, 1.70)) compared to occasional use. Conclusions: Study findings imply that efforts targeting prevention/cessation of EVP use should consider reducing food insecurity in high school students.

Metal Concentrations in E-Cigarette Aerosol Samples: A Comparison by Device Type and Flavor

BACKGROUND

The rapid evolution of electronic cigarette (e-cigarette) products warrants surveillance of the differences in exposure across device types-modifiable devices (MODs), cartridge ("pod")-containing devices (PODs), disposable PODs (d-PODs)-and flavors of the products available on the market.

OBJECTIVE

This study aimed to measure and compare metal aerosol concentrations by device type and common flavors.

METHODS

We collected aerosol from 104 MODs, 67 PODs (four brands: JUUL, Bo, Suorin, PHIX), and 23 d-PODs (three brands: ZPOD, Bidi, Stig) via droplet deposition in a series of conical pipette tips. Metals and metalloids [aluminum (Al), arsenic (As), cobalt (Co), chromium (Cr), copper (Cu), iron (Fe), manganese (Mn), nickel (Ni), lead (Pb), antimony (Sb), tin (Sn), and zinc (Zn)] were measured using inductively coupled plasma mass spectrometry (ICP-MS), results were log-transformed for statistical analysis, and concentrations are reported in aerosol units (mg / m 3 ).

RESULTS

Of the 12 elements analyzed, concentrations were statistically significantly higher in MOD devices, except for Co and Ni, which were higher in PODs and d-PODs. Of the POD brands analyzed, PHIX had the highest median concentrations among four metals (Al, Ni, Pb, and Sn) compared to the rest of the POD brands. According to POD flavor, seven metals were three to seven orders of magnitude higher in tobacco-flavored aerosol compared to those in mint and mango flavors. Among the d-POD brands, concentrations of four metals (Al, Cu, Ni, and Pb) were higher in the ZPOD brand than in Bidi Stick and Stig devices. According to d-POD flavor, only Cr concentrations were found to be statistically significantly higher in mint than tobacco-flavored d-PODs.

DISCUSSION

We observed wide variability in aerosol metal concentrations within and between the different e-cigarette device types, brands, and flavors. Overall, MOD devices generated aerosols with higher metal concentrations than PODs and d-PODs, and tobacco-flavored aerosols contained the highest metal concentrations. Continued research is needed to evaluate additional factors (i.e., nicotine type) that contribute to metal exposure from new and emerging e-cigarette devices in order to inform policy. https://doi.org/10.1289/EHP11921.

E-Cigarettes and Associated Health Risks: An Update on Cancer Potential

The potential cancer risk associated with electronic-cigarette (e-cigarette) use is ongoing and remains a subject of debate. E-Cigarettes work by heating a liquid that usually contains nicotine, flavorings, and other chemicals. When the liquid is heated, users inhale an aerosol into their lungs. While e-cigarettes are generally considered less harmful than traditional tobacco products, they still contain potentially harmful chemicals, which can damage DNA and lead to cancer. Several studies have investigated the potential cancer risk associated with e-cigarette use, while other studies have suggested that e-cigarette aerosol may contain carcinogenic chemicals that could increase the risk of lung and bladder cancer in humans. However, these studies are limited in their scope and do not provide conclusive evidence. Overall, the long-term cancer risk associated with e-cigarette use remains uncertain, more research is needed to fully understand the potential risks and benefits of e-cigarettes. However, this review will allow the investigator to get more recent updates about e-cigarettes.

Quick nic: novel smokeless nicotine products and pediatric trends

PURPOSE OF REVIEW

The development and marketing of smokeless nicotine products in recent years have become increasingly popular among adolescents. In addition to well known conventional inhaled nicotine products, noninhaled products, such as nicotine toothpicks, orbs, lozenges, strips, and more, have dangerously captivated a new youth audience. Although smokeless nicotine products may seem to be less threatening than conventional inhaled nicotine products, there are significant risks associated with the use of these products, including addiction and severe health issues. The purpose of this review is to provide up-to-date information about alternative nicotine products currently on the market that may appeal to youth, and the dangers of nicotine use for pediatric populations.

RECENT FINDINGS

Smokeless nicotine products appeal to minors with their varying flavors and discrete packaging. These products may lead to nicotine toxicity as well as severe health problems, such as cancer, issues with reproduction, and heart attacks. Nicotine is extremely dangerous for young children; in fact, using nicotine products before the age of 18 years can lead to addiction and is linked to an increased likelihood of experimenting with stronger nicotine products or illicit drugs. The development of inconspicuous nicotine packaging has led to increasing concerns for accidental nicotine exposure and overdose in youth.

SUMMARY

Greater knowledge regarding current nicotine products on the market, specifically smokeless nicotine products, will help clinicians be more aware of the dangers associated with these products. Clinicians will be better able to provide their patients and families with proper guidance to avoid nicotine addiction, further drug use, and detrimental health issues. Caregivers and medical professionals must recognize novel and inconspicuous nicotine products commonly used among youth, understand the signs of nicotine abuse and dependence, and take measures to address possible nicotine-related health risks.

Vape-associated lung injury in immediate postoperative period: an upcoming perioperative respiratory risk factor

There has been a rapid increase in e-cigarette usage, especially among young adults. E-cigarettes are often thought to be a safe substitute to traditional smoking and are frequently used as a bridge to smoking cessation. E-cigarette or vaping product use-associated lung injury often presents with subacute or acute respiratory failure. We report a case of a young man in his 20s, who developed rapidly worsening respiratory failure in the postoperative period. This case highlights the importance of recognising this entity on time, especially in the perioperative period, and its impact on patient outcomes.

Impact of a Multidisciplinary Curriculum Training Students and Residents in Tobacco Cessation Strategies for Adult Caregivers of Children

Introduction

Children's exposure to secondhand smoke is an underaddressed public health threat. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated framework that trains pediatric providers to screen, counsel, refer to quitlines, and prescribe tobacco cessation medications to adult caregivers of children.

Methods

A physician champion at a major urban academic center delivered a longitudinal didactic curriculum of CEASE principles to medical and nurse practitioner students and pediatrics and family medicine residents. At the end of each session, participants completed an anonymous survey measuring changes in self-perceived knowledge, comfort, and familiarity with smoking cessation skills and concepts. Using a separate end-of-year questionnaire, we also surveyed a group of pediatric residents to compare the impact of CEASE training on clinical practice. Finally, we tracked the number of referrals to the state's quitline for the duration of the training.

