Exploring Attitudes of Children 12-17 Years of Age Toward Electronic Cigarettes

Youth Smoking Behavior and Policy Attitudes: A Study of High-School Students in the Maldives

Background

Tobacco use significantly impacts health and economic sectors. In the Maldives, 4 out of 10 men smoke daily, despite anti-tobacco policies. The Maldives Global Youth Tobacco Survey (GYTS) shows fluctuating cigarette smoking prevalence among secondary school students: 6.9% (2004), 3.8% (2007), 4.3% (2011), and 4.7% (2019). No studies have investigated smoking prevalence and attitudes toward anti-smoking policies among higher-secondary students in Addu City. This study examines smoking habits, susceptibility, and attitudes toward anti-smoking regulations to support policy development.

Methods

We conducted an observational cross-sectional study using a self-administered survey based on the GYTS and the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS), involving 335 high school students in Addu City. Variables included sociodemographic factors, ever-smokers, current smokers, age at first cigarette, smoking dependency, use of other tobacco products, smoking susceptibility, willingness to quit, and reasons to quit or not smoke. Results with p-values < 0.05 were statistically significant.

Results

22.8% of the students had tried smoking, with 4.74% currently smoking, predominantly males. Additionally, 32.2% had tried e-cigarettes. Smoking susceptibility was 44.2%. Seven students showed smoking dependency, with a significant gender difference (75.4% boys vs 33.3% girls, p < 0.05). Among smokers, 20% wanted to quit, and 70% cited cost as a deterrent. Only 20% of smokers supported a total ban on smoking in media compared to 49.8% of non-smokers (p = 0.03). Non-smokers significantly supported anti-smoking measures (73% vs 12.5% of smokers).

Conclusion

Cigarette smoking among high school students in Addu is below the national average, but the high number of ever-smokers and interest in smoking and e-cigarettes suggest potential future increases. Policymakers should enact stronger legislation, enforce age restrictions, raise tobacco taxes, and implement comprehensive smoking cessation programs to address tobacco use effectively.

Understanding the Associations Between Adolescents' Exposure to E-Cigarette Information and Vaping Behavior Through the Theory of Planned Behavior

Adolescents have actively looked for and passively scanned information about electronic cigarettes (e-cigarettes) from a variety of media and interpersonal sources. Despite the evidence that exposure to e-cigarette information is associated with youth's increased vaping intention, there is a paucity of scholarship that differentiates the sources where adolescents obtain e-cigarette information in their investigation, which limits our understanding of the unique association between vaping intention and e-cigarette information acquisition from specific sources. In addition, few studies have systematically examined the mechanism of the aforementioned associations. To fill the gap, an online national survey on a panel of adolescents between 13 to 17 years old was conducted. After controlling for potential confounders, several significant indirect effects were observed. Specifically, adolescents' vaping intention was negatively associated with e-cigarette information seeking from health professionals but positively with e-cigarette information exposure from family and friends, outdoors advertisements, social media, and other online channels, with the theory of planned behavior (TPB) constructs mediating these relationships. The findings not only contribute to the body of scholarship on TPB but also provide important suggestions for regulating outdoor and online e-cigarette information and designing persuasive interventions and campaigns.

Looking Cool, Doing Tricks, Managing Stress, and Nicotine Addiction: Youth Perspectives on Nicotine Vaping and Implications for Prevention

PURPOSE

To understand the contextual and psychosocial factors associated with youth vaping in Colorado, the state with the highest youth vaping rates in 2019, and to propose strategies for prevention interventions.

DESIGN

Focus groups.

SETTING

In-person.

PARTICIPANTS

24 youth aged 11-17, including youth who had vaped (n = 11) and who had never vaped (n = 13).

METHOD

Qualitative responses using a semi-structured focus group guide were analyzed using a matrix approach with a mixed deductive/inductive content analysis.

RESULTS

Analysis revealed the highly social nature of vaping initiation and use; the use of vaping to control negative emotions; and the acquisition of vaping products through retail outlets, friends, family, and other youth who sell a variety of substances and devices to youth. Youth provided insight into how vaping is concealed from parents and teachers, and their attitudes about the health risks and benefits of vaping.

