From tobacco-endgame strategizing to Red Queen's race: The case of non-combustible tobacco products

Products and patterns through which adolescents, young adults, and adults initiate co-use of tobacco and cannabis

BACKGROUND

Co-use of tobacco and cannabis is common. However, few studies have examined the temporal sequencing through which individuals initiate co-use, and how these patterns vary across age. This study addresses this gap by examining the specific products and temporal sequencing through which adolescents, young adults, and adults initiate co-use of tobacco and cannabis. Among adolescents, young adults, and adults who co-used tobacco and cannabis in the past 30 days, we examined (a) whether tobacco or cannabis was used first in their lifetime and (b) which specific tobacco or cannabis product (e.g., nicotine e-cigarettes, cannabis edibles) was the first used.

METHODS

Data were from a cross-sectional national survey (N = 6,131, 13-40 years old) in which participants reported ever use, past-30-day-use, and order of use for 17 different tobacco and cannabis products. Results were analyzed overall and by age group (13-20; 21-24; 25-40).

RESULTS

38.4% of participants reported use of both tobacco and cannabis in the past 30 days. Among these participants, 70.9% used tobacco first in their lifetime (66.6% < 21; 71.7% 21-24; 76.6% > 24). Approximately 60% of participants who initiated co-use with tobacco reported nicotine e-cigarettes as their first tobacco product (63.3% < 21; 66.7% 21-24; 49.6% > 24).

CONCLUSIONS

The majority of participants who used both tobacco and cannabis used tobacco first in their lifetime, and nicotine e-cigarettes were the most common form of tobacco initiation, particularly among adolescents and young adults. Findings emphasize the need for co-use prevention programs to target common products of initiation.

Sociodemographic differences in use of nicotine, cannabis, and non-nicotine E-cigarette devices

BACKGROUND

Sociodemographic differences in e-cigarette use have been documented; however, disparities in use of specific e-cigarette types with various ingredients have yet to be thoroughly investigated. This study examines ever- and past-30-day-use of nicotine, cannabis, and non-nicotine e-cigarette device types by sex, sexual orientation, race/ethnicity, and financial comfort.

METHODS

Data were drawn from a 2021 national cross-sectional survey of adolescents, young adults, and adults (N = 6131, ages 13-40 years old). Participants reported ever and past-30-day-use of (1) disposable nicotine e-cigarettes, (2) pod/cartridge-based nicotine e-cigarettes, (3) "other" nicotine e-cigarettes, (4) non-nicotine e-cigarettes, (5) e-cigarettes with THC, and (6) e-cigarettes with CBD. We constructed summary tables for each e-cigarette device type in which percentages of ever and past-30-day-use were calculated by birth year category and sociodemographic variables: (a) sex, (b) sexual orientation, (c) race/ethnicity, and (d) financial comfort.

RESULTS

Females born between 1996 and 2008 reported higher rates of past-30-day disposable e-cigarette use relative to males (females 26.4%; males 22.4%). Compared to their heterosexual counterparts, LGBTQ+ participants reported higher overall rates of past-30-day-use for disposable (LGBTQ+ 27.9%; Heterosexual 23.8%), THC (LGBTQ+ 30.8%; Heterosexual 24.1%), and CBD e-cigarettes (LGBTQ+ 20.0%; Heterosexual 16.9%). Hispanic/Latino participants generally reported higher rates of past-30-day-use across device types relative to those identifying as Black or White non-Hispanic, particularly disposable nicotine e-cigarettes.

CONCLUSIONS

Findings highlight sociodemographic disparities in e-cigarette use, though differences varied based on e-cigarette device type and participant birth year category. Tailored preventive efforts may be necessary to mitigate e-cigarette use among populations at highest risk.

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.

Puff bars: a dangerous trend in adolescent disposable e-cigarette use

PURPOSE OF REVIEW

Puff Bars, a brand of disposable e-cigarettes, have skyrocketed in popularity recently, presenting significant health and safety risks to adolescents. Puff Bars and other disposable e-cigarette products are attractive to children and teenagers because of their vibrant colors and flavors, low cost, and ease of access. This review examines the rise in Puff Bar popularity, describes notable health and safety concerns, and provides advice for parents and pediatricians in identifying and preventing adolescent Puff Bar use.

