Intensive Longitudinal Study of the Relationship Between Cigalike E-cigarette Use and Cigarette Smoking Among Adult Cigarette Smokers Without Immediate Plans to Quit Smoking

Assessment of abuse liability and switching potential of menthol-flavored pod-based electronic nicotine delivery systems among US adults who smoke cigarettes

BACKGROUND

Menthol-flavored electronic nicotine delivery systems (ENDS) are a focus of public health and regulatory policy considerations. The abuse liability of five menthol-flavored pod-based ENDS was compared to combustible cigarettes, and switching potential of ENDS was also evaluated.

METHODS

215 US adults who smoke cigarettes (34.4% female; mean age[SD]=29.60[8.75]; 40.9% non-Hispanic White; mean cigarettes/day[SD]=12.04[8.52]) completed a randomized 6-arm within-person cross-over product-use study. Participants used five pod-based menthol-flavored ENDS (JUUL2 Polar Menthol 1.5%, JUUL2 Prototype Fresh Menthol 3.0%, JUUL Menthol 5.0%, Vuse Alto Menthol 5.0%, NJOY Ace Menthol 5.0%) and their usual brand (UB) cigarette for 20minutes ad libitum. After each product use, subjective reinforcing effects relevant to abuse liability and associated with switching away from cigarettes (e.g., satisfaction, product liking) were assessed.

RESULTS

All ENDS products were rated substantially and statistically significantly lower than UB cigarette on measures of subjective reinforcing effects (ps<0.001). Satisfying effects of JUUL2 1.5% were rated significantly higher than other ENDS products. JUUL2 Prototype 3.0% and Vuse Alto 5.0% did not significantly differ (ps>0.05), and both were rated significantly higher than JUUL 5.0% and NJOY Ace 5.0% (ps<0.05). Differences in subjective responses to study products did not significantly differ by preference for menthol cigarettes or by current ENDS use.

CONCLUSIONS

Abuse liability of all menthol-flavored ENDS in this study was substantially lower than combustible cigarettes. Abuse liability of JUUL2 1.5% was within the range of currently marketed pod-based menthol-flavored ENDS products. JUUL2 1.5% likely has high potential for facilitating switching among US adults who smoke.

E-Cigarette Use Among US Adults in the 2021 Behavioral Risk Factor Surveillance System Survey

Importance

After the initial disruption from the COVID-19 pandemic, it is unclear how patterns of e-cigarette use in the US have changed.

Objective

To examine recent patterns in current and daily e-cigarette use among US adults in 2021.

Design, Setting, and Participants

This cross-sectional study used data from the 2021 Behavioral Risk Factor Surveillance System (BRFSS) database. The BRFSS is the largest national telephone-based survey of randomly sampled adults in the US. Adults aged 18 years or older, residing in 49 US states (all except Florida), the District of Columbia, and 3 US territories (Guam, Puerto Rico, and the US Virgin Islands), were included in the data set. Data analysis was performed in January 2023.

Main Outcomes and Measures

The main outcome was age-adjusted prevalence of current and daily e-cigarette use overall and by participant characteristics, state, and territory. Descriptive statistical analysis was conducted, applying weights to account for population representation.

