E-Cigarettes and the Use of Conventional Cigarettes

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the "Präventionsradar" from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

Longitudinal associations between anxiety sensitivity and substance use in adolescents: Mediation by depressive affect

Though anxiety sensitivity (AS)-fear of anxiety-related experiences-is primarily tied to anxiety vulnerability, AS has also been prospectively associated with general negative affect and depression. Furthermore, depression has been longitudinally associated with different forms of substance use, and some AS subfactors (e.g., cognitive concerns) have been associated more consistently with depression and substance use than others. However, no previous study has investigated if longitudinal associations of AS with substance use may be mediated by depression or whether aspects of AS may be prospectively associated with substance use among adolescents. Hence, the present study tested depressive affect (the negative affective aspect of depression) as a prospective mediator of AS associations with substance use and examined longitudinal AS subfactor associations with substance use and problems. High school 9th graders (N = 2,877; Mage = 14.1 years; 55.3% female) completed self-report measures at baseline and at 6 months and 1 year later. Depressive affect mediated AS associations with subsequent alcohol, cigarette, electronic cigarette, cannabis, benzodiazepine, and opioid use. Also, AS cognitive and social concerns (vs. physical concerns) were more consistently associated with later depressive affect and substance use and problems. Current findings suggest that adolescents high in anxiety sensitivity tend to prospectively experience greater depressive affect, which in turn is related to a higher likelihood of engaging in several different forms of substance use. Thus, it is possible that interventions which target AS (particularly AS cognitive concerns) may help to treat or prevent depression and substance use among adolescents. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the 'Präventionsradar' from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

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.

Exploring the gateway hypothesis of e-cigarettes and tobacco: a prospective replication study among adolescents in the Netherlands and Flanders

BACKGROUND

Studies demonstrated that adolescent e-cigarette use is associated with subsequent tobacco smoking, commonly referred to as the gateway effect. However, most studies only investigated gateways from e-cigarettes to tobacco smoking. This study replicates a cornerstone study revealing a positive association between both adolescent e-cigarette use and subsequent tobacco use; and tobacco and subsequent e-cigarette use in the Netherlands and Flanders.

DESIGN

The longitudinal design included baseline (n=2839) and 6-month (n=1276) and 12-month (n=1025) follow-up surveys among a school-based cohort (mean age: 13.62). Ten high schools were recruited as a convenience sample. The analyses involved (1) associations of baseline e-cigarette use and subsequent tobacco smoking among never smokers; (2) associations of e-cigarette use frequency at baseline and tobacco smoking frequency at follow-up; and (3) the association of baseline tobacco smoking and subsequent e-cigarette use among non-users of e-cigarettes.

FINDINGS

Consistent with prior findings, baseline e-cigarette use was associated with higher odds of tobacco smoking at 6-month (OR=1.89; 95% CI 1.05 to 3.37) and 12-month (OR=5.63; 95% CI 3.04 to 10.42) follow-ups. More frequent use of e-cigarettes at baseline was associated with more frequent smoking at follow-ups. Baseline tobacco smoking was associated with subsequent e-cigarette use (OR=3.10; 95% CI 1.58 to 6.06 at both follow-ups).

CONCLUSION

Our study replicated the positive relation between e-cigarette use and tobacco smoking in both directions for adolescents. This may mean that the gateway works in two directions, that e-cigarette and tobacco use share common risk factors, or that both mechanisms apply.

Association of Electronic Cigarette Use by US Adolescents With Subsequent Persistent Cigarette Smoking

Importance

Many studies have reported a positive association of youth electronic cigarette (e-cigarette) use with subsequent cigarette smoking initiation, but it remains unclear whether e-cigarette use is associated with continued cigarette smoking after initiation.

Objective

To assess the association of youth baseline e-cigarette use with their continued cigarette smoking 2 years after initiation.

Design, Setting, and Participants

The Population Assessment of Tobacco and Health (PATH) Study is a national longitudinal cohort study. This sample consisted of youth who participated in waves 3, 4, and 5 of the study (wave 3 was from October 2015 to October 2016, wave 4 was from December 2016 to January 2018, and wave 5 was from December 2018 to November 2019) and had never used cigarettes (cigarette-naive) by wave 3. The current analysis used multivariable logistic regressions in August 2022 to assess the association between e-cigarette use among cigarette-naive adolescents aged 12 to 17 years in 2015 and 2016 and subsequent continued cigarette smoking. PATH uses audio computer-assisted self-interviewing and computer-assisted personal interviewing to collect data.

Exposures

Ever and current (past 30-day) use of e-cigarettes in wave 3.

Main Outcomes and Measures

Continued cigarette smoking in wave 5 after initiating smoking in wave 4.

Results

The current sample included 8671 adolescents who were cigarette naive in wave 3 and also participated in waves 4 and 5; 4823 of the participants (55.4%) were aged 12 to 14 years, 4454 (51.1%) were male, and 3763 (51.0%) were non-Hispanic White. Overall, regardless of e-cigarette use, few adolescents (362 adolescents [4.1%]) initiated cigarette smoking at wave 4, and even fewer (218 participants [2.5%]) continued smoking at wave 5. Controlling for multiple covariates, the adjusted odds ratio of baseline ever e-cigarette use, compared with never e-cigarette use, was 1.81 (95% CI, 1.03 to 3.18) for continued smoking measured as past 30-day smoking at wave 5. However, the adjusted risk difference (aRD) was small and not significant. The aRD was 0.88 percentage point (95% CI, -0.13 to 1.89 percentage points) for continued smoking, with the absolute risk being 1.19% (95% CI, 0.79% to 1.59%) for never e-cigarette users and 2.07% (95% CI, 1.01% to 3.13%) for ever e-cigarette users. Similar results were found using an alternative measure of continued smoking (lifetime ≥100 cigarettes and current smoking at wave 5) and using baseline current e-cigarette use as the exposure measure.