RECENT FINDINGS

Puff Bars have increased in popularity as their product design evaded strict regulations imposed on alternate e-cigarette products, such as Juul. In addition, Puff Bars' sweet and fruit flavors and marketing on social media have made their use pervasive among youth. Puff Bar use can lead to increased risk of e-cigarette product use-associated lung injury (EVALI) and potential exposure to carcinogens. Furthermore, the developmental risks of nicotine use during adolescence include negative effects on cognitive function and detriments to short-term memory.

SUMMARY

Puff Bars present a significant danger to adolescents, and it is imperative that parents and pediatricians are aware of the health risks involved with vaping. Pediatricians should explore e-cigarette use during patient visits, and parents must communicate these dangers to their children and be able to identify these products to regulate their use.

Sociodemographic Factors Associated with Adolescents' and Young Adults' Susceptibility, Use, and Intended Future Use of Different E-Cigarette Devices

Numerous studies have identified sociodemographic factors associated with susceptibility, ever-use and past-30-day use of e-cigarettes, including JUUL. However, it remains unknown which sociodemographic factors are associated with adolescents' and young adults' (AYA) use of the entire spectrum of different types of e-cigarette devices (e.g., disposables, pod/cartridge-based, and other e-cigarettes, like mods or tanks). The aim of this study was to examine the relationship between sociodemographic factors and use, future use intent and susceptibility to use different e-cigarette device types. We conducted a national online survey using a convenience sample of 13-24-year-olds, 50:50 e-cigarette ever- to never-users and sex and race/ethnicity balanced per the U.S. Census (n = 4351). Sociodemographic factors were not associated with ever use of disposables among AYAs or generally with intent to use e-cigarette devices in the future. However, sociodemographic factors were related to the use of pod/cartridge-based and other e-cigarette devices. LGBTQ+ AYAs were more likely to use pod/cartridge-based devices and to be susceptible to using all device types compared to other AYAs. Young adults, males, and other/multiracial non-Hispanic AYAs were more likely to report past-30-day-use of all devices and AA/Black non-Hispanic AYAs were more likely to report past-30-day use of pod/cartridge-based and other devices compared to former users. AA/Black non-Hispanic AYAs were more likely to be susceptible to using all devices and other/multiracial non-Hispanic AYAs were susceptible to using other devices (compared to White non-Hispanic AYAs). AYAs under 21 who were former users were more likely to intend using other devices in the future compared to AYAs 21 years or above. These findings may inform targeted prevention efforts to curb the growing popularity of different devices among AYAs.

Adolescent Use of and Susceptibility to Heated Tobacco Products

BACKGROUND AND OBJECTIVES

A leading brand of heated tobacco products (HTPs), IQOS, was authorized to be sold in the United States in 2019. Researchers have examined the awareness and use of HTPs among US adults. In this study, we examined high school students' awareness, use, and susceptibility pertaining to HTPs.

METHODS

A large, cross-sectional population survey of randomly sampled 10th- and 12th-graders in California (N = 150 516) was conducted online during school hours from September 2019 to March 2020.

RESULTS

Overall, 8.9% (95% confidence interval [CI], 8.7%-9.1%) of California high school students had heard of HTPs. Approximately 0.67% (95% CI, 0.61%-0.73%) had ever tried HTPs, and 0.20% (95% CI, 0.17%-0.23%) were current users (ie, ∼30% of ever users continued to use HTPs at the time of survey). Among those who never tried HTPs, 18.3% (95% CI, 17.9%-18.8%) were susceptible to future use. The susceptibility to HTP use was greater among users of cigarettes or e-cigarettes than among nonusers.

