Examining the correlates of cigarette smoking, e-cigarette use and dual use among Canadian post-secondary students

Many Canadians use nicotine products such as cigarettes and e-cigarettes. A particular subpopulation of concern is post-secondary students given they have a higher prevalence of use. Many correlates of cigarette smoking and e-cigarette use have been identified. However, less focus has been on examining the correlates of cigarette smoking, e-cigarette use and dual use. This study explores the correlates of different nicotine modality use in post-secondary students. Using data from the Canadian Campus Wellbeing Survey (CCWS; n = 27,164), a multi-level nominal regression assessed the correlates of nicotine modality use. In comparison to individuals who were <20, individuals 20-24 (OR = .448, 95% CI .321, .625), 25-29 (OR = .140, 95% CI .093, .212), 30-34 (OR = .076, 95% CI .046, .125) and over 35 (OR = .041, 95% CI .024, .071) had lower odds of e-cigarette use compared to cigarette smoking. Identifying as a woman (OR = 1.553, 95% CI 1.202, 2.006), non-heterosexual (OR = .642, 95% CI = .485,0.851), current cannabis user (OR = 1.651, 95% CI 1.296, 2.104), and being an international student (OR = .350, 95% CI .251, .487) also impacted the odds of e-cigarette use vs only cigarette smoking. When considering dual use vs cigarette smoking, individuals aged 20-24 (OR = .491, 95% CI .337, .717), 25-29 (OR = .221, 95% CI .137, .357), 30-34 (OR = .163, 95% CI .091, .292) and over 35 (OR = .122, 95% CI .065, .230) had lower odds than individuals <20. Current cannabis use (OR = 1.680, 95% CI = 1.209, 2.138), binge drinking (OR = 1.885, 95% CI 1.384, 2.568), and international student status (OR = .689, 95% CI .476, .996) also impacted cigarette smoking vs dual-use. Overall, a minority of young adults (11.5%) at post-secondary institutions in our sample use nicotine products, and the higher prevalence of e-cigarette use warrants continued monitoring. Health promotion campaigns addressing e-cigarette use are required. Additionally, tailored intervention efforts could prioritize the treatment needs of international students studying in Canada.

Eating Disorder Symptomatology Among Young Adult Cigarette and E-Cigarette Users

Objective: Tobacco use is elevated among individuals with eating disorders (EDs). Yet, further research is needed to understand associations between cigarette and e-cigarette use patterns and ED symptomatology. To gain a more comprehensive understanding of tobacco use and EDs, this study characterized ED symptomatology and tobacco use patterns, including exclusive cigarette use, e-cigarette use, dual use, and nonuse. Method: Young adults aged 18-24 years who self-reported exclusive cigarette, e-cigarette, dual, or nonuse (N = 2500) were recruited via Lucid, an online survey management company. Participants completed questionnaires assessing body dissatisfaction, global ED psychopathology, binge eating and self-induced vomiting frequency, and demographics. ED diagnostic groups included: anorexia nervosa (AN), bulimia spectrum eating disorders (BSED), atypical AN, and night eating syndrome (NES). Results: Multinomial logistic models revealed those with AN were more likely to be dual users, those with atypical AN were more likely to be exclusive e-cigarette users, and participants with a BSED or NES were more likely to be exclusive e-cigarette or dual users, compared to those without an ED. General linear models suggested body dissatisfaction and global ED psychopathology were higher among exclusive e-cigarette and dual users, while binge eating and self-induced vomiting frequencies were greater among all tobacco use groups compared to nonusers. Discussion: Our findings suggest young adults with ED symptomatology were more likely to be users of e-cigarettes exclusively or dual users. It will be necessary to examine how these associations manifest using longitudinal and clinical populations in future research.

Adverse Childhood Experiences and Tobacco Use Patterns Among Adults in the United States: Exploring sex differences

OBJECTIVE

Adverse childhood experiences (ACEs), which refer to childhood traumatic events, have been identified as risk factors for tobacco use in adulthood. However, studies are limited on the effect of sex on the association of ACEs with e-cigarettes and dual use of e-cigarettes and cigarettes. This study explored sex differences in the association of ACEs with e-cigarettes, cigarettes, and dual use of e-cigarettes and cigarettes among adults in the United States.

METHODS

This was a cross-sectional analysis of data from adults aged ≥18 years in the 2020 Behavioral Risk Factor Surveillance System (N = 62,768). ACEs, the independent variable, was a composite score assessed from 11 questions (with responses yes-1 or no/never-0) related to childhood emotional abuse, physical abuse, sexual abuse, and household dysfunction and categorized as 0 (reference), 1, 2, 3, or ≥4. The dependent variable, tobacco use patterns, included nonuse (reference), e-cigarette only, cigarette only, and dual use of e-cigarettes and cigarettes. Multinomial logistic regression was performed to test the interaction between sex and ACEs while controlling for potential confounders.

RESULTS

Although we found no statistically significant interaction by sex, a greater number of ACEs were associated with higher odds of the different tobacco use patterns among females and males, with varying strengths of associations. Specifically, females who reported ≥4 ACEs compared with none had higher odds of e-cigarette (aOR [95% CI]: 3.58 [1.49-8.63]), cigarette (2.57 [1.72-3.83]) and dual use (3.25 [1.79-5.91]) relative to nonuse. Males with ≥4 ACEs had higher odds of cigarette (1.75 [1.15-2.65]) and dual use (7.64 [3.95-14.79]).

CONCLUSION

Our findings underscore the importance of developing appropriate, tailored trauma-informed intervention strategies for females and males. It is also important to consider ACEs in designing tobacco-specific preventive programs to curb initiation and promote cessation among U.S. adults.

Dual Electronic and Combustible Cigarette Use: Understanding the Relation of Cannabis Use with E-Cigarette Outcomes

Background: E-cigarette use is on the rise and many who use e-cigarettes also smoke combustible cigarettes. Dual use (i.e., use of both electronic and combustible cigarettes) is associated with greater rates of cannabis use and cannabis use among individuals who engage in dual use is related to more severe ecigarette-related problems. Yet, no known studies have tested whether cannabis use is related to more severe e-cigarette problems via negative affect and the expectation that e-cigarettes can help manage negative affect. Objectives: The current study tested this hypothesis among 400 adults who endorsed dual use, 33% of whom endorsed current (past three month) cannabis use. Results: Results indicated that participants with cannabis use reported more anxiety, depression, e-cigarette problems, and the following e-cigarette use expectancies: negative consequences, negative reinforcement, and weight concerns. Multiple mediator models found that the relation between cannabis use status and e-cigarette problem severity was mediated by anxiety (but not depression) and by negative reinforcement and weight concerns (but not negative consequences) expectancies. Serial mediator models indicated that the relation between cannabis use and e-cigarette problems occurred via the serial effects of anxiety and negative reinforcement (but not weight concerns) expectancies. Conclusions: These results highlight several clinical correlates of cannabis use among adults who smoke combustible and e-cigarettes, and suggest that anxiety and the expectation that e-cigarettes may help manage such negative emotions play important roles in e-cigarette-related problems among these individuals.

The association between health literacy and e-cigarette use: evidence from Zhejiang, China

Objectives

The worldwide popularity of electronic cigarettes (ECIG) is becoming a public health concern. Compared to conventional cigarettes (CIG), the harm caused by ECIG is more insidious. Studies have shown that lower health literacy (HL) is associated with CIG use; however, the relationship between HL and ECIG use remains controversial. Because ECIG emerged more recently than CIG, there are fewer relevant studies, and the sample populations and evaluation methods of HL in existing studies differ. This study conducted a large-sample survey to examine the relationship between HL and ECIG use.

Methods

As part of the 2022 China Health Literacy Survey, a total of 60,998 valid questionnaires were collected from September to November in 2022 using a stratified multistage probability proportional to the population size sampling frame. Chi-square tests and multinomial logistic regression was used to analyze the relationship between HL and ECIG use. Some demographic variables were included as covariates in the analysis.

Results

The study showed that the average HL score and the HL level of Zhejiang residents in 2022 were 42.8 and 30.8%, respectively. The prevalence of CIG and ECIG was 19.7 and 1.0%, respectively; 19% of participants exclusively used CIG, while only 0.3% of participants used ECIG exclusively; dual users accounted for 0.6%. After adjusting for covariates, adequate HL was associated with lower odds of ECIG-exclusive use (odds ratio [OR] = 0.452, p < 0.001), CIG-exclusive use (OR = 0.833, p < 0.001), and dual use (OR = 0.632, p < 0.001). Young age, male sex, unmarried status, high-income status, and absence of chronic disease were also associated with ECIG use.

Conclusion

HL was a protective factor against both patterns of ECIG use, especially ECIG-exclusive use. Health policymakers and public health practitioners should consider HL as a potential measure for ECIG control.

Alcohol and cannabis dual use among Black adults: Associations with alcohol use, use-related problems, and race-based discrimination

BACKGROUND AND OBJECTIVES

Black adults who drink alcohol appear at risk for poor alcohol-related outcomes, yet little research has examined whether cannabis use among those who consume alcohol (alcohol-cannabis dual use) is related to worse alcohol-related consequences, as observed in predominantly White samples. Further, it may be that experiencing more race-based discrimination may be related to using multiple substances to cope with such experiences; however, no known studies have examined the impact of race-based discrimination on alcohol-cannabis dual use.

