Prevalence of E-Cigarette Use and Its Associated Factors Among Youths Aged 12 to 16 Years in 68 Countries and Territories: Global Youth Tobacco Survey, 2012‒2019

The association between electronic cigarette use and respiratory symptoms among university students: A cross-sectional study in Saudi Arabia

INTRODUCTION

Electronic cigarette use is on the rise. It is critical to understand the respiratory hazards connected with their use for public health reasons. However, there are limited data concerning this issue in the Middle East and in Saudi Arabia in particular. This study aimed to investigate the association between e-cigarette use and respiratory symptoms among university students in Madinah city, Saudi Arabia.

METHODS

A cross-sectional study was conducted among university students using a self-administered questionnaire with self-reported respiratory symptoms as the primary outcome; a non-probability convenience sampling strategy was used. Emails were sent to all registered students in undergraduate programs between October and November 2024. Appropriate statistical tests were performed on the data, including multivariable logistic regression.

RESULTS

A total of 499 students participated in the study, of which 17.6% were current e-cigarette users and 13.2% were ever users. Respiratory symptoms were most prevalent among current users. Current e-cigarette users and ever users had higher odds of respiratory symptoms than never users (adjusted odds ratio, AOR=2.26; 95% CI: 1.14-4.51 and AOR=2.32; 95% CI: 1.21-4.46, respectively), after adjusting for demographic characteristics, tobacco use, exposure to tobacco and e-cigarettes, and other health factors.

CONCLUSIONS

We found a significant association between e-cigarette use and adverse respiratory symptoms among university students, independent of tobacco use.

#Discreetshipping: Selling E-cigarettes on TikTok

INTRODUCTION

Youth and young adult use of e-cigarette products continues to remain high despite regulatory approaches to reduce youth access. This study sought to examine TikTok content regarding the sale and distribution of e-cigarettes.

AIMS AND METHODS

TikTok videos (n = 475) and metadata posted between June 2022 and August 2023 were scraped using a TikTok application programming interface and popular hashtags used to sell vaping products (ie, #discreetshipping [40.8 million], #puffbundle [14.8 million], #hiddennic [1.0 million]). After watching the 25 most viewed videos (39 600-868 800 views), a codebook was developed. All metadata were annotated using 11 unique codes: Small business, brand, cannabis, bundled, hidden, fake, international sales, no ID, order via Instagram, order via another method, and cost.

RESULTS

Overall, 367 videos (with an average of 2017 likes) were deemed relevant. Videos advertised popular vaping brands (50.4%) that included cannabis products (45%). Products were described as bundled (28.6%), hidden (8.7%), and able to be shipped internationally (6%) without age verification (45.2%). Some videos (8.2%) evaded algorithms' detection of illegal activity by describing the post as "Fake." Customers were directed to other social media platforms (most often Instagram, 57.5%) and/or other websites/links (58.3%) to purchase products; 22.1% advertised discounts, free shipping, or low costs (ranging from $25-$35).

CONCLUSIONS

Social media platforms, such as TikTok and Instagram, are being used to circumvent e-cigarette regulatory policies. Regulatory agencies should expand enforcement strategies to include social media platforms where users are illegally selling and distributing e-cigarettes internationally to young audiences.

IMPLICATIONS

TikTok users across the globe are violating local, state, and federal laws by selling e-cigarettes concealed inside other products or bundled in packages that avoid detection. TikTok videos posted by self-proclaimed small business owners advertise discreet shipping practices that evade age verification in order to sell nicotine and cannabis bundles worldwide. Accounts used phrases describing the post to be "fake" to avoid detection by algorithms or TikTok administrators. E-cigarette regulatory agencies can partner with social media platforms to close regulatory gaps.

Prevalence of vaping, vaping-associated short-term symptoms of respiratory and cardiovascular morbidities, and factors associated with the initiation of vaping among young adults in Kuwait

INTRODUCTION

E-cigarette use or vaping is a public health concern, especially among young adults worldwide. This cross-sectional study aimed to: 1) assess the prevalence of vaping among young adults; 2) assess the prevalence of short-term vaping-associated respiratory and cardiovascular symptoms; and 3) identify factors associated with vaping status among a student population in Kuwait.

METHODS

In October 2024, a cross-sectional study enrolled students, aged ≥18 years, from various colleges of Kuwait University. Data were collected using a structured e-questionnaire administered through in-person invitations and online platforms. The prevalence (%) of vaping was computed. A multivariable log-binomial regression model was used to estimate adjusted prevalence ratios (APRs) and corresponding 95% confidence intervals (CI) for the factors significantly associated with vaping status. All the statistical tests were two-tailed.

RESULTS

Of 1144 participants, most were females (78.5%), Kuwaiti (85.5%), and aged 18-21 years (70.6%). The prevalence of vaping in our sample was 15.5% (177/1144). After adjusting for the effects of age and monthly family income (in KWD), the factors that were significantly (p<0.05) and independently associated with vaping status were male gender (APR=4.52; 95% CI: 3.28-6.22), being a student at a literary college (APR=1.50; 95% CI: 1.12-2.02), a positive belief that 'vaping is less harmful than cigarette smoking' (APR=1.46; 95% CI: 1.06-2.01), and a 'disbelief that vaping leads to cigarette smoking' (APR=1.80; 95% CI: 1.32-2.45), and 'perception about easy accessibility of vaping products' (APR=3.27; 95% CI: 1.04-10.32).

