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Reasons for Using Flavored Liquids among Electronic Cigarette Users: a Concept Mapping Study
Abstract
Background:
Electronic cigarettes (ECIGs) aerosolize liquids often containing flavorants for inhalation. Few studies have examined the role of flavors in ECIG use. This study's purpose was to examine reasons for flavored ECIG use using a mixed-method approach, concept mapping (CM).
Methods:
Forty-six past 30-day adult ECIG users recruited from vape forums/conferences completed three online CM tasks. Participants brainstormed responses to a prompt: "A specific reason I use flavored e-liquid in my electronic cigarette product is…". The final 107 brainstormed statements were sorted by participants into groups of similar content. Participants rated each statement on a 7-point scale (1-Definitely NOT a reason to 7-Definitely a reason) based on a prompt: "This is a specific reason why I used flavored e-liquid in my electronic cigarette product in the past month." A cluster map was generated from participants' sorting and ratings using CM statistical software. Cluster mean ratings were compared.
Results:
Analysis revealed five clusters of reasons for flavored ECIG use including Increased Satisfaction/Enjoyment, Better Feel/Taste than Cigarettes, Variety/Customization, Food Craving Suppression, and Social Impacts. Statements in the Increased Satisfaction/Enjoyment and Better Feel/Taste than Cigarettes clusters were rated significantly higher than statements from other clusters (ps<0.05). Some statements indicated flavors were perceived as masking agents for nicotine or other bad tastes associated with cigarette smoking making ECIG use more palatable.
Conclusions:
Flavored ECIGs are used for many reasons. Some statements suggested flavors may increase the rewarding and possible addictive effects of ECIGs. These results support continued examination of the role of flavors and ECIG use behaviors.
... E-cigarettes are available in over 15,000 distinct flavors, including 'cotton candy', 'tropical blue slushie' and 'crazy berry' (Hsu et al., 2018). Flavors offer users the ability to customize their products and increase their opportunities for experimentation, both of which are cited as important reasons for ecigarette use Soule et al., 2016;Zare et al., 2018). The availability of such a massive variety of sweet and attractive flavors has played a role in e-cigarettes' exploding popularity. ...
... In general, men are more likely to use e-cigarettes (Barnett et al., 2015;Choi et al., 2012;Hedman et al., 2018;Saddleson et al., 2015;Soule et al., 2016;Sutfin et al., 2013). However, research suggests that women are more likely than men to use characterizing flavored products and/or to value flavor availability Dawkins et al., 2013;Delnevo et al., 2015;King et al., 2013;Kistler et al., 2017;Piñeiro et al., 2016;Schneller et al., 2019b;Smith et al., 2016;Soneji et al., 2019;Villanti et al., 2013). ...
... Unfortunately, many studies have not been able to measure possible sex differences. This might partially be explained by the fact that less women than men vape (Barnett et al., 2015;Choi et al., 2012;Hedman et al., 2018;Saddleson et al., 2015;Soule et al., 2016;Sutfin et al., 2013) and women could be harder to recruit for clinical studies. However, many preclinical studies have also used only male subjects, which is not justifiable. ...
The popularity of e-cigarettes has skyrocketed in recent years, and most vapers use flavored e-cigarette products. Consumption of flavored e-cigarettes exceeds that of combustible cigarettes and other tobacco products among adolescents, who are particularly vulnerable to becoming nicotine dependent. Flavorings have been used by the tobacco industry since the 17th century, but the use of flavors by the e-cigarette industry to create products with "characterizing" flavors (i.e. flavors other than tobacco or menthol) has sparked a public health debate. This review addresses the possibility that characterizing flavors make nicotine more appealing, rewarding and addictive. It also discusses ways in which preclinical and clinical studies could improve our understanding of the mechanisms by which flavors may alter nicotine reward and reinforcement.
This article is part of the special issue on ‘Contemporary Advances in Nicotine Neuropharmacology’.
... The addition of flavorings is shown to reduce the harshness of the nicotine taste in many tobacco products, which allows for increased inhalation, increased nicotine delivery, and increased appeal [18][19][20][21][22][23]. Established cigarette smokers looking to quit may use e-cigarettes as a cessation tool in part because of appealing flavors [5]. However, the FDA has expressed concern that certain flavored e-cigarettes (e.g., JUUL brand) are appealing to youth who may be unaware of the products' addictiveness and otherwise may have never tried a nicotine product [24]. ...
