Association between electronic cigarette use and tobacco cigarette smoking initiation in adolescents: a systematic review and meta-analysis

Preventing smoking initiation in adolescents living in vulnerable socioeconomic conditions: Study protocol of the KickAsh!-intervention

AIMS

Adolescents living in vulnerable socioeconomic conditions are confronted with tobacco-related health disparities. As school-based interventions appear to be less effective among these youngsters, other approaches are necessary. One promising avenue is youth social work settings that offer sport and recreational activities (SR-settings). SR-settings have been examined as a levering context for health promotion, but evidence regarding smoking prevention is currently lacking.

METHODS

This study describes the protocol of a non-randomised cluster controlled trial evaluating a smoking prevention intervention for adolescents. At least 24 SR-settings are needed for the intervention and control group. A mixed-method design will be used. Quantitative measures will be used to assess effectiveness, involving validated questionnaires on smoking initiation behaviour and influencing factors (i.e. attitude, self-efficacy, social influence and risk perception). In addition, feasibility will be assessed with regard to intervention fidelity, dose and reach. Data will be collected at baseline, three and nine months following the intervention. To gain deeper understanding on the impact and underlying processes of the intervention, we will conduct qualitative interviews with users (adolescents) and implementers (youth workers within the SR-settings) of the intervention.

CONCLUSIONS

Conducting this trial will offer novel insights into the effectiveness of a smoking prevention intervention designed for adolescents living in vulnerable socioeconomic conditions. A mixed-method design will enable to measure impact, implementation and underlying processes of the intervention. Overall, this design will enhance our understanding on the suitability of SR-settings as contexts for smoking prevention initiatives targeting hard-to-reach youth. This trial is registered on Clinicaltrials.gov: NCT05920772.

Evidence update on e-cigarette dependence: A systematic review and meta-analysis

INTRODUCTION

We conducted this review to examine the risk of e-cigarette dependence in different populations by updating the review on this topic by the National Academies of Science, Engineering, and Medicine.

METHODS

Six academic databases were searched for studies published between September 2017 and December 2023. We included peer-reviewed human, animal, cell/in vitro original studies examining associations of e-cigarette use and dependence but excluded qualitative studies. Three types of e-cigarette exposure were examined: acute, short-to-medium term, and long-term. Meta-analysis were conducted when possible. Different risk of bias tools were used for assessing quality of the included human studies.

RESULTS

We included 107 studies, of which 34 studies were included in the subgroup analysis. Meta-analyses showed that non-smoker current vapers had no statistically significant difference in level or prevalence of dependence compared to non-vaper current smokers and dual users. However, never smoker current vapers had a lower level of dependence (SMD -0.723, p < 0.01) compared to dual users, which was also supported by ANOVA test. Narrative review findings suggest that nicotine vapers had higher level of dependence than non-nicotine vapers and e-cigarette dependence is positively associated with nicotine concentration, frequency, and duration of use. No strong relationship was found between dependence and product types or features. Socio-demographic factor-based subgroup findings were inconclusive.

CONCLUSIONS

The level and prevalence of e-cigarette dependence is similar to cigarette dependence. There was high variability in the definitions and methods used for defining populations and assessing dependence. Further research and monitoring are crucial.

The Relationship Between Time Spent on Social Media and Adolescent Cigarette, E-cigarette, and Dual Use: A Longitudinal Analysis of the UK Millennium Cohort Study

INTRODUCTION

To estimate the effect of social media use in 14 year olds on risk of and inequalities in cigarette, e-cigarette, and dual use at 17 years, using the UK-representative Millennium Cohort Study (born 2000-2002).

AIMS AND METHODS

The relationship of time spent on social media (using questionnaires [n = 8987] and time-use-diaries [n = 2520]) with cigarette, e-cigarette, and dual use was estimated using adjusted odds ratios (AORs) or relative risk ratios (ARRRs). Effect modification was examined (using parental education as an indicator for socioeconomic circumstances) by comparing adjusted risk differences within low and high-parental education groups. Analyses accounted for prespecified confounders (identified via directed acyclic graphs), baseline outcome measures (to address reverse causality), sample design, attrition, and item-missingness (through multiple imputation).

RESULTS

Time spent on social media was associated with increased risk of cigarette, e-cigarette, and dual use in a dose-response manner. Social media use for ≥2 hours/day (vs. 1-<30 minutes) was associated with increased cigarette (AOR 2.76 [95% confidence interval 2.19 to 3.48]), e-cigarette (3.24 [2.59 to 4.05]), and dual use (ARRR 4.11 [2.77 to 6.08]). The risk of cigarette use among 30 minutes-<1 hour/day users (vs. non-users) were smaller in those with high versus low parental education (ARDs 1.4% vs. 12.4%). Similar findings were observed across the higher time categories. Analyses using time-use-diaries, in complete case samples, and with additional adjustment for baseline outcome measures generally revealed similar findings.

CONCLUSIONS

After accounting for observed confounders and potential reverse causality, findings suggest social media use increases the risk of cigarette, e-cigarette, and dual use in a dose-response manner. Guidance addressing adolescent online safety should be prioritized.

IMPLICATIONS

This study's identification of a dose-response relationship and differential effects across socioeconomic groups, could assist in the development of guidance on time spent on social media. The adverse effects of social media use on adolescent cigarette, e-cigarette, and dual use supports legislation aimed at promoting adolescent online safety. Study findings strengthen calls to prohibit social media marketing of nicotine-related products and importantly highlight the need to increase awareness and understanding of the underlying algorithms which drive adolescent exposure to nicotine-related content on social media to ensure they are functioning in a way that best serves the adolescent population.

Implementation of school tobacco policies: The advocacy coalition approach. Protocol of the ADHAirE study, a cluster randomized controlled trial

Secondary schools still struggle to enforce their tobacco policy and to keep their learning environment smoke-free. Yet, enforcement is the key to improve the effectiveness of those policies. This article describes the ADHAirE study which aims to reduce smoking at school through an improved enforcement of the school's tobacco policy. The ADHAirE study will be carried out during 2 years in 20 Belgian secondary schools. Schools will be randomized either in the experimental or the control group. Schools in the experimental group will create an advocacy coalition involving students, staff and the principal. Those schools will also be linked to the others to share best practices about their school tobacco policy. Members of the advocacy coalition will share beliefs and values about the tobacco policy and about the school's role in tobacco prevention. This randomized controlled trial will assess the effectiveness of the advocacy coalition to enforce the school tobacco policy. The ADHAirE study is based on the latest research and recommendations on school tobacco prevention. Following the social norm theory, this study goes further than many others before which only focused on health education, targeting the individual and not the social environment in which smoking occurs. Through the advocacy coalition, ADHAirE will initiate a community-level intervention that will ensure that all stakeholders are involved in decision-sharing about the rules, ensuring their acceptability, adoption and sustainability. CLINICAL TRIAL REGISTRATION: The study is registered on the official website of ClinicalTrials.gov IDENTIFIER: ID NCT06655038.

Health Messaging Strategies for Vaping Prevention and Cessation Among Youth and Young Adults: A Systematic Review

This systematic review evaluates health messaging strategies for the prevention and cessation of e-cigarette use among youth and young adults. Health messaging strategies were defined as the strategic process of developing messages with the intent to shape, reinforce, or change recipients' health attitudes and behaviors. McGuire's Communication/Persuasion Model guided the analysis of the messaging strategies, focusing on the model's five communication inputs (i.e. source, message, channel, audience, destination) and 14 persuasive outcomes. Nine databases were searched from January 2007 to September 2023. The inclusion criteria encompassed studies in English that presented quantitative data on messaging strategies aimed at discouraging vaping among youth and young adults. Each study was also coded for study characteristics and the utilization of theory. Out of 6,045 studies, 25 met the inclusion criteria. The reviewed studies exhibit a diverse array of research methods and a consistent integration of theories. The review emphasizes the nuanced main and interaction effects of various communication inputs, such as message features and audience characteristics, while also pointing out a research gap in message sources. In addition, the utilization of social media for effective messaging to engage the audience requires further research. Only one study specifically evaluated messaging strategies for vaping cessation. More research is imperative to develop targeted and tailored messages that effectively prevent and reduce vaping, especially among populations at higher risk of vaping-related harms, while also leveraging effective channels and innovative communication technologies to engage the audience.

Longitudinal analysis of predictors of electronic cigarette trial among adolescents in Guatemala

BACKGROUND

Understanding factors influencing electronic cigarette (e-cigarette) trial in adolescents is crucial for shaping policies and interventions to reduce consumption and potentially prevent addictive tendencies, particularly in countries with weak regulations like Guatemala.