Results

Fifty-two trainees (55% students, 45% residents) responded to the evaluation survey administered immediately following training. There were statistically significant improvements in median scores after CEASE training for comfort in screening, counseling, motivational interviewing, referring to smokers' helplines, and providing caregivers with nicotine replacement therapy (NRT) prescriptions. Fifty-one percent of pediatric residents (41 of 80) responded to the end-of-year survey, which showed statistically significant differences in the number of patients/caregivers offered a referral to California's quitline and prescription of NRT according to completion of CEASE training.

Discussion

CEASE training successfully improved the self-efficacy of health professions students and residents in smoking cessation techniques for adult caregivers of children.

Youth's engagement and perceptions of disposable e-cigarettes: a UK focus group study

OBJECTIVES

Evidence suggests that use of flavoured disposable electronic cigarettes (e-cigarettes) is increasing. Considering the growing popularity and rapid evolution of e-cigarettes, we explored youth's perceptions and engagement with disposable e-cigarettes.

DESIGN

Twenty focus groups were conducted between March and May 2022, with 82 youths aged 11-16 living in the Central belt of Scotland.

METHODS

Youths were asked about smoking and vaping behaviours and disposable e-cigarettes and were shown vaping-related images and videos from social media which were used to stimulate discussion about different messages, presentations and contextual features. Transcripts were imported into NVivo V.12, coded thematically, and analysed.

RESULTS

Youths described disposable e-cigarettes as 'cool', 'fashionable' and enticing and viewed as a modern lifestyle 'accessory'. Tank models were perceived as being used by older adults. Youths stated that disposable e-cigarettes were designed in a way to target youths and the brightly coloured devices and range of flavourings encouraged youths to want to try the products, particularly sweet flavourings. Participants perceived e-cigarettes to be less harmful compared with combustible cigarettes but noted the uncertainty of ingredients in disposable e-cigarettes.

CONCLUSIONS

Youths distinguish between e-cigarettes with varying characteristics and social perceptions of users. These findings provide evidence that disposable e-cigarettes are attractive to youths. Future research is needed to understand the factors that contribute to youth perceptions of disposable e-cigarettes. Policymakers should work together to design and implement policies and strategies to prevent youth uptake of vaping.

Impacts of a Multicenter Medical Education Curriculum for Training Pediatric Residents on Tobacco Cessation for Adult Caregivers of Pediatric Patients

The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers' ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers' quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients' caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents' attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

How Does Social Media Exposure and Engagement Influence College Students' Use of ENDS Products? A Cross-lagged Longitudinal Study

Electronic nicotine delivery systems (ENDS) products have been marketed heavily on social media throughout the past years, which exerts great influence on young adults' ENDS use. Despite scholars' pioneering efforts in investigating the influence of tobacco and nicotine products marketing on young adults' vaping behavior, scholarly attention has been paid primarily to passive exposure to rather than active engagement with the information on social media. In addition, the majority of existing research has been cross-sectional or focused on the unidirectional path from marketing information to behavior. To extend previous research in tobacco regulatory science on new media, we examined the bidirectional associations between self-reported exposure to and engagement with tobacco and nicotine products messaging on social media, and subsequent use of ENDS products one year later among a large, diverse sample of young adults. Results from cross-lagged panel analyses indicated that pro-tobacco/ENDS engagement and advertising exposure elevated risk whereas anti-tobacco/ENDS engagement decreased risk for the subsequent use of ENDS products one year later. On the other hand, the use of ENDS products positively predicted both pro- and anti-tobacco/ENDS engagement one year later. Findings provide empirical support for the reasoned action approach and the confirmation bias rooted in cognitive dissonance theory through rigorous longitudinal examination. Our findings not only point to the imperativeness of and offer guidance for regulating marketing information on social media, but also suggest social media as a promising platform to prevent young adults from initiating ENDS product use.

Health effects and known pathology associated with the use of E-cigarettes

In recent years, new nicotine delivery methods have emerged, and many users are choosing electronic cigarettes (e-cigarettes) over traditional tobacco cigarettes. E-cigarette use is very popular among adolescents, with more than 3.5 million currently using these products in the US. Despite the increased prevalence of e-cigarette use, there is limited knowledge regarding the health impact of e-cigarettes on the general population. Based on published findings by others, E-cigarette is associated with lung injury outbreak, which increased health and safety concerns related to consuming this product. Different components of e-cigarettes, including food-safe liquid solvents and flavorings, can cause health issues related to pneumonia, pulmonary injury, and bronchiolitis. In addition, e-cigarettes contain alarmingly high levels of carcinogens and toxicants that may have long-lasting effects on other organ systems, including the development of neurological manifestations, lung cancer, cardiovascular disorders, and tooth decay. Despite the well- documented potential for harm, e-cigarettes do not appear to increase susceptibility to SARS-CoV- 2 infection. Furthermore, some studies have found that e-cigarette users experience improvements in lung health and minimal adverse effects. Therefore, more studies are needed to provide a definitive conclusion on the long-term safety of e-cigarettes. The purpose of this review is to inform the readers about the possible health-risks associated with the use of e-cigarettes, especially among the group of young and young-adults, from a molecular biology point of view.

Effects of tobacco smoke on indoor air quality: the use of mosses in biomonitoring

This research was carried out to assess the possibility of using Pleurozium schreberi mosses as bioindicators of atmospheric aerosol pollution in living quarters (kitchen and bedroom), with metals originating from tobacco smoke from various types of cigarettes: conventional cigarettes, e-cigarettes and heated tobacco products. The moss-bag method of active biomonitoring was used. The mosses were exposed in these indoor spaces for three months and, after the exposition period, their analytes - Ni, Cu, Zn, Cd and Pb - were determined using flame atomic absorption spectrometry (F-AAS). Results were interpreted using the relative accumulation factors (RAF), coefficients of variation (CV) and the Wilcoxon test. As a result of the research, it was found that there were statistically significant differences in Zn and Cd concentrations in tobacco smoke from different types of cigarettes. The analyses showed that heated tobacco products contaminate indoor air with metals, similar to conventional cigarettes and e-cigarettes. It was demonstrated that the reliability of biomonitoring results was affected, for example, by the method of preparation of bioindicator samples, such as mosses.

Health Care Professionals' Clinical Skills to Address Vaping and e-Cigarette Use by Patients: Needs and Interest Questionnaire Study

BACKGROUND

Widespread vaping and e-cigarette use is a relatively new phenomenon. Youth vaping peaked in 2019, with over 25% of high school students currently vaping. e-Cigarettes are used where smoking is not permitted or as an alternative smoking cessation treatment instead of Food and Drug Administration-approved options. Vaping and e-cigarette use has the potential to harm health, including causing adverse respiratory effects and nicotine addiction. Health care professionals need skills training to help their patients with this relatively new and evolving health problem.