... Previous studies have looked at why consumers use flavored e-cigarettes [2,5], the health perceptions of flavored e-cigarettes [28], the effect of flavored e-cigarettes on youth and young adult tobacco use [3], flavored e-cigarette use among youth versus adults [29][30][31], and common flavors and number of flavors used by consumers [32]. However, newer data from the Population Assessment of Tobacco and Health (PATH) Study allows researchers to assess the use of different flavors, such as tobacco flavor, in combination with other flavors, as questionnaires were updated to keep up with the changing e-cigarette marketplace. ...
... Per these regulations, the FDA now has the authority to regulate the presence of 'characterizing flavors' in e-cigarettes, as was done with cigarettes through the Family Smoking Prevention and Control Act of 2009 [1]. The wide variety of flavored e-cigarettes is enticing to both new consumers and established cigarette smokers [2][3][4][5][6]. In 2018, 4.9% of U.S. middle schoolers and 20.8% of U.S. high schoolers used an e-cigarette in the past 30-days [7], while 2.8% of U.S. adults were current e-cigarette users in 2017 [8]. ...
The United States (U.S.) Food and Drug Administration has expressed concern about flavored e-cigarettes (e.g., JUUL brand) because they are appealing to youth who may be unaware that the product is addictive. The Population Assessment of Tobacco and Health Study Wave 3 provided data on flavor categories, type of e-cigarette product, and smoking status among past 30-day youth and adult e-cigarette users in the US. Most past 30-day youth and adult users reported using only one flavor category, with fruit (53% youth, 31% adult) being the most commonly reported category. Adults were far more likely to report using tobacco flavor alone, compared to any other individual flavor category or flavor category combinations (OR: 21.08, 95%CI: 5.92, 75.12). Whereas, youth were more likely to report using multiple flavor categories (OR: 2.03, 95%CI: 1.55, 2.65), with the most reported pairing being fruit and candy (36%). The variety of flavors on the market appeals to consumers of all ages. Although most past 30-day e-cigarette users reported only one flavor category, non-tobacco flavors were far more common among youth. Differences in flavor preferences among adult versus youth vapers may have implications for the role of flavors in both the initiation of youth vaping and adult vaping for smoking cessation.
... In August 2016, the Deeming rule extended FDA's regulatory authority to all tobacco products including electronic nicotine delivery systems (ENDS), which include e-cigarettes [4,5]; to date, there has been a lack of action assessing characterizing flavors in these products [6]. The availability of flavored e-cigarettes is enticing to new users as well as established cigarette smokers who are looking for an alternative to traditional cigarettes [3,[7][8][9][10][11]. Many users, primarily youth (ages [12][13][14][15][16][17] and young adults (ages [18][19][20][21][22][23][24], report the availability of flavors as a reason they use e-cigarettes [7]. ...
... Many users, primarily youth (ages [12][13][14][15][16][17] and young adults (ages [18][19][20][21][22][23][24], report the availability of flavors as a reason they use e-cigarettes [7]. Adult e-cigarette users report using flavored e-cigarettes because it increased their satisfaction, created a better feel and taste, and allowed for variation and customization of their product [10]. Established cigarette smokers who want to quit smoking may also try e-cigarettes as a cessation tool, in part because of the appealing flavors available [10]. ...
... Adult e-cigarette users report using flavored e-cigarettes because it increased their satisfaction, created a better feel and taste, and allowed for variation and customization of their product [10]. Established cigarette smokers who want to quit smoking may also try e-cigarettes as a cessation tool, in part because of the appealing flavors available [10]. ...
Introduction
Flavored e-cigarettes are enticing to new users and established cigarette smokers using e-cigarettes to quit smoking due to the wide variety of flavor options. However, specific flavor combinations that are popular among e-cigarette users are understudied. Recently, the Deeming rule extended the US Food and Drug Administration’s authority over all tobacco products, including e-cigarettes.