CONCLUSION

When considered with other studies, our findings suggest a universality in the youth vaping experience that is highly social. Interventions should include peer-to-peer messaging with an emphasis on changing social norms and highlighting undesirable outcomes of vaping such as negative reactions by friends and close adults, adverse effects on athletic success and future aspirations, expense, addiction, and punishment. Parent education is also recommended. Rigorous research is needed to test interventions to reverse the growing trend of youth vaping.

Youth-appealing features in popular e-cigarette brand advertising in the USA after heightened scrutiny in 2018

PURPOSE

Youth electronic cigarette (e-cigarette) use remains high in the USA, and advertising is a contributor. The purpose of this study was to identify themes and characteristics of popular e-cigarette companies' advertising after e-cigarette companies became more highly scrutinised in 2018.

METHODS

Using a systematic, quantitative content analysis, three trained coders coded e-cigarette advertisements from JUUL, Puff Bar, Vuse and Blu from 2019 and 2020. Based on previous work, they coded for: type of advertisement, flavours, promotions, product cues, descriptors, claims, imagery, youth-oriented themes and sensational appeals.

RESULTS

Of the 401 e-cigarette advertisements, the majority were emails (38.2%) and Instagram posts (30.9%). Over half (53.6%) showed flavours other than tobacco, with Puff Bar leading the brands (70.2%; p<0.001). The most frequently used product cues were showing the product (51.4%) or packaging (42.4%). The most common claim was being an alternative to smoking (14.2%). The most frequently used imagery was fruit (14.0%), employed most by Puff Bar (p<0.001). The only youth-oriented theme present was humour (4.2%). Positive sensations (eg, good taste, good smell or satisfying; 17.1%) was the most common form of appeal, with Puff Bar using it at the highest frequency (p<0.001).

CONCLUSION

Even with heightened scrutiny of e-cigarette brands, advertisements still included youth-appealing content such as flavours, fruit imagery and positive sensations. Puff Bar led in all these categories, and it rapidly gained market share after market leader JUUL limited the sales of its flavoured products. Research should continue to monitor the characteristics of e-cigarette advertisements and consider their impact on youth.

"That's the whole thing about vaping, it's custom tasty goodness": a meta-ethnography of young adults' perceptions and experiences of e-cigarette use

BACKGROUND

E-cigarettes are increasing in popularity, particularly among young adults. With public health organisations contesting the possible benefits of e-cigarettes, research is required to explore young adults' use of e-cigarettes as a smoking cessation and recreational tool. This study examined existing qualitative data to understand how transition into adulthood and issues of identity affect young adults' perceptions and experiences of e-cigarette use.

METHODS

A meta-ethnography was conducted to examine how young adults perceive and use e-cigarettes. Data were synthesised using Noblit and Hare's (1988) meta-ethnographic approach. Bronfenbrenner's socio-ecological model (1979) was used to conceptualise themes and map findings.

RESULTS

A total of 34 studies were included in the review. Young adults viewed e-cigarettes as a safer alternative to traditional cigarette smoking and perceived e-cigarettes as an effective cessation tool. Users were able to personalise their e-cigarette use due to the variety of flavours and devices available. E-cigarettes were found to be a sociable tool as they allowed users to align themselves with their peers who used e-cigarettes and facilitated use within smoke-free environments. Young adults demonstrated high levels of self-efficacy with regards to obtaining e-cigarettes from various retailers and were active consumers of e-cigarette marketing.

CONCLUSION

This meta-ethnography provides an in-depth insight into social norms around e-cigarette use and beliefs that e-cigarettes could be a safer alternative to traditional cigarettes. As young adults increasingly engage with e-cigarettes, there is a need for informed policy decisions regarding appropriate use. Engagement with e-cigarettes is often reflected within social media, so this medium could be a key platform for creating tailored interventions which inform young adults about the appropriate use of these products.