OBJECTIVE

The aim of this study is to understand health care professionals' training needs in this subject area to determine the focus for web-based continuing education training.

METHODS

We reviewed the literature on clinical aspects of vaping and e-cigarette use. Using the results and our experience in substance use continuing education, we created a list of key clinical skills and surveyed health care professionals about their training needs. We also asked about their interest in a list of related topics. We recruited individuals who completed our web-based courses on substance use, members of health care professional-related groups, and experts who had published an article on the subject. Half of the 31 health care professionals who completed the survey were physicians and the remainder were primarily nurses, social workers, and counselors. Participants self-identified as nonexperts (n=25) and experts (n=6) on vaping.

RESULTS

Participants who were nonexperts on average agreed or strongly agreed that they needed training in each of 8 clinical skills (n=25; range 3.7-4.4 agreement out of 5). The top two skills were recommending treatments for patients (4.4 out of 5, SD 0.49) and evaluating and treating the health effects of vaping and e-cigarette use (4.4 out of 5, SD 0.50). Experts agreed on the importance of training for health care professionals in all skills but rated the need for training higher than nonexperts for each topic. Over half of the participating health care professionals (44%-80%) were interested in nearly all (9/10, 90%) vaping-related topics on a checklist. The topics participants were most interested in were the pros and cons of vaping versus smoking and the health effects of second- and third-hand vaping. Primary care physicians showed more interest in vaping-related topics than nonprimary care physicians (t13=2.17; P=.02).

CONCLUSIONS

This study confirmed gaps in health care professionals' vaping-related clinical skills identified in the literature by identifying a perceived need for training in related skills and health care professionals' interest in key topics related to vaping prevention and cessation. This study provides specific guidance on which clinical skills training is most needed and which topics are most interesting to health care professionals.

Acute injury or illness related to the inhalation of vaping aerosols among children and adolescents across Canada: A cross-sectional survey of Canadian paediatricians

Background

Vaping prevalence rates have increased among Canadian youth. Evidence suggests that vaping poses significant health risks to children and adolescents.

Objectives

The objectives of the study were to investigate epidemiological characteristics of acute injury/illness cases due to the inhalation of vaping aerosols among children and adolescents across Canada and to explore factors contributing to severe cases.

Methods

Data from the 2019 Canadian Paediatric Surveillance Program cross-sectional survey on vaping-related injury/illness were used. Analyses focused on injury/illness cases (n=71) among children and adolescents aged 0 to 17 years who presented to participating paediatricians for a harm related to the inhalation of vaping aerosols. We conducted descriptive analyses and performed logistic regression to explore associations between severe presentations requiring hospitalization or intensive care unit (ICU) admission and selected case characteristics.

Results

Of the 71 reported injury/illness cases related to inhalation of vaping aerosols, 56% of patients were male, and 68% were aged 15 to 17 years. Nicotine vaping was reported in 42% of cases, and cannabis vaping in 24%. Fifty-four per cent presented with respiratory distress, 18% with symptoms of nicotine toxicity, and 41% required hospitalization and/or admission to the ICU. Cases presenting with respiratory distress were more likely to be hospitalized/admitted to the ICU (odds ratio [OR]=5.37, 95% confidence interval [CI]:1.76 to 16.39).

Conclusions

The inhalation of vaping aerosols among children and adolescents may contribute to acute injury/illness. Clear associations between study variables and severe cases could not be established due to a small sample size. Additional research is needed to determine predictors and preventable risk factors of severe vaping-related injuries.

Managing intoxications with nicotine-containing e-liquids

INTRODUCTION

Nicotine is an addictive and poisonous agent. The recent development of e-cigarettes has caused a new demand for highly concentrated nicotine-containing solutions. These concentrated nicotine solutions have also increased the risk of nicotine overdoses.

AREAS COVERED

Essential factors for nicotine exposure are the concentration of the nicotine-containing e-liquid solution and its pharmacokinetics. Liquid nicotine refills contain nicotine in varying concentrations, which vary widely between and within products. The pharmacokinetics of nicotine are dependent on the route of administration, renal/hepatic clearance and urinary pH. The dose is another essential determinant of nicotine exposure. There is a considerable discrepancy between the generally accepted lethal dose and symptoms reported in case studies. Ingested doses correlate poorly to clinical symptoms. Symptoms of liquid nicotine toxicity vary from mild to severe between patients and are the result of overstimulation of nicotinic acetylcholine receptors, which may lead to fatal respiratory failure and cardiovascular collapse.

EXPERT OPINION

The literature on nicotine-containing e-liquid intoxications originating from vaping device refills are mainly case reports. Based on these case reports, we propose a treatment plan which is primarily symptomatic. Research should focus on providing insight on its toxicity, based on oral and transdermal pharmacokinetics and on toxicodynamics.

La protection des enfants et des adolescents contre les risques du vapotage

Le vapotage chez les jeunes comporte des risques importants pour la santé et la sécurité des enfants et des adolescents canadiens. Le présent document de principes fournit de l'information générale sur le vapotage et les produits et dispositifs qui y sont liés, traite des méfaits à court et à long terme associés à leur utilisation et propose des stratégies de prévention et d'abandon pour les jeunes vapoteurs ou ceux qui sont à risque de commencer à vapoter. Le vapotage chez les jeunes est associé à un risque accru d'usage de tabac et de substances psychoactives, de troubles de santé mentale, de pneumopathie, de cardiopathie et de blessures accidentelles. Le vapotage ne doit pas servir d'outil d'abandon du tabac chez les jeunes, en raison de son manque d'efficacité et des données probantes sur les méfaits qu'il occasionne. De nombreuses stratégies préventives et thérapeutiques utilisées pour l'abandon du tabac, y compris les stratégies comportementales et pharmacologiques, peuvent être adaptées pour aider les jeunes à arrêter de vapoter. Des recommandations sont formulées pour les intervenants communautaires et les décideurs.

Protecting children and adolescents against the risks of vaping

Youth vaping presents significant risks for the health and safety of Canadian children and adolescents. This statement provides background information about vaping, vaping products, and related devices, discusses the short- and long-term harms known to be associated with their use, and offers prevention and cessation strategies for youth who vape or are at risk for starting. Youth vaping is associated with increased risk for tobacco and other substance use, mental health problems, pulmonary and cardiovascular disease, and unintentional injuries. Vaping should not be used as a smoking cessation tool for youth, due to lack of effectiveness and evidence of harm. Many preventive and treatment strategies used for tobacco cessation, including behavioural and pharmacological options, can be adapted to help youth quit vaping. Recommendations for community stakeholders and policy makers are included.

