Electronic Cigarettes and Youth in the United States: A Call to Action (at the Local, National and Global Levels)

Vaping cessation support recommendations from adolescents who vape: a qualitative study

BACKGROUND

Youth vaping is a serious public health concern, being more prevalent than any other tobacco use. To inform cessation interventions, we explored what adolescents perceive as their reasons for quitting and strategies to help them quit.

METHOD

Semi-structured interviews were conducted with a convenience sample of 11 adolescents reporting vaping in the past 90 days and recruited from a high school in Massachusetts. Interviews were transcribed and dual-coded. Inductive thematic analysis was employed, and thematic summaries were prepared.

RESULTS

Reasons adolescents reported for quitting included cost, experiencing "nic-sick" from nicotine withdrawal or excess intake, negative impacts on mood, concentration, or health, and experiencing symptoms of nicotine dependence. Nearly all tried to quit multiple times. Barriers to quitting included exposure to vaping, access to vape products, stress, and "cool" new products or flavors. Quit strategies included avoiding others vaping, seeking social support to quit, addressing peer pressure to continue vaping, learning successful quit strategies from peers, and using distraction strategies or alternatives to vaping.

CONCLUSION

Many adolescents who vape want to quit, and most have tried multiple times. Interventions need to engage adolescents with varying reasons to quit, barriers, and quit strategy preferences.

CLINICAL TRIAL REGISTRATION

This study is registered through ClinicalTrials.gov. The trial registration number is NCT05140915. The trial registration date is 11/18/2021.

Electronic Cigarette Use and Anxiety Among College Students: "Trapped in That Cycle"

INTRODUCTION

Electronic cigarette use is the most prevalent form of tobacco among young college adults between 18 and 25 years old. In addition, during the young adult years, mental health issues surface, such as anxiety. As a result of these factors, it is imperative to describe the experience of electronic cigarettes among college students to better understand the cycle of addiction among electronic cigarette users.

OBJECTIVE

This study aims to explore and describe the experience of electronic cigarette use among college students who report feelings of anxiety.

METHODS

A qualitative descriptive study design with the Roy Adaptation Model as the theoretical framework was used to describe the experience. The setting was at one medium-sized private university on the east coast of the United States. Twenty participants met the study inclusion criteria of traditional undergraduate students aged 18-25 years. Data were collected using a demographic questionnaire, a smoking status questionnaire, a self-report feelings of anxiety questionnaire, and a semistructured interview guide.

RESULTS

Data analysis synthesized three themes: the perfect storm, the power of ripping the nic, and trapped in that cycle. It was found through interviews that feelings of anxiety and the vape culture, along with the college experience, led to the powerful draw to electronic cigarette use among this population.

CONCLUSION

This study reflects findings that the college life experience, the vape culture, and the feelings of anxiety contribute to electronic cigarette use and, finally, lead to intense addiction.

Adolescents Who Vape Nicotine and Their Experiences Vaping: A Qualitative Study

Introduction

Understanding adolescent perceptions of vaping and roles it plays in their lives is needed to design effective interventions to help adolescents quit. We explored vaping experiences of 11 adolescents from initiation through quit attempts.

Methods

A convenience sample of students who vaped in the last 90 days was recruited from one suburban high school in Massachusetts. Qualitative interviews were transcribed and coded. An inductive thematic analysis approach was employed. Areas of agreement and range of responses in code reports were summarized.

Results

Eleven open-ended semi-structured interviews were conducted (mean = 32.5 minutes each). Vaping initiation often occurred when socializing with friends who also supplied vaping devices. Vaping was "something to do" and new flavors engaged adolescents further. Solitary activities coupled with vaping included video gaming, getting ready for school, talking on the phone, or studying. Peak hours for vaping included morning, before and after school, before parents returned from work, and after parents went to bed. Several vaped to address anxiety/stress. For some, anxiety control was a main reason for vaping. Participants were concerned about health effects and nicotine dependence. Cost and health effects were drivers of quitting. Quit strategies relied on willpower and distraction.

Conclusions

Peers have powerful influences on the initiation and maintenance of adolescent vaping. Vaping habits can become routinized into adolescent lives. Addiction is a concern although nicotine's anxiolytic effects were valued by many. Social connection was enhanced by communal vaping, sharing, and common vernacular, secrecy and rule-breaking. We describe the context in which adolescents vape nicotine, their reasons for vaping, and reasons to quit. This information can inform the development of interventions to better address adolescents' triggers to vape, and social and psychosocial barriers to quitting. Our findings suggest a desire to quit vaping but a limited awareness of quitting strategies.

Regulation of endothelial function by cigarette smoke and next-generation tobacco and nicotine products

Cigarette smoking is the most important avoidable cardiovascular risk factor. It causes endothelial dysfunction and atherosclerosis and increases the risk of its severe clinical complications like coronary artery disease, myocardial infarction, stroke, and peripheral artery disease. Several next-generation tobacco and nicotine products have been developed to decrease some of the deleterious effects of regular tobacco smoking. This review article summarizes recent findings about the impact of cigarette smoking and next-generation tobacco and nicotine products on endothelial dysfunction. Both cigarette smoking and next-generation tobacco products lead to impaired endothelial function. Molecular mechanisms of endothelial dysfunction like oxidative stress, reduced nitric oxide availability, inflammation, increased monocyte adhesion, and cytotoxic effects of cigarette smoke and next-generation tobacco and nicotine products are highlighted. The potential impact of short- and long-term exposure to next-generation tobacco and nicotine products on the development of endothelial dysfunction and its clinical implications for cardiovascular diseases are discussed.

