Flavored Tobacco Product Use Among US Youth Aged 12-17 Years, 2013-2014

What Is (Un)Flavored? A Scoping Review of the Conceptualization of Flavored Cigarillos

INTRODUCTION

To identify how flavor is conceptualized with respect to cigarillos to illuminate areas of concordance and discordance and provide a pathway for the harmonization of tobacco flavor measurement.

AIMS AND METHODS

Three methods were used to identify research measuring flavors respective to cigarillo products including: (1) querying research databases using key words "cigarillo," "tobacco" and "flavor"/'flavour,' (2) sub-sampling of the eligible literature with backward and forward reference searching, and (3) a bibliographic search of key experts. Two reviewers independently screened titles, abstracts, and full texts. Inclusion criteria required manuscripts to be available in English, published prior to 3/1/2022, be original and peer-reviewed, and include a measure of flavor pertaining to cigarillo products. A total of 163 manuscripts met these criteria and were subsequently evaluated.

RESULTS

Cigarillo flavor determinations were made based on the presence of flavoring agents, sensory characteristics, marketing or package characteristics, pre-defined lists, the absence of any of these, and/or were undefined. Individual flavors and their related classifications were not altogether mutually exclusive due to differences in conceptualization which has evolved over time.

CONCLUSIONS

Flavor measures continue to evolve, likely in response to both tobacco control policies and industry shifts. There is a lack of standardization in flavor conceptualization that can be ameliorated through intentional integration of multiple forms of research such as identifying patterns of flavoring agents and/or marketing strategies that elicit a specific flavor profile. By doing this, we may more comprehensively evaluate the impact of flavors, their constituents, and related marketing strategies on broader population health.

IMPLICATIONS

There are discrepancies in the conceptualization of flavor in tobacco and nicotine products. The lack of standardized, definitive language limits our ability to comprehensively evaluate the population-level health impact of flavors in addition to our ability to effectively inform, implement, and enforce policies restricting flavors in tobacco and nicotine products.

Evaluation and comparison of DNA alkylation and oxidative damage in e-cigarette and heated tobacco users

OBJECTIVES

This study, aimed to determine and compare DNA damage in e-cigarette and HTP (IQOS) users by assessing DNA-adducts, which are biomarkers of various DNA alkylation and oxidation.

METHODS

For the evaluation of DNA alkylation, N3-Ethyladenine (N3-EtA) and N3-Methyladenine (N3-MeA) adducts were used. DNA oxidation was assessed using, 8-hydroxy-2'-deoxyguanosine(8-OHdG). The urinary cotinine, N3-MeA, N3-EtA, and 8-OHdG concentrations of the cigarette smokers (n:39), e-cigarette users (n:28), IQOS users (n:20), passive smokers (n:32), and nonsmokers(n:41) who lived Ankara, Turkiye were determined using, liquid chromatography-tandem mass spectrometry (LC-MS/MS).

RESULTS

In light of the detected 8-OHdG levels, e-cigarette (3.19 ng/g creatinine) and IQOS (4.38 ng/g creatinine) users had higher oxidative DNA damage than healthy nonsmokers (2.51 ng/g creatinine). Alkylated DNA-adducts were identified in the urine of e-cigarette (N3-MeA: 3.92 ng/g creatinine; N3-EtA: 0.23 ng/g creatinine) and IQOS (N3-MeA: 7.54 ng/g creatinine; N3-EtA: 0.29 ng/g creatinine) users. In the generation of N3-MeA adducts, a significant difference was found between IQOS users and e-cigarette users (p < 0.05). Also, DNA alkylation in flavored e-cigarette users (N3-MeA: 4.51 ng/g creatinine; N3-EtA: 0.27 ng/g creatinine) was higher than in non-flavored e-cigarette users (N3-MeA: 2.27 ng/g creatinine; N3-EtA: 0.06 ng/g creatinine). The highest cotinine levels were found in cigarette smokers (16.1316 ng/g creatinine). No significant difference was found when e-cigarette (1163.02 ng/g creatinine) and IQOS smokers were compared (1088.3 ng/g creatinine).

CONCLUSION

People who use e-cigarettes and IQOS may be at higher risk of genotoxicity than those who do not use and are not exposed to any tobacco products. Furthermore, the usage of flavoring additives in e-cigarettes contributed to additional genotoxic damage risks.

Free Radicals in Little Cigar Mainstream Smoke and the Potential Influence of Flavoring Chemicals on Free Radical Production

Implementation of the Tobacco Control Act in 2009 banned characterizing flavors in cigarettes (except menthol and tobacco), but substitution has occurred by the continued availability of alternative flavored products (i.e., flavored little cigars). Little is known about how flavorants in noncigarette tobacco products impact human health. Thus, we investigated the impact of flavorants on free radical production in the mainstream smoke of little cigars. Gas- and particulate-phase free radical yields in mainstream smoke generated from 12 commercial little cigar brands and research little cigars and cigarettes were measured via electron paramagnetic resonance spectroscopy using the International Organization of Standardization (ISO) smoking protocol. Flavorants were extracted from unsmoked little cigars and analyzed by gas chromatography-mass spectroscopy. Gas- and particulate-phase radical yields from little cigars ranged from 13.5 to 97.6 and 0.453-1.175 nmol/unit, respectively. Comparatively, research cigarettes yielded an average of 4.9 nmol gas-phase radicals/unit and 0.292 nmol particulate-phase radicals/unit. From the products, 66 flavorants were identified, with each brand containing 4-24 individual flavorants. The free radical content was strongly correlated with the number of flavorants present in each cigar (r = 0.74, p = 0.01), indicating that highly flavored little cigars may produce higher levels of toxic free radicals. The presence of the flavorant ethyl methylphenylglycidate (strawberry) was associated with >2-fold higher levels of GP radicals (p = 0.001). Our results show that free radical delivery from little cigars is greater than that from research cigarettes and provide empirical evidence for the harmfulness of flavored tobacco products. Additionally, it demonstrates that flavorants present in combustible tobacco products can influence the levels of free radicals produced. Therefore, future tobacco product standards should consider little cigars.

The association between vaping and health behaviors among undergraduate college students in the United States

Objective: To examine the association between vaping and health behaviors (physical activity, fruit and vegetable consumption, sleep, cigarette use, alcohol consumption) and mental health among college students. Methods: Socio-demographic characteristics, vaping, health behaviors, perceived stress, and depressive symptoms of undergraduates enrolled at a large university located in the Northeast of the United States were assessed via an online survey. Results: Of all participants (n = 1775), less than a fifth (n = 314, 17.7%) reported any vaping in the past month. More men reported vaping than women (23.2% vs. 14.5%). Those who vaped reported fewer nights of restful sleep and greater alcohol consumption. Those who smoked and binge drank were more likely to report vaping. Perceived stress was greater among women who vaped, and depressive symptoms were greater among those who vaped regardless of gender. Conclusions: Vaping was associated with smoking, alcohol consumption, and poorer mental health among young adults.

Waterpipe Tobacco Brands and Flavors Sold Online in the USA

INTRODUCTION

Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies.

METHODS

We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder.

RESULTS

We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2953 flavors, including 1871 unique flavors. Brands averaged 45 flavors (range: 1-183). Almost three quarters (73.5%, n = 2171) used explicit flavor names and 26.5% (n = 782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%).

CONCLUSIONS

WT is available in 1871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Longitudinal Assessment of Association Between Tobacco Use and Tobacco Dependence Among Adults: Latent Class Analysis of the Population Assessment of Tobacco and Health Study Waves 1-4

INTRODUCTION

With increasing tobacco product varieties, understanding tobacco use (TU) profiles and their associations with tobacco dependence (TD) has also become increasingly challenging.

AIMS AND METHODS

We aimed to identify TU profiles and their associations with TD over time, and to identify subgroups with high risk of TD. We included 3463 adult recent tobacco users who had complete TU and TD data across waves 1-4 of the Population Assessment of Tobacco and Health (PATH) study. We used a composite index of TD and a summed TD score from an established 16-item TD measure. We applied a latent class analysis to identify TU profiles based on participants' usage of eight common tobacco product groups at each survey wave and to check the stability of the TU profiles over time. We then used generalized estimating equations regressions to evaluate the longitudinal TU-TD association, adjusting for potential confounders.

RESULTS

We identified three distinct TU profiles that remained consistent across four survey waves: Dominant cigarette users (62%-68%), poly users with high propensity of using traditional cigarettes, e-cigarettes, and cigars (24%-31%), and dominant smokeless product users (7%-9%). Covariate-adjusted models showed that TD was significantly lower among the poly users and the dominant smokeless users, compared to that among the dominant cigarette users.

CONCLUSIONS

Both TU profiles and their associations with TD were stable over time at the population level. Poly users and smokeless product users were consistently associated with lower TD than cigarette-dominant users, suggesting the need for tailored tobacco cessation interventions for users with different TU profiles.