Conclusions and Relevance

In this cohort study, absolute and relative measures of risks yielded findings suggesting very different interpretations of the association. Although there were statistically significant odds ratios of continued smoking comparing baseline e-cigarette users with nonusers, the minor risk differences between them, along with the small absolute risks, suggest that few adolescents are likely to continue smoking after initiation regardless of baseline e-cigarette use.

E-Cigarette Markets and Policy Responses in Southeast Asia: A Scoping Review

BACKGROUND

The global e-cigarette market has proliferated and is increasingly dominated by transnational tobacco companies. While Southeast Asian countries have received relatively little attention in e-cigarette research, the region represents an area of potentially untapped growth for the industry. We review the e-cigarette situation in Southeast Asia in terms of the e-cigarette markets, advertising and promotion of e-cigarettes, reported health impacts of e-cigarette use, and policy responses in the region.

METHODS

We examined e-cigarette market data from the Euromonitor Global Market Information Database (GMID) Passport database, searched in the academic literature, grey literature and news archives for any reports or studies of e-cigarette related diseases or injuries, e-cigarette marketing, and e-cigarette policy responses in Southeast Asian countries, and browsed the websites of online e-cigarette retailers catering to the region's active e-cigarette markets.

RESULTS

In 2019, e-cigarettes were sold in six Southeast Asian markets with a total market value of $595 million, projected to grow to $766 million by 2023. E-commerce is a significant and growing sales channel in the region, with most of the popular or featured brands in online shops originating from China. Southeast Asian youth are targeted with a wide variety of flavours, trendy designs and point of sale promotions, and several e-cigarette related injuries and diseases have been reported in the region. Policy responses vary considerably between countries, ranging from strict bans to no or partial regulations.

CONCLUSION

Although Southeast Asia's e-cigarette market is relatively nascent, this is likely to change if transnationals invest more heavily in the region. Populous countries with weak e-cigarette regulations, notably Indonesia, Malaysia, Vietnam and the Philippines, are desirable targets for the transnationals. Regulatory action is needed to prevent e-cigarette use from becoming entrenched into these societies, especially among young people.

Association between perceived harm of tobacco and intention to quit: a cross-sectional analysis of the Vietnam Global Adult Tobacco Survey

BACKGROUND

Perception of harm plays an important role in predicting intention to quit-an integral part of the cessation process. Perception on harm from bamboo waterpipe tobacco was unknown, even the predominant of this type of tobacco use. This study investigated the effects of perceived harm from cigarette and bamboo waterpipe tobacco on intention to quit among adult male Vietnamese tobacco users.

METHODS

From the nationally-representative 2015 Global Adult Tobacco Survey, we included 1,351 adult males (≥ 18 years old) who used cigarettes, bamboo waterpipes, or both. Demographic characteristics, tobacco use behaviors, perceived harm from tobacco use, and regulation/policy exposure were measured. Effects of perceived harm from cigarette and bamboo waterpipe tobacco on intention to quit were assessed by logistic regression.

RESULTS

Intention to quit prevalence was 59.0%, 55.0%, and 58.4% for cigarette, waterpipe, and dual users, respectively. Tobacco users who perceived that "using cigarettes and/or waterpipe could cause severe illness" and "waterpipe use is less harmful than cigarette smoking", had tobacco use bans at home, or were exposed to anti-smoking campaigns or encouragement to quit information were more likely to intend to quit. When analyzed by tobacco users, intention to quit was more likely for those users who perceived their tobacco product as more harmful than the other product type, although statistical significance was only observed for cigarette users.

CONCLUSIONS

Misperceptions regarding harm from tobacco use could negatively affect intention to quit. Dissemination of accurate information on the risks from all forms of tobacco use and enforcement of tobacco control policies are important for encouraging intention to quit.

Study protocol: evaluation of the addictive potential of e-cigarettes (EVAPE): neurobiological, sociological, and epidemiological perspectives

BACKGROUND

Tobacco use is the largest preventable cause of diseases and deaths; reducing tobacco intake is, therefore, an urgent public health goal. In recent years, e-cigarettes have been marketed as a 'healthier' alternative to tobacco smoking, whilst product features have evolved tremendously in the meantime. A lively scientific debate has developed regarding the potential benefits and risks of e-cigarettes although, surprisingly, there are few studies investigating the addictive potential of nicotine-containing e-cigarettes. The present work comprises three work packages investigating the addictive potential of e-cigarettes from different perspectives: (1) the neurobiological addictive potential of e-cigarettes; (2) the experience and perception of dependence symptoms among users of e-cigarettes in a social context; and (3) the epidemiological perspective regarding factors influencing the potential for dependence.

METHODS

Work package I: the neurobiological study will investigate the key elements of addiction in e-cigarettes compared to tobacco cigarettes using neurobiological and neuropsychological correlates associated with craving, incentive motivation, cue reactivity and attentional bias. Work package II: the sociological study part examines self-reports on the experience and perception of dependence symptoms in a social context, using focus group interviews and the analysis of posts in online discussion forums on e-cigarettes. Work package III: the epidemiological study part focuses on tolerance development and the role of psychosocial and product factors by analyzing longitudinal data from the International Tobacco Control Policy Evaluation Project (ITC).

DISCUSSION

The present study offers a chosen mix of three methodological approaches, thereby comprehensively examining core symptoms of positive and negative reinforcement in addiction. Whether e-cigarettes are as reinforcing and addictive as combustible tobacco cigarettes is an important public health issue with implications for prevention and treatment programs.

TRIAL REGISTRATION

Work package I: Registered at clinicaltrials.gov/ct2/show/NCT04772014. Work package II: Registered at OSF Registries: https://osf.io/dxgya (2021, January 14).

Waterpipe smoking and subsequent cigarette and e-cigarette use: a cohort study

Aim

We tested the hypothesis that waterpipe smoking increases the likelihood to try conventional and electronic cigarettes.