Restricting the Sale of Electronic Nicotine Delivery System Flavors

Electronic nicotine delivery system use contributes to the epidemic of youth vaping. Regulations to curtail or prohibit the sale of flavored nicotine products aim to disrupt initiation of child nicotine use by reducing access to enticing nicotine flavorings. A total of 6 states and >300 localities have restricted or banned flavored nicotine product sales. In this case study, we outline the use of a localized town-based strategy, which offered 2 potential bills to incrementally restrict or prohibit sale of flavored vape products when county or state legislation was not politically feasible. Over the course of 18 months, these bills reduced the number of municipalities where these products could be sold or advertised until county, city, and statewide bans were effectively in place, ultimately making the passage of a bill in the statehouse palatable. Strong partnerships with officials who had expertise in local town government, local American Academy of Pediatrics chapter physician champions, and a diverse coalition were instrumental in motivating smaller governments, which often pass legislation faster than larger legislatures, to create child-protective tobacco policies.

Electronic Vapor Product Use and Sexual Risk Behaviors in US Adolescents

BACKGROUND AND OBJECTIVES

Adolescent electronic vapor product (EVP) usage continues to increase and is associated with heightened engagement in other risk behaviors. However, there is limited research on associations between youth EVP use and sexual risk behaviors (SRBs). In this study, we examined how current youth EVP and/or cigarette usage, as well as EVP usage frequency, is related to several SRBs.

METHODS

Respondents (N = 12 667) of the 2017 National Youth Risk Behavior Survey were categorized by previous 30-day EVP and/or cigarette usage: nonuse, EVP use only, cigarette use only, or dual use. Separately, respondents were categorized by previous 30-day EVP usage frequency: 0, 1 to 9, 10 to 29, or 30 days. Ten SRBs were identified as dependent variables. Adjusted prevalence ratios were calculated by using modified Poisson regression to determine associations between SRBs and both current EVP and/or cigarette usage and EVP usage frequency. Linear contrasts compared adjusted prevalence ratios across usage and frequency categories.

RESULTS

Youth EVP-only users and dual users were more likely than nonusers to engage in 9 of 10 SRBs. Prevalence proportions did not differ between EVP-only users and dual users for 7 of 10 behaviors. Occasional EVP users were more likely than nonusers to engage in 9 of 10 SRBs and were similarly as likely as frequent and daily users to engage in all 10 SRBs.

CONCLUSIONS

EVP usage among US high school students, with or without concurrent cigarette use, was associated with heightened engagement in several SRBs. Prevalence of engagement in most SRBs did not differ among occasional, frequent, and daily EVP users.

Flavors Enhance Nicotine Vapor Self-administration in Male Mice

INTRODUCTION

Although the use of combustible cigarettes has decreased in many urban regions of America, the use of electronic nicotine delivery systems (ENDS) has dramatically increased. ENDS, or electronic cigarettes (e-cigarettes), differ from combustible cigarettes given that there are no restrictions on flavorant additives in e-liquids. With 95% of ENDS users vaping flavored e-liquids, it is critical to understand how flavors alter vaping-related behaviors. We have previously shown that menthol and green apple flavors enhance nicotine reward-related behavior in a mouse model and in the present study have investigated how menthol and green apple flavors alter e-Vape self-administration behavior in male mice.

METHODS

Adult C57/BL6J male mice were used in vapor-inhalation self-administration assays. Mice were assigned vaping e-liquids (6 mg/mL nicotine with or without menthol or green apple flavor) to escalate on a fixed-ratio 1 (FR1) schedule in daily 3-hour sessions to examine initiation-related behaviors. Following escalation, mice were transitioned to a FR3 and progressive ratio schedules in 3-hour sessions to examine reinforcement-related behaviors.

RESULTS

Here we observed that male mice exhibited increased rates of self-administration escalation on a FR1 schedule when assigned to flavored e-liquids. Upon transition to FR3, mice continued to exhibit enhanced levels of reinforcement with flavored e-liquids. We also observed that mice self-administer zero-nicotine green apple flavored e-liquids.

CONCLUSIONS

These data provide additional evidence that ENDS flavors enhance vaping-related initiation and reinforcement-related behavior and promote the need to continue investigating the role ENDS flavors play in vaping-related behaviors.

IMPLICATIONS

There has been much discussion recently regarding the impact of flavors on vaping-related behavior. Our study here shows that flavors significantly enhance the acquisition and reinforcement of vaping-related behavior. This suggests that flavors in electronic nicotine delivery systems significantly increase the risk of addiction-related behaviors among users of vaping products.

Adolescent Use and Perceptions of JUUL and Other Pod-Style e-Cigarettes: A Qualitative Study to Inform Prevention

JUUL, a discrete pod-style e-cigarette, popular among adolescents, delivers high levels of nicotine. Limited research has assessed social and environmental influences that contribute to use of JUUL and other pod-style devices. We examined how these factors, as well as individual characteristics, shape adolescent use. Twenty-nine middle and high school students participated in six focus groups in June 2019 (58.6% female, 65.5% White, 27.6% Hispanic). Groups were stratified by e-cigarette use status and grade to understand perceptions and experiences among groups. Transcripts were coded using thematic analysis for individual, social, and environmental factors contributing to use. Users (n = 13) described their first experience with JUUL as mostly negative, mentioning reactions such as burning in the throat, coughing, wheezing, and headaches. Despite a negative first experience, stress relief and addiction were mentioned as reasons for continued use. Users and non-users identified vaping as a source of disruption to their daily life. Social factors included peer and parental influences, lack of support for quitting, and accessibility. Environmental factors included contrasting messages about long- and short-term health effects of e-cigarettes, as well as a lack of school vaping policy enforcement, health education, medical screenings, and cessation resources. Findings highlight the complex social system that influences adolescent e-cigarette use and have important implications for school and community responses. Strategies to prevent or reduce use may include reviewing existing school tobacco policies, providing counseling and cessation resources, training staff, and increasing knowledge through public education campaigns.

The Role of Novel (Tobacco) Products on Tobacco Control in Italy

In Italy, electronic cigarettes have spread since 2010 and heated tobacco products (HTP) since 2016. We investigated their public health consequences on conventional cigarette smoking, taking advantage of a series of cross-sectional studies annually conducted between 2001 and 2019 in Italy. Every year, the sample, including around 3000 individuals, was representative of the general Italian population aged ≥15 years. In Italy, smoking prevalence steadily declined from 29.1% in 2001 to 20.6% in 2013, then increased to 22.0% in 2019. In 2017-2019, current electronic cigarette users were 2.1% and in 2019 current HTP users were 1.1%. Among 498 ever electronic cigarette users, 23.2% started or re-started smoking and 15.7% quit smoking after electronic cigarette use; of 49 ever HTP users, 19.1% started or re-started smoking combusted cigarettes and 14.6% quit smoking after HTP use. The availability of novel products in Italy resulted in a halt of the decreasing trend in smoking prevalence. For the first time, we observed an increase of Italians inhaling nicotine, concurrently with the spread of novel (tobacco) products. More importantly, the use of novel products appears to increase-rather than decrease-the likelihood of smoking conventional cigarettes. Considering this evidence, we see no argument to justify the huge fiscal and regulatory benefits these products continue to have, at least in Italy.

