E-cigarettes in Nigeria: A scoping review of evidence

Background and Aims

E-cigarettes will continue to be a public health issue in Nigeria. To curb the growing menace of the e-cigarette use in Nigeria through evidence-based approach, it is crucial to first map the empirical research landscape of e-cigarettes in Nigeria. No known study has mapped the existing empirical evidence and gaps concerning e-cigarettes in Nigeria; hence, this scoping review was conducted.

Methods

This scoping review adopted the research design by Arksey and O'Malley. Four databases (PubMed, SCOPUS, CINAHL Complete, and APA PsycINFO) were searched to retrieve literature on e-cigarettes in Nigeria. With the aid of Rayyan web application, all retrieved literature were deduplicated and screened based on the review's eligibility criteria. Only those peer-reviewed journal papers meeting the inclusion criteria were included in the review. Relevant data from the included papers were charted, collated, and summarized.

Results

A total of six papers were included in this review. The reviewed papers reported a lifetime prevalence of e-cigarette use (or vaping) ranging from 5.8% to 19.8%, with a current e-cigarette use prevalence of 11.8%, among different population groups in Nigeria. The major determinants of e-cigarette use, as reported in these articles, include being a youth, having a health condition, severe anxiety, tobacco use, peer influence, and current alcohol use. Dry mouth and oral lesions (gingival inflammation and oral ulcers) were also identified to be the medical conditions associated with e-cigarette use in Nigeria. Lastly, one of the included papers identified a lack of clear regulation on e-cigarettes in Nigeria.

Conclusion

There is an urgent need for more scientific investigations on the sociodemographic, economic, health, and regulatory landscape of e-cigarettes in Nigeria, as robust empirical evidence is needed for the effective planning, implementation, and evaluation of evidence-based policies and interventions on e-cigarettes control and regulation in Nigeria.

Expanding on cross-price elasticity: Understanding tobacco product demand and substitution from the cross-price purchase task

We examine whether cigarettes serve as substitutes for electronic nicotine delivery systems (ENDS) among ENDS users and demonstrate methodological extensions of data from a cross-price purchase task to inform policies and interventions. During a clinical laboratory study, n = 19 exclusive ENDS users and n = 17 dual cigarette/ENDS users completed a cross-price purchase task with cigarettes available at a fixed price while prices of own-brand ENDS increased. We estimated cross-price elasticity using linear models to examine substitutability. We defined five additional outcomes: nonzero cross-price intensity (purchasing cigarettes if ENDS were free), constant null demand (not purchasing cigarettes at any ENDS price), cross-product crossover point (first price where participants purchased more cigarettes than ENDS), dual-demand score (percentage of prices where both products were purchased), and dual-use break point (minimum relative price to force complete substitution). The cross-price elasticity results indicated that cigarettes could serve as substitutes for ENDS among ENDS users on average, but this average effect masked substantial heterogeneity in profiles of demand (here, a measure of the drug's reinforcement potential). Policies and regulations that increase ENDS prices appear unlikely to steer most exclusive ENDS users toward cigarette use, as most would not purchase cigarettes at any ENDS price, but they could prompt some dual users to substitute cigarettes completely while others remain dual users. This heterogeneity in consumer responses suggests additional indices of cross-product demand are useful to characterize the anticipated and unanticipated effects of tobacco price policies more fully.

How to Identify e-Cigarette Brands Available in the United States During 2020-2022: Development and Usability Study

BACKGROUND

Prior studies have demonstrated that the e-cigarette market contains a large number of brands. Identifying these existing e-cigarette brands is a key element of market surveillance, which will further assist in policy making and compliance checks.

OBJECTIVE

To facilitate the surveillance of the diverse product landscape in the e-cigarette market, we constructed a semantic database of e-cigarette brands that have appeared in the US market as of 2020-2022.

METHODS

In order to build the brand database, we searched and compiled e-cigarette brands from a comprehensive list of retail channels and sources, including (1) e-liquid and disposable brands sold in web-based stores, (2) e-cigarette brands sold in brick-and-mortar stores and collected by the Nielsen Retail Scanner Data, (3) e-cigarette brands compiled by Wikipedia, (4) self-reported e-cigarette brands from the 2020 International Tobacco Control Four-Country Smoking and Vaping (ITC 4CV) US survey, and (5) e-cigarette brands on Twitter. We also estimated the top 5 e-cigarette brands by sales volume in brick-and-mortar stores, by the frequency and variety of offerings in web-based shops, and by the frequency of self-reported brands from the 2020 ITC 4CV US survey.

RESULTS

As of 2020-2022, a total of 912 e-cigarette brands have been sold by various retail channels. During 2020-2022, the top 5 brands are JUUL, vuse, njoy, blu, and logic in brick-and-mortar stores; blu, king, monster, twist, and air factory for e-liquids in web-based stores; hyde, pod mesh, suorin, vaporlax, and xtra for disposables sold in web-based stores; and smok, aspire, vaporesso, innokin, and eleaf based on self-reported survey data.

CONCLUSIONS

As the US Food and Drug Administration enforces the premarket tobacco market authorization, many e-cigarette brands may become illegal in the US market. In this context, how e-cigarette brands evolve and consolidate in different retail channels will be critical for understanding the regulatory impacts on product availability. Our semantic database of e-cigarette brands can serve as a useful tool to monitor product and marketplace development, conduct compliance checks, assess manufacturers' marketing behaviors, and identify regulatory impacts.

Cross-state Border Nicotine Vaping Products Purchase - Early Evidence from State Emergency Sales Restrictions in 2019

INTRODUCTION

While retail sales and retailer inspection studies generally indicate high compliance with state sales restrictions on Nicotine Vaping Products (NVPs) within the restricted area, studies using survey data generally indicate that most users could readily continue gaining access to restricted NVPs. Our study bridges a gap in the current literature and investigates the potential role of cross-state border purchases to evade state emergency NVP sales restrictions in 2019.

METHODS

The study sample was restricted to NVP sales from the states neighboring Massachusetts (MA), Rhode Island (RI), and Washington (WA), three states that implemented all NVP or flavored NVP sales restrictions in 2019. Among these neighboring states, the 2019 weekly county-level NVP sales by flavors (tobacco, mint/menthol, and other flavors) were compiled using Nielsen Scanner data. A quasi-experimental, comparison group pre-post study design was used to study the impacts of NVP sales restrictions on cross-state border NVP purchases.

RESULTS

Weekly NVP sales for border counties significantly increased in response to the MA, RI, and WA bans for tobacco flavored (56%, 45%, 14%, respectively), menthol/mint flavored (51%, 2%, 41%, respectively), and other flavored (79%, 3%, 4%, respectively) products, compared to sales for non-border counties (all p-values <0.01).

CONCLUSIONS

Our study identified significant cross-state border NVP purchases in all studied states to circumvent NVP emergency sales restrictions in response to the EVALI outbreak. Policymakers should factor in these purchasing behaviors to evade sales restrictions when evaluating any future potential policies at the state or local levels.

IMPLICATIONS

While retail sales data and retailer inspections indicate high compliance with Nicotine Vaping Product (NVP) flavor sales restrictions from major retail outlets, survey data obtain mixed findings on the effects of sales restrictions on vaping behaviors. Our study identified a significant increase in cross-state border NVP purchases to circumvent NVP sales restrictions in 2019, consistent across all three settings of Massachusetts, Rhode Island, and Washington. Policymakers should factor in these cross-state border NVP purchases in response to sales restrictions when evaluating any future potential NVP sales restrictions.

Periodontal Health Status in Adults Exposed to Tobacco Heating System Aerosol and Cigarette Smoke vs. Non-Smokers: A Cross-Sectional Study

Tobacco heating systems (THS) are new products on the market, advertised as a less harmful alternative for smokers, in which tobacco is heated and not burned like in conventional cigarettes. This research explored the effect on periodontal tissues in contact with heating and burning tobacco residual products (smoke and tobacco).

METHODS

The sample included 66 subjects, patients of the Clinic of Dentistry in Rijeka, Croatia, aged 26-56 (median 38), 64% females. Three age- and gender-matched groups were formed (each N = 22): non-smokers, classic cigarettes smokers and THS smokers. Probing depth (PD) and clinical attachment loss (CAL) were primary research parameters.