IMPLICATIONS

The finding of consistent TU profiles across four survey waves extends the current literature in capturing TU patterns in an evolving tobacco product landscape. The finding of the overall higher level of TD among the cigarette-dominant users compared to the other TU latent profiles (the Cig+eCig+Cigar dominant poly users and the dominant smokeless product users) can help identify high-risk groups for potential interventions. Our application of innovative statistical methods to high-quality longitudinal data from the PATH study helps improve the understanding of the dynamic TU-TD relationship over time.

Electronic cigarettes and cardiovascular disease: epidemiological and biological links

Electronic cigarettes (e-cigarettes), as alternative nicotine delivery methods, has rapidly increased among youth and adults in recent years. However, cardiovascular safety is an important consideration regarding e-cigarettes usage. e-cigarette emissions, including nicotine, propylene glycol, flavorings, nitrosamine, and metals, might have adverse effects on cardiovascular health. A large body of epidemiological evidence has indicated that e-cigarettes are considered an independent risk factor for increased rates of cardiovascular disease occurrence and death. The incidence and mortality of various types of cardiovascular disease, such as cardiac arrhythmia, hypertension, acute coronary syndromes, and heart failure, have a modest growth in vapers (users of e-cigarettes). Although the underlying biological mechanisms have not been fully understood, studies have validated that oxidative stress, inflammation, endothelial dysfunction, atherosclerosis, hemodynamic effects, and platelet function play important roles in which e-cigarettes work in the human body. This minireview consolidates and discusses the epidemiological and biological links between e-cigarettes and various types of cardiovascular disease.

Importance of Various E-Cigarette Device and E-Liquid Characteristics by Smoking Status among Young Adults Who Vape

BACKGROUND

E-cigarette product characteristics are known to influence appeal among young adults. Understanding which characteristics appeal to individuals with (vs. without) a history of combusted tobacco use is essential for developing effective tobacco control policies.

METHODS

Anonymous, self-report data were collected from young adults (18-30 years) who had used e-cigarettes in the past 30 days (n = 295) online via Prolific from September-October 2019. Using a visual analogue scale (range: 0-100), participants rated the importance of ten e-cigarette device and nine e-liquid characteristics. Adjusted linear regression models were used to evaluate the association of combusted tobacco use status (never, former, current) with mean rating scores for each of the nineteen characteristics.

RESULTS

The most important e-cigarette device characteristics were price (Mean = 81.1; [SD = 17.9]), size (Mean = 75.5 [SD = 20.9]), and hit strength (Mean = 73.8 [SD = 20.4]) while the most important e-liquid characteristics were flavor (M = 85.1 [SD = 16.3]), price (M = 80.9 [SD = 18.4]), and nicotine level (M = 77.8 [18.9]). Differences by combusted tobacco use status were observed for device brand, temperature/voltage, customizability, color, and popularity, with the highest ratings generally observed among those concurrently using combustible tobacco products. For e-liquids, differences by use status were observed for flavor, price, and bottle type. Notably, those concurrently using combusted products rated flavor as less important than those with no history of combustible tobacco use (B=-5.01[95%CI=-9.97, -0.05]).

CONCLUSIONS

The self-rated importance of e-cigarette device and e-liquid attributes varies by combustible tobacco use status among young adults which may be used to inform regulatory decisions regarding e-cigarette product characteristics.

A review of the toxicity of ingredients in e-cigarettes, including those ingredients having the FDA's "Generally Recognized as Safe (GRAS)" regulatory status for use in food

INTRODUCTION

Some firms and marketers of electronic cigarettes (e-cigarettes; a type of electronic nicotine delivery system (ENDS)) and refill liquids (e-liquids) have made claims about the safety of ingredients used in their products based on the term "GRAS or Generally Recognized As Safe" (GRAS). However, GRAS is a provision within the definition of a food additive under section 201(s) (21 U.S.C. 321(s)) of the U.S. Federal Food Drug and Cosmetic Act (FD&C Act). Food additives and GRAS substances are by the FD&C Act definition intended for use in food, thus safety is based on oral consumption; the term GRAS cannot serve as an indicator of the toxicity of e-cigarette ingredients when aerosolized and inhaled (i.e., vaped). There is no legal or scientific support for labeling e-cigarette product ingredients as "GRAS". This review discusses our concerns with the GRAS provision being applied to e-cigarette products and provides examples of chemical compounds that have been used as food ingredients but have been shown to lead to adverse health effects when inhaled. The review provides scientific insight into the toxicological evaluation of e-liquid ingredients and their aerosols to help determine the potential respiratory risks associated with their use in e-cigarettes.

IMPLICATIONS

The rise in prevalence of e-cigarette use and emerging evidence of adverse effects, particularly on lung health, warrant assessing all aspects of e-cigarette toxicity. One development is manufacturers' stated or implied claims of the safety of using e-cigarette products containing ingredients determined to be "Generally Recognized As Safe" (GRAS) for use in food. Such claims, typically placed on e-cigarette product labels and used in marketing, are unfounded, as pointed out by the United States Food and Drug Administration (FDA)1 and the Flavor and Extract Manufacturers Association (FEMA)2. Assessment of inhalation health risks of all ingredients used in e-liquids, including those claimed to be GRAS, is warranted.

A Patchy Prohibition: Product and Flavor Substitution After the Food and Drug Administration's Prioritized Enforcement Policy on Flavored E-cigarettes

INTRODUCTION

E-cigarettes have rapidly grown in use among U.S. adolescents; in response, the Food and Drug Administration (FDA) engaged in an "enforcement policy on banned e-cigarette flavors" ("enforcement action") for pod-based e-cigarettes in January 2020, which accounted for most U.S. e-cigarette sales. No literature has yet examined long-term changes in e-cigarette sales patterns changed in relation to the FDA enforcement action.

AIMS AND METHODS

We analyzed U.S. e-cigarette sales using Nielsen retail scanner data between March 2017 and December 2021, describing e-cigarette sales trends overall, by device type, and by flavor category. We also performed joinpoint regression analysis on the sales trends to detect significant changes in the rate of change of sales over time.

RESULTS

The FDA enforcement action was associated with a sharp initial decrease in prefilled pod dollar sales, followed by a steady increase from April 2020 through the end of 2021, growing beyond the previous maximum in August 2019. We also observed a dramatic change in the composition of flavors sold: A large decline in mint-flavored pod sales was offset by a similar increase in menthol-flavored sales. Simultaneously, disposable product sales increased nearly ten-fold from July 2019 to July 2020 before stabilizing, dominated by fruit-flavored products.

CONCLUSIONS

Our findings suggest rapid product substitution without a long-term decline in e-cigarette sales in association with the enforcement action, along with a growing dominance of youth-friendly flavors, contrasting against FDA policy goals. Our study revealed the weakness of the "patchy" enforcement action, raising concern about its unintended consequences as consumption simply shifted to other e-cigarette products.

IMPLICATIONS

This is the first detailed longitudinal study on e-cigarette sales trends in the United States following the FDA flavor enforcement action, with novel findings on flavor trends and their relation to policy events. We report sales overall, by product type, and by flavor category, and highlight several important trends following the action, such as the rise and persistence of disposable e-cigarettes increasingly and overwhelmingly dominated by youth-friendly flavors, and likely substitution of prefilled e-cigarette flavors without any long-term decline in sales. Our results highlight the weaknesses of "patchy" regulation and suggest the need for a more comprehensive approach to flavor regulation.

Measuring susceptibility to use tobacco in an increasingly complex consumer marketplace: How many questions do we really need?

OBJECTIVE

Predicting which young people are likely to use tobacco in the future is critical for prevention and intervention. Although measures for assessing susceptibility to using tobacco have fulfilled this goal for decades, there is almost no standard for the number of items that should be administered, or which items should be administered for which products. This study explored whether brief but psychometrically sound versions of commonly used susceptibility measures can adequately capture the construct relative to longer measures.

METHOD

A sample of young people (N = 451; Mage = 16.5 years; 64% females; 65% White) completed 33 susceptibility items, which are designed to assess susceptibility to use different types of tobacco products (cigarette, smokeless tobacco, vaping products, and little cigars/cigarillos) of various flavors (tobacco, menthol, and sweet).

RESULTS

Analysis of these 33 items indicated that asking about the likelihood of using each tobacco product class when a best friend offers it (four items in all) captures 98.5% of information that is captured using the longer set of items; asking the best friend question for each product by each flavor category (11 items in all) captures 99.7% of the information.

CONCLUSIONS

Depending on research needs, tobacco use susceptibility can be measured with little loss of information by administering a limited set of items assessing the likelihood that a young person will use a tobacco product if a friend offers it for any product-flavor combination. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Effect of State and Local Flavored Cigar Sales Restrictions, on Retail Sales of Large Cigars, Cigarillos, and Little Cigars in Massachusetts, California, Illinois, and New York

INTRODUCTION

In 2009, the Family Smoking Prevention and Tobacco Control Act prohibited flavored cigarettes but allowed for flavored cigars. Since, there has been a 34% increase in youth cigar use and widened racial disparities. State and local jurisdictions have increasingly enacted flavored tobacco product sales restrictions. As more jurisdictions consider implementing flavor restrictions, it is important to understand their effect on tobacco markets that have high flavor proliferation, including the cigar market.