A review of nicotine-containing electronic cigarettes-Trends in use, effects, contents, labelling accuracy and detection methods

Electronic cigarettes (ECs) are thought to be less harmful than traditional combustible cigarettes and were originally intended to help smokers quit. Over the past two decades, they have especially gained popularity with the younger generation. To date, there are over 7000 unique e-liquid flavours available and over 400 different e-cigarette brands. The accuracy of nicotine strength labelling in e-liquids was assessed in this work. Twenty-three studies from around the world were chosen to assess the level and frequency of nicotine mislabelling in 545 e-liquid products. Nicotine strengths were most commonly mislabelled by between 5% and 20%, with the majority testing lower than what the label indicated. Fifteen European e-liquids that were assessed were labelled as 20 mg/ml or less, yet when tested, they contained more than 20 mg/ml of nicotine. One e-liquid that was supposed to contain no nicotine in fact contained 23.91 mg/ml of nicotine. Furthermore, the difference between the medians of the available labelled and experimental nicotine concentrations was significant (p < 0.001, Wilcoxon signed rank test). Preliminary studies show that high nicotine levels delivered via aerosol increase the risk for nicotine poisoning and cause airway inflammation. Other EC ingredients, such as flavourings, contribute to EVALI and 'popcorn lung'. There is evidence that certain flavourings, such as menthol, reinforce the effects of nicotine and modify drug absorption and metabolism. There is a global need for better quality control in EC products in order to make these safe for consumers.

Vaping: Impact of Improving Screening Questioning in Adolescent Population: A Quality Improvement Initiative

The use of Electronic Nicotine Delivery Systems (ENDS) increased dramatically over the past decade, making them the most common tobacco product used among youth. While physicians often screen for the use of tobacco, very few screen for vaping product usage. This quality improvement project aimed to increase the screening rate of ENDS use among adolescents to 85% to match the Healthy People 2020 screening target of 83.3% for smoking.

Electronic Cigarettes Associated With Incident and Polysubstance Use Among Youth

PURPOSE

Electronic cigarette (e-cigarette) use has increased exponentially among the youth in the United States and may increase the incidence of substance use.

METHODS

Youth participants (12-17 years) were surveyed through the Population Assessment of Tobacco and Health study over a three-year time period. Youth with any baseline substance use or diagnosis of an attention deficit disorder were excluded from the analysis. Multivariable logistic regressions were used to assess the association between e-cigarette use at Wave 1 and incident substance use (marijuana, painkillers, sedatives, or tranquilizers and Ritalin/Adderall) and polysubstance use at Wave 2 or 3, and marijuana use in the electronic nicotine device at Wave 3.

RESULTS

Baseline ever e-cigarette users who had no history of marijuana, nonprescribed drugs and illicit substance use in Wave 1 had increased odds of reporting incident use of marijuana (odds ratio 2.59, 95% confidence interval: 1.90-3.52), nonprescribed Ritalin/Adderall use (1.89, 1.09-3.28), or polysubstance use (2.09, 1.43-3.05) in Wave 2 or 3 compared to never e-cigarette users. They were also more likely to report use of marijuana in the electronic nicotine product (2.26, 1.56-3.27) in Wave 3 compared to never e-cigarette users. There was no statistically significant association between baseline e-cigarette use and incident use of painkillers, sedatives, or tranquilizers in Wave 2 or 3 (1.21, .79-1.87).

CONCLUSIONS

E-cigarette use is associated with incident use of marijuana, marijuana in electronic nicotine devices, Ritalin/Adderall, and polysubstance use but not painkillers, sedatives, or tranquilizers. Results indicate that e-cigarettes are associated with subsequent additional risky health behaviors in youth.

E-cigarette use behaviors and device characteristics of daily exclusive e-cigarette users in Maryland: Implications for product toxicity

INTRODUCTION

Few studies to date have characterized daily exclusive e-cigarette users, device characteristics, and use behaviors. This study describes daily e-cigarette user characteristics, and assesses the association between user behaviors and demographics.

METHODS

From 2015–2017, 100 daily exclusive e-cigarette users and 50 non-users were recruited in Maryland, USA. Sociodemographic characteristics, health status, e-cigarette/tobacco use behaviors, device characteristics, and reasons for e-cigarette use were collected by interview. Chi-squared tests (categorical variables), Student’s t-test (continuous variables), and linear regressions were used to assess relationships between variables.

RESULTS

Most daily exclusive e-cigarette users were men, White, former smokers, used MODs/tanks, and vaped on average 365 puffs/day (SD: 720). A third of users first vaped within 5 minutes of waking in the morning, and 56% vaped throughout the day. E-liquid consumption ranged from 5–240 mL/week (median: 32.5), with nicotine concentration 0–24 mg/mL (median: 3). E-cigarette users were more likely to report wheezing/whistling and hypertension than controls, although the finding was not statistically significant after adjustment. Less than half planned to quit vaping.

CONCLUSIONS

Daily e-cigarette users between 2015–2017 most commonly vaped MOD/tank devices. Being male and of lower education was associated with higher usage. Daily users with no intention to quit may be at risk for increased exposure to emissions from e-cigarettes that include inorganic (metals) and organic (e.g. acrolein, formaldehyde) compounds with known toxic effects, particularly to the lung. Further research is needed to characterize the long-term health effects of daily e-cigarette use.

The Role of Information Avoidance in Managing Uncertainty from Conflicting Recommendations about Electronic Cigarettes

Insufficient scientific evidence about electronic cigarettes (e-cigarettes) has led to conflicting recommendations (CRs) by credible scientific organizations, creating a public health debate that could prove especially difficult to reconcile as current and former smokers make decisions about whether to use e-cigarettes. To investigate how CRs about e-cigarettes may affect intentions to engage in healthy behaviors, 717 former and current smokers were randomly exposed to one of five conditions (varying in the level of conflict in recommendations) in this between-subject experiment. Our results indicated a significant interaction between the message level of conflict and individuals' information avoidance, employed to maintain hope and deniability. These results suggest the effects of CRs stemming from scientific uncertainty vary with subgroups of people, pointing to several pressing theoretical and practical implications.