RESULTS

Three groups differed in average PD and CAL (p ≤ 0.002), with cigarette smokers having the highest and non-smokers the lowest values (p ≤ 0.002). THS consumers generally had lower values of periodontal indices than smokers, but only CAL differed significantly (p = 0.011). Periodontal indices CAL and PD were worse in THS consumers than non-smokers, but they did not reach a level of statistical significance. Cigarette smoking was the only predictor of periodontitis (average CAL ≥ 4 mm) in logistic regression models, with an odds ratio of 4.7 (95% confidence interval 1.2-18.3; p = 0.027).

CONCLUSIONS

Exposure to nicotine-containing aerosol of THS in adults has a less harmful effect on periodontal tissues, measurable through periodontal indices (PD and CAL), compared to burning tobacco of conventional cigarettes. THS, presented as an alternative product to classic cigarettes, also has a detrimental effect on the periodontium.

Using a Novel Connected Device for the Collection of Puffing Topography Data for the Vuse Solo Electronic Nicotine Delivery System in a Real-World Setting: Prospective Ambulatory Clinical Study

BACKGROUND

Over the last decade, the use of electronic nicotine delivery systems (ENDSs) has risen, whereas studies that describe how consumers use these products have been limited. Most studies related to ENDS use have involved study designs focused on use in a central location environment or attempted to measure use outcomes through subjective self-reported end points. The development of accurate and reliable tools to collect data in a naturalistic real-world environment is necessary to capture the complexities of ENDS use. Using connected devices in a real-world setting provides a convenient and objective approach to collecting behavioral outcomes with ENDS.

OBJECTIVE

The Product Use and Behavior instrument was developed and used to capture the use of the Vuse Solo ENDS in an ambulatory setting to best replicate real-world use behavior. This study aims to determine overall mean values for topography outcomes while also providing a definition for an ENDS use session.

METHODS

A prospective ambulatory clinical study was performed with the Product Use and Behavior instrument. Participants (n=75) were aged between 21 and 60 years, considered in good health, and were required to be established regular users of ENDSs. To better understand use behavior within the population, the sample was sorted into percentiles with bins based on daily puff counts. To frame these data in the relevant context, they were binned into low-, moderate-, and high-use categories (10th to 40th, 40th to 70th, and 70th to 100th percentiles, respectively), with the low-use group representing the nonintense category, the high-use group representing the intense category, and the moderate-use group being reflective of the average consumer.

RESULTS

Participants with higher daily use took substantially more puffs per use session (6.71 vs 4.40) and puffed more frequently (interpuff interval: 32.78 s vs 61.66 s) than participants in the low-use group. Puff duration remained consistent across the low-, moderate‑, and high-use groups (2.10 s, 2.18 s, and 2.19 s, respectively). The moderate-use group had significantly shorter session lengths (P<.001) than the high- and low-use groups, which did not differ significantly from each other (P=.16).

CONCLUSIONS

Using connected devices allows for a convenient and robust approach to the collection of behavioral outcomes related to product use in an ambulatory setting. By using the variables captured with these tools, it becomes possible to move away from predefined periods of use to better understand topography outcomes and define use sessions. The data presented here offer a possible method to define these sessions. These data also begin to frame international standards used for the analytical assessments of ENDSs in the correct context and begin to shed light on the differences between standardized testing regimens and actual use behavior.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04226404; https://clinicaltrials.gov/study/NCT04226404.

Transitions in device and liquid characteristic groupings among US adults frequently using electronic nicotine delivery systems (ENDS) over three timepoints, 2020-2021

INTRODUCTION

Electronic nicotine delivery system (ENDS) and liquid characteristics affect nicotine and toxicant exposure and use behaviors. Little is known about how adults who frequently use ENDS transition between ENDS device/liquid groupings.

METHODS

A total of 379 US adults (≥21 years) using ENDS frequently (≥5 days/week) self-reported and uploaded photos of their most used ENDS device and liquid in three waves of online surveys (May 2020 - November 2021). Device/liquid grouping was defined by device (i.e. disposable/refillable tank/refillable pod or cartridge/disposable pod or cartridge, adjustable/no adjustable settings) and liquid (i.e. salt/freebase) characteristics. Participants using the same grouping across waves were considered stable users.

RESULTS

The most prevalent wave (W) 1 grouping was tank (freebase, adjustable settings; 36.8%). From W1 to W3, the number of disposable device (salt, no adjustable settings) users increased 156.4% and the number of disposable pod/cartridge (salt, no adjustable settings) users decreased 15.2%. In W2 and W3, compared to stable users, participants using tank (freebase, adjustable settings) in W1 and another grouping in W2 and/or W3 reported significantly higher nicotine concentrations (mg/mL) (W2: 15.1 vs 5.5, p<0.001; W3: 22.9 vs 5.6, p<0.001) and lower device power (watt) (W2: 46.8 vs 58.7, p=0.02; W3: 34.0 vs 57.2, p<0.001).

CONCLUSIONS

Over a 1.5-year period, a rapid growth in disposable device (salt, no adjustable settings) use and a decrease in disposable pod/cartridge (salt, no adjustable settings) use were observed. Participants who transitioned from tank (freebase, adjustable settings) to other groupings were more likely to increase liquid nicotine concentration and reduce device power compared to stable users.

Human abuse liability assessment of e-cigarettes: Why, what and how?

Cigarette smoking is the world's leading cause of preventable death and disease. Alternative nicotine products such as e-cigarettes have tobacco harm reduction potential, by providing smokers with an alternative form of nicotine delivery but with either the reduced presence or absence of the numerous harmful chemicals found in combustible cigarette smoke. One aspect of importance in determining the potential of e-cigarettes to provide a viable alternative to combustible cigarettes for smokers is their ability to cause dependence, also known as their abuse liability. E-cigarettes with little or no abuse liability would be unlikely to be used as a substitute for cigarettes, whereas at least some degree of abuse liability is acknowledged as supportive both to aiding cigarette substitution or complete cessation and to preventing relapse. Given this link between abuse liability and substitution efficacy, human studies assessing the abuse liability of e-cigarettes are important to determine their true harm reduction potential. In this review, the concept of tobacco product abuse liability is discussed, along with the primary elements-pharmacokinetics and pharmacodynamics (subjective effects)-that need to be assessed to determine abuse liability. The review also presents a number of human abuse liability study design considerations and discusses what existing studies in the literature tell us about the abuse liability and harm reduction potential of e-cigarettes.

Biochemical validation of self-reported electronic nicotine delivery system and tobacco heaviness of use

Research on tobacco use disorder relies on a combination of self-reported use (e.g., cigarettes per day) and biochemical validation to quantify heaviness of use. However, electronic nicotine delivery system (ENDS) users may be unaware of how much they have vaped per day. The aim of this study was to test the relationship between self-reported heaviness of ENDS/tobacco use and nicotine biomarkers. Young adults (n = 30) who currently use ENDS and other tobacco products completed a detailed tobacco use history, timeline follow-back, and an ENDS topography session. We evaluated the self-reports of own-brand ENDS use and tested correlations to determine which self-report measures of own-brand use, and which self-reported measures of puff topography, had the strongest correlations with urine and/or blood biomarkers of nicotine use. Participants reported using a variety of different ENDS devices and had a range of usage. The sum of the self-reported number of occasions or hours of ENDS use, along with the number of cigarettes and other tobacco products used, over the past 24 hr was significantly correlated with plasma cotinine levels. Puff topography measures correlated with increased nicotine concentrations, although participants underestimated the number of puffs they took during the topography session. This study provides preliminary evidence that summing together the hours of ENDS use, or the number of occasions of ENDS use, in addition to the number of other tobacco products used (i.e., cigarettes) based on self-report may be an accurate method of quantification. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Actual Use Behavior Assessment of a Novel Puff Recording Electronic Nicotine Delivery System: Observation Study

BACKGROUND

Compared with combustible cigarettes, electronic cigarettes (e-cigarettes) can deliver a sufficient amount of nicotine with a significantly reduced emission of toxicants, which renders them as potential harm reduction candidates for tobacco and smoking replacement. However, the use of e-cigarettes is not harm free and the long-term health effect of using e-cigarettes is yet to be established. Given the high prevalence of e-cigarette use across the globe and its potential health concerns, it is imperative to conduct actual use behavior assessments to better understand how e-cigarettes are being consumed in real-world conditions. However, with the currently available technologies, there is still a lack of noninvasive, noninterventional, and convenient instruments for the real-time and real-world use behavior monitoring of e-cigarette product use. Novel technology-based systems that do not primarily rely on self-report or intrusive measurements to monitor e-cigarette use behaviors are therefore highly desired.