Methods
The Population Assessment of Tobacco and Health Study Wave 2 data were analyzed to assess the prevalence of self-reported flavor categories that are used individually and in combination with other flavor categories among past 30-day youth and adult e-cigarette users in the US.
Results
Most youth and adult participants reported using a flavored e-cigarette. Reporting an individual flavor category was more common than reporting a combination of flavor categories. Fruit flavor was the most common flavor category reported among youth, and ‘menthol/mint’ was most common among adults. Fruit and candy/other sweets were the most common flavor categories reported together among both youth and adult past 30-day e-cigarette users.
Conclusions
The use of flavored e-cigarettes is very popular among youth and adults. Most consumers reported using a single flavor category, although some consumers did use a combination of flavor categories. Preference for menthol/mint among adults may represent a carryover from associations with tobacco cigarettes. Typically, sweeter flavors, such as fruit, were among the most popular flavor categories reported, both individually and in combination with other flavors, while more bitter flavors (i.e.: clove/spice) were less common.
Implications
This study identified predominant flavor categories among past 30-day youth and adult e-cigarette users. Findings indicate that the wide variety of flavors available and the freedom to “mix-and-match” flavors may maintain use of e-cigarettes among youth and adults, and future research should focus on the composition of the ENDS liquid/vapor to disentangle the contributions of sweeteners and flavorants.
... Three previous studies have investigated similar topics, but in these studies, participants generated and sorted statements related to various e-cigarette prompts, which were then aggregated and grouped into clusters via concept mapping. 18,28,29 In contrast, the present study utilized one-on-one interviews, which enabled researchers to engage participants in conversations and obtain rich narrative data. Interviews assist in understanding new and emerging behaviors and in collecting detailed, comprehensive information from actual ecigarette users. ...
... Our results suggest the importance of flavors in e-cigarette use, which prior studies have also high-lighted. 18,20,23,28 Most participants used and enjoyed flavored products due to their pleasant taste/smell and the fact that the vapor covers any smell of cigarette smoke. We also found a flavor-related sex difference, with more women endorsing flavored e-liquid. ...
... In addition, our findings support previous reports that e-cigarettes enable users to enjoy different tastes without consuming calories and that females more commonly endorse ecigarette use for weight control. 28,35,36 Sex differences behind reasons for e-cigarette use indicate that public health messages can be tailored by sex to achieve maximum impact. ...
Objectives: Whereas controversy about the e-cigarette's effectiveness and safety as a smoking cessation tool continues, e-cigarette use prevalence continues rising. In this study, we sought to describe experiences of adult e-cigarette users and to examine their motivations, beliefs, and use patterns. Methods: This qualitative study included one-on-one semi-structured phone interviews with 20 current California e-cigarette users (mean age = 38 ± 9.44 years). Interviews were transcribed and thematically analyzed using MAXQDA. Results: E-cigarettes initially addressed participants' problems related to smoking; they no longer smelled like cigarette smoke and could avoid smoke-free regulations. Participants highlighted the importance of e-cigarette flavors and of "receiving moral credit" for harm reduction by using e-cigarettes to quit smoking cigarettes. Many described eventual dissatisfaction with e-cigarettes, which resulted in relapse to cigarette smoking and/or dual use with cigarettes. The convenience of e-cigarettes coupled with the pattern of constant use left participants increasingly reliant on e-cigarettes. Conclusions: Ultimately, failed cessation and dual use exposes smokers to greater levels of nicotine, while still exposing them to cigarette smoke. Public health campaigns should promote awareness of the risks of using e-cigarettes, including failed cessation attempts, dual use, addiction, and other health consequences.
... The category for alcohol-like flavors was named "alcohol" in each of the six articles using this category. 11,27,[34][35][36][37] Fruit-like flavors were classified as "fruit" in 18 articles 5,6,[11][12][13]27,[34][35][36][37][38][39][40][41][42][43][44][45] ; only one of the articles reviewed used "cherry" as main category. 4 Articles commonly used a separate "spice" category 11,12,37,40 ; two articles used a "seasonings" category for flavors such as cinnamon and pepper. ...
... "Dessert" has been mentioned as a separate category in Table 1, 38 or together with "bakery", 6 "sweets", 27 "candy", 11,12 or "food/spice". 43 Dessert-like flavors were also classified as "cream." 39,44 Similarly, while "sweet" is a separate category in seven studies, 3,5,39,41,44,45,48 some studies classified sweet flavors together with "dessert" 27 or "chocolate". ...