The emerging norms of e-cigarette use among adolescents: A meta-ethnography of qualitative evidence

While qualitative research has indicated that adolescents' motivation for e-cigarette use is different than adults', this body of literature has not yet been brought together and synthesised. We reviewed qualitative evidence on perceptions and uses of e-cigarettes in order to explore the emerging norms of vaping among adolescents. We searched five databases for qualitative research in October 2019 with no restrictions on date of publication or data collection. We identified fifteen papers from thirteen studies. Using a meta-ethnographic approach, we identified a spectrum of descriptive and injunctive norms of vaping across the themes of addiction; perceptions of comparative harm; parental perceptions and peer perceptions. We found addiction and perceptions of comparative harm to reflect descriptive norms, while we found clearer evidence explaining the use and non-use of e-cigarettes through parental and peer approval of vaping. However, these norms were fluid, diverse and sometimes contradictory. This review provides a resource for researchers, policymakers and practitioners to better understand the ways that emerging norms could be influenced through policy and practice.

Electronic cigarette use among 14- to 17-year-olds in Europe

BACKGROUND

Studies comparing adolescent e-cigarette use in different countries are scarce. We study students' e-cigarette and conventional cigarette ever-use, their social correlates and e-liquid use in seven EU countries.

METHODS

SILNE-R data (N=12 167, response rate 79.4%) of 14-17-year-olds from Amersfoort (NL), Coimbra (PT), Dublin (IR), Hanover (GE), Latina (IT), Namur (BE) and Tampere (FI) were used. E-cigarette and conventional cigarette ever-use, dual-use, type of e-liquid and social correlates were measured with a school survey and analyzed with cross-tabulations and multinomial logistic regression.

RESULTS

About 34% had tried e-cigarettes, but the variation was large between the cities (Latina 50%; Hanover 23%). Of e-cigarette ever-users, 37% had used nicotine e-liquid, 43% exclusively non-nicotine liquid and 20% did not know the content. Nicotine e-liquid was more prevalent among monthly e-cigarette users and weekly smoking e-cigarette users. The social correlates were mainly the same for exclusive e-cigarette ever-use, exclusive conventional cigarette ever-use and dual-use. Boys had greater odds for exclusive e-cigarette and dual-use compared to girls. Of social correlates, low academic achievement and parental smoking were positively associated with all categories of use, but parental education and immigrant background were not. The strongest association was found between peer smoking (most/all best friends smoke) and dual-use (OR 34.29).

CONCLUSIONS

Students' e-cigarette ever-use varies greatly between EU countries. E-cigarettes seem not to be a substitute for conventional cigarettes but more a complementary product. Tobacco control policies might also prevent e-cigarette use but specific regulations on e-cigarettes are needed to prevent nicotine addiction originating from them.

Adolescent's Health Perceptions of E-Cigarettes: A Systematic Review

CONTEXT

E-cigarette use is increasing among adolescents, particularly in high-income countries. This review examines the health perceptions of E-cigarettes among adolescents (aged 12-17 years) residing in the U.S., United Kingdom, Canada, Australia, and New Zealand and their sources of E-cigarette information.

EVIDENCE ACQUISITION

Peer-reviewed literature published in January 2009-April 2019 in MEDLINE, Embase, and ProQuest were systematically reviewed using identified keywords. The search identified 654 references. Studies (n=99) that met the inclusion criteria were subjected to full-text screening. A total of 27 articles were subjected to quality appraisal using the Joanna Briggs Institute's critical appraisal checklists.

EVIDENCE SYNTHESIS

A total of 7 qualitative and 18 quantitative studies were included in the review, and the study characteristics, results, and limitations were extracted. A total of 4 main themes emerged from the study findings: (1) perceived relative harm of E-cigarettes versus that of cigarettes, (2) perceived health effects of E-cigarettes, (3) perceived benefits and safety of E-cigarettes, and (4) sources of E-cigarette information and exposure. Most adolescents perceived E-cigarettes to be less harmful than cigarettes; however, often, their health perceptions of E-cigarettes were conflicting. Sources of exposure to E-cigarette information included friends, family, retail point of sale, TV and online advertising, national agencies, healthcare providers, and from direct experience.