OBJECTIVE

The primary goal of this study is to investigate the e-cigarette actual use behaviors in the real world via a novel puff recording electronic nicotine delivery system (PR-ENDS). Specifically, we aim to analyze and summarize the survey and PR-ENDS use data and to study the relationships and effects of different factors on these variables.

METHODS

In real-world conditions, 61 enrolled UK e-cigarette users were instructed to use PR-ENDS as the primary source of nicotine with their selected e-liquids for at least 3 weeks (21 days). A baseline survey was conducted to collect information about participants' demographics and nicotine use history (cigarette and ENDS). The puff data (ie, puff number, puff duration for each puff, device power, e-liquid nicotine concentrations) were directly recorded by PR-ENDS and uploaded to the cloud for further analyses. The nicotine emission and nicotine consumption were estimated based on recorded puff data.

RESULTS

Middle-aged adults with a nicotine history represented the major user profile during the PR-ENDS trial. A wide range of device power and e-liquid nicotine concentrations was applied and their combinations during actual use were found to be rather complex. Various puff parameters (ie, puff duration, puff number, nicotine emission) were assessed with contributing factors from device, e-liquid, and user nicotine history in different effect sizes. The real-time observation revealed substantial intra- and interindividual variabilities in PR-ENDS use behaviors. The use pattern of a quick adaptation followed by consistent product use was recognized for at least 3 weeks during actual use.

CONCLUSIONS

The actual use behavior assessment of PR-ENDS was conducted as a proof-of-concept application. The complex interactions of product attributes and significant intra- and interindividual variabilities in e-cigarette use behaviors provided new insights of compensatory behavior, which can inspire future studies in the field of nicotine addiction and abuse liability behavior assessment.

Effect of tobacco and nicotine in causing staining of dental hard tissues and dental materials: A systematic review and meta-analysis

INTRODUCTION

Dental staining is a common concern for tobacco users. However, little is known about which components of tobacco are responsible for the staining and whether nicotine may be implicated. This is of increasing relevance with the popularity of novel products such as heated-tobacco products and electronic cigarettes (E-cigarettes).

OBJECTIVES

This systematic review aimed to establish the evidence base for the effect if any, of the various tobacco and nicotine products in causing staining of dental hard tissues and materials.

MATERIAL AND METHODS

This systematic review was performed in accordance with the preferred reporting items for systematic reviews and meta-analyses guidelines. There were four structured population intervention comparison outcomesquestions. A search was conducted up to December 2021 in three databases: MEDLINE, EMBASE, and Web of Science, and manual searching of relevant sources was also completed. Two researchers individually reviewed the titles then abstracts and finally full articles. A reporting quality appraisal was conducted appropriately to the study methodology.

RESULTS

Of the 815 records titles identified, 56 full-text articles were assessed for eligibility, of which 27 were included for analysis. The included studies were mainly laboratory studies of varying reporting quality. There was evidence from 18 studies that tobacco exposure caused staining of dental hard tissues (pooled results from three studies- enamel/dentine; mean difference [MD]: 16.22; 95% confidence interval[12.11, 20.32; I² : 96%)and materials (pooled result from four studies-resin composite; MD: 11.90; 95% CI: 11.47, 12.34; I² : 100%). There was limited evidence that E-cigarettes 99%) and heated tobacco products (HTPs; pooled results from three studies--1.07, 6.54; I² : 99%) cause staining, but this was lower than with traditional tobacco/found 11 compounds, of which 8 were terpenoids, from tobacco products implicated in causing staining. Finally, there was some evidence that resin composites stained more than other materials.

CONCLUSIONS

Tobacco smoking causes dental staining. There was limited evidence that E-cigarettes and HTPs did cause dental staining that was less intense than that caused by traditional tobacco products.

A Novel Puff Recording Electronic Nicotine Delivery System for Assessing Naturalistic Puff Topography and Nicotine Consumption During Ad Libitum Use: Ancillary Study

BACKGROUND

Assessing the naturalistic puff topography and associated nicotine consumption during e-cigarette use is important as such information will not only unveil how these products are being consumed in real-world conditions, but also enable investigators and regulatory bodies to conduct quantitative, accurate, and realistic harmful exposure and nicotine abuse liability risk assessments based on actual e-cigarette use. Conventional approaches cannot accurately, conveniently, and noninvasively determine e-cigarette puff topography in a natural use environment. Thus, novel technology-enabled systems that do not primarily rely on self-report mechanisms or intrusive measurements to monitor e-cigarette product use behaviors are highly desired.

OBJECTIVE

This study aimed to explore and demonstrate the feasibility of a novel puff recording electronic nicotine delivery system (PR-ENDS) device for measuring naturalistic puff topography and estimating nicotine consumption during the ad libitum use of products among smokers and vapers.

METHODS

An ancillary data analysis based on a completed parent study was conducted. The parent study was a 1-way randomized controlled open-label puff topography and nicotine pharmacokinetic assessment carried out in 24 healthy adults (12 smokers and 12 vapers). Participants were assigned a randomized product use sequence of a PR-ENDS device within 5 site visits for both controlled and ad libitum product use sessions. Blood samples were obtained for plasma nicotine analysis, and questionnaires were administered at various time points. During the ad libitum use session, puff topography was measured using a Clinical Research Support System (CReSS) device as a benchmark, as well as the PR-ENDS device with a built-in puff recording feature.

RESULTS

There were no significant differences in representative puff topography parameters (number of puffs, total puff duration, and average puff duration) between the PR-ENDS and CReSS devices at the populational level across different device powers, e-liquid nicotine strengths, and flavors. The nicotine consumption estimated by the PR-ENDS device suggested that this device can be employed as a convenient monitoring tool for estimating nicotine use without measuring e-liquid weight loss between puffs. The linear relationship between nicotine consumption estimated by the PR-ENDS device and the pharmacokinetic parameter AUC_{ad lib} (plasma concentration-time curve for 1-hour ad libitum use) substantiated the potential of using this device as a pragmatic, noninvasive, and convenient means for estimating nicotine intake in the human body without blood collection.

CONCLUSIONS

The novel PR-ENDS device was feasible for assessing naturalistic puff topography and estimating nicotine consumption and intake in the human body during ad libitum use. Several key factors can influence users' puff topography, including device power levels, e-liquid nicotine strengths, and flavors. The study results pave the way for further research in the real-time measurement of naturalistic puff topography and puffing behaviors in the real world.

A systematic review

OBJECTIVES

This work attempts to summarize current knowledge on the effects of cigarettes, electronic nicotine delivery systems and tobacco heating products on miRNA-mediated gene expression regulation and on their possible impact on smoking-related respiratory disease development.

MATERIALS AND METHODS

Literature search by terms combination: 'smoking', 'cigarette' 'THP', 'tobacco heating product', 'ENDS', 'electronic nicotine delivery system', 'e-cigarette', electronic cigarette' and 'miRNA-mediated gene expression' has been performed from October 2021 to February 2022. In this systematic review all relevant literature, including clinical trials, cellular and animal-based studies were included.

RESULTS

Cigarette smoke (CS) significantly altered transcriptome, including miRNAs expression profile. MiRNA-mediated gene expression is mentioned as one of the mechanisms associated with smoking-related respiratory disease development. Differential expression of miRNAs was reduced in aerosol from e-cigarettes (EC) and tobacco heating products (THP) when compared to CS. However, there was a significant alteration of some miRNAs expression when compared to air-controls in both EC and THP.

DISCUSSION

CS negatively affects transcriptome and miRNA-mediated gene expression regulation because of a huge number of hazardous substances which predispose to smoking-related diseases. Despite the reduced effect of ENDS and THP on miRNAs profile compared to CS, differences in expression of miRNAs when compared to air-control were observed, which may be harmful to never-smokers who may perceive such alternative smoking products as non-hazardous. To clearly indicate the role of ENDS and THP in the alteration of miRNA-mediated gene expression and the development of smoking-related respiratory diseases associated with this mechanism, more long-term studies should be performed in the future.