... Coffee-flavored e-liquids were classified within a separate category for "coffee/tea," 27 or within a "beverages," 39,44,45 or "food/ dessert/spice" category. 43 Vanilla-flavored e-liquids were classified within a broad range of categories, such as "candy or dessert," 12 "candy," 36 "food/dessert/spice," 43 "cream," 39,44 "sweet," 45 and "dessert/sweets." 27 Even though not consistently classified, vanilla seems a popular e-liquid flavor as it is mentioned as an example of three of the unspecified categories for other flavors as well. ...
Introduction:
E-liquids are available in a high variety of flavors. A systematic classification of e-liquid flavors is necessary to increase comparability of research results. In the food, alcohol and fragrance industry, flavors are classified using flavor wheels. We systematically reviewed literature on flavors related to e-cigarette use, to investigate how e-liquid flavors have been classified in research, and propose an e-liquid flavor wheel to classify e-liquids based on marketing descriptions.
Methods:
The search was conducted in May 2017 using PubMed and Embase databases. Keywords included terms associated with e-cigarettes, flavors, liking, learning, and wanting in articles. Results were independently screened and reviewed. Flavor categories used in the articles reviewed were extracted.
Results:
Searches yielded 386 unique articles of which 28 were included. Forty-three main flavor categories were reported in these articles (e.g., tobacco, menthol, mint, fruit, bakery/dessert, alcohol, nuts, spice, candy, coffee/tea, beverages, chocolate, sweet flavors, vanilla, unflavored). Flavor classifications of e-liquids in literature showed similarities and differences across studies. Our proposed e-liquid flavor wheel contains 13 main categories and 90 subcategories, which summarize flavor categories from literature to find a shared vocabulary. For classification of e-liquids using our flavor wheel, marketing descriptions should be used.
Conclusions:
We have proposed a flavor wheel for classification of e-liquids. Further research is needed to test the flavor wheels' empirical value. Consistently classifying e-liquid flavors using our flavor wheel in research (e.g., experimental, marketing, or qualitative studies) minimizes interpretation differences and increases comparability of results.
Implications:
We reviewed e-liquid flavors and flavor categories used in research. A large variation in the naming of flavor categories was found and e-liquid flavors were not consistently classified. We developed an e-liquid flavor wheel and provided a guideline for systematic classification of e-liquids based on marketing descriptions. Our flavor wheel summarizes e-liquid flavors and categories used in literature in order to create a shared vocabulary. Applying our flavor wheel in research on e-liquids will improve data interpretation, increase comparability across studies, and support policy makers in developing rules for regulation of e-liquid flavors.
... A total of thirteen studies described adults' preference for flavor [13,15,22,24,27,36,49,54,56,[60][61][62][63]. Two studies of adults using a concept mapping approach found that the variety of e-cigarette flavors was one reason they used e-cigarettes, and flavors may enhance the experience of e-cigarette use, respectively [62,63]. ...
... A total of thirteen studies described adults' preference for flavor [13,15,22,24,27,36,49,54,56,[60][61][62][63]. Two studies of adults using a concept mapping approach found that the variety of e-cigarette flavors was one reason they used e-cigarettes, and flavors may enhance the experience of e-cigarette use, respectively [62,63]. A study of 33 countries mostly on exand current smokers showed that the most popular (or preferred) e-cigarette flavors in descending order were tobacco, fruit, and menthol [24]. ...
... For example, in one study the age range is 18-30-years-old, and we considered it as a young adult cohort (18-24-years-old) [11]. Also, another study reported a mean age of 35 [63], and we placed it in the adult cohort (more than 25 years old). Finally, this study was restricted to peer-reviewed articles available in English, and most of them focused only on the United States (53 out of 66 studies), which limits the external validity of this research. ...
Objective:
Systematic review of research examining consumer preference for the main electronic cigarette (e-cigarette) attributes namely flavor, nicotine strength, and type.