Alcohol and cannabinoid binges and daily exposure to nicotine in adolescent/young adult rats induce sex-dependent long-term appetitive instrumental learning impairment

Adolescence is a critical developmental period, concerning anatomical, neurochemical and behavioral changes. Moreover, adolescents are more sensitive to the long-term deleterious effects of drug abuse. Binge-like consumption of alcohol and marijuana, along with tobacco smoking, is a dangerous pattern often observed in adolescents during weekends. Nevertheless, the long-term effect of their adolescent co-exposure has not been yet experimentally investigated. Long-Evans adolescent male (n = 20) and female (n = 20) rats from postnatal day 30 (P30) until P60 were daily treated with nicotine (0.3 mg/kg, i.p.), and, on two consecutive 'binging days' per week (for a total of eight times), received an intragastric ethanol solution (3 g/kg) and an intraperitoneal (i.p.) dose of cannabinoid 1/2 receptor agonist WIN55,212-2 (1.2 mg/kg). These rats were tested after treatment discontinuation at > P90 for associative food-rewarded operant learning in the two-lever conditioning chambers for six consecutive days on a fixed ratio 1 (FR1) schedule followed by another six days of daily FR2 schedule testing, after 42 days rest. We found the main effects of sex x treatment interactions in FR1 but not in FR2 experiments. Treated females show attenuated operant responses for food pellets during all FR1 and the FR2 schedule, whilst the treated males show an impairment in FR2 but not in the FR1 schedule. Moreover, the treated females' percentage of learners was significantly lower than female controls in FR1 while treated males were lower than controls in FR2. Our findings suggest that intermittent adolescent abuse of common drugs, such as alcohol and marijuana, and chronic tobacco exposure can cause significant long-term effects on motivation for natural reinforcers later in adulthood in both sexes. Females appear to be sensitive earlier to the deleterious effects of adolescent polydrug abuse, with both sexes having an increased likelihood of developing lifelong brain alterations.

Product variety and regulation avoidance in the sale of new tobacco products: findings from a point-of-sale survey in Indonesia

BACKGROUND

Since the imposition of the 2018 excise tax, new tobacco products (electronic nicotine delivery system, heated tobacco products, and nicotine pouches) have been considered legal, and their sale has grown rapidly in Indonesia. This study aims to assess the variety of new tobacco products available on the market and evaluate the point-of-sale (POS) environment.

METHODS

Data collection was carried out by 12 trained surveyors between March 7 and 13, 2022, in three provinces that had the most e-cigarette users: Yogyakarta, East Kalimantan, and Jakarta. All the vape stores with a Google rating of 4.5 stars or higher and a minimum of 100 reviews were included. In addition to vape stores, the nearest retail stores were included. The data collected included information about available products, product displays, and whether the POS followed tobacco-control measures, such as health warnings and smoke-free regulations.

RESULTS

A total of 27 vape stores and 35 retail stores were observed. The available liquid volumes ranged from 15 to 100 ml, with nicotine levels from 3 to 50 mg. No stores sold flavorless products, and all the products were sold without pictorial health warnings (PHWs). Most of the vape stores (92.6%) reported selling products that used cartoon images or public figures, and most (96.3%) allowed customers to use the products inside the store. Five vape stores and four retail stores reported that they did not require customers to undergo an identity-verification process to buy products. More than half (55.6%) of the vape stores and 46.6% of the retail stores reported that they were located less than 500 m from a school.

CONCLUSION

The available products were widely varied, and they were easy to access through online and offline stores. The new tobacco products had successfully avoided several tobacco-control measures, including smoke-free regulations and the appearance of PHWs on the products. The government needs to impose regulations sufficient to prevent youth from consuming new tobacco products.

School-based programs to prevent adolescent e-cigarette use: A report card

Given high rates and known health consequences of adolescent e-cigarette use as well as adolescents' susceptibility to nicotine addiction, school-based efforts to prevent and reduce adolescent e-cigarette use should continue to be developed, implemented, disseminated, and evaluated. This paper elaborates on best practices for developing and implementing prevention programs, including the importance of grounding programs in theories and frameworks that empower adolescents, including normative and interactive education, and having programs that are easily accessible and free of cost. Programs should also address key factors driving adolescent e-cigarette use, including discussing misperceptions, flavors, nicotine content, addiction, and the role that marketing plays in appealing to adolescents. The paper also discusses the gap areas of currently available prevention programs and highlights the need for evidence-based approaches and the importance of rigorous evaluation of programs.