AIMS AND METHODS

This study uses data from Truth Initiative's flavor policy database and NielsenIQ retailer scanners for California, Illinois, Massachusetts, and New York. We use a three-way fixed-effect model to assess the impact of the percentage of the population covered by a flavored cigar sales restriction on per capita unit sales of cigars.

RESULTS

We find that population coverage by cigar sales restrictions was significantly associated with decreases in per capita cigar sales. More specifically, a 25% increase in the percentage of the population covered by a flavored cigar sales restriction was associated with a decrease in per capita all cigar sales of 15%-19%, 4%-10% for large cigars, 17%-21% for cigarillos, and 2%-41% for little cigars.

CONCLUSION

Flavored cigar sales restrictions are an effective policy to reduce per capita cigar sales. The Food and Drug Administration (FDA)'s proposed product standards would increase population covered by a flavored cigar sales restriction to 100%, leading to potential significant reductions in cigar sales, especially little cigar, and cigarillo sales. This may also substantially reduce youth cigar use and racial disparities in cigar use.

IMPLICATIONS

In April 2022, the U.S. FDA published a proposed rule to prohibit characterizing flavors in all cigars and menthol cigarettes. Besides this proposed rule, there has been little federal action to date to reduce sales of flavored cigars. However, as of March 31, 2022, Massachusetts and 333 localities across 10 states have enacted policies that restrict the sale of flavored cigars and other tobacco products. We find that population coverage by cigar sales restrictions is significantly associated with decreases in per capita cigar sales.

Electronic Vapor Products: Alarming Trends in United States Adolescents

Background: The use of electronic vapor products (EVPs) increases the risks of nicotine addiction, drug-seeking behavior, mood disorders, and avoidable premature morbidities and mortality. We explored temporal trends in EVP use among US adolescents. Methods: We used data from the Youth Risk Behavior Survey for school grades 9 through 12 from 2015 (earliest available data) to 2021 (the most recently available data) from the US Centers for Disease Control and Prevention (n=57,006). Results: Daily use of EVPs increased from 2.0% in 2015 to 7.2% in 2019, a greater than 3.5-fold increase. Although the percentage decreased to 5.0% in 2021, it was still a >2.5-fold increase since 2015. In 2015, the percentage of EVP use was significantly higher in boys (2.8%) than girls (1.1%). By 2021, the percentage of EVP use was higher in girls (5.6%) than boys (4.5%), a 1.24-fold increase. In addition, the percentage of EVP use in 2021 was higher in White youth (6.5%) vs Black (3.1%), Asian (1.2%), and Hispanic/Latino (3.4%) youth compared to 2015, but White and Black adolescents had the highest increases of approximately 3.0-fold between 2015 and 2021. Adolescents in grade 12 had the highest percentages of EVP use at all periods. Conclusion: These data show alarming statistically significant and clinically important increases in EVP use in US adolescents in school grades 9 through 12. The magnitude of the increases may have been blunted by coronavirus disease 2019, a hypothesis that requires direct testing in analytic studies. These trends create clinical and public health challenges that require targeted interventions such as mass media campaigns and peer interventions to combat the influences of social norms that promote the adoption of risky health behaviors during adolescence.

Early evidence of flavored tobacco product restrictions in Massachusetts and New York State

INTRODUCTION

With many US states and localities enacting policies that restrict flavored e-cigarette sales, evaluation of these restrictions is critical to inform future efforts. This study analyzed both survey and retail scanner data to assess early-stage impacts of flavored tobacco sales restrictions in Massachusetts and New York State on e-cigarettes sales and product use among young people.

METHODS

This study uses state-level e-cigarette retail sales data and survey data from youth and young adults (aged 13-24 years). Cross-sectional surveys were conducted at two time points in Massachusetts (both post policy implementation) and New York (pre and post policy implementation); retail sales data in both states were analyzed from 2019 through 2020 and compared to sales in control states.

RESULTS

E-cigarette unit sales decreased significantly following the implementation of statewide restrictions on flavored e-cigarettes in both Massachusetts and New York State (p<0.001). Survey data showed a decrease in mint flavored e-cigarette use in Massachusetts and an increase in tobacco flavored e-cigarette use in New York State over time (p=0.001). In both states, a greater proportion of respondents reported using disposable e-cigarettes at Time 2 compared to Time 1 (p=0.001). Among those who reported using fruit-flavored e-cigarettes in New York State, a significantly greater proportion reported disposable device use at Time 2 compared to Time 1 (p=0.004).

CONCLUSIONS

Findings from these case studies from two US states suggest that statewide policies reduce the availability of e-cigarettes and have the potential to reduce use of many youth-appealing flavors. The increase in use of disposable e-cigarettes likely reflects existing loopholes in federal policy, which may be attenuating the potential impact of strong state-level policies.

Flavored Tobacco and Nicotine Use Among California Adolescents: Preferences by Use Experience and Survey Format Effects

PURPOSE

This study assessed flavored tobacco use among adolescent e-cigarette, cigarette, cigar, hookah, and smokeless tobacco users; specific e-cigarette flavor preferences; risk profiles of youth that use various flavors; and the impact of survey question wording on prevalence.

METHODS

Cross-sectional data from 4,956 California adolescent participants (aged 12-17 years) in the Teens, Nicotine, and Tobacco 2021-2022 online panel survey estimated the survey-weighted prevalence of flavored tobacco use. An embedded randomized experiment assessed survey wording effects (i.e., any vs. "usual" flavor use). Qualitative data from four contemporaneous cycles of Teens, Nicotine, and Tobacco focus groups with California adolescents (N = 63) added themes relevant to the quantitative findings.

RESULTS

88.1% of current any tobacco users reported flavored tobacco use in the past 30 days. Flavor use was lowest for cigarettes (66.7%) and highest for hookah (92.8%). Fruit was the most popular e-cigarette flavor (51.6% any use; 28.8% usual use). E-cigarette users also commonly reported use of candy and cooling flavors. Sweet flavors were used most often among adolescents otherwise at low risk of tobacco use. Survey item format did not meaningfully affect overall prevalence of flavored product use but did impact reports of specific e-cigarette flavors. Focus group participants described sweet and fruity flavors as a motivating factor in their own e-cigarette use and as designed to appeal to children.

DISCUSSION

Despite local policies, flavored tobacco use remains common among California adolescents. Survey items asking about any flavor use rather than usual use provide more information without affecting the overall prevalence of flavored tobacco use.

Preliminary assessment of the subjective effects of electronic-cigarettes in young-adult low-dose electronic-cigarette users: Effects of nicotine dose and e-liquid flavor

OBJECTIVE

The present study evaluated the effects of nicotine concentration (0-10 mg/ml) and flavor (gummy bear vs unflavored) on the subjective experiences of vaporized nicotine in young adult low-dose nicotine (3 mg/ml) ECIG users.

PARTICIPANTS

Eight young adult ECIG users were recruited.

METHODS

A single blinded crossover study was used. Participants were instructed to take ten 1.5 second puffs, each separated by 20 seconds. After self-administration, heart rate was recorded, and participants completed the Drug Effects, Direct Effects of Nicotine, and Direct Effects of ECIG questionnaires.

RESULTS

ECIG user's standard daily nicotine dose influenced the rewarding and aversive effects of nicotine as the 10 mg/ml dose was found to be aversive in this user group. The combination of flavor and nicotine increased the subjective effects of ECIGs.

CONCLUSIONS

Flavored e-liquids contribute to the reinforcing properties of nicotine by enhancing the subjective effects, which may lead to continued ECIG use.

Should Tobacco-Related Marketing on Social Media Have Stronger Restrictions? Commentary

Background: Tobacco-related promotional content on social media often features young-looking influencers, models, or brand ambassadors who are appealing to youth; their posts often have inconsistent disclosures of partnerships with tobacco brands and lack age-restrictions prohibiting access to users under 18 or 21 years of age. These examples demonstrate violations of the U.S. Federal Food and Drug Administration (FDA) marketing restrictions. Methods: Marketing granted orders issued by the FDA to RJ Reynolds, Logic Technology, NJOY and Phillip Morris as part of the Premarket Tobacco Product Applications (PMTA) review process were qualitatively analyzed. Marketing practices that the tobacco companies intended to adhere to (e.g., refrain from using young-looking influencers in marketing materials) were documented. Perceived age of 55 micro-influencers who promote e-cigarette products on Instagram were assessed by 15 undergraduate student raters. Results: Despite the existing regulations of tobacco-related online marketing, the use of models or influencers and overall social media marketing is not prohibited, which leaves room for potential use of loopholes. The tobacco companies that were issued marketing granted orders set different age limits for the models to be considered young-looking and not to be used in marketing materials. The perceived age of the 55 influencers assessed by the raters was between 21-30, which is below the age limit proposed in several PMTA applications. Conclusion: Tobacco product online marketing, especially on social media, is underregulated. Strengthening tobacco marketing regulations, along with partnering of policymakers with social media platforms on establishing and maintaining effective tobacco-restriction policies, could help reduce proliferation of youth-appealing marketing of tobacco products.