Results

This study included 414 755 BRFSS participants with information on e-cigarette use. More than half of participants were women (51.3%). In terms of race and ethnicity, 0.9% of participants were American Indian or Alaska Native, 5.8% were Asian, 11.5% were Black, 17.3% were Hispanic, 0.2% were Native Hawaiian or Other Pacific Islander, 62.2% were White, 1.4% were of multiple races or ethnicities, and 0.6% were of other race or ethnicity. Individuals aged 18 to 24 years comprised 12.4% of the study population. The age-standardized prevalence of current e-cigarette use was 6.9% (95% CI, 6.7%-7.1%), with almost half of participants using e-cigarettes daily (3.2% [95% CI, 3.1%-3.4%]). Among individuals aged 18 to 24 years, there was a consistently higher prevalence of e-cigarette use, with more than 18.6% reporting current use and more than 9.0% reporting daily use. Overall, among individuals reporting current e-cigarette use, 42.2% (95% CI, 40.7%-43.7%) indicated former combustible cigarette use, 37.1% (95% CI, 35.6%-38.6%) indicated current combustible cigarette use, and 20.7% (95% CI, 19.7%-21.8%) indicated never using combustible cigarettes. Although relatively older adults (aged ≥25 years) who reported current e-cigarette use were more likely to report former or current combustible cigarette use, younger adults (aged 18-24 years) were more likely to report never using combustible cigarettes. Notably, the proportion of individuals who reported current e-cigarette use and never using combustible cigarettes was higher in the group aged 18 to 20 years (71.5% [95% CI, 66.8%-75.7%]) compared with those aged 21 to 24 years (53.0% [95% CI, 49.8%-56.1%]).

Conclusion and Relevance

These findings suggest that e-cigarette use remained common during the COVID-19 pandemic, particularly among young adults aged 18 to 24 years (18.3% prevalence). Notably, 71.5% of individuals aged 18 to 20 years who reported current e-cigarette use had never used combustible cigarettes. These results underscore the rationale for the implementation and enforcement of public health policies tailored to young adults.

Associations between nicotine vaping uptake and cigarette smoking cessation vary by smokers' plans to quit: longitudinal findings from the International Tobacco Control Four Country Smoking and Vaping Surveys

BACKGROUND AND AIMS

Most population studies that evaluate the relationship between nicotine vaping and cigarette cessation focus on limited segments of the smoker population. We evaluated vaping uptake and smoking cessation considering differences in smokers' plans to quit.

DESIGN

Longitudinal International Tobacco Control (ITC) Four Country Smoking and Vaping Surveys were conducted in 2016, 2018 and 2020.

SETTING

This study was conducted in the United States, Canada, England and Australia.

PARTICIPANTS

Participants of this study were adult daily cigarette smokers who had not vaped in the past 6 months at baseline and had participated in two or more consecutive waves of the ITC Four Country Smoking and Vaping Surveys (n = 2815).

MEASUREMENTS

Plans to quit cigarette smoking was assessed at baseline (within 6 months, beyond 6 months, not planning to quit) and at follow-up (within 6 months vs not within 6 months), cigarette smoking cessation was assessed at follow-up (smoking less than monthly [including complete cessation] vs daily/weekly/monthly smoking) and inter-wave vaping uptake was assesed between baseline and follow-up (none, only non-daily vaping and any daily vaping). Generalized estimating equations were used to evaluate whether inter-wave vaping uptake was associated with smoking cessation at follow-up and with planning to quit at follow-up, each stratified by plans to quit smoking at baseline.

FINDINGS

Overall, 12.7% of smokers quit smoking. Smokers not initially planning to quit within 6 months experienced higher odds of smoking cessation when they took up daily vaping (32.4%) versus no vaping (6.8%; adjusted odds ratio [AOR], 8.58; 95% CI, 5.06-14.54). Among smokers planning to quit, smoking cessation rates were similar between those who did and did not take up daily vaping (25.1% vs 16.8%; AOR, 1.91; 95% CI, 0.91-4.00), although we could not account for potential use of cessation aids. Daily vaping uptake was associated with planning to quit smoking at follow-up among those initially not planning to quit (AOR,6.32; 95% CI, 4.17-9.59).

CONCLUSIONS

Uptake of nicotine vaping appears to be strongly associated with cigarette smoking cessation among smokers with no initial plans to quit smoking. Excluding smokers not planning to quit from studies on vaping and smoking cessation may underestimate potential benefit of daily vaping for daily smokers.

Designing Studies to Inform Tobacco Harm Reduction: Learnings From an Oral Nicotine Pouch Actual Use Pilot Study

Background

Introduction of new tobacco products in the United States, including those that may be lower on the risk continuum than traditional combustible cigarettes, requires premarket authorization by the US Food and Drug Administration and information on the potential impact of the products on consumer behaviors. Efficient recruitment and data capture processes are needed to collect relevant information in a near-to-real-world environment.