CONCLUSIONS

Findings indicate that adolescents, particularly E-cigarette users, have more favorable perceptions of E-cigarettes than of cigarettes; however, these perceptions are conflicting. Advertising, marketing, and peer and family networks appear to influence adolescents' perceptions. More research is required, particularly in Australia and New Zealand, to better understand adolescents' health perceptions of E-cigarettes and where they source information from so that misperceptions can be addressed through appropriate channels with suitable messaging.

PMI's heated tobacco products marketing claims of reduced risk and reduced exposure may entice youth to try and continue using these products

IMPORTANCE

Philip Morris International (PMI) is seeking Food and Drug Administration's (FDA) authorisation to market IQOS as a modified risk tobacco product and to make marketing claims of reduced risk and reduced exposure. Such claims may be misunderstood by youth, thereby increasing their risk for tobacco initiation.

OBJECTIVE

To assess youth (mean age 19.3, SD=1.7) understanding and perceptions of PMI's proposed consumer marketing claims of reduced risk and reduced exposure, we embedded a randomised controlled experiment into a survey of 450 California youth (April to August 2018). Participants were randomised to see 'reduced exposure', 'reduced risk' or neither claim. Perceptions of IQOS-related health risks and general harm and understanding of the term 'switching completely' as used in PMI's proposed claims were compared.

RESULTS

Mean expectancies to experience specific health risks did not differ by claim exposure. The reduced exposure group's perceptions of general harm did not differ from those of controls nor from the reduced risk group. The reduced risk group had the largest proportion who perceived IQOS as moderately/less harmful (n=78, 52%); controls the largest proportion perceiving IQOS as quite/extremely harmful (n=91, 63%). While 71% of the sample understood the term 'switch completely' correctly as used in the reduced risk (n=194, 71%) and reduced exposure (n=206, 72%) claims, more than 1 in 4 did not.

CONCLUSIONS

FDA and other regulators must use caution when considering allowing claims of reduced risk or reduced exposure to appear on retail tobacco packaging. Youth misunderstand such claims, and misperceptions of harm are known to lead to tobacco-use initiation.

E-cigarettes: How can they help smokers quit without addicting a new generation?

The dramatic increase in youth use of electronic nicotine delivery systems (ENDS; e.g., e-cigarettes) in the United States has focused regulatory efforts to address this concern while still encouraging smokers to switch completely to lower risk products or quit all tobacco product use. Increases in the minimum age for purchase of all tobacco products and changes in enforcement policy for ENDS have been recently enacted in an effort to address the youth vaping epidemic. Since all ENDS marketed after February 15, 2007 will be required to meet the "appropriate for the protection of public health" standard for marketing authorization of new products, ENDS manufacturers will have to demonstrate, in part, that their products help lessen the adverse impact on youth use. Some, such as disallowing flavors other than tobacco or menthol or limiting nicotine delivery, may help reduce youth use but could also inhibit smokers from quitting smoking. Other approaches, including reducing the high-tech appearance and discreteness of ENDS, discontinuing use of coupons and two-for-one type price incentives for ENDS, limiting retail sales of these products to adult-only facilities, and incorporating technological innovations such as biometrics or geofencing into ENDS, may help manufacturers demonstrate that marketing of their products would help reduce youth use of ENDS and lessen the epidemic, while still assuring adult smokers have access to products that encourage discontinuing combusted product use.

Associations Between Risk Perceptions and Cigarette, E-cigarette, and Dual-Product Use Among Canadian Adolescents

Introduction:

The popularity of e-cigarettes has increased significantly in recent years. E-cigarettes are perceived as less harmful than cigarettes, and both dual-use of cigarette and e-cigarette use is common among adolescents. This study assessed cigarette and e-cigarette risk perception and associations with dual-product use among Canadian adolescents.