CONCLUSIONS

The awareness of HTPs among adolescents was remarkable given the low availability of products at the time of survey. Only a small percentage of adolescents experimented with HTPs. However, almost a third of those who had experimented with HTPs continued to use them. This high ratio and the fact that almost 1 out of 5 never users were susceptible to future HTP use should put the public health community on high alert as more HTP products are coming into the market, with promotion of these products likely to increase.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Rethink Vape: Development and evaluation of a risk communication campaign to prevent youth E-cigarette use

INTRODUCTION

E-cigarettes are now the most common form of tobacco use among adolescents, and use is associated with increased risk of initiation of cigarette smoking. This project used a community-engaged research process to develop and pilot a risk communication campaign to prevent youth vaping.

METHOD

The research team worked with a 36-member Teen Advisory Council and a 19-member Expert Panel. Together, the team employed survey (N = 674) and focus group (N = 82) methodologies, and hired a marketing company to partner on development of the campaign. Campaign concepts were developed, eliminated, and/or modified through an iterative process of feedback and refinement. The final campaign included video ads (https://bit.ly/2QMR8gH) a microsite (rethinkvape.org), and social media sites (@rethinkvape). The campaign communicated three messages to teens: what's in the vapor, health risks, and connections to big tobacco. Prior to launch of the campaign, a randomized controlled 2 (time) × 2 (group) online experiment was conducted to evaluate the campaign (N = 268).

RESULTS

Repeated measures mixed analyses of variance indicated that vaping knowledge, perceptions of risk, and anti-vape intentions significantly increased among teens viewing the Rethink Vape Materials compared to their own baseline, while control participants did not change. Following evaluation, the team launched a 6-week online media campaign with a teen-targeted geo-fence radius to deliver 3,838,465 impressions, 770,443 completed video views, and 18,316 clicks in mobile app, Snapchat, YouTube, and Spotify platforms. The majority of placements exceeded industry standards, with mobile pre-roll and Snapchat as top performers.

CONCLUSIONS

The e-cigarette campaign showed promising signs of effectiveness and scalability.

Longitudinal trends in e-cigarette devices used by Californian youth, 2014-2018

The rate of adolescent and young adult (AYA) e-cigarette usage has increased in recent years, possibly due to the introduction of sleek new e-cigarette devices such as JUUL. This study analyzed data from 400 California AYA to examine trends in e-cigarette usage by device type (disposables, large-size rechargeables, vape/hookah pens, JUUL/pod-based). Participants were asked about their ever, past 30-day, and past 7-day use of e-cigarettes; their usual e-cigarette device used; and co-use of devices in seven surveys administered approximately biannually from 2014 to 2018. During this time period, total e-cigarette ever-usage in our cohort increased linearly from 14.1% to 46.2% (p_trend < 0.001). JUUL/pod-based e-cigarette ever-usage increased from 14.9% to 22.5% in just six months in 2018. Furthermore, a majority of new e-cigarette users at the time of the survey endorsed using JUUL/pod-based devices (58.3% in Wave 6, 73.0% in Wave 7). With newer device options, AYA were also increasingly less likely to endorse older models such as disposables (19.1% to 6.9% from 2014 to 2018, p_trend < 0.01) and rechargeables (69.1% to 26.2% from 2014 to 2018, p_trend < 0.001) as their usual e-cigarette device. Participants who used JUUL/pod-based only as their usual device were more likely to endorse using only JUUL/pod-based devices during follow-up survey (70%), and none switched to a new device completely. Overall, this study provides a snapshot of how AYA's e-cigarette preferences appear to respond to new devices entering the market.

What Does It Meme? A Qualitative Analysis of Adolescents' Perceptions of Tobacco and Marijuana Messaging

OBJECTIVES

With the increasing popularity of electronic cigarettes and legalization of recreational marijuana, messaging from websites and social media is shaping product perceptions and use. Quantitative research on the aesthetic appeal of these advertisements from the adolescent and young adult perspective is lacking. We evaluated (1) how adolescents and young adults perceived tobacco and marijuana messaging online and through social media platforms and (2) interactive behaviors related to these messages.