Objective

The aim of this pilot study was to develop and test a protocol for an actual use study of a new tobacco product. The product included in this study was a commercially available oral nicotine pouch. Through the process of study design and execution, learnings were garnered to inform the design, execution, analysis, and report writing of future full-scale actual use studies with tobacco products.

Methods

A small sample (n=100) of healthy adult daily smokers of 7 or more cigarettes per day were recruited to participate in an 8-week prospective observational study conducted at 4 geographically dispersed sites in the United States. A smartphone-based customized electronic diary (eDiary) was employed to capture daily tobacco product use, including 1 week of baseline smoking and 6 weeks during which participants were provided with oral nicotine pouches for use as desired.

Results

Online screening procedures with follow-up telephone interviews and on-site enrollment were successfully implemented. Of 100 participants, 97 completed the study, with more than half (59/99, 60%) identifying as dual- or poly-users of cigarettes and other types of tobacco products at baseline. There was more than 90% (91-93/99, 92%-94%) compliance with daily eDiary reporting, and the majority (92/99, 93%) of participants expressed satisfaction with the study processes. Product use data from the eDiary indicated that after an initial period of trial use, pouches per day increased among those continuing to use the products, while per day average cigarette consumption decreased for 82% (79/97) of all study participants. At the end of the week 6, 16% (15/97) of participants had reduced their cigarette consumption by more than half.

Conclusions

The design of this study, including recruiting, enrollment, eDiary use, and oversight, was successfully implemented through the application of a detailed protocol, a user-friendly eDiary, electronically administered questionnaires, and remote monitoring procedures. High-resolution information was obtained on prospective changes in tobacco product use patterns in the context of availability of a new tobacco product. Future, larger actual use studies will provide important evidence supporting the role that alternatives to combustible cigarettes may play in smoking reduction and/or cessation and lowering the population health burden of tobacco and nicotine-containing products.

Assessment of Patterns in e-Cigarette Use Among Adults in the US, 2017-2020

Importance

Updated data on the patterns of e-cigarette use among adults in the US are needed.

Objective

To examine recent patterns in current and daily e-cigarette use among US adults.

Design, Setting, and Participants

This repeated cross-sectional study used data from the 2017, 2018, and 2020 Behavioral Risk Factor Surveillance System, a nationally representative state-based survey of noninstitutionalized US adults. A total of 994 307 adults 18 years and older who were living in states and territories that provided data on e-cigarette use in 2017 (53 states and territories), 2018 (36 states and Guam), and 2020 (42 states and Guam) were included.

Main Outcomes and Measures

The weighted prevalence of current (past 30 days) and daily e-cigarette use was estimated for each year, and changes in prevalence from 2017 to 2020 were assessed, first overall and then stratified by participant characteristics, including state or territory of residence.