Methods

In 2017 and 2018, 2752 German adolescents (mean age: 14.9 years), who had never tried conventional cigarettes or e-cigarettes, took part in a longitudinal survey with a 6-month observational period. Multiple regression analyses tested the association between waterpipe use at baseline and first experimentation with e-cigarettes at follow-up. The models adjusted for risk-taking propensity (sensation seeking and experimentation with alcohol and marijuana), age, sex, migration background, type of school and peer substance use.

Results

Some 381 adolescents (12.5% of the survey population) reported waterpipe smoking at baseline. The overall initiation rate during the 6 months was 4.9% (n=134) for conventional cigarettes and 10.5% (n=288) for e-cigarettes. Prior waterpipe smoking significantly predicted cigarette use (adjusted relative risk (ARR)=1.81, 95% CI 1.19-2.76), as well as e-cigarette use (ARR=3.29, 95% CI 2.53-4.28). In addition, a significant interaction between waterpipe use and sensation seeking was found (ARR=0.56, 95% CI 0.33-0.95), with waterpipe use being more predictive of later e-cigarette initiation for lower sensation-seeking individuals.

Discussion

Waterpipe use predicted both later cigarette and e-cigarette use independent of all other assessed risk factors, indicating that waterpipe use might be a risk factor on its own. The results suggest that the association was stronger for adolescents with a lower risk-taking propensity, which brings this group into focus for prevention efforts. However, further research is needed to understand whether these associations are causal.

Association between electronic nicotine delivery systems and electronic non-nicotine delivery systems with initiation of tobacco use in individuals aged < 20 years. A systematic review and meta-analysis

BACKGROUND

This systematic review described the association between electronic nicotine delivery systems and electronic non-nicotine delivery systems (ENDS/ENNDS) use among non-smoking children and adolescents aged <20 years with subsequent tobacco use.

METHODS

We searched five electronic databases and the grey literature up to end of September 2020. Prospective longitudinal studies that described the association between ENDS/ENNDS use, and subsequent tobacco use in those aged < 20 years who were non-smokers at baseline were included. The Joanna Briggs Institute Critical Appraisal Checklist was used to assess risk of bias. Data were extracted by two reviewers and pooled using a random-effects meta-analysis. We generated unadjusted and adjusted risk ratios (ARRs) describing associations between ENDS/ENNDS and tobacco use.

FINDINGS

A total of 36 publications met the eligibility criteria, of which 25 were included in the systematic review (23 in the meta-analysis) after exclusion of overlapping studies. Sixteen studies had high to moderate risk of bias. Ever users of ENDS/ENNDS had over three times the risk of ever cigarette use (ARR 3·01 (95% CI: 2·37, 3·82; p<0·001, I2: 82·3%), and current cigarette use had over two times the risk (ARR 2·56 (95% CI: 1·61, 4·07; p<0·001, I2: 77·3%) at follow up. Among current ENDS/ENNDS users, there was a significant association with ever (ARR 2·63 (95% CI: 1·94, 3·57; p<0·001, I2: 21·2%)), but not current cigarette use (ARR 1·88 (95% CI: 0·34, 10·30; p = 0·47, I2: 0%)) at follow up. For other tobacco use, ARR ranged between 1·55 (95% CI 1·07, 2·23) and 8·32 (95% CI: 1·20, 57·04) for waterpipe and pipes, respectively. Additionally, two studies examined the use of ENNDS (non-nicotine devices) and found a pooled adjusted RR of 2·56 (95% CI: 0·47, 13·94, p = 0.035).

CONCLUSION

There is an urgent need for policies that regulate the availability, accessibility, and marketing of ENDS/ENNDS to children and adolescents. Governments should also consider adopting policies to prevent ENDS/ENNDS uptake and use in children and adolescents, up to and including a ban for this group.

Prospective association between use of electronic cigarettes and use of conventional cigarettes: a systematic review and meta-analysis

Objective

The aim of this systematic review and meta-analysis was to assess the association between e-cigarette use and subsequent initiation or recurrence of cigarette smoking.

Data sources

A systematic literature search was finalised on 11 November 2019 using PubMed (including MEDLINE), EMBASE, Cochrane Library, Scopus, PubMed Health, NICE Evidence Search, PROSPERO, CRD and PsycInfo.

Study selection

Studies were included if meeting the following criteria: reporting empirical results; longitudinal observational design with a minimum of 3 months of follow-up; including general population samples; allowing for the comparison between users and nonusers of e-cigarettes. Studies rated as having high risk of bias were excluded. Studies were independently assessed by at least two authors. The procedures described by PRISMA were followed, and the quality of evidence was rated using GRADE.

Data synthesis

30 longitudinal studies from 22 different cohorts assessing e-cigarette use among nonsmokers or never-smokers at baseline, and subsequent use of cigarette smoking at follow-up, were included in this review. A random-effects meta-analysis based on 89 076 participants showed a pooled unadjusted odds ratio (OR) of cigarette smoking among baseline nonsmoker e-cigarette users compared with nonusers of 4.68 (CI 3.64–6.02), while the adjusted OR was 3.37 (CI 2.68–4.24). These results were consistent irrespective of whether the outcome was measured as ever-smoking or as past 30-day smoking. The evidence was graded as moderate.

Conclusions

Use of e-cigarettes may predict the initiation or recurrence of cigarette smoking.

This meta-analysis shows that e-cigarette use increases the risk of future initiation or recurrence of cigarette smoking, even after adjusting for potential confounders, suggesting that e-cigarette use could be considered a predictor of subsequent smokinghttps://bit.ly/3buMccm

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.

State Medical Marijuana Laws and Initiation of Cigarettes among Adolescents in the U.S., 1991-2015

Objective

Although cigarette use has declined among adolescents, marijuana use has increased in subgroups of this population. The association between medical marijuana laws (MMLs) and cigarette initiation among adolescents, however, needs further examination. We investigated the association between MMLs and age of cigarette initiation and stratified findings by gender, race/ethnicity, and state dispensary status.

