The E-Cigarette Debate: What Counts as Evidence?

Acute exposure to electronic cigarette components alters mRNA expression of pre-osteoblasts

The use of traditional nicotine delivery products such as tobacco has long been linked to detrimental health effects. However, little work to date has focused on the emerging market of aerosolized nicotine delivery known as electronic nicotine delivery systems (ENDS) or electronic cigarettes, and their potential for new effects on human health. Challenges studying these devices include heterogeneity in the formulation of the common components of most available ENDS, including nicotine and a carrier (commonly composed of propylene glycol and vegetable glycerin, or PG/VG). In the present study, we report on experiments interrogating the effects of major identified components in e-cigarettes. Specifically, the potential concomitant effects of nicotine and common carrier ingredients in commercial "vape" products are explored in vitro to inform the potential health effects on the craniofacial skeleton through novel vectors as compared to traditional tobacco products. MC3T3-E1 murine pre-osteoblast cells were cultured in vitro with clinically relevant liquid concentrations of nicotine, propylene glycol (PG), vegetable glycerin (VG), Nicotine+PG/VG, and the vape liquid of a commercial product (Juul). Cells were treated acutely for 24 h and RNA-Seq was utilized to determine segregating alteration in mRNA signaling. Influential gene targets identified with sparse partial least squares discriminant analysis (sPLS-DA) implemented in mixOmics were assessed using the PANTHER Classification system for molecular functions, biological processes, cellular components, and pathways of effect. Additional endpoint functional analyses were used to confirm cell cycle changes. The initial excitatory concentration (EC50) studied defined a target concentration of carrier PG/VG liquid that altered the cell cycle of the calvarial cells. Initial sPLS-DA analysis demonstrated the segregation of nicotine and non-nicotine exposures utilized in our in vitro modeling. Pathway analysis suggests a strong influence of nicotine exposures on cellular processes including metabolic processes and response to stimuli including autophagic flux. Further interrogation of the individual treatment conditions demonstrated segregation by treatment modality (Control, Nicotine, Carrier (PG+VG), Nicotine+PG/VG) along three dimensions best characterized by: latent variable 1 (PLSDA-1) showing strong segregation based on nicotine influence on cellular processes associated with cellular adhesion to collagen, osteoblast differentiation, and calcium binding and metabolism; latent variable 2 (PLSDA-2) showing strong segregation of influence based on PG+VG and Control influence on cell migration, survival, and cycle regulation; and latent variable 3 (PLSDA-3) showing strong segregation based on Nicotine and Control exposure influence on cell activity and growth and developmental processes. Further, gene co-expression network analysis implicates targets of the major pathway genes associated with bone growth and development, particularly craniofacial (FGF, Notch, TGFβ, WNT) and analysis of active subnetwork pathways found these additionally overrepresented in the Juul exposure relative to Nicotine+PG/VG. Finally, experimentation confirmed alterations in cell count, and increased evidence of cell stress (markers of autophagy), but no alteration in apoptosis. These data suggest concomitant treatment with Nicotine+PG/VG drives alterations in pre-osteoblast cell cycle signaling, specifically transcriptomic targets related to cell cycle and potentially cell stress. Although we suspected cell stress and well as cytotoxic effects of Nicotine+PG/VG, no great influence on apoptotic factors was observed. Further RNA-Seq analysis allowed for the direct interrogation of molecular targets of major pathways involved in bone and craniofacial development, each demonstrating segregation (altered signaling) due to e-cigarette-type exposure. These data have implications directed toward ENDS formulation as synergistic effects of Nicotine+PG/VG are evidenced here. Thus, future research will continue to interrogate how varied formulation of Nicotine+PG/VG affects overall cell functions in multiple vital systems.

In Utero Exposure to Maternal Electronic Nicotine Delivery System use Demonstrate Alterations to Craniofacial Development

OBJECTIVE

Develop a model for the study of Electronic Nicotine Device (ENDS) exposure on craniofacial development.

DESIGN

Experimental preclinical design followed as pregnant murine dams were randomized and exposed to filtered air exposure, carrier exposure consisting of 50% volume of propylene glycol and vegetable glycine (ENDS Carrier) respectively, or carrier exposure with 20 mg/ml of nicotine added to the liquid vaporizer (ENDS carrier with nicotine).

SETTING

Preclinical murine model exposure using the SciReq exposure system.

PARTICIPANTS

C57BL6 adult 8 week old female pregnant mice and exposed in utero litters.

INTERVENTIONS

Exposure to control filtered air, ENDS carrier or ENDS carrier with nicotine added throughout gestation at 1 puff/minute, 4 h/day, five days a week.

MAIN OUTCOME MEASURES

Cephalometric measures of post-natal day 15 pups born as exposed litters.

RESULTS

Data suggests alterations to several facial morphology parameters in the developing offspring, suggesting electronic nicotine device systems may alter facial growth if used during pregnancy.

CONCLUSIONS

Future research should concentrate on varied formulations and exposure regimens of ENDS to determine timing windows of exposures and ENDS formulations that may be harmful to craniofacial development.

Multistate transition modelling of e-cigarette use and cigarette smoking among youth in the UK

INTRODUCTION

E-cigarette use remains a controversial topic, with questions over how people transition between e-cigarette use and cigarette smoking. This paper examined transitions into and out of nicotine product use in a representative sample of UK youth.

METHODS

We used Markov multistate transition probability models on data from 10 229 participants (10-25 years old) in the UK Household Longitudinal Study (2015-2021). We used four product use states ('never', 'non-current use', 'e-cigarette only' and 'smoking and dual use') and estimated likelihood of transitions according to sociodemographic characteristics.

RESULTS

Among participants who had never used nicotine products, most were still non-users a year later (92.9% probability; 95% CI 92.6%, 93.2%); a small proportion transitioned to using e-cigarettes only (4.0%; 95% CI 3.7%, 4.2%) and cigarettes (2.2%; 95% CI 2.0%, 2.4%). Those aged 14-17 years were the most likely to start using a nicotine product. E-cigarette use was less persistent overtime than cigarette smoking, with a 59.1% probability (95% CI 56.9%, 61.0%) of e-cigarette users still using after 1 year compared with 73.8% (95% CI 72.1%, 75.4%) for cigarette smoking. However, there was a 14% probability (95% CI 12.8%, 16.2%) that e-cigarette users went onto smoke cigarettes after 1 year, rising to 25% (95% CI 23%, 27%) after 3 years.

CONCLUSION

This study found that although overall nicotine product use was relatively rare, participants were more likely to experiment with e-cigarette use than cigarette smoking. This was mostly not persistent over time; however, approximately one in seven transitioned to cigarette smoking. Regulators should aim to deter all nicotine product use among children.

Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2022)

BACKGROUND

Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios.

METHODS

Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data.

RESULTS

Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy.

CONCLUSIONS

Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.

Sources of exposure to non-tobacco nicotine electronic nicotine delivery systems and associations with susceptibility to use and use behaviors among young adults in the United States

INTRODUCTION

The Electronic Nicotine Delivery Systems (ENDS) industry recently introduced non-tobacco nicotine (NTN), which is not tobacco-derived and is often marketed as "tobacco-free nicotine." Given its novelty, it is important to understand where young adults learn about NTN ENDS. This study examined sources of exposure to NTN ENDS and relationships with NTN ENDS use and susceptibility.

METHODS

We analyzed online survey data collected in Fall 2021 from 642 young adults (18-25 years) who had heard of NTN ENDS. We assessed 9 sources of NTN ENDS exposure (e.g., retail stores, social media) and examined associations between sources of exposure and NTN current (past-month) use, lifetime (non-current) use, and susceptibility to use, adjusting for demographics and other tobacco product use.

RESULTS

Participants reported current NTN ENDS use (37.4%), lifetime use (12.0%), susceptibility (18.5%), or no susceptibility to use (32.1%). The most common sources of NTN ENDS exposure were retail stores (87.7%) and social media (81.0%). Exposure to NTN ENDS via social media was associated with greater odds of current NTN ENDS use (vs. no susceptibility) (aOR = 1.83, 95%CI: 1.02-3.28). Exposure via online streaming platforms was associated with greater odds of current (aOR = 1.75, 95%CI: 1.08-2.82) and lifetime NTN ENDS use (aOR = 2.42, 95%CI: 1.25-4.68).

CONCLUSIONS

Young adults were exposed to and learned about NTN ENDS from diverse sources, primarily retail shops and social media. Further, exposure via social media and streaming platforms were associated with NTN ENDS use. Future studies should explore the content of NTN information from various sources to inform prevention efforts.