CONCLUSIONS

A moderately high prevalence (15.5%) of vaping in the study sample was recorded. Male gender and some misplaced beliefs and perceptions were significantly associated with vaping status in the study sample. The high prevalences of respiratory symptoms among the participants call for targeted interventions. If instituted, future studies may evaluate the impact of such efforts.

Burden of nasopharyngeal carcinoma in Asia from 1990 to 2021

OBJECTIVES

The study aimed to investigate the disease burden of nasopharyngeal carcinoma (NPC) in Asia.

MATERIAL AND METHODS

The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 data evaluated NPC metrics by sex, and age in Asia. Estimated annual percentage changes (EAPCs) were calculated to assess the trends of NPC burden. The decomposition analysis was used to analyze drivers of deaths and disability-adjusted life years (DALYs) of NPC. The DALYs of NPC attributed to modifiable risk factors were also assessed. And we predicted changes of NPC burden to 2044.

RESULTS

In 2021, there were 101,841.49 (95 % UI: 88,093.77 to 118,402.42) incident cases, 62,079.09 (95 % UI: 54,879.91 to 70,240.60) deaths, and 2,041,239.04 (95 % UI: 1,796,551.45 to 2,315,547.51) DALYs due to NPC in Asia. From 1990 to 2021, age-standardized rates (ASR) showed a downward trend in Asia. East Asia bore the heaviest burden of NPC in the Asian region. China and India stood out as facing the most severe burdens. Central Asia was the only region in Asia where both ASIR and ASMR showed an upward trend, while ASR in Armenia experienced the fastest growth in Asian countries. The decomposition analysis showed that population growth was the main factor influencing NPC in Asia. Behavioral risks were the primary factors affecting NPC in Asia.

CONCLUSION

NPC remains a significant public health issue in Asia, especially in East Asia. China and India still face challenges due to population aging and population growth. Armenia's rising incidence highlights urgent concerns. Strengthening prevention and treatment of NPC is crucial.

CLINICAL SIGNIFICANCE

NPC continues to pose a significant public health challenge in Asia, especially in East Asia. The disease burden of Asian NPCs is increased by population growth. Targeted prevention and control policies of NPC must be implemented for high-risk areas, alongside efforts to reduce behavioral risk factors.

Immunological Effects of Electronic Cigarette Use: A Review of Current Evidence

Electronic cigarettes (EC) have emerged as a popular alternative to traditional tobacco products, but their impact on immune function has raised significant health concerns. This review explores the immunological effects of EC exposure, focusing on innate and adaptive immune responses. Electronic cigarette aerosol (ECA) induces widespread inflammation. These changes compromise immune cell function, impairing neutrophil chemotaxis, phagocytosis, and oxidative burst while increasing macrophage and dendritic cell recruitment and activation. ECA also disrupts epithelial barriers, increasing susceptibility to bacterial and viral infections. Studies show enhanced biofilm formation in bacteria such as Staphylococcus aureus and Streptococcus pneumoniae and impaired antiviral responses against pathogens like influenza A and SARS-CoV-2. Additionally, EC exposure modulates adaptive immunity, affecting T and B cell function and increasing systemic inflammatory markers. The long-term consequences of these immunological disruptions include heightened risks for chronic inflammatory diseases, respiratory infections, and potentially autoimmune conditions. The widespread adoption of EC, particularly among younger users, poses a growing public health challenge. As the popularity of vaping continues to rise, these immunological disruptions could result in increased healthcare burdens in the future, with higher rates of infections, chronic inflammatory diseases, and immune system-related disorders among those who begin using e-cigarettes at a young age. Understanding the full scope of EC-related health risks is essential for informing public health policies and protecting future generations from the potential long-term effects of vaping.

Electronic cigarettes use and parental factors among children and adolescents, Jeddah. A cross-sectional study

E-cigarettes are gaining popularity worldwide, necessitating their control. This study investigated the impact of parental factors on E-cigarette use among children-adolescents in Jeddah, Saudi Arabia. A cross-sectional survey involving 1,044 parents of children aged 10- to 21 was conducted in malls. A structured questionnaire assessed parental socio-economic status, smoking/vaping habits, and attitudes toward E-cigarette use.Data were analysed using chi-square, Mann-Whitney, and binary logistic regression (significance set at 0.05). Results showed 176 (16.9%) parents reported their children using E-cigarettes. Older adolescents (18-21 age group) were significantly more likely to use E-cigarettes compared to younger ones (adjusted odds ratio [AOR]:6.456, 95% CI:3.664-11.374). Parents with a permissive attitude were more likely to have children who vape. (AOR:1.643, 95% CI:1.149-2.348). While open parent-child communication about traditional smoking reduced E-cigarettes use (AOR:0.772, 95% CI:0.639-0.934). Parental attitudes and open communication are crucial for mitigating youth E-cigarette use.