Method

Data were from N=939,725 adolescents in 9th-12th grade living in 46 states who participated in the Youth Risk Behavior Surveillance System between 1991-2015. Participants were asked the age they first smoked a cigarette and other sociodemographic characteristics. States were categorized as MML states if they had legalized marijuana for medicinal purposes by 2015. We used a difference-in-difference methodology and logistic regressions to assess the relationship between MMLs and cigarette initiation.

Results

Our results indicate lower odds of initiating cigarettes, in every age group (8 years old or younger, 9-10, 11-12, 13-14, 15-16, 17 years old or older) in states with MMLs when compared to non-MML states. After stratification, we find lower odds of cigarette initiation in certain age groups by gender, race/ethnicity, and state dispensary status. We report no difference in state MML implementation and age of cigarette initiation among Hispanic adolescents in every age group, and Black adolescents 8 years or younger and 17 years or older.

Conclusions

Cigarette initiation has decreased among adolescents in MML states compared with those in non-MML states. Further research should evaluate how MMLs and recreational marijuana policies are associated with e-cigarette initiation and use.

E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis

OBJECTIVE

To review and summarise the current evidence on the uptake of combustible cigarette smoking following e-cigarette use in non-smokers-including never-smokers, people not currently smoking and past smokers-through an umbrella review, systematic review and meta-analysis.

DESIGN

Umbrella review, systematic review and meta-analysis.

DATA SOURCES

PubMed, Scopus, Web of Science, PsychINFO (Ovid), Medline (Ovid) and Wiley Cochrane Library up to April 2020.

RESULTS

Of 6225 results, 25 studies of non-smokers-never, not current and former smokers-with a baseline measure of e-cigarette use and an outcome measure of combustible smoking uptake were included. All 25 studies found increased risk of smoking uptake with e-cigarette exposure, although magnitude varied substantially. Using a random-effects model, comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the OR for smoking initiation was 3.25 (95% CI 2.61 to 4.05, I2 85.7%) and among non-smokers at baseline the OR for current smoking was 2.87 (95% CI 1.97 to 4.19, I2 90.1%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50 to 3.83, I2 12.3%).

CONCLUSIONS

Across multiple settings, non-smokers who use e-cigarettes are consistently more likely than those avoiding e-cigarettes to initiate combustible cigarette smoking and become current smokers. The magnitude of this risk varied, with an average of around three times the odds. Former smokers using e-cigarettes have over twice the odds of relapse as non-e-cigarettes users. This study is the first to our knowledge to review and pool data on the latter topic.

PROSPERO REGISTRATION NUMBER

CRD42020168596.

Sex Difference in the Association between Electronic Cigarette Use and Subsequent Cigarette Smoking among U.S. Adolescents: Findings from the PATH Study Waves 1-4

E-cigarettes are the most-used tobacco products among U.S. adolescents. Emerging evidence suggests that adolescents using e-cigarettes are at elevated risk for initiating cigarette smoking. However, whether this risk may differ by sex remains unknown. This study analyzed data from Wave 1 to 4 of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative longitudinal survey. Generalized estimation equations (GEE) were performed to estimate the associations between baseline e-cigarette use and subsequent cigarette smoking, controlling for sociodemographic characteristics, mental health conditions, and other tobacco use. Effect modifications by sex were examined. Multivariate analyses showed that, among baseline never cigarette smokers, past-30-day e-cigarette use at baseline waves was significantly associated with past-30-day cigarette smoking at follow-up waves (aOR = 3.90, 95% CI: 2.51-6.08). This association was significantly stronger for boys (aOR = 6.17, 95% CI: 2.43-15.68) than for girls (aOR = 1.10, 95% CI: 0.14-8.33). Additionally, using other tobacco products, older age, and having severe externalizing mental health problems at baseline were significantly associated with an increased likelihood of cigarette smoking at follow-up. The prospective association between e-cigarette use and cigarette smoking differs by sex among U.S. adolescents. Sex-specific tobacco control interventions may be warranted to curb the youth tobacco use epidemic.

Further investigation of gateway effects using the PATH study

Background: Interest exists in whether youth e-cigarette use (“vaping”) increases risk of initiating cigarette smoking. Using Waves 1 and 2 of the US PATH study we previously reported adjustment for vaping propensity using Wave 1 variables explained about 80% of the unadjusted relationship. Here data from Waves 1 to 3 are used to avoid over-adjustment if Wave 1 vaping affected variables recorded then.

Methods: Main analyses M1 and M2 concerned Wave 2 never smokers who never vaped by Wave 1, linking Wave 2 vaping to Wave 3 smoking initiation, adjusting for predictors of vaping based on Wave 1 data using differing  propensity indices.  M3 was similar but derived the index from Wave 2 data.  Sensitivity analyses excluded Wave 1 other tobacco product users, included other product use as another predictor, or considered propensity for smoking or any tobacco use, not vaping. Alternative analyses used exact age (not previously available) as a confounder not grouped age, attempted residual confounding adjustment by modifying predictor values using data recorded later, or considered interactions with age.

Results: In M1, adjustment removed about half the excess OR (i.e. OR–1), the unadjusted OR, 5.60 (95% CI 4.52-6.93), becoming 3.37 (2.65-4.28), 3.11 (2.47-3.92) or 3.27 (2.57-4.16), depending whether adjustment was for propensity as a continuous variable, as quintiles, or the variables making up the propensity score. Many factors had little effect: using grouped or exact age; considering other products; including interactions; or using predictors of smoking or tobacco use rather than vaping. The clearest conclusion was that analyses avoiding over-adjustment explained about half the excess OR, whereas analyses subject to over-adjustment explained about 80%.

Conclusions: Although much of the unadjusted gateway effect results from confounding, we provide stronger evidence than previously of some causal effect of vaping, though doubts still remain about the completeness of adjustment.

Trends in the Age of Cigarette Smoking Initiation Among Young Adults in the US From 2002 to 2018

IMPORTANCE

Success in reducing the prevalence of adolescent smoking could reflect complete prevention of smoking initiation or a shift in the age of cigarette smoking initiation from adolescence into early adulthood.