E-cigarette Transitions Among US Youth and Adults: Results from the Population Assessment of Tobacco and Health Study (2013-2018)

Currently, the debate surrounding the regulation of e-cigarettes focuses mainly on the size of e-cigarettes' potentially beneficial effects (i.e., adult cessation) versus their unwarranted effects (i.e., initiation among tobacco-naïve adolescents). Therefore, we investigated the relative scale of e-cigarette use transitions in the United States. We reported cross-sectional weighted prevalence estimates of past-month e-cigarette use by ever cigarette use from Waves 1-4 of the Population Assessment of Tobacco and Health study (2013-2018) among youth (12-17 years) and adults (≥ 18 years). We also examined past-month e-cigarette mono and dual transitions related to cigarette smoking and reported the longitudinal weighted prevalence across waves. Among youth new e-cigarette users, the proportion of never-cigarette smokers increased from 24.1 in Wave 1 (n = 418) to 51.4% in Wave 4 (n = 310) (p < 0.0001 for trend). Of youth past-month e-cigarette mono-users in Wave 1 (n = 151), 15.2% transitioned to cigarette mono-use and 8.2% dual-use at Wave 2 or 3 or 4, compared to 60.2% no tobacco use and 16.4% e-cigarette mono-use. Among young adult past-month dual-users (18-24 years; n = 684), 22.6% transitioned to no tobacco use, 60.1% continued cigarette use, 11.4% dual use, and 5.9% e-cigarette mono-use. Among adult dual-users ≥ 25 years old (n = 1560), 13.6% transitioned to no tobacco use, 71.3% cigarette mono-use, 9.0% dual-use, and 6.1% e-cigarette mono-use. Transition to cigarette mono-use and continued dual-use were common among adult past-month e-cigarette users, while e-cigarette initiation was common among youth never-cigarette smokers. These findings contrast with data from other countries showing limited evidence of e-cigarette initiation among youth never cigarette smokers. Both e-cigarette and cigarette use should be addressed in youth and adults, given the potential for dual use in both populations.

A New Ingenious Enemy: Heat-Not-Burn Products

While cigarette smoking is still a major source of morbidity and mortality, e-cigarette usage is skyrocketing, and the tobacco industry is finding new ways to market nicotine. With updated published research highlighting the dangers of cigarette smoking and now vaping, the industry has been developing new techniques and devices that circumvent this research to hook users on tobacco and nicotine. The FDA allowed Philip Morris International (PMI) to sell their heat not burn tobacco products known as iQOS in 2019. By 2019, 49 countries had permitted the sale of iQOS. This commentary summarizes the recent research on heat not burn cigarettes, also known as heated tobacco products and their effects on public policy. We urge policy makers to consider the research published regarding these new products and prevent the widespread use of these products that will harm public health.

Does Tobacco Screening in Youth Primary Care Identify Youth Vaping?

PURPOSE

The purpose of this study was to evaluate the sensitivity of a tobacco use screening question, modified to include the word "e-cigarette," in detecting past 12-month nicotine vaping and past 12-month tobacco product use inclusive of nicotine vaping, among adolescent primary care patients.

METHODS

We conducted secondary analysis of data from a pilot trial of adolescent substance use screening and brief intervention in pediatric primary care. Participants were patients aged 12-18 years (N = 278) presenting for annual well-visits at five practices in Massachusetts in 2015-2017. Study measures consisted of a clinical brief screener item and tobacco/electronic cigarette items on a confidential, self-administered research questionnaire (criterion measure).

RESULTS

The clinical brief screener item identified 24 of 30 adolescents with past 12-month tobacco use (sensitivity 80%); 15 of 30 with past 12-month electronic cigarette use (sensitivity 50.0%), and 25 of 42 with tobacco and/or electronic cigarette use (sensitivity 59.5%).

CONCLUSIONS

These findings support the need to develop and test a screening measure that is sensitive for capturing electronic cigarette use.

E-Cigarette Use in Young Adult Never Cigarette Smokers with Disabilities: Results from the Behavioral Risk Factor Surveillance System Survey

Young adult never cigarette smokers with disabilities may be at particular risk for adopting e-cigarettes, but little attention has been paid to these people. This study examines the associations between different types of disability and e-cigarette use in this population. Young adult never-smokers from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) survey who were either never or current e-cigarette users (n = 79,177) were selected for the analysis. The Least Absolute Shrinkage and Selection Operator (LASSO) algorithm was used to select confounders for multivariable logistic regression models. Multivariable logistic regression models were used to determine the associations between current e-cigarette use and different types of disability after incorporating BRFSS survey design and adjusting for confounders. Young adult never-smokers who reported any disability had increased odds (OR 1.44, 95% CI 1.18-1.76) of e-cigarette use compared to those who reported no disability. Young adult never-smokers who reported self-care, cognitive, vision, and independent living disabilities had higher odds of e-cigarette use compared to those who reported no disability. There was no statistically significant difference in the odds of e-cigarette use for those reporting hearing and mobility disabilities compared to those who reported no disability. This study highlights the need for increased public education and cessation programs for this population.

Association Between Social Media Use and Vaping Among Florida Adolescents, 2019

INTRODUCTION

With the growing popularity of vaping, evidence has emerged about the association between social media use and vaping among adolescents, possibly because of the proliferation of e-cigarette advertisements and other related content on social media. Our study examined the association between social media use and vaping among adolescents.

METHODS

Using data from the 2019 Florida Youth Tobacco Survey (N = 10,776), we conducted logistic regression models on adolescent vaping status (experimental and current vaping) by nondaily and daily use of social media platforms - Facebook, Instagram, Twitter and Snapchat, controlling for other confounders.