METHODS

Participants were 270 Black undergraduates who endorsed past-month drinking, 112 of whom endorsed alcohol-cannabis dual use.

RESULTS

The dual use group reported heavier drinking, more drinking-related problems, and more race-based microaggressions (but not overt racism) than the alcohol-only group.

CONCLUSIONS

The use of cannabis among Black young adults who drink alcohol was related to heavier drinking and more alcohol-related problems. Further, experiencing more microaggressions may place these individuals at risk for using multiple substances, presumably to cope with these experiences.

SCIENTIFIC SIGNIFICANCE

Considering models suggesting that the dual use of cannabis may result in less alcohol use, the current study highlights that for Black adults who consume alcohol, cannabis dual use is related to heavier drinking and more alcohol-related problems, which can inform intervention and treatment efforts.

Vaping Behavior in Young Adults During the COVID-19 Pandemic

BACKGROUND

Electronic nicotine delivery systems (ENDS) continue to be popular among young adults. These devices are often advertised as a healthy alternative to quitting tobacco cigarettes. However, young adults represent a population who view it as a novel behavior that provides a sense of popularity, social acceptance, and desired physiologic properties. The objective of this study was to examine characteristics of vaping behavior among college students and explore possible associations between groups of vaping behavior (stopped, initiated, increased, decreased, stayed the same).

METHODS

In a multi-center cross-sectional study, 656 students from University of Tampa in the United States and University of Applied Sciences in Germany (IST) were recruited to answer a 31-item online questionnaire. A chi-square test was used to evaluate associations between the groups.

RESULTS

Prevalence rates indicated approximately 31% of all students were currently using ENDS. Even though more negative than positive experiences with ENDS were reported, most students stated their vaping increased during COVID-19 lockdowns. Addiction and stress relief emerged to be predictors (P < .001) of an increase in vaping, whereas social motives were not statistically significant. Living situation (P = .63) and depression (P = .10) were not significantly associated with vaping behavior.

CONCLUSIONS

ENDS products continue to yield very high levels of nicotine creating addiction in young adults. Addiction counseling and evidenced-based practices should be employed at every level (individual, community, and school). Additionally, mental health counseling for students in pandemic and high-stress environments may help to combat stress in a more proactive manner than self-medicating.

Cigarette and Alternative Tobacco Product Use among Adult Cancer Survivors Enrolled in 9 ECOG-ACRIN Clinical Trials

BACKGROUND

While cigarette smoking has declined among the U.S. general population, sale and use of non-cigarette alternative tobacco products (ATP; e.g., e-cigarettes, cigars) and dual use of cigarettes/ATPs are rising. Little is known about ATP use patterns in cancer survivors enrolled in clinical trials. We investigated prevalence of tobacco product use, and factors associated with past 30-day use, among patients with cancer in national trials.

METHODS

Cancer survivors (N = 756) enrolled in 9 ECOG-ACRIN clinical trials (2017-2021) completed a modified Cancer Patient Tobacco Use Questionnaire (C-TUQ) which assessed baseline cigarette and ATP use since cancer diagnosis and in the past 30 days.

RESULTS

Patients were on average 59 years old, 70% male, and the mean time since cancer diagnosis was 26 months. Since diagnosis, cigarettes (21%) were the most common tobacco product used, followed by smokeless tobacco use (5%), cigars (4%), and e-cigarettes (2%). In the past 30 days, 12% of patients reported smoking cigarettes, 4% cigars, 4% using smokeless tobacco, and 2% e-cigarettes. Since cancer diagnosis, 5.5% of the sample reported multiple tobacco product use, and 3.0% reported multiple product use in the past 30 days. Males (vs. females; OR 4.33; P = 0 < 0.01) and individuals not living with another person who smokes (vs. living with; OR, 8.07; P = 0 < 0.01) were more likely to use ATPs only versus cigarettes only in the past 30 days.

CONCLUSIONS

Among patients with cancer, cigarettes were the most prevalent tobacco product reported.

IMPACT

Regardless, ATPs and multiple tobacco product use should be routinely assessed in cancer care settings.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021

Introduction

The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the outbreak of lung injuries related to vaping THC, flavor bans, and the COVID pandemic. We analyzed patterns of initiation, cessation, and transitions between cigarettes, ENDS, and dual use before and after 2019.

Methods

Using the Population Assessment of Tobacco and Health (PATH) Study, we applied a multistate transition model to 28,061 adults in Waves 4-5 (2017-19) and 24,751 adults in Waves 5-6 (2019-21), estimating transition rates for initiation, cessation, and switching products for each period overall and by age group.

Results

Cigarette initiation among adults who never used either product decreased from 2017-19 to 2019-21, but ENDS initiation did not significantly change. Persistence of ENDS-only use remained high, with 75-80% still using ENDS only after 1 year. Cigarette-only use transitions remained similar, with about 88% remaining, 7% transitioning to non-current use, and 5% transitioning to dual or ENDS-only use. In contrast, dual use to ENDS-only transitions increased from 9.5% (95%CI: 7.3-11.7%) to 20.1% (95%CI: 17.5-22.7%) per year from 2017-19 to 2019-21, decreasing the persistence of dual use. The dual use to cigarette-only transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use.

Conclusions

Persistence of ENDS use among adults remained high in 2019-21, but a larger fraction of dual users transitioned to ENDS-only use compared to 2017-19. Because the fraction of cigarette-only users switching to dual use remained low, the public health implications of the increased dual use to ENDS-only transition are minimal.

Association between the dual use of electronic and conventional cigarettes and NAFLD status in Korean men

INTRODUCTION

This study investigated the association between smoking types, including dual use (usage of both combustible cigarettes and e-cigarettes), and non-alcoholic fatty liver disease (NAFLD) status in Korean men.

METHODS

Data from the 7th and 8th Korea National Health and Nutrition Examination Survey (KNHANES) 2016-2020 were used. The presence of NAFLD was defined by the respective cut-off values for the Hepatic Steatosis Index (HSI), NAFLD Ridge Score (NRS), and Korea National Health and Nutrition Examination Survey NAFLD score (KNS). Multivariate logistic regression analyses were used to determine the associations between smoking types and NAFLD as determined by HSI, NRS, and KNS.

RESULTS

After adjustment for confounders, an independent association was observed between dual use and NAFLD (HSI: AOR=1.47; 95% CI: 1.08-1.99, p=0.014; NRS: AOR=2.21; 95% CI: 1.70-2.86, p=0.000; KNS: AOR=1.35; 95% CI: 1.01-1.81, p=0.045). Cigarette only smokers also had significantly higher odds of NAFLD compared to never smokers for all of the NAFLD indices (HSI: AOR=1.22; 95% CI: 1.05-1.42, p=0.008; NRS: AOR=2.13; 95% CI: 1.87-2.42, p=0.000; KNS: AOR=1.33; 95% CI: 1.14-1.55, p=0.000). In subgroup analyses, no significant interaction effects were found for age, BMI, alcohol consumption, income, physical activity, and the diagnosis of T2DM. Moreover, cigarette only smokers and dual users differed significantly in terms of log-transformed urine cotinine and pack-years. The relationship between smoking type and pack-years was attenuated after stratification by age.

CONCLUSIONS

This study shows that the dual use of e-cigarettes and combustible cigarettes is associated with NAFLD. Age differences may explain why dual users, with a greater proportion of young people, appear to have fewer pack-years than cigarette only smokers. Further research should be conducted to investigate the adverse effects of dual use on hepatic steatosis.

Perceptions and reasons for quitting and transitioning between smoking and smokeless tobacco products: Findings from four waves of the ITC Bangladesh survey

INTRODUCTION

Transitions between different tobacco products are frequent among tobacco users in Bangladesh; however, the reasons leading to such transitions and why they quit are not well researched. The aim of the study is to examine perceptions and reasons reported by tobacco users in Bangladesh to transition to other products or quit.

METHODS

Data from four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach.

RESULTS

Common reasonsig for respondents switching to other tobacco products were influence of friends/family (73.8-86.0%), and curiosity (44.4-71.3%). The perceived calming effect of smoking cigarettes and bidis (43.2-56.9%), and the impression that bidis were less harmful (52.3%) and taste better (71.2%) were major reasons for exclusive SLT users to switch products. Health concerns (16.5-62.7%) and disapproval from friends/family (29.8-56.4%) were generally the main reasons for quitting. For smoked tobacco users, doctor's advice (41.6%), package warning labels (32.3%), and price (32.4%) seemed to be the major driving factors to quit.

CONCLUSIONS

Results highlight that the reasons for switching between tobacco products and quitting include social factors (e.g. friends/family) and (mis) perceptions regarding the products. Tobacco control policy could emphasize cessation support, increased price and education campaigns as key policies to reduce overall tobacco use in Bangladesh. Data from four waves (2009-2015) of the International Tobacco Control (ITC) Bangladesh Survey were used. Repeated data on perceptions and reasons for exclusive cigarette (n=520), bidi (n=130), and SLT users (n=308) to either start using other products or quit were analyzed with sampling weights. The percentages of responses across waves were used to calculate the pooled proportion data using a meta-analysis approach.