#Delta8: a retailer-driven increase in Delta-8 THC discussions on Twitter from 2020 to 2021

Background: Delta-8 tetrahydrocannabinol (THC) has experienced significant cultivation, use, and online marketing growth in recent years.Objectives: This study utilized natural language processing on Twitter data to examine trends in public discussions regarding this novel psychoactive substance.Methods: This study analyzed the frequency of #Delta8 tweets over time, most commonly used words, sentiment classification of words in tweets, and a qualitative analysis of a random sample of tweets containing the hashtag "Delta8" from January 1, 2020 to September 26, 2021.Results: A total of 41,828 tweets were collected, with 30,826 unique tweets (73.7%) and 11,002 quotes, retweets, or replies (26.3%). Tweet activity increased from 2020 to 2021, with daily original tweets rising from 8.55 to 149. This increase followed a high-engagement retailer promotion in June 2021. Commonly used terms included "cbd," "cannabis," "edibles," and "cbdoil." Sentiment classification revealed a predominance of "positive" (30.93%) and "trust" (14.26%) categorizations, with 8.42% classified as "negative." Qualitative analysis identified 20 codes, encompassing substance type, retailers, links, and other characteristics.Conclusion: Twitter discussions on Delta-8 THC exhibited a sustained increase in prevalence from 2020 to 2022, with online retailers playing a dominant role. The content also demonstrated significant overlap with cannabidiol and various cannabis products. Given the growing presence of retailer marketing and sales on social media, it is crucial for public health researchers to monitor and promote relevant Delta-8 health recommendations on these platforms to ensure a balanced conversation.

E-cigarettes may serve as a gateway to conventional cigarettes and other addictive drugs

Electronic cigarettes (e-cigarettes) are devices that allow the user to inhale nicotine in a vapor, and are primarily marketed as a means of quitting smoking and a less harmful replacement for traditional cigarette smoking. However, further research is needed to determine if vaping nicotine via e-cigarettes can be effective. Conversely, nicotine has been considered a gateway drug to alcohol and other addictive drugs and e-cigarettes containing nicotine may have the same effects. Previous reports have shown that e-cigarette use may open the gate for the use of other drugs including conventional cigarettes, cannabis, opioids, etc. The increasing prevalence of e-cigarettes, particularly among youth and adolescents in the last decade have led to an increase in the dual use of e-cigarettes with alcohol, cannabis, and other illicit drug use like heroin and 3-4-methylenedioxymethamphetamine (MDMA). The advent of e-cigarettes as a device to self-administer addictive agents such as cocaine and synthetic cathinones may bring about additional adverse health effects associated with their concurrent use. This review aims to briefly describe e-cigarettes and their different generations, and their co-use with other addictive drugs as well as the use of the device as a tool to self-administer addictive drugs, such as cocaine, etc.

Electronic Nicotine Delivery System flavor use over time by age group in the US: A longitudinal analysis

INTRODUCTION

The prevalence of flavor use in Electronic Nicotine Delivery Systems (ENDS) has been assessed in numerous studies, but limited research has focused on flavor use trends and maintenance of flavor preference over time. This study investigated the general trends and maintenance of ENDS flavor use for youth (aged 12-17 years), young adults (aged 18-24 years), and older adults (aged ≥25 years) between 2014 and 2019.

METHODS

Population Assessment of Tobacco and Health (PATH) Study Wave 2 (2014-2015), Wave 3 (2015-2016), Wave 4 (2016-2017), and Wave 5 (2018-2019) youth and adult data were used. Cross-sectional flavor use prevalence (trends) and flavor maintenance (using the same flavor category in at least three consecutive waves) were assessed.

RESULTS

The most reported primary flavor category was fruit among all age groups in all waves. Candy/desserts in waves two, three, four, and menthol/mint in wave five were the second most reported flavor in all age groups. The highest increase was observed for menthol/mint use among youth between wave two (21.9%) and five (58.1%) (OR=5.33; 95% CI: 3.58-7.96). Overall, 37.6% of fruit flavor users, 25.3% of candy/desserts users, 32.0% of menthol/mint users, and 33.4% of tobacco flavor users, maintained use of the same flavor in at least three consecutive waves.

CONCLUSIONS

Fruit flavor had the highest percentages of use and maintenance between 2014 and 2019. While the maintenance of fruit and candy/desserts flavors were higher among youth, adults had substantially higher maintenance percentages for menthol/mint and tobacco flavor. There was a substantial increase in menthol/mint use in wave five among youth, which may affect ENDS flavor maintenance patterns in the future. Understanding maintenance of flavors over time can inform regulation of ENDS flavors.

Cannabis use among adolescents and emerging adults who use e-cigarettes: Findings from an online, national U.S. Sample

Concurrent use of e-cigarettes and cannabis among adolescents and emerging adults is a growing public health concern. More research is needed describing cannabis use among adolescents and emerging adults who vape. The objective of this study was to characterize cannabis use among adolescents and emerging adults (age 14-20) who reported e-cigarette ever-use, particularly their use of blunts and liquid cannabis vape (LCV) products. Using cross-sectional data from a national online survey, we describe their patterns of cannabis use, detail their use of flavored cannabis and tobacco products, and estimate associations of demographic factors and other current substance use behaviors with levels of blunt and LCV use. Of the 2253 respondents in the sample, 1379 (61 %) reported some form of cannabis use in the past 30 days, among whom 80 % used flavored cannabis (including edibles). Significant associations with current cannabis use were observed on several demographic measures, with current cannabis blunt use more frequent among participants not in school, non-Hispanic Blacks, multiracial respondents, and those whose incomes do not meet their expenses. Other than income, demographic characteristics were generally not associated with LCV use frequency. Use of other substances was associated with more frequent use of both blunts and LCV in the past 30 days, and enrollment in college or the military seems somewhat protective for emerging adults. These findings suggest a need for tailored prevention efforts among high-risk adolescents and emerging adults, potential regulation of added flavors in commercialized cannabis products, and stronger enforcement of retail restrictions for individuals under age 21 more broadly.

Development of a nicotine aerosol self-administration model in rats and the effects of e-liquid flavors

Electronic nicotine delivery system (ENDS) use is maintained by the positive reinforcement associated with preferred flavors. These flavors become conditioned reinforcers through pairings with primary reinforcers. This study sought to extend prior research with intravenous nicotine self-administration and develop a more ecologically valid preclinical model of aerosol self-administration in rats that incorporated flavors paired with sucrose. Rats were first trained to respond for oral sucrose with or without raspberry flavor to establish the flavor as a conditioned reinforcer for some groups. Rats were then exposed to aerosol self-administration. All groups responded for raspberry-flavored aerosol with or without nicotine. Rats responded more for raspberry flavored sucrose than unflavored sucrose. Despite raspberry increasing responding for sucrose, the flavor did not function as a conditioned reinforcer during aerosol self-administration and did not increase responding for nicotine. Throughout the aerosol self-administration phase, most groups responded more on the active than inactive lever, and some groups increased their response when the fixed ratio value was increased. At the end of the study, rats in nicotine groups earned similar or fewer aerosol deliveries than rats in vehicle groups. Aerosolized nicotine did not function as a reinforcer in this study, whereas aerosolized raspberry flavor may have maintained self-administration. Further preclinical investigation is needed to articulate the impact of flavors on ENDS use and whether they offset some aversive effects of nicotine or maintain responding on their own. If flavors reduce some aversive effects of self-administered nicotine, then policies to regulate flavors in e-liquids are prudent.

The Effects of Oral Nicotine Pouch Packaging Features on Adult Tobacco Users' and Non-Users' Product Perceptions

BACKGROUND

Oral nicotine pouches (ONPs) are novel products that are marketed as "tobacco-free" alternatives to cigarettes and smokeless tobacco (ST). This study examined the effects of ONP packaging features on adult tobacco users' and non-users' product perceptions.

MATERIALS AND METHODS

Adult tobacco users (cigarettes, ST, and dual cigarette/ST) and non-users (total N = 301) viewed ONP pack images in a 4 × 3 × 2 between-subject experiment testing the effects of the displayed flavor (cool mint, coffee, dark frost, and smooth), nicotine concentration (none displayed on the package, 3 mg, and 6 mg), and addiction warning label (yes or no). The outcomes were perceived substitutability of ONPs for cigarettes and ST and perceived risks. We modeled the effects of tobacco user status and the experimental factors on these outcomes.

RESULTS

All tobacco user groups perceived ONPs to be significantly less harmful and less addictive than non-users. There were significant effects of nicotine concentration on perceived risks. Compared to packages that did not display nicotine concentration, packages displaying 6 mg nicotine concentration produced significantly lower perceived harm (β = -0.23, 95% CI -0.44, -0.02), perceived addictiveness (β = -0.28, 95% CI -0.51, -0.05), risk appraisals of harm (β = -0.50, 95% CI -0.88, -0.12) and risk appraisals of addictiveness (β = -0.53, 95% CI -0.95, -0.11).