RESULTS

Use of all 4 selected social media platforms was significantly associated with vaping status (P <.001 for all). Once jointly analyzed, daily use of Instagram was significantly associated with increased relative risks of experimental (adjusted relative risk ratio [aRRR] = 1.76; 95% CI, 1.38-2.25) and current vaping (aRRR = 1.51; 95% CI, 1.16-1.95); nondaily use of Snapchat was significantly associated with increased relative risk of experimental (aRRR = 1.57; 95% CI, 1.17-2.10) and current vaping (aRRR = 1.87; 95% CI, 1.31-2.66); daily use of Snapchat was associated with increased relative risk of experimental (aRRR = 2.38; 95% CI, 1.85-3.08) and current vaping (aRRR = 5.09; 95% CI, 3.78-6.86); nondaily use of Facebook was associated with increased relative risk of current vaping (aRRR = 1.20; 95% CI, 1.00-1.43), and nondaily use of Twitter was associated with increased relative risk of current vaping (aRRR = 1.29; 95% CI, 1.07-1.56).

CONCLUSION

Multilevel efforts are warranted to monitor social media use and vaping status among adolescents, including media use monitoring plans, developing counter-marketing campaigns, and strict regulatory action on social media.

Where There Is (No) Smoke, There Is Still Fire: a Review of Trends, Reasons for Use, Preferences and Harm Perceptions of Adolescent and Young Adult Electronic Cigarette Use

Purpose of the review

To review the current prevalence, trends, perceptions, and effects of e-cigarette or vaping product use associated lung injury (EVALI) on e-cigarette use among US adolescents and young adults.

Recent findings

COVID-19 diagnosis was more likely among the current/ever dual cigarette and e-cigarettes users, as well as ever e-cigarette only users. Additionally, the EVALI outbreak may have influenced harm perceptions, as daily nicotine vaping declined significantly from 2019 to 2020, and more youth and young adults perceived vaping as harmful.

Summary

The prevalence of e-cigarette use, specifically flavored use, remains high among adolescents and young adults, which is concerning due to the short-term and unknown long-term effects of e-cigarettes and their association with future cigarette and other substance use.

Inside the adolescent voice: A qualitative analysis of the appeal of different tobacco products

INTRODUCTION

While cigarette use has decreased, adolescents’ overall use of tobacco (e.g. e-cigarettes, cigars, and hookah) has increased. The purpose of this qualitative study is to highlight the decision-making process of adolescents to use certain products over others and why certain tobacco products appeal to them.

METHODS

Twenty-five participants were recruited from a larger study surveying adolescents’ perceptions and tobacco use (772 high school students). The participants were involved in one-on-one semi-structured phone interviews on the appeal of different tobacco products. Interviews were recorded, transcribed verbatim, and analyzed by identifying relevant codes and themes.

RESULTS

Participants for this study had a mean age of 16.4 (SD=1.2) years; over half (14/25) were female. Three major themes emerged from the interviews: 1) social context and circumstances to use, including using and sharing with peers, and reducing boredom; 2) importance of flavors, smell, taste, smoke tricks, and accessibility of products; and 3) misperceptions and misinformation of product risks.

CONCLUSIONS

The findings that emerged showed why participants favored certain tobacco products, especially e-cigarettes, over others. The results support areas for future research and practice, and inform how interventions can better address the appeal of different tobacco products to ultimately prevent adolescent use.

Nicotine Dependence among Adolescents Single and Dual Cigarette Users

The prevalence of concurrent use of combustible and electronic cigarettes (dual-use) is on the rise among Malaysian adolescents. This study compares nicotine dependence among exclusive cigarette users, e-cigarette users, and dual adolescent users. A total of 227 adolescent smokers completed a self-administrated questionnaire with items based on Hooked on Nicotine Checklist (HONC) incorporated. Endorsement of at least one HONC item indicates nicotine dependence. Exhaled carbon monoxide readings and salivary cotinine data were also collected. Over half (52.9%) of the participants were exclusive e-cigarette users (EC). The prevalence of exclusive conventional cigarette smokers (CC) and dual users was 11.9% and 35.2%, respectively. Adolescents who have mothers with secondary school education were more likely to become addicted to nicotine (Adjusted Odd Ratio (aOR) = 2.72; 95% CI = 1.17–6.32). Adolescents’ “mother’s education” level predicted nicotine dependence. This highlighted the need to target families within the identified demography with a more supportive anti-tobacco program.

Adolescent Substance Abuse, Transgenerational Consequences and Epigenetics

Adolescence is the transitional period between childhood and adulthood and a critical period in brain development. Adolescence in humans is also associated with increased expression of risk-taking behaviors. Epidemiological and clinical studies, for example, show a surge of drug abuse and raise the hypothesis that the adolescent brain undergoes critical changes resulting in diminished control. Determining how substance abuse during this critical period might cause longterm neurobiological changes in cognition and behavior is therefore critically important. The present work aims to provide an evaluation of the transgenerational and multi-generational phenotypes derived from parent animals exposed to drugs of abuse only during their adolescence. Specifically, we will consider changes found following the administration of cannabinoids, nicotine, alcohol and opiates. In addition, epigenetic modifications of the genome following drug exposure will be discussed as emerging evidence of the underlying adverse transgenerational effects. Notwithstanding, much of the new data discussed here is from animal models, indicating that future clinical studies are much needed to better understand the neurobiological consequences and mechanisms of drug actions on the human brains' development and maturation.