The Health Effects of Real-World Dual Use of Electronic and Conventional Cigarettes versus the Health Effects of Exclusive Smoking of Conventional Cigarettes: A Systematic Review

BACKGROUND

A high prevalence of dual use of e-cigarettes and conventional cigarettes has been reported across the world.

METHODS

A systematic search was carried out. We included original articles on any topic relevant to health, excluding mental health, in all languages. The PRISMA guidelines were followed. Both reviewers independently screened and read all publications. We compared dual use with exclusive smoking of conventional cigarettes (ESCC).

RESULTS

Fifty-two publications (49 studies) were included. Thirteen papers/10 studies were prospective. There was great heterogeneity across studies. Many methodological weaknesses, such as inaccurate exposure measurement, lack of adjustment for former tobacco consumption, and lack of significance testing were identified. Most prospective studies found dual use to be at least as harmful as ESCC. The longest follow-up was six years. Most of the best available cross-sectional studies found dual use associated with the same and, in several studies, significantly higher risk of self-reported symptoms/disease than in ESCC. The intensity of cigarette smoking seems associated with worse health.

CONCLUSION

Existing studies indicate that dual use is at least as, or probably even more, harmful than ESCC. Due to the predominance of cross-sectional studies and the methodological weaknesses we judged the overall certainty of the evidence as "low certainty".

A new statistical model for longitudinal ecological momentary assessment data on dual use of electronic and combustible cigarettes

Background: Existing studies of dual use of electronic and combustible cigarettes either collected longitudinal data with long gaps in between waves or conducted ecological momentary assessment (EMA) over a short period of time. In recent years, the measurement burst design that embeds an EMA protocol in each wave assessment of a traditional longitudinal study has become more popular and yet conventional generalized linear mixed models (GLMM) have important limitations for handling data from this design.Objectives: This study proposed a new statistical method to analyze data from the measurement burst design.Methods: This new statistical method was designed to model the short-term (within-wave) as well as long-term (between-wave) changes and was validated by a simulation study. Secondary analysis was conducted to analyze data from 205 dual users (52% male) and 146 exclusive smokers (50% male) who participated in a recent study using the measurement burst design.Results: The simulation study shows that the proposed method can handle the gap between waves well and is also robust to nonlinear changes across waves. Although no short-term change in smoking was found, dual users reported a long-term reduction in cigarette use that was more rapid compared to exclusive smokers (β ˆ = - 0.0127 , p = .0167 ). Vaping more was associated with smoking less (β ˆ = - 0.0058 , p = .0054 ).Conclusion: The proposed method is highly applicable as it can be easily implemented by substance use researchers and the results can be straightforwardly interpreted. The results suggest that e-cigarette use may play a role in promoting a long-term reduction in smoking among dual users.

Identifying prospective subpopulations of combustible and electronic cigarette dual users in the United States via finite mixture modeling

AIMS

To identify subpopulations of dual users of combustible and electronic cigarettes using current smoking and vaping behaviors.

DESIGN

Secondary analysis of baseline data from a randomized controlled trial testing a smoking cessation intervention for dual users. Finite mixture modeling of frequency, quantity, and dependence on combustible and electronic cigarettes was used to identify classes. Demographics and additional smoking and vaping variables were used to further characterize the classes.

SETTING

United States.

PARTICIPANTS

A total of 2896 adults who smoked weekly for the past year and vaped weekly for the past month.

MEASUREMENTS

Self-report baseline measures assessed demographics and smoking and vaping behaviors and characteristics including days of use per week, frequency of use within a day, time to first use after waking, urges to smoke, smoking cessation motivation, self-efficacy to abstain from smoking, months since vaping initiation, reasons for initiating and maintaining vaping, and future plans to stop vaping.

FINDINGS

Eight probabilistic classes were identified and well-defined (relative entropy = 0.95, Lo-Mendell-Rubin adjusted likelihood ratio test P < 0.0001; class probabilities 0.89-0.97). In general, classes crossed two levels of smoking with four levels of vaping. The largest class (31%) had relatively high levels of smoking (72% daily, 56% 11+ cigarettes per day [CPD], 96% within 30 minutes of waking) and vaping (74% daily, 100% 20+ electronic-CPD, 74%  <30 minutes). The next largest class (27%) had relatively high levels of vaping (93% daily, 100% 20+ electronic-CPD, 82%  <30 minutes) and very low levels of smoking (28% daily, 12% 11+ CPD, 0%  <30 minutes). The six smaller classes (3%-13%) also had distinct smoking and vaping behaviors. All eight classes exhibited distinguishing characteristics beyond current smoking and vaping behaviors.

CONCLUSIONS

Dual users of combustible and electronic cigarettes are not a homogeneous population, having eight well-defined prospective subpopulations.

Use of Tobacco and Nicotine Products among Young People in Denmark-Status in Single and Dual Use

Lots of new tobacco or nicotine products are being launched, e.g., e-cigarettes and smokeless tobacco, which appeal especially to the youngest part of the population. For example, the use of smokeless tobacco among Danish youth rose from approx. 2% in 2010 to 9% in 2020. Hence, there is an urgent need to follow and intervene against youth tobacco or nicotine product use. This study explored the current use of cigarettes, e-cigarettes, heated tobacco, and smokeless tobacco among Danish 15- to 29-year-olds. Further, we examined the concurrent use of two products or more. We used a nationwide survey conducted among 15- to 29-year-olds in February and March 2020. Overall, approx. 35,700 individuals received the questionnaire of which 35.5% responded (n = 13,315). One out of five (20.1%) smoked cigarettes, half of them daily, the other half occasionally. About one in twenty (3.9%) used e-cigarettes (daily or occasionally), and more than one in three (31.6%) had tried e-cigarettes. The use of heated tobacco among Danish youth is still relatively limited (0.3%). In comparison, about 9% used smokeless tobacco (daily or occasionally). Overall, 27.0% stated that they use at least one type of tobacco or nicotine product, while 5.6% used more than one product. Monitoring tobacco-related behavior in youth provides extremely important information for, e.g., policymakers and health professionals.

Trends in Use of Alcohol and Cigarettes among Danish Adolescents, 2002-2018: Exclusive and Dual Use

Many young adolescents experiment with substance use which can have substantial health implications later in life. This study examined trends in substance use among Danish adolescents from 2002 to 2018, including exclusive and dual current use of alcohol and cigarettes. Data on 13- and 15-year-olds (N = 15,295) from five comparable cross-sectional Health Behavior in School-aged Children (HBSC) surveys were used. Cochran-Armitage test for trend assessed the development in substance use patterns over time. Overall, a decreasing trend in current use of alcohol and cigarettes was found among Danish adolescents during the 16-year study period: from 71.7% in 2002 to 51.6% in 2018. In 2018, most adolescents (41.8%) currently used alcohol exclusively, 8.6% had a dual current use of cigarettes and alcohol, and 1.3% smoked cigarettes exclusively. Trends in alcohol use differed according to age groups, while no gender-specific trends in substance use were found. Findings suggest that a significant prevention potential in adolescent substance use remains, and future initiatives may focus on dual use of substances as well as tailored efforts to specific subgroups in high risk of using substances.

Sociodemographic Patterns of Exclusive and Dual Combustible Tobacco and E-Cigarette Use among US Adolescents-A Nationally Representative Study (2017-2020)

This study assessed the sociodemographic predictors of exclusive and dual use of the most frequently used nicotine/tobacco products, e-cigarettes, and combustible tobacco among adolescents. Cross-sectional data was from the 2017-2020 Monitoring the Future nationally representative study of eighth, tenth, and twelfth-grade students. We coded past 30 day nicotine/tobacco use into four mutually exclusive categories: no use, e-cigarette use only, combustible use (cigarette or cigar) only, and dual use (e-cigarette and combustible). We pooled the 2017-2020 data to examine the relationship between sex, race/ethnicity, parental education, and each product-use category using multinomial logistic regression, stratified by grade level. Among eighth (N = 11,189), tenth (N = 12,882), and twelfth graders (N = 11,385), exclusive e-cigarette use was the most prevalent pattern (6.4%, 13.2%, 13.8%, respectively), followed by dual use (2.7%, 4.5%, 8.9%), and exclusive combustible use (1.5%, 2.5%, 5.3%). eighth and tenth-grade adolescents whose highest parental education was a 4-year college degree or more had lower odds of exclusive combustible and dual use when compared to adolescents whose highest parental education was less than a high school degree. Research should continue to monitor the differential use of combustible tobacco products and e-cigarettes among adolescents from low socioeconomic status backgrounds or racial/ethnic minority households to inform ongoing and future interventions or policies.