Synthetic nicotine descriptors: awareness and impact on perceptions of e-cigarettes among US youth

BACKGROUND

Electronic cigarettes (e-cigarettes) are being advertised and sold with synthetic nicotine. Little research has examined youth awareness of synthetic nicotine or the impact of synthetic nicotine descriptors on perceptions of e-cigarettes.

METHODS

Participants were a sample of 1603 US adolescents (aged 13-17 years) from a probability-based panel. The survey assessed knowledge of nicotine source in e-cigarettes (from 'tobacco plants' or 'other sources besides tobacco plants') and awareness of e-cigarettes containing synthetic nicotine. Then, in a between-subjects experiment with a 2×3 factorial design, we manipulated descriptors on e-cigarette products: (1) nicotine label (inclusion of the word 'nicotine': present or absent) and (2) source label (inclusion of a source: 'tobacco-free', 'synthetic' or absent).

RESULTS

Most youth were either unsure (48.1%) or did not think (20.2%) that nicotine in e-cigarettes comes from tobacco plants; similarly, most were unsure (48.2%) or did not think (8.1%) that nicotine in e-cigarettes comes from other sources. There was low-to-moderate awareness of e-cigarettes containing synthetic nicotine (28.7%), with higher awareness among youth who use e-cigarettes (48.0%). While no main effects were observed, there was a significant three-way interaction between e-cigarette status and the experimental manipulations. The 'tobacco-free nicotine' descriptor increased purchase intentions relative to 'synthetic nicotine' (simple slope: 1.20, 95% CI 0.65 to 1.75) and 'nicotine' (simple slope: 1.20, 95% CI 0.67 to 1.73) for youth who use e-cigarettes.

CONCLUSIONS

Most US youth do not know or have incorrect beliefs about the sources of nicotine in e-cigarettes and describing synthetic nicotine as 'tobacco-free nicotine' increases purchase intentions among youth who use e-cigarettes.

Socioeconomics of e-cigarette use in Colombia: 2019 National Substance Use Survey

Background

E-cigarettes have been extensively marketed and popularized worldwide despite their harmful effects. To effectively plan and implement preventive measures, comprehensive analyses are needed to understand the influence of individual and contextual factors on their use.

Objective

This study aimed to analyze the influence of poverty and demographic and socioeconomic patterns on e-cigarette use in Colombia.

Methods

This study is based on a secondary analysis of the 2019 Colombian Survey on Psychoactive Substance Use, which included 49,756 individuals aged between 12 and 68. State-level multidimensional poverty and individual health-related, socioeconomic, and demographic characteristics were analyzed. Two-level regression models adjusted for the individual and contextual effects.

Results

The prevalence of vaping was 4.4% (95% CI: 4.2%-4.6%), with substantial variation across departments, ranging from 0.0% to 9.6%. In the multilevel models, younger age, male sex, technical or higher education, middle-income stratum, not contributing economically to the household, affiliation with the subsidized health scheme, history of tobacco smoking, alcohol consumption, and self-reported use of other drugs were all significantly associated with vaping. The estimated median odds ratio for multidimensional poverty was 1.23 (95% CI: 1.14-1.33; p= 0.012).

Conclusions

E-cigarette use in Colombia is a health risk and an indicator of social vulnerability that is influenced by structural determinants. Urgent action from health authorities, the education system, regulatory bodies, and civil society is needed to prevent the normalization of vaping among youth. If left unaddressed, vaping could worsen health inequalities and lead to chronic addiction-related disorders in underserved communities.

Adolescents' Experiences and Perceptions of E-Cigarettes and Nicotine Addiction

BACKGROUND

 E-cigarettes are the most-used tobacco product among US adolescents and are associated with nicotine addiction. This qualitative investigation aimed to understand adolescents' experiences and perceptions with nicotine addiction, and related influences of addiction, to inform product regulation, health communication, and cessation resource development.

METHODS

 Between May 2020 and December 2021, in-depth, semi-structured individual interviews were conducted with 47 California (United States) adolescents ages 13-17 who reported recent tobacco use (primarily e-cigarette use). The topic of addiction both arose organically and followed specific interviewer questions. Researchers used thematic analysis techniques to identify unifying themes related to addiction.

RESULTS

 Adolescents described e-cigarette addiction in ways that reflected a loss of control over their routines and activities and as physical symptoms, including reward and withdrawal. While some viewed addiction risk as a reason not to vape, others perceived it possible to use e-cigarettes and avoid or manage addiction. Specific characteristics of e-cigarette devices, particularly disposable nicotine-salt products, including flavors, "cool" designs, concealable size and odor, low price, and ease-of-use, were seen as enhancing addiction risk. Quit attempts were difficult and usually unsupported by adults or formal cessation aids.

CONCLUSIONS

 For many adolescents, addiction is a major component of their experience with e-cigarettes, often in ways that disrupt their routines and reduce their quality of life. Tobacco control or regulation could target e-cigarette product characteristics to decrease potential for addiction among adolescents. Needed are youth-targeted public communication about nicotine addiction and adolescent-tailored, evidence-based cessation support.