METHODS

We interviewed 24 participants from the Tobacco Perceptions Study, a longitudinal study of adolescents' and young adults' (aged 17-21) tobacco-related perceptions and tobacco use. We collected qualitative data from October 2017 through February 2018, through individual semi-structured interviews, on participants' experiences and interactions with online tobacco and marijuana advertisements and the advertisements' appeal. Two analysts recorded, transcribed, and coded interviews.

RESULTS

Themes that emerged from the interviews focused on the direct appeal of online messaging to adolescents and young adults; the value of trusting the source; the role of general attitudes and personal decision-making related to using tobacco and/or marijuana; the appeal of messaging that includes colors, interesting packaging, and appealing flavors; and the preference of messages communicated by young people and influencers rather than by industry.

CONCLUSION

These findings suggest the need for increased regulation of social media messaging and marketing of tobacco and marijuana, with a particular focus on regulating social media, paid influencers, and marketing that appeals to adolescents and young adults. The findings also suggest the importance of prevention programs addressing the role of social media in influencing the use of tobacco and marijuana.

Public Health Considerations for Adolescent Initiation of Electronic Cigarettes

Adolescent use of electronic cigarettes (e-cigarettes) has increased dramatically, with younger and nicotine-naive adolescents starting to use these devices and use them more frequently than combustible cigarettes. In emerging evidence, it is shown that e-cigarettes are not effective in helping adult smokers quit and that youth using e-cigarettes are at risk for becoming nicotine dependent and continuing to use as adults. Important gaps in our knowledge remain regarding the long-term health impact of e-cigarettes, effective strategies to prevent and reduce adolescent e-cigarette use, and the impact of provider screening and counseling to address this new method of nicotine use.

Point-of-sale marketing of heated tobacco products in Israel: cause for concern

Understanding how PMI markets IQOS at the point-of-sale in Israel is critical to determining whether marketing practices adhere to regulations and appeal to groups most at risk at initiating new tobacco products, such as adolescents. An article by Bar-Zev, Levine, Rubinstein, Khateb, and Berg (2019) examined the marketing of IQOS in retail stores in Israel. They found that while no free samples or promotions were provided at the point-of-sale, IQOS and their related HEETS (HeatSticks) were placed near youth-oriented merchandise and in prominent locations easily seen by youth. Further, package colors were used to indicate tobacco flavorings and strength, and retailers described the IQOS products as being less harmful, a cessation device, and not producing smoke. These findings are concerning given numerous studies linking marketing of novel tobacco products, product misperceptions, and subsequent tobacco use. Studies are needed to ensure that the marketing of IQOS, including the use of package colors, product placement at point-of-sales, and other product characteristics are significantly reducing harm and risk of tobacco-related disease to IQOS users, and that the health of the population as a whole, including those not using IQOS or other tobacco products, will not be harmed. Until such evidence is available, caution is warranted and regulations needed in the marketing of these novel products.

Impact of tobacco-pack pictorial warnings on youth and young adults: A systematic review of experimental studies

INTRODUCTION

We conducted a systematic review of the experimental literature on the impact of tobacco-pack pictorial warning labels (PWLs) on youth and young adults.

METHODS

We systematically searched computerized databases and the reference lists of relevant articles. We included studies that used an experimental protocol to assess PWLs. Studies had to report findings for youth or young adult samples (aged <30 years). Thirty-one studies met the inclusion criteria, with a total sample size of 27506. Two coders independently coded all study characteristics and outcomes.

RESULTS

Twenty-eight studies experimentally evaluated PWLs for cigarette packs while three studies evaluated PWLs for smokeless tobacco packs. Generally, PWLs led to higher attention, stronger cognitive and affective reactions, more negative pack attitudes and smoking attitudes, and increased intentions not to use tobacco products compared to text warnings. PWLs were perceived to be more effective than text warnings for both cigarette packs and smokeless tobacco packs.

CONCLUSIONS

The systematic review showed that PWLs on tobacco products are effective across a wide range of tobacco-related outcomes among young people. Gaps in the literature include a lack of research on tobacco initiation and cessation and a dearth of literature on non-cigarette tobacco products.