OBJECTIVE

We aimed to longitudinally assess predictors of e-cigarette trial among Guatemalan adolescents surveyed in 2019, 2020, and 2021.

METHODS

Students (13 to 18 years old) from nine private schools completed self-administered questionnaires about e-cigarette use and associated risk factors. Data from those who had at least one follow-up survey after reporting that they had never tried e-cigarettes at either the 2019 or 2020 survey (N = 838) was analyzed. We used a mixed-effects logistic regression clustered by student and school to assess predictors of ever e-cigarette use.

RESULTS

Nearly one-quarter (21.0 %) of unique students tried e-cigarettes at follow-up. Risk factors for e-cigarette trial included cigarette or heated tobacco products use (adjusted odds ratio [AOR] = 2.95, 95 %CI = 1.24-7.04), frequent exposure to online e-cigarette marketing (AOR = 2.46, 95 %CI = 1.39-4.35), alcohol or marihuana use (AOR = 1.74, 95 %CI = 1.17-2.58), and parental approval of e-cigarette use (AOR = 1.65, 95 %CI = 1.14-2.40). The perception that serious illness from life-long e-cigarette use is likely or certain (AOR = 0.57, 95 %CI = 0.36-0.91, and AOR = 0.37, 95 %CI = 0.19-0.72, respectively) appeared as a protective factor for e-cigarette trial.

CONCLUSION

Our findings align with international research, indicating shared risk factors across youth worldwide. The incorporation of these factors into policies and interventions targeting the reduction of e-cigarette trial is imperative for optimizing their efficacy.

Trends in smoking prevalence among 14-15-year-old adolescents before and after the emergence of vaping in New Zealand; an interrupted time series analysis of repeated cross-sectional data, 1999-2023

Background

New Zealand experienced a prolonged period of minimal regulation on e-cigarettes until the passing of the 2020 Smokefree Environments and Regulated Products (Vaping) Amendment Act.

Methods

Interrupted time series analyses of the Action for Smokefree 2025 (ASH) Year 10 Snapshot Survey data from 1999 to 2023 to compare changes in smoking trends among 14-15-year-old students (n = 690,470) before and after the advent of vaping in New Zealand (around 2010).

Findings

The prevalence of daily-vaping increased from 1.1% in 2015 (the first year the question was asked) to 1.8% in 2018 before rising to 10.0% in 2023, a nine-fold increase over eight years. From 1999 to 2023, considerable declines in ever-, regular-, and daily-smoking prevalence were observed. However, the rates of decline in ever- and regular-smoking slowed significantly from 2010 onwards (p < 0.001 for both), coinciding with the advent and rapid growth of vaping among New Zealand adolescents. In contrast, the rate of decline in daily-smoking did not significantly change from 2010 onwards (p = 0.066). These findings were robust to sensitivity analyses, including the use of different time series interruption points (change-years) and controlling for inflation-adjusted cigarette prices.

Interpretation

Our findings starkly contrast with those from a previous analysis of ASH data, which suggested that e-cigarettes appear to be displacing smoking among New Zealand youth. Instead, our findings suggest that among 14-15-year-olds, the rapid rise of vaping may have slowed the rates of decline in ever- and regular-smoking, while having little or no impact on the rate of decline in daily smoking. Our findings underscore the importance of effective policy approaches to curb both adolescent vaping and smoking.

Funding

None.

Trends and Sociodemographic Differences in Tobacco/Nicotine Transitions Among U.S. Adolescents and Young Adults Using e-cigarettes, 2014-2023

PURPOSE

E-cigarette use among adolescents and young adults (AYAs) remains prevalent in the United States and is linked with combustible tobacco product use. This study examines sociodemographic differences (i.e., sex, age, sexual identity, transgender identity, race, ethnicity, and income) in transitions from e-cigarette use to other forms of tobacco use among AYAs from 2014 to 2023.

METHODS

AYAs aged 14-25 years from the nationally representative Population Assessment of Tobacco and Health study waves 2-7 (2014/15-2022/23) were used to examine transitions in e-cigarette and combustible tobacco use over 1-to-2-year periods (n = 7,523). Using multinomial logistic regression models, we examined associations of sociodemographic characteristics and wave with e-cigarette and combustible tobacco transitions.

RESULTS

Maintaining e-cigarette use only (21.2% in 2014/15-49.2% in 2022/23) and transitioning from e-cigarette and combustible use (i.e., dual use) to e-cigarettes only (7.6% in 2014/15-29.7% in 2022/23) increased over time. Simultaneously, transitioning from e-cigarettes to dual use (18.2% in 2014/15-17.9% in 2022/23) and maintaining dual use remained steady. Bisexual individuals were more likely to transition from e-cigarette use only to dual use (adjusted relative risk ratio = 2.07; 95% confidence interval = 1.44, 2.99) and maintain dual use (adjusted relative risk ratio = 2.01; 95% confidence interval = 1.43, 2.84), compared to heterosexual individuals. Female, Hispanic, and Black individuals were less likely to transition to dual use or maintain dual use compared to male, non-Hispanic, and White individuals, respectively.

DISCUSSION

Findings identify important sociodemographic groups at greater risk of transitions to combustible tobacco use that warrant attention in future research and prevention strategies to reduce health disparities.

Associations between interpersonal violence and cigarette smoking, e-cigarette use, and dual use among Mexican adolescent students

Objective

To assess associations between experienced violence and the use of combustible cigarettes, e-cigarettes, and of both products ("dual use") among adolescent students from Mexico.

Methods

Data comes from an online survey among 3,046 adolescents (12-19 years) conducted between September and December 2021. Students reported experiences of neglect, physical, psychological, and sexual violence perpetrated by household members, and digital violence (by anyone) in the previous 12 months, as well as current (last 30 day) use of cigarettes and e-cigarette. In multinomial logistic models, exclusive cigarette use, exclusive e-cigarette use, and dual use (reference = no use) were regressed on experienced violence and covariates.

Results

The prevalence of exclusive use of cigarettes was 1.4%, exclusive e-cigarette use was 6.1, and 2.4% for dual use. Almost half (46.9%) of adolescents reported having been the target of physical violence, followed by psychological violence (42.6%), neglect (34.9%), digital violence (12.3%), and sexual violence (5.2%). In adjusted multinomial models, adolescents who experienced physical violence (Adjusted Relative Risk Ratios: ARRR = 2.28, 95% CI [1.05-4.96]) were more likely to exclusively smoke cigarettes. Adolescents were also more likely to exclusively use e-cigarettes if they had been targeted by psychological or digital violence (ARRR = 1.55, 95% CI [1.05-2.29] and ARRR = 1.69, 95% CI [1.12-2.54], respectively). Experience of physical, digital, neglect, and sexual violence were positively associated with dual use.

Conclusion

Experiences of violence may increase the likelihood of tobacco use, particularly dual use. Prevention programs may need to include the family environment to reduce violence.

Factors influencing suicidal ideation among female adolescents with smoking experience: A cross-sectional study using National Big Data

OBJECTIVE

This study aimed to investigate the factors influencing suicidal ideation among female adolescents with smoking experience.

MATERIAL AND METHODS

A secondary analysis was conducted using national survey data collected in Korea in 2023, involving 1880 female adolescents with smoking experience. Complex sample logistic regression analysis was used to evaluate the influencing factors.

RESULTS

The factors significantly associated with suicidal ideation among female adolescents included depressive symptoms, generalized anxiety disorder (GAD), loneliness, stress, and habitual and intentional drug use.

CONCLUSION

This study is the only research that examines the factors influencing suicidal ideation among female adolescents with smoking experience, providing valuable insights for suicide prevention efforts targeting this population.

IMPLICATIONS FOR PRACTICE

Nurses should regularly monitor the mental health status of female adolescents with smoking experience and recognize that proper education on medication use is a crucial strategy for preventing suicide, aiming to reduce suicidal ideation in this population.

Lifetime and active use of electronic cigarettes among Brazilian adolescents: The 2019 national school health survey - PeNSE 2019

OBJECTIVES

To investigate the prevalence and the factors associated with experimentation and use of e-cigarettes.

STUDY DESIGN

Cross-sectional study.

METHODS

Cross-sectional analysis of data from the National School Health Survey (PeNSE 2019), with students attending elementary school and high school in Brazil. Two outcomes were investigated: experimentation and last 30-day use of e-cigarettes. Potential exposures included family and adolescents' socio-demographic, mental health, and behavioral characteristics. Adjusted prevalence ratios (PR) were obtained by Poisson regression with robust variance.