Perceiving E-Cigarettes as Safe and Safer Alternative to Cigarettes Among Young Adults

BACKGROUND

Young adults are using e-cigarettes at high rates. While the literature on the health risks associated with e-cigarettes is extensive and growing, little is known about young adults' thoughts and perceptions of the safety and harms of e-cigarettes.

METHODS

We conducted one-on-one interviews with young adults aged 18 to 25 years in Los Angeles, California between June 2018 and June 2019. We interviewed and audio-recorded young adults (N = 62) who consented to the study and self-reported to have used e-cigarettes on a weekly basis or more for at least 5 months prior to study enrollment. Interviews examined participants' thoughts, feelings, and experiences related to e-cigarette use. We audio-recorded, transcribed, and coded the interviews using grounded theory analysis methods.

RESULTS

Young adults often believed that e-cigarettes were safer than cigarettes and were safe to use, especially following positive vaping experiences. Young adults were skeptical of the available science on e-cigarette use and felt there was not conclusive data on the harms of e-cigarettes. In their selection of e-cigarettes over cigarettes, young adults felt they were making a conscious and healthier choice. Because young adults viewed e-cigarettes to be better for them based on their personal experiences with vaping, they felt e-cigarettes were a superior alternative to combustible tobacco.

CONCLUSIONS

Young adults in our study believed that the long-term health effects of e-cigarette use are not clearly understood and were generally skeptical of the research on e-cigarette harms. Policy, education, and anti-smoking campaigns need to clarify the negative health-related consequences of e-cigarette use for young people.

Comparison Between Smoked Tobacco and Medical Cannabis Cigarettes Concerning Particulate Matter

Introduction: Cannabis is a widely used drug like tobacco and alcohol. In the meantime, it is also prescribed for medical treatment in some countries. Tobacco smoke contains chemical carcinogens and particulate matter (PM) that are both harmful to health. Method: In this study, we investigated PM levels in second-hand smoke (SHS) of hand-tamped cannabis cigarettes compared to cigarettes with tubing tobacco and the 3R4F reference cigarette. Results: It could be demonstrated that the largest proportion of the particle mass is attributable to particles with a diameter of less than 1μm and that every tested cigarette emitted more PM than the 3R4F reference cigarette. In addition, our data clearly revealed that cannabis smoke contains higher PM levels in SHS than tobacco cigarettes. Compared to the reference cigarette, the PM1 emissions of cannabis were 105% higher. Also, the cannabis mixed cigarettes had higher PM levels than the 3R4F cigarettes. For instance, the PM10 emissions were 93% higher. Also, the Gauloises Mélange tubing tobacco also reached higher PM concentrations than the 3R4F cigarette. Discussion: Regardless of negative health effects, cannabis is seen as a harmless drug in the public eye. We found strong indications for potential health risks by PM from cannabis products and, therefore, the public should be educated about a potential harm.

Terms tobacco users employ to describe e-cigarette aerosol

BACKGROUND

The scientific term for the substance people inhale and exhale from a vaping device is 'aerosol', but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols.

METHODS

Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what 'people inhale and exhale when they vape', using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term 'aerosol' or 'vapor' (eg, 'E-cigarette aerosol/vapor contains nicotine, which can lead to seizures').

RESULTS

In open-ended responses, tobacco users most commonly provided the terms 'vapor' (31%) and 'smoke' (23%) but rarely 'aerosol' (<1%). In closed-ended responses, the most commonly endorsed terms were again 'vapor' (57%) and 'smoke' (22%) but again infrequently 'aerosol' (2%). In closed-ended responses, use of the term 'vapor' was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p<0.05). In the experiment, warnings using the terms 'aerosol' and 'vapor' were equally effective (all p>0.05).

CONCLUSIONS

The public rarely uses the term 'aerosol' to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms 'aerosol' and the more popular 'vapor' to better inform vaping risk communication.

Influence of Disclosed and Undisclosed Funding Sources in Tobacco Harm Reduction Discourse: A Social Network Analysis

INTRODUCTION

Tobacco harm reduction (THR) discourse has been divisive for the tobacco control community, partially because it sometimes aligns public health and tobacco industry interests. Industry funding is contentious as it influences study outcomes, and is not always disclosed in scientific publications. This study examines the role of disclosed and undisclosed industry support on THR publications via social network analysis.

METHODS

We reviewed 826 English-language manuscripts (1992-2016) to determine disclosed and undisclosed industry (pharmaceutical, tobacco, and e-cigarette) and non-industry (including government) support received by 1405 authors. We used social network analysis to identify the most influential authors in THR discourse by assessing the number of their collaborators on publications, the frequency of connecting other authors in the network, and tendency to form groups based on the presence of sponsorship disclosures, sources of funding, and THR stance.

RESULTS

About 284 (20%) out of 1405 authors were supported by industry. Industry-sponsored authors were more central and influential in the network: with twice as many publications (Median = 4), 1.25 as many collaborators on publications (Median = 5), and higher likelihood of connecting other authors and thus having more influence in the network, compared to non-industry-sponsored authors. E-cigarette industry-sponsored authors had the strongest association with undisclosed industry support.

CONCLUSIONS

Authors with industry support exerted a stronger influence on the THR scientific discourse than non-industry-supported authors. Journals should continue adhering to strict policies requiring conflicts of interest disclosures. An increase in public health spending on tobacco control research may be necessary to achieve funding parity.

The smoking and vaping model, A user-friendly model for examining the country-specific impact of nicotine VAPING product use: application to Germany

BACKGROUND

Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs.

METHODS

SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM's adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data.

RESULTS

Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period.

CONCLUSIONS

SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.

An analysis of key stakeholder policy perspectives in the proposed e-cigarette regulations in New Zealand

ISSUE ADDRESSED

The use of e-cigarettes is increasing; New Zealand (NZ) has witnessed a rapid rise in consumption. Policymakers face a challenge to balance the impacts of regulation on those who use e-cigarettes as a smoking cessation tool while protecting people who do not smoke from the harms of e-cigarette use, particularly young people. Previous research has demonstrated varying perspectives on e-cigarette regulation according to different stakeholders and interest groups. This study examined key stakeholders' positions on the drafted legislation to regulate e-cigarettes in NZ.

METHODS

Using written submissions made during public consultation in 2020, we conducted a content analysis to determine levels of support for e-cigarette regulations. Submissions made by the e-cigarette industry and the health sector were included for analysis.

RESULTS

The tobacco industry is heavily invested in ensuring that e-cigarettes continue to be promoted and available in NZ with minimal restrictions. On the contrary, health organisations supported the introduction of regulations to reduce marketing to, and use of e-cigarettes by youth and people who do not smoke.

CONCLUSIONS

The industry opposes restrictions using similar approaches employed against tobacco control measures. Despite perceptions of division, the health sector is generally unified in support of e-cigarette restrictions. SO WHAT?: Policymakers must protect public health policies from commercial interests and be cautious of opposition framed as public health concerns.

Exploring electronic cigarette portrayals: a content and thematic analysis of African online news coverage

BACKGROUND

Electronic cigarette use has surged internationally in recent years, with numerous countries noting an uptick in users. Despite this, the portrayal of e-cigarette usage in African news remains unclear.

METHODS

This research investigates the subject, employing a mixed-methodology approach. The study units were news articles on electronic cigarette use retrieved from AllAfrica, an online African news archive. A total of 38 online news and opinion articles published between June 2017 and June 2022 qualified the exclusion and inclusion criteria. A content analysis revealed prevalent codes and themes, while a thematic analysis explored the association between news sources and framing.

RESULTS

The results indicate that articles and arguments presenting e-cigarettes positively outnumber those with a negative slant. The health impacts of electronic cigarettes emerged as the most discussed topic, with health authorities frequently cited as news sources. However, these health authorities often lacked a unified stance on e-cigarette safety.

CONCLUSION

The lack of consensus among health officials could have public health consequences, possibly resulting in the formulation of uninformed policies.

Differentiating Reasons for Young Adult E-cigarette Use Using Maximum Difference Choice Models

INTRODUCTION

Understanding the reasons young adults use e-cigarettes (ie, vape)-and whether these motivations vary across groups-is essential for informing tobacco regulatory efforts.