Methods:

We used data from the 2016-2017 Canadian Student Tobacco, Alcohol, and Drugs Survey. Perceived risks of cigarette and e-cigarette use were classified into 4 categories: “high-risk perception,” “high-e-cigarette-risk and low-cigarette-risk perception,” “low-e-cigarette-risk and high-cigarette-risk perception,” and “low-risk perception.” Adjusted odds ratios (aOR) were estimated from multinomial logistic regression.

Results:

Of the population, 92% perceived high risk from cigarettes, and 65% from e-cigarettes. Compared to students with low-risk perception, those with high-risk perception of both products had lower odds of dual-use (aOR: 0.21; 95% confidence interval [CI]: 0.15, 0.28), cigarette-only use (aOR: 0.33; 95% CI: 0.25, 0.45), and e-cigarette-only use (aOR: 0.64; 95% CI: 0.51, 0.79) relative to nonusers. Adolescents with high-e-cigarette and low-cigarette-risk perception had higher odds of e-cigarette-only use, relative to nonusers. Those with high-risk perception were more likely to be e-cigarette-only users relative to cigarette-only users.

Conclusion:

Results highlight that high perceived risk is associated with lower odds of use. However, those with a high-risk perception of both products had higher odds of e-cigarette use relative to cigarette-only users; as did those with high-e-cigarette and low-cigarette-risk perception, relative to nonusers. Future research should assess ways of communicating the risks of adolescent tobacco use.

E-Cigarette Marketing and Communication: How E-Cigarette Companies Market E-Cigarettes and the Public Engages with E-cigarette Information

Introduction

Given the lack of regulation on marketing of electronic cigarettes (e-cigarettes) in the United States and the increasing exchange of e-cigarette-related information online, it is critical to understand how e-cigarette companies market e-cigarettes and how the public engages with e-cigarette information.

Methods

Results are from a systematic review of peer-reviewed literature on e-cigarettes via a PubMed search through June 1, 2017. Search terms included: "e-cigarette*" or "electronic cigarette" or "electronic cigarettes" or "electronic nicotine delivery" or "vape" or "vaping." Experimental studies, quasi-experimental studies, observational studies, qualitative studies, and mixed methods studies providing empirical findings on e-cigarette marketing and communication (ie, nonmarketing communication in the public) were included.

Results

One hundred twenty-four publications on e-cigarette marketing and communication were identified. They covered topics including e-cigarette advertisement claims/promotions and exposure/receptivity, the effect of e-cigarette advertisements on e-cigarette and cigarette use, public engagement with e-cigarette information, and the public's portrayal of e-cigarettes. Studies show increases in e-cigarette marketing expenditures and online engagement through social media over time, that e-cigarettes are often framed as an alternative to combustible cigarettes, and that e-cigarette advertisement exposure may be associated with e-cigarette trial in adolescents and young adults.

Discussion

Few studies examine the effects of e-cigarette marketing on perceptions and e-cigarette and cigarette use. Evidence suggests that exposure to e-cigarette advertisements affects perceptions and trial of e-cigarettes, but there is no evidence that exposure affects cigarette use. No studies examined how exposure to e-cigarette communication, particularly misleading or inaccurate information, impacts e-cigarette, and tobacco use behaviors.

Implications

The present article provides a comprehensive review of e-cigarette marketing and how the public engages with e-cigarette information. Studies suggest an association between exposure to e-cigarette marketing and lower harm perceptions of e-cigarettes, intention to use e-cigarettes, and e-cigarette trial, highlighting the need to for advertising regulations that support public health goals. Findings from this review also present the methodological limitations of the existing research (primarily due to cross-sectional and correlational analyses) and underscore the need for timely, rigorous research to provide an accurate understanding of e-cigarette marketing and communication and its impact on e-cigarette and tobacco product use.