The actual and anticipated effects of restrictions on flavoured electronic nicotine delivery systems: a scoping review

Objective

To synthesize the outcomes of policy evaluations of flavoured electronic nicotine delivery systems (ENDS) restrictions.

Data sources

PubMed, Scopus, Embase and Web of Science before May 3, 2022.

Study selection

Studies that report sales, behaviour, or compliance outcomes related to implemented or hypothetical ENDS flavour restrictions.

Data extraction

Restriction details, whether implemented or hypothetical, whether additional products were restricted, jurisdictional level, study locations, and outcomes classified by sales, behaviour, and compliance.

Data synthesis

We included 30 studies. Of those, 26 were conducted exclusively in the US, two in India, and two surveyed respondents in multiple countries, including the US. Twenty-one evaluated implemented restrictions, while nine considered hypothetical restrictions. Five studies evaluated product sales, 17 evaluated behaviour, and 10 evaluated compliance, with two studies reporting multiple outcomes. Two studies reported an increase and one a reduction in cigarette sales following restrictions, while three reported reductions in ENDS sales. Behavioural studies presented a mixed view of the impacts of regulations on ENDS and cigarette use. However, the use of disparate outcomes limits the comparability of studies. Studies of hypothetical restrictions suggest decreased ENDS use, increased cigarette use, and increased use of illicit markets. Studies of compliance with flavoured product restrictions that included ENDS found that 6–39% of stores sold restricted flavoured products post-restrictions. Online stores remain a potential source of restricted products.

Conclusion

Our findings highlight the need for additional research on the impacts of ENDS restrictions. Research should further evaluate the impact of restrictions on youth and adult use of nicotine and tobacco products in addition to the effects of restrictions in countries beyond the US to enable a robust consideration of the harm-benefit trade-off of restrictions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14440-x.

Periodontal and Peri-Implant Health Status in Traditional vs. Heat-Not-Burn Tobacco and Electronic Cigarettes Smokers: A Systematic Review

The aim of the present systematic review was to evaluate and possibly differentiate the effects of traditional cigarettes, heat-not-burn tobacco, and electronic cigarettes on periodontal and peri-implant health status. Electronic cigarettes and heat-not-burn tobacco have become very popular in recent years and have been proposed to consumers as a safer alternative to conventional tobacco smoke, although their effect on periodontal and peri-implant health remains unclear. The study protocol was developed according to PRISMA guidelines, and the focus question was formulated according to the PICO strategy. A literature search was conducted across PubMed/MEDLINE and the COCHRANE library from 2003 to April 2022. From the 1935 titles initially identified, 18 articles were finally included in the study and extracted data were qualitatively synthesized. It may be carefully concluded that e-cigarettes may cause attenuated clinical inflammatory signs of periodontitis and, hypothetically, of peri-implantitis when compared to conventional tobacco smoke. Both alternative smoking products, containing nicotine, may likewise exert negative effects on periodontal and peri-implant health, as demonstrated by in vitro studies. Further investigations are needed to assess the impact of electronic cigarettes and heat-not-burn tobacco products on periodontal and peri-implant health status.

Young Adults May Be Engaging in Risky Behaviors with their E-Cigarettes

E-cigarette use has significantly escalated among young adults in recent years. The purpose of the current study was to better understand alternative ways in which young adults use their e-cigarettes in situations where ad-lib use is prohibited. The current study is a secondary analysis to a parent study assessing facilitators and barriers for tobacco use among young adult military personnel. Ten focus groups were conducted with 83 Airmen at the end of their Technical (advanced) Training. Focus group discussions were transcribed and thematic analysis was used to determine trends related to risky e-cigarette use. Participants described using liquids with extremely high nicotine contents or using the e-cigarette so quickly and intensely that they could not stand up or became ill. Results highlight the ease by which individuals can make alterations to their e-cigarettes or their use behaviors, which could potentially increase their risk of nicotine poisoning.

Nominal Operating Envelope of Pod and Pen Style Electronic Cigarettes

Many Electronic Nicotine Delivery Systems (ENDS) employ integrated sensors to detect user puffing behavior and activate the heating coil to initiate aerosol generation. The minimum puff flow rate and duration at which the ENDS device begins to generate aerosol are important parameters in quantifying the viable operating envelope of the device and are essential to formulating a design of experiments for comprehensive emissions characterization. An accurate and unbiased method for quantifying the flow condition operating envelope of ENDS is needed to quantify product characteristics across research laboratories. This study reports an accurate, unbiased method for measuring the minimum and maximum aerosolization puff flow rate and duration of seven pod-style, four pen-style and two disposable ENDS. The minimum aerosolization flow rate ranged from 2.5 to 23 (mL/s) and the minimum aerosolization duration ranged from 0.5 to 1.0 (s) across the ENDS studied. The maximum aerosolization flow rate was defined to be when the onset of liquid aspiration was evident, at flow rates ranging from 50 to 88 (mL/s). Results are presented which provide preliminary estimates for the effective maximum aerosolization flow rate and duration envelope of each ENDS. The variation in operating envelope observed between ENDS products of differing design by various manufacturers has implications for development of standardized emissions testing protocols and data reporting required for regulatory approval of new products.

Patterns of Tobacco Smoking and Nicotine Vaping among University Students in the United Arab Emirates: A Cross-Sectional Study

Various forms of tobacco smoking and nicotine vaping tools are available on the market. This study quantified the prevalence of and identified factors associated with patterns of smoking and nicotine vaping among university students in the United Arab Emirates (UAE). A cross-sectional sample of students enrolled in three public universities was surveyed. Self-reported current smoking and nicotine vaping were recorded. Of 1123 students, 81.7% completed the online survey (mean age, 20.7 ± 3.4 (SD) years; 70.7% females). The prevalence of current smoking was 15.1% while the prevalence of current nicotine vaping was nearly 4.0%. Among current smokers, 54.7% reported conventional smoking only, 15.1% reported nicotine vaping only, and 28.8% were poly-users. Conventional midwakh (47.5%), followed by conventional shisha/waterpipe (36.7%), conventional cigarettes (36.7%), electronic shisha/waterpipe (25.2%), and electronic cigarettes (24.5%), were most commonly reported by students. Students aged 20–25 years (adjusted odds ratios (aOR): 2.08, 95% confidence interval (CI): 1.18–3.67) or >25 years (aOR: 4.24, 95% CI: 1.41–12.80) had higher odds of being current smokers compared to those aged 17–19 years. The male gender was also independently associated with higher odds of being a current smoker (aOR: 5.45, 95% CI: 3.31–8.97) as well as higher odds of smoking cigarettes, shisha, and midwakh, or nicotine vaping compared to being female. Of nicotine vaping users, 36.1% reported using nicotine vaping because they enjoyed the flavor and vaporizing experience and 34.4% used it to help them to quit smoking. A relatively high prevalence of self-reported smoking was reported among university students in the UAE. The findings also suggest that nicotine vaping use is relatively widespread, but still less common than traditional smoking. Vigilant and tailored university-based smoking control and preventive measures are warranted.

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.

Effects of Providing Tailored Information About e-Cigarettes in a Web-Based Smoking Cessation Intervention: Protocol for a Randomized Controlled Trial

Background

There is an ongoing debate whether electronic cigarettes (e-cigarettes) should be advocated for smoking cessation. Because of this uncertainty, information about the use of e-cigarettes for smoking cessation is usually not provided in governmental smoking cessation communications. However, there is an information need among smokers because despite this uncertainty, e-cigarettes are used by many smokers to reduce and quit tobacco smoking.

Objective

The aim of this study is to describe the protocol of a randomized controlled trial that assesses the effect of providing tailored information about e-cigarettes compared to not providing this information on determinants of decision making and smoking reduction and abstinence. This information is provided in the context of a digital smoking cessation intervention.

Methods

A randomized controlled trial with a 6-month follow-up period will be conducted among adult smokers motivated to quit smoking within 5 years. Participants will be 1:1 randomized into either the intervention condition or control condition. In this trial, which is grounded on the I-Change model, participants in both conditions will receive tailored feedback on attitude, social influence, preparatory plans, self-efficacy, and coping plans. Information on 6 clusters of smoking cessation methods (face-to-face counselling, eHealth interventions, telephone counselling, group-based programs, nicotine replacement therapy, and prescription medication) will be provided in both conditions. Smokers in the intervention condition will also receive detailed tailored information on e-cigarettes, while smokers in the control condition will not receive this information. The primary outcome measure will be the number of tobacco cigarettes smoked in the past 7 days. Secondary outcome measures will include 7-day point prevalence tobacco abstinence, 7-day point prevalence e-cigarette abstinence, and determinants of decision making (ie, knowledge and attitude regarding e-cigarettes). All outcomes will be self-assessed through web-based questionnaires.