Electronic nicotine delivery system use and its relation to waterpipe smoking among youth in seven Arab countries

OBJECTIVES

Electronic Nicotine Delivery System (ENDS) use and Waterpipe Tobacco Smoking (WTS) are reported to be a growing strain of tobacco epidemic among youth in the Arab world. Therefore, we aimed to: (1) estimate the regional prevalence of ENDS use among youth in 7 Arab countries and, (2) to explore the bidirectional relationship between ENDS use and WTS among Arab adolescents.

METHODS

We analyzed data from the World Health Organization Global Youth Tobacco Survey (GYTS 2014-2018) of 18,536 schoolchildren aged 12-16 from Iraq, Mauritania, Morocco, Oman, Qatar, Tunisia, and Yemen. The weighted prevalence was calculated to generate nationally representative estimates. Adjusted multilevel logistic regression models were conducted to assess the association between ENDS use and WTS.

RESULTS

The pooled weighted prevalence of ENDS use was 9.5%. Higher odds of ENDS use were significantly associated with WTS (AOR: 5.26, 95%CI: 4.28-6.46), smoking conventional cigarettes (AOR: 1.54, 95%CI: 1.23-1.94) and first tobacco use prior to the age of 12 (AOR: 1.40, 95%CI: 1.14-1.72). Females and children who were taught in school the dangers of tobacco had less odds of using ENDS.

CONCLUSION

WTS was associated with increased odds of ENDS use by >5 folds, and vice versa. Tobacco consumption at age younger than 12 years was associated with higher odds of ENDS use, but less odds of WTS. Females and those who were taught in school the dangers of tobacco were less likely to report ENDS use.

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.

Vaping: Public Health, Social Media, and Toxicity

This viewpoint aims to provide a comprehensive understanding of vaping from various perspectives that contribute to the invention, development, spread, and consequences of e-cigarette products and vaping. Our analysis showed that the specific characteristics of e-cigarette products as well as marketing strategies, especially social media marketing, fostered the spread of vaping and the subsequent effects on human health and toxicity. We analyzed the components of e-cigarette devices and e-liquids, including the latest variants whose impacts were often overlooked. The different forms of nicotine, including salts and freebase nicotine, tobacco-derived nicotine, tobacco-free nicotine, and cooling agents (WS3 and WS23), have brought more choices for vapers along with more ways for e-cigarette manufacturers to advertise false understandings and present a greater threat to vapers' health. Our work emphasized the products of brands that have gained significant influence recently, which are contributing to severe public health issues. On the other hand, we also discussed in detail the toxicity of e-liquid components and proposed a toxicity mechanism. We also noticed that nicotine and other chemicals in e-liquids promote each other's negative effects through the oxidative stress and inflammatory nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) pathway, a mechanism leading to pulmonary symptoms and addiction. The impact of government regulations on the products themselves, including flavor bans or regulations, has been limited. Therefore, we proposed further interventions or harm reduction strategies from a public health perspective.

Kowitt S, Ritchie C, Sutfin EL, Sheeran P, Noar SM. Awareness and Perceptions of US Food and Drug Administration's JUUL Marketing Denial Order: A National Study of US Adolescents

INTRODUCTION

We examined awareness and perceptions of the US Food and Drug Administration (FDA) JUUL marketing denial order (MDO) that occurred in June 2022 among a nationally representative sample of US adolescents.

AIMS AND METHODS

Data were collected in August 2022 via an online survey (n = 1603). Adolescents were asked whether they had heard about the JUUL MDO, and, if yes, where they heard the news. Those who had heard were asked about the MDO's impact on their harm beliefs about JUUL and vape products in general. We examined correlates of awareness of the MDO and of increased JUUL and vape harm perceptions.

RESULTS

Twenty-seven percent of adolescents had heard about the MDO. Older adolescents (adjusted odds ratio [aOR] = 1.13) and LGBTQ+ adolescents (aOR = 2.05) had significantly higher odds of having heard the news, while those who identified as Black or African American had significantly lower odds of having heard (aOR = 0.56). Most participants who were aware of the MDO indicated that they had higher harm perceptions about JUUL itself (77.9%) and vapes in general (79.6%). Youths susceptible to vaping and current users were less likely to report increased harm perceptions about JUUL (B = -0.34 and -0.46, respectively) and vapes in general (B = -0.27 and -0.43) compared with youth not susceptible to vaping.

CONCLUSIONS

The results of this nationally representative survey demonstrate that over one-quarter of US youth heard about the JUUL MDO and the vast majority of those indicated increased harm perceptions about vapes. Large-scale news events about vaping can reach youth audiences and may impact what youth think about the harms of vaping.

IMPLICATIONS

Analysis of a nationally representative survey of adolescents aged 13-17 revealed that more than 25% had heard about the marketing denial order issued to JUUL Labs by the FDA in June of 2022. We also found that the vast majority of adolescents reported increased JUUL and vape harm perceptions in response to hearing about the MDO. This indicates that news coverage about vaping-including coverage of regulatory actions-can reach and potentially impact adolescents. It is therefore important to monitor news coverage about vaping, how it is framed and discussed across media platforms, and its reach among priority populations.