Method:
A systematic search of peer-reviewed articles resulted in a pool of 12,933 articles. We included only articles that meet all the selection criteria: (1) peer-reviewed, (2) written in English, and (3) addressed consumer preference for one or more of the e-cigarette attributes including flavor, strength, and type.
Results:
66 articles met the inclusion criteria for this review. Consumers preferred flavored e-cigarettes, and such preference varied with age groups and smoking status. We also found that several flavors were associated with decreased harm perception while tobacco flavor was associated with increased harm perception. In addition, some flavor chemicals and sweeteners used in e-cigarettes could be of toxicological concern. Finally, consumer preference for nicotine strength and types depended on smoking status, e-cigarette use history, and gender.
Conclusion:
Adolescents could consider flavor the most important factor trying e-cigarettes and were more likely to initiate vaping through flavored e-cigarettes. Young adults overall preferred sweet, menthol, and cherry flavors, while non-smokers in particular preferred coffee and menthol flavors. Adults in general also preferred sweet flavors (though smokers like tobacco flavor the most) and disliked flavors that elicit bitterness or harshness. In terms of whether flavored e-cigarettes assisted quitting smoking, we found inconclusive evidence. E-cigarette users likely initiated use with a cigarette like product and transitioned to an advanced system with more features. Non-smokers and inexperienced e-cigarettes users tended to prefer no nicotine or low nicotine e-cigarettes while smokers and experienced e-cigarettes users preferred medium and high nicotine e-cigarettes. Weak evidence exists regarding a positive interaction between menthol flavor and nicotine strength.
... Methods that allow for in-depth examination of ECIG use behaviors where users can describe their own experiences are needed to understand the association between ECIG use and cigarette smoking cessation or reduction. Concept mapping (CM; Kane & Trochim, 2007;Trochim, 1989), a mixed-method participatory approach, is such a method that has been used previously to examine ECIG use behaviors (Soule et al., 2016a(Soule et al., , 2016b(Soule et al., , 2016c(Soule et al., , 2017. Importantly, this method allows individuals with firsthand knowledge on a topic (i.e., experienced ECIG users who selfreport having decreased cigarette smoking by using ECIGs) to generate, organize, and rate importance of content related the research topic. ...
... Each participant completed the brainstorming task individually, however, statements entered by previous participants were visible. Each participant was instructed to review the list of statements and attempt to avoid duplicating content that had been submitted previously (as in Soule et al., 2016aSoule et al., , 2016bSoule et al., , 2016cSoule et al., , 2017Trochim et al., 2003). The brainstorming task was closed after content saturation was reached, that is, when enrolling additional participants no longer resulted in new/unique statement content. ...
... Rating-After sorting, participants completed the rating task: all statements were presented in a list and participants rated each statement based on a prompt: "This is a way that I have used electronic cigarettes or an aspect of electronic cigarettes that has helped me reduce my cigarette smoking." with a seven point semantic differential response option scale (as in Soule et al., 2016aSoule et al., , 2016bSoule et al., , 2016cSoule et al., , 2017 with anchors at 1 (Definitely NOT true for me) and 7 (Definitely true for me). Participants received a $10 e-gift card for completing the rating task. ...
Background:
There is limited evidence on how cigarette smokers use electronic cigarettes (ECIGs) for smoking cessation and reduction. This study used concept mapping, a participatory mixed-methods research approach, to identify ECIG use behaviors and device characteristics perceived to be associated with cigarette smoking cessation or reduction.
Methods:
Current ECIG users aged 18-64 were recruited from seven cities selected randomly from U.S. census tract regions. Participants were invited to complete concept mapping tasks: brainstorming, sorting and rating (n=72). During brainstorming, participants generated statements in response to a focus prompt ("A SPECIFIC WAY I HAVE USED electronic cigarettes to reduce my cigarette smoking or a SPECIFIC WAY electronic cigarettes help me reduce my cigarette smoking is…") and then sorted and rated the statements. Multidimensional scaling and hierarchical cluster analyses were used to generate a cluster map that was interpreted by the research team.
Results:
Eight thematic clusters were identified: Convenience, Perceived Health Effects, Ease of Use, Versatility and Variety, Advantages of ECIGs over Cigarettes, Cigarette Substitutability, Reducing Harms to Self and Others, and Social Benefits. Participants generated several statements that related to specific behavioral strategies used when using ECIGs for smoking reduction/complete switching behaviors such as making rapid transitions from smoking to ECIG use or using certain ECIG liquids or devices. Former smokers rated the Perceived Health Effects cluster and several behavioral strategy statements higher than current smokers.