Cross-Sectional Association of Lifetime Electronic Cigarette Use with Wheezing and Related Respiratory Symptoms in U.S. Adults

Introduction

Electronic cigarette use (vaping) has been found to be associated with respiratory symptoms like wheezing or whistling in the chest. Whether or not lifetime vaping occurrences are associated with wheezing has not yet been investigated.

Methods

Population Assessment of Tobacco and Health (PATH) Study Wave 4 data with 22,233 adults collected from December 2016 to January 2018 were used. The cross-sectional association of lifetime vaping occurrences with wheezing and related respiratory symptoms was examined using multivariable weighted logistic regression models considering the complex sampling design.

Results

According to the weighted PATH Wave 4 data, about 89.9% adults never vaped, 3.2% adults vaped one time, 3.2% vaped 2–10 times, 1.3% vaped 11–20 times, 1.1% vaped 21–50 times, 0.4% vaped 51–99 times, and 0.9% vaped 100 or more times in their entire life. Compared to adults who never vaped, adults who vaped 2–10 times had a significantly higher association with ever wheezing (aOR = 1.4, 95% CI: 1.1 to 1.6), past 12-month wheezing (aOR = 1.5, 95% CI: 1.2 to 1.9) and the number of wheezing attacks in the past 12 months (aOR = 1.5, 95% CI: 1.2 to 1.8). Adults who vaped 11–20 times and 100 or more times had similar associations with wheezing as that for adults who vaped 2–10 times. Controlling other tobacco use attenuated the associations.

Conclusions

Lifetime vaping occurrences were found to be associated with some definitions of self-reported wheezing in cross-sectional analyses adjusted for other tobacco use.

Implications

Using the cross-sectional PATH Wave 4 data with 22,233 adults, we found significant associations between lifetime vaping occurrences and ever wheezing or whistling in the chest, past 12 months wheezing or whistling in the chest, as well as the number of wheezing attacks in the past 12 months. The study results suggest that larger studies with more precise time frames and measures are needed to further understand possible connections between vaping experimentation and wheezing symptoms that could inform our understanding of the health effects of electronic cigarettes and resultant policy decisions.

Directions and Challenges in Smoking Cessation Treatment

Raising the tax on tobacco-related products is the most effective and sustainable intervention for smoking cessation. The 2015 tobacco-tax increase resulted in a decreased smoking rate among Korean adult men. However, participation in the government-sponsored smoking-cessation programs developed after the 2015 tobacco tax increase has declined sharply since 2018. The popularity of electronic cigarettes (e-cigarettes) seems to be an important factor in this decline. Indeed, the market share of e-cigarettes has increased steadily since 2007, when the e-cigarette was introduced in Korea as a vaporizer. The introduction of the tobacco-heating device IQOS in 2017 resulted in the skyrocketing popularity of e-cigarettes, especially among the young generation of Koreans. The U.S. Food and Drug Administration (FDA) authorized marketing of IQOS as a “reduced exposure” tobacco product on July 7, 2020, further complicating smoking-cessation efforts. The agency announced that IQOS produces fewer or lower levels of some toxins than combustible cigarettes. However, FDA authorization does not mean that these products are safe. There is no evidence that reducing the harmful chemical components leads to health benefits. Clinicians need to maintain the position that those who smoke, regardless of tobacco-product type, should be counseled for smoking cessation and prescribed appropriate proven pharmacologic agents.

Early Cardiovascular Risk in E-cigarette Users: the Potential Role of Metals

PURPOSE OF REVIEW

Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs.

RECENT FINDINGS

In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide-mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic. Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.

E-Cigarette or Vaping Product Use-Associated Lung Injury: A Severe Case That Responded to Corticosteroid Treatment

Vaping is associated with an increased risk of lung injury; however, each case of vaping-associated lung injury leads to varying degrees of lung injury, and the response to therapy can be heterogeneous. Corticosteroid use has been suggested as a treatment for lung injuries associated with vaping.

We report a case of e-cigarette or vaping product use-associated lung injury (EVALI) that resulted in acute hypoxic respiratory failure. A 20-year-old woman presented with complaints of sore throat, dry cough, shortness of breath, and pleuritic chest pain. The patient admitted to vaping regularly for the past three years. The patient was found to be severely hypoxemic with respiratory distress and was intubated shortly after her arrival at the emergency department. She was treated with a short course of corticosteroids with tapering of the dose based on her response with significant improvement, and she was extubated on the seventh day of her admission.

EVALI is a syndrome associated with severe lung injury that results in acute respiratory failure that is clinically indistinguishable from acute respiratory distress syndrome, and it is largely a diagnosis of exclusion. The use of systemic corticosteroids in treating these patients should be considered after excluding an infectious etiology.

A Breath of Knowledge: Overview of Current Adolescent E-cigarette Prevention and Cessation Programs

PURPOSE

Adolescent use of electronic cigarettes (e-cigarettes) has risen rapidly, which is concerning given the health effects of e-cigarettes and youth susceptibility to nicotine addiction. It is critical that efforts to educate, prevent, and reduce adolescent use of e-cigarettes are developed and evaluated. The purpose of this paper is to review available current prevention and cessation programs.