The potential health effects associated with electronic-cigarette

A good old gateway theory that electronic-cigarettes (e-cigarettes) are widely recognized as safer tobacco substitutes. In actuality, demographics also show that vaping cannibalizes smoking, the best explanation of the data is the "common liability". However, the utilization of e-cigarette products remains a controversial topic at present. Currently, there has been a widespread and substantial growth in e-cigarette use worldwide owing to their endless new flavors and customizable characteristics. Furthermore, e-cigarette has grown widespread among smokers as well as non-smokers, including adolescents and young adults. And some studies have shown that e-cigarette users are at greater risk to start using combustible cigarettes while e-cigarettes use was also observed the potential benefits to people who want to quit smoking or not. Although it is true that e-cigarettes generally contain fewer toxic substances than combustible cigarettes, this does not mean that the chemical composition in e-cigarettes aerosols poses absolutely no risks. While concerns about toxic substances in e-cigarettes and their widespread use in the population are reasonable, it is also crucial to consider that e-cigarettes have been associated with the potential for promoting smoking cessation and the clinically relevant improvements in users with smoking-related pathologies. Meanwhile, there is still short of understanding of the health impacts associated with e-cigarette use. Therefore, in this review, we discussed the health impacts of e-cigarette exposure on oral, nasal, pulmonary, cardiovascular systems and brain. We aspire for this review to change people's previous perceptions of e-cigarettes and provide them with a more balanced perspective. Additionally, we suggest appropriate adjustments on regulation and policy for e-cigarette to gain greater public health benefits.

Effects of Nicotine Content and Preferred Flavor on Subjective Responses to E-cigarettes: A Randomized, Placebo-controlled Laboratory Study

INTRODUCTION

Evidence suggests that e-liquid flavor and nicotine concentration are important factors in the initiation and maintenance of e-cigarette use (vaping). Flavors may increase the initiation and maintenance of vaping, and nicotine content is a factor in e-cigarette dependence and the efficacy of e-cigarettes for cigarette smoking cessation. Few human laboratory studies have assessed the joint and interactive effects of flavor and nicotine on subjective responses to e-cigarettes.

METHODS

Regular e-cigarette users (N = 89) completed a multi-session study involving a paced vaping procedure with e-liquid cartridges containing their preferred flavor (berry, menthol, or tobacco) or no flavor, with or without nicotine (18 mg). Subjective effects of vaping (satisfaction, reward, aversion, airway sensations, and craving relief) were assessed.

RESULTS

Nicotine significantly increased psychological reward and craving relief, whereas flavor significantly increased vaping satisfaction and taste. Nicotine dependence severity moderated the effect of nicotine on reward, such that those with the greatest dependence severity reported the greatest reward.

CONCLUSIONS

These findings support differential and noninteractive effects of e-liquid nicotine content and flavor on reinforcing effects of e-cigarettes.

IMPLICATIONS

E-liquid flavor and nicotine content have independent, non-interactive effects on subjective responses to vaping under controlled laboratory conditions. Among regular e-cigarette users, vaping a preferred flavor increased taste and satisfaction, but did not interact with nicotine to alter reward or craving. Further research on the ways in which these subjective effects may motivate vaping behavior among different populations of e-cigarette users would be useful to inform regulatory policy of ENDS products.

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.

Marketing claims, promotional strategies, and product information on Malaysian e-cigarette retailer websites-a content analysis

BACKGROUND

Marketing and sales of e-cigarettes are unregulated in Malaysia. We analyzed content displayed on e-cigarette retailer websites to identify marketing claims, promotional strategies, and product details in the year 2022.

METHODS

We analyzed 30 Malaysia-based retailer websites using a mixed methods approach. Data were extracted as the frequency of occurrences of marketing claims, presence of regulatory information, product types, and flavors of e-juice as per a predefined codebook based on published literature. We also extracted textual details published on the websites about marketing claims, and slogans.

RESULTS

Most retailer websites provided contact information and physical store addresses (83%) but only half had 'click through' age verification (57%) that seldom needed any identification proof for age (3%). Marketing claims were related to health (47%), smoking cessation (37%), and modernity/trend (37%) and none had health warnings. Promotional strategies were discounts (80%). starter kits (57%) and email subscriptions (53%). Product types displayed were rechargeable (97%) and disposable (87%) devices and e-liquids (90%) of an array of flavors (> 100). Nicotine presence, its concentration, and "nicotine is an addictive chemical" were displayed in 93%, 53%, and 23% of websites respectively.

CONCLUSION

Surveillance of content displayed online on e-cigarette retailer websites and regulation of online marketing and sales should be implemented by the Ministry of Health, Malaysia. Such measures are needed to prevent access to, and initiation of e-cigarette use among the youth and adults who do not smoke.