Results

This project is supported by a research grant of the National Institute for Public Health and the Environment (Rijksinstituut voor Volksgezondheid en Milieu). Ethical approval was granted by the Ethics Review Committee Health, Medicine and Life Sciences at Maastricht University (FHML-REC/2019/072). Recruitment began in March 2020 and was completed by July 2020. We enrolled 492 smokers in this study. The results are expected to be published in June 2021.

Conclusions

The experimental design of this study allows conclusions to be formed regarding the effects of tailored information about e-cigarettes on decision making and smoking behavior. Our findings can inform the development of future smoking cessation interventions.

Trial Registration

Dutch Trial Register Trial NL8330; https://www.trialregister.nl/trial/8330

International Registered Report Identifier (IRRID)

DERR1-10.2196/27088

Toxicological assessment of electronic cigarette vaping: an emerging threat to force health, readiness and resilience in the U.S. Army

The U.S. Army and U. S. Army Public Health Center are dedicated to protecting the health, and readiness of Department of the Army Service Members, civilians, and contractors. Despite implementation of health programs, policies and tobacco control interventions, the advent of electronic nicotine delivery systems (ENDS), including electronic cigarettes (e-cigs), represent unregulated and poorly defined systems to supplant or substitute use of conventional nicotine products (e.g., cigarettes and pipe tobacco). E-cigs present unique challenges to healthcare officials vested in preventive medicine. The health impact of an e-cig and vaping on an individual's acute or chronic disease susceptibility, performance and wellness, is fraught with uncertainty. Given the relatively recent emergence of e-cigs, high-quality epidemiological studies, and applied biological research studies are severely lacking. In sparsely available epidemiological studies of short-term cardiovascular and respiratory health outcomes, any attempt at addressing the etiology of acute and chronic health conditions from e-cig use faces incredible challenges. Until relatively recently, this was complicated by an absent national regulatory framework and health agency guidance on the manufacture, distribution, selling and use of e-cigs or similar ENDS devices and their chemical constituents. Two key issues underpin public health concern from e-cig use: 1) continued or emergent nicotine addiction and potential use of these devices for vaping controlled substances; and 2) inadvertent sudden-onset or chronic health effects from inhalational exposure to low levels of complex chemical toxicants from e-cig use and vaping the liquid. Herein, the health impacts from e-cig vaping and research supporting such effects are discussed.

Method for Quantifying Variation in the Resistance of Electronic Cigarette Coils

In electronic nicotine delivery systems (ENDS), coil resistance is an important factor in the generation of heat energy used to change e-liquid into vapor. An accurate and unbiased method for testing coil resistance is vital for understanding its effect on emissions and reporting results that are comparable across different types and brands of ENDS and measured in different laboratories. This study proposes a robust, accurate and unbiased method for measuring coil resistance. An apparatus is used which mimics the geometric configuration and assembly of ENDS reservoirs, coils and power control units. The method is demonstrated on two commonly used ENDS devices—the ALTO by Vuse and JUUL. Analysis shows that the proposed method is stable and reliable. The two-wire configuration introduced a positive measurement bias of 0.086 (Ω), which is a significant error for sub-ohm coil designs. The four-wire configuration is far less prone to bias error and is recommended for universal adoption. We observed a significant difference in the coil resistance of 0.593 (Ω) (p < 0.001) between the two products tested. The mean resistance and standard deviation of the reservoir/coil assemblies was shown to be 1.031 (0.067) (Ω) for ALTO and 1.624 (0.033) (Ω) for JUUL. The variation in coil resistance between products and within products can have significant impacts on aerosol emissions.

Factors Associated with E-Cigarette Use in U.S. Young Adult Never Smokers of Conventional Cigarettes: A Machine Learning Approach

E-cigarette use is increasing among young adult never smokers of conventional cigarettes, but the awareness of the factors associated with e-cigarette use in this population is limited. The goal of this work was to use machine learning (ML) algorithms to determine the factors associated with current e-cigarette use among US young adult never cigarette smokers. Young adult (18-34 years) never cigarette smokers from the 2016 and 2017 Behavioral Risk Factor Surveillance System (BRFSS) who reported current or never e-cigarette use were used for the analysis (n = 79,539). Variables associated with current e-cigarette use were selected by two ML algorithms (Boruta and Least absolute shrinkage and selection operator (LASSO)). Odds ratios were calculated to determine the association between e-cigarette use and the variables selected by the ML algorithms, after adjusting for age, gender and race/ethnicity and incorporating the BRFSS complex design. The prevalence of e-cigarette use varied across states. Factors previously reported in the literature, such as age, race/ethnicity, alcohol use, depression, as well as novel factors associated with e-cigarette use, such as disabilities, obesity, history of diabetes and history of arthritis were identified. These results can be used to generate further hypotheses for research, increase public awareness and help provide targeted e-cigarette education.

Investigating the Attitudes of Adolescents and Young Adults Towards JUUL: Computational Study Using Twitter Data

Background

Increases in electronic nicotine delivery system (ENDS) use among high school students from 2017 to 2019 appear to be associated with the increasing popularity of the ENDS device JUUL.

Objective

We employed a content analysis approach in conjunction with natural language processing methods using Twitter data to understand salient themes regarding JUUL use on Twitter, sentiment towards JUUL, and underage JUUL use.

Methods

Between July 2018 and August 2019, 11,556 unique tweets containing a JUUL-related keyword were collected. We manually annotated 4000 tweets for JUUL-related themes of use and sentiment. We used 3 machine learning algorithms to classify positive and negative JUUL sentiments as well as underage JUUL mentions.

Results

Of the annotated tweets, 78.80% (3152/4000) contained a specific mention of JUUL. Only 1.43% (45/3152) of tweets mentioned using JUUL as a method of smoking cessation, and only 6.85% (216/3152) of tweets mentioned the potential health effects of JUUL use. Of the machine learning methods used, the random forest classifier was the best performing algorithm among all 3 classification tasks (ie, positive sentiment, negative sentiment, and underage JUUL mentions).

Conclusions

Our findings suggest that a vast majority of Twitter users are not using JUUL to aid in smoking cessation nor do they mention the potential health benefits or detriments of JUUL use. Using machine learning algorithms to identify tweets containing underage JUUL mentions can support the timely surveillance of JUUL habits and opinions, further assisting youth-targeted public health intervention strategies.

Assessment of knowledge of use of electronic cigarette and its harmful effects among young adults

Background

The practice of young adults smoking e-cigarette may have been adopted as a way of smoking cessation or just to follow a trend. Most people still remain unaware of the detrimental effects of e-cigarette. This study was carried out to assess the prevalence of the habit of smoking e-cigarette and the awareness of its harmful effects among adults aged 18–23 years.

Methods

A questionnaire adopted from a study conducted in Italy was used in the study following due permission. After taking their consent, participants were requested to fill the survey irrespective of their smoking status.

Results

In total the study comprised 710 participants aged 20.7 ± 1.7 years (females = 412 and males = 298) from six countries. Most respondents were from India followed by the USA and then the UK. The most common mode of information for the participants on the existence of e-cigarette was from the family members, friends followed by Internet search engines and TV/newspaper advertisements. Among the participants, e-cigarette had a prevalence of 5.63%. Among these, 26 participants were using e-cigarette for less than 1 year and 2 participants for more than 5 years. E-cigarette smokers also experienced sore throat, cough, headache, dizziness and sleeplessness.

Conclusion

Majority of the young population was unaware about the use and harmful effects of e-cigarette.

Characterizing Social Media Messages Related to Underage JUUL E-Cigarette Buying and Selling: Cross-Sectional Analysis of Reddit Subreddits

Background

Stopping the epidemic of e-cigarette use among youth has become the common goal of both regulatory authorities and health departments. JUUL is currently the most popular e-cigarette brand on the market. Young people usually obtain and exchange information about JUUL with the help of social media platforms. Along with the rising prevalence of JUUL, posts about underage JUUL buying and selling have appeared on social media platforms such as Reddit, which sharply increase the risk of minors being exposed to JUUL.