RESULTS

133,237 adolescents aged ≥13 years were included. Prevalence of experimentation and last 30-day use was higher in males (20.7 % and 4.1 %, respectively) than in females (15.4 % and 2.6 %, respectively). The higher PR were with ever use of hookah in males (PR = 3.34 for e-cigarettes experimentation and PR = 4.05 for last 30-day use) and females (PR = 3.26 for experimentation and PR = 4.14 for last 30-day use). For males who ever used alcoholic beverages, the PR for e-cigarettes experimentation ranged from 2.86 to 3.18, and the PR for last 30-day use ranged from 3.09 to 3.39, depending upon the age of first alcoholic beverage experimentation. Among the females who ever used alcoholic beverages, PR for experimentation ranged from 3.46 to 4.31 and PR for last 30-day use ranged from 2.44 to 4.09.

CONCLUSION

About a quarter of school age adolescents had already tried e-cigarettes and 3.4 % used e-cigarettes in the prior 30 days. There were sex differences in the prevalence and in factors associated with experimentation and last 30-day use of e-cigarettes.

Temporal changes and correlates of tobacco and E-cigarettes use among school-going students in Albania: insights from global youth tobacco surveys (2015-2020)

Tobacco use often starts during adolescence, with many adults beginning before 21. This study investigated the patterns and factors associated with tobacco and e-cigarette use among school-aged adolescents in Albania. Data were analyzed from two Albania Global Youth Tobacco Surveys (GYTS) conducted in 2015 and 2020. Participants included 7th-10th grade students (ages 12-16) who completed the survey (n = 9985). Descriptive statistics depicted demographic characteristics, tobacco, and e-cigarette use across survey years. Logistic regression assessed temporal changes and the odds of use across independent variables, adjusting for age and sex. From 2015 to 2020, tobacco and e-cigarette use among students aged 13-15 increased from 12.86 to 14.49% and from 6.8 to 8.8%, respectively. Cigarette smoking declined from 8.4 to 4.3%, but the use of other tobacco products nearly doubled, from 6.4 to 12.3%. Higher odds of use were found among males, older students, and those with more pocket money. Environmental factors like family, peer, and media exposure to smoking increased the likelihood of use. Anti-tobacco messages had no significant impact, while advertising strongly influenced usage. Knowledge of tobacco harms and anti-smoking attitudes correlated with lower odds of use. Increased availability of cigarettes near schools was linked to higher odds of tobacco use. The study highlights gaps in anti-tobacco messaging and the strong influence of advertising, underscoring the need for targeted and effective tobacco control strategies in Albania.

The Impact of E-Cigarettes on Oral Health-A Narrative Review

Background/Objectives: Electronic cigarettes (e-cigarettes) are commonly used by former smokers as an alternative product to conventional cigarettes and also by young adults and adolescents to deliver nicotine. E-cigarettes are thought to be a less harmful and more socially acceptable alternative to tobacco smoking; however, their long-term effects on health, including oral health, are currently unknown. Methods: A literature search for relevant papers indexed in the literature from 2016 to 2023 was conducted using the PubMed, Scopus, and Google Scholar databases. In our paper, we included clinical trials and both in vivo and in vitro research concerning the impact of e-cigarettes on oral health. Results: E-cigarettes impact the oral cavity, which is directly exposed to inhaled chemicals present in e-cigarette aerosols. The use of e-cigarettes has been linked to teeth discoloration and dental caries, promoting the development of periodontal diseases and causing oral mucosa lesions, including oral cancer. E-cigarette aerosols might also negatively affect the oral microbiome by suppressing the growth of commensal bacteria and increasing the population of bacteria responsible for developing numerous oral disorders. E-cigarettes also impact saliva composition and its properties, including reducing saliva's antibacterial and antioxidant properties, which may subsequently lead to the promotion of oral diseases. Conclusions: The outcomes suggest that e-cigarette usage may cause the development of oral diseases, however further longitudinal studies of a larger and homogenous group of e-cigarette users are required.

Reasons for cigarette and tobacco product use, dual use, and poly use among university students

INTRODUCTION

Tobacco use remains a significant public health issue worldwide, causing over 7 million deaths annually. Polytobacco use has become a common phenomenon. This study aims to analyze reasons for cigarette and tobacco product use, dual use and poly use among university students by sex, in China and Cyprus, selected owing to their still high consumption rates.

METHODS

An online survey was conducted among 589 university students (55% women) with a mean age of 24.2 years from Guangzhou, China, and the Republic of Cyprus. Participants reported their use of cigarettes, e-cigarettes, and waterpipes, as well as their reasons for using these products. Statistical analyses included chi-squared tests, and effect sizes were computed using the phi (φ) coefficient.

RESULTS

The Chinese participants gave as reasons for using cigarettes: 'because of the taste', 'because it looks cool', 'to get high' and 'because friends and family use them'. These were less frequently given by the Cypriots who opted more for 'to relax and relieve tension'. Compared to the Cypriot participants, the more frequent reasons given for consuming e-cigarettes and waterpipes among Chinese students were: 'due to boredom', 'because it looks cool', 'to get high', 'because I am hooked', 'because friends or family members use them', 'because they are less harmful than regular cigarettes' and 'because friends of family members allow their use more'. Dual or poly users felt more addicted than those who practiced single use. Among e-cigarette users, dual users and poly users valued the taste of the product more than single users. In general, men found more reasons for tobacco use than women did.

CONCLUSIONS

This study shows substantial differences in the motivation for using these products according to the product type, number of tobacco/nicotine products used, country, and sex. Understanding the reasons for tobacco use can inform targeted interventions aimed at reducing tobacco consumption among young adults.

Assessment of e-cigarette dependence and influencing factors among Palestinian young adults: a cross-sectional study

E-cigarette use is a growing public health concern, especially because of the potential health risks it poses. This study focuses on assessing e-cigarette dependence and the factors associated with it among Palestinian young adults. A cross-sectional survey was conducted from January to May 2023 among university students in the West Bank. A self-administered questionnaire was used to collect demographic data, knowledge, and attitudes regarding e-cigarettes. E-cigarette dependence was assessed using the Penn State Electronic Cigarette Dependence Index. The study included 386 university students who used e-cigarettes. Many of them started using e-cigarettes at a young age, and 54.7% were dual users of e-cigarettes and traditional tobacco. High levels of dependence were reported in 11.4% of participants, and moderate dependence in 28.8%. Several factors were identified through multivariate linear regression as significantly associated with e-cigarette dependence: a higher monthly allowance (β = 0.116, 95% CI: 0.128- 1.124, p = .014), having a father who uses tobacco (β = 0.095, 95% CI: 0.030- 1.638, p = .042), having a close friend who smokes traditional cigarettes (β = 0.095, 95% CI: 0.019- 1.667, p = .045), using e-cigarettes in areas where traditional smoking is prohibited (β = 0.175, 95% CI: 0.689-2.330, p < .001), using e-cigarettes to quit other forms of tobacco (β = 0.134, 95% CI: 0.434-2.314, p = .004), and a more negative attitude score (β = - 0.210, 95% CI: - 0.285- - 0.112, p < .001). The study revealed high levels of e-cigarettes dependence among the participants among young adults, with associated variables such as monthly allowance, attitudes, and age of e-cigarette initiation. Policymakers, educators, and healthcare professionals should collaborate to address e-cigarette dependence among young adults, taking into consideration social, environmental, and socioeconomic factors.

An adaptation and exploratory factor analysis of the smoking-related weight and eating episodes test (SWEET) for electronic cigarette users

INTRODUCTION

Smoking for weight control is a well-documented behavior. There is emerging evidence to suggest electronic cigarettes (e-cigarettes) may be used for similar motivations yet measure development for the use of e-cigarettes for weight control has received less attention. The objective of the current study was to adapt and explore the psychometric properties of The Smoking-Related Weight and Eating Episodes Test (SWEET) for e-cigarette users.

METHODS

Young adult (N=1875) current cigarette, e-cigarette, and dual users completed the original SWEET (SWEET-C) and/or adapted SWEET for e-cigarette use (SWEET-EC) based on current tobacco product use. Demographics, associated e-cigarette characteristics, nicotine dependence, outcome expectancies, and eating disorder behaviors were also assessed. Participants were recruited online and measures were completed via self-report.

RESULTS

Four exploratory factor analyses using principal components extraction and direct oblimin rotation methods were run to explore the SWEET-C and SWEET-EC. A one-factor solution explaining 66 % of the variance was retained for the SWEET-C, and a one-factor solution explaining 73 % of the variance was retained for the SWEET-EC. Both measures exhibited excellent internal consistency. Higher SWEET-EC scores were observed among dual users, and were associated with daily e-cigarette use, JUUL use, self-reported vaping for weight control, older age, higher body mass index, and problematic eating behaviors.

CONCLUSION

Our findings support the adaptation of the SWEET-EC to measure e-cigarette use for weight control. The SWEET-EC will help to better understand how individuals use e-cigarettes to curb eating behavior and for weight control.