A Critical Review of E-Cigarette Regulation in China: Challenges and Prospects for Youth Prevention and Tobacco Control

INTRODUCTION

The increasing popularity of electronic cigarettes (e-cigarettes) has led to the emergence of public health concerns, particularly among the youth. As a major producer and exporter of e-cigarettes, China has faced public health challenges in regulating the unregulated e-cigarette industry.

AIMS AND METHODS

This study aims to evaluate the regulatory development of e-cigarettes in China. We searched and obtained national policy documents related to e-cigarettes and subnational smoke-free laws from LexisNexis on August 2, 2023, which were enacted between January 1, 2023 and July 31, 2023. We used 99 policy documents for the final analysis, specifically 68 national policy documents on e-cigarettes and 31 subnational smoke-free laws. We chronologically reviewed these policy documents in full text and summarized them on the basis of their content and the requirements of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC).

RESULTS

Chinese policymakers established the current regulatory framework for e-cigarettes by amending, enacting, and enforcing laws and regulations. E-cigarettes are categorized as tobacco products, and the State Tobacco Monopoly Administration regulates the e-cigarette industry. The Chinese authorities prioritize youth prevention in strengthening the regulation on e-cigarettes. China adopts various tobacco control measures for e-cigarettes and cigarettes.

CONCLUSIONS

China gained certain degrees of progress on tobacco control by regulating e-cigarettes and adopting measures required by the WHO FCTC. However, tobacco monopoly hinders the full realization of tobacco control goals, which necessitates the National Health Commission to assume its responsibility for the complete implementation of the WHO FCTC.

IMPLICATIONS

This study presents a critical review of the development of e-cigarette regulation in China by reviewing relevant policy documents and analyzing tobacco control measures. It recognizes the degrees of progress of tobacco control measures and highlights tobacco monopoly as a significant hindrance of the full implementation of the WHO FCTC. Furthermore, empirical studies are required on the enforcement of tobacco control measures in China.

Prevalence and Covariates of Electronic Cigarette Use among Students Aged 13-15 Years in the Philippines: 2019 Global Youth Tobacco Survey

Electronic cigarette use is growing in popularity and accessibility among youth in the Southeast Asia region. We analyzed data on 6670 students, aged 13-15 years, from the Philippines' 2019 Global Youth Tobacco Survey. Prevalence estimates and 95% confidence intervals (CI) were estimated for current use (i.e., past 30 days), ever use, and awareness of e-cigarettes. Chi-square tests compared prevalence differences between groups. Multiple logistic regression models assessed factors associated with e-cigarette use while controlling for sociodemographic characteristics, current use of other tobacco products, and secondhand smoke exposure. Prevalence of current e-cigarette use was 14.1% (95% CI = 12.4%, 15.8%), ever use was 24.6% (95% CI = 22.4%, 26.9%), and awareness was 75.5% (95% CI = 73.0%, 78.0%). Current use of any other tobacco products and exposure to secondhand smoke at home, school, or other public places were positively associated with current and ever use of e-cigarettes. Boys and youth living in Luzon or Mindanao had higher odds of current e-cigarette use compared to girls and youth in Visayas. Findings indicated that one in four Philippine students aged 13-15 years ever used e-cigarettes and one in seven currently use e-cigarettes. This study highlights the importance of implementing evidence-based strategies, including relevant tobacco control policies.

Recent advances in the analysis of electronic cigarette liquids and aerosols: Sample preparation and chromatographic characterization

Electronic cigarette (e-cigarette) usage has risen dramatically worldwide in recent years. It has been publicized as a safer alternative to the conventional combustible cigarette. This, however, has not yet been supported by robust toxicological research evidence. Analysis of the chemical compositions of e-liquids and generated aerosols is an important step in evaluating the toxicity effects of e-cigarettes. Currently, a broad spectrum of analytical methods have been employed for qualitative and quantitative analysis of chemical compositions of e-cigarette liquids and aerosols. The aim of this article is to review the advances in the chromatographic characterization of chemical composition of the latter in the recent five years. In addition, sample preparation methods for e-liquids and aerosols are surveyed and discussed. A study of the relevant literature indicates that, expectedly, gas chromatography and liquid chromatography with a variety of detection systems, particularly mass spectrometry, have been the main analytical techniques used in this field. Sample preparation procedures primarily include headspace sampling, dilute-and-shoot approach, liquid-liquid extraction and sorbent-based extraction for e-liquids and for aerosols (the latter usually with laboratory-built collection devices). Some challenges of current e-cigarette analytical research, and an overview on prospective work are also presented.

Changes in Tobacco Product Use Among Students Aged 13 to 15 Years in 34 Countries, Global Youth Tobacco Survey, 2012-2020

INTRODUCTION

Most adults who currently use tobacco start before age 21. Comprehensive, cost-effective strategies and interventions to prevent initiation and encourage tobacco use cessation among youth are critical aspects of protecting youth from the harms of commercial tobacco. We describe changes in current tobacco product use among youth in 34 sites using data from the Global Youth Tobacco Survey (GYTS).