AIMS AND METHODS

An online panel of young adults who vape (n = 230; age = 18-30 years) completed a maximum difference discrete choice task for 15 reasons for vaping. Over 9 choice sets, participants were presented a subset of 5 reasons and selected the most and least important. Hierarchical bayesian analysis estimated the relative importance of each reason. Latent class analysis (LCA) identified groups with similarly ranked reasons for use. Multinomial regression evaluated the association between sample characteristics and class membership.

RESULTS

Overall, relaxation had the highest probability of being the most important reason for use (14.8%), followed by harm reduction (13.2%), and flavors (10.3%). LCA identified five distinct classes, based on top reasons for use: 1. cessation (cigarette cessation [20.2%]; n = 80); 2. dependence (relaxation [20.5%] and unable to quit [19.2%]; n = 21); 3. relaxation (relaxation [20.6%]; n = 66); 4. socializing (socializing [22.2%]; n = 27); and 5. variable (boredom [10.5%] and acceptability [10.2%]; n = 36). Participants who were older, smoked cigarettes, or vaped more frequently were more likely to belong to the cessation class while those who were younger or more e-cigarette dependent were more likely to belong to the dependence class.

CONCLUSIONS

Perceived reasons why young adults vape are highly heterogeneous and dependent on the type of user. Tobacco regulatory efforts targeting distinct types of vapers are needed to minimize the adverse public health impact of vaping without compromising appeal for smoking cessation.

IMPLICATIONS

E-cigarette use remains high among young adults, with flavors, cost, and harm reduction (vs. combustible cigarettes) among the mostly commonly reported reasons for use. Yet, little is known about how relatively important these reasons are to the individual. Leveraging a maximum difference task, young adults' reasons for use were evaluated on a common interval scale and groups sharing similar reasons identified. Smoking cessation, dependence, relaxation, socialization, and boredom were respectively the most important reasons for use among five classes of vapers. E-cigarette regulatory policies should consider the distinct reasons for use as to not compromise their appeal for smoking cessation.

Arguments used by proponents and opponents in Brazil's regulatory discussions of e-cigarettes and heated tobacco products

OBJECTIVES

To identify proponents and opponents of the commercialisation and marketing of e-cigarettes and heated tobacco products (HTPs), identify the arguments used on both sides and compare how the arguments have changed over time, we analysed three policy discussions occurring in 2009, 2018 and 2019.

METHODS

We conducted a content analysis of one document and six videos from these discussions, provided on the Brazilian Health Regulatory Agency website, or upon request.

RESULTS

The arguments most used by tobacco companies were related to claims that the use of e-cigarettes and HTPs is less harmful than conventional tobacco. Unions that support its commercialisation also argued that lifting the ban would prevent smuggling and guarantee their quality. On the other side, universities, medical and anti-tobacco institutions argued that such devices may have health risks, including the risk of inducing cigarette smoking. In 2009, most arguments belonged to the 'health' theme, while in 2018 and 2019 economic arguments and those related to morals and ethics were frequently used.

CONCLUSIONS

Those that supported the commercialisation and marketing of e-cigarettes and HTPs first focused on arguments of harm reduction, while 10 years later the right to access and potential economic consequences also became common. Public health agents and academics must gather evidence to effectively respond to these arguments and discuss these policies, and must prepare themselves to use and respond to arguments related to moral and economic themes.

Vaping among Norwegians who smoke or formerly smoked: reasons, patterns of use, and smoking cessation activity

BACKGROUND

The majority of Norwegians who use e-cigarettes are adults who have smoked. Little is known about vaping reasons and -patterns in this group. The aim of this paper was to study vaping prevalence, patterns, and motivations among adults who smoke. Furthermore, to investigate smoking intensity and smoking cessation behaviour differences between those who vape and those who do not.

METHODS

This study was based on two separate Norwegian samples: People who had ever smoked, from 2017 (N = 2099), and people who currently smoked and recent quitters, from 2018/2019 (N = 1336). Measures of vape frequencies, vape motives, and smoking cessation behaviours were utilised in descriptive analyses of relationships between vaping and smoking behaviour.

RESULTS

Less than 1 in 10 in the ever-smoked group, 1 in 5 of the currently smoked or recently quit group, were currently vaping. Ever trial rates for vaping were much higher at 1 in 3 in the ever-smoked group, and 1 in 2 in the currently smoked or recently quit group. Dual use with combustible cigarettes was common, but people who smoked tended to use e-cigarettes less frequently while those who formerly smoked tended to use them more frequently. Both quitting attempts and smoking intensity reduction were positively associated with vaping, and the most common reasons for e-cigarette use were reported to be desires to reduce harm, to stop smoking, or to reduce smoking intensity.

CONCLUSION

The results indicate that Norwegians who smoke tend to see e-cigarettes as a tool to reduce or completely stop smoking. The predominance of use-motivations related to reducing harm points at the importance of conveying correct information about relative harmfulness of tobacco- and nicotine products.

How do patients and staff in an opioid agonist treatment service view smoking cessation medications and e-cigarettes?

INTRODUCTION

Tobacco use and related mortality is common in people receiving opioid agonist treatment (OAT). Smoking cessation medications are available and e-cigarettes are increasingly recommended for high risk populations. This study explores experience, knowledge and attitudes around smoking cessation medications (nicotine replacement therapy [NRT], bupropion and varenicline) and e-cigarettes in patients and clinicians in two public Australian OAT clinics.

METHODS

Cross-sectional surveys of patients and clinicians and a randomly sampled retrospective medical record review. Patients were recruited through an advertisement in the clinic, and clinicians through advertisement at an educational session.

RESULTS

Ninety-one patients and 10 clinicians completed the surveys. Most patients had at least one quit attempt and 43% were currently trying to quit. There were high levels of exposure to NRT, lower levels with varenicline and very limited exposure to bupropion. Patients considered e-cigarettes most helpful, but were more likely to consider using NRT. Few patients reported smoking cessation interventions from their clinicians. Most clinicians identified high tobacco use prevalence, considered this problematic, but reported low rates of smoking cessation intervention. NRT was the preferred medication. E-cigarettes were not considered helpful. Sixty-six percent of the 140 records reviewed documented patients as smokers. Tobacco cessation medication was rarely discussed or provided.

DISCUSSION AND CONCLUSIONS

Patients report high rates of tobacco cessation planning, but low rates of intervention. Experience of varenicline and bupropion is limited. E-cigarettes were preferred over varenicline and bupropion. Improving patient's and clinician's knowledge of tobacco cessation medications could improve smoking cessation interventions and uptake of approved medications.

Clinical testing of the cardiovascular effects of e-cigarette substitution for smoking: a living systematic review

Some persons who smoke have substituted e-cigarettes for tobacco cigarettes, either completely or partially. What effect does this have on cardiovascular functioning? We conducted a living systematic review on human clinical studies measuring the cardiovascular effects of e-cigarette substitution for smoking. The Scopus, PubMed, and CENTRAL Cochrane Library databases were searched on January 31 and April 29, 2021. Three secondary searches and a grey literature search were conducted. Included study designs were randomized controlled trials, quasi-experimental clinical trials, and cohort studies. Risk of bias and study quality were evaluated with the JBI Critical Appraisal tools and the Oxford Catalogue of Bias. The systematic review covered 25 studies comprising 1810 participants who smoked. Twenty studies were rated at high risk of bias, and five as some concerns. A tabular synthesis by direction of effect was conducted due to heterogeneity in the data. Nearly two-thirds of the test analyses indicated that e-cigarette use had no significance difference compared with tobacco cigarettes on heart rate, blood pressure, and in other cardiovascular tests. In two studies, participants with hypertension experienced a clinically relevant reduction in systolic blood pressure after 1 year of e-cigarette use. E-cigarette substitution incurs no additional cardiovascular risks, and some possible benefits may be obtained, but the evidence is of low to very low certainty. An update search on May 30, 2022 retrieved five studies that did not alter our conclusion.Registration PROSPERO #CRD42021239094.

Flavour loyalty may predict cessation or substitution following a cigarillo flavour ban among young adults in the USA

Significance

The purpose of this research was to measure flavour loyalty and identify how current cigarillo users may respond to a hypothetical flavour ban in the USA.

Methods

Cigarillo users aged 21–28 (n=531) were recruited between October 2020 and April 2021 to participate in an online survey. Respondents categorised their preferred, usual and current cigarillo flavours. Individuals who preferred tobacco flavours were compared with individuals who preferred any other flavours. Strength of preferences, or flavour loyalty, was defined when an individual’s preferred flavour matched what they use both usually and currently creating a spectrum of individuals with a strong tobacco preference (n=34), weak tobacco preference (n=20), weak flavour preference (n=162) and strong flavour preference (n=315). Those preferring tobacco were aggregated into any tobacco preference (n=54).