Relations among cigarette dependence, e-cigarette dependence, and key dependence criteria among dual users of combustible and e-cigarettes

Objective: The aim of this study was to examine dependence on combustible and e-cigarettes among users of both products (dual users), which may provide important insights into long-term use patterns. Method: Dual users (smoking daily for 3 months, using e-cigarettes at least once/week for the past month; N = 256; 45% women, 71% White, M age 39.0 years) not interested in quitting either product participated in a longitudinal, 2-year, observational study. At baseline, participants completed measures of combustible and e-cigarette dependence (Fagerström Test of Cigarette Dependence [FTCD], e-FTCD, Wisconsin Inventory of Smoking Dependence Motives [WISDM], e-WISDM, Penn State Cigarette Dependence Index, and Penn State E-Cigarette Dependence Index) and carried a study smartphone for 2 weeks to record cigarette and e-cigarette use events. Results: Most measures of dependence were product specific (e.g., FTCD and e-FTCD were not correlated, r = -0.003) and predicted product-specific outcomes (e.g., long-term use of that product). However, individuals used the two products for some of the same secondary dependence motives (e.g., weight control, cognitive and affective enhancement). These secondary, or instrumental, motives predicted use of both products at 1 year. Which product was used first in the morning was strongly related to product dependence scores and likelihood of continued product use at 1 year. Conclusions: Among dual users of combustible and e-cigarettes, measures of e-cigarette and cigarette dependence tended to be unrelated to one another, but dual users tended to use both products for the same instrumental motives. Which product is used first in the morning may serve as a valuable measure of relative dependence on the two products. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Negative Affect and Cigarette Cessation in Dual Users of Cigarettes and Electronic Nicotine Delivery Systems

Objectives: Dual use of cigarettes and electronic nicotine delivery systems (ENDS) is increasingly common in adult smokers, who often report using ENDS to quit smoking. Elevated negative affect is an established predictor of increased difficulty quitting smoking combustible cigarettes but has not yet been examined in the context of cigarette cessation for dual users. Method: This study examined whether mood-related factors predict cigarette smoking cessation among dual users (N = 364) over 12-months. Self-reported cigarette smoking at 12 months, with abstinence defined as no smoking for the past 7 days, was the primary outcome variable. Logistic regression included baseline levels of depression symptoms (CES-D), anxiety symptoms (MASQ), and negative affect expectancies for smoking, with baseline nicotine dependence for cigarettes (NDSS), motivation to quit, age, race/ethnicity, rate of cigarette smoking at baseline, and ENDS usage at baseline and 12 months as covariates. Interactions between CES-D, MASQ, and negative affect expectancies were examined. We predicted that negative affect, especially for smokers who had high negative affect expectancies for smoking, would be negatively associated with quitting. Results: Contrary to expectations, negative affect constructs did not predict quitting. Baseline nicotine dependence for cigarettes, gender, and race/ethnicity significantly predicted the likelihood of cigarette cessation. Higher rates of ENDS use, higher motivation, and lower negative affect smoking expectancies were significantly correlated with quitting cigarettes. Conclusion: In this non-treatment seeking sample of dual users, negative affect did not predict cigarette cessation over and above nicotine dependence for cigarettes, gender, and race/ethnicity.

Changes in dependence, withdrawal, and craving among adult smokers who switch to nicotine salt pod-based e-cigarettes

BACKGROUND AND AIMS

For electronic cigarettes (e-cigarettes) to be a viable substitute for combustible cigarettes, it is likely that they must be rewarding enough for regular use, indicated by factors such as craving and dependence, important aspects of reinforcement. This study aimed to understand short-term changes in measures of nicotine dependence between groups differing by use trajectory in a switching trial, and within group changes of these measures.

DESIGN

Secondary data analysis of one arm of an e-cigarette randomized clinical trial.

SETTING

San Diego, California and Kansas City, Missouri, United States.

PARTICIPANTS

114 African American (n = 60) and Latinx (n = 54) smokers (58.8% male) attempting to switch to nicotine salt pod system (NSPS) e-cigarettes in a 6-week trial.

MEASUREMENTS

At week 6, participants were classified by use trajectory: exclusive smokers (n = 16), exclusive e-cigarette (n = 32), or dual users (n = 66). E-cigarette, cigarette, and total nicotine dependence (cigarette + e-cigarette), use patterns, cigarette craving and nicotine withdrawal, and cotinine were assessed at baseline and week 6 using standard measures.

FINDINGS

In between group comparisons, exclusive e-cigarette and dual users showed greater reductions in cigarette dependence (e-cigarette: -32.38, 95% CI = -37.7,-27.1; dual: -18.48, 95% CI = -22.2,-14.7), withdrawal (e-cigarette: -6.25, 95% CI = -8.52,-3.98; dual: -3.18, 95% CI = -5.02,-1.34), craving (e-cigarette: -11.44, 95% CI = -14.2,8.7; dual: -9.59, 95% CI = -11.6,-7.59), and cigarettes per day (CPD; e-cigarette: -11.19, 95% CI = -13.1,-9.27; dual: -9.39, 95% CI = -11.3, -7.52) compared with exclusive smokers. In within group analyses, e-cigarette and dual users showed reductions in craving and withdrawal from baseline to week 6. Exclusive e-cigarette and dual users, maintained cotinine levels (all Ps > 0.05) and showed reductions in CPD and cigarette dependence (all Ps < 0.01). Findings were inconclusive regarding changes in total nicotine dependence from baseline to week 6 among exclusive e-cigarette users (P = 0.123). Dual users showed increased total nicotine dependence (P < 0.001) and smokers showed decreased total dependence (P = 0.004).

CONCLUSIONS

Smokers who switch to nicotine salt pod system e-cigarettes maintain their nicotine levels and transfer their dependence, suggesting that nicotine salt pod system e-cigarettes have a similar reinforcement potential to cigarettes and facilitate switching.

Exploring the Association of e-Cigarette and/or Cannabis Use with Heavy Episodic Drinking among Ontario Adults

Background: The use of electronic cigarettes and cannabis has significantly increased in recent years, which raises public health concerns. There are also concerns about the association of these substances with drinking behaviors. The main objective of the present study is to examine the association of e-cigarettes and/or cannabis use with heavy episodic drinking (HED) among Ontario adults. Methods: The sample consisted of 5,564 adults from the Monitor Survey in 2018 and 2019. Cannabis and e-cigarette use reflected any use of the substances in the past 12 months. HED was defined as consumption of four/five or more drinks on a single occasion at least monthly in the past 12 months. Odds ratios (OR) were estimated from logistic regression models accounting for complex survey design and sociodemographic factors. Results: Overall, the prevalence of HED was 17.5% in 2018 and 2019. Among participants who reported both e-cigarette and cannabis use, about one-half (50.4%) reported HED at least monthly. Adjusting for covariates, the odds of HED were 5.71 (95%CI, 3.92-8.30) times higher among those who reported both e-cigarette and cannabis use compared to those who used neither substance. Conclusions: The use of e-cigarettes and cannabis are significantly associated with heavy episodic drinking among adults, indicating that those who engage in the dual use of e-cigarette and cannabis may be an important group to target with intervention programs.

Factors Associated with the Dual Use of Electronic Cigarettes and Cigarettes among Thai Undergraduate Students Who Smoked Cigarettes

This study proposed to identify factors associated with the dual use of electronic cigarettes (e-cigarettes) and cigarettes among undergraduate students who smoked cigarettes. This cross-sectional study employed a self-administered, anonymous online questionnaires to collect information from undergraduate smokers in northern Thailand. Of the 494 participants, 82.8% were dual users of e-cigarettes and cigarettes. The two main reasons for using e-cigarettes were an absence of cigarette smoke odor (76.8%) and availability of flavors (70.7%). Undergraduate smokers who initiated smoking at ≥18 years old were more likely to be dual users than those who initiated smoking at younger age (adjusted odds ratio [aOR]: 2.79, 95% confidence intervals [CI]: 1.32-5.89, p = 0.007). Undergraduate smokers who smoked ≥11 cigarettes daily were more likely to be dual users than those who smoked less (aOR: 2.64, 95% CI: 1.52-4.61, p = 0.001). Conversely, undergraduate smokers who had attempted to quit during the past year were less likely to be dual users (aOR: 0.26, 95% CI: 0.12-0.56, p = 0.001). In conclusion, dual use of e-cigarettes and cigarettes among undergraduate smokers was associated with older age at cigarette smoking initiation, a higher number of cigarettes smoked daily, and having no past year's cigarette quit attempts.

Trends in Exclusive, Dual and Polytobacco Use among U.S. Adults, 2014-2019: Results from Two Nationally Representative Surveys

Although increases in the variety of tobacco products available to consumers have led to investigations of dual/polytobacco use patterns, few studies have documented trends in these patterns over time. We used data from the 2014/2015 and 2018/2019 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) and the 2015–2019 National Health Interview Survey (NHIS) to estimate trends in the following use patterns: exclusive use of cigarettes, electronic nicotine delivery systems (ENDS), other combustibles (cigars/cigarillos/little filtered cigars and traditional pipes/hookah), and smokeless tobacco (four categories); dual use (two product groups) of each product group with cigarettes (three categories); polyuse with cigarettes (all four product groups; one category); and dual/polyuse without cigarettes (one category). We estimated trends in product use patterns overall and by age, sex, and race/ethnicity using two-sample tests for differences in linear proportions. From 2014/2015 to 2018/2019, exclusive ENDS use increased, whereas cigarettes and ENDS dual use decreased. Furthermore, polyuse with cigarettes decreased, whereas dual/polyuse without cigarettes increased, with trends varying by age, sex, and race/ethnicity. Our findings suggest that patterns of dual/polyuse with and without cigarettes have changed in recent years, indicating the need for further surveillance of concurrent tobacco product use patterns.