Objective

This study aims to analyze Reddit messages about JUUL buying and selling among the users of the UnderageJuul subreddit, and to further summarize the characteristics of those messages. The findings and insights can contribute to a better understanding of the patterns of underage JUUL use, and help public health officials provide timely education and guidance to minors who have intentions of accessing JUUL.

Methods

We used a novel cross-subreddit method to analyze the Reddit messages on 2 subreddits. From July 9, 2017, to January 7, 2018, we collected data from the UnderageJuul subreddit, which was created for underage JUUL use discussion. The data set included 716 threads, 2935 comments, and 844 Reddit users (ie, Redditors). We collected our second data set, comprising 23,840 threads and 162,106 comments posted between July 9, 2017, and January 8, 2019, from the JUUL subreddit. We conducted analyses including the following: (1) annotation of users with buying/selling intention, (2) posting patterns discovery and topic comparison, and (3) posting activeness observation of discovered Redditors. Term frequency–inverse document frequency and regular expression-enhanced keyword search methods were applied during the content analysis to extract the posting patterns. The public posting records of the discovered users on the JUUL subreddit during the year after the UnderageJuul subreddit was shut down were analyzed to determine whether they were still active and interested in obtaining JUUL.

Results

Our study revealed the following: (1) Among the 716 threads on the UnderageJuul subreddit, there were 214 threads related to JUUL sale and 168 threads related to JUUL purchase, which accounted for 53.5% (382/714) of threads. (2) Among the 844 Redditors of the UnderageJuul subreddit, 23.82% (201/844) of users were annotated with buying intention, and 21.10% (178/844) of users were annotated with selling intention. There were 34 users with buying/selling intention that self-reported as being <21 years old. (3) The most common key phrases used in selling threads were “WTS,” “want to sell,” “for sale,” and “selling” (154/214, 72.0%). The most common key phrases used in buying threads were “look for/get JUUL/pods” (58/168, 34.5%) and “WTB” (53/168, 31.5%). (4) The most important concern that UnderageJuul Redditors had in obtaining JUULs was the price (311/1306, 23.81%), followed by the delivery service (68/1306, 5.21%). (5) The most popular flavors among the users with buying/selling intention were mango, cucumber, and mint. The flavor preferences remained consistent on both subreddits. Adverse symptoms related to the mango flavor were reported by 3 users on the JUUL subreddit. (6) In total, 24.4% (49/201) of users wanted to buy JUULs and 46.6% (83/178) of users wanted to sell JUULs, including 11 self-reported underage users, who also participated in the discussions on the JUUL subreddit. (7) Within one year of the UnderageJuul subreddit shutting down, there were 40 users who continued to post 186 threads on the JUUL subreddit, including 10 threads indicating buying/selling willingness that were posted shortly after the UnderageJuul subreddit was closed.

Conclusions

There were overlapping users active in the JUUL and UnderageJuul subreddits. The buying/selling-related content appeared in multiple venues with certain posting patterns from July 9, 2017, to January 7, 2018. Such content might lead to a high risk of health problems for minors, such as nicotine addiction. Based on these findings, this study provided some insights and suggestions that might contribute to the decision-making processes of regulators and public health officials.

Content Analysis of Electronic Nicotine Delivery System Publications in Core Clinical Journals from 2012 to 2018

There is no consensus if electronic nicotine delivery systems (ENDS) should be used to reduce harm among the smoking population. Physicians, who represent a trusted source of health communication, are exposed to a range of often conflicting ENDS information and this information may be relayed to patients looking to quit smoking. Previous studies have examined ENDS content of various sources of media but there is a lack of knowledge about ENDS content in medical journals. We analyzed 421 ENDS publications printed between 2012 and 2018 from PubMed's Core Clinical Journal list. Publications were analyzed based on publication type, journal type, study design, geographic focus, theme, terminology, outcomes, and positive/negative statements. The number of ENDS publications grew since 2012, and peaked in 2015. Across all years, negative statements about ENDS outnumbered positive statements, though this difference decreased over time. Over time, negative statements about "toxins and carcinogens" were made less frequently, while negative statements about "gateway effects" and "youth appeal" became more prevalent. UK journals had fewer negative statements relative to US journals. Only 12.6% of publications included guidance for healthcare professionals about ENDS. As published ENDS topics change over time, physicians' communications with patients may be impacted.

Online Information on Electronic Cigarettes: Comparative Study of Relevant Websites From Baidu and Google Search Engines

BACKGROUND

Online information on electronic cigarettes (e-cigarettes) may influence people's perception and use of e-cigarettes. Websites with information on e-cigarettes in the Chinese language have not been systematically assessed.

OBJECTIVE

The aim of this study was to assess and compare the types and credibility of Web-based information on e-cigarettes identified from Google (in English) and Baidu (in Chinese) search engines.

METHODS

We used the keywords vaping or e-cigarettes to conduct a search on Google and the equivalent Chinese characters for Baidu. The first 50 unique and relevant websites from each of the two search engines were included in this analysis. The main characteristics of the websites, credibility of the websites, and claims made on the included websites were systematically assessed and compared.

RESULTS

Compared with websites on Google, more websites on Baidu were owned by manufacturers or retailers (15/50, 30% vs 33/50, 66%; P<.001). None of the Baidu websites, compared to 24% (12/50) of Google websites, were provided by public or health professional institutions. The Baidu websites were more likely to contain e-cigarette advertising (P<.001) and less likely to provide information on health education (P<.001). The overall credibility of the included Baidu websites was lower than that of the Google websites (P<.001). An age restriction warning was shown on all advertising websites from Google (15/15) but only on 10 of the 33 (30%) advertising websites from Baidu (P<.001). Conflicting or unclear health and social claims were common on the included websites.

CONCLUSIONS

Although conflicting or unclear claims on e-cigarettes were common on websites from both Baidu and Google search engines, there was a lack of online information from public health authorities in China. Unbiased information and evidence-based recommendations on e-cigarettes should be provided by public health authorities to help the public make informed decisions regarding the use of e-cigarettes.

Socioeconomic Inequalities in e-Cigarette Use in Korea: Comparison with Inequalities in Conventional Cigarette Use Using Two National Surveys

Socioeconomic inequalities in conventional cigarette smoking are well established in developed countries. The aim of this study was to investigate socioeconomic inequalities in e-cigarette use in Korea, in comparison with inequalities in conventional cigarette use. Data from the Korea National Health and Nutrition Examination Survey (KNHANES) and the Korea Community Health Survey (KCHS) were analyzed. The years of data collected were 2013 to 2016 for the KNHANES and 2014 to 2016 for the KCHS, respectively. The age-adjusted prevalence of ever and current e-cigarette use and conventional cigarette use was calculated according to socioeconomic status indicators, including education, occupation, and income. The prevalence of ever e-cigarette use in men increased from 12.1% in 2013 to 19.2% in 2016 in the KNHANES, and from 13.4% in 2014 to 17.9% in 2016 in the KCHS. Ever and current e-cigarette use was concentrated among current smokers and was much more prevalent among men and also more common among younger age groups in men and women. There was higher prevalences of conventional cigarette use among men and women with less education, manual occupational class and lower income, with the differences more pronounced for women. There was higher ever and current use of e-cigarettes among women with less education, manual occupational class and lower income, but among men there was much less difference in e-cigarette use by these indicators of socio-economic status.

A narrative review evaluating the safety and efficacy of e-cigarettes as a newly marketed smoking cessation tool

Introduction:

E-cigarettes are an alternative to traditional tobacco-based cigarettes. While having considerable societal awareness, conflicting evidence exists to support their claims that they are an effective smoking cessation tool and are safe. Currently >7000 flavours exist with evidence that they exhibit detrimental cellular and tissue effects. A literature review was conducted utilising PubMed and Google Scholar Databases identifying papers between 2014 and 2019. The aims of this study were to accurately gauge the safety and efficacy of e-cigarettes as a smoking cessation tool.

Methods:

Search terms including ‘electronic cigarettes’ and ‘vaping’ were used to identify suitable references. A total of 314 articles were identified from which papers were excluded due to risk of bias, insufficient detail or were duplicate from which 58 papers were used in the final review.