CONCLUSIONS

The study findings demonstrate that the nicotine concentration displayed on ONP packaging can affect adults' perceptions of ONPs. Further research on the effects of ONP packaging features emphasizing nicotine (e.g., "tobacco free" nicotine claims) on tobacco users and non-users is needed to assess their potential public health impact.

Perceived Sensory Characteristics of Blended and Ambiguous "Concept" Flavors Among Adolescent and Young Adult E-cigarette Users

INTRODUCTION

Flavors with names describing blended tastes/sensations or with ambiguous terminology ("concept flavors") are available on the e-cigarette market.

AIMS AND METHODS

This study investigates adolescent and young adult use and sensory perceptions of blended and concept flavors. Current e-cigarette users aged 15-24 years (N = 2281) completed an online convenience sample survey (October 20-November 23, 2020) and rated the sensory attributes (fruity, cooling, sweet, and minty) of their current flavor(s) using nine-point scales. T-tests compared mean sensory perception scores within and between flavors. To compare concept flavors to blends, reference categories used the average of blends with relevant descriptors: fruit (Banana Ice, Iced Mango, Melon Ice, Cool Cucumber); cooling (Banana Ice, Iced Mango, Melon Ice, Blue B Ice, Cool Cucumber, Lush Ice, and Menthol Purple); sweet (Vivid Vanilla) and mint (Mint-sation).

RESULTS

Most respondents had used at least one product with blended descriptors (74.8%) or concept flavor (57.9%) in the past 30 days. All flavors had high perceived strength for at least two sensory attributes. Mint taste was not perceived to be a strong sensory characteristic for all but two flavors (Mint-sation and Winter) in the study. The most commonly used flavors used blended descriptors (Iced Mango was used by 30.2% of the sample; Banana Ice: 26.2%; Lush Ice: 23.8%; Melon Ice: 22.9%). Some concept flavors did not significantly differ from flavor blend reference categories for strength of: fruit taste (Bahama Mama and Tropic); cooling sensation (Marigold, Island Breeze, Winter); sweet taste (Bahama Mama, Honeymoon, Island Breeze, Island Cream, Meteor Milk, OMG, Royal Dagger and Tropic); and mint taste (Winter).

CONCLUSIONS

Blended and concept flavors are used by most young e-cigarette users, who describe these products as fruity, sweet, and cooling. A variety of flavored products with high youth appeal are available in the U.S. market.

IMPLICATIONS

This study of adolescent and young adult e-cigarette users finds evidence of the popularity of e-cigarette flavors combining a cooling sensation with fruity and sweet flavorings. Some products with this flavor profile do not use characterizing descriptors. Findings inform public health interventions intended to reduce e-cigarette use in young people.

Prevalence, patterns, and determinants of electronic cigarette and heated tobacco product use in Greece: A cross-sectional survey

BACKGROUND

Electronic cigarettes (EC) and heated tobacco products (HTP) have been introduced in the global market as safer nicotine delivery systems; however, there is skepticism about their link to smoking and long-term risks. The aim of this study was to evaluate the prevalence, patterns, and determinants of EC/HTP use in Greece.

METHODS

This was a cross-sectional survey of 1,044 individuals aged ≥15 years old, who were randomly selected from the general Greek population. The study was conducted in May 2022, and participants were assessed through face-to-face interviews using a questionnaire designed to collect information on smoking and EC/HTP use, as well as their sociodemographic, lifestyle, and medical data.

RESULTS

The use of EC/HTP was reported by 16.2% of the participants, slightly more prevalent in males (17.2%) than in females (15.2%), and significantly more prevalent in <40-year-olds (21.3%) than ≥40-year-olds (11.3%). Most EC/HTP users (72.8%) were current smokers, 13.0% were former smokers, and 14.2% were never smokers. Among users, 60.6% used nicotine-containing products, 30.2% used EC/HTP in parallel with conventional tobacco, and 56.9% used EC/HTP for the first time while being <25 years old. In multiple logistic regression analysis, younger age, being employed, being a former/current smoker, adopting a Western-type diet, and believing that EC/HTP are less harmful than conventional tobacco products and can help toward smoking cessation emerged as significant determinants of EC/HTP use.

CONCLUSIONS

EC/HTP are commonly used in combination with conventional tobacco, are quite popular among the youth, and also appeal to a small fraction of nonsmokers.

Mouth Level Intake of Nicotine from Three Brands of Little Filtered Cigars with Widely Differing Product Characteristics Among Adult Consumers

Little filtered cigars are tobacco products with many cigarette-like characteristics. However, despite cigars falling under the U.S. Food and Drug Administration regulatory authority, characterizing flavors, which are still allowed in little filtered cigars, and filter design may influence how people use the products and the resulting exposure to harmful and potentially harmful constituents. We estimated nicotine mouth level intake (MLI) from analyses of little cigar filter butt solanesol levels, brand characteristics, carbon monoxide boost, and puff volume in 48 dual cigarette/cigar users during two repeat bouts of ad lib smoking of three little filtered cigar brands. Mean nicotine MLI for the three brands was significantly different with Swisher Sweets (0.1% ventilation) Cherry at 1.20 mg nicotine, Cheyenne Menthol (1.5%) at 0.63 mg, and Santa Fe unflavored (49%) at 0.94 mg. The association between nicotine MLI and puff volume was the same between Cheyenne Menthol and Santa Fe unflavored. However, these were different from Swisher Sweets Cherry. At least five main factors─flavor, ventilation, filter design, nicotine delivery related to tar, and user puff volume─may directly or indirectly impact MLI and its association with other measures. We found that users of little filtered cigars that have different filter ventilation and flavor draw dissimilar amounts of nicotine from the product, which may be accompanied by differences in exposure to other harmful smoke constituents.

Common Measures to Evaluate Flavored Tobacco Products: Recommendations From the Tobacco Centers for Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee

INTRODUCTION

Flavored electronic nicotine delivery systems (ENDS) and tobacco products are associated with the initiation and progression of tobacco use. With recent restrictions around flavored products, it is critical to measure both the product and the flavor being used. The Tobacco Centers of Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee (FTPMS) was established to develop core measures to assess flavored tobacco and ENDS product usage, facilitate data harmonization, replicability, and comparisons across studies.

AIMS AND METHODS

The FTPMS used a mixed-method approach to inform the development of recommended measures (first use, current use, reasons for use) to assess tobacco and ENDS product flavors. This included reviewing existing surveys, identifying priority areas, developing new measures, cognitive testing, and finalization of recommended measures.

RESULTS

Recommended measures were selected from national surveys (e.g. PATH study) and survey items used in TCORS studies to evaluate first use, current use, and reasons for use of tobacco and ENDS products. Response options were expanded for questions about specific flavors and adapted to allow for assessments relevant to recent federal policies. Supplemental measures were developed for researchers conducting more in-depth research around flavored products.

CONCLUSIONS

Using an expert consensus process supplemented with cognitive testing, the FTPMS developed recommendations for core and supplemental measures for flavored tobacco and ENDS products. Harmonizing data on these factors for flavored tobacco and ENDS products are critical for researchers and may provide actionable evidence to federal, state, and local regulators and policymakers, as well as support evaluations of policies restricting flavors in these products.

IMPLICATIONS

The development of core measures to assess first use, current use, and reasons for use of flavored tobacco and ENDS products will facilitate data harmonization, replicability, and comparisons across studies conducted in different samples or across communities with varying levels of regulation for these products. Use of these standardized measures will allow for a greater understanding of the role of flavors and helps to build a more robust evidence base to inform regulatory decisions to reduce tobacco and ENDS use at the population level.

Evaluation of the intensity of cigarette odors based on the perception of consumers

INTRODUCTION

We evaluated the tobacco odor intensity of cigarettes based on a large consumer panel and explored the differences of odor intensity perception based on sex, age and smoking habits.

METHODS

The perceived intensity of tobacco odor of cigarettes was evaluated using a consumer group method. A consumer panel of 240 volunteers (80 smokers, 80 ex-smokers and 80 non-smokers) was asked to smell eleven unlit cigarettes and then report their tobacco odor intensity in a specific questionnaire.

RESULTS

All volunteers clearly determined the presence of tobacco odor in all cigarettes. There is a general decrease of the perceived odor intensity with age, for both males and females. Moreover, tobacco odor perceived intensity, among all volunteer groups (smokers, non-smokers, ex-smokers), was higher for females than for males. Non-smokers declared the highest perceived tobacco odor intensities, followed by ex-smokers and smokers, who recorded the lowest perceived odor intensity. Perceived odor intensity decreased with age, with a higher rate for females compared to males, but independently of the smoking habits.

CONCLUSIONS

Regular and untrained consumers confirmed that a tobacco odor of different intensity can be perceived during the smelling of unlit cigarettes. This perceived intensity depends on sex, age and smoking habits.