Tobacco-use behavior and toxicant exposure among current dual users of electronic cigarettes and tobacco cigarettes

Electronic cigarette (e-cigarette) use continues to grow with most users reporting concurrent cigarette smoking, but few studies have focused on tobacco use and toxicant exposure among naturalistic dual-using populations. This controlled clinical laboratory study examined how dual versus exclusive use of e-cigarettes and cigarettes and no tobacco/nicotine affected behavioral, physiological, and subjective measures among current dual users. Twenty-two participants identifying as cigarette (≥ 10 cigarettes per day [CPD]) and e-cigarette (≥ 3 days/week) users of "cig-a-like" e-cigarettes completed four 5-day outpatient conditions, which differed by their own brand of products used ad libitum: (a) cigarette and e-cigarette (dual), (b) cigarette-only, (c) e-cigarette-only, and (d) no tobacco/nicotine. Primary outcomes included daily tobacco use, expired air carbon monoxide (CO), and urinary cotinine and NNAL. Linear mixed models with pairwise comparisons (Bonferroni corrected) were performed (p < .05). CPD did not differ significantly between dual and cigarette-only use, but e-cigarette use and liquid consumed increased significantly during e-cigarette-only relative to dual use. Relative to dual use, expired air CO did not differ during cigarette-only and was significantly lower during e-cigarette-only use. Urinary cotinine was significantly lower during e-cigarette-only use relative to dual and cigarette-only use, while urinary NNAL did not differ between the nicotine-containing conditions. In summary, among current dual users, e-cigarettes in combination with cigarettes did not reduce CPD relative to exclusive cigarette use or toxicant exposure relative to exclusive use of either product. However, exclusive e-cigarette use did reduce CO and cotinine, highlighting the benefits of cigarette cessation. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Assessing the potential impact of age and inhalant use on sleep in adolescents

STUDY OBJECTIVES

Targeted marketing has caused a recent surge in teen electronic cigarette usage. In all-age surveys, we isolated adolescent data (13-20 years) to assess age alongside electronic cigarettes, traditional tobacco, and dual usage of both with sleep quality and cough. Based on existing adult literature, we hypothesized an association between dual usage and increased sleep latency.

METHODS

Participants were recruited to complete surveys via social media sites. We performed 3 surveys: Survey 1 (n = 347) in 2018, Survey 2 (n = 1198) in 2019, Survey 3 (n = 554) in 2020. Surveys 1 and 2 had 3 sections: UCSD Inhalant Use Survey, Pittsburgh Sleep Quality Index, and Leicester Cough Questionnaire. Survey 3 did not include the Leicester Cough Questionnaire, instead the Hospital Anxiety and Depression Scale and Patient Health Questionnaire were used. The adolescent data were isolated (n = 609).

RESULTS

Adolescents reported longer sleep duration with increasing age by one-way analysis of variance. By Tukey's multiple comparisons test, females slept more at ages 19 and 20 years than at age 14 years (P < .01). Female dual users slept more than nonsmokers, (P = .01; mean difference 43.8 minutes; confidence interval = 0.11 to 1.36). We observed an association between dual use and sleep latency vs nonsmokers (P = .0008; mean difference 6.27 minutes; confidence interval = 1.40 to 11.13). We saw no correlation between inhalant use and cough.

CONCLUSIONS

In females, we observed a peak in sleep hours at age 19 years. College-aged females may wake later than younger adolescent females. The data also raised concern for sleep disruption and nicotine-induced wakefulness. Further data are required to guide public health strategies.

CITATION

Malhotra CK, Gunge D, Advani I, Boddu S, Nilaad S, Crotty Alexander LE. Assessing the potential impact of age and inhalant use on sleep in adolescents. J Clin Sleep Med. 2021;17(11):2233-2239.

Factors Associated with Cigarette, E-Cigarette, and Dual Use among South Korean Adolescents

Dual use of e-cigarettes and cigarettes has become common among Korean adolescents but has decreased among adults. Dual use refers to using two tobacco products; however, in this study, it is defined as using both e-cigarettes and cigarettes. We assessed the prevalence of dual use among Korean adolescents and its relationship with socio-demographic, smoking-related characteristics, and other risk behaviors. The 2019 Korea Youth Risk Behavior Survey’s data on 57,303 adolescents were analyzed using logistic regression. Overall, 13.8% had recently (in the past 30 days), used some type of cigarette, 3.3% were dual users, 3.4% exclusively smoked conventional cigarettes, and 0.6% exclusively vaped e-cigarettes. After adjusting for socio-demographic and psychological factors, substance use, smoking initiation by 13 years, secondhand smoke in school and public, and amount of cigarette consumption proved significant for all cigarette user types. Dual use was strongly associated with younger age (≤15 years), cigarette smoking initiation before 13 years, secondhand smoke exposure at school, and heavy cigarette smoking. Limited smoking cessation attempts, secondhand smoke exposure in public, and ease of cigarette purchases decrease the odds of adolescents becoming dual users. Thus, surveillance and enforcement of the juvenile protection measures need updating to prevent a shift into dual use.

Use of Single, Dual, and Poly Tobacco Products in Korean Adolescents

This study aimed to examine the prevalence of single, dual, and poly use of conventional cigarettes, e-cigarettes, and heated tobacco products among Korean adolescent smokers and identify factors related to dual and poly tobacco product use. Data from 4028 current smokers in the 2019 Korea Youth Behavior Web-based Survey were included. Single users accounted for 53.1%, followed by dual users at 24.8% and poly users at 22.1%. The factors influencing dual and poly tobacco product use included male, living in a metropolitan area, risky alcohol drinking, sexual experience, number of cigarettes smoked, secondhand smoke exposure, and easy-to-buy tobacco products. The findings suggest restricting the use of new types of tobacco products in the high-risk group are required to prevent dual and poly use. Furthermore, it is necessary to provide support like education for new tobacco products and smoking cessation, programs for secondhand smoke prevention, or rigorous marketing regulations for adolescents.

Adverse Childhood Experiences and Past 30-Day Cigarette and E-Cigarette Use Among Sexual and Gender Minority College Students

Purpose: Sexual and gender minority (SGM) young adults report disproportionately higher rates of tobacco and nicotine product use. This study assessed the role of adverse childhood experiences (ACEs) in nicotine and tobacco product use among SGM young adults. Methods: A cross-sectional survey was administered to 11,694 college students (ages 18-29 years) between 2017 and 2018 in California, Minnesota, and Texas. Results: For every additional ACE reported, the odds of cigarette, e-cigarette, and dual use increased for all students, with significantly higher past 30-day cigarette use among ACE-exposed SGM students. Conclusion: ACEs are an important contributing factor to tobacco-related disparities facing SGM groups.

A Descriptive Analysis of Transitions from Smoking to Electronic Nicotine Delivery System (ENDS) Use: A Daily Diary Investigation

OBJECTIVES

We aimed to examine patterns in smoking and electronic nicotine delivery system (ENDS) use over an extended period of time (up to 20 weeks) in people who smoked and who had never previously made a successful quit attempt using an ENDS.

DESIGN AND SETTING

We conducted a longitudinal mixed-methods study in Dunedin, New Zealand, during 2018 and 2019.

PARTICIPANTS

Purposively selected participants (N = 45; age (≥18 years), gender, ethnicities, cigarettes/day) who wished to quit smoking.

INTERVENTIONS

Participants were provided with a second-generation ENDS device (vape pen or starter "tank" device) at the start of their quit attempt, and asked to complete smartphone-based daily diary surveys assessing smoking and ENDS use.

OUTCOME MEASURES

Sunburst plots and a sequence plot were used to describe weekly and daily patterns of smoking and ENDS use (smoking only, ENDS use only, dual use, abstinent).

RESULTS

The most frequently reported movements among participants, classified according to their study week behaviour, occurred between dual use and exclusive ENDS use (and vice versa). A smaller group reported moving from dual use to exclusive smoking (and often back to dual use), and a small number reported moving between abstinence and different ENDS and smoked tobacco usage behaviours. Data visualisations focussing on those participants who had provided data during each of weeks 9-12 indicate that only a minority reported sustained dual use; instead, most participants indicated varied smoked tobacco and ENDS use, which included periods of dual use.

CONCLUSIONS

The considerable variety observed within and between study participants suggests that high variability is typical rather than exceptional. Transitions from smoking to ENDS use may involve considerable periods of dual use, which is likely to be dynamic and potentially sustained over several months.

E-cigarette and dual product use as an emerging health threat to the US military

INTRODUCTION

Cigarette and e-cigarette use are threats to the health and readiness of the US military. The study objective was to determine the prevalence and factors associated with e-cigarette, cigarette, and dual use among active duty service members (SMs).

METHODS

We used data from the 2015 Health Related Behaviors Survey—a crosssectional survey weighted to represent the US military (n=16699). Weighted prevalence and odds ratios assessed associations between risk factors and e-cigarette/cigarette use via weighted multinomial logistic models.

RESULTS

The prevalence of cigarette use in the US military declined from 24% in 2011 to 13.8% in 2015. However, e-cigarette use (12.4%) and dual product use (4.7%) increased during this period. Additionally, prevalence of e-cigarette use was higher in the military compared to the general population (12.4% vs 3.5%), particularly among those aged 17–24 years (22.8% vs 5.2%); cigarette use was also higher in the military in this age group (19.3% vs 13.0%). After adjustment, SMs who were enlisted, lacked a Bachelor’s degree, and/or had probable alcohol use disorder had significantly greater odds of cigarette, e-cigarette, and dual use. While SMs aged 17–24 years had the highest prevalence of all types of product use, only being aged ≥45 years was significantly associated with decreased odds of product use in adjusted models.