Influence of Electronic Cigarette Characteristics on Susceptibility, Perceptions, and Abuse Liability Indices among Combustible Tobacco Cigarette Smokers and Non-Smokers

This study assessed how electronic cigarette (ECIG) characteristics amenable to regulation-namely nicotine content, flavor, and modified risk messages-impact ECIG use susceptibility, harm/addiction perceptions, and abuse liability indices among combustible tobacco cigarette (CTC) smokers and non-smokers. CTC smokers and non-smokers varying in ECIG use recruited via Amazon Mechanical Turk (MTurk) completed an online survey in 2016 (analytic n = 706). Participants were randomly assigned to one of eight conditions differing in ECIG characteristics: nicotine content (no, low, high), flavor (menthol, tobacco, fruit), or modified risk message (reduced harm, reduced carcinogen exposure). Regressions assessed ECIG susceptibility, harm/addiction perceptions, and abuse liability indices (purchase task measures of breakpoint/intensity) within each regulatory domain (nicotine content, flavor, message) and their interactions with CTC/ECIG status. Differential effects on ECIG susceptibility, harm/addiction perceptions, and abuse liability indices were observed by regulatory domain with many effects moderated by CTC/ECIG status. ECIG nicotine content and flavor conditions were the most influential across outcomes. Greater nicotine content, tobacco-flavored and reduced carcinogen exposure ECIGs were more highly preferred by CTC smokers with some differing preferences for non-users. Findings reinforce consideration of discrete ECIG preferences across tobacco use status to improve regulatory efficacy.

Offers of Cigarettes and E-Cigarettes Among High School Students: A Population Study from California

Receiving offers of cigarettes or e-cigarettes can contribute to the progression from intention to actual use. However, there is a lack of data about the prevalence or characteristics of youth being offered cigarettes or e-cigarettes. A random sample of 91 high schools in the state of California (with 40,137 students) participated in the 2015–16 California Student Tobacco Survey. Offers of cigarettes and e-cigarettes in the last 30 days were assessed. Separate multilevel logistical regression models identified student characteristics associated with being offered cigarettes and e-cigarettes. On average, 11.1% and 16.1% of all students reported being offered cigarettes and e-cigarettes in the last 30 days, respectively. Among those who received offers of cigarettes, 45.5% were never smokers. Among those who received offers of e-cigarettes, 29.6% were never vapers. Male students were more likely to report being offered an e-cigarette than female students (Adjusted Odds Ratio (AOR) 1.13), as were students with friends that used e-cigarettes (AOR 5.14–23.31) and those with high sensation seeking tendencies (AOR 1.33). Similar characteristics were associated with offers of cigarettes. Including measures of offers of cigarettes and e-cigarettes in surveillance systems could help identify those at risk of future cigarette and e-cigarette use.

Heated tobacco products likely appeal to adolescents and young adults

BACKGROUND

Beginning in the 1960s in the USA and globally since 1998, tobacco companies have beenaggressively promoting heated tobacco products (HTP). In 2016, Philip Morris International (PMI) applied to the US Food and Drug Administration (FDA) seeking authorisation to market their IQOS HTP system and flavoured 'HeatSticks' in the USA as a modified-risk tobacco product (MRTP).

METHODS

We systematically evaluated the publicly available data PMI submitted to FDA in its MRTP application to determine whether PMI's IQOS product meets the US Tobacco Control Act's standard for MRTP claims. We examined whether PMI provided sufficient data showing tobacco users will not initiate with IQOS, that youth will not misperceive the MRTP-related claims being made concerning IQOS, and how youth perceive health risks associated with IQOS.

RESULTS

PMI's own studies failed to provide evidence that youth, including non-users and former users, will not find IQOS appealing, will not initiate use of IQOS and will not perceive these products as risk-free. Further, PMI did not refer to independent studies conducted among adolescents which could influence their conclusions. Finally, their studies suffered from design and implementation flaws and cannot be relied on to support the proffered claims.

CONCLUSION

PMI's own data and available evidence from scientific studies conducted independent of the tobacco industry regarding how novel tobacco products are currently being marketed suggest that introduction of IQOS will result in adolescent and young adult non-users initiating tobacco use with IQOS and could also increase poly-use of IQOS along with other tobacco products.