Results

Among 994 307 adults from states with data on e-cigarette use, 429 370 individuals (weighted 51.3% female) were participants in the 2017 survey, 280 184 (weighted 52.1% female) were participants in the 2018 survey, and 284 753 (weighted 52.1% female) were participants in the 2020 survey. The weighted proportions of young adults aged 18 to 24 years were 12.6% in 2017, 11.8% in 2018, and 11.9% in 2020. Across all 3 years, 17 035 participants (weighted, 1.0%) were American Indian or Alaska Native, 22 313 (weighted, 4.6%) were Asian, 75 780 (weighted, 12.2%) were Black, 72 190 (weighted, 15.1%) were Hispanic, 4817 (weighted, 0.2%) were Native Hawaiian, 757 140 (weighted, 65.1%) were White, 20 332 (weighted, 1.3%) were multiracial, and 6245 (weighted, 0.5%) were of other races and/or ethnicities. The prevalence of current e-cigarette use was 4.4% (95% CI, 4.3%-4.5%) in 2017, which increased to 5.5% (95% CI, 5.4%-5.7%) in 2018 and decreased slightly to 5.1% (95% CI, 4.9%-5.3%) in 2020. The recent decrease, though modest, was observed mainly among young adults aged 18 to 20 years (from 18.9% [95% CI, 17.2%-20.7%] to 15.6% [95% CI, 14.1%-17.1%]; P = .004). However, the prevalence of daily e-cigarette use increased consistently from 1.5% (95% CI, 1.4%-1.6%) in 2017 to 2.1% (95% CI, 2.0%-2.2%) in 2018 and 2.3% (95% CI, 2.2%-2.4%) in 2020. Among young adults aged 21 to 24 years, there was a slight, albeit insignificant, increase in the prevalence of current e-cigarette use (from 13.5% [95% CI, 12.3%-14.7%] to 14.5% [95% CI, 13.2%-15.9%]; P = .28) but a significant increase in the prevalence of daily e-cigarette use (from 4.4% [95% CI, 3.8%-5.1%] to 6.6% [95% CI, 5.6%-7.6%]; P < .001) between 2018 and 2020. State-level patterns in the prevalence of current e-cigarette use were heterogeneous, with states like Massachusetts (from 5.6% [95% CI, 4.8%-6.5%] to 4.1% [95% CI, 3.1%-5.3%]; P = .03) and New York (from 5.4% [95% CI, 4.9%-5.9%] to 4.1% [95% CI, 3.5%-4.7%]; P = .001) recording significant decreases between 2018 and 2020. In contrast, Guam (from 5.9% [95% CI, 4.5%-7.9%] to 11.4% [95% CI, 8.7%-14.8%]; P = .002) and Utah (from 6.1% [95% CI, 5.5%-6.7%] to 7.2% [95% CI, 6.5%-8.0%]; P = .02) recorded significant increases in current e-cigarette use over the same period.

Conclusions and Relevance

In this study, a slight decrease in the prevalence of current e-cigarette use was found between 2018 and 2020; this decrease was mainly observed among young adults aged 18 to 20 years. In contrast, daily e-cigarette use consistently increased, particularly among young adults aged 21 to 24 years. This increase in daily use suggests greater nicotine dependence among those who use e-cigarettes, warranting continued surveillance.

Pharmacokinetic and subjective assessment of prototype JUUL2 electronic nicotine delivery system in two nicotine concentrations, JUUL system, IQOS, and combustible cigarette

RATIONALE

Electronic nicotine delivery systems and heated tobacco products are noncombustible alternatives for adult smokers. Evidence suggests sufficient nicotine delivery and satisfying effects are necessary to facilitate switching away from smoking; nicotine delivery varies across electronic nicotine delivery systems within limited nicotine concentrations.

OBJECTIVES

To assess the nicotine delivery and subjective effects of prototype JUUL2 System in two nicotine concentrations, currently-marketed US JUUL System ("JUUL"), IQOS-brand heated tobacco product, and combustible cigarettes.

METHODS

Adult smokers (N = 40) completed a 5-arm cross-over product-use laboratory confinement study. Nicotine pharmacokinetics and subjective effects were assessed following use of: (1) JUUL2 prototype 18 mg/mL nicotine; (2) JUUL2 prototype 40 mg/mL; (3) JUUL 59 mg/mL; (4) IQOS 18 mg/g; and (5) usual brand combustible cigarette, each evaluated during ad libitum (10 min) and controlled (5 min, 10 standardized puffs) use.

RESULTS

Nicotine delivery was greatest for combustible cigarettes, followed by JUUL2 prototype 40 mg/mL, IQOS, JUUL2 prototype 18 mg/mL, and JUUL 59 mg/mL. Nicotine delivery from JUUL2 prototype 18 mg/mL was significantly greater than JUUL 59 mg/mL after ad libitum use. JUUL products were significantly more satisfying and effective at reducing craving than IQOS. JUUL2 prototype 40 mg/mL was significantly more aversive than other JUUL products.