E-cigarettes: A new hazard for children and adolescents

Objectives

Electronic cigarettes and fluid (e-cigarettes, e-fluid) are hazardous materials that when inhaled or ingested may pose significant health risks to children and adolescents. The objective of this work was to explore the spectrum of injury related to e-cigarette exposure among Canadian children and adolescents.

Methods

A one-time survey was sent to all paediatricians in Canada. Information was collected on children and adolescents who presented with e-cigarette exposure (inhalation and ingestion cases) in the previous 12 months. Questions included the number of injuries and symptoms, in addition to age, sex, treatment setting, intentional e-cigarette use, and how the products were accessed.

Results

A total of 520 surveys were completed and returned, identifying 35 cases. Symptoms related to inhalation were present in 30 cases and in 5 ingestion cases (5 unintentional, 0 intentional). For inhalation cases, most were male, ages 15 to 19 years, who sought treatment for nausea/vomiting, cough, throat irritation, or acute nicotine toxicity in an outpatient clinic/office. Most inhalation cases reported e-cigarette use 2 to 3 days/week, and e-cigarettes purchases from a mall kiosk/store. For ingestion cases, most were male, ages 1 to 4 years presenting to an emergency department with nausea/vomiting, cough, or respiratory irritation. Younger cases accessed e-fluid at home, older cases purchased in a mall kiosk/store. E-fluid flavours reported consumed were fruit, candy, and tobacco.

Conclusions

E-cigarettes, recently introduced into the North American market are hazardous to children and adolescents. Given the low response rate to the survey, further investigation into the true burden of injury, as well as the risks that e-cigarettes pose, together with ways to reduce exposure, is needed.

Marijuana and the Pediatric Population

Cannabinoids, the psychoactive compounds in marijuana, are one of the most commonly used substances in the United States. In this review, we summarize the impact of marijuana on child and adolescent health and discuss the implications of marijuana use for pediatric practice. We review the changing epidemiology of cannabis use and provide an update on medical use, routes of administration, synthetic marijuana and other novel products, the effect of cannabis on the developing brain, other health and social consequences of use, and issues related to marijuana legalization.

Exploring Associations between Susceptibility to the Use of Electronic Nicotine Delivery Systems and E-Cigarette Use among School-Going Adolescents in Rural Appalachia

Electronic nicotine delivery systems (ENDS) use, including e-cigarettes, has surpassed the use of conventional tobacco products. Emerging research suggests that susceptibility to e-cigarette use is associated with actual use among adolescents. However, few studies exist involving adolescents in high-risk, rural, socioeconomically distressed environments. This study examines susceptibility to and subsequent usage in school-going adolescents in a rural distressed county in Appalachian Tennessee using data from an online survey (N = 399). Relying on bivariate analyses and logistic regression, this study finds that while 30.6% of adolescents are ever e-cigarette users, 15.5% are current users. Approximately one in three adolescents are susceptible to e-cigarettes use, and susceptibility is associated with lower odds of being a current e-cigarette user (OR = 0.03; CI: 0.01–0.12; p < 0.00). The age of tobacco use initiation was significantly associated with decreased current use of e-cigarettes (OR = 0.89; CI: 0.83–0.0.97; p < 0.01). Overall, the results of this exploratory study suggest the need for larger studies to identify unique and generalizable factors that predispose adolescents in this high-risk rural, socioeconomically disadvantaged region to ENDS use. Nevertheless, this study offers insight into e-cigarette usage among U.S adolescents in rural, socioeconomically disadvantaged environments and provides a foundation for a closer examination of this vulnerable population.

Harmful chemicals emitted from electronic cigarettes and potential deleterious effects in the oral cavity

Use of electronic nicotine delivery systems (ENDS), such as electronic cigarettes (e-cigs), is increasing across the US population and is particularly troubling due to their adoption by adolescents, teens, and young adults. The industry’s marketing approach for these instruments of addiction has been to promote them as a safer alternative to tobacco, a behavioral choice supporting smoking cessation, and as the ‘cool’ appearance of vaping with flavored products (e.g. tutti frutti, bubble gum, and buttered popcorn etc.). Thus, there is a clear need to better document the health outcomes of e-cig use in the oral cavity of the addicted chronic user. There appears to be an array of environmental toxins in the vapors, including reactive aldehydes and carbonyls resulting from the heating elements action on fluid components, as well as from the composition of chemical flavoring agents. The chemistry of these systems shows that the released vapors from the e-cigs frequently contain levels of environmental toxins that considerably exceed federal occupational exposure limits. Additionally, the toxicants in the vapors appear to be retained in the host fluids/tissues at levels often approximating 90% of the levels in the e-cig vapors. These water-soluble reactive toxins can challenge the oral cavity constituents, potentially contributing to alterations in the autochthonous microbiome and host cells critical for maintaining oral homeostasis. This review updates the existing chemistry/environmental aspects of e-cigs, as well as providing an overview of the somewhat limited data on potential oral health effects that could occur across the lifetime of daily e-cig users.

Perioperative Implications of Vaping

Over the past 10 - 15 years, there has been a significant increase in the use of electronic cigarettes. These devices are generally used to deliver nicotine through inhalation by aerosolization. While the long-term risk of lung cancer is yet to be known, the chemicals and impurities in the solutions may have other acute and chronic effects on the respiratory system including respiratory failure from adult respiratory distress syndrome. Recent concerns have been raised regarding the potential for significant acute and chronic health care risks of these devices including pneumonitis, airway reactivity and respiratory failure. Given that many of the acute effects are related to the respiratory system, anesthetic care may be required during diagnostic procedures including bronchoscopy to investigate the etiology of acute respiratory symptomatology. We present an adolescent who presented to the operating room for bronchoscopy and bronchoalveolar lavage to investigate the etiology of respiratory involvement following an episode of vaping. The healthcare and end-organ effects of nicotine, tobacco smoke and vaping are discussed, and potential anesthetic implications are presented.

Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

Tobacco use is the leading cause of preventable death in the US. An estimated annual 480 000 deaths are attributable to tobacco use in adults, including from secondhand smoke. It is estimated that every day about 1600 youth aged 12 to 17 years smoke their first cigarette and that about 5.6 million adolescents alive today will die prematurely from a smoking-related illness. Although conventional cigarette use has gradually declined among children in the US since the late 1990s, tobacco use via electronic cigarettes (e-cigarettes) is quickly rising and is now more common among youth than cigarette smoking. e-Cigarette products usually contain nicotine, which is addictive, raising concerns about e-cigarette use and nicotine addiction in children. Exposure to nicotine during adolescence can harm the developing brain, which may affect brain function and cognition, attention, and mood; thus, minimizing nicotine exposure from any tobacco product in youth is important.