Conclusions:
These results help to identify ECIG use behaviors and characteristics perceived by ECIG users to aid in cigarette smoking cessation or reduction.
... 1 2 ENDS are now the leading tobacco product among young people in the USA. 3 4 Young people are particularly drawn to ENDS use due to the novelty of the devices, nicotine buzz, flavours, targeted industry marketing and the perception of their safety. [5][6][7] ENDS have their own health risk profile including emitting toxic substances, prompting nicotine dependence and increasing the risk of initiating CC product use. 8 9 Nicotine exposure has also been found to interfere with healthy brain development among youth, and its influence can remain until the mid-20s. ...
... We conducted quality appraisal using the Measurement Tool to Assess Systematic Reviews. 22 A score between 0 and 11 was calculated based on this tool, and the quality of the review was determined low (0-4), medium (5)(6)(7)(8) or high (9-11). 23 ...
Objectives
This umbrella review aims to summarise the evidence about electronic nicotine delivery systems’ (ENDS) risk and safety health profile to inform ENDS health communication strategies.
Data sources and study selection
Six databases were searched for systematic reviews presenting evidence on ENDS-related health effects. Ninety reviews divided into five categories were included: toxicity=20, health effects=40, role in smoking cessation=24, role in transition to combustible cigarettes (CCs)=13 and industry marketing claims=4.
Data extraction
Findings were synthesised in narrative summaries. Meta-analyses were conducted by study type when appropriate. Quality assessment was conducted using the Measurement Tool to Assess Systematic Reviews. The Institute of Medicine’s Levels of Evidence Framework was used to classify the evidence into high-level, moderate, limited-suggestive and limited-not-conclusive.
Data synthesis
We found high-level evidence that ENDS exposes users to toxic substances; increases the risk of respiratory disease; leads to nicotine dependence; causes serious injuries due to explosion or poisoning; increases smoking cessation in clinical trials but not in observational studies; increases CC initiation; and exposure to ENDS marketing increases its use/intention to use. Evidence was moderate for ENDS association with mental health and substance use, limited-suggestive for cardiovascular, and limited-not-conclusive for cancer, ear, ocular and oral diseases, and pregnancy outcomes.
Conclusions
As evidence is accumulating, ENDS communication can focus on high-level evidence on ENDS association with toxicity, nicotine addiction, respiratory disease, ENDS-specific harm (explosion, poisoning) and anti-ENDS industry sentiment. Direct comparison between the harm of CCs and ENDS should be avoided.
PROSPERO registration number
CRD42021241630.
... Table 9. Proportion of dual users before and after using ECs by cigarette ?tar" bands, n (%). (11). Flavor was grouped into four categories: food/desserts/spices (36.8%), fruit (36.0%), tobacco or menthol (14.9%), and others or a combination of flavors (12.3%). ...
... Users have identified ECs as a means to have access to vaping at any time, with an added benefit of limitless flavors (12). A survey of 46 traditional cigarette users found that approximately three out of four people surveyed admitted to use ECs on all 30 days of the month past (11). The data suggested that the most important reasons to start using ECs were to reduce or completely quit smoking (74.8%) and to reduce the exposure of family members to second-hand smoke. ...
The use of electronic cigarettes (ECs) has grown exponentially over the past few years in China. To obtain the basic information of Chinese EC users, a questionnaire survey was performed to collect the data that describe characteristics of study populations, including daily usage, consumption preference, and risk perception. Volunteers were recruited from Beijing, Shanghai, Guangzhou, and Shenzhen cities of China. In total, among the 511 participants that were included in the analysis, 491 participants (95%) used refillable ECs in the past 3 months. There was a strong association between EC use and traditional cigarette smoking. The majority of participants were dual users and the number of cigarettes smoked decreased with the use of ECs. After using an EC, 20.7% of conventional cigarette smokers attempted to quit smoking. Young people were the primary users across all geographic locations. Specifically, the daily usage for the participants who were 18–39 years old, was higher than those over 40 years old. The majority of participants (59.9%) preferred fruit flavors and 57.8% of them used 1–5 mg/mL nicotine-concentration liquids. Most EC users are motived to quit smoking, and 74.6% claimed that the ECs had no irritant effect on the oral cavity. A total of 50.5% of family members of the study participants reported an improvement of health status while the participants used ECs instead of traditional cigarettes. Overall, the results of this Chinese survey indicate that the per-day cigarette consumption of the dual users decreased whereas their proportion of smokers of low-“tar” cigarettes increased.