Results

Individuals who preferred any flavour scored higher on a scale of nicotine dependence. There was a dose–response relationship in those who said they would discontinue cigarillos if flavoured options were not available: 11.4% of individuals with any tobacco flavour preference, 27.8% of those with a weak flavour preference and 38.1% of those with a strong flavour preference. A similar trend was noted among those who would switch to another product: 19.2% of those with tobacco flavour preference, 34.3% of those with a weak flavour preference and 43.2% of those with a strong flavour preference.

Conclusion

Individuals who display strong flavour preferences were more likely to say they would discontinue use or seek out alternative flavoured products following a ban on flavoured cigarillos.

Chronic E-Cigarette Use Impairs Endothelial Function on the Physiological and Cellular Levels

BACKGROUND

The harmful vascular effects of smoking are well established, but the effects of chronic use of electronic cigarettes (e-cigarettes) on endothelial function are less understood. We hypothesized that e-cigarette use causes changes in blood milieu that impair endothelial function.

METHODS

Endothelial function was measured in chronic e-cigarette users, chronic cigarette smokers, and nonusers. We measured effects of participants' sera, or e-cigarette aerosol condensate, on NO and H2O2 release and cell permeability in cultured endothelial cells (ECs).

RESULTS

E-cigarette users and smokers had lower flow-mediated dilation (FMD) than nonusers. Sera from e-cigarette users and smokers reduced VEGF (vascular endothelial growth factor)-induced NO secretion by ECs relative to nonuser sera, without significant reduction in endothelial NO synthase mRNA or protein levels. E-cigarette user sera caused increased endothelial release of H2O2, and more permeability than nonuser sera. E-cigarette users and smokers exhibited changes in circulating biomarkers of inflammation, thrombosis, and cell adhesion relative to nonusers, but with distinct profiles. E-cigarette user sera had higher concentrations of the receptor for advanced glycation end products (RAGE) ligands S100A8 and HMGB1 (high mobility group box 1) than smoker and nonuser sera, and receptor for advanced glycation end product inhibition reduced permeability induced by e-cigarette user sera but did not affect NO production.

CONCLUSIONS

Chronic vaping and smoking both impair FMD and cause changes in the blood that inhibit endothelial NO release. Vaping, but not smoking, causes changes in the blood that increase microvascular endothelial permeability and may have a vaping-specific effect on intracellular oxidative state. Our results suggest a role for RAGE in e-cigarette-induced changes in endothelial function.

Text mining tweets on e-cigarette risks and benefits using machine learning following a vaping related lung injury outbreak in the USA

Electronic nicotine delivery systems (ENDS) (also known as 'e-cigarettes') can support smoking cessation, although the long-term health impacts are not yet known. In 2019, a cluster of lung injury cases in the USA emerged that were ostensibly associated with ENDS use. Subsequent investigations revealed a link with vitamin E acetate, an additive used in some ENDS liquid products containing tetrahydrocannabinol (THC). This became known as the EVALI (E-cigarette or Vaping product use Associated Lung Injury) outbreak. While few cases were reported in the UK, the EVALI outbreak intensified attention on ENDS in general worldwide. We aimed to describe and explore public commentary and discussion on Twitter immediately before, during and following the peak of the EVALI outbreak using text mining techniques. Specifically, topic modelling, operationalised using Latent Dirichlet Allocation (LDA) models, was used to discern discussion topics in 189,658 tweets about ENDS (collected April-December 2019). Individual tweets and Twitter users were assigned to their dominant topics and countries respectively to enable international comparisons. A 10-topic LDA model fit the data best. We organised the ten topics into three broad themes for the purposes of reporting: informal vaping discussion; vaping policy discussion and EVALI news; and vaping commerce. Following EVALI, there were signs that informal vaping discussion topics decreased while discussion topics about vaping policy and the relative health risks and benefits of ENDS increased, not limited to THC products. Though subsequently attributed to THC products, the EVALI outbreak disrupted online public discourses about ENDS generally, amplifying health and policy commentary. There was a relatively stronger presence of commercially oriented tweets among UK Twitter users compared to USA users.

A Decision-Theoretic Public Health Framework for Heated Tobacco and Nicotine Vaping Products

Markets for nicotine vaping products (NVPs) and heated tobacco products (HTPs) have grown as these products became positioned as harm-reduction alternatives to combusted tobacco products. Herein, we present a public health decision-theoretic framework incorporating different patterns of HTP, NVP, and cigarette use to examine their impacts on population health. Our framework demonstrates that, for individuals who would have otherwise smoked, HTP use may provide public health benefits by enabling cessation or by discouraging smoking initiation and relapse. However, the benefits are reduced if more harmful HTP use replaces less harmful NVP use. HTP use may also negatively impact public health by encouraging smoking by otherwise non-smokers or by encouraging initiation or relapse into smoking. These patterns are directly influenced by industry behavior as well as public policy towards HTPs, NVPs, and cigarettes. While substantial research has been devoted to NVPs, much less is known about HTPs. Better information is needed to more precisely define the health risks of HTPs compared to cigarettes and NVPs, the relative appeal of HTPs to consumers, and the likelihood of later transitioning to smoking or quitting all products. While our analysis provides a framework for gaining that information, it also illustrates the complexities in distinguishing key factors.

E-Cigarettes and the Multiple Responsibilities of the FDA

This paper considers the responsibilities of the FDA with regard to disseminating information about the benefits and harms of e-cigarettes. Tobacco harm reduction advocates claim that the FDA has been overcautious and has violated ethical obligations by failing to clearly communicate to the public that e-cigarettes are far less harmful than cigarettes. We argue, by contrast, that the FDA's obligations in this arena are more complex than they may appear at first blush. Though the FDA is accountable for informing the public about the health risks and benefits of products it regulates, it also has other roles (and attendant responsibilities) that inform when and how it should disseminate information. In addition to being a knowledge purveyor, it is also a knowledge producer, an advisor to the public, and a practical agent shaping the material conditions in which people make health-related choices. In our view, those other roles call for caution in the way the FDA interprets and communicates the available evidence.

Use of supporting evidence by health and industry organisations in the consultation on e-cigarette regulations in New Zealand

OBJECTIVES

Scientific evidence to support the development of appropriate policy for electronic cigarette use is limited by rapidly changing technology and a lack of long-term data. Perceptions of risk and benefits determine diverse framings of the e-cigarette debate and complicate policy decisions. E-cigarette use by smokers who are attempting to quit may result in improved health outcomes, while their use among young people and non-smokers may lead to adverse health consequences. The purpose of this study was to identify the types of evidence used during public consultations on proposed revisions to New Zealand's e-cigarette legislation in 2020.

METHODS

Using submissions to parliament made by the tobacco/e-cigarette industry and the health sector, we assessed the cited evidence for quality and independence measured by publication type and tobacco industry connections. We identified themes from a sub-sample of frequently cited evidence to understand how stakeholders and organisations used evidence.

RESULTS

The sample consisted of 57 submissions from the e-cigarette and tobacco industry (n = 21) and health organisations (n = 36). A total of 442 pieces of evidence were cited at least once. Health organisations were more likely to cite peer-reviewed evidence (OR = 2.99). The industry was more likely to cite evidence outside of peer review and sources with tobacco industry connections (OR = 4.08). In the sample of frequently cited evidence, youth prevalence and flavours were the most common themes. In some cases the same evidence was used by both groups to support opposing policy positions.

CONCLUSIONS

The industry continues to rely more heavily on evidence published outside of the peer-review process, which is, therefore, subjected to less scientific scrutiny. By using a smoking-cessation or harm-reduction narrative, the industry could be seen as a legitimate stakeholder in policy development.

E-cigarette addiction and harm perception: Does initiation flavor choice matter?

Introduction

The 21^st century was marked by a dramatic increase in adolescent e-cigarette use in the United States (US). The popularity of non-traditional flavor types, including fruit and pastry, is thought to contribute toward growing product use nationally, leading to a variety of federal and state regulations limiting the use of non-traditional flavors in the US. The relationship between flavor type and increased adolescent use suggests a possible link between flavor use and addiction and harm perception. This study assessed if the flavor type used when initiating e-cigarette use predicted addiction and harm perceptions.