OBJECTIVE

To assess trends in early adult (ages 18-23 years) vs adolescent (age <18 years) cigarette smoking initiation and transition to daily cigarette smoking from 2002 to 2018.

DESIGN, SETTING, AND PARTICIPANTS

Ages at initiation of smoking and the transition to daily smoking were ascertained from the National Survey on Drug Use and Health (2002-2018), an annual, population-based, repeated cross-sectional study representative of the US population. This cross-sectional analysis was restricted to young adults who completed the survey at ages 22 to 23 years during survey years 2002 to 2018 to limit potential age-related recall bias. Retrospectively collected age of cigarette smoking initiation was assessed among ever cigarette smokers; age of transition to daily smoking was assessed among ever daily cigarette smokers. Data analysis was performed from June 2019 to July 2020.

EXPOSURES

Calendar year of survey (2002 to 2018).

MAIN OUTCOMES AND MEASURES

The main outcomes were population-weighted cigarette smoking prevalence and cigarette smoking initiation and transition to daily smoking in adolescence (age <18 years) vs early adulthood (ages 18-23 years).

RESULTS

Among 71 756 young adults aged 22 to 23 years (38 226 women [50.5%]), ever cigarette smoking prevalence decreased from a population-weighted estimate of 74.6% (95% CI, 73.1%-75.9%) in 2002 to 51.4% (95% CI, 49.3%-53.5%) in 2018 (P < .001). Daily smoking prevalence rates similarly decreased from 41.1% (95% CI, 39.1%-43.1%) in 2002 to 20.2% (95% CI, 18.6%-21.8%) in 2018 (P < .001). However, among 48 015 ever smokers, the proportion initiating smoking in early adulthood (ages 18-23 years) increased over this time, from 20.6% (95% CI, 18.5%-22.8%) in 2002 to 42.6% (95% CI, 39.6%-45.7%) in 2018 (P < .001). Similarly, among 24 490 daily cigarette smokers, the proportion who transitioned to daily smoking in early adulthood increased from 38.7% (95% CI, 35.9%-41.6%) in 2002 to 55.9% (95% CI, 52.0%-59.8%) in 2018 (P < .001).

CONCLUSIONS AND RELEVANCE

A substantial proportion of beginning smokers and most new daily smokers are now young adults, reflecting a shift from adolescence to early adulthood, a population segment once considered beyond the critical risk period for cigarette smoking onset. Expanding the long-standing emphasis on adolescent surveillance and prevention in adolescence to include the young adult population is warranted.

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

Impulsivity across substance use categories: Consideration of sex/gender

PURPOSE OF REVIEW

The goal was to review recent (1/2015-2/2020) evidence of impulsivity as a feature of substance use disorders or use of substances (alcohol, cannabis, nicotine, opioids, stimulants) in males compared to females in terms of: a) impulsivity in substance-using groups (or substance-using compared to control groups), and b) relationship between impulsivity and substance use behavior, clinical severity, or treatment outcomes.

RECENT FINDINGS

Of 361 papers identified by the searches, 69 met inclusion criteria, and 39 were highlighted for considering sex/gender in relation to impulsivity in substance-using populations. Taken together, findings supported higher impulsivity in males and females who use substances, relative to controls; and higher impulsivity was linked with more substance use/severity in both sex/genders. There were mixed findings regarding male versus female differences in impulsivity among individuals who use substances, or in the magnitude of the relationship between impulsivity and substance use severity.

SUMMARY

The current body of evidence does not point to a consistent sex/gender difference in the role of impulsivity within and across substance use disorders. Impulsivity is a clinically-relevant construct for male and female individuals who use substances, across a range of substances.

The Use of Alcohol, Tobacco, Illegal Drugs and Medicines: An Estimate of Consumption and Substance-Related Disorders in Germany

BACKGROUND

Prevalence estimates of the use of tobacco, alcohol, illegal drugs, and psychoactive medications and of substance-related disorders enable an assessment of the effects of substance use on health and society.

METHODS

The data used for this study were derived from the 2018 Epidemiological Survey of Substance Abuse (Epidemiologischer Suchtsurvey, ESA). The sample of the German adult population comprised 9267 persons aged 18 to 64 (response rate, 42%). Population estimates were obtained by extrapolation to a total resident population of 51 544 494 people.

RESULTS

In the 30 days prior to the survey, 71.6% of the respondents (correspond- ing to 36.9 million persons in the population) had consumed alcohol, and 28.0% (14.4 million) had consumed tobacco. 4.0% reported having used e-cigarettes, and 0.8% reported having used heat-not-burn products. Among illegal drugs, cannabis was the most commonly used, with a 12-month prevalence of 7.1% (3.7 million), followed by amphetamines (1.2%; 619 000). The prevalence of the use of anal- gesics without a prescription (31.4%) was markedly higher than that of the use of prescribed analgesics (17.5%, 26.0 million); however, analgesics were taken daily less commonly than other types of medication. 13.5% of the sample (7.0 million) had at least one dependence diagnosis (12-month prevalence).

CONCLUSION

Substance use and the consumption of psychoactive medications are widespread in the German population. Substance-related disorders are a major burden to society, with legal substances causing greater burden than illegal substances.

E-cigarette Product Characteristics and Subsequent Frequency of Cigarette Smoking

BACKGROUND

There is a dearth of evidence regarding the association of use of electronic cigarettes (e-cigarettes) with certain product characteristics and adolescent and young adult risk of unhealthy tobacco use patterns (eg, frequency of combustible cigarette smoking), which is needed to inform the regulation of e-cigarettes.

METHODS

Data were collected via an online survey of participants in the Southern California Children's Health Study from 2015 to 2016 (baseline) and 2016 to 2017 (follow-up) (N = 1312). We evaluated the association of binary categories of 3 nonmutually exclusive characteristics of the e-cigarette used most frequently with the number of cigarettes smoked in the past 30 days at 1-year follow-up. Product characteristics included device (vape pen and/or modifiable electronic cigarette [mod]), use of nicotine in electronic liquid (e-liquid; yes or no), and use for dripping (directly dripping e-liquid onto the device; yes or no).