OBJECTIVE

To update its 2013 recommendation, the USPSTF commissioned a review of the evidence on the benefits and harms of primary care interventions for tobacco use prevention and cessation in children and adolescents. The current systematic review newly included e-cigarettes as a tobacco product.

POPULATION

This recommendation applies to school-aged children and adolescents younger than 18 years.

EVIDENCE ASSESSMENT

The USPSTF concludes with moderate certainty that primary care-feasible behavioral interventions, including education or brief counseling, to prevent tobacco use in school-aged children and adolescents have a moderate net benefit. The USPSTF concludes that there is insufficient evidence to determine the balance of benefits and harms of primary care interventions for tobacco cessation among school-aged children and adolescents who already smoke, because of a lack of adequately powered studies on behavioral counseling interventions and a lack of studies on medications.

RECOMMENDATION

The USPSTF recommends that primary care clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. (B recommendation) The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-feasible interventions for the cessation of tobacco use among school-aged children and adolescents. (I statement).

Relationship between population characteristics, e-cigarette and tobacco-related perceptions, and likelihood of ever using e-cigarettes

INTRODUCTION

Electronic nicotine delivery systems (ENDS) are a relatively new type of nicotine-containing product that has risen greatly in use within the past decade, displacing conventional tobacco products as the dominant source of nicotine exposure by many groups. Among those impacted are large sections of US youth. Though health outcomes associated with ENDS use are still being assessed, several potential harms have been noted in the extant literature. The purpose of this study is to examine which US youth subpopulations are at greatest risk for ENDS ever use and how perceptions pertaining to nicotine-containing products relate to this risk.

METHODS

A nationwide online survey was administered to US youth ENDS users and non-users aged 13–18 years. A total weighted sample of 2501 participants was obtained. Statistical analyses included binomial logistic regression and a likelihood ratio test.

RESULTS

Of these youth, 1346 (53.8%) reported having ever used an ENDS product. Those most likely to have used ENDS were White males in their late teens. Those who reported ever using a conventional tobacco product were much more likely to have reported ever using ENDS (AOR= 19.96; 95% CI: 15.30–26.05). A number of perceptions related to nicotine-containing products, including product safety and health effects, were significantly associated with an increased likelihood of ENDS use.

CONCLUSIONS

Certain sections of the US youth population have elevated odds of being ENDS ever users. As increasing evidence supports the need to combat ENDS use by youth, effectively targeted education and prevention campaigns will be necessary.

Nicotine toxicity: Protecting children from e-cigarette exposure

Compared with children exposed to traditional cigarettes, those exposed to nicotine in e-cigarettes are 5.2 times more likely to be admitted to a healthcare facility and have 2.6 times the risk of a severe outcome. This article discusses nicotine toxicity in children accidentally exposed to e-cigarettes containing nicotine and reviews appropriate nursing interventions.

Electronic Nicotine Delivery Systems and Serum Folate: A Case Study

Introduction:

In 2018, the US Surgeon General declared youth electronic nicotine delivery systems (ENDS) use as an epidemic. Combustible cigarettes have been shown to adversely affect folate status; however, no study to date has explored how ENDS impact folate status.

Methods:

In this case study, a white 18-year-old woman was followed for a 1-month period as part of a larger study. During her participation in the study, a self-report of dietary folate consumption and use of alcohol, tobacco, and other drugs (ATOD) was collected. Each week, dried blood spots were collected to assess red blood cell (RBC) and serum folate.

Results:

During the first 2 weeks of the study, she used ENDS and her serum folate values were depleted in the ranges of 1.91 to 4.39 µg/L. During the third week, when no ENDS were used, her serum folate value was measured at 29.44 µg/L. When ENDS use resumed during the fourth week, her serum folate value fell to 7.50 µg/L.

Conclusions:

This relationship suggests the need for additional studies on ENDS use and serum folate status, particularly among adolescent women who already have the lowest folate status nationally.

Combining Crowd-Sourcing and Automated Content Methods to Improve Estimates of Overall Media Coverage: Theme Mentions in E-cigarette and Other Tobacco Coverage

Exposure to media content can shape public opinions about tobacco. Accurately describing content is a first step to showing such effects. Historically, content analyses have hand-coded tobacco-focused texts from a few media sources which ignored passing mention coverage and social media sources, and could not reliably capture over-time variation. By using a combination of crowd-sourced and automated coding, we labeled the population of all e-cigarette and other tobacco-related (including cigarettes, hookah, cigars, etc.) 'long-form texts' (focused and passing coverage, in mass media and website articles) and social media items (tweets and YouTube videos) collected May 2014-June 2017 for four tobacco control themes. Automated coding of theme coverage met thresholds for item-level precision and recall, event validation, and weekly-level reliability for most sources, except YouTube. Health, Policy, Addiction and Youth themes were frequent in e-cigarette long-form focused coverage (44%-68%), but not in long-form passing coverage (5%-22%). These themes were less frequent in other tobacco coverage (long-form focused (13-32%) and passing coverage (4-11%)). Themes were infrequent in both e-cigarette (1-3%) and other tobacco tweets (2-4%). Findings demonstrate that passing e-cigarette and other tobacco long-form coverage and social media sources paint different pictures of theme coverage than focused long-form coverage. Automated coding also allowed us to code the amount of data required to estimate reliable weekly theme coverage over three years. E-cigarette theme coverage showed much more week-to-week variation than did other tobacco coverage. Automated coding allows accurate descriptions of theme coverage in passing mentions, social media, and trends in weekly theme coverage.

Potential for non-combustible nicotine products to reduce socioeconomic inequalities in smoking: a systematic review and synthesis of best available evidence

BACKGROUND

While some experts have emphasised the potential for e-cigarettes to facilitate cessation among smokers with low socioeconomic status (SES), there is limited evidence of their likely equity impact. We assessed the potential for electronic cigarettes and other non-combustible nicotine-containing products (NCNPs) to reduce inequalities in smoking by systematically reviewing evidence on their use by SES in countries at stage IV of the cigarette epidemic.

METHODS

Ten electronic databases were searched in February 2017 using terms relating to e-cigarettes, smokeless tobacco and nicotine replacement therapy (NRT); and SES. We included studies published since 1980 that were available in English and examined product use by SES indicators such as income and education. Data synthesis was based on those studies judged to be of medium- to high-quality using guidelines adapted from the Critical Appraisal Skills Programme.