METHODS

GYTS is a nationally representative school-based survey of students aged 13 to 15 years. The analysis included 34 sites that completed 2 survey waves during 2012-2020. Prevalence of current tobacco use was assessed for each country. Marginal effects in multivariable logistic regression models were used to estimate adjusted prevalence difference (aPD) between waves.

RESULTS

The adjusted prevalence of current tobacco product use remained unchanged in more than 60% of the included sites. For any tobacco use, significant decreases were reported for Bhutan (aPD = -8.1; 95% CI, -12.9 to -3.4), Micronesia (aPD = -7.2; 95% CI, -9.7 to -4.7), San Marino (aPD = -7.0; 95% CI, -11.2 to -2.7), Togo (aPD = -2.7; 95% CI, -4.6 to -0.7), and Panama (aPD = -2.2; 95% CI, -4.1 to -0.4); significant increases were reported for Moldova, Albania, and Paraguay. Current e-cigarette use increased significantly in 7 of 10 sites.

CONCLUSION

Data show that progress toward reducing tobacco use among youth stalled during 2012-2020, while e-cigarette use increased in a few sites with available data.

Learning from their experiences: Strategies used by youth and young adult ex-vapers

INTRODUCTION

The prevalence of vaping among youth and young adults (YYAs; 16-18 and 19-24 years old, respectively) is moderate worldwide. Existing vaping cessation evidence lacks input from ex-vapers with a history of regular use and substantial maintenance periods. This study noted cessation strategies, relapse triggers, and recommendations for quitting identified by ex-vapers and assessed differences in outcomes across age and gender groups.

METHODS

We recruited ex-vapers (N = 290; mean use = 6.5 days/week, SD = 1.05) with a minimum maintenance period of 30 days and a history of three months of consecutive use of nicotine-based devices from Nova Scotia, Canada. The ex-vapers responded to open-ended questions regarding vaping cessation strategies, triggers, and recommendations for quit strategies in an online survey. We coded responses to each topic (e.g., triggers) and grouped them into categories (e.g., social influences). We used chi-square tests and Bonferroni correction tests to determine group differences by topic and within each category.

RESULTS

YYA ex-vapers identified cold turkey (28.9 %), self-restriction (27.5 %), and alternative coping mechanisms (19.0 %) as the most common cessation strategies; social influences (35.5 %,), mental state (18.3 %), and substance use (15.7 %) as the top triggers; and support systems (29.5 %), apps (17.3 %), and education (11.8 %) as the most useful recommendations for others. A higher proportion of female youth (51.3 %) identified social influences as a relapse trigger than male YAs (21.2 %) and female YAs (30.3 %). Further, male YAs (36.5 %) reported higher proportions of substance use as a relapse trigger than male youth (3.0 %) and female youth (2.6 %). Female youth (23.7 %) and YAs (22.6 %) recommended apps as a useful cessation strategy more often than male YAs (3.8 %).

CONCLUSIONS

Input from ex-vapers can help to inform cessation practices, and gender and age differences shed light onto the need to tailor treatments, such as using social-centric behavioral therapy, for female youth and adopting a polysubstance substance use treatment approach for YAs.

Proportions of and trends in exposure to pro-tobacco and anti-tobacco advertisements among young adolescents aged 12-16 years in 142 countries and territories, 1999-2018: an analysis of repeated cross-sectional surveys

BACKGROUND

The proportions and trends in exposure to pro-tobacco and anti-tobacco advertisements among young people remain unknown globally. We determined recent (2010-18) proportions of exposure to pro-tobacco and anti-tobacco advertisements among young adolescents and their secular trends from 1999 to 2018.

METHODS

In this analysis of repeated cross-sectional surveys, we used the most recent data from 142 countries and territories (hereafter referred to as countries) collected between Jan 1, 2010, and Dec 31, 2018, comprising 710 191 participants, to assess the proportions of exposure to pro-tobacco and anti-tobacco advertisements among young adolescents aged 12-16 years. Data from 120 countries that had performed two or more Global Youth Tobacco Surveys between Jan 1, 1999, and Dec 31, 2018, comprising 1 482 031 participants, were used to assess trends in the proportions of exposure to pro-tobacco and anti-tobacco advertisements over time. A χ² test analysis was used for proportion comparisons between subgroups. Exposure to pro-tobacco and anti-tobacco advertisements were calculated as proportions using sampling weights, strata, and primary sampling units.

FINDINGS

The most recent global proportion of past 30-day exposure to tobacco advertisements among young adolescents was 433 585 (64·6%) of 710 191 (95% CI 63·5-65·7; all final percentages were weighted) for messages on electronic media, 206 766 (33·1%) of 710 191 (31·9-34·4) for exposure at the point of sale, and 63 385 (10·2%) of 710 191 (9·7-10·6) for owning something with a tobacco brand logo. The most recent global proportion of exposure to anti-tobacco advertisements was 431 862 (63·6%) of 710 191 (62·3-64·9) for messages on electronic media and 227 658 (34·1%) of 710 191 (32·8-35·3) for exposure to gathering activities. The majority of included countries showed a decreasing trend in exposure to tobacco advertisements (111 [93%] of 120) and anti-tobacco advertisements (110 [92%] of 120) between 1999 and 2018.