CONCLUSIONS

Military efforts to control cigarette use among SMs seem to have been successful, as demonstrated by the dramatic declines in its use and the lower prevalence seen in the military compared to the general population. However, the concurrent increases in e-cigarette use are concerning, particularly among the youngest members of the military. The US military must continue to monitor emerging trends in e-cigarette, cigarette, and dual use and rapidly take steps to address them as threats to health and readiness.

E-Cigarette Flavors and Frequency of E-Cigarette Use among Adult Dual Users Who Attempt to Quit Cigarette Smoking in the United States: Longitudinal Findings from the PATH Study 2015/16-2016/17

Potential mechanisms by which e-cigarette use may relate to combustible cigarette smoking cessation are not well-understood. We used U.S. nationally representative data to prospectively evaluate the relationship between e-cigarette flavor use and frequency of e-cigarette use among adult cigarette/e-cigarette dual users who attempted to quit smoking cigarettes. Analyses used Population Assessment of Tobacco and Health (PATH) Study data from adult dual users (2015/16) who attempted to quit smoking between 2015/16 and 2016/17 (Wave 3-Wave 4, n = 685, including those who did/did not quit by 2016/17). E-cigarette flavor use (usual/last flavor, past 30-day flavor; assessed in 2015/16) was categorized into Only tobacco; Only menthol/mint; Only non-tobacco, non-menthol/mint; and Any combination of tobacco, menthol/mint, other flavor(s). The key outcome, evaluated at follow-up in 2016/17, was frequent e-cigarette use, which was defined as use on 20+ of past 30 days. Logistic regression was used to evaluate associations between e-cigarette flavor use in 2015/16 and frequent e-cigarette use at follow-up in 2016/17. Dual users who attempted to quit smoking had greater odds of frequent e-cigarette use at follow-up when they used only non-tobacco, non-menthol/mint flavor than when they used only tobacco flavor as their regular/last e-cigarette flavor (OR = 1.9, 95% CI: 1.1-3.4); findings were no longer significant when adjusted for factors including e-cigarette device type (AOR = 1.4, 95% CI: 0.7-2.8). Past 30-day e-cigarette flavor use results were generally similar, although frequent e-cigarette use at follow-up was highest among those who used any combination of tobacco, menthol/mint, or other flavors. Findings indicate that e-cigarette flavor use among dual users who attempt to quit smoking may be related to e-cigarette use frequency overall, which may indicate a mechanism underlying findings for e-cigarette use and smoking cessation. Further longitudinal research may help to disentangle how e-cigarette characteristics uniquely impact e-cigarette use frequency and smoking cessation/sustained use.

Cigarette and E-Cigarettes Dual Users, Exclusive Users and COVID-19: Findings from Four UK Birth Cohort Studies

INTRODUCTION

The relationship between current cigarette and electronic cigarette (e-cigarette) dual use, exclusive use and COVID-19-related measures are still unclear. This study aims to assess the association between different tobacco use patterns and coronavirus disease 2019 (COVID-19) symptoms, testing, self-reported infection and social distancing behaviors in the United Kingdom (UK).

METHODS

Data come from the first wave of the Centre for Longitudinal Studies (CLS) COVID-19 survey, comprising four birth cohorts (N = 13,077, aged 20-63 years) surveyed between 2 to 31 May 2020, during the COVID-19 pandemic. Sociodemographic characteristics and COVID-19-related outcomes (symptoms, testing, diagnosis and social distancing behaviors) were compared across different product user groups (non-users, exclusive cigarette users, exclusive e-cigarettes users and dual use) using Cochran-Mantel-Haenszel χ2 test. Multivariable logistic regression models were used to explore associations between COVID-19-related outcomes and different smoking patterns.

RESULTS

Across all four cohorts, 12.6% and 4.9% of the respondents were current exclusive cigarette and e-cigarette users, respectively, with approximately 3% of the respondents being dual users. Significant differences in prevalence were observed between different tobacco use patterns and COVID-19 symptoms (p = 0.02), self-reported infection (p = 0.04) and social distancing behaviors (p < 0.001). Current cigarette and e-cigarette dual use was associated with 2.15-fold higher odds for reporting COVID-19 infection (aOR = 2.15; CI [1.15-4.05]). Compliance of social distancing behaviors were the lowest for current dual users (aOR = 0.58; CI [0.41-0.83]) and exclusive cigarette users (aOR = 0.72; CI [0.63-0.92]).

CONCLUSIONS

The findings highlight dual users' higher prevalence of having COVID-19 symptoms, infection and incompliance of social distancing behaviors. Self-reported infection was associated with dual product use; dual users and exclusive cigarette users were linked to poor adherence to social distancing behaviors. Smoking cessation support and further monitoring on multiple tobacco use among these populations should be reinforced as preventive measures to tackle the pandemic.

Exclusive, Dual, and Polytobacco Use Among US Adults by Sociodemographic Factors: Results From 3 Nationally Representative Surveys

PURPOSE

To provide tobacco product use patterns for US adults by sociodemographic group.

DESIGN

A secondary analysis of Tobacco Use Supplement to the Current Population Survey (2014-15), National Health Interview Survey (2015), and Population Assessment of Tobacco and Health (2015-16).

SETTING

United States.

SAMPLE

Three nationally representative samples of adults (N = 28,070-155,067).

MEASURES

All possible combinations of cigarette, Electronic Nicotine Delivery Systems (ENDS), other combustible product, and smokeless tobacco use, defined as current use every day or some days.

ANALYSIS

Weighted population prevalence and proportion among tobacco users of exclusive, dual, and polyuse patterns by sex, race/ethnicity, education, income, and age.

RESULTS

Exclusive cigarette use was the most prevalent pattern (10.9-12.8% of US population). Dual and polyuse were less prevalent at the population level (2.6-5.2% and 0.3-1.3%, respectively) but represented 16.7-25.5% of product use among tobacco users. Cigarette plus ENDS use was similar by sex, but men were more likely to be dual users of cigarettes plus other combustibles or smokeless tobacco. Among race/ethnic subgroups, non-Hispanic (NH) Whites were most likely to use cigarettes plus ENDS, while NH Blacks were most likely to use cigarettes plus other combustibles. Dual and polyuse were generally less common among adults with higher education, income, and age.

CONCLUSION

Differences in product use patterns by sociodemographic group likely represent different risk profiles with important implications for resulting health disparities.

Development of a Self-Help Smoking Cessation Intervention for Dual Users of Tobacco Cigarettes and E-Cigarettes

Most users of electronic cigarettes (e-cigarettes) report initiating use to quit combustible cigarettes. Nevertheless, high levels of dual use (i.e., using both combustible cigarettes and e-cigarettes) occur among adults. Using formative data from in-depth interviews and employing learner verification, we adapted an existing, validated self-help smoking-cessation intervention (Stop Smoking for Good; SSFG) to create a targeted intervention for dual users, If You Vape: A Guide to Quitting Smoking (IYV). In Phase I, in-depth interviews (n = 28) were conducted to assess relevance of the existing SSFG materials (10 booklets, nine pamphlets) and identify new content for the booklets. Next, for Phase II, learner verification interviews (n = 20 dual users) were conducted to assess their appeal and acceptability. Several key themes emerged from the Phase I in-depth interviews. Findings led to the inclusion of e-cigarette-specific strategies used by successful quitters such as gradually reducing nicotine levels, switching from tobacco flavor to alternative flavors, and limiting e-cigarette use to places one would normally smoke (i.e., not expanding use). Suggestions from Phase II learner verification included broadening the visual appeal for a younger, more diverse demographic, expanding tips for quitting smoking via e-cigarettes, and expanding terminology for e-cigarette devices. Beginning with an efficacious self-help intervention, we used a systematic process to develop a version specifically for dual users.

Prevalence and social determinants of tobacco use in Afghanistan

Background

Limited evidence exists on the prevalence and social determinants of tobacco use in Afghanistan—a fragile post-war context where the tobacco epidemic is on the rise. This study aimed to estimate the prevalence and social determinants of tobacco use in Afghan men and women.

Methods

Data from the 2015 Afghanistan Demographic and Health Survey of 10 760 men and 29 461 women were used to generate weighted prevalence estimates for smoking, smokeless tobacco (SLT) products including chew and snuff tobacco, ‘any tobacco use’ and ‘dual tobacco use’. We also modelled associations with tobacco outcomes using binary logistic regressions.

Results

We found that for men, smoking cigarettes was the most prevalent form of tobacco use (21.9% [95% confidence interval {CI} 21.2–22.7]). Prevalence rates were far lower for women, with cigarette/pipe smoking at 3.4% (95% CI 3.2–3.7). For both sexes, tobacco use was inversely associated with education and positively associated with agricultural and skilled and unskilled manual labour occupations. Wealth increased the odds of smoking for men but decreased the odds for women. Media exposure had little influence on tobacco use among women; however, the effects were more varied for men.

Conclusions

Our results demonstrate social inequalities in tobacco use among Afghan men and women, which calls for stronger tobacco control measures and continued monitoring of this growing epidemic.

