Global youth vaping and respiratory health: epidemiology, interventions, and policies

Perception of e-cigarette control policies and education in schools on increased legal knowledge, harm perception, susceptibility and e-cigarette use among students in Thailand: A cross-sectional classroom-based survey

INTRODUCTION

In Thailand, school smoke-free policies initially targeted cigarette smoking but now extend to include electronic cigarettes (e-cigarettes). Yet, the impact of this expansion on curbing e-cigarette use in schools is uncertain. This study seeks to explore how e-cigarette control policies and educational initiatives in Thai secondary schools influence students' legal knowledge, perception of harm, current e-cigarette use, and susceptibility to future use.

METHODS

This cross-sectional survey was conducted in four regions of Thailand between May and August 2023, involving 6147 students selected through multistage sampling. Data collection utilized a self-reported online questionnaire in Thai, developed using Google Forms. For continuous outcomes, multiple linear regression models assessed relationships between school e-cigarette policy perceptions, covariates, knowledge of e-cigarette laws, and harm perception. Multiple logistic regression models analyzed the association between policy perceptions, covariates, and categorical outcomes: current e-cigarette use and susceptibility.

RESULTS

Adjusting for covariates, a positive association was found between students' perceptions of e-cigarette policies and teachings and their knowledge of e-cigarette control laws (B=0.083, p<0.001) and harm perceptions (B=0.491, p<0.001). Additionally, these perceptions were protective against current e-cigarette use (AOR=0.970; 95% CI: 0.95-0.99, p=0.002) and susceptibility among non-users (AOR=0.962; 95% CI: 0.95-0.97; p<0.001).

CONCLUSIONS

A heightened perception of e-cigarette policies and teachings in schools is associated with increased legal knowledge, heightened harm perception, and a lower likelihood of current or future e-cigarette use. This underscores the importance of enforcing the e-cigarette-free policy in schools to mitigate vaping susceptibility amid the ongoing youth e-cigarette epidemic.

Impact of electronic cigarettes (e-cigs) and heat-not-burn/heated tobacco products (HnB/HTP) on asthma and chronic obstructive pulmonary disease: a viewpoint of the Italian Society of Internal Medicine

The association of cigarette smoking with several severe and very severe diseases (oncological, cardiovascular, respiratory) which have dramatic epidemiological, medical, and financial impact, is a well-known public threat. Asthma and chronic obstructive pulmonary disease (COPD) are highly prevalent diseases in Italy, posing significant public health challenges. Tobacco smoking, a primary risk factor for COPD and a common asthma trigger, remains a critical preventable public health issue. While universally acknowledged that quitting smoking drastically reduces the risk of smoking-related health issues, a significant portion of smokers and patients find quitting challenging or undesirable, hence a need for new ways to deal with it. A worth considering alternative might be the switch to electronic cigarettes (e-cig), and heat-not-burn/heated tobacco products (HnB/HTP). Emerging evidence suggests potential benefits in asthma and COPD management when transitioning from traditional smoking to e-cigs or HnB devices. However, the effectiveness of these products in facilitating smoking cessation is still debated, alongside concerns about their role in promoting smoking initiation among non-smokers. Internists are among the physicians who most frequently assist patients with smoking-related diseases, and in this perspective they cannot avoid paying attention to the progressive diffusion of smoking products alternative to the traditional cigarette, and to the controversies with respect to their use. In this context, the Italian Society of Internal Medicine, also recognizing a growing need for clarity for healthcare providers, has undertaken a comprehensive analysis of existing literature to offer an informed perspective on the health impact of e-cigs and HnB/HTP on asthma and COPD.

Lung cancer screening in Brazil: recommendations from the Brazilian Society of Thoracic Surgery, Brazilian Thoracic Association, and Brazilian College of Radiology and Diagnostic Imaging

Although lung cancer (LC) is one of the most common and lethal tumors, only 15% of patients are diagnosed at an early stage. Smoking is still responsible for more than 85% of cases. Lung cancer screening (LCS) with low-dose CT (LDCT) reduces LC-related mortality by 20%, and that reduction reaches 38% when LCS by LDCT is combined with smoking cessation. In the last decade, a number of countries have adopted population-based LCS as a public health recommendation. Albeit still incipient, discussion on this topic in Brazil is becoming increasingly broad and necessary. With the aim of increasing knowledge and stimulating debate on LCS, the Brazilian Society of Thoracic Surgery, the Brazilian Thoracic Association, and the Brazilian College of Radiology and Diagnostic Imaging convened a panel of experts to prepare recommendations for LCS in Brazil. The recommendations presented here were based on a narrative review of the literature, with an emphasis on large population-based studies, systematic reviews, and the recommendations of international guidelines, and were developed after extensive discussion by the panel of experts. The following topics were reviewed: reasons for screening; general considerations about smoking; epidemiology of LC; eligibility criteria; incidental findings; granulomatous lesions; probabilistic models; minimum requirements for LDCT; volumetric acquisition; risks of screening; minimum structure and role of the multidisciplinary team; practice according to the Lung CT Screening Reporting and Data System; costs versus benefits of screening; and future perspectives for LCS.