Methods

The study utilized data from the multi-wave youth Population Assessment of Tobacco Health Study. It explored the impact initiating e-cigarette use with traditional versus non-traditional flavor types among cigarette users on the outcome variables: e-cigarette addiction and harm perception. Both e-cigarette addiction and harm perception were measured using self-report, Likert scale questionnaires. Descriptive statistics characterized the study variables and linear regression analyses performed to test whether flavor initiation type is associated with addiction and harm perception.

Results

The study sample consisted of 1,043 youth (weighted N = 1,873,617) aged 12 to 17 years who reported at least one instance of e-cigarette use. After adjusting for age, age of onset, sex, race and annual household income there was no statistically significant difference in addiction levels between those initiating with traditional versus non-traditional flavors (p = 0.294). Similarly, traditional versus non-traditional flavor initiation did not show a statistically significant difference in adolescent e-cigarette harm perceptions (p = 0.601).

Conclusions

Traditionally flavored e-cigarette initiation produces similar risk for addiction and harm perceptions as non-traditionally flavored initiation. These findings suggest that banning non-traditional flavors alone may be ineffective in curbing e-cigarette addiction and harm perception. Additional research is needed to better understand which e-cigarette product characteristics and behaviors may be associated with greater addiction and reduced harm perceptions.

The Use of Tobacco Industry Vaping Products in the UK and Product Characteristics: A Cross-Sectional Survey

BACKGROUND

Tobacco industry (TI) companies have entered the UK e-cigarette ("vaping") market in recent years. However, their motives and ambitions are unclear. This study explored how popular TI vaping products are and who uses them, and how they differ from independent products.

METHODS

Secondary analysis of data from a longitudinal web-based survey of smokers, ex-smokers, and vapers (n = 3883) in the UK in 2019. The main study sample consisted of daily and nondaily vapers, who were current or ex-cigarette smokers, and had stated the brand of their preferred e-cigarette device (n = 1202). Proportions using TI and independent brands were calculated and regression analysis assessed associations with sociodemographic and smoking/vaping characteristics between vapers of TI and independent products. Chi-square tests were used to analyze differences between TI and independent products.

RESULTS

Overall, 53.4% used TI products. A university education (67.6%; adjOR = 1.54; 95% CI, 1.140-2.088), nondaily vaping (68.2%; adjOR = 1.39; CI, 1.029-1.880), and cigarette dependence (moderate, strong and very strong urges to smoke) were associated with using TI vaping brands. TI products used were less likely to be refillable ("open") than independent brands (60.9% vs. 18.3%, chi-square = 228.98, p < .001), more likely to use nicotine salts (16.7% vs. 8.6%, chi-square = 25.04, p < .001) and tobacco flavors (23.8% vs. 17.9%, chi-square = 12.65, p < .001).

CONCLUSION

TI vaping products were popular in the UK, associations with product and user characteristics suggest that TI products may be less conducive to smoking cessation, although the findings were not always consistent.

IMPLICATIONS

Consequences of regulations need to be carefully considered to ensure that independent producers are not more negatively impacted than tobacco industry producers, and to avoid reducing utility of products for smoking cessation.

E-Cigarettes-a review of the evidence-harm versus harm reduction

The World Health Organization estimates there are 1.1 billion cigarette smokers across the globe and that tobacco related deaths number 7 million per year. Electronic nicotine delivery systems (ENDS) are available to contribute options for smoking cessation and include e-cigarettes, e-hookahs, vape pens, mods, and vaping. The growing use of ENDS, or e-cigarettes, in the US and globally across populations is dramatic. Although users may think that e-cigarettes are less harmful than combustible tobacco products, the evidence shows that there are known risks and harms for users. E-cigarettes have varying amounts of toxicants, nicotine, and carcinogens and put the user at risk for lung diseases and COVID-19 similar to smokers. Currently, most governing bodies have not approved e-cigarettes as a smoking cessation tool but do state if a person has failed conventional smoking cessation treatments that e-cigarettes used alone for the short term may help those to quit combustible tobacco and nicotine. A shared decision-making approach should be used when discussing e-cigarettes as a harm reduction tool. More studies and long-term data are needed to assess potential benefits and harms. What is known is that prevention efforts and policy are needed to avoid adolescents and other vulnerable populations from initiating tobacco or e-cigarette use.

Developing Competency-Based Nursing Treatment for Persons With Tobacco Use Disorder

BACKGROUND

Tobacco continues to have a deleterious impact on health outcomes in the United States. Professional nurses at all levels of practice have an opportunity to be a part of the solution. The development of nurse-specific competencies for treating tobacco use disorder (TUD) disorder is long overdue. A task force of American Psychiatric Nurses Association (APNA) subject matter experts was assembled to engage in the process of reviewing the available peer-reviewed literature and additional evidence-based resources (e.g., professional organization position statement, toolkits, national survey results) to create the Nursing Competencies for Treating Tobacco Use Disorders.

OBJECTIVE

The aim of this article is ultimately to improve patient access to quality, evidence-based TUD nursing care by all nurses who are competent, full partners in TUD multidisciplinary care.

METHOD

Search terms were defined and a scoping search and review of the TUD literature and resources was performed from November 2018 to November 2020.

RESULTS

Over 300 articles and evidence-based resources (e.g., professional organization position statements, toolkits, etc.) were discovered. Thirteen competencies were developed and were internally and externally reviewed prior to APNA Board of Director's approval.

CONCLUSION

TUD competencies have the potential to guide nursing education, practice, and research, allowing nurses to be full partners in the design, development, and implementation of effective TUD treatment.

Within-person longitudinal associations between electronic nicotine delivery systems use and smoking cessation efforts among U.S. continuing adult cigarette smokers

OBJECTIVES

Prior studies that examined the role of electronic nicotine delivery systems (ENDS) use in smoking cessation have shown divergent conclusions. This study examined the time-course of ENDS-associated smoking abstinent behaviors among continuing cigarette smokers who were willing but unable to quit smoking.

METHODS

Data were drawn from the four waves of the Population Assessment of Tobacco and Health Study. Of the 1,684 smokers who tried to quit smoking completely at Wave 1, a total of 1,094 who were continuing smokers until Wave 4 and were not lost to follow-ups comprised the sample. Using generalized linear mixed modeling, we fitted weighted negative binomial regression models to examine within-person associations of ENDS use with quit attempts and number of days abstinent from smoking.

RESULTS

Quit attempt frequency and smoking abstinent days were highest at Wave 1, dropped at Wave 2, and then either increased a little or remained stagnant in later waves. ENDS use to quit smoking was associated with more frequent quit attempts (aIRR=1.67, 95% CI=1.42-1.95) and more abstinent days (aIRR=3.28, 95% CI=2.43-4.44), and the magnitude of such associations became stronger over time. ENDS use was associated with becoming a non-daily smoker among baseline daily smokers.

CONCLUSIONS

ENDS use among continuing smokers may help increase the number of quit attempts and smoking abstinent days. Given that the study sample is continuing smokers who failed in complete smoking cessation, future research would be desirable that evaluates whether such abstinent behaviors sustain and manifest harm reduction with improved health outcomes.

IMPLICATIONS

Smokers increasingly adopt electronic nicotine delivery systems (ENDS) to quit smoking. However, the association of ENDS use with smoking cessation efforts among continuing cigarette smokers who were willing but unable to quit smoking is largely unknown. This study found that quit attempts and smoking abstinent days increased with ENDS use to quit smoking by following up with population-representative continuing smokers. Additionally, this study assessed whether cigarette smokers' abstinent behaviors vary with their use of ENDS by estimating within-person associations with frequent assessments of both exposures and outcomes in a long-term perspective.

Effects of brief exposure to misinformation about e-cigarette harms on twitter: a randomised controlled experiment

OBJECTIVES

To assess the effect of exposure to misinformation about e-cigarette harms found on Twitter on adult current smokers' intention to quit smoking cigarettes, intention to purchase e-cigarettes and perceived relative harm of e-cigarettes compared with regular cigarettes.

SETTING

An online randomised controlled experiment conducted in November 2019 among USA and UK current smokers.

PARTICIPANTS

2400 adult current smokers aged ≥18 years who were not current e-cigarette users recruited from an online panel. Participants' were randomised in a 1:1:1:1 ratio using a least-fill randomiser function.

INTERVENTIONS

Viewing 4 tweets in random order within one of four conditions: (1) e-cigarettes are just as or more harmful than smoking, (2) e-cigarettes are completely harmless, (3) e-cigarette harms are uncertain, and (4) a control condition of tweets about physical activity.

PRIMARY OUTCOMES MEASURES

Self-reported post-test intention to quit smoking cigarettes, intention to purchase e-cigarettes, and perceived relative harm of e-cigarettes compared with smoking.