Examining Use and Dual Use of Tobacco Products and Marijuana among Minnesota Adults

BACKGROUND

An increasing number of states are legalizing the medicinal and/or recreational use of marijuana. Adult perceptions of harm have decreased and marijuana use has increased. This is in contrast to declining cigarette smoking. In this article we examine independent use and dual use of marijuana and tobacco products.

METHODS

Data are from the 2018 Minnesota Adult Tobacco Survey (N = 6055). Estimates were calibrated on sex, race, location, and education from the American Community Survey.

RESULTS

In 2018, 15.4% of adults smoked cigarettes in the past 30 days, 7.6% used marijuana and 6.0%, 3.0%, and 1.1% used e-cigarettes, cigars, and waterpipe, respectively. Use of marijuana and cigarettes was 3.3% and use of marijuana and e-cigarettes was 2.2%. Among past 30-day marijuana users, 89.7% smoked it as a joint, blunt, or in waterpipes, 22.1% vaped it in an e-cigarette or a vaping device. Across multinomial regression models, marijuana use and dual use with tobacco products was more likely among males, younger age groups, and African Americans.

CONCLUSIONS

As policies to expand the sale and use of marijuana are considered, states should anticipate the need to monitor trends and to plan surveys of sufficient sample size with specific questions on marijuana use. Understanding the proportion of the population that uses both marijuana and tobacco has implications for prevention and treatment of both substances.

Anxiety Sensitivity and Emotion Dysregulation in Dual and Exclusive E-Cigarette Users

Background: E-cigarette use has increased exponentially over the past decade, particularly among current combustible cigarette users. Preliminary evidence has demonstrated differences across exclusive and dual e-cigarette/combustible cigarette users, such that dual users represent a more clinically severe group. Yet, the extent to which these groups differ on critical transdiagnostic risk factors that may promote and maintain nicotine dependence, such as anxiety sensitivity and emotional dysregulation has yet to be systematically studied. The purpose of the current study was to examine differences between exclusive e-cigarette users and dual e-cigarette and combustible cigarette users in anxiety sensitivity and both global emotion regulation difficulties as well as within specific emotion regulation difficulty domains. Methods: Participants were 192 exclusive e-cigarette users and 315 dual e-cigarette and combustible cigarette users (52.1% female, Mage = 34.8 years, SD = 11.42). Results: Compared to exclusive e-cigarette users, dual users reported higher anxiety sensitivity, overall emotion regulation difficulties, and specific emotion regulation difficulties related to impulse control and lack of access to effective emotion regulation strategies. There were no group differences in emotion regulation difficulties related to emotional clarity, ability to engage in goal-directed behavior when upset, and emotional non-acceptance. Conclusion: The current data suggest that dual users are an at-risk group in terms of emotional processes. Dual users would likely benefit from targeted intervention efforts focused on reducing anxiety sensitivity and improving emotion regulation in order to reduce nicotine consumption and/or promote cessation.

Tobacco quitline engagement and outcomes among primary care patients reporting use of tobacco or dual tobacco and cannabis: An observational study

Background: Dual use of tobacco and cannabis is increasingly common, but it is unclear how it impacts individuals' interest in or ability to stop smoking. If dual users fail to engage in treatment or have worse treatment outcomes, it would suggest that tobacco treatment programs may need to be tailored to the specific needs of those using cannabis and tobacco. Methods: We conducted an observational study using electronic treatment records from adults (18 years and older) who (a) were enrolled in a regional healthcare system in Washington state, (b) sought tobacco cessation treatment through an insurance-covered quitline from July 2016 to December 2018 and (c) had cannabis use frequency during the period of their quitline enrollment documented in their electronic health record (EHR) (n = 1,390). Treatment engagement was defined by the total number of quitline counseling calls and web-logins completed. Point prevalent self-reported tobacco abstinence was assessed 6 months post-quitline enrollment. Results: Thirty-two percent of participants (n = 441) reported dual use of tobacco and any cannabis during the observation period; 9.4% (n = 130) reported daily cannabis use. Among dual users reporting daily cannabis use, 13.9% had a diagnosed cannabis user disorder in the EHR. Neither engagement with quitline counseling nor long-term tobacco abstinence rates differed between those using tobacco-only and either dual-use group (i.e., persons using any cannabis or daily cannabis). Conclusions: Dual use of tobacco and cannabis is common among smokers seen in primary care and those enrolling in quitline care, but it may not undermine tobacco quitline engagement or smoking cessation. Opportunities exist in the US to leverage quitlines to identify and intervene with dual users of tobacco and cannabis.HIGHLIGHTSTobacco quitline care was equally engaging and effective among tobacco users and dual users of tobacco and cannabisMany daily cannabis users calling tobacco quitlines likely have a cannabis use disorderTobacco quitlines can be leveraged to identify and intervene with dual users of tobacco and cannabis.

What Motivates Smokers to Switch to ENDS? A Qualitative Study of Perceptions and Use

Switching completely from cigarettes to electronic nicotine delivery systems (ENDS) may reduce health risks for addicted smokers. This paper provides information about perceptions and other factors that may influence smokers’ ENDS use and substitution for cigarettes. We conducted 12 online focus groups (N = 61) among smokers who had never tried using ENDS (Never Users, N = 11), currently used both cigarettes and ENDS (Dual Users, N = 21), used but discontinued ENDS (Rejectors, N = 14), and switched completely to ENDS use (Switchers, N = 15). Thematic analysis was used to interpret the transcripts. Participants described initial interest in trying ENDS in hopes of quitting smoking and because of convenience (i.e., due to rules, regulations, or social norms). Risk perceptions and higher prices relative to cigarettes were reported as disadvantages of ENDS that discouraged initiation. Dual Users and Rejectors reported product problems (e.g., products breaking) and dissatisfaction (i.e., inability to satisfy cravings for cigarettes) as factors that lowered their substitutability for cigarettes or led to discontinuing ENDS use. Switchers indicated that satisfaction, lack of product problems, and perceived safety facilitated successfully switching from cigarette smoking to exclusive ENDS use. However, Switchers reported trying many products before they found ones that satisfied their needs. We recommend that policymakers consider the potential impact of tobacco control policies on smokers’ motivation and ability to switch completely from cigarettes to ENDS.

Veteran Perspectives on Care Coordination Between Veterans Affairs and Community Providers: A Qualitative Analysis

OBJECTIVE

To investigate veteran perspectives on challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers in rural areas.

METHODS

We completed qualitative interviews with a geographically diverse sample of 51 veterans who had used both VA and community health care services. Interviews were audio-recorded and transcribed verbatim. We used directed content analysis (informed by previous work with VA and community staff) to elucidate findings, while remaining attentive to emergent themes.

RESULTS

We report results in 5 key domains related to interorganizational care coordination: organizational mechanisms, organizational culture, relational practices, contextual factors, and the role of the Third-Party Administrators responsible for scheduling and payment for community services. Veterans described successes and challenges in interorganizational coordination across these domains, while also reporting a variety of workarounds and mitigation strategies.

CONCLUSIONS

Veterans living in rural areas face myriad challenges when using health care services both within and outside of VA. In the absence of strong mechanisms for ensuring coordination and communication between health care providers at different institutions, veterans themselves may carry the primary burden for coordinating their care. Our results suggest the utility of both structural and relational approaches to enhancing interorganizational care coordination in these settings.

Adverse Childhood Experiences and Prevalence of Cigarette and E-Cigarette Use Among Adolescents in Bangkok, Thailand

Currently, e-cigarettes are the most popular tobacco product among adolescents. The purpose of this study was to explore the relationship between exposure to adverse childhood experiences (ACEs) and use of cigarettes, e-cigarettes, and dual use in a sample of adolescents in Bangkok, Thailand. The sample comprises 6167 students from 48 schools (grades 9, 11, and vocational year 2) who participated in the 2019 round of the Behavior Surveillance Survey. History of 11 ACEs was used to calculate a cumulative ACE score (range 0-11). Multinomial logistic regression was used to assess the relationship between history of ACEs and smoking. In the sample, 7.0% reported using e-cigarettes only and 9.5% used e-cigarettes and cigarettes (dual use). After controlling for sociodemographic characteristics, history of ACEs was associated with increased odds of dual use. The odds of cigarette, e-cigarette, and dual use was significantly greater if the adolescent had a history of ≥4 ACEs. Special attention is needed to prevent smoking of different types among those with a history of ACEs.

Exposure to nicotine-free and flavor-free e-cigarette vapors modifies the pulmonary response to tobacco cigarette smoke in female mice

Most of electronic cigarette (e-cigarette) users are also smoking tobacco cigarettes. Because of the relative novelty of this habit, very little is known on the impact of vaping on pulmonary health, even less on the potential interactions of dual e-cigarette and tobacco cigarette use. Therefore, we used well-established mouse models to investigate the impact of dual exposure to e-cigarette vapors and tobacco cigarette smoke on lung homeostasis. Groups of female BALB/c mice were exposed to room air, tobacco smoke only, nicotine-free flavor-free e-cigarette vapors only or both tobacco smoke and e-cigarette vapors. Moreover, since tobacco smoke and electronic cigarette vapors both affect circadian processes in the lungs, groups of mice were euthanized at two different time points during the day. We found that dual-exposed mice had altered lung circadian gene expression compared with mice exposed to tobacco smoke alone. Dual-exposed mice also had different frequencies of dendritic cells, macrophages, and neutrophils in the lung tissue compared with mice exposed to tobacco smoke alone, an observation also valid for B-lymphocytes and CD4+ and CD8+ T lymphocytes. Exposure to e-cigarette vapors also impacted the levels of immunoglobulins in the bronchoalveolar lavage and serum. Finally, e-cigarette and dual exposures increased airway resistance compared with mice exposed to room air or tobacco smoke alone, respectively. Taken together, these data suggest that e-cigarette vapors, even without nicotine or flavors, could affect how the lungs react to tobacco cigarette smoke exposure in dual users, potentially altering the pathological course triggered by smoking.