RESULTS

Relative to never e-cigarette users, past-30-day e-cigarette use was associated with greater frequency of past-30-day cigarette smoking at follow-up. Among baseline past-30-day e-cigarette users, participants who used mods (versus vape pens) smoked >6 times as many cigarettes at follow-up (mean: 20.8 vs 1.3 cigarettes; rate ratio = 6.33; 95% confidence interval: 1.64-24.5) after adjustment for sociodemographic characteristics, baseline frequency of cigarette smoking, and number of days of e-cigarette use. After adjustment for device, neither nicotine e-liquid nor dripping were associated with frequency of cigarette smoking.

CONCLUSIONS

Baseline mod users (versus vape pen users) smoked more cigarettes in the past 30 days at follow-up. Regulation of e-cigarette device type warrants consideration as a strategy to reduce cigarette smoking among adolescents and young adults who vape.

Is e-cigarette use in non-smoking young adults associated with later smoking? A systematic review and meta-analysis

OBJECTIVE

The aim of this review was to investigate whether e-cigarette use compared with non-use in young non-smokers is associated with subsequent cigarette smoking.

DATA SOURCES

PubMed, Embase, Web of Science, Wiley Cochrane Library databases, and the 2018 Society for Research on Nicotine and Tobacco and Society for Behavioural Medicine conference abstracts.

STUDY SELECTION

All studies of young people (up to age 30 years) with a measure of e-cigarette use prior to smoking and an outcome measure of smoking where an OR could be calculated were included (excluding reviews and animal studies).

DATA EXTRACTION

Independent extraction was completed by multiple authors using a preprepared extraction form.

DATA SYNTHESIS

Of 9199 results, 17 studies were included in the meta-analysis. There was strong evidence for an association between e-cigarette use among non-smokers and later smoking (OR: 4.59, 95% CI: 3.60 to 5.85) when the results were meta-analysed in a random-effects model. However, there was high heterogeneity (I2 =88%).

CONCLUSIONS

Although the association between e-cigarette use among non-smokers and subsequent smoking appears strong, the available evidence is limited by the reliance on self-report measures of smoking history without biochemical verification. None of the studies included negative controls which would provide stronger evidence for whether the association may be causal. Much of the evidence also failed to consider the nicotine content of e-liquids used by non-smokers meaning it is difficult to make conclusions about whether nicotine is the mechanism driving this association.

Risk factors associated with subsequent initiation of cigarettes and e-cigarettes in adolescence: A structural equation modeling approach

BACKGROUND

Previous youth tobacco research has identified multiple correlated risk factors for initiation of cigarette and e-cigarette use; whether these factors are independently associated with initiation is not known, due to challenges with disentangling the independent effects of these correlated risk factors.

METHODS

Students in 11th/12th grade enrolled in the Southern California Children's Health Study were surveyed in 2014 (baseline) and again in 2015 (N = 1553). Structural equation models (SEM) were developed to investigate associations of susceptibility, marketing, and the social environment (as latent factors), and other tobacco use at baseline with cigarette or e-cigarette initiation between baseline and follow-up. Analyses were restricted to baseline never cigarette users (N = 1293) for models evaluating cigarette initiation, and to never e-cigarette users (N = 1197) for models evaluating e-cigarette initiation.

RESULTS

In fully-adjusted prospective SEM models, latent factors for cigarette susceptibility, marketing, and the social environment, along with ever e-cigarette use and ever hookah use at baseline were independently associated with cigarette initiation between baseline and follow-up (P < 0.05). Similarly, latent factors for e-cigarette susceptibility, marketing, and the social environment, along with ever hookah use at baseline were associated with e-cigarette initiation between baseline and follow-up (P < 0.05); however, cigarette use at baseline was not associated with e-cigarette initiation in SEM models (P = 0.16).

CONCLUSIONS

We identified independent effects of multiple risk factors in SEM models on initiation of cigarettes and e-cigarettes. E-cigarette use was associated with cigarette initiation, but cigarette use was not associated with e-cigarette initiation in fully adjusted models. Research to identify underlying causal mechanisms is warranted.

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.

Patterns of Youth Cigarette Experimentation and Onset of Habitual Smoking

INTRODUCTION

Although research suggests that youth e-cigarette experimentation is associated with later combustible cigarette experimentation, it is unclear how this relates to habitual smoking. This study assesses how minors' patterns of combustible cigarette and e-cigarette experimentation relate to habitual smoking at ages 18-21 years.

METHODS

Between November 2016 and May 2017, a cross-sectional, online survey of current and retrospective cigarette use was fielded among individuals aged 18-21 years who had tried combustible cigarettes or e-cigarettes (n=1,424). Logistic regressions tested how experimentation patterns prior to age 18 years related to two indicators of current habitual smoking: daily smoking and current established smoking (past 30-day use among those who had smoked ≥100 cigarettes).

RESULTS

Respondents who first tried combustible cigarettes or e-cigarettes as minors (n=1,096) were more likely to be current established users (64%) than those who first experimented at ages 18-21 years (41%). Experimentation patterns in individuals aged <18 years beginning with combustible cigarettes were the most predictive of later smoking. Relative to those who first experimented at ages >17 years (n=328), trying only combustible cigarettes as a minor yielded a 175% increase in one's odds of being an established smoker (AOR=2.75, 95% CI=1.99, 3.79) and a 161% increase for daily smoking (AOR=2.61, 95% CI=1.75, 3.90). Trying combustibles and then e-cigarettes yielded sizable increases in both habitual smoking measures, whereas trying e-cigarettes before combustibles yielded smaller effects. Trying only e-cigarettes as a minor yielded a 78% decrease in both outcomes, relative to those who did not try either product as minors.

CONCLUSIONS

Minors who tried combustible cigarettes were more likely to be habitual smokers at ages 18-21 years than those who tried e-cigarettes alone.