RESULTS

We identified 54 studies describing NCNP use by SES across 12 countries, of which 27 were judged of sufficient quality to include in data synthesis. We found mixed patterns of e-cigarette current use by SES, with evidence of higher use among low-income adults but unclear or mixed findings by education and occupation. In contrast, smokeless tobacco current use was consistently higher among low SES adults. There was very limited evidence on the SES distribution of NRT in adults and of all NCNPs in young people.

CONCLUSIONS

The only NCNP for which there are clear patterns of use by SES is smokeless tobacco, where prevalence is higher among low SES groups. While this suggests a potentially positive impact on inequalities in smoking (if NCNP use displaces smoked tobacco use), this has not been seen in practice. These findings do not support the suggestion that e-cigarettes have the potential to reduce social inequalities in smoking, since i) current evidence does not show a clear trend of higher e-cigarette use in population groups with higher tobacco consumption, and ii) the experience of smokeless tobacco suggests that - even where NCNP use is higher among low SES groups - this does not necessarily replace smoked tobacco use in these groups.

Inclusion of electronic nicotine delivery systems in indoor smoke-free air policies and associated vaping behavior

INTRODUCTION

Despite an ongoing debate over regulations of use of electronic nicotine delivery systems (ENDS) in public places, fourteen U.S. states or territories banned use of ENDS in indoor areas such as workplaces, restaurants, or bars (aerosol-free policies), as of March 31 ,2018. However, there is a paucity of studies on state-level aerosol-free policies. This study aimed to investigate the relationship between statewide aerosol-free policies and U.S. adults' ENDS use.

METHODS

We analyzed data from the 2016 Behavioral Risk Factor Surveillance System, a nationally representative sample of U.S. adults (N = 240,849, ages 18-59 years), using multilevel logistic regressions, taking into account clustering of individuals within a state. We conducted stratified analyses by age groups to examine if the association between aerosol-free policy and ENDS use would be different between different age groups of adults.

RESULTS

Adults living in the states with an aerosol-free policy were less likely to use ENDS compared with those living in the states without an aerosol-free policy, controlling for individual- and state-level covariates (adjusted odds ratio = 0.79, 95% confidence interval = 0.64, 0.97). Stratified analyses showed that the association varied by age group; the statewide aerosol-free policies was associated with lower odds of ENDS use only in adults aged 25-59 but not young adults (aged 18-24).

CONCLUSIONS

The results supported enforcement of prohibiting ENDS as well as traditional tobacco product indoor areas as a means of ENDS use prevention. Our findings also confirmed that young adults should be a priority target population for ENDS use prevention policies and programming efforts.

La reducción de riesgos y daños vs. el régimen internacional de control de drogas (1990-2017)

A pesar de la evidente efectividad de ciertos programas de Reducción de Riesgos y Daños de Drogas (RRDD), el Régimen Internacional de Control de Drogas (RICD) históricamente ha desincentivado su implementación, los defensores de la cara más rígida del RICD se han referido a la RRDD como el caballo de Troya de las facciones que defienden la legalización. No obstante, una gran cantidad de Estados han hecho uso del margen de flexibilidad interpretativo de las Convenciones internacionales de drogas para implementar en sus políticas nacionales estrategias de RRDD, algunas promovidas inclusive por órganos propio de Naciones Unidas como la OMS, UNODC y UNAIDS. A partir de una revisión de literatura, este documento evalúa las principales tensiones que han ocurrido dentro del RICD a causa de la perspectiva de RRDD entre 1990 y 2017.  

Newer Forms of Tobacco Products: Characteristics of Poly Users Among Adults Living in Colorado-A Secondary Data Analysis of the Attitudes and Behaviors Survey on Health 2015

Aims:

Data from The Attitudes and Behaviors Survey (TABS) conducted in 2015 were used to investigate the prevalence of different forms of tobacco use and marijuana use among adults in Colorado.

Methods:

A secondary analysis of TABS on health data was conducted. A representative sample of 8616 adults 18 years and older participated in the survey, with sample weights used to adjust for oversampling.

Results:

Lifetime prevalence of cigarette-only use was 25.8%, compared with 10.6% for hookah use, 7.0% for both hookah and cigarettes, 12.6% for anything except cigarettes, and 43.0% for marijuana. The typical hookah user was a single/living alone (15.9%), English-speaking (11.6%), male (16.7%), age < 30 years (24.2%), with some college education (13.0%), and income less than 35 000 per year (14.3%). Hookah users, whether or not they also used cigarettes, were similar to those who used any other noncigarette tobacco products. The typical marijuana user was a single/living alone (50.2%), white (46.0%), English-speaking (46.7%), male (48.5%), age < 30 years (50.1%), with a graduate degree (40.8%) and salary of at least 50 000 per year (43.4%).

Implications:

In Colorado, in 2015, cigarette use was still highest among all forms of tobacco, but the use of other tobacco products such as vaping and hookah is on the rise, especially among young adults. Marijuana and hookah users were demographically similar to each other, and different from the typical cigarette user. These results indicate the need for further study of alternative tobacco product use, especially among young adults.

Electronic Vapor Product Usage and Substance Use Risk Behaviors Among U.S. High School Students

Objectives: The initiation of substance use at a young age increases one's likelihood of developing substance use disorders (SUDs). Understanding trends in youth substance-related risk behaviors is important in identification and prevention of SUDs. The objective of this study was to assess, in a nationally representative sample of U.S. high school students, how current electronic vapor product (EVP), cigarette, and dual-product usage as well as EVP usage frequency are related to other substance use behaviors. Methods: Respondents (N = 12,667) of the 2017 National Youth Risk Behavior Survey were categorized by previous 30-day EVP and cigarette usage into one of four groups: nonuse, cigarette only, EVP only, or dual use. Separately, respondents were categorized by 30-day EVP usage frequency: 0, 1-9, 10-29, or 30 days. Thirteen substance use behaviors were selected as dependent variables. Adjusted prevalence ratios (aPRs) were calculated using multivariable modified Poisson regression to determine associations between outcome behaviors and both current EVP/cigarette usage and EVP usage frequency. Linear contrasts were conducted to compare aPRs across categories. Results: Cigarette, EVP, and dual users were more likely to engage in 12 of 13 substance use behaviors compared to nonusers (p < 0.001). Dual-users were more likely than EVP-only users to engage in 12 of 13 behaviors. Past 30-day EVP users at any frequency were also more likely to engage in nearly all risk behaviors examined. Occasional EVP users were similarly likely as frequent and daily users to engage in 11 of 13 behaviors. Conclusions: Adolescent EVP use, with or without concurrent cigarette smoking, is associated with a higher likelihood of engagement in several substance use behaviors. Prevalence of risk behaviors is generally greater for dual users than EVP-only users, but prevalence proportions do not significantly differ among occasional, frequent, or daily EVP users for most behaviors.