Electronic Nicotine Delivery Systems: An Updated Policy Statement From the American Association for Cancer Research and the American Society of Clinical Oncology

Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15%-42% of adults who use ENDS have never used another tobacco product, and another 36%-54% dual use both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.

Correlates of behavior change intents in response to a hypothetical flavored cigar sales restriction among U.S. adult flavored cigar smokers

Flavored cigar sales restrictions (FCSRs) may reduce cigar smoking and protect public health. This study examined the correlates of behavior change intents in response to a hypothetical FCSR. Data were from a nationally representative sample of adult flavored cigar smokers (ages ≥21; n = 343) collected through an online survey in 2021. Respondents selected their behavior change intents in response to a hypothetical FCSR, including (1) quitting cigars altogether; (2) smoking plain or non-flavored cigars; (3) smoking other flavored tobacco products; (4) smoking cannabis; and (5) other options. Weighted logistic regressions were used to examine the associations of socio-demographic backgrounds, tobacco use history, and tobacco dependence with behavioral change intents. In response to an FCSR, 15.1% of respondents would quit smoking cigars altogether, 41.6% would smoke plain cigars without flavors, 33.4% would substitute flavored cigars with other flavored tobacco products, and 29.2% would substitute flavored cigars with cannabis. Large cigar smokers and blunt smokers were less likely to quit cigars altogether than non-smokers of those products; females and racial/ethnic minorities were more likely to substitute flavored cigars with other flavored tobacco and cannabis products, respectively, than males and non-Hispanic White respondents. Results suggest that FCSRs may reduce cigar smoking among a portion of U.S. flavored cigar smokers while leaving more continuing to smoke plain cigars or transitioning to use other flavored tobacco products or cannabis. Implementing FCSRs should be accompanied by comprehensive flavored tobacco sales restrictions, cessation programs, and educational messages aimed at reducing the use of cigars and other substances.

Impact of tobacco flavoring on oral nicotine consumption in C57BL/6J mice

BACKGROUND

The continued use of flavors in tobacco products has been a prominent factor in their popularity, yet little is known regarding their role in nicotine dependence. This study aimed to investigate the impact of tobacco flavoring on oral nicotine consumption in mice using the two-bottle choice (2BC) test and assessed the potential impact of age and sex in their interactions.

METHODS

Adolescent and adult male and female C57BL/6J mice were used. First, voluntary consumption of tobacco flavor concentrate from a commercial electronic cigarette liquid vendor (Avail Vapor LLC) was measured; then, the effects of tobacco flavoring in combination with nicotine were examined. In one approach, tobacco flavor concentration was kept constant while nicotine concentration varied, and in the second, nicotine was kept constant while the tobacco flavor concentration varied.

RESULTS

Overall, tobacco flavoring decreased oral nicotine consumption in mice, and its effects were sex- and age-dependent. Although females consumed the tobacco-flavored solution at a slightly higher rate than males, male mice were more sensitive to the effects of the combination (nicotine + tobacco). Furthermore, adolescent mice showed a starker reduction in nicotine consumption in the presence of tobacco flavoring compared to adult mice. This attenuation was most likely due to a basal aversion to the tobacco flavoring itself, thus, creating a negative synergistic effect with nicotine.

CONCLUSIONS

Tobacco flavoring increases aversion to nicotine in the 2BC test in C57BL6J mice, suggesting that some flavors may diminish rather than enhance oral nicotine consumption in rodents.

Electronic Nicotine Delivery Systems: An Updated Policy Statement from the American Association for Cancer Research and the American Society of Clinical Oncology

Combustible tobacco use has reached historic lows, demonstrating the importance of proven strategies to reduce smoking since publication of the 1964 Surgeon General's report. In contrast, the use of electronic nicotine delivery systems (ENDS), specifically e-cigarettes, has grown to alarming rates and threatens to hinder progress against tobacco use. A major concern is ENDS use by youth and adults who never previously used tobacco. While ENDS emit fewer carcinogens than combustible tobacco, preliminary evidence links ENDS use to DNA damage and inflammation, key steps in cancer development. Furthermore, high levels of nicotine can also increase addiction, raise blood pressure, interfere with brain development, and suppress the immune system. The magnitude of long-term health risks will remain unknown until longitudinal studies are completed. ENDS have been billed as a promising tool for combustible tobacco cessation, but further evidence is needed to assess their potential efficacy for adults who smoke. Of concern, epidemiological studies estimate that approximately 15% to 42% of adults who use ENDS have never used another tobacco product, and another 36% to 54% "dual use" both ENDS and combustible tobacco. This policy statement details advances in science related to ENDS and calls for urgent action to end predatory practices of the tobacco industry and protect public health. Importantly, we call for an immediate ban on all non-tobacco-flavored ENDS products that contain natural or synthetic nicotine to reduce ENDS use by youth and adults who never previously used tobacco. Concurrently, evidence-based treatments to promote smoking cessation and prevent smoking relapse to reduce cancer incidence and improve public health remain top priorities for our organizations. We also recognize there is an urgent need for research to understand the relationship between ENDS and tobacco-related disparities.

Electronic Cigarette Use, Misuse, and Harm

Electronic cigarettes (e-cigarettes) are battery-powered devices that use heat to aerosolize a liquid containing a variety of substances (usually nicotine and/or cannabinoids, flavorings, and glycerol or propylene glycol base) that is then inhaled. E-cigarettes are rapidly evolving over time, so the true health effects of e-cigarettes are difficult to study and remain largely unknown. We review the effects of e-cigarettes on nicotine addiction and on pulmonary disease including the effects of dual use and switching from combustible cigarettes to e-cigarettes. Studies show that e-cigarette use can increase the risk to nicotine dependence and combustible tobacco use. Studies show an association between e-cigarette use and pulmonary disease. Some studies suggest reduced harm from e-cigarette use compared with smoking, but this requires further study. Most adults who use e-cigarettes also smoke cigarettes; epidemiologic studies suggest that the combination of e-cigarettes and cigarettes is more harmful than using either product alone.

Ethyl maltol, vanillin, corylone and other conventional confectionery-related flavour chemicals dominate in some e-cigarette liquids labelled 'tobacco' flavoured

BACKGROUND

The increased popularity of electronic cigarettes (e-cigarettes) has been linked to the abundance of flavoured products that are attractive to adolescents and young adults. In the last decade, e-cigarette designs have evolved through four generations that include modifications in battery power, e-cigarette liquid (e-liquid) reservoirs and atomiser units. E-liquids have likewise evolved in terms of solvent use/ratios, concentration and number of flavour chemicals, use of nicotine salts and acids, the recent increased use of synthetic cooling agents and the introduction of synthetic nicotine. Our current objective was to evaluate and compare the evolving composition of tobacco-flavoured e-liquids over the last 10 years.

METHODS

Our extensive database of flavour chemicals in e-liquids was used to identify trends and changes in flavour chemical composition and concentrations.

RESULTS

Tobacco-flavoured products purchased in 2010 and 2011 generally had very few flavour chemicals, and their concentrations were generally very low. In tobacco-flavoured refill fluids purchased in 2019 and Puff Bar Tobacco e-cigarettes, the total number and concentration of flavour chemicals were higher than expected. Products with total flavour chemicals >10 mg/mL contained one to five dominant flavour chemicals (>1 mg/mL). The most frequently used flavour chemicals in tobacco e-liquids were fruity and caramellic.

CONCLUSIONS

There is a need for continuous surveillance of e-liquids, which are evolving in often subtle and harmful ways. Chemical constituents of tobacco flavours should be monitored as they clearly can be doctored by manufacturers to have a taste that would appeal to young users.

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

Significance

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

Methods

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

Results

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

Conclusion

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

TikTok - Potential Impact on the Use of Smokeless Tobacco and Betel Quid by Young People

INTRODUCTION

TikTok has gained increasing popularity over the past year. The social media may affect awareness and perceptions of betel quid (BQ) and smokeless tobacco (SLT) by utilizing content generated by TikTok users. The purpose of this study is to examine how BQ and SLT are portrayed on TikTok.

METHODS

The 28 most viewed hashtag-based keywords were used to identify popular BQ and SLT-related videos on TikTok (n=513) from June 2018 to September 2021. Two researchers independently coded the number of likes, shares, views, user category and themes.

RESULTS

A final sample of 513 videos containing BQ and SLT that met the study criteria were included. Collectively, these videos were viewed over 725 million times, with a median 'view' count of 17,300 (range 152-155,000,000) and a median 'likes' count of 831 (range 4-2,400,000) and a median 'share' count of 21 (range 0-48,400). Majority of the videos showed BQ and SLT use positively i.e promoting the product (390/513; 76%) and these had more than 686 million times views. Neutral depictions of BQ and SLT use were viewed 15 million times (72/513; 14%) and negative portrayals of BQ and SLT have been viewed 193 million times (105/808; 13%). The video themes included 'life style' (349/513; 68.0%), 'marketing' (62/513; 12.09%), 'comedy' (44/513; 8.6%), 'warning' (25/513; 4.87%), 'awareness' (12/513; 2.3%), 'sports and other' (12/513; 2.3%) and social events or culture (9/513; 1.75%).