CONCLUSIONS

Prototype JUUL2 and JUUL 59 mg/mL products were rated higher than IQOS on subjective measures associated with switching away from smoking. The JUUL2 prototype 40 mg/mL produced aversive responses and would require modifications to be a viable product for adult smokers. Nicotine delivery and subjective responses to JUUL2 prototype 18 mg/mL suggest a product based on this prototype may facilitate increased switching among adult smokers.

Association of e-Cigarette Use With Discontinuation of Cigarette Smoking Among Adult Smokers Who Were Initially Never Planning to Quit

IMPORTANCE

Cigarette smokers not planning to quit are often overlooked in population studies evaluating the risk-benefit potential of electronic nicotine delivery products (e-cigarettes).

OBJECTIVE

To evaluate whether e-cigarette use is associated with discontinuing cigarette smoking among smokers who were initially never planning to quit.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used US nationally representative data from the longitudinal Population Assessment of Tobacco and Health Study (waves 2-5 conducted between October 2014 and November 2019), with participants evaluated in 3 pairs of interviews. Adult daily cigarette smokers initially not using e-cigarettes and with no plans to ever quit smoking for good (2489 observations from 1600 individuals) were included.

EXPOSURES

e-Cigarette use (ie, daily use, nondaily use, or no use) at follow-up interview among smokers not using e-cigarettes at baseline interview.

MAIN OUTCOMES AND MEASURES

The main outcomes were discontinuation of cigarette smoking (ie, no cigarette smoking) and discontinuation of daily cigarette smoking (ie, no daily cigarette smoking) at follow-up interview. Generalized estimating equations were used to evaluate the association between the exposure and each outcome, controlling for demographic characteristics and cigarettes smoked per day at baseline interview; all estimates were weighted.

RESULTS

The weighted population of adult daily cigarette smokers who were not using e-cigarettes and had no plans to ever quit smoking, based on data from 1600 participants, was 56.1% male (95% CI, 53.4%-58.7%), 10.1% Hispanic (95% CI, 8.2%-12.3%), 10.1% non-Hispanic Black (95% CI, 8.7%-11.7%), 75.6% non-Hispanic White (95% CI, 72.9%-78.2%), and 4.2% of other non-Hispanic race (95% CI, 3.3%-5.4%); 29.3% were aged 55 to 69 years (95% CI, 26.2%-32.6%), 8.9% were aged 70 years or older (95% CI, 6.8%-11.5%), 36.8% did not graduate from high school (95% CI, 34.1%-39.6%), 55.2% had an annual household income of less than $25 000 (95% CI, 52.3%-58.1%), 37.6% smoked 20 to 29 cigarettes per day (95% CI, 34.7%-40.6%), and 12.7% smoked 30 or more cigarettes per day (95% CI, 10.9%-14.7%). Overall, 6.2% of the population (95% CI, 5.0%-7.5%) discontinued cigarette smoking. Discontinuation rates were higher among those who used e-cigarettes daily (28.0%; 95% CI, 15.2%-45.9%) compared with not at all (5.8%; 95% CI, 4.7%-7.2%; adjusted odds ratio [aOR], 8.11; 95% CI, 3.14-20.97). Furthermore, 10.7% (95% CI, 9.1%-12.5%) discontinued daily cigarette smoking, with higher rates of discontinuation observed among those who used e-cigarettes daily (45.5%; 95% CI, 27.4%-64.9%) compared with not at all (9.9%; 95% CI, 8.2%-11.8%; aOR, 9.67; 95% CI, 4.02-23.25). Nondaily e-cigarette use was not associated with cigarette discontinuation (aOR, 0.53; 95% CI, 0.08-3.35) or daily cigarette discontinuation (aOR, 0.96; 95% CI, 0.44-2.09).

CONCLUSIONS AND RELEVANCE

In this cohort study, daily e-cigarette use was associated with greater odds of cigarette discontinuation among smokers who initially had no plans to ever quit smoking. These findings support the consideration of smokers who are not planning to quit when evaluating the risk-benefit potential of e-cigarettes for smoking cessation in the population.