Results:

Evidence shows that e-cigarettes can have detrimental effects on several cell lines and animal models with their flavourings and nicotine content implicated; this has, however, not translated into major health outcomes after 3.5 years follow-up but has been linked to chronic lung disease and cardiovascular disease. While advertised as an effective smoking cessation tool, no consensus can be made regarding their effectiveness although the first robust randomised controlled trial reports some success. This, however, is offset by the fact that the most common e-cigarette use is as a dual user and that there is evidence of threefold increased risk of future tobacco smoking.

Conclusion:

Future research is needed to evaluate the long-term health outcomes and efficacy of e-cigarettes as a smoking cessation tool with greater discussion between patients and clinicians regarding this smoking cessation tool.

Product attributes important to US adult consumers' use of electronic nicotine delivery systems: a discrete choice experiment

OBJECTIVE

To understand the importance of electronic nicotine delivery systems (ENDS) product attributes to adult consumers in the USA by age and gender.

DESIGN

Cross-sectional survey with a discrete choice experiment (best-worst, case 2, scaling) of 19 choice tasks in which participants answered what would make them most want to use and least want to use an ENDS product.

SETTING AND PARTICIPANTS

A national sample of adults (aged 18+ years) in the USA who had tried an ENDS product at least once.

MEASURES

We included 9 ENDS attributes with levels that varied across 19 choice tasks. We performed a multinomial logistic regression to obtain overall importance scores, attribute-level part-worth utilities and most important attribute.

RESULTS

Of 660 participants, 81% were white, 51% women and 37% had at least a 4-year college degree with an average age of 42.0 years (SD ±19.4). The attributes had the following importance: harms of use 17.6%; general effects 14.1%; cessation aid 12.6%; purchase price 12.1%; monthly cost 12.0%; nicotine content 11.4%; flavour availability 8.4%; device design 7.2%; modifiability 4.6%. Harms of use was the most important attribute for all ages and genders (p<0.05); variation in other important attributes existed by age though not by gender.

CONCLUSION

This study identified the importance of nine ENDS attributes. Perceived harms of use of ENDS use appeared most important, and modifiability was least important. Variation by consumer group existed, which may allow for targeted interventions to modify ENDS use.

E-cigarette Awareness among Young Adults: A Pilot Survey Study

Objectives

This study sought to assess: 1) pervasiveness of vaping or electronic cigarette (e-cigarette) use, 2) General understanding of information on vaping or e-cigarette use, 3) Prevalence and respondent awareness of smoking/vaping prevention programs, and 4) Awareness of the harmful effects of e-cigarettes.

Methods

This was a cross-sectional survey of 101 young adults (ages 18-24) in the United States designed to assess the prevalence and knowledge of vaping. Ten questions tested this knowledge and prevalence, some directly (for example, "Which of the following have you used? Select all that apply") and some indirectly (Which of the following pictures corresponds with that of an e-cigarette?). After the results were obtained, the crosstabs showed the percentage of respondents who identified a particular answer for each question.

Results

Most of the surveyants had heard about e-cigarettes (about 88.6% of all respondents). About 55% of the study’s sample attended schools with tobacco prevention programs. Sixty-four percent of the cohort thought that vaping is actually safer than traditional cigarettes. Most (87.4%) of the people were able to identify an e-cigarette when shown a picture of e-cigarettes versus two computer flash-drives and a cigarette. However, 78.2% of respondents were aware of at least one of the effects of nicotine in humans, which corresponds with the number of respondents who were familiar with any of the provided e-cigarette brands (as 71.7% of respondents to question six knew of the six provided brands of e-cigarettes) and the respondents with parents who smoke (as about 75% of respondents said that neither parent smokes). Thirty-eight percent of respondents had used either traditional tobacco products (such as cigarettes, cigars, or chewing tobacco) or e-cigarettes before, with 13% of respondents having used both tobacco and e-cigarettes.

Bibliometric Analysis of Electronic Cigarette Publications: 2003⁻2018

Electronic cigarettes are at the center of a public health policy debate which leverages scientific publications. This study characterizes e-cigarette publication trends over the past 15 years via a bibliometric analysis. Scopus was searched for “electronic cigarette”, “e-cig”, “e-cigarette”, “vape”, “vaping”, “juul”, or “electronic nicotine delivery system” between 2003–2018. Data included Hirsch index, document type and frequency, and publications by institution, journal, and country. VOSviewer was used to visualize authorship network maps. A total of 4490 e-cigarette publications were identified, most (62.8%) being articles. After 2009, the annual growth rate for e-cigarette publications was the largest in 2014. The annual growth rate was nearly flat in 2017 but increased in 2018. The U.S. produced 51.6% of publications. Annual National Institutes of Health NIH funding for tobacco research mapped closely with the annual volume of e-cigarette publications. Author network analyses illustrated investigator collaborative patterns. The frequency of e-cigarette publications increased significantly in the past decade. A strong relationship of NIH funding for tobacco research and e-cigarette publications demonstrates the importance of e-cigarettes in tobacco research.

Electronic cigarettes: One size does not fit all

Electronic cigarettes (ECs) have been growing rapidly in popularity among youth and adults in the United States over the last decade. This increasing prevalence is driven partially by the ability to customize devices, flavors, and nicotine content and the general notion that ECs are harmless, particularly in comparison with conventional cigarettes. In vitro and in vivo murine models have demonstrated a number of harmful biological effects of e-liquids and their aerosols. However, limited clinical data exist on whether these effects translate into detrimental long-term outcomes in human subjects. The short-term harmful respiratory effects of EC use demonstrated in nonsmokers argue against their use. However, slightly more favorable data exist for the respiratory benefits of substituting conventional cigarettes with ECs and the short-term efficacy of ECs as smoking cessation tools. Nonetheless, available research is severely limited in regard to long-term outcomes and by study designs fraught with bias, pointing to the need for additional research efforts with well-designed longitudinal studies to guide US Food and Drug Administration regulatory efforts. The hurdle presented by diverse device designs and e-liquid permutations, which contribute to the inconsistency of available data, also highlights the need for legislative standardization of ECs.

E-Cigarette Surveillance With Social Media Data: Social Bots, Emerging Topics, and Trends

Background

As e-cigarette use rapidly increases in popularity, data from online social systems (Twitter, Instagram, Google Web Search) can be used to capture and describe the social and environmental context in which individuals use, perceive, and are marketed this tobacco product. Social media data may serve as a massive focus group where people organically discuss e-cigarettes unprimed by a researcher, without instrument bias, captured in near real time and at low costs.

Objective

This study documents e-cigarette–related discussions on Twitter, describing themes of conversations and locations where Twitter users often discuss e-cigarettes, to identify priority areas for e-cigarette education campaigns. Additionally, this study demonstrates the importance of distinguishing between social bots and human users when attempting to understand public health–related behaviors and attitudes.

Methods

E-cigarette–related posts on Twitter (N=6,185,153) were collected from December 24, 2016, to April 21, 2017. Techniques drawn from network science were used to determine discussions of e-cigarettes by describing which hashtags co-occur (concept clusters) in a Twitter network. Posts and metadata were used to describe where geographically e-cigarette–related discussions in the United States occurred. Machine learning models were used to distinguish between Twitter posts reflecting attitudes and behaviors of genuine human users from those of social bots. Odds ratios were computed from 2x2 contingency tables to detect if hashtags varied by source (social bot vs human user) using the Fisher exact test to determine statistical significance.

Results

Clusters found in the corpus of hashtags from human users included behaviors (eg, #vaping), vaping identity (eg, #vapelife), and vaping community (eg, #vapenation). Additional clusters included products (eg, #eliquids), dual tobacco use (eg, #hookah), and polysubstance use (eg, #marijuana). Clusters found in the corpus of hashtags from social bots included health (eg, #health), smoking cessation (eg, #quitsmoking), and new products (eg, #ismog). Social bots were significantly more likely to post hashtags that referenced smoking cessation and new products compared to human users. The volume of tweets was highest in the Mid-Atlantic (eg, Pennsylvania, New Jersey, Maryland, and New York), followed by the West Coast and Southwest (eg, California, Arizona and Nevada).

Conclusions

Social media data may be used to complement and extend the surveillance of health behaviors including tobacco product use. Public health researchers could harness these data and methods to identify new products or devices. Furthermore, findings from this study demonstrate the importance of distinguishing between Twitter posts from social bots and humans when attempting to understand attitudes and behaviors. Social bots may be used to perpetuate the idea that e-cigarettes are helpful in cessation and to promote new products as they enter the marketplace.