CONCLUSION

Our results demonstrated that video clips related to BQ and SLT on TikTok, a fast-growing, popular video-sharing platform among teens, which is available with no age restrictions has been viewed multiple times. Majority (76%) promoted these two products, that could be detrimental to oral health. Therefore, the age restrictions especially for the videos containing BQ and SLT is mandatory in order to reduce the potential exposure of adolescents/young adults.

Changes in product labelling practices and the use of flavouring chemical additives in vaping products after enactment of statewide flavour legislation

INTRODUCTION

On 18 May 2020, New York State enacted legislation banning the sale of vaping products with distinguishable flavours (other than tobacco). According to this new statute, vaping products are deemed flavoured if they include a statement, whether expressed or implied, that have distinguishable tastes or aromas other than tobacco. This study aimed to determine how manufacturers responded.

METHODS

We collected 555 vaping products from daily vapers (238 preban and 317 postban). We compared preban and postban labelling of products for expressed and implied flavour descriptions, graphics and colours. Flavouring chemicals and concentrations were identified using chromatography methods and were compared preban and postban.

RESULTS

Analysis of the labels preban and postban did not reveal a change in products with expressed flavoured descriptors (45.8% vs 44.2%) and a minimal decrease in implied descriptors (22.3% vs 14.5%). An increase in products without any descriptors was observed (28.2% vs 37.2%) notably within products from a popular pod brand. The average concentration of eight popular flavourings identified preban was 1.4±2.7 compared with 2.3±3.5 mg/mL (p<0.001) postban. No significant changes between individual flavouring concentrations in the most popular refill solutions and pods were found.

CONCLUSION

While a majority of products appeared to remain non-compliant, this study suggests that enactment of legislation on vaping products making expressed or implied flavour claims may result in some manufacturer changes to product labelling including removal of flavour descriptors. However, use of flavouring additives in vaping products appeared not to be impacted by the ban.

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

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

Differences in intention to use flavored oral nicotine products among young adult e-cigarette users and non-users

New oral nicotine products (ONPs; nicotine pouches, gums, lozenges, and gummies), which are regulated as nonmedicinal tobacco products in the U.S., have flavors and other characteristics that previously attracted young adults to e-cigarettes. Whether young adults' interest in ONPs differs by e-cigarette use status and quit-vaping motivation is unknown but important for understanding the possible health impact of ONPs. It is particularly important to study if nonmedicinal ONPs attract e-cigarette users interested in quitting vaping, given that nicotine replacement (NRT) therapy uptake in young adults is low. In this study, ONP non-users (ages: 20-24) from California viewed digital images of 5 flavored ONPs (4 nonmedicinal and one NRT gum product) and reported intention to use each ONP (0-100 score). Main and interactive effects of Group (past-6-month e-cigarette non-users [n = 1,1388], e-cigarette users unmotivated to quit vaping [n = 168], and e-cigarette users motivated to quit vaping [n = 99]) and ONP type (nonmedicinal gum, nonmedicinal lozenge, gummy, pouch, and NRT gum) on use intention were tested. For each nonmedicinal ONP, use intention was higher in both e-cigarette user groups than non-users (ds = 0.47-0.59; Ps < 0.001), but did not differ between e-cigarette users with and without quit-vaping motivation (Ps ≥ 0.31). A Group × ONP type interaction was found, whereby higher use intention for e-cigarette users with vs without quit motivation was present for only gum NRT (Cohens d = 0.17; P =.01). Among young adults, e-cigarette users might be more inclined than e-cigarette non-users to try nonmedicinal ONPs regardless of quit-vaping motivation.

The impact of two state-level approaches to restricting the sale of flavored tobacco products

BACKGROUND

Flavored tobacco products are highly appealing to youth. The Federal government lacks a comprehensive flavored tobacco products policy and states have adopted different approaches restricting these products. This study analyzes the impact of Massachusetts' comprehensive prohibition and New Jersey's partial restriction on the sale of flavored tobacco products.

METHODS

NielsenIQ Retail Scanner data were used to construct four log per capita dependent variables: e-liquid milliliters, cigarette packs, cigars, and smokeless tobacco ounces for products flavored as fruit, menthol, mint, tobacco and other. All models used difference-in-differences regressions, with Virginia and Pennsylvania serving as controls. The models controlled for state level product prices, population percentages by race/ethnicity, proportion male, median household income, unemployment rate, minimum legal sales age, tobacco 21 policies, and cumulative cases and deaths of COVID-19; the models accounted for time-specific factors by using 4-week period fixed-effects.

RESULTS

There was a significant decrease in sales across all flavored tobacco products in Massachusetts, including fruit [-99.83%, p < 0.01], menthol [-98.33%, p < 0.01], and all other flavored [-99.28%, p < 0.01] e-cigarettes. The cigar group "all other-flavors" [-99.92%, p < 0.01] and menthol flavored cigarettes [-95.36%, p < 0.01] also significantly decreased. In New Jersey, there was a significant decrease in per capita sales of menthol-flavored e-cigarettes [-83.80%, p < 0.05] and cigar group "all other-flavors" experienced a significant increase in per capita sales [380.66%, p < 0.01].

CONCLUSIONS

This study contributes to the growing body of evidence demonstrating the impact of sales prohibitions on reducing sales of flavored tobacco products. Statewide comprehensive approaches appear more effective than partial restrictions and should be prioritized.

IMPLICATIONS

Results from this study support emerging research that demonstrates the promising effects of comprehensive flavoring sales prohibitions. This study can be used to inform future flavored tobacco product policy solutions developed by advocates and policy makers to curb overall tobacco initiation and use by youth and adults.

Policies restricting flavors and non-cigarette tobacco product availability: A study of vape shops in San Francisco and Alameda Counties, California, USA

We examined flavored non-cigarette tobacco availability in brick-and-mortar vape shops in San Francisco (SF) and Alameda Counties, California (USA), comparing cities organized by flavored tobacco sales restriction policy. A total of 22 brick-and-mortar vape shops were identified and audited in October-November 2019; shops were located in SF City-County and nine cities in Alameda County. Fisher Exact Tests were used to assess differences in the availability of products between vape shops in cities with versus without comprehensive or partial flavored tobacco sales restrictions enacted before November 21, 2019 (n = 15 shops in six cities with policies vs n = 7 shops in four cities without policies). In the six cities with any flavored sales restrictions, fewer vape shops sold menthol/mint flavored JUUL pods (27% vs 71%, p = 0.074), candy/fruit (53% vs 100%, p = 0.051) and menthol/mint (53% vs 100%, p = 0.051) nicotine e-cigarette liquids compared to cities without flavored tobacco sales restrictions, but results were borderline significant. Tobacco-flavored JUUL pods (47% vs 71%, p = 0.381), tobacco-flavored nicotine e-cigarette liquids (67% vs 100%, p = 0.135), and flavored e-cigarette liquids without nicotine (candy/fruit: 87% vs 71%, p = 0.565 and menthol/mint: 87% vs 57%, p = 0.274) were not included in the policies, and availability was not significantly different between cities with or without policies. Enactment of local policies was associated with lower flavored e-cigarette tobacco product availability but not tobacco-flavored or non-nicotine product availability; federal policies restricting sales of flavored tobacco products may reduce access to flavored e-cigarette products in vape shops.

Determinants of E-Cigarette and Cigarette Use among Youth and Young Adults in Poland-PolNicoYouth Study

Teen use of tobacco-related products is a significant public health concern. This study evaluated the predictors of e-cigarette use among secondary school students who were never cigarette smokers and ever cigarette smokers in Poland.

METHODS

This study examined a sample of Polish youths aged 13-19 (n = 19,241) attending 200 schools, 12 on average in each county. The study was a part of the National Health Program in Poland for 2016-2020. Logistic regression and multivariable logistic regression models were used to calculate crude and adjusted odds ratios.

RESULTS

Of all participants, 32.5% were ever cigarette users. Among the never cigarette users, 13.6% were deemed susceptible to e-cigarette use. Among the ever cigarette users, 60.6% were deemed susceptible to e-cigarette use. Of those susceptible to e-cigarette use, 68.2% were among the 32.5% ever cigarette users. The profile of e-cigarette use among never e-cigarette users also included: pocket money available per month (more than 150 PLN) (OR = 1.7; p = 0.001), 16-17 years old (OR = 1.9; p = 0.001), parental tobacco smoking and e-cigarette usage (OR = 2.0; p = 0.01 and OR = 1.7; p = 0.001 respectively), maternal secondary education (OR = 1.1; p = 0.04), and living in big cities >500,000 inhabitants (OR = 1.4; p = 0.04). E-cigarette users among ever cigarette users were similar to never cigarette users in their opinion that e-cigarette use is less harmful than traditional smoking (OR = 1.6; p = 0.0012) and living with both parents smoking cigarettes (OR = 1.3; p = 0.02). Additionally, the determinants were: female gender (OR = 1.5; p = 0.009) in the age group less than 15 years of age (OR = 1.3; p = 0.007).