RESULTS

Among US and UK participants, after controlling for baseline measures of the outcome, exposure to tweets that e-cigarettes are as or more harmful than smoking versus control was associated with lower post-test intention to purchase e-cigarettes (β=-0.339, 95% CI -0.487 to -0.191, p<0.001) and increased post-test perceived relative harm of e-cigarettes (β=0.341, 95% CI 0.273 to 0.410, p<0.001). Among US smokers, exposure to tweets that e-cigarettes are completely harmless was associated with higher post-test intention to purchase e-cigarettes (β=0.229, 95% CI 0.002 to 0.456, p=0.048) and lower post-test perceived relative harm of e-cigarettes (β=-0.154, 95% CI -0.258 to -0.050, p=0.004).

CONCLUSIONS

US and UK adult current smokers may be deterred from considering using e-cigarettes after brief exposure to tweets that e-cigarettes were just as or more harmful than smoking. Conversely, US adult current smokers may be encouraged to use e-cigarettes after exposure to tweets that e-cigarettes are completely harmless. These findings suggest that misinformation about e-cigarette harms may influence some adult smokers' decisions to consider using e-cigarettes.

TRIAL REGISTRATION NUMBER

ISRCTN16082420.

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.

Statewide vaping product excise tax policy and use of electronic nicotine delivery systems among US young adults, 2014-2019

OBJECTIVES

An increasing number of US states have required a tax on electronic nicotine delivery systems (ENDS) in the past few years. This study evaluated the effect of statewide vaping product excise tax policy on ENDS use among young adults.

METHODS

We used the two recent waves (2014-2019) of the Tobacco Use Supplement to the Current Population Survey. A total of 17 896 US young adults were analysed. Difference-in-differences approach along with weighted multilevel logistic regressions were used to evaluate the association of vaping product excise tax policy adoption with current ENDS use, accounting for the clustering of respondents within the same states.

RESULTS

There was an increase in current ENDS use prevalence from 2014-2015 (3.4%) to 2018-2019 (5.4%). The presence of a tax on ENDS products was significantly associated with reduced current ENDS use (adjusted OR (AOR)=0.64, 95% CI=0.43 to 0.95). Importantly, respondents living in states with the policy showed significantly lower increase in ENDS use prevalence during the study period (interaction between within-state changes and between-state differences: AOR=0.57, 95% CI=0.35 to 0.91), controlling for other state-level policies and sociodemographic characteristics.

CONCLUSIONS

Our findings suggest that adopting a vaping product excise tax policy may help reduce ENDS use and suppress the increase of ENDS use prevalence among young adults. Considering that there are still a number of US states that have not implemented vaping product excise tax policy, wider adoption of such policy across the nation would likely help mitigate ENDS use prevalence.

How does the British Soft Drink Association respond to media research reporting on the health consequences of sugary drinks?

Background

Sugar-sweetened beverages (SSBs) are the leading global source of added sugar intake and their consumption is associated with negative health outcomes, such as diabetes, cancers, cardiovascular diseases, and overall mortality. Despite consensus within the public health community about the need to reduce sugar intake, the non-alcoholic beverage industry engages in efforts to publicly undermine the evidence base surrounding the harmful effects of SSBs. There has been limited investigation of how SSB industry actors engage in public debates to challenge public health research and policy on SSBs. To address this gap, we thematically analyze the public comments and press releases of the British Soft Drinks Association (BSDA) since May 2014.

Results

A total of 175 news articles and 7 press releases were identified where the BSDA commented upon new SSB research in public settings. In these comments, four strategies were observed to undermine new research. First, the BSDA challenged study rigour and research design (n = 150). They challenged the policy implications of research by stating observational studies do not demonstrate causation, refuted data sources, questioned researcher motivations, and claimed research design did not account for confounding factors. Second, the BSDA positioned themselves as an altruistic public health partner (n = 52) intent on improving population-level nutrition citing their voluntary industry commitments. Third, the BSDA promoted concepts of safety that align with industry interests (n = 47). Lastly, the BSDA argued that the lifestyle of individual consumers should be the focus of public health interventions rather than the industry (n = 61).

Conclusion

The findings illustrate the BSDA reliance on arguments of causation to discredit research and avoid policy interventions. Given the attention by the BSDA regarding the purported lack of evidence of causation between SSBs and non-communicable diseases, it is imperative that members of the public health community try to educate policy makers about (a) the complex nature of causation; (b) that evidence in favour of public health interventions cannot, and do not, solely rely on causation studies; and (c) that public health must sometimes abide by the precautionary principle in instituting interventions.

Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis

BACKGROUND

This systematic review of prospective longitudinal primary studies sought to determine whether electronic cigarette (e-cigarette) use by teenagers who had never smoked conventional tobacco cigarettes (tobacco cigarettes) at baseline was associated with subsequently commencing tobacco cigarette smoking.

METHODS

The review followed the principles of a systematic review and meta-analysis. A key word search identified peer-reviewed articles published between 1 January 2005 and 2 October 2019 from seven bibliographic databases and one search engine. Using pre-prepared inclusion/exclusion criteria two researchers independently screened abstracts, and subsequently, full text papers. Selected articles were quality assessed in duplicate. Data on study participants characteristics, exposure and outcome measures were recorded in an adapted Cochrane Data Extraction Form. Feasibility assessment was done to detect clinical heterogeneity and choose an approach to meta-analysis. Analysis comprised pairwise random effects meta-analyses, and sensitivity and subgroup analyses.

RESULTS

From the 6619 studies identified, 14 one-off primary studies in 21 articles were suitable for inclusion. The participants ages ranged from 13 to 19 years and comprised teenagers based in Europe and North America. Nine of the 14 one-off studies, with follow-up periods between 4 and 24 months, met the criteria for inclusion in a meta-analysis of the association between ever use of e-cigarettes and subsequent initiation of tobacco cigarette use. Based on primary study adjusted odds ratios, our meta-analysis calculated a 4.06 (95% confidence interval (CI): 3.00-5.48, I2 68%, 9 primary studies) times higher odds of commencing tobacco cigarette smoking for teenagers who had ever used e-cigarettes at baseline, though the odds ratio were marginally lower (to 3.71 times odds, 95%CI: 2.83-4. 86, I2 35%, 4 primary studies) when only the four high-quality studies were analysed.

CONCLUSION

The systematic review found that e-cigarette use was associated with commencement of tobacco cigarette smoking among teenagers in Europe and North America, identifying an important health-related harm. Given the availability and usage of e-cigarettes, this study provides added support for urgent response by policymakers to stop their use by teenagers to decrease direct harms in this susceptible population group, as well as to conserve achievements in diminishing tobacco cigarette initiation.

Respiratory and Cardiovascular Health Effects of e-Cigarette Substitution: Protocol for Two Living Systematic Reviews

Background

Despite the clear risks of tobacco use, millions of people continue to smoke. Electronic nicotine delivery systems (ENDS), commonly called e-cigarettes, have been proposed as a substitute for those who are unwilling or unable to quit. Current systematic and narrative reviews on the health effects of ENDS use, particularly respiratory and cardiovascular effects, have come to differing conclusions.

Objective

We conducted two systematic reviews to critically assess and synthesize available human studies on the respiratory and cardiovascular health effects of ENDS substitution for people who smoke. The primary goal is to provide clinicians with evidence on the health effects of ENDS substitution to inform their treatment recommendations and plans. The twin goal of the reviews is to promote health literacy in ENDS users with facts on the health effects of ENDS.

Methods

These two reviews will be living systematic reviews. The systematic reviews will be initiated through a baseline review. Studies will be evaluated using the JBI quality assessment tools and a checklist of biases drawn from the Centre for Evidence Based Medicine Catalogue of Bias. A narrative synthesis is planned because of the heterogeneity of data. A search for recently published studies will be conducted every 3 months, and an updated review will be published every 6 months for the duration of the project or possibly longer.

Results

The baseline and updated reviews will be published in a peer-reviewed journal. The findings of the reviews will be reported in a white paper for clinicians and a fact sheet for people who use ENDS.

Conclusions

The substitution of ENDS for cigarettes is one way to potentially reduce the risks of smoking. Clinicians and their patients need to understand the potential benefits and possible risks of substituting ENDS for cigarettes. Our living systematic reviews seek to highlight the best and most up-to-date evidence in this highly contentious and fast-moving field of research.