The association between vaping and subsequent initiation of cigarette smoking in young Australians from age 12 to 17 years: a retrospective cohort analysis using cross-sectional recall data from 5114 adolescents

OBJECTIVE

The objective of this study was to estimate the association between vaping and subsequent initiation of smoking among Australian adolescents and explore the impact of design and analytical methods in previous studies.

METHODS

We conducted a retrospective cohort analysis of cross-sectional data from 5114 Australian adolescents aged 14-17 recalling information on smoking and vaping initiation from age 12 to 17. The outcome was smoking initiation, analysed with negative-binomial regression to estimate incidence rate ratios (IRRs) for vape status (ever-vaped vs never-vaped) as a time-varying exposure. We also re-analysed using the methods of previous studies not accounting for the time-varying nature of e-cigarette exposure.

RESULTS

Participants (n=5114) were retrospectively followed for 20478 person-years. After adjusting for socio-demographic variables and proxy measures of common liabilities for vaping and smoking, the rate of smoking initiation for those who ever-vaped was nearly 5 times that of those who never-vaped (IRR=4.9; 95% confidence interval: [3.9, 6.0], p<0.001), with IRRs considerably higher at younger ages. Not accounting for the time-varying nature of e-cigarette exposure in re-analysis attenuated the estimated IRR by 44%.

CONCLUSIONS

Controlled analyses indicate that vaping markedly increases the risk of subsequent smoking initiation among Australian adolescents from age 12 to 17, with those aged 12, 13, and 14 bearing an alarmingly disproportionate burden of the elevated risk. Additionally, the relative risk of future smoking due to vaping may have been underestimated in other studies due to methodological differences.

IMPLICATIONS FOR PUBLIC HEALTH

Our findings highlight the need for public health interventions and strict e-cigarette access laws.

Longitudinal associations of e-cigarette use with cigarette, marijuana, and other drug use initiation among US adolescents and young adults: Findings from the population assessment of tobacco and health study (Waves 1-6)

INTRODUCTION

Research examining prospective links of e-cigarette use with cigarette, marijuana, and other substance use has been limited largely to 1-2-year follow-up periods and focused on younger adolescents. This study examined longitudinal associations of e-cigarette use with cigarette, marijuana, and other substance use initiation among U.S. adolescents and young adults (AYAs) across an eight-year period.

METHODS

Adolescent (ages 12-17) and young adult (ages 18-25) data from waves 1-6 of the nationally representative Population Assessment of Tobacco and Health study (2013-2021) were used. Discrete time survival models with time-varying weights were employed to examine the risk of cigarette, marijuana, and other drug use initiation over an eight-year follow-up period among AYAs with no lifetime use of e-cigarettes/other tobacco, lifetime but no past 30-day use of e-cigarettes/other tobacco, past 30-day e-cigarettes only, other tobacco use only, or past 30-day e-cigarette/other tobacco use. We compare our time-varying weighting approach to a traditional time-invariant/complete case weighting approach.

RESULTS

Across six follow-up waves, all three past 30-day nicotine/tobacco use groups, including e-cigarettes only, had greater risk for cigarette, marijuana, and other drug use initiation relative to those not using nicotine/tobacco. The three past 30-day nicotine/tobacco use groups did not differ from each other in risk for marijuana use initiation. Associations were smaller in magnitude for young adults compared to adolescents, but significant for both age groups.

CONCLUSIONS

Substance use initiation risks persist beyond 1-2 years for U.S. AYAs using e-cigarettes. Prevention strategies to reduce AYA e-cigarette use are needed to reduce cancer-related risk.

Causal inference in tobacco research: a public health challenge

Causal inference represents a rapidly expanding interdisciplinary subfield that involves various assumptions, study designs, and estimation strategies, allowing researchers to establish causal relationships from both clinical trials and observational data. In tobacco research, numerous studies address causal questions, including the contentious issue of whether vaping in nonsmoking youth leads to smoking initiation, known as the "gateway effect." Determining the effectiveness and safety of many health interventions will continue to rely on observational [mainly longitudinal] data because randomized trials are not always feasible, ethical, or timely. Therefore, review articles that are synthesizing evidence on the gateway effects of electronic nicotine delivery systems [ENDS] on subsequent cigarette smoking must also consider observational studies as first-rate evidence that can help bring together the polarized tobacco research community and help better understand the "gateway effect." In addition, this will help ongoing efforts to rigorously prevent ENDS use by youth while expanding the cessation potential of ENDS among adult established smokers who are unwilling to quit otherwise. In this commentary, we discuss causal inference tobacco research as one of the public health challenges and provide some recommendations/implications.

Electronic cigarettes and subsequent use of cigarettes in young people: An evidence and gap map

BACKGROUND AND AIMS

The use of e-cigarettes may influence later smoking uptake in young people. Evidence and gap maps (EGMs) are interactive on-line tools that display the evidence and gaps in a specific area of policy or research. The aim of this study was to map clusters and gaps in evidence exploring the relationship between e-cigarette use or availability and subsequent combustible tobacco use in people aged < 30 years.

METHODS

We conducted an EGM of primary studies and systematic reviews. A framework and an interactive EGM was developed in consultation with an expert advisory group. A systematic search of five databases retrieved 9057 records, from which 134 studies were included. Systematic reviews were appraised using AMSTAR-2, and all included studies were coded into the EGM framework resulting in the interactive web-based EGM. A descriptive analysis of key characteristics of the identified evidence clusters and gaps resulted in this report.

RESULTS

Studies were completed between 2015 and 2023, with the first systematic reviews being published in 2017. Most studies were conducted in western high-income countries, predominantly the United States. Cohort studies were the most frequently used study design. The evidence is clustered on e-cigarette use as an exposure, with an absolute gap identified for evidence looking into the availability of e-cigarettes and subsequent cessation of cigarette smoking. We also found little evidence analysing equity factors, and little exploring characteristics of e-cigarette devices.

CONCLUSIONS

This evidence and gap map (EGM) offers a tool to explore the available evidence regarding the e-cigarette use/availability and later cigarette smoking in people under the age of 30 years at the time of the search. The majority of the 134 reports is from high-income countries, with an uneven geographic distribution. Most of the systematic reviews are of lower quality, suggesting the need for higher-quality reviews. The evidence is clustered around e-cigarette use as an exposure and subsequent frequency/intensity of current combustible tobacco use. Gaps in evidence focusing on e-cigarette availability, as well as on the influence of equity factors may warrant further research. This EGM can support funders and researchers in identifying future research priorities, while guiding practitioners and policymakers to the current evidence base.

Trends in smoking initiation and cessation over a century in two Australian cohorts

BACKGROUND

Historical data on smoking can enhance our comprehension of the effectiveness of past tobacco control policies and play a key role in developing targeted public health interventions. This study was undertaken to assess trends in smoking initiation and cessation in Australia for the period 1910-2005.

METHODS

Rates of smoking initiation and cessation were calculated for participants in two population-based cohorts, the Busselton Health Study and the Tasmanian Longitudinal Health Study. The effects of time trends, gender and age group were evaluated.

RESULTS

Of the 29,971 participants, 56.8% ever smoked. In males, over the period 1910-1999, the rate of smoking initiation in young adolescents remained high with a peak in the 1970s; in older adolescents it peaked in the 1940s and then declined; in young adults it showed a steady decline. In females, the rate of smoking initiation in young adolescents rose sharply in the 1960s and peaked in the 1970s, in older adolescents it increased throughout the period, and in young adults it declined after 1970. In the period 1930-2005, 27.3% of 9,605 people aged 36-50 years who smoked ceased smoking. Rates of cessation in this age group increased throughout but decreased in males after 1990 and plateaued around 2000 in females.

CONCLUSION

Our findings show substantial variation in the efficacy of tobacco control policies across age groups, with a notable lack of success among the younger population.

The relationship between insecure attachment and nicotine dependence among users of classic cigarettes, e-cigarettes, and heated tobacco products: a moderated mediation model

BACKGROUND

Previous research has investigated the association between attachment styles and smoking behaviors, indicating a positive association of insecure attachment styles with nicotine dependence. However, these links were mostly explored in adolescent and student samples. Moreover, the explanatory mechanisms and the variables influencing the strength of this relationship remained understudied. In this context, the present study aims to: (1) examine the associations between attachment anxiety, avoidance, and nicotine dependence; (2) investigate the mediating role of emotion dysregulation and metacognitions about smoking; and (3) test the moderating roles of psychological capital and type of tobacco product used by the participants.