E-cigarette users commonly stealth vape in places where e-cigarette use is prohibited

INTRODUCTION

'Stealth vaping' is the practice of vaping discreetly in places where electronic cigarette (e-cigarette) use is prohibited. While anecdotal evidence suggests that stealth vaping is common, there have been no formal studies of the behaviour. The purpose of this study is to examine stealth vaping behaviour among experienced e-cigarette users.

METHODS

Data were collected from the follow-up survey of a large longitudinal cohort study of adult experienced e-cigarette users conducted in January 2017. To measure stealth vaping behaviour, participants were asked 'Have you ever 'stealth vaped', that is to say, used an e-cig in a public place where it was not approved and attempted to conceal your e-cig use? (yes/no)'. Participants indicating yes completed additional questions about the frequency of stealth vaping and were asked to select all the locations where they commonly stealth vape. Frequencies were used to examine the overall prevalence, frequency and common locations for stealth vaping. A logistic regression model was run to predict stealth vaping.

RESULTS

Approximately two-thirds (64.3%, n=297/462) of the sample reported ever stealth vaping, of which 52.5% (n=156/297) reported stealth vaping in the past week. Among stealth vapers (n=297), 31% reported owning a smaller device solely for stealth vaping. The most common places to stealth vape included at work (46.8%), followed by bars/nightclubs (42.1%), restaurants (37.7%), at the movies (35.4%) and in airports/on airplanes (11.7%). Predictors of stealth vaping were greater dependence and owning a smaller device solely for stealth vaping.

CONCLUSIONS

Stealth vaping is a common behaviour for many experienced e-cigarette users. More research is needed to understand the reasons for stealth vaping and its potential health and safety implications. This information could help researchers and regulators to design interventions to minimise the public health impact of stealth vaping.

Adolescents' perceptions of flavored tobacco products, including E-cigarettes: A qualitative study to inform FDA tobacco education efforts through videogames

INTRODUCTION

Flavored tobacco products have been shown to appeal to youth, however tobacco control strategies have traditionally not focused on these products. To inform the adaptation of an existing videogame to focus on the prevention of flavored tobacco product use, this study explored adolescents' perceptions, beliefs, and social norms surrounding these products, including flavored e-cigarettes.

METHODS

We conducted and analyzed transcripts from seven focus groups with 11-17-year-old adolescents (n = 33) from after-school programs in CT and CA in 2016. Participants discussed flavored tobacco product beliefs and experiences, and how these compared to traditional cigarettes.

RESULTS

Thematic analysis of transcripts revealed that participants could name flavors in tobacco products, even though few discussed first-hand experience with the products. Most groups perceived that flavored tobacco product and flavored e-cigarette use facilitated peer approval and acceptance. All groups discussed how youth could easily access flavored tobacco products, including e-cigarettes. Flavoring was a salient aspect of e-cigarette advertisements; however the groups did not recall exposure to other types of flavored tobacco product counter-marketing.

CONCLUSIONS

These data can help inform the development of tobacco control strategies, novel interventions (such as videogames), and future FDA efforts to prevent adolescent tobacco product use through education and risk communication.

Favourable Perceptions of Electronic Cigarettes Relative to Cigarettes and the Associations with Susceptibility to Electronic Cigarette Use in Hong Kong Chinese Adolescents

We investigated favourable perceptions of electronic cigarettes (ECs) relative to cigarettes and their associations with EC use susceptibility in adolescents. Hong Kong Chinese Secondary 1-6 (U.S. grade 7-12) students (n = 40,202) were surveyed in 2014/2015 on EC use, cigarette smoking, favourable perceptions of ECs relative to cigarettes, EC use susceptibility, family smoking, and socio-demographic characteristics. Cox regression yielded adjusted prevalence ratios (APRs) of EC use susceptibility in never users, excluding those unaware of ECs. In all students, 8.9% were ever EC users, 47.2% reported favourable perceptions of ECs relative to cigarettes, such as less likely to cause accidents (25.2%) and less harmful to users (24.5%), and 28.9% did not know ECs. Among never EC users who were aware of ECs (n = 24,663), EC use susceptibility was associated with each of the favourable perceptions, especially greater attractiveness (APR 2.84, 95% CI 2.53-3.19), and better parental (2.75, 2.41-3.15) and school acceptability (2.56, 2.15-3.05). An increased number of favourable perceptions of ECs relative to cigarettes was associated more strongly with the susceptibility (p for trend < 0.001). Our findings inform strategies to reduce unwarranted favourable perceptions and prevent adolescent EC use.