INTERPRETATION

Among young adolescents, exposure to tobacco advertisements remains high, and exposure to anti-tobacco advertisements is not high enough. The proportion of young adolescents exposed to pro-tobacco and anti-tobacco advertisements had decreased over time in the majority of included countries. These findings underscore the importance of strict implementation of regulation on tobacco control including strengthening anti-tobacco marketing and prohibiting tobacco marketing.

FUNDING

Youth Team of Humanistic and Social Science of Shandong University.

TRANSLATION

For the Chinese translation of the abstract see Supplementary Materials section.

Prevalence of waterpipe smoking and its associated factors among adolescents aged 12-16 years in 73 countries/territories

Introduction

To describe the recent prevalence of, and trends in, waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years in 73 countries/territories (hereafter "countries").

Methods

Data from 72 countries that had conducted a Global Youth Tobacco Survey (GYTS) in 2010-2019 and from the National Youth Tobacco Survey in the United States in 2019 were used to assess the recent prevalence of waterpipe smoking and to examine its associated factors among adolescents aged 12-16 years. Data from 38 countries that had carried out at least 2 surveys from 2000 to 2019 were used to determine trends in the prevalence of waterpipe smoking among adolescents.

Results

The recent prevalence of current waterpipe smoking (on 1 day during the past 30 days) among adolescents was 6.9% (95%CI 6.4-7.5). The prevalence was highest in the European region (10.9%, 9.9-11.8) and Eastern Mediterranean region (10.7%, 9.5-11.9), but lowest in the Western Pacific region (1.9%, 1.4-2.4). The prevalence of current waterpipe smoking increased or remained unchanged in 19 (50%) of 38 countries, but decreased in the remaining 19 countries (50%). Parental smoking, closest friends' smoking, secondhand smoke exposure, tobacco advertisement exposure, not being taught the dangers of smoking, particularly cigarette smoking, were positively associated with adolescent waterpipe smoking.

Discussion

Waterpipe smoking among adolescents remains a major public health issue worldwide, especially in the regions of Europe and the Eastern Mediterranean. Effective prevention and control strategies and measures are needed to curb the epidemic of adolescent waterpipe smoking.

An International Systematic Review of Prevalence, Risk, and Protective Factors Associated with Young People's E-Cigarette Use

While the prevalence of young people's conventional cigarette use has decreased in many countries, the use of e-cigarettes has risen. To effectively counteract the growing popularity of e-cigarettes among young people internationally, researchers should know the exact prevalence as well as the protective and risk factors associated with vaping. Based on five eligibility criteria, 53 articles were chosen and analyzed by general characteristics, prevalence, sample characteristics, gender difference, protective factors, and risk factors. In this study, the international pooled prevalence of young people's lifetime e-cigarette use was 15.3%, the current use was 7.7%, and dual use was 4.0%. While the highest lifetime, current, and dual prevalence were found in Sweden, Canada, and the United Kingdom, respectively, the lowest prevalence was found in Germany, followed by South Korea and Sweden. Some protective and risk factors include perceived cost and danger of vaping, parental monitoring, internal developmental assets, cigarette use, family and peer smoking, exposure to online advertisements, and the presence of nearby retail stores. Based on this review, researchers and practitioners can develop different intervention programs and strategies for young smokers.

Differences in risk indicators associated with electronic cigarette use and tobacco smoking among adolescents and young people in Nigeria

Introduction

The study determined the proportion of adolescents and young persons (AYP) in Nigeria who use e-cigarettes and smoke tobacco; and identified factors associated with the use of e-cigarettes and tobacco smoking.

Methods

AYP aged 11–23 years were recruited to participate in an online survey. The independent variables were respondents’ health, HIV and COVID-19 status and their level of anxiety. The dependent variables were tobacco smoking and use of e-cigarettes. Binary logistic regression was used to determine the associations between the dependent and independent variables after adjusting for confounders (age, sex, educational level and vulnerability status).

Results

There were 2206 respondents of which 568 (19.8%) used e-cigarettes and 787 (27.4%) smoked tobacco. Individual (18–23 years, having a health condition, high anxiety and being vulnerable) and familial (having father, mother, siblings or friends who used e-cigarettes) factors were associated with both the use of e-cigarettes and tobacco smoking. Tobacco smoking was a significant risk indicator for e-cigarettes use and vice versa. COVID-19 infection (adjusted OR, AOR: 3.602) and living with HIV (AOR: 1.898) were associated with higher odds of using e-cigarettes. Males (AOR: 1.577), 15–17 years (AOR: 6.621) and moderate anxiety (AOR: 2.500) were associated with higher odds of tobacco smoking. AYP with health conditions had higher odds of using e-cigarettes (AOR: 1.514) while AYP with moderate anxiety had lower odds of using e-cigarettes (AOR: 0.627).

Conclusion

The proportion of AYP in Nigeria who used e-cigarettes and smoked tobacco is high. Public health interventions that target the common risk factors for e-cigarettes use and tobacco smoking among AYP in Nigeria are urgently needed.