Trial Registration

PROSPERO CRD42021239094; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=239094

International Registered Report Identifier (IRRID)

DERR1-10.2196/29084

High school seniors who used e-cigarettes may have otherwise been cigarette smokers: Evidence from Monitoring the Future (United States, 2009-2018)

INTRODUCTION

Studies have indicated that youth who use e-cigarettes are more likely to progress to cigarette smoking; however, the likelihood that these youth would have used tobacco products in the pre-vaping era is unclear. This study sought to determine whether youth who used e-cigarettes in 2014-2018 would have likely been smokers in the period preceding e-cigarette availability.

METHODS

Analyzing Monitoring the Future 12 th grade data (USA, 2009-2018), we forecasted the prevalence of current smoking with logistic regression-derived propensity scores. Models predicted smoking for all subsequent years, incorporating sociodemographic, family, alcohol, and school-related variables, and a linear time trend. We compared forecasted to observed smoking prevalence annually, and prevalence of current e-cigarette use among non-smokers across smoking propensity tertiles.

RESULTS

Until 2014, observed smoking prevalence mirrored forecasted prevalence. Afterward, forecasted rates consistently overestimated prevalence. Among non-smoking youth, e-cigarette use was lowest among those with lowest predicted probability of cigarette smoking (3.8%; 95% CI: 3.3, 4.4) and highest among those with highest probability (23.5%; 95% CI: 22.2, 24.9).

DISCUSSION

Youth e-cigarette use has increased rapidly, with high prevalence among non-smoking youth. However, the decline in current smoking among 12 th graders has accelerated since e-cigarettes have become available. E-cigarette use is largely concentrated among youth who share characteristics with smokers of the pre-vaping era, suggesting e-cigarettes may have replaced cigarette smoking.

IMPLICATIONS

Vaping is largely concentrated among non-smoking youth who would likely have smoked prior to the introduction of e-cigarettes, and the introduction of e-cigarettes has coincided with an acceleration in the decline in youth smoking rates. E-cigarettes may be an important tool for population-level harm reduction, even considering their impact on youth.

Public health implications of vaping in the USA: the smoking and vaping simulation model

Background

Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA.

Methods

SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses.

Results

The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters.

Discussion

Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data.

Conclusion

The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12963-021-00250-7.

Understanding commercial actors' engagement in policy debates on proposed e-cigarette regulation in Scotland

INTRODUCTION

There is growing concern about transnational tobacco corporations' (TTCs) and other commercial actors' involvement in e-cigarette policy development. Previous analyses suggest that TTCs used e-cigarette debates to demonstrate alignment with public health and re-gain policy influence. Less is known about the engagement of other types of commercial actors in e-cigarette policy debates.

METHODS

This paper is the first to empirically analyse commercial actors' engagement in an e-cigarette policy consultation process and to examine their views on proposed regulation. It applies mixed methods, drawing on policy consultation submissions (n=32), semi-structured interviews (n=9) and a social network analysis of website links among 32 commercial actors.

RESULTS

The results show that commercial actors' positions on e-cigarette regulation aligned with business interests. TTCs, independent e-cigarette manufacturers and other non-licensed commercial actors were opposed to most aspects of potential e-cigarette regulation (except for age of sale restrictions), whereas licensed commercial actors, including pharmaceutical companies, supported more stringent regulation. While collaboration was viewed as strategically important to gain policy influence, distinct commercial interests and concerns about TTC credibility led to strategic distancing and to collaboration being largely confined to sector boundaries. In addition to reiterating arguments employed by TTCs in previous regulatory debates, commercial actors focused on highlighting the technical complexity and harm reduction potential of e-cigarettes.

CONCLUSION

Awareness of the various commercial interests and strategic positioning of commercial actors in e-cigarette policy should inform public health advocacy and policy development, including managing conflicts of interest in the context of Framework Convention on Tobacco Control Article 5.3.

"Is it banned? Is it illegal?": Navigating Western Australia's regulatory environment for e-cigarettes

BACKGROUND

In Australia, there is no Federal legislation that directly applies to e-cigarettes, instead, several existing laws relating to poisons, therapeutic goods and tobacco control apply. Across all Australian States and Territories, it is illegal to sell nicotine-containing e-cigarettes, however, users can legally import nicotine-containing vaporisers through the Personal Importation Scheme. Western Australia differs from other Australian States and Territories in that products which resemble tobacco products are banned, effectively prohibiting the use of e-cigarettes. This study aimed to understand how e-cigarette users navigate Western Australia's regulatory environment to access vaping products and the health and safety issues encountered.

METHODS

Working from a constructionist epistemology and a symbolic interaction framework, in-depth interviews were conducted with a purposive sample of 37 current (89%) and former (11%) adult vapers (70% male, mean age of 32.5). Data was analysed via thematic analysis.

RESULTS

Vape retailers were said to be circumventing Western Australia's e-cigarette restrictions by selling the components of 'open system' devices that do not resemble a tobacco product when sold individually. Participants were unsure of the legality of importing, accessing and using nicotine and e-cigarettes, however, the majority continued to use nicotine-containing vaporisers and implemented strategies in an attempt to avoid detection and safeguard their health. The internet facilitated access to desired products, information on health and safety, and discussions of personal experiences.

CONCLUSIONS

The Australian Therapeutic Goods Administration has recently (21 December 2020) confirmed that from 1 October 2021 smokers who have tried quitting with other approved cessation pharmacotherapies will be required to obtain a prescription for nicotine-containing vaporiser products from a registered medical practitioner. The results of this study suggest further consideration of regulatory measures are however required to support the different characteristics of vapers and to mitigate the health and safety concerns experienced by e-cigarette users.

The Misuse of the Precautionary Principle in Justifying Australia's Ban on the Sale of Nicotine Vaping Products

In Australia, the precautionary principle has been used to justify an effective sales ban on nicotine vaping products (NVPs) by requiring all NVPs to be approved as medicines. Australia's policy is out of step with other English-speaking countries, which allow the sale of NVPs as consumer products. We provide a brief history of the precautionary principle, discuss guidelines on how it should be used, and examine key documents from Australian policy debates to describe how the precautionary principle has been misapplied in justifying Australian NVP policy. We argue that the precautionary principle has been inappropriately applied to NVP regulation in Australia in that it has: failed to consider the regulation of similar products, imposed regulations that are disproportionate to the level of risk, failed to assess the costs of its regulatory approach, and failed to undertake a cost/benefit analysis of a range of available regulatory options. Australian policy illustrates the risks of regulating nicotine products in isolation rather than considering NVPs as falling on a continuum of harmful nicotine products. Implications: The precautionary principle has been misapplied to NVP regulation in Australia. We recommend that the precautionary principle be used in a way that regulates nicotine products in proportion to their risks.

Use of Electronic Cigarettes to Aid Long-Term Smoking Cessation in the United States: Prospective Evidence From the PATH Cohort Study

Electronic cigarettes (e-cigarettes) are the preferred smoking-cessation aid in the United States; however, there is little evidence regarding long-term effectiveness among those who use them. We used the Population Assessment of Tobacco and Health Study to compare long-term abstinence between matched US smokers who tried to quit with and without use of e-cigarettes as a cessation aid. We identified a nationally representative cohort of 2,535 adult US smokers in 2014-2015 (baseline assessment), who, in 2015-2016 (exposure assessment), reported a past-year attempt to quit and the cessation aids used, and reported smoking status in 2016-2017 (outcome assessment; self-reported ≥12 months continuous abstinence). We used propensity-score methods to match each e-cigarette user with similar nonusers. Among US smokers who used e-cigarettes to help quit, 12.9% (95% confidence interval (CI): 9.1%, 16.7%) successfully attained long-term abstinence. However, there was no difference compared with matched non-e-cigarette users (cigarette abstinence difference: 2%; 95% CI: -3%, 7%). Furthermore, fewer e-cigarette users were abstinent from nicotine products in the long term (nicotine abstinence difference: -4%; 95% CI: -7%, -1%); approximately two-thirds of e-cigarette users who successfully quit smoking continued to use e-cigarettes. These results suggest e-cigarettes may not be an effective cessation aid for adult smokers and, instead, may contribute to continuing nicotine dependence.