FINDINGS

A web-based search of currently available e-cigarette prevention and cessation/treatment programs was conducted using Google in May of 2020. Programs were then reviewed on whether they included theory- and evidence-based practices of effective adolescent prevention and cessation programs. Eight prevention programs, seven cessation programs, and one program that addressed both prevention and cessation were identified and included in this review. Most prevention programs included the importance of understanding flavored e-cigarette products, addressed industry-targeted marketing, included social learning activities to develop refusal skills, delivered free-of-cost, available online, and explicitly stated their incorporation of theory. Five prevention programs and two cessation programs had empirically evaluated their e-cigarette-related components.

CONCLUSIONS

Although the programs reviewed largely incorporated theory and included key components known to be effective, there are some gaps in the programs' overall ability to prevent and stop adolescents from using e-cigarettes, such as lack of dedicated e-cigarette materials. More evidence-based tools, resources, and evaluations are needed to best inform adolescent e-cigarette cessation. Addressing the gaps that existing prevention and cessation programs present requires intervening at multiple systematic levels, conducting more rigorous program evaluations, and bolstering the availability of cessation programs.

Local and State Policy Action Taken in the United States to Address the Emergence of E-Cigarettes and Vaping: A Scoping Review of Literature

INTRODUCTION

In response to rising rates of youth vaping and e-cigarette use, states and localities in the United States have adopted various tobacco control policies and have extended their utility to these emerging products. However, the extent to which these policies have been evaluated for their impact on youth use is unknown.

METHOD

Two databases (PubMed, Google Scholar) were searched for English language peer-reviewed articles pertaining to electronic cigarette policy evaluation between 2009 and 2020. Primary articles of interest were journal articles that evaluated an e-cigarette policy. Secondary articles of interest were journal articles that identified any e-cigarette policy action without a formal evaluation component, those that evaluated tobacco policy, or those that described e-cigarette behaviors and trends. Tertiary articles included gray literature that provided context for e-cigarette trends and additional policy identification.

RESULTS

The final sample consisted of 12 relevant articles with an e-cigarette policy evaluation component and 62 relevant articles without such component, and 19 gray literature sources. Findings were synthesized based on policy type: product classification, age restrictions, smoke-free policies, flavor bans, sales restrictions, taxation, packaging, and advertising.

CONCLUSION

Policies that address access and use of e-cigarettes are common on the federal, state, and local level, are mostly reactionary, and mimic tobacco control efforts. Few policies have been formally evaluated for their effectiveness in reducing or preventing youth vaping. Strengthening the evidence base should be a priority for researchers going forward, given the potential of these policies to intervene on social and environmental conditions that affect youth initiation and uptake.

Unique, long-term effects of nicotine on adolescent brain

Adolescence is a time of major plasticity of brain systems that regulate motivated behavior and cognition, and is also the age of peak onset of nicotine use. Although there has been a decline in teen use of cigarettes in recent years, there has been a huge increase in nicotine vaping. It is therefore critically important to understand the impact of nicotine on this critical phase of brain development. Animal studies have shown that nicotine has unique effects on adolescent brain. The goal of this review is therefore to systematically evaluate age- and sex-differences in the effects of nicotine on brain and behavior. Both acute and chronic effects of nicotine on brain biochemistry and behavior, particularly drug reward, aversion, cognition and emotion, are evaluated. Gaps in our current knowledge that need to be addressed are also highlighted. This review compares and integrates human and animals findings. Although there can be no experimental studies in humans to confirm similar behavioral effects of teen nicotine exposure, an emerging observational literature suggests similarities across species. Given the substantial evidence for long-term negative impact of adolescent nicotine exposure on brain and behavior, further longitudinal assessment of health outcomes in teen and young adult e-cigarette users is warranted.

Knowledge and attitudes of adolescents to e-cigarettes: an international prospective study

Purpose The aim of the study was to assess the familiarity of adolescents with e-cigarettes. We performed a survey to investigate the frequency of their contact with e-cigarettes, beliefs about this sort of smoking (vaping), and their real knowledge of its effects. Methods The survey was carried out among 1600 high school students in the USA, Israel, Ukraine and Australia. The questionnaire comprised three parts, each with five questions. The first part was designed to assess the frequency of contact with the phenomenon. The second part assessed misconceptions and opinions concerning vaping. The third part questioned the participants' real knowledge of the subject. Results Out of a maximum score of 5, the average score of 4.25 for Part 1 indicated that the participants had frequent contact with e-cigarettes. The score of 3.65 for Part 2 showed that adolescents have both right and wrong beliefs on the subject. Part 3 was completed by 1224 participants (76.5%) while 376 (23.5%) reported a lack of any specific knowledge about vaping. The average score of 3.33 demonstrated that adolescents who completed Part 3 of the survey have incomplete knowledge about e-cigarettes. For the whole cohort of 1600 participants, the average score was 2.80. No significant sex differences were detected. The Ukranian participants had poor knowledge about the dangers of vaping in comparison with the participants in the USA and Australia (p = 0.03). Conclusion While the contact of adolescents with e-cigarettes users is extensive, their actual knowledge remains inadequate. Various school-based smoking risk campaigns face a necessity for further adjustments and improvements.