Overview of Electronic Nicotine Delivery Systems: A Systematic Review

CONTEXT

Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.

EVIDENCE ACQUISITION

The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.

EVIDENCE SYNTHESIS

There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.

CONCLUSIONS

Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.

Secondhand smoke exposure at home among middle and high school students in the United States - does the type of tobacco product matter?

BACKGROUND

A decline in the prevalence of secondhand smoke (SHS) exposure has been observed in the United States of America (USA) during the past few decades. Nevertheless, nearly half of non-smoking students are still exposed to SHS. This paper aims to describe the factors associated with SHS exposure stratified by type of exposure (overall, cigarettes and electronic cigarettes).

METHODS

The analysis is based on secondary data taken from the National Youth Tobacco Survey 2014. Overall, 22,007 middle and high school students from the USA are included in the sample. Descriptive and bivariate statistics as well as binary logistic regression models were performed.

RESULTS

Overall, 44.5% (n=9,798) of the study participants declared themselves to be exposed to SHS, 29.1% (n=6,394) declared to be exposed to SHS caused by cigarette smoke and 9.4% (n=2,067) claimed that a person who lives with them uses electronic cigarettes. There is a considerable overlap between the two types of SHS exposure, because 74.9% (n=1,548) of students declaring that a person within their household uses electronic cigarettes also declare a person in the household smoking cigarettes. The strengths of association between independent variables and SHS exposure differs by type of exposure and also by smoking status of respondents.

CONCLUSIONS

Although only small differences are obvious in the factors associated with SHS exposure stratified by the type of tobacco product, there are still some variations which should be considered in policy making to allow for a targeted approach in prevention campaigns or legislation.

Adolescents' attitudes towards e-cigarette ingredients, safety, addictive properties, social norms, and regulation

E-cigarette use has dramatically increased. While studies have examined adolescents' attitudes towards smoking, few have extended this research to adolescents' attitudes towards e-cigarettes. The goal of this study was to examine adolescents' attitudes regarding e-cigarette ingredients, safety, addictive properties, social norms, accessibility, price, and regulation; and determine whether attitudes differ by past cigarette/e-cigarette use. Participants were 786 9th and 12th graders from California (63.21% females; mean age=16.10years [SD=1.6]; 26.61% White, 21.98% Asian/Pacific Islander, 29.82% Hispanic, and 21.59% other). Results indicated that 19.05% of participants believed smoke from e-cigarettes is water; 23.03% believed e-cigarettes aren't a tobacco product; 40.36% considered e-cigarettes to be for cessation, and 43.13% felt they were safer than cigarettes. Participants felt it was more acceptable to use e-cigarettes indoors and outdoors compared to cigarettes (p<0.0001), 23.13% felt raising e-cigarette taxes is a bad idea, 63.95% thought e-cigarettes were easier to get than cigarettes, 54.42% felt e-cigarettes cost too much, 64.33% felt the age for buying e-cigarettes should be raised, and 64.37% favored e-cigarette regulation. Adolescents who used e-cigarettes and/or cigarettes had significantly more favorable e-cigarette attitudes than non-users. This study indicates that adolescents are aware of some of the risks of e-cigarettes, although many harbor misperceptions and hold more favorable attitudes towards e-cigarettes than cigarettes. Of concern is the relationship between favorable e-cigarette attitudes and use. Findings suggest the need to provide adolescents with correct information about e-cigarette ingredients, risks, and the insufficient evidence of their role in cigarette cessation.