METHOD

This cross-sectional study was conducted on a convenience sample of 447 participants who reported smoking. The age range of participants was 18 to 64 (M = 26.76; 59.7% women). All participants have completed five questionnaires measuring nicotine dependence, adult attachment, emotion dysregulation, metacognitions about smoking, and psychological capital. They also reported the type of tobacco product commonly used: classic cigarettes, e-cigarettes, or heated tobacco products.

RESULTS

Our findings show that the direct link between insecure attachment and nicotine dependence is rather inconsistent. However, it was mediated by the metacognitions about smoking. Psychological capital can act as a protective factor against the effects of attachment on nicotine dependence, especially for those using alternative tobacco products alongside classic cigarettes.

CONCLUSIONS

The findings highlight the possibility of developing better-tailored interventions and treatments to discourage smoking and increase smoking cessation. These should focus on eliminating the dysfunctional beliefs related to the metacognitions about smoking and on improving the levels of psychological capital. In addition, targeting attachment insecurities in early adolescence can also function as a mean to prevent smoking.

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.

The paradox of the safer cigarette: understanding the pulmonary effects of electronic cigarettes

Electronic cigarette (e-cigarette) use continues to rise globally. E-cigarettes have been presented as safer alternatives to combustion cigarettes that can mitigate the harm associated with tobacco products; however, the degree to which e-cigarette use itself can lead to morbidity and mortality is not fully defined. Herein we describe how e-cigarettes function; discuss the current knowledge of the effects of e-cigarette aerosol on lung cell cytotoxicity, inflammation, antipathogen immune response, mucociliary clearance, oxidative stress, DNA damage, carcinogenesis, matrix remodelling and airway hyperresponsiveness; and summarise the impact on lung diseases, including COPD, respiratory infection, lung cancer and asthma. We highlight how the inclusion of nicotine or flavouring compounds in e-liquids can impact lung toxicity. Finally, we consider the paradox of the safer cigarette: the toxicities of e-cigarettes that can mitigate their potential to serve as a harm reduction tool in the fight against traditional cigarettes, and we summarise the research needed in this underinvestigated area.

Flavored Tobacco Sales Restrictions and Youth E-cigarette Behavior: Impact by Tobacco Retailer Density in Diverse Communities in California

INTRODUCTION

Factors that impact flavored tobacco sales restriction (flavor restrictions) effectiveness on youth e-cigarette behavior are unclear. Tobacco retailer density (retailer density) is a health equity issue with greater retailer density in high-minority, low-income areas. We examined the association between flavor restrictions and youth e-cigarette behavior by retailer density across diverse communities in the California Bay Area.

AIMS AND METHODS

We analyzed data from the California Healthy Kids Survey using a difference-in-differences (DID) strategy. We compared pre- and post-policy changes in e-cigarette access and use one-year post-implementation among high school students in the Bay Area with a flavor restriction (n = 20 832) versus without (n = 66 126). Separate analyses were conducted for students in cities with low and high retailer density, with a median cutoff of 3.3 tobacco retailers/square mile.

RESULTS

Students with high retailer density were more likely to identify as a minority and have parents with lower education. Among students with low retailer density, flavor restrictions were associated with 24% lower odds in the pre- to post-policy increase in ease of access relative to unexposed students (DID = 0.76, 95% CI: 0.58, 0.99). Among students with high retailer density, flavor restrictions were associated with 26% higher odds in ease of access (DID: 1.26, 95% CI: 1.02, 1.56) and 57% higher odds of current use (DID = 1.57, 95% CI: 1.31, 1.87).

CONCLUSIONS

Flavor restrictions had positive impacts on youth e-cigarette access in low, but not high retailer density cities. From a health equity perspective, our results underscore how flavor restrictions may have uneven effects among vulnerable groups.

IMPLICATIONS

In diverse communities in the California Bay Area, our results suggest a protective association between flavored tobacco sales restrictions and youth access to e-cigarettes in low, but not high tobacco retailer density cities one-year post-implementation. These results underscore how flavor restrictions may have uneven effects, and when implemented in high retailer density areas, may disproportionately place already vulnerable groups at heightened exposure to e-cigarette use and access. In high retailer density areas, additional tobacco control efforts may need to be included with flavor restriction implementation, such as increased education, youth prevention and cessation programs, policies to reduce tobacco retailer density, or stronger tobacco retailer enforcement or compliance monitoring.

The efficacy and acceptability of pharmacological monotherapies and e-cigarette on smoking cessation: a systemic review and network meta-analysis

Background and aims

Several pharmacological interventions, such as nicotine replacement therapy (NRT), varenicline, and bupropion, have been approved for clinical use of smoking cessation. E-cigarettes (EC) are increasingly explored by many RCTs for their potentiality in smoking cessation. In addition, some RCTs are attempting to explore new drugs for smoking cessation, such as cytisine. This network meta-analysis (NMA) aims to investigate how these drugs and e-cigarettes compare regarding their efficacy and acceptability.

Materials and methods

This systematic review and NMA searched all clinical studies on smoking cessation using pharmacological monotherapies or e-cigarettes published from January 2011 to May 2022 using MEDLINE, COCHRANE Library, and PsychINFO databases. NRTs were divided into transdermal (TDN) and oronasal nicotine (ONN) by administrative routes, thus 7 network nodes were set up for direct and indirect comparison. Two different indicators measured the efficacy: prevalent and continuous smoking abstinence. The drop-out rates measured the acceptability.

Results

The final 40 clinical studies included in this study comprised 77 study cohorts and 25,889 participants. Varenicline is more effective intervention to assist in smoking cessation during 16-32 weeks follow-up, and is very likely to prompt dropout. Cytisine shows more effectiveness in continuous smoking cessation but may also lead to dropout. E-cigarettes and oronasal nicotine are more effective than no treatment in encouraging prevalent abstinence, but least likely to prompt dropout. Finally, transdermal nicotine delivery is more effective than no treatment in continuous abstinence, with neither significant effect on prevalent abstinence nor dropout rate.

Conclusion

This review suggested and agreed that Varenicline, Cytisine and transdermal nicotine delivery, as smoking cessation intervention, have advantages and disadvantages. However, we had to have reservations about e-cigarettes as a way to quit smoking in adolescents.

The impact of chronic electronic cigarette use on endothelial dysfunction measured by flow-mediated vasodilation: A systematic review and meta-analysis

INTRODUCTION

Despite electronic cigarettes (e-cigarettes) being marketed as a safer alternative to combustible cigarettes, the effects of chronic e-cigarette use on vascular health remain uncertain. Our meta-analysis aimed to assess the health implications of chronic exclusive e-cigarette use on endothelial dysfunction, as measured by flow-mediated vasodilation (FMD).

METHODS

PubMed, Embase and Scopus were searched for studies from 1 January 2004 to 31 March 2024. Four cross-sectional studies (n=769) were pooled using a random-effects model. The mean differences (MD) of FMD were reported by comparing exclusive e-cigarette use versus non-use; exclusive e-cigarette use versus combustible cigarette use; and combustible cigarette use versus non-use.

RESULTS

A non-significant reduction in FMD in exclusive e-cigarette use compared to non-use was reported (MD of FMD: -1.47%; 95% CI: -3.96 - 1.02; I2= 84%). Similar MD of FMD in exclusive e-cigarette use and exclusive combustible cigarette use (vs non-use) suggested that both of these products might have comparable adverse influences on endothelial health.

CONCLUSIONS

The limited availability of studies assessing the chronic impact of e-cigarette use restricted our ability to provide definitive findings. We emphasize the importance of additional research that explores the long-term impact of e-cigarette use on endothelial dysfunction, and identify key areas and give suggestions for further study.

A systematic review and meta-analysis of the association between e-cigarette use among non-tobacco users and initiating smoking of combustible cigarettes

INTRODUCTION

The rapid increase in e-cigarette use over the past decade has triggered an important public health question on the potential association between e-cigarette use and combustible cigarette smoking. Following AMSTAR 2 and PRISMA guidelines, this evidence synthesis sought to identify and characterize any associations between e-cigarette use among individuals not smoking cigarettes and initiation of cigarette smoking.

METHODS

The protocol was registered on September 24, 2018 (PROSPERO 2018 CRD42018108540). Three databases were queried from January 01, 2007 to April 26, 2023. Search results were screened using the PICOS review method.

RESULTS

Among 55 included studies (40 "good" and 15 "fair"; evidence grade: "high") that adjusted for gender, age, and race/ethnicity between groups, generally, there was a significant association between non-regular e-cigarette use and initiation of cigarette smoking, further supported by the meta-analytic results (AOR 3.71; 95% CI 2.86-4.81). However, smoking initiation was most often measured as ever/current cigarette smoking. Two studies (quality: 2 "good") evaluated progression to regular cigarette smoking among individuals with regular use of e-cigarettes, and generally found no significant associations. One study ("good") evaluated smoking initiation among individuals with regular use of e-cigarettes, finding an increasing probability of ever smoking cigarettes with increased e-cigarette use. Twelve studies (10 "good" and two "fair") examining progression to regular smoking among individuals with non-regular use of e-cigarettes reported inconsistent findings.