Passive Exposure to Pollutants from a New Generation of Cigarettes in Real Life Scenarios

The use of electronic cigarettes (e-cigarettes) and heat-not-burn tobacco (HNBT), as popular nicotine delivery systems (NDS), has increased among adult demographics. This study aims to assess the effects on indoor air quality of traditional tobacco cigarettes (TCs) and new smoking alternatives, to determine the differences between their potential impacts on human health. Measurements of particulate matter (PM₁, PM_2.5 and PM₁₀), black carbon, carbon monoxide (CO) and carbon dioxide (CO₂) were performed in two real life scenarios, in the home and in the car. The results indicated that the particle emissions from the different NDS devices were significantly different. In the home and car, the use of TCs resulted in higher PM₁₀ and ultrafine particle concentrations than when e-cigarettes were smoked, while the lowest concentrations were associated with HNBT. As black carbon and CO are released by combustion processes, the concentrations of these two pollutants were significantly lower for e-cigarettes and HNBT because no combustion occurs when they are smoked. CO₂ showed no increase directly associated with the NDS but a trend linked to a higher respiration rate connected with smoking. The results showed that although the levels of pollutants emitted by e-cigarettes and HNBT are substantially lower compared to those from TCs, the new smoking devices are still a source of indoor air pollutants.

A Systematic Literature Review of E-Cigarette-Related Illness and Injury: Not Just for the Respirologist

Following the recent electronic cigarette (e-cigarette) illness outbreak, the current review aimed to collect all related clinical cases for study and analysis and provide a critical synopsis of the proposed injury mechanism. Adhering to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analysis) guidelines, e-cigarette-related clinical cases were identified via Google Scholar and PubMed databases. Additionally, references of published case reports and previous review papers were manually searched, revealing 159 publications presenting e-cigarette-related case reports and 19 reports by the Centers for Disease Control and Prevention. 238 individual cases were identified; 53% traumatic injuries due to e-cigarette explosion or self-combustion, 24% respiratory cases, and 12% poisonings. Additional cases pertained to oral, cardiovascular, immunologic, hematologic, allergic reactions, infant complications, and altered medication levels. Case reports were mainly published between 2016-2019 (78%). The oldest case, a lipoid pneumonia, was published in 2012. The current review showed that e-cigarette-related health effects extend beyond the acute lung injury syndrome, including traumatic, thermal injuries and acute intoxications. Physicians should be aware of the distinct clinical presentations and be trained to respond and treat effectively. Regulators and public health authorities should address the regulatory gap regarding electronic nicotine delivery systems (ENDS) and novel tobacco products.

In utero exposures to electronic-cigarette aerosols impair the Wnt signaling during mouse lung development

Currently, more than 9 million American adults, including women of childbearing age, use electronic-cigarettes (e-cigs). Further, the prevalence of maternal vaping now approaching 10% is similar to that of maternal smoking. Little, however, is known about the effects of fetal exposures to nicotine-rich e-cig aerosols on lung development. In this study, we assessed whether in utero exposures to e-cig aerosols compromised lung development in mice. A third-generation e-cig device was used to expose pregnant BALB/c mice by inhalation to 36 mg/mL of nicotine cinnamon-flavored e-cig aerosols for 14-31 days. This included exposures for either 12 days before mating plus during gestation (preconception groups) or only during gestation (prenatal groups). Respective control mice were exposed to filtered air. Subgroups of offspring were euthanized at birth or at 4 wk of age. Compared with respective air-exposed controls, both preconception and prenatal exposures to e-cig aerosols significantly decreased the offspring birth weight and body length. In the preconception group, 7 inflammation-related genes were downregulated, including 4 genes common to both dams and fetuses, denoting an e-cig immunosuppressive effect. Lung morphometry assessments of preconception e-cig-exposed offspring showed a significantly increased tissue fraction at birth. This result was supported by the downregulation of 75 lung genes involved in the Wnt signaling, which is essential to lung organogenesis. Thus, our data indicate that maternal vaping impairs pregnancy outcomes, alters fetal lung structure, and dysregulates the Wnt signaling. This study provides experimental evidence for future regulations of e-cig products for pregnant women and developmentally vulnerable populations.

Microglial activation increases cocaine self-administration following adolescent nicotine exposure

With the rise of e-cigarette use, teen nicotine exposure is becoming more widespread. Findings from clinical and preclinical studies show that the adolescent brain is particularly sensitive to nicotine. Animal studies have demonstrated that adolescent nicotine exposure increases reinforcement for cocaine and other drugs. However, the mechanisms that underlie these behaviors are poorly understood. Here, we report reactive microglia are critical regulators of nicotine-induced increases in adolescent cocaine self-administration. Nicotine has dichotomous, age-dependent effects on microglial morphology and immune transcript profiles. A multistep signaling mechanism involving D2 receptors and CX3CL1 mediates nicotine-induced increases in cocaine self-administration and microglial activation. Moreover, nicotine depletes presynaptic markers in a manner that is microglia-, D2- and CX3CL1-dependent. Taken together, we demonstrate that adolescent microglia are uniquely susceptible to perturbations by nicotine, necessary for nicotine-induced increases in cocaine-seeking, and that D2 receptors and CX3CL1 play a mechanistic role in these phenomena.