CONCLUSIONS

The major determinant of e-cigarette use in this population was prior smoking. Additionally, the results revealed that fairly obvious predictors such as parental smoking and a belief in the less harmfulness of e-cigarette use are important determinants for smoking among never or ever e-cigarette users.

E-Cigarettes Reexamined: Product Toxicity

The introduction of e-cigarettes, or electronic nicotine delivery systems (ENDS), has been accompanied by controversy regarding their safety and effectiveness as a cessation aid and by an explosion in their use by youth. Their use does not involve the combustion of tobacco and the creation of harmful combustion products; they have been seen as a "harm reduction" tool that may be of assistance in promoting smoking cessation. Recognition that ENDS can deliver an array of chemicals and materials with known adverse consequences has spurred more careful examination of these products. Nicotine, nitrosamines, carbonyl compounds, heavy metals, free radicals, reactive oxygen species, particulate matter, and "emerging chemicals of concern" are among the constituents of the heated chemical aerosol that is inhaled when ENDS are used. They raise concerns for cardiovascular and respiratory health that merit the attention of clinicians and regulatory agencies. Frequently cited concerns include evidence of disordered respiratory function, altered hemodynamics, endothelial dysfunction, vascular reactivity, and enhanced thrombogenesis. The absence of evidence of the consequences of their long-term use is of additional concern. Their effectiveness as cessation aids and beneficial impact on health outcomes continue to be examined. It is important to ensure that their production and availability are thoughtfully regulated to optimise their safety and permit their use as harm reduction devices and potentially as smoking-cessation aids. It is equally vital to effectively prevent them from becoming ubiquitous consumer products with the potential to rapidly induce nicotine addiction among large numbers of youth. Clinicians should understand the nature of these products and the implications of their use.

A formative evaluation of an adolescent online E-cigarette prevention program

Purpose

This study is a formative evaluation of an adolescent online e-cigarette prevention program (Clearing the Vapor) giving attention to identifying higher risk adolescent populations, confirming the theory of change, and assessing short-term outcomes.

Design/methodology/approach

The evaluation was conducted using online pre-test and post-test survey data collected from adolescent program participants age 10–18 from 2019 to 2021. Analyses included risk ratios on perceived risk, self-efficacy, and behavioral intentions across demographic variables. Pre-test and post-test comparisons were conducted with analysis involving the t-test and the McNemar test.

Findings

Prevalence of e-cigarette use was higher among males, older adolescents, and in racial/ethnic groups other than Whites and Asians. Adolescents with lower confidence to say “no” were more likely to use e-cigarettes. Greater perception of harm by using e-cigarettes increased the likelihood of adolescents feeling competent to explain to peers the harmful effects of e-cigarettes. Mean change in commitment levels to not use e-cigarettes increased for males and females, all ages, and racial/ethnic groups other than non-Hispanic Blacks and American Indians. Improvement in non-Hispanic Whites was significantly greater than for non-Hispanic Blacks, American Indians, and Hispanics.

Originality/value

Improvement in programming should give careful attention to the incorporation of more prevention activities and to materials tailored specifically to racial/ethnic participants. As a theory of change, findings support the utility of the Clearing the Vape prevention programming to address perceptions of harm that e-cigarettes are safe, confidence in explaining the harmful effects of use, and the development of skills to resist use.

Early adoption of heated tobacco products resembles that of e-cigarettes

BACKGROUND

Heated tobacco products (HTP) generate nicotine-containing aerosol by heating tobacco rather than burning it. The US Food and Drug Administration (FDA) has recently authorised the sale of one HTP brand, iQOS, in the USA. This study examined the awareness, use and risk perceptions of HTP in the USA following FDA authorisation.

METHODS

A national probability sample of 20 449 US adults completed an online survey between November 2019 and February 2020. In addition to assessing awareness and use of HTP, two ratios were calculated: the ratio of those who experimented with HTP given that they had heard about it (E/H) and the ratio of those who currently used HTP given experimentation (C/E). These ratios for HTP were compared against those for e-cigarettes from a similar national survey in 2012.

RESULTS

Overall, 8.1% of respondents had heard of HTP. Only 0.55% had tried and 0.10% were current users. The rate of experimentation among those who heard about HTP and the rate of current use among experimenters were, however, similar to those for e-cigarettes in 2012: E/H and C/E for HTP were 6.8% and 18.2%, respectively; and 10.7% and 17.8%, respectively for e-cigarettes. The majority of respondents considered HTP either less harmful than (11.6%), or equally harmful as e-cigarettes (42.7%).

CONCLUSIONS

Only a small fraction of US population in 2020 have tried any HTP. However, the similarity in early adoption rates following awareness, suggests that future adoption for HTP may be similar to that for e-cigarettes, if HTP are marketed more aggressively.

Adolescents, Young Adults, and Adults Continue to Use E-Cigarette Devices and Flavors Two Years after FDA Discretionary Enforcement

This study assesses the use of e-cigarette devices and flavors using a large, cross-sectional survey of adolescents, young adults, and adults (N = 6131; ages 13−40 years old; Mage = 21.9) conducted from November to December 2021, 22 months after the FDA announced its prioritized enforcement policy against some flavored pod/cartridge-based e-cigarettes. We analyzed the patterns of use by age group: adolescents and young adults (AYAs) under 21 (minimum age of e-cigarette sales), young adults (21−24 years old), and adults (25−40 years old). The participants reported using e-cigarettes ever (44.2% < 21; 67.1% 21−24; 58.0% > 24), in the past 30 days (29.8% < 21; 52.6% 21−24; 43.3% > 24), and in the past 7 days (24.5% < 21; 43.9% 21−24; 36.5% > 24). Disposables were the most used e-cigarette device type across age groups (39.1% < 21; 36.9% 21−24; 34.5% > 24). Fruit, sweet, mint, and menthol flavors were popular across age groups; however, chi-squared tests for trends in proportions revealed age-related trends in past 30-day flavor use by device type. Findings suggest current AYA e-cigarette use may be higher than recorded by the NYTS 2021. The FDA, states, and localities should adopt more comprehensive restrictions on flavored e-cigarette products in order to reduce adolescent and young adult e-cigarette use.

Cardiopulmonary Consequences of Vaping in Adolescents: A Scientific Statement From the American Heart Association

Although the US Food and Drug Administration has not approved e-cigarettes as a cessation aid, industry has at times positioned their products in that way for adults trying to quit traditional cigarettes; however, their novelty and customizability have driven them into the hands of unintended users, particularly adolescents. Most new users of e-cigarette products have never smoked traditional cigarettes; therefore, understanding the respiratory and cardiovascular consequences of e-cigarette use has become of increasing interest to the research community. Most studies have been performed on adult e-cigarette users, but the majority of these study participants are either former traditional smokers or smokers who have used e-cigarettes to switch from traditional smoking. Therefore, the respiratory and cardiovascular consequences in this population are not attributable to e-cigarette use alone. Preclinical studies have been used to study the effects of naive e-cigarette use on various organ systems; however, almost all of these studies have used adult animals, which makes translation of health effects to adolescents problematic. Given that inhalation of any foreign substance can have effects on the respiratory and cardiovascular systems, a more holistic understanding of the pathways involved in toxicity could help to guide researchers to novel therapeutic treatment strategies. The goals of this scientific statement are to provide salient background information on the cardiopulmonary consequences of e-cigarette use (vaping) in adolescents, to guide therapeutic and preventive strategies and future research directions, and to inform public policymakers on the risks, both short and long term, of vaping.

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

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

Increased nicotine vaping due to the COVID-19 pandemic among US young adults: Associations with nicotine dependence, vaping frequency, and reasons for use

Previous research has not examined increased vaping because of the pandemic using a national sample of young adults (YAs), which is a critical gap because pandemic-related increases in vaping among YAs could have important implications for nicotine dependence, prolonged regular use, and using substances to cope with stress. We examined self-reported increased vaping attributed to the COVID-19 pandemic among YAs, and its associations with outcomes that have important implications for future nicotine use. Data came from the Monitoring the Future (MTF) Vaping Supplement. Participants were selected from a nationally representative sample of US 12th-graders who were surveyed at age 19 in fall 2020 (N = 1244). Cross-sectional analyses of the 2020 survey included YAs who vaped nicotine in the past year (35%; N = 440). Weighted descriptive analyses and logistic regression models examined self-reported pandemic-related increased vaping (vs. decreased vaping, or no change), and its associations with current nicotine dependence, vaping behavior, and reasons for vaping. Among YAs who vaped nicotine in the past year, 16.8% reported increased and 44.4% reported decreased vaping due to the pandemic, while 38.9% reported no change. Increased vaping (vs. decreased and/or no change) was significantly associated with nicotine dependence symptoms, current regular nicotine vaping, and vaping to relax, get high, and because of boredom. Self-reported increased vaping because of the pandemic was associated with increased risk for current nicotine dependence and frequent use. Increased vaping may have been a form of coping with pandemic-related stressors, which increases risk for future substance use problems.