CONCLUSIONS

Numerous methodological flaws in the body of literature limit the generalizability of these results to all individuals who are not smoking cigarettes with few studies measuring established/regular use/smoking of e-cigarettes and cigarettes. Further, studies did not control adequately for specific confounding variables representing common liabilities between e-cigarette use and cigarette smoking, nor did they account for sufficient follow-up durations. Collectively, these flaws limit the generalizability of findings to the question of an association between e-cigarette use and cigarette smoking initiation.

Comparison of the Predictors of Smoking Cessation Plans between Adolescent Conventional Cigarette Smokers and E-Cigarette Smokers Using the Transtheoretical Model

Recently, there has been a shift in smoking patterns among adolescents, with a decrease in the prevalence of conventional cigarette smoking and an increase in the use of electronic cigarettes (e-cigarettes). The harmful effects of e-cigarettes are remarkable, highlighting the need for proactive interventions for adolescent users and smoking cessation that consider the characteristics of both conventional cigarette smokers and e-cigarette users. This study aims to investigate the smoking status of adolescent conventional cigarette and e-cigarette smokers and to analyze the predictors of their smoking cessation plans (SCPs) based on the transtheoretical model. Self-rated health, prior smoking cessation education, consciousness-raising, and dramatic relief as types of experiential processes of change, and formation of helping relationships as a type of behavioral process of change significantly differed according to the type of cigarette behavior among adolescents. The predictors of SCP among adolescents were perceived pros of smoking and academic performance among conventional cigarette smokers and behavioral process of change, perceived pros of smoking, and economic status among e-cigarette users. This study identified differences in the characteristics and predictors of SCP. Strategies tailored to each specific adolescent smoking population are further required to promote smoking cessation.

Longitudinal impact of perceived harm and addiction on e-cigarette initiation among tobacco-naïve youth: Population Assessment of Tobacco and Health study (Waves 1-5)

OBJECTIVES

This study investigates the effect of e-cigarette-related harm and addiction perceptions on e-cigarette initiation among US tobacco-naïve adolescents.

STUDY DESIGN

This is a longitudinal study.

METHODS

Using data from five waves (2013-2019) of the Population Assessment of Tobacco and Health Study, we created a longitudinal data set for 2775 youth aged 12-17 years who had no prior use of tobacco products at Wave 1. E-cigarette initiation was defined as transitioning from non-use at Wave 1 to ever use in subsequent waves. Kaplan-Meier survival and Cox proportional hazard regression models were used to assess the impact of harm and addiction perceptions on e-cigarette initiation.

RESULTS

Our analytic sample comprised 63.1% of youth who had never used tobacco products at Wave 1 and consequently initiated e-cigarette use in subsequent waves. Over time, fewer individuals perceived e-cigarettes as harmless (14.1%-2.1%), whereas more perceived them as likely to cause addiction (53.7%-76.6%). Compared with perceiving e-cigarettes as a lot of harm, those perceiving some harm (adjusted hazard ratio [aHR] = 1.30, 95% confidence interval [CI]: 1.12-1.52), little harm (aHR = 1.42, 95% CI: 1.20-1.68), or no harm (aHR = 2.09, 95% CI: 1.64-2.65) were more likely to initiate e-cigarette use. Demographic factors for initiation included being Black or Hispanic ethnicity (vs White), younger age (12-14 vs15-17 years), and receiving over $20 per week (vs $0) in pocket money, with P-values <0.05. However, in adjusted results, addiction perceptions did not significantly impact e-cigarette initiation (P-values >0.05).

CONCLUSIONS

Among youth without prior tobacco/nicotine use, perceiving e-cigarettes as having low harm significantly predicted initiation over time. Effective prevention strategies, including targeted risk communication interventions, are essential for discouraging e-cigarette use among youth.

Longitudinal bidirectional association between youth electronic cigarette use and tobacco cigarette smoking initiation in Thailand

INTRODUCTION

This study quantifies the longitudinal association between e-cigarette use and subsequent conventional cigarette initiation and vice versa among Thai youths.

METHODS

Data from a longitudinal survey of 6045 Thai seventh grade students with baseline in 2019 and the 12-month follow-up in 2020 were analysed using complex survey multivariate logistic regressions to assess whether e-cigarette use was associated with subsequent cigarette smoking (ever, current and dual product users at follow-up) among baseline never smokers.

RESULTS

Consistent with prior findings from other countries, among those who had never smoked cigarettes at baseline, ever e-cigarette users were more likely to try cigarette smoking (adjusted OR 4.44; 95% CI 2.23 to 8.86; p<0.001), or become dual users (adjusted OR 5.31; 95% CI 2.63 to 10.74; p<0.001) 1 year later. Baseline current e-cigarette users were more likely to become ever smokers (adjusted OR 5.37; 95% CI 1.82 to 15.90; p=0.005), current smokers (OR 3.92; 95% CI 1.69 to 9.14; p=0.003) and dual product users (adjusted OR 6.96; 95% CI 1.54 to 31.38; p=0.015) at the 12-month follow-up than non-e-cigarette users. Similarly, among never e-cigarette users at baseline, ever cigarette smoking were more likely to try e-cigarettes (adjusted OR 3.38; 95% CI 1.66 to 6.88; p=0.002), currently use e-cigarettes (adjusted OR 2.75; 95% CI 1.47 to 5.13; p=0.003) and currently use both e-cigarettes and cigarettes (adjusted OR 4.87; 95% CI 2.92 to 8.13; p<0.001) at the follow-up than never smokers. Among never e-cigarette users at baseline, current-cigarette smoking were more likely to try e-cigarettes (adjusted OR 6.21; 95% CI 2.58 to 14.95; p<0.001), currently use e-cigarettes (adjusted OR 2.80; 95% CI 1.27 to 6.14; p=0.014) and currently use both e-cigarettes and cigarettes (adjusted OR 7.70; 95% CI 3.45 to 17.19; p<0.001) at the follow-up than never smokers.

CONCLUSIONS

This longitudinal study in Asian low-income and middle-income countries supports the prospective association of youth e-cigarette use with subsequent smoking initiation and youth cigarette use with subsequent e-cigarette initiation that is similar to that observed in high-income Western countries.

First experience with nicotine products and transition to regular tobacco use: a secondary data analysis in 28 European countries

OBJECTIVE

The majority of tobacco users have had their first contact with nicotine at a young age. The aim of this study was to explore the association between the first tobacco or nicotine product tried and the transition to regular product use in 28 European countries.

METHODS

A secondary analysis of participants aged 15-40 years (n=8884) from 28 countries was conducted (Eurobarometer wave 93.2; August-September 2020). Participants who reported having ever tried tobacco or nicotine products were asked which product they tried first. Self-reported history of tobacco use determined whether they were established users (≥1 time weekly) of a range of products at any point in their life. Multilevel logistic regression was used to measure the association between first product tried and becoming a regular user of tobacco or nicotine products.

RESULTS

There was large variation between countries in the proportion of participants aged ≤40 years that ever tried tobacco or nicotine; Estonia had the highest proportion of ever users (85.8%) and Poland had the lowest (38.9%). Among those who had ever tried tobacco or nicotine, boxed cigarettes were the most common first product (72.3%) and pipe was the least common (0.4%). Compared with those who first tried e-cigarettes, the odds of ever becoming a regular user of any tobacco or nicotine product were higher among those who first had hand-rolled cigarettes (adjusted OR, aOR 2.23; 95% CI 1.43 to 3.48) or boxed cigarettes (aOR 2.08; 95% CI1.43 to 3.02) and lower among those who first tried waterpipe (aOR 0.22; 95% CI 0.14 to 0.34).

CONCLUSIONS

Although this study cannot infer causality, the findings show that odds of becoming a regular tobacco user differs widely depending on the first product used. Better understanding of the associations between first product use and regular tobacco use could be informative to tobacco control policy-makers and help tailor prevention programmes.