Electronic Cigarette Use and Smoking Initiation in Taiwan: Evidence from the First Prospective Study in Asia

A growing literature indicates that electronic cigarette use increases the risk of subsequent initiation of conventional smoking among cigarette-naïve adolescents in several Western countries. This research assesses the same relationship in an Asian country, Taiwan. The Taiwan Adolescent to Adult Longitudinal Study is a school-based survey that was carried out in two waves in 2014 (baseline) and in 2016 (follow-up). It employs probability sampling to create nationally representative samples of students in junior high school (mean age 13, 7th grade at baseline) and in senior high school (mean age 16, 10th grade at baseline). Data from this survey were analyzed via logistic regression to estimate the association between ever use of e-cigarettes at baseline and smoking initiation at follow-up, accounting for susceptibility to smoking, socio-demographic profile, depression status, and peer support. Among the 12,954 cigarette-naïve students surveyed, those with e-cigarette experience at baseline exhibited higher odds of smoking initiation at follow-up (Odds Ratio = 2.14, 95% CI (1.66, 2.75), p < 0.001). For the first time, we confirmed, through a longitudinal survey, a prospective association between ever use of e-cigarettes and smoking initiation in an Asian adolescent population. The restrictive policy on e-cigarettes currently in force in Taiwan is justified to prevent both e-cigarette and cigarette use among adolescents.

Investigating gateway effects using the PATH study

BACKGROUND

A recent meta-analysis of nine cohort studies in youths reported that baseline ever e-cigarette use strongly predicted cigarette smoking initiation in the next 6-18 months, with an adjusted odds ratio of 3.62 (95% confidence interval 2.42-5.41).  A recent review of e-cigarettes agreed there was substantial evidence for this "gateway effect".  However, the number of confounders considered in the studies was limited, so we investigated whether the effect might have resulted from inadequate adjustment, using Waves 1 and 2 of the Population Assessment of Tobacco and Health study.

METHODS

Our main analyses considered Wave 1 never cigarette smokers who, at Wave 2, had information available on smoking initiation.  We constructed a propensity score for ever e-cigarette use from Wave 1 variables, using this to predict ever cigarette smoking.  Sensitivity analyses accounted for use of other tobacco products, linked current e-cigarette use to subsequent current smoking, or used propensity scores for ever smoking or ever tobacco product use as predictors.  We also considered predictors using data from both waves to attempt to control for residual confounding from misclassified responses.

RESULTS

Adjustment for propensity dramatically reduced the unadjusted odds ratio (OR) of 5.70 (4.33-7.50) to 2.48 (1.85-3.31), 2.47 (1.79-3.42) or 1.85 (1.35-2.53), whether adjustment was made as quintiles, as a continuous variable or for the individual variables.  Additional adjustment for other tobacco products reduced this last OR to 1.59 (1.14-2.20).  Sensitivity analyses confirmed adjustment removed most of the gateway effect.  Control for residual confounding also reduced the association.

CONCLUSIONS

We found that confounding is a major factor, explaining most of the observed gateway effect.  However, our analyses are limited by small numbers of new smokers considered and the possibility of over-adjustment if taking up e-cigarettes affects some predictor variables.  Further analyses are intended using Wave 3 data which should avoid these problems.

Investigating gateway effects using the PATH study

BACKGROUND

A recent meta-analysis of nine cohort studies in youths reported that baseline ever e-cigarette use strongly predicted cigarette smoking initiation in the next 6-18 months, with an adjusted odds ratio of 3.62 (95% confidence interval 2.42-5.41).  A recent review of e-cigarettes agreed there was substantial evidence for this "gateway effect".  However, the number of confounders considered in the studies was limited, so we investigated whether the effect might have resulted from inadequate adjustment, using Waves 1 and 2 of the Population Assessment of Tobacco and Health study.

METHODS

Our main analyses considered Wave 1 never cigarette smokers who, at Wave 2, had information available on smoking initiation.  We constructed a propensity score for ever e-cigarette use from Wave 1 variables, using this to predict ever cigarette smoking.  Sensitivity analyses accounted for use of other tobacco products, linked current e-cigarette use to subsequent current smoking, or used propensity scores for ever smoking or ever tobacco product use as predictors.  We also considered predictors using data from both waves to attempt to control for residual confounding from misclassified responses.

RESULTS

Adjustment for propensity dramatically reduced the unadjusted odds ratio (OR) of 5.70 (4.33-7.50) to 2.48 (1.85-3.31), 2.47 (1.79-3.42) or 1.85 (1.35-2.53), whether adjustment was made as quintiles, as a continuous variable or for the individual variables.  Additional adjustment for other tobacco products reduced this last OR to 1.59 (1.14-2.20).  Sensitivity analyses confirmed adjustment removed most of the gateway effect.  Control for residual confounding also reduced the association.

CONCLUSIONS

We found that confounding is a major factor, explaining most of the observed gateway effect.  However, our analyses are limited by small numbers of new smokers considered and the possibility of over-adjustment if taking up e-cigarettes affects some predictor variables.  Further analyses are intended using Wave 3 data which should avoid these problems.

Toxic emissions resulting from sucralose added to electronic cigarette liquids

Electronic cigarettes (ECIGs) are appealing in part because of the many flavors of the liquids used in them. Concerns have been raised that some ECIG liquid flavors, especially those that are sweet, are attracting otherwise nicotine-naïve youth to ECIGs. Sucralose is an artificial, non-caloric sweetener that is added to some ECIG liquids. In this study, we evaluated the toxicants, namely isomers of chloropropanols that can be produced when sucralose-containing ECIG liquid is aerosolized. An analytical separation method relying on solid-phase extraction (SPE) to isolate chloropropanols from the propylene glycol/glycerol matrix was developed. Chloropropanols were then derivatized by silylation before they were analyzed on GC-MS. The influence of different ECIG operating conditions on the generation of chloropropanols was studied by varying ECIG device design and power output and also the sucralose concentration of the liquid. Heated sucralose-containing ECIG liquids produce two toxic compounds that can be found in the resulting aerosols. The two chloropropanols, 3-monochloro-1,2-propanediol (3-MCPD) and 1,3-dichloropropanol (1,3-DCP) that were detected under all conditions were found to be correlated significantly with liquid sucralose content. Effective regulation of ECIGs will minimize user and bystander exposure to these and other ECIG toxicants.