An update on controversies in e-cigarettes

E-cigarettes are electronic nicotine delivery systems (ENDS) which mimic tobacco smoking without the combustion of tobacco. These devices have been misleadingly marketed as "less harmful" alternatives to conventional smoking tobacco products. The e-liquid in e-cigarettes include nicotine, a humectant and other additives including flavourings, colourants, or adulterants such as bacterial and fungal products. In this review, we discuss the contrasting views of the tobacco lobby and most professional societies. We describe the epidemiology of the use of these devices, with a widespread and significant rise in youth e-cigarette use seen in both the USA and Europe. We also describe what is known about the toxicity and mechanisms of EVALI (e-cigarette or vaping associated lung injury). This characterised by respiratory failure with an intense inflammatory response. The presentations are diverse and clinicians should consider vaping as a possible cause of any unusual respiratory illness in patients who have a history of vaping or other use of e-cigarette-related products. Second hand exposure to e-cigarettes is also harmful through respiration and transdermal absorption. E-cigarettes have a worse acute toxicity than tobacco and their long-term toxicity is unknown, and we advocate for the immediate, most vigorous anti-vaping legislation possible.

E-Cigarette Advocates on Twitter: Content Analysis of Vaping-Related Tweets

Background

As the majority of Twitter content is publicly available, the platform has become a rich data source for public health surveillance, providing insights into emergent phenomena, such as vaping. Although there is a growing body of literature that has examined the content of vaping-related tweets, less is known about the people who generate and disseminate these messages and the role of e-cigarette advocates in the promotion of these devices.

Objective

This study aimed to identify key conversation trends and patterns over time, and discern the core voices, message frames, and sentiment surrounding e-cigarette discussions on Twitter.

Methods

A random sample of data were collected from Australian Twitter users who referenced at least one of 15 identified e-cigarette related keywords during 2012, 2014, 2016, or 2018. Data collection was facilitated by TrISMA (Tracking Infrastructure for Social Media Analysis) and analyzed by content analysis.

Results

A sample of 4432 vaping-related tweets posted and retweeted by Australian users was analyzed. Positive sentiment (3754/4432, 84.70%) dominated the discourse surrounding e-cigarettes, and vape retailers and manufacturers (1161/4432, 26.20%), the general public (1079/4432, 24.35%), and e-cigarette advocates (1038/4432, 23.42%) were the most prominent posters. Several tactics were used by e-cigarette advocates to communicate their beliefs, including attempts to frame e-cigarettes as safer than traditional cigarettes, imply that federal government agencies lack sufficient competence or evidence for the policies they endorse about vaping, and denounce as propaganda “gateway” claims of youth progressing from e-cigarettes to combustible tobacco. Some of the most common themes presented in tweets were advertising or promoting e-cigarette products (2040/4432, 46.03%), promoting e-cigarette use or intent to use (970/4432, 21.89%), and discussing the potential of e-cigarettes to be used as a smoking cessation aid or tobacco alternative (716/4432, 16.16%), as well as the perceived health and safety benefits and consequences of e-cigarette use (681/4432, 15.37%).

Conclusions

Australian Twitter content does not reflect the country’s current regulatory approach to e-cigarettes. Rather, the conversation on Twitter generally encourages e-cigarette use, promotes vaping as a socially acceptable practice, discredits scientific evidence of health risks, and rallies around the idea that e-cigarettes should largely be outside the bounds of health policy. The one-sided nature of the discussion is concerning, as is the lack of disclosure and transparency, especially among vaping enthusiasts who dominate the majority of e-cigarette discussions on Twitter, where it is unclear if comments are endorsed, sanctioned, or even supported by the industry.

Home smoking and vaping policies among US adults: results from the Population Assessment of Tobacco and Health (PATH) study, wave 3

We examined the prevalence of home smoking and vaping restrictions among US adults, and compared home policy differences for smoking and vaping among vapers, smokers, and dual users. Secondary data from the Population Assessment of Tobacco and Health (PATH) Study Wave 3 (2015-2016) with 28,148 adults were analyzed using weighted multivariable logistic regression models that account for complex sampling design to compare differences in home policies among non-users, vapers only, smokers only, and dual users. Compared to never-users, current vapers who were ex-smokers and dual users were more likely to allow home vaping (aOR = 11.06, 95% CI: 8.04-15.21; aOR = 6.44, 95% CI: 5.01-8.28) and smoking (aOR = 1.62, 95% CI: 1.19-2.22; aOR = 3.58, 95% CI: 2.88-4.45). Current smokers were more likely to allow vaping (aOR = 3.53, 95% CI: 3.06-4.06) and smoking (aOR = 4.27, 95% CI: 3.73-4.89) inside the home than never-users. Current vapers who never smoked were more likely to allow vaping inside the home than never-users (aOR = 2.45, 95% CI: 1.53-3.93). Vapers reported much lower rates of vape-free home policies relative to both their smoke-free home policies and to vape-free home policies among smokers. Vapers may be using e-cigarettes in hopes of harm reduction, but interpreting "harm reduction" as safe, thus exposing non-users in their homes to second- and thirdhand aerosols. This underscores the need to healthcare providers to extend intervention with vapers to include implementing vape-free home policies.

What is the face of new nicotine users? 2012-2018 e-cigarettes and tobacco use among young students in Italy

BACKGROUND

With increased use of electronic-nicotine delivery devices (e-cigarettes) and non-cigarettes tobacco products (heated tobacco products, shisha, moist snuff/snus) among adolescents, the percentage of Italian students who use nicotine products is at its highest level of the past ten years, even though prevention and anti-smoking policies have produced tangible results in decreasing tobacco smoking prevalence. This cross-sectional study examined trends in exclusive and dual smoking, identified new poly-consumption patterns and profiled old and new nicotine users.

METHODS

We used the annual cross-sectional ESPAD® Italia survey which sampled students (aged 15-19), currently used for surveillance and monitoring of at risk population, between 2012 and 2018 (N = 170,974) to describe Italian trends in exclusive cigarette, exclusive vaping, and dual cigarette and vaping use. . For the 2018 sample, patterns of poly-consumption were described, and a multinomial logistic regression (N = 15,732) estimated characteristics associated with exclusive and dual cigarette and vaping use.

RESULTS

The lifetime prevalence of cigarette smokers slightly decreased from 60.9% in 2012 to 56.9% in 2018, whereas the proportion of vaping users substantially increased from 32.9% in 2013 to 52.0% in 2018. Combining cigarette and vaping use, these trends result in an increase in the lifetime prevalence of any use from 60.8% in 2013 to 66.2% in 2018. Three out of every 10 minors have experienced smoking and/or vaping, and younger students were more prone to be dual users. Overall, current vapers were generally less prone to risky behaviours.

CONCLUSION

In contrast to a slight decrease in cigarette smoking, the prevalence of Italian students approaching old and/or new smoking habits in their lifetime is substantially increasing. The popularity of alternative nicotine-based products, particularly e-cigarettes, has increased among teenagers, resulting in a summation of usage patterns rather than a compensation, and attracting a novel slice of young users. The lack of regulation within current drug policy to limit the access to such licit psychoactive substance use, is urgently needed to avoid a future nicotine addicted population.

E-cigarette Tobacco Retail Licensing Laws: Variance Across US States as of January 1, 2020

Objectives. To describe how US states and the District of Columbia regulate e-cigarette sales by examining e-cigarette-specific tobacco retail licensing (TRL) laws.Methods. We coded 25 state-level e-cigarette TRL laws (effective as of January 1, 2020) for provisions we labeled as either "core" (e.g., presence of license terms, fees, and penalties) or "descriptive" (e.g., license fee amount and term length).Results. Overall, 23 laws clearly defined a license term, 23 laws required a license fee, and 19 laws identified penalties for violations that included both license suspension and revocation. Fees widely ranged ($5-$1000 annually), and 8 laws did not explicitly direct fees toward TRL administration or enforcement. No law required that retailers comply with all local, state, and federal tobacco or e-cigarette laws.Conclusions. Most laws contained core TRL provisions. Several laws, however, had minimal license fees and did not direct fees toward administration or enforcement. As youth e-cigarette use increases, more states should consider establishing e-cigarette TRL laws or incorporating provisions into existing TRL laws.

Public Health Considerations for Adolescent Initiation of Electronic Cigarettes

Adolescent use of electronic cigarettes (e-cigarettes) has increased dramatically, with younger and nicotine-naive adolescents starting to use these devices and use them more frequently than combustible cigarettes. In emerging evidence, it is shown that e-cigarettes are not effective in helping adult smokers quit and that youth using e-cigarettes are at risk for becoming nicotine dependent and continuing to use as adults. Important gaps in our knowledge remain regarding the long-term health impact of e-cigarettes, effective strategies to prevent and reduce adolescent e-cigarette use, and the impact of provider screening and counseling to address this new method of nicotine use.