E-cigarettes and Youth: The Known, the Unknown, and Implications for Stakeholders

ABSTRACT

Despite the decline in the prevalence of e-cigarette use among youth during the coronavirus disease 2019 pandemic, more than 2.5 million of US high and middle schoolers are still using e-cigarettes. Furthermore, those who use e-cigarettes are starting at a younger age and are using them more intensely, reflecting, at least in part, a high addiction liability of modern e-cigarettes. Beyond addiction, accumulating evidence suggests that, in the short-term, e-cigarettes are associated with cardiovascular and pulmonary effects, whereas the long-term effects of e-cigarette use are yet to be established. The aim of this review is to synthesize current knowledge on e-cigarette use among youth, including established and potential risks and efforts to date to curb youth exposure to e-cigarettes. In addition, we provide recommendations for health care providers, researchers, and other stakeholders to address this significant public health issue.

Assessing the public discourse on Twitter: Reactions to the JUUL e-cigarettes ban in the United States

INTRODUCTION

JUUL is a high-nicotine pod-based vaping device that is popular among adolescents and young adults. On 23 June 2022, the US Food and Drug Administration (FDA) denied authorization to market JUUL, and ordered JUUL Labs to remove products from the US market. The next day, a US federal appeals court temporarily suspended the ban. The mixed public discourse surrounding the FDA ban warrants further investigation.

METHODS

This study examined Twitter data to describe public reaction to these announcements. Posts containing terms 'JUUL' and/or '#JUUL' (N=97548 unique tweets) were collected from 23 June to 3 July 2022, from Twitter's Streaming Application Programming Interface (API). After removing retweets, we used an inductive approach to become familiar with the data, generated a codebook, and conducted a content analysis on a random sample of n=4000 tweets.

RESULTS

A total of 2755 (68.9%) tweets discussed JUUL in the context of the FDA ban. News (n=1425/2755; 51.7%) about the JUUL ban, government distrust (n=588; 21.3%), and individual rights (n=253; 9.2%) were the most prevalent themes. Less commonly discussed themes included inconsistencies between policies (n=174; 6.3%), mentions of switching to other products (n=162; 5.9%), smoking cessation (n=99; 3.6%), and craving for JUUL (n=94; 3.4%). Sentiment analysis of JUUL ban-related posts (n=2755) demonstrated that 1989 (72.2%) tweets were categorized as neutral, while anti-ban posts (n=566; 20.5%) were more prevalent than pro-ban posts (n=200; 7.3%).

CONCLUSIONS

Besides straightforward announcements of the JUUL ban and its suspension, Twitter posts discussed government distrust, individual rights, and policy inconsistencies. While most posts conveyed neutral sentiments, anti-ban posts were almost three times more prevalent than pro-ban posts. Our findings suggest that text-based social media platforms like Twitter may be an effective instrument to understand opinions, attitudes, and beliefs regarding the FDA's JUUL ban.

The combination of propylene glycol and vegetable glycerin e-cigarette aerosols induces airway inflammation and mucus hyperconcentration