Internet-based Advertising Claims and Consumer Reasons for Using Electronic Cigarettes by Device Type in the US

Objectives

Important differences exist between closed-system and open-system e-cigarettes, but it is unknown whether online companies are marketing these devices differently and whether consumer reasons for using e-cigarettes vary by device type. This paper compares Internet-based advertising claims of closed- versus open-system products, and evaluates US consumers' reasons for using closed- versus open-system e-cigarettes.

Methods

Internet sites selling exclusively closed (N = 130) or open (N = 129) e-cigarettes in December 2013-January 2014 were coded for advertising claims. Current users (≥18 years old) of exclusively closed or open e-cigarettes (N = 860) in a nationally representative online survey in February-March 2014 provided their main reason for using e-cigarettes.

Results

Internet sites that exclusively sold closed-system e-cigarettes were more likely to make cigarette-related claims such as e-cigarettes being healthier and cheaper than cigarettes (ps < .0001) compared to sites selling open systems. Many sites implied their products could help smokers quit. Exclusive users of both systems endorsed cessation as their top reason. Closed-system users were more likely to report their reason as "use where smoking is banned."

Conclusions

Although promotion of e-cigarettes as cessation aids is prohibited, consumers of both systems endorsed smoking cessation as their top reason for using e-cigarettes.

Consumers' Preferences for Electronic Nicotine Delivery System Product Features: A Structured Content Analysis

To inform potential governmental regulations, we aimed to develop a list of electronic nicotine delivery system (ENDS) product features important to U.S. consumers by age and gender. We employed qualitative data methods. Participants were eligible if they had used an ENDS at least once. Groups were selected by age and gender (young adult group aged 18–25, n = 11; middle-age group aged 26–64, n = 9; and women’s group aged 26–64, n = 9). We conducted five individual older adult interviews (aged 68–80). Participants discussed important ENDS features. We conducted a structured content analysis of the group and interview responses. Of 34 participants, 68% were white and 56% were female. Participants mentioned 12 important ENDS features, including: (1) user experience; (2) social acceptability; (3) cost; (4) health risks/benefits; (5) ease of use; (6) flavors; (7) smoking cessation aid; (8) nicotine content; (9) modifiability; (10) ENDS regulation; (11) bridge between tobacco cigarettes; (12) collectability. The most frequently mentioned ENDS feature was modifiability for young adults, user experience for middle-age and older adults, and flavor for the women’s group. This study identified multiple features important to ENDS consumers. Groups differed in how they viewed various features by age and gender. These results can inform ongoing regulatory efforts.

Changes in Electronic Cigarette Use from 2013 to 2015 and Reasons for Use among Finnish Adolescents

Electronic cigarettes are quite a new potential source of nicotine addiction among youth. More research is needed, particularly on e-liquid use and socioeconomic factors as potential determinants. We studied changes from 2013 to 2015 in adolescent e-cigarette awareness and ever-use, types of e-liquids, and determinants in Finland. In 2015, we studied weekly use and reasons for ever-use. Data were from two national surveys of 12–18-year-old Finns (2013, n = 3535, response rate 38%; 2015, n = 6698, 41%). Descriptive statistics and logistic regression analysis were used. Awareness and ever-use of e-cigarettes increased significantly from 2013 to 2015 in all age and gender groups. Ever-use increased from 17.4% to 25%, with half having tried nicotine e-liquids. In 2015, weekly use was rare (1.5%). Daily cigarette smoking was the strongest determinant (OR 51.75; 95% CI 38.18–70.14) for e-cigarette ever-use, as for e-cigarette weekly use, but smoking experimentation and ever-use of snus (Swedish type moist snuff) and waterpipes alongside parental smoking and poor academic achievement also increased the odds for ever-use. The most common reason behind e-cigarette ever-use was the desire to try something new. To conclude, adolescent e-cigarette ever-use is increasing, and also among never-smokers. Tobacco-related factors are stronger determinants for e-cigarette use than socioeconomic factors.

Determination of nicotine, glycerol, propylene glycol and water in electronic cigarette fluids using quantitative 1 H NMR

The variability of the electronic cigarette liquids (e-liquid) composition has the potential to influence not only the amount of nicotine delivered to the user, but also the type and amount of generated byproducts and subsequent health risks. For this reason, it is important to characterize all of the chemical components of e-liquids. We report the development and application of a single ¹H NMR analysis method to identify and quantify the most abundant chemical components (nicotine, glycerol, 1,2-propylene glycol, and water) likely to be present as their influence on the composition of inhaled vapor is not know. For ¹H NMR, the solvent has to dissolve the e-liquids at a concentration sufficient to readily determine the concentration of nicotine present, and the solvent and internal standard cannot possess exchangeable protons which would interfere with determining the concentrations of the analytes of interest. To fulfill these requirements, perdeuterated N,N-dimethylformamide (DMF-d₇) was selected as the solvent, with 1,2,4,5-tetrachloro-3-nitrobenzene as the internal standard. Nicotine concentrations from 58 different e-liquids obtained using ¹H NMR were found to agree with the results from GC-MS analysis. Generally, the amount of nicotine present was close to that claimed by the manufacturer. In some cases, the proportions of 1,2-propylene glycol, glycerol, and water varied significantly between flavors within a brand and within flavors depending on the nicotine content. In one case, 1,2-propylene glycol was identified where the manufacturer had stated none should be present.

Clinical Laboratory Evaluation of Electronic Cigarettes/Electronic Nicotine Delivery Systems: Methodological Challenges

OBJECTIVE

Evaluating electronic cigarettes (ECIGs) in the clinical laboratory is critical to understanding their effects. However, laboratory evaluation of ECIGs can be challenging, as they are a novel, varied, and evolving class of products. The objective of this paper is to describe some methodological challenges to the clinical laboratory evaluation of ECIGs.

METHODS

The authors gathered information about challenges involved in the laboratory evaluation of ECIGs. Challenges were categorized and solutions provided when possible.

RESULTS

Methods used to study combustible cigarettes may need to be adapted to account for ECIG novelty and differences within the class. Challenges to ECIG evaluation can include issues related to 1) identification of ECIG devices and liquids, 2) determination of short -term ECIG abstinence, 3) measurement of use behavior, and 4) assessment of dependence. These challenges are discussed, and some suggestions to inform ECIG evaluation using clinical laboratory methods are provided.

CONCLUSIONS

Awareness of challenges and developing, validating, and reporting methods used to address them aids interpretation of results and replication efforts, thus enhancing the rigor of science used to protect public health through appropriate, empirically-based, ECIG regulation.

Electronic cigarette use among adult population: a cross-sectional study in Barcelona, Spain (2013-2014)

OBJECTIVE

This study seeks to analyse the prevalence and correlates of electronic cigarette (e-cigarette) use, purchase location and satisfaction with its use in a sample of the general population of the city of Barcelona, Spain.

DESIGN, SETTING AND PARTICIPANTS

We used participants from a longitudinal study of a representative sample of the adult (≥16 years old) population of Barcelona (336 men and 400 women). The field work was conducted between May 2013 and February 2014. We computed the prevalence, adjusted odds ratios (ORs) and their corresponding 95% confidence interval (CI).

RESULTS

The prevalence of ever e-cigarette use was 6.5% (95% CI 4.7% to 8.3%): 1.6% current use, 2.2% past use and 2.7% only e-cigarette experimentation. 75% (95% CI 62.8% to 87.3%) of ever e-cigarette users were current cigarette smokers at the moment of the interview. E-cigarette use was more likely among current smokers (OR=54.57; 95% CI 7.33 to 406.38) and highly dependent cigarette smokers (OR=3.96; 95% CI 1.60 to 9.82). 62.5% of the ever users charged their e-cigarettes with nicotine with 70% of them obtaining the liquids with nicotine in a specialised shop. 39.6% of ever e-cigarette users were not satisfied with their use, a similar percentage of not satisfied expressing the smokers (38.9%) and there were no statistically significant differences in the satisfaction between the users of e-cigarettes with and without nicotine.

CONCLUSIONS

E-cigarette use is strongly associated with current smoking (dual use) and most users continue to be addicted to nicotine. Six out of 10 e-cigarette users preferred devices that deliver nicotine. The satisfaction with e-cigarette use is very low.