Veterans Affairs and Rural Community Providers' Perspectives on Interorganizational Care Coordination: A Qualitative Analysis

OBJECTIVE

To investigate challenges in care coordination between US Department of Veterans Affairs (VA) clinics and community providers serving rural veterans.

METHODS

We completed qualitative interviews in 2017-2018 with a geographically diverse sample of 57 VA and community staff. Interviews were audio-recorded and transcribed verbatim. We used Rapid Qualitative Inquiry (RQI) to guide analyses.

RESULTS

Results suggested 5 pivotal domains related to interorganizational care coordination at these sites: organizational mechanisms; organizational culture; relational coordination; contextual factors; and the role of the third party administrators charged with management of scheduling and reimbursement of community services through recent legislation. Across these domains, strategies to bridge gaps between organizations (eg, contracts with third party administrators, development of VA-based community care offices, provision of boundary-spanning staff) at times exacerbated coordination challenges.

CONCLUSIONS

Steps taken to improve interorganizational care coordination between VA and community clinics may inadvertently complicate an already complex process. Our findings emphasize the importance of attending to key contextual barriers in coordinating care for rural veterans, and they illustrate the value of fundamental structural and relational approaches to enhancing such care coordination.

Simultaneous Control of Endogenous and User-Defined Genetic Pathways Using Unique ecDHFR Pharmacological Chaperones

Destabilizing domains (DDs), such as a mutated form of Escherichia coli dihydrofolate reductase (ecDHFR), confer instability and promote protein degradation. However, when combined with small-molecule stabilizers (e.g., the antibiotic trimethoprim), DDs allow positive regulation of fusion protein abundance. Using a combinatorial screening approach, we identified and validated 17 unique 2,4-diaminopyrimidine/triazine-based ecDHFR DD stabilizers, at least 15 of which were ineffective antibiotics against E. coli and S. aureus. Identified stabilizers functioned in vivo to control an ecDHFR DD-firefly luciferase in the mouse eye and/or the liver. Next, stabilizers were leveraged to perform synergistic dual functions in vitro (HeLa cell death sensitization) and in vivo (repression of ocular inflammation) by stabilizing a user-defined ecDHFR DD while also controlling endogenous signaling pathways. Thus, these newly identified pharmacological chaperones allow for simultaneous control of compound-specific endogenous and user-defined genetic pathways, the combination of which may provide synergistic effects in complex biological scenarios.

Concurrent Daily and Non-Daily Use of Heated Tobacco Products with Combustible Cigarettes: Findings from the 2018 ITC Japan Survey

Use of heated tobacco products (HTPs) among current smokers is becoming increasingly popular in Japan. This study aims to compare characteristics and tobacco-related behaviors among concurrent users of HTPs and combustible cigarettes (n = 644) with exclusive smokers (n = 3194) or exclusive HTP users (n = 164). The secondary aim was to explore heterogeneity within concurrent use subgroups. Data were from Wave 1 of the ITC Japan Survey, a nationally representative web survey conducted from February to March 2018. Concurrent cigarette-HTP users were younger and wealthier than exclusive smokers. However, there were no difference in the frequency of smoking, number of cigarettes per day, and smoking cessation behaviors between the two groups, suggesting that HTPs reinforce nicotine dependence. Compared to exclusive HTP users, concurrent cigarette-HTP users reported higher frequency of non-daily HTP use, and lower number of tobacco-containing inserts per day. Almost all concurrent cigarette-HTP users smoked every day (93.9%); 48.4% both smoked and used HTPs daily (dual daily users, n = 396), while 45.5% were daily smokers and non-daily HTP users (predominant smokers, n = 213). Concurrent user subgroups differed from each other on age, tobacco use behaviors, and quit intention. Alongside heterogeneity between concurrent and exclusive product users, differences across concurrent use subgroups highlight the importance of considering frequency of use in characterizing poly-tobacco users.

Is dual use of nicotine products and cigarettes associated with smoking reduction and cessation behaviours? A prospective study in England

OBJECTIVES

To investigate associations of dual use of e-cigarettes and cigarettes with subsequent quitting activity (smoking reduction, quit attempts and use of evidence-based cessation aids). To overcome potential confounding by factors associated with use of pharmacological support, we selected dual use of over-the-counter nicotine replacement therapy (OTC NRT) and cigarettes as a behavioural control.

DESIGN

Prospective cohort study with 6-month follow-up.

SETTING

England, 2014-2016.

PARTICIPANTS

413 current smokers participating in the Smoking Toolkit Study, a representative survey of adults in England, who reported current use of e-cigarettes or OTC NRT and provided data at 6-month follow-up.

MAIN OUTCOME MEASURES

The exposure was dual use of e-cigarettes or OTC NRT at baseline. Outcomes were change in cigarette consumption, quit attempts and use of evidence-based cessation aids during quit attempts over 6-month follow-up. Relevant sociodemographic and smoking characteristics were included as covariates.

RESULTS

After adjustment for covariates, dual e-cigarette users smoked two fewer cigarettes per day at follow-up than at baseline compared with dual OTC NRT users (B=2.01, 95% CI -3.62; -0.39, p=0.015). While dual e-cigarette users had 18% lower odds than dual OTC NRT users to make a quit attempt at follow-up (risk ratio (RR) 0.82, 95% CI 0.67 to 1.00, p=0.049), the groups did not differ in use of cessation aids (RR 1.06, 95% CI 0.93 to 1.21, p=0.388).

CONCLUSIONS

Dual use of e-cigarettes is associated with a greater reduction in cigarette consumption than dual use of OTC NRT. It may discourage a small proportion of users from making a quit attempt compared with dual OTC NRT use but it does not appear to undermine use of evidence-based cessation aids.

Changes in Nicotine Product Use among Dual Users of Tobacco and Electronic Cigarettes: Findings from the Population Assessment of Tobacco and Health (PATH) Study, 2013-2015

Background: Dual use of tobacco cigarettes and e-cigarettes ("dual use") is the most common poly-tobacco use pattern among U.S. adults. Whether dual use facilitates or inhibits smoking cessation is of concern, yet limited information exists regarding continuation of dual use over time. Purpose: This study examined variation in nicotine product use over a one-year period, and evaluated predictors of smoking abstinence among dual users. Methods: Data from 1,082 dual users of tobacco cigarettes and e-cigarettes were analyzed using Wave 1 (2013-2014) and Wave 2 (2014-2015) of the Population Assessment of Tobacco and Health Study. Descriptive analyses assessed variation in nicotine product use at Wave 2. Weighted logistic regression was used to identify correlates of smoking abstinence. Results: The majority of Wave 1 dual users (88.5%) continued using combustible tobacco at Wave 2: 59.2% were exclusive cigarette smokers, 25.5% remained dual users, and 3.8% reported some other combustible tobacco use pattern. The odds of being smoke-free at Wave 2 were higher among dual users who reported everyday (versus someday) e-cigarette use (aOR: 1.85; 95% CI: 1.18-2.89). Everyday use of tobacco cigarettes was inversely associated with smoking abstinence (aOR 0.33; 95% CI: 0.21-0.51). Conclusions: Over a one year period, most dual users still smoked tobacco cigarettes. Frequency of cigarette and e-cigarette use at Wave 1 were each associated with odds of smoking abstinence. Findings suggest that daily e-cigarette use may increase dual users' chances of becoming smoke free.

Characteristics of Current Betel Quid/Chewing Tobacco Users, Smokers and Dual Users in Indonesia: An Analysis of GATS 2011 Data

Background: Indonesia has the third largest population of smokers in the world, however, little is known about the use of chewing tobacco/betel quid in Indonesia. This paper describes the characteristics of chewing tobacco/betel quid users in Indonesia, to understand the user population and inform future research. Methods: The 2011 Indonesia GATS included 8,176 adults ages 15 and older. These data are weighted to be nationally representative. Weighted descriptive statistics and multivariate logistic regression were run using SAS 9.4. Results: Estimated national prevalence for exclusive chewing tobacco/betel quid use was 0.9%, for exclusive smoked tobacco use was 33.9% and for dual use was 0.8%. Multivariate logistic regression analyses showed that exclusive chewing tobacco/betel quid users were significantly more likely to be female, and to be older adults (45-64); while smokers are more likely to be male and younger (25-44). Conclusions/Importance: These results provide information on the different characteristics of users by product type, and show that users' demographics vary by their product of choice. This study helps to inform researchers and practitioners of the burden of chewing tobacco/betel quid use in Indonesia. These data, especially specific data on chewing tobacco/betel quid use patterns, are limited in this context, and this knowledge can help to identify populations who need quit tobacco interventions.