Electronic cigarette marketing and smoking behaviour in adolescence: a cross-sectional study

The aim of this study was to investigate the association between exposure to electronic cigarette (e-cigarette) advertisements and use of e-cigarettes, combustible cigarettes and hookahs. A cross-sectional survey of 6902 German students (mean age 13.1 years, 51.3% male) recruited in six German states was performed. Exposure to e-cigarette advertisements was measured with self-rated contact frequency to three advertising images. Multilevel mixed-effect logistic regression models were used to assess associations between exposure to e-cigarette advertisement and use of e-cigarettes, combustible cigarettes and hookahs (ever and past 30 days). Overall, 38.8% of the students were exposed to e-cigarette advertisements; ever-use of e-cigarettes was 21.7%, of combustible cigarettes was 21.8% and of hookahs was 23.2%, and poly-use of all three products was 12.4%. Exposure to e-cigarette advertisements was positively related to ever and past 30-day use of e-cigarettes, combustible cigarettes, hookahs and combined use. We concluded that a considerable number of German teenagers are exposed to e-cigarette advertisement. There was a clear exposure-behaviour link, indicating that advertising contact was associated with different kinds of "vaping" and also smoking behaviour. Although causal interpretation is not possible due to the cross-sectional design, findings raise concerns about the current tobacco control policies.

E-cigarette Use and Subsequent Smoking Frequency Among Adolescents

: media-1vid110.1542/5839992666001PEDS-VA_2018-0486Video Abstract BACKGROUND AND OBJECTIVES: Electronic cigarette (e-cigarette) use is associated with cigarette initiation among adolescents. However, it is unclear whether e-cigarette use is associated with more frequent cigarette use after initiation. Also, the extent to which cigarette or dual cigarette and e-cigarette users transition to exclusive e-cigarette use or to the nonuse of either product is not yet known.

METHODS

Data were pooled from 3 prospective cohort studies in California and Connecticut (baseline: 2013-2014; follow-up: 2014-2016; N = 6258). Polytomous regression models were used to evaluate the association of baseline e-cigarette use (never or ever) with cigarette use frequency at follow-up (experimental: initiation but no past-30-day use; infrequent: 1-2 of the past 30 days; frequent: 3-5 or more of the past 30 days). Polytomous regression models were also used to evaluate transitions between baseline ever or past-30-day single or dual product use and past-30-day single or dual product use at follow-up.

RESULTS

Among baseline never smokers, e-cigarette users had greater odds of subsequent experimental (odds ratio [OR] = 4.58; 95% confidence interval [CI]: 3.56-5.88), infrequent (OR = 4.27; 95% CI: 2.75-6.62) or frequent (OR = 3.51; 95% CI: 1.97-6.24) cigarette use; the 3 OR estimates were not significantly different. Baseline past-30-day exclusive cigarette use was associated with higher odds at follow-up of exclusive cigarette or dual product use than of exclusive e-cigarette use.

CONCLUSIONS

Tobacco control policy to reduce adolescent use of both e-cigarettes and cigarettes is needed to prevent progression to more frequent tobacco use patterns and reduce combustible cigarette use (with or without concurrent e-cigarette use) to lessen the adverse public health impact of e-cigarettes.

[E-cigarettes: Perceived harmfulness and use for smoking cessation]

BACKGROUND

The perception that e‑cigarettes are less harmful than traditional tobacco products can influence the consumption of e‑cigarettes.

OBJECTIVES

Three questions were examined: (1) How do different population groups perceive health risks of e‑cigarettes? (2) Do sociodemographic variables explain differences in the risk assessment of e‑cigarettes? (3) Does the perception of health risks predict the use of e‑cigarettes for smoking cessation?

METHODS

Data came from the 2015 Epidemiological Survey of Substance Abuse (ESA) with a sample size of n = 9204 participants, aged 18 to 64 years (response rate 52.2%). Data were collected by telephone, online, or by written questionnaires. Assessments of risk perception of e‑cigarettes and conventional cigarettes (more harmful, just as harmful, less harmful, do not know) were compared. Descriptive statistics and logistic regressions were performed.

RESULTS

Individuals with lower education rated e‑cigarettes as more harmful. Older people and women perceived e‑cigarettes as just as harmful. Smokers considered e‑cigarettes to be more harmful than or just as harmful as conventional tobacco products. The likelihood of using e‑cigarettes for smoking cessation was higher if people thought they were less harmful than conventional cigarettes.

CONCLUSIONS

Only one-third of the population knows that e‑cigarettes are less harmful to health than conventional cigarettes. The perception of health risks is related to the usage of e‑cigarettes for smoking cessation.

Electronic cigarettes: the solution or yet another phase of the tobacco epidemic?

Tobacco use is the single largest preventable cause of death globally. For years, the tobacco industry sought to create a tobacco product that is less controversial than conventional cigarettes. Electronic cigarettes were created out of the supposed need to supply consumers of tobacco products with a less harmful tobacco product. The question remains, is it really less harmful for consumers of traditional cigarettes and other tobacco products to switch to electronic cigarettes? This article takes a closer look at the overall harm in relation to benefits of using electronic cigarettes for the individual and public health and the unintended negative consequences the introduction of electronic cigarette has had on overall public health. Given the evidence that the use of electronic cigarettes is a gateway to the use of other tobacco products especially among adolescents, we view electronic cigarettes as having the potential to cause a rebound of the tobacco use glut which the global public health community has been succeeding in reversing. We therefore support the World Health Organization’s suggestion that electronic cigarettes should be regulated as other tobacco products since there is, as yet, no harmless tobacco product. In the same vein, we view the new Tobacco Products and Electronic Delivery Systems Bill seeking to regulate electronic cigarettes in South Africa as other tobacco products as a step in the right direction.