Unveiling the Impact of Electronic Cigarettes (EC) on Health: An Evidence-Based Review of EC as an Alternative to Combustible Cigarettes

Cigarette smoking has been considered a major public health concern due to its serious impact on health. However, smokers intending to quit may find long-term abstinence challenging. When smoking an electronic cigarette (EC), users can experience a sensation and taste similar to that of smoking a combustible cigarette. Therefore, manufacturers promote these products as a viable substitute for combustible cigarettes. However, several researchers report the serious health impacts experienced by EC users. Therefore, this review aims to examine the health impacts of EC use. Based on the findings of the research papers reported in the literature, the role of EC as a smoking cessation tool is unclear. Several researchers have also reported a significant association between EC usage among non-smokers at baseline and the future initiation of combustible cigarette smoking. EC use significantly impacts user health. The nicotine that is present in EC e-liquids can elevate blood pressure, resulting in blood vessel constriction and an increase in heart rate, ultimately leading the body to an ischemic condition, resulting in myocardial infarction (MI), stroke, and increased arterial stiffness. Researchers report a higher likelihood of prediabetes among EC users; its usage was associated with higher OR of having asthma attacks and higher OR of reporting depression and has an impact on birth outcomes among pregnant women. Men using EC are more likely to report erectile dysfunction than non-users. EC also has a significant impact on oral health, which includes periodontal diseases, mucosal lesions, irritation in the mouth and throat, reduced salivary flow, and an increased risk of developing cancer. The physical injury resulting from exploding EC is another health concern. The frequently burned areas included the hands, face, genitalia, and thighs. Marketers promote EC as an alternative to combustible cigarettes and a tool for quitting smoking. However, the Food and Drug Administration has not approved them for smoking cessation. EC can have a serious impact on the health of their users; hence, the findings of this paper have several implications, including the need for regulation of the sales and marketing of these products and educating the users on the impact of these products on their health and safety.

Current thinking about the effects of e-cigarettes on oral cancer risk

In the last decade there has been a significant increase in the appeal and popularity of e-cigarettes. Recent national news headlines outline that one million smokers will be given a free vaping starter kit to encourage them to give up tobacco products. An independent report commissioned by the UK Government has cited promotion of vaping as a critical recommendation to ensuring England is smoke-free by 2030. Undoubtedly, the dental team will now encounter many more questions from patients keen to know more regarding the safety of electronic nicotine delivery systems and their effects on the oral cavity. However, it is often difficult to answer these questions due to a lack of evidence regarding their impact. Although there are some preliminary animal and in vitro data, additional well-designed, long-term studies are required to investigate oral health outcomes of e-cigarette use.We aim to summarise the latest evidence to better inform clinicians about the effects of vaping on oral health, particularly regarding the risks of oral cancer, so they can better inform their patients.

Susceptibility to e-cigarette use and associated factors in high school youth, Oklahoma Youth Tobacco Survey, 2021-2022

Introduction

Susceptibility predicts subsequent uptake of e-cigarettes (EC) by youth. This study identified factors associated with EC susceptibility among high school students who have never used a tobacco/nicotine product.

Methods

The Oklahoma Youth Tobacco Survey was administered to a random sample of 36 Oklahoma High Schools during the 2021-2022 school year (n = 1,220 participating students). Associations between EC susceptibility and covariates were identified using stepwise logistic regression for weighted survey data.

Results

More than one third of Oklahoma high school students who had never used tobacco or nicotine products (36.4%) were susceptible, and males had higher susceptibility than females (38.8 and 33.9%, respectively). In males, EC susceptibility was associated with race (Black, American Indian, and other were less susceptible), psychological distress (aOR = 2.4, 95% CI = 1.1, 4.8), disagreement that all tobacco products are dangerous (aOR = 3.1, 95% CI = 1.2, 7.9), and perception of little/no harm from secondhand vapor (aOR = 3.4, 95% CI = 2.1, 5.3). In females, identifying as gay, lesbian, or bisexual (aOR = 2.1, 95% CI = 1.1, 3.9), poor academic performance (aOR = 4.5, 95% CI = 1.6, 12.6), psychological distress (aOR = 2.6, 95% CI = 1.2, 5.5) and interacting with EC content on social media (aOR = 5.9, 95% CI = 1.9, 18.1) were associated with EC susceptibility.

Conclusion

Males and females had different patterns of susceptibility to EC use. Understanding groups of adolescents most susceptible to using nicotine products can help target prevention efforts at home, in schools, and within communities.

Immigration status-related exclusive e-cigarette use and cannabis use and their dual use disparities associated with mental health disorder symptoms

INTRODUCTION

E-cigarette and cannabis use has been linked to various health risks, including respiratory and cardiovascular conditions. Yet, extant knowledge about the risk factors for exclusive and dual use of e-cigarettes and cannabis is limited, especially among immigrants. We examined exclusive e-cigarette and cannabis use and their dual use associated with mental health disorders among immigrants and U.S.-born.

METHODS

We analyzed national cross-sectional data collected between May 13, 2021, and January 9, 2022, among adults aged >18 years (n= 4766) living in U.S. Multinomial logistic regression analyses were conducted to model the associations of exclusivity and dual-use (reference group= non-use) with anxiety/depression.

RESULTS

The dual-use prevalence was higher than exclusive e-cigarette and cannabis use, especially among U.S.-born (dual use= 14.79% vs. cannabis use= 13.53% vs. e-cigarette use= 7.11%) compared to immigrants (dual use= 8.23% vs. cannabis use= 5.03% vs. e-cigarette use= 6.31%). Immigrants had lower risks of exclusive cannabis and dual use compared to U.S.-born. Anxiety/depression was associated with higher risks of exclusive cannabis use and dual use across immigration status, but was associated with exclusive e-cigarette use among only immigrants. While effect sizes of dual-use associated with anxiety/depression were higher among U.S.-born, the effect sizes of exclusive e-cigarette and cannabis use associated with anxiety/depression were higher among immigrants.

CONCLUSIONS

The findings revealed significant mental health risks for e-cigarette, cannabis, and their dual use among immigrants and U.S.-born, especially among U.S.-born. These findings highlight the need for public health research and interventions to consider immigration status-related disparities in substance use.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

Cross-sectional study of the associations between the implementation of the WHO FCTC tobacco advertising, promotion and sponsorship bans and current e-cigarette use among youth from countries with different income levels

BACKGROUND

The WHO Framework Convention on Tobacco Control (WHO FCTC) Article 13 requires countries to ban tobacco advertising, promotion and sponsorship (TAPS), and bans are recommended to cover electronic cigarettes (e-cigarettes). We examined youth e-cigarette prevalence by TAPS regulations in countries with different income levels.

METHODS

We analysed data on 165 299 respondents from 48 countries with 2016/2018 WHO FCTC implementation reports and 2016-2019 Global Youth Tobacco Survey. We used multilevel logistic regressions to examine associations between TAPS regulations and current e-cigarette use, stratified by country income.

RESULTS

About 1 in 10 respondents was currently using e-cigarettes. Respondents in countries with TAPS bans on the internet were less likely to use e-cigarettes (adjOR=0.58; 95% CI 0.39 to 0.86) than youth in countries without such bans. In lower middle-income and low-income countries, bans on displaying tobacco products at the point of sale (adjOR=0.55; 95% CI 0.34 to 0.90), bans on product placement (adjOR=0.44; 95% CI 0.28 to 0.69) and strength of additional TAPS measures were associated with lower prevalence of e-cigarette use among students. Being taught about the dangers of the use of tobacco in school was associated with lower odds of e-cigarette use. No differences in the use of e-cigarettes were observed by types of TAPS among respondents in high-income countries.

CONCLUSIONS

Strengthening implementation of TAPS policies and assuring they cover new and emerging products, online channels and points of sales are essential, especially in lower income countries. Maintaining tobacco health education is also important to protect youth from e-cigarette use.

Safety, efficacy and health impact of electronic nicotine delivery systems (ENDS): an umbrella review protocol

BACKGROUND

Electronic nicotine delivery systems (ENDS), commonly known as e-cigarettes or vapes, have witnessed a rise in popularity, particularly among the youth. Although they were initially introduced as an alternative to traditional smoking, the design and function of ENDS vary. The potential health effects of ENDS, especially in comparison to traditional cigarettes, are a matter of ongoing debate. Given the increasing number of clinical studies and systematic reviews on this topic, there exists a demand for an umbrella review that offers a comprehensive assessment. The goal of this study is to perform an umbrella review of systematic reviews and meta-analyses to assess the safety, efficacy, health implications and potential gateway effect associated with ENDS.

METHODS AND ANALYSIS

This umbrella review will adhere to the Joanna Briggs Institute (JBI) framework and the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A planned literature search will be executed across databases such as OVID, PubMed/MEDLINE, EMBASE, Cochrane Library and Web of Science. The inclusion criteria are systematic reviews that discuss ENDS and e-liquids in the context of safety, efficacy and health outcomes. The exclusion criteria include narrative reviews, non-systematic reviews and studies not in English. Quality of the selected studies will be evaluated using the AMSTAR V.2 Scale. An overlap assessment will be done using the Corrected Covered Area, and data synthesis will be presented both narratively and in tabulated forms ETHICS AND DISSEMINATION: Ethics approval is not required for this study, as it does not involve the collection of original data. The results will be disseminated through peer-reviewed publication. The findings will offer crucial insights for stakeholders, policy-makers and the general public, underlining the health implications and the role of ENDS in tobacco cessation.