Vaping-Related Adverse Events and Perceived Health Improvements: A Cross-Sectional Survey among Daily E-Cigarette Users

Web-based samples of e-cigarette users commonly report significant vaping-related health improvements (HIs) and mild adverse events (AEs). This cross-sectional study with in-person interviewing data collection examined self-reported AEs and perceived HIs among Hungarian adult current daily exclusive e-cigarette (n = 65) and dual users (n = 127), and former daily e-cigarette users (n = 91) in 2018. Logistic regression was used to evaluate associations between reporting any AEs/HIs, vaping status, and covariates. More former users (52.7%) reported AEs than current users (39.6%; p = 0.038). Exclusive and dual daily users reported similar rates of AEs (44.6% and 37.0%, respectively; p = 0.308). More current users (46.9%) experienced HIs than former users (35.2%; p = 0.064). Exclusive daily users were more likely to report HIs than dual users (63.1% versus 38.6%; p = 0.001). Former user status and smoking cessation/reduction reasons increased the odds of reporting AEs, whereas nicotine-containing e-liquid use and older age decreased the odds of reporting AEs. Exclusive vaper status, using advanced generation devices, and smoking cessation/reduction reasons increased the odds of experiencing HIs. This study, which used a traditional data collection methodology, found a higher rate of AEs and a lower rate of HIs compared to web-based surveys. Our results highlight that experiencing AEs and HIs is affected by users’ characteristics, in addition to the device and e-liquid type.

An Open-Label, Randomized, Controlled, Crossover Study to Assess Nicotine Pharmacokinetics and Subjective Effects of the JUUL System with Three Nicotine Concentrations Relative to Combustible Cigarettes in Adult Smokers

Introduction

This randomized, open-label, crossover clinical study evaluated nicotine pharmacokinetics (PK) and subjective effects of the JUUL System (JS; Juul Labs, Inc.) with three nicotine concentrations compared to the usual brand (UB) cigarettes in 24 adult smokers.

Methods

At five study visits, subjects used either the JS in 59 mg/mL, JS 18 mg/mL (two visits), and JS 9 mg/mL (all tobacco-flavored) or smoked their UB cigarette first during a controlled puffing sequence (CPS) and then ad libitum (5 min) use sessions. Blood samples were taken at specified timepoints for 60 min in each session. The modified Product Evaluation Scale assessed subjective effects 30-min post-use in the CPS session.

Results

Maximum plasma nicotine concentration (C_max-BL), total nicotine exposure (AUC_0-60-BL), and rate of plasma nicotine rise were significantly lower for all JS products compared to subjects' UB cigarette in CPS and ad libitum use sessions. In both use sessions these PK parameters were significantly higher for JS 59 mg/mL compared to 18 and 9 mg/mL. Subjective measures of cigarette craving relief and “Enough Nicotine” for JS 59 mg/mL did not differ significantly from UB cigarettes, but JS 18 and 9 mg/mL were rated significantly lower than JS 59 mg/mL and UB cigarettes.

Conclusions

Nicotine exposure and subjective relief were directly related to JS nicotine concentration: higher nicotine concentrations gave rise to significantly greater plasma nicotine levels and relief from craving. Heavier and more dependent smokers may require the greater nicotine delivery of JS 59 mg/mL to successfully transition away from cigarettes.

Implications

It has been suggested that electronic nicotine delivery systems (ENDS) and other alternative nicotine delivery products that more closely mimic the nicotine pharmacokinetics (PK) of cigarettes may facilitate smokers transitioning away from cigarettes. We examined nicotine PK and subjective effects of JUUL System (JS) ENDS with three nicotine concentrations (59, 18 and 9 mg/mL) compared to combustible cigarettes. Nicotine delivery from JS ENDS was nicotine concentration dependent, with higher nicotine concentrations giving rise to higher nicotine exposure. These findings suggest that heavier and more dependent smokers may require ENDS with nicotine concentrations greater than 20 mg/mL to successfully transition away from cigarettes.