Adolescents are particularly sensitive to nicotine. Here the authors show that in mice, microglial activation contributes to the enhanced sensitivity to cocaine caused by nicotine exposure in young mice.

Electronic cigarettes: where to from here?

Although the usage of electronic (e)-cigarettes (EC) and similar devices has gained in popularity as an apparent smoking cessation strategy, serious concerns are emerging in relation to both the efficacy of this strategy, as well as the inappropriate use of these devices. While the comparative safety of e-cigarettes is based on the reasonable contention that the levels of inhaled toxicants present in the aerosols generated by these devices are considerably lower than those present in tobacco smoke, the perception that they are indeed relatively risk-free is being challenged on several fronts. Notwithstanding lack of convincing evidence of efficacy as a superior smoking cessation strategy, foremost among emerging concerns is the increasing use of electronic nicotine-delivery devices by young never-smokers. Other concerns include increasing levels of sophistication in the design and capacity of these devices in relation to nicotine content and delivery, the potential threat of manipulation of the contents of e-liquids, as well as other additives such as illicit drugs and other potentially toxic agents that can be vaporised. These issues, together with the potential risks to respiratory health, specifically "e-cigarette or vaping product use-associated lung injury" represent the major thrusts of this review.

The Effect of E-cigarette Commercials on Youth Smoking: A Prospective Study

Objectives: In this study, we assessed whether commercials for electronic cigarettes (e-cigarettes) influence the use of e-cigarettes, cigarettes, and cigars among high-risk youth in southern California. Methods: We recruited students (N = 1060) from 29 alternative high schools into a prospective cohort study. We used multilevel Poisson regression models to examine whether exposure to e-cigarette commercials and perceptions of their appeal predicted increased use of e-cigarettes, cigarettes, and cigars one year later. We also tested the potential moderating effect of gender and ethnicity. Results: Models with and without covariates suggest that exposure to e-cigarette commercials is a statistically significant predictor of increased use of e-cigarettes. When gender was added to the models as a moderator, the relationships between commercial exposure and future use of e-cigarettes and cigars were found to be stronger among females. Unadjusted and adjusted models also indicated that students with favorable perceptions of e-cigarette commercials reported greater use of e-cigarettes, cigarettes, and cigars one year later. Conclusions: E-cigarette commercials may play an important role in persuading high-risk youth to use nicotine and tobacco products. Extending the Broadcast Advertising Ban of 1971 to include a broader range of products may be critical to preventing future generations from becoming addicted to nicotine.

Public Health Policies on E-Cigarettes

Abstract

Tobacco continues to kill about 0.48 million Americans per year and there are currently 34.3 million smokers in the USA. As a consequence of the First Surgeon General’s Report on Tobacco in 1964, tobacco control interventions on part of the government led to a significant decline in conventional tobacco product usage over the last few decades. However, more recently, a new entity in the form of electronic cigarettes has risen rapidly and has exposed a younger population to a plethora of dangerous consequences. Looking at e-cigarettes from the perspective of tobacco control however raises a lot of challenges. There is little doubt that existing smokers of combustible cigarettes who switch to e-cigarettes will be switching to a less harmful product. However, if the younger generation begins using e-cigarettes as a result of targeted marketing, appealing flavors and ‘safer alternative’ perception, decades of progress made in conventional tobacco control will be negated. Governments at the federal, state, and local levels have a mandate to once again implement new public health policies to ensure that non-conventional tobacco products like e-cigarettes are available as smoking cessation tools for existing smokers but at the same time do not play a role in ruining the health of future generations through addiction and disease.

Purpose of Review

To review the present scenario of regulations and policies impacting public health with respect to electronic nicotine delivery systems (ENDS) with the objective of providing a meaningful and balanced view of the challenges at hand with plausible recommendations.

Recent Findings

Nicotine in tobacco is known to cause addiction and dependence. It is particularly potent in children and young adults. E-cigarettes can deliver high concentrations of nicotine, and these concentrations can vary depending on the numerous constituents within the e-cigarette which vary greatly from one another. Use of e-cigarettes is implicated as a risk factor for future cigarette use in young adults. Moreover, e-cigarette usage patterns also depend on several sociodemographic factors. Banning tobacco products has shown to reduce smoking risk in youth and as such, strong e-cigarette regulation measures are needed for prevention.

Summary

Effective regulation of ENDS faces a multitude of challenges. One such challenge is to prevent youth and non-smokers from getting habituated to nicotine through e-cigarettes. The intention of tobacco companies to sustain sales through harmful marketing strategies that tone down the risks and highlight e-cigarettes as a “much safer alternative” while promoting flavors appealing to children should be immediately prohibited. Another hazard is the endorsement of ENDS as devices meant for enhancing social interaction which opens a path for youth to make erroneous choices under peer pressure. On the other hand, several studies have reported that e-cigarettes significantly reduce an existing smoker’s risk of being exposed to toxic tobacco smoke constituents that are normally present in cigarette smoke. This leads to the conclusions that e-cigarettes can be a tool for smoking cessation for current smokers. Public policy must take a multi-dimensional approach to balance these two extremes.