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.

Adolescents' electronic devices use during the COVID-19 pandemic and its relationship to anxiety and depression levels: a cross-sectional study

BACKGROUND

The aim of this study is to assess the prevalence of anxiety and depression symptoms among adolescent students in the West Bank region of Palestine, with a particular focus on the impact of electronic device usage on their mental well-being.

METHODS

This cross-sectional study included a representative sample of 1,140 adolescents enrolled in governmental secondary schools. We targeted schools located in Nablus, Ramallah, and Hebron districts, which, respectively, represent the northern, central, and southern regions of the West Bank. We collected data on their sociodemographic characteristics, patterns of electronic device usage, scores from the Beck Depression Inventory-II, and the 7-item Generalized Anxiety Disorder scale, all gathered through a self-administered online questionnaire. To explore the independent relationship between anxiety, depression, and various factors, we calculated odds ratios and their corresponding 95% CI using a binary logistic regression model.

RESULTS

The study revealed a prevalence of moderate to severe anxiety at 35.4% [95% CI: 32.7-38.3%] and moderate to severe depression at 23.9% [95% CI: 21.4-26.4%]. Notably, anxiety scores were significantly higher among females [OR = 3.8, 95% CI: 2.5-5.9], individuals with lower academic performance [OR = 3.4, 95% CI: 2.1-5.4], and smokers [OR = 1.9, 95% CI: 1.1-3.0]. Similarly, significantly elevated depressive scores were observed among females [OR = 2.0, 95% CI: 1.3-3.1], those with lower academic performance [OR = 3.4, 95% CI: 2.1-5.4], and smokers [OR = 1.9, 95% CI: 1.3-2.8]. Conversely, students who used electronic devices for shorter durations were less likely to experience depression [OR = 0.49, 95% CI: 0.32-0.76] or anxiety [OR = 0.47, 95% CI: 0.32-0.69].

CONCLUSION

Considering the alarming rates of anxiety and depression in adolescents, along with their connection to the time spent using electronic devices, we strongly recommend the creation of initiatives and support networks to alleviate this issue's impact. Encouraging healthier lifestyles, such as reducing screen time and increasing physical activity, could potentially enhance the mental well-being of adolescents.

A Content Analysis of Behavior Change Techniques Employed in North American Vaping Prevention Interventions

Introduction

Vaping among North American youth has surfaced as a concerning public health epidemic. Increasing evidence of harms associated with E-cigarette use, especially among the young, has prompted urgency in addressing vaping. Although a number of individual behavior change campaigns have arisen as a result, little is known about which behavior change techniques are being employed to influence youth vaping behavior. In this study, we aimed to code all North American vaping prevention campaigns using the behavior change technique taxonomy (Version 1) to determine which behavior change techniques are being used.

Methods

We identified the sample of campaigns through systematic searches using Google. After applying the exclusion criteria, the campaigns were reviewed and coded for behavior change techniques.

Results

In total, 46 unique vaping prevention campaigns were identified, including 2 federal (1 from Canada, 1 from the U.S.), 43 U.S. state-level, and 1 Canadian provincial-level campaign(s). The number of behavior change technique categories and behavior change techniques in a campaign ranged from 0 to 5 (mean=1.56) and 0 to 6 (mean=2.13), respectively. Of the 16 possible behavior change technique categories, 4 were utilized across the campaigns, which included 5. Natural consequences (89%), 6. Comparison of behavior (22%), 13. Identity (20%), and 3. Social support (11%).

Conclusions

Only a small number of behavior change techniques were used in North American vaping prevention campaigns, with a heavy and often sole reliance on communicating the health consequences of use. Incorporating other promising behavior change techniques into future campaigns is likely a productive way forward to tackling the complex and multifaceted issue of youth vaping.

Systematic Review and Critical Analysis of Longitudinal Studies Assessing Effect of E-Cigarettes on Cigarette Initiation among Adolescent Never-Smokers

Prospective longitudinal studies mainly conclude on a causal role of e-cigarettes in the initiation of cigarettes in flagrant contradiction with conclusions drawn from epidemiology and other studies showing a sharp decline in cigarette use in parallel with the spread of e-cigarette use. This systematic review explores the reasons for this discrepancy.

METHODS

Among 84 publications on e-cigarette/cigarette association in adolescents identified in the Medline database from 2011 to 2022, 23 concern 22 never-smoker longitudinal sub-cohorts.

RESULTS

A link between e-cigarette experimentation at T1 and cigarette initiation at T2 is reported in sub-cohort analyses of never-smokers (AOR: 1.41 to 8.30). However, studies exclude 64.3% of T1 e-cigarette experimenters (because of dual-use) and 74.1% of T2 cigarette experimenters. With this study design, e-cigarettes contribute only to 5.3% of T2 cigarette experimentation, casting major doubt on the external validity of results and authors' conclusions that e-cigarettes have a significant effect on the initiation of cigarettes (Gateway effect) at the population level. This sub-cohort design prohibits highlighting any Diversion effect, which is the most likely mechanism accounting for the competition between these two products.

CONCLUSIONS

While nicotine abstinence remains the best medical option, over-regulation of e-cigarettes because of misinterpretation of longitudinal study results may be detrimental to public health and tobacco control.

Latin America and the Caribbean Code Against Cancer 1st edition: Tobacco and nicotine-related products, secondhand smoke, and alcohol and cancer

Tobacco, secondhand smoke (SHS), and alcohol, all carcinogens, are leading preventable cancer risk factors in Latin America and the Caribbean (LAC). Since 2000, smoking and SHS exposure have significantly decreased in the region. Yet alcohol consumption remains high. The entry of nicotine-related products such as electronic cigarettes (e-cigs) threatens achievements made in tobacco control and chronic diseases prevention, including cancer. E-cigs use is likely associated with smoking initiation among adolescents who had never smoked and dual use with combustible tobacco products. Therefore, the LAC Code Against Cancer recommends to the public actions they can take to reduce their risk of cancer: 1. Don't smoke or use any type of tobacco. If you do, quitting is possible, with professional help if needed. Don't use e-cigarettes either, as they lead to tobacco use. 2. Make your home a smoke-free place. Respect and promote laws that ensure smoke-free spaces to protect our health. and 3. Avoid drinking alcoholic beverages. This helps prevent several types of cancer. The Code recommends to policymakers a package of cost-effective policies based on the MPOWER and SAFER to prevent cancer at the population level. It also recommends that primary care health professionals: 1. Ask all their patients and their families whether they smoke or vape, inform them about the harms of smoking and vaping, and promote tobacco and nicotine related products cessation strategies among users. 2. Inform about the harms of exposure to SHS, especially among children, and promote smoke-free environments, and 3. Prevent alcohol use by their patients and their families, use tools to assess use, intensity, and frequency, and apply brief counseling intervention to support alcohol abstinence in primary care.

The sweet spot study-Developing e-liquid product standards for nicotine form and concentration to improve public health: Protocol for a randomized, double-blinded, crossover study

OBJECTIVES

E-cigarettes pose significant risks to youth, but smokers may benefit from switching to e-cigarettes by reducing their exposure to toxicants, which creates a challenge for the Food and Drug Administration (FDA) in regulating e-cigarettes to protect population health. This study aims to develop e-liquid product standards for nicotine form and concentration that reduce the appeal of e-cigarettes to young people while keeping e-cigarettes available as a safer alternative for smokers.

DESIGN AND PARTICIPANTS

A single-visit, double-blinded, randomized crossover design will be used to examine the effects of e-liquids with varying fractions of free-base nicotine (5%, 25%, 45%, 65%, 85%) among a sample of 66 young adult EC users and 66 older adult smokers, across ecologically valid total nicotine concentrations (20 mg or 50 mg/mL).

INTERVENTIONS AND OUTCOMES

A 2-puff session will be conducted to test each of the 10 e-liquids in randomly assigned sequences, followed by a 10-minute washout period and participant ratings on appeal and sensory attributes such as throat hit and harshness, as well as behavioral intentions for continued use. Generalized linear mixed models will be used to determine a free-base nicotine level that has limited or no appeal to young adult e-cigarette users while remaining acceptable to smokers.

CONCLUSIONS

This study will provide the FDA with scientific evidence regarding the effect of product standards that mandate a minimum threshold for the fraction of free-base nicotine.

TRIAL REGISTRATION

The study is registered on clinicaltrials.gov under the identifier NCT05864586.