Despite concerns over their safety, e-cigarettes (e-cigs) remain a popular tobacco product. Although nicotine and flavors found in e-cig liquids (e-liquids) can cause harm in the airways, whether the delivery vehicles propylene glycol (PG) and vegetable glycerin (VG) are innocuous when inhaled remains unclear. Here, we investigated the effects of e-cig aerosols generated from e-liquid containing only PG/VG on airway inflammation and mucociliary function in primary human bronchial epithelial cells (HBEC) and sheep. Primary HBEC were cultured at the air-liquid interface (ALI) and exposed to e-cig aerosols of 50%/50% v/v PG/VG. Ion channel conductance, ciliary beat frequency, and the expression of inflammatory markers, cell type-specific markers, and the major mucins MUC5AC and MUC5B were evaluated after seven days of exposure. Sheep were exposed to e-cig aerosols of PG/VG for five days and mucus concentration and matrix metalloproteinase-9 (MMP-9) activity were measured from airway secretions. Seven-day exposure of HBEC to e-cig aerosols of PG/VG caused a significant reduction in the activities of apical ion channels important for mucus hydration, including the cystic fibrosis transmembrane conductance regulator (CFTR) and large conductance, Ca2+-activated, and voltage-dependent K+ (BK) channels. PG/VG aerosols significantly increased the mRNA expression of the inflammatory markers interleukin-6 (IL6), IL8, and MMP9, as well as MUC5AC. The increase in MUC5AC mRNA expression correlated with increased immunostaining of MUC5AC protein in PG/VG-exposed HBEC. On the other hand, PG/VG aerosols reduced MUC5B expression leading overall to higher MUC5AC/MUC5B ratios in exposed HBEC. Other cell type-specific markers, including forkhead box protein J1 (FOXJ1), keratin 5 (KRT5), and secretoglobin family 1A member 1 (SCGB1A1) mRNAs, as well as overall ciliation, were significantly reduced by PG/VG exposure. Finally, PG/VG aerosols increased MMP-9 activity and caused mucus hyperconcentration in sheep in vivo. E-cig aerosols of PG/VG induce airway inflammation, increase MUC5AC expression, and cause dysfunction of ion channels important for mucus hydration in HBEC in vitro. Furthermore, PG/VG aerosols increase MMP-9 activity and mucus concentration in sheep in vivo. Collectively, these data show that e-cig aerosols containing PG/VG are likely to be harmful in the airways.

Influence of age on clinical characteristics, pharmacological management and exacerbations in children with asthma

BACKGROUND

Asthma trials and guidelines often do not distinguish between adolescents and younger children. Using a large English data set, we evaluated the impact of age on asthma characteristics, management and exacerbations.

METHODS

Primary care medical records, 2004-2021, were linked to hospital records. Children were categorised by age at diagnosis and followed until the next age bracket. Ages (based on management guidelines) were 5-8 years, 9-11 years and adolescents (12-16 years). Characteristics evaluated included body mass index, allergies and events before and after diagnosis (symptoms, medication). Exacerbation incidence was calculated. Multivariable Cox proportional hazards determined associations with exacerbations.

RESULTS

119 611 children were eligible: 61 940 (51.8%) 5-8 years, 32 316 (27.7%) 9-11 years and 25 355 (21.2%) adolescents. Several characteristics differed by age; children aged 5-8 years had the highest proportion with eczema, food/drug allergy and cough, but adolescents had the highest proportion with overweight/obesity, aeroallergen sensitisation, dyspnoea and short-acting-beta-agonist only use. Exacerbation rates were highest in the youngest children (per 100 person-years (95% CI): 5-8 years =13.7 (13.4-13.9), 9-11 years =10.0 (9.8-10.4), adolescents =6.7 (6.5-7.0)). Exacerbation risk factors also differed by age; 5-8 years: male, eczema and food/drug allergy were strongly associated, but for children ≥9 years old, obesity and aeroallergen sensitisation were strongly associated. For all children, higher socioeconomic deprivation was significantly associated with having an exacerbation. Delayed diagnosis was most common in children aged 5-8 years and was associated with increased exacerbations across all ages.

CONCLUSION

Children's baseline characteristics and exacerbation rates varied according to their age group. Clinical guidelines should consider age at time of diagnosis more discretely than the broad range, 5-16 years, as this appears to impact on asthma severity and management.

The commercial promotion of electronic cigarettes on social media and its influence on positive perceptions of vaping and vaping behaviours in Anglophone countries: A scoping review

There is ongoing scientific and policy debate about the role e-cigarettes play in tobacco control, with concerns centring around unknown long-term effects, and the potential industry co-option of harm reduction efforts, including marketing to youths. There is substantial evidence of the influence of conventional cigarette promotion on smoking behaviours in Anglophone countries, and the popularity of social networking sites, as well as the lack of marketing regulations on the commercial promotion of electronic cigarettes online, suggest an urgent need to explore this topic further. This scoping review aims to map the existing evidence related to the influence of e-cigarette commercial promotion on social media on positive perceptions of vaping and vaping behaviours in core Anglophone countries. Searches were conducted in CENTRAL, Cochrane Database of Systematic Reviews (CDSR), Embase, Epistemonikos, MEDLINE, PsycINFO and Science Citation Index, on the 21st of July 2022. From 1,385 studies, 11 articles were included in the final review, using diverse study designs, including focus groups, content analysis, cross-sectional studies, and experiments. The studies were primarily based in the U.S. and evidenced the association between the commercial promotion of e-cigarettes on social media with positive perceptions of vaping and vaping behaviours, particularly among young people, addressing diverse themes including celebrities' sponsorship, e-liquid appeal (including flavours and nicotine levels), users' engagement with ads, and other marketing strategies. Further, social networking sites commercially promoting e-cigarettes might increase positive attitudes towards vaping and vaping behaviours, particularly among youths. Future research should be conducted in broader settings, incorporate larger and diverse sample sizes, ensure research transparency, cover multiple social networking sites, emphasize ecological validity, and foment longitudinal studies.

Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review

INTRODUCTION

Many jurisdictions have implemented different regulatory strategies to reduce vaping among youth. The objective of this systematic review is to synthesize the evidence of the effectiveness of different regulatory strategies for preventing and reducing nicotine vaping among youth.

METHODS

Five electronic databases were searched from January 1, 2004 to July 17, 2022 for primary studies examining state/provincial or national regulations targeting vaping among youth (aged 12-21 years) in high-income countries. The primary outcome was vaping prevalence. Included studies were qualitatively synthesized through systematic review.

RESULTS

The systematic review included 30 studies. There was insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping. Included studies had moderate-to-serious risks of bias.

DISCUSSION

Although several regulatory interventions have been shown to be effective at reducing vaping among youth, evidence is insufficient to recommend a specific type of regulation. Regulatory authorities could implement various regulations targeting the price, accessibility, and desirability (i.e., flavors and packaging) of E-cigarettes.

Electronic Nicotine Delivery Systems (ENDS) use Among Members of a Community Engagement Program

Electronic nicotine delivery systems (ENDS) are relatively new and ENDS use data from community engagement programs may help us understand usage patterns and facilitate targeted longitudinal studies. Community members in Florida, USA, were asked about ENDS use, tobacco use, and health history/concerns by Community Health Workers. Among 7253 members recruited during 2014 to 2021 into our HealthStreet program, 1177 had ever used ENDS; the proportion increased from 12 to 27% from 2014 to 2021 (adjusted odds ratio (aOR) 2.5; 95% CI 1.7-3.5; Ever versus never used ENDS). Ever tobacco use was strongly associated with ENDS use; 69% of ever users were current tobacco users. Demographic determinants (sex, age, race) and food insecurity were strongest predictors of ENDS use. Most who had ever used ENDS were aged 18-25 (aOR 5.9; 95% CI 4.6-7.6; vs. aged 60 + years), White (aOR 3.7; 95% CI 3.2-4.3; vs. Black/African American), male (aOR 1.5; 95% CI 1.3-1.7; vs. female), and recently food insecure (aOR 1.8; 95% CI 1.5-2.0; vs. not recently food insecure). Those with respiratory issues were more likely to have used ENDS compared to those without (aOR 2.0; 95% CI 1.6-2.6; aOR 1.3; 95% CI 1.1-1.5). Members concerned about hypertension were less likely to have used ENDS (aOR 0.7; 95% CI 0.5-0.9). In this relatively rural, micropolitan sample, tobacco use, socio-economic determinants, and certain health history/concerns were strongly associated with ENDS use. Community outreach approaches are needed to further understand these factors and implement interventions.

Youth E-Cigarette Use and Functionally Important Respiratory Symptoms: The Population Assessment of Tobacco and Health (PATH) Study Waves 3 and 4

Respiratory effects of e-cigarette use among youth are not fully understood. This study investigated the longitudinal association between e-cigarette use and a validated index of functionally important respiratory symptoms among US youth. Data from Waves 3-4 of the Population Assessment of Tobacco and Health Study were analyzed. The sample included youth (aged 12-17) without asthma at baseline (Wave 3), who completed a follow-up survey (Wave 4), and were not missing data for analytic variables (n = 3899). Exposure was e-cigarette use status (never, former, or current) at baseline. The outcome was a respiratory symptom index based on responses for seven wheezing items at Wave 4. An index of ≥2 was defined as having functionally important respiratory symptoms. Lagged logistic regression models examined the association between baseline e-cigarette use and functionally important respiratory symptoms at follow-up by combustible tobacco use status (never or ever), and controlling for baseline covariates. At baseline, 13.7% of participants reported former e-cigarette use, and 4.3% reported current use. Baseline e-cigarette use did not increase the odds of having functionally important respiratory symptoms at follow-up regardless of combustible tobacco use status. Future research on larger populations of e-cigarette users with longer follow-up periods will improve our understanding of the respiratory risks associated with e-cigarette use among youth.