... The number of surrounding vape shops (i.e., density), for example, could influence descriptive social norms directly, and injunctive norms indirectly (Agaku et al., 2019(Agaku et al., , 2020Tversky and Kahneman, 1975;Carroll, 1978;Clore, 1992). Seeing many vape shops spring up in their neighborhood in a relatively short period could distort the perception of the true extent of e-cigarette uptake, possibly leading to overestimation of e-cigarette use prevalence (Agaku et al., 2020;Soule et al., 2016). The number of vape shops could also influence injunctive norms through habituation (dampening of negative perceptions) and positive reinforcement (heightening of positive perceptions). ...
... For example, young adults constantly exposed to e-cigarette aerosol by virtue of the number of vape shops in their neighborhood, or who constantly see others vaping in public areas, may begin to have altered perceptions of the harmfulness of secondhand aerosol exposure (Agaku et al., 2020). At the same time, seeing e-cigarettes being advertised with attractive flavors may reinforce the perceptions of harmlessness, especially if these are characterizing flavors associated with food, drinks, or other nutritious substances (Soule et al., 2016). For example, in our study, 44.5% of those who perceived that e-cigarettes "Taste better than burning tobacco products" had never used an e-cigarette in their lifetime, suggesting that such perceptions may be instilled from environmental cues from advertisements. ...
We estimated the spatial distribution of e-cigarette vape shops in South Africa and measured associations with tobacco use among adults. We linked geocoordinates of identified vape shops to internet protocol addresses of individual participants in the 2018 Health 24 survey (n = 18,208). We used logistic regression to measure the associations between proximity to vape shops and tobacco-related behaviors. In total, we identified 240 vape shops; 49.6% of these were within a 5 km radius of a higher educational institution. Proximity to vape shops was associated with ever e-cigarette use among young adults aged 18–29 years (AOR = 1.33, 95%CI = 1.16–1.54). Efforts to regulate e-cigarette marketing can benefit public health.
... Obese smokers [3], especially women [35], have reported using cigarette smoking for weight control. Electronic cigarettes (e-cigarettes) are also marketed [36] and perceived as safer for weight/appetite control than tobacco cigarettes [37,38]. E-cigarettes allow the inhalation of vaporized vegetable glycerol-or propylene glycol-containing fluids (e-liquids/e-juices) that vary in nicotine concentrations and flavorings. ...
... E-cigarettes allow the inhalation of vaporized vegetable glycerol-or propylene glycol-containing fluids (e-liquids/e-juices) that vary in nicotine concentrations and flavorings. Sweet e-juice flavors are the most popular [39], increasing the liking [40], reward and reinforcement values of e-cigarettes [41], and ability to enjoy vaping flavors that mimic sweets without ingesting calories [38]. These factors may have contributed to the substantial increase in e-cigarette usage, with global sales totaling $3.5 billion USD in 2015 [42] and may surpass $20 billion USD by 2025 [43]. ...
Chronic smokers have a greater risk for altered chemosensation, unhealthy dietary patterns, and excessive adiposity. In an observational study of chronic smokers, we modeled relationships between chemosensation, fat/carbohydrate liking, smoking-associated dietary behaviors, and body mass index (BMI). Also tested in the model was liking for sweet electronic cigarette juice (e-juice). Smokers (n = 135, 37 ± 11 years) were measured for: Taste genetics (intensity of 6-n-propylthiouracil—PROP); taste (NaCl and quinine intensities) and olfactory (odor identification) function; liking for cherry e-juice; and weight/height to calculate BMI. Smokers survey-reported their food liking and use of smoking for appetite/weight control. Structural equation models tested direct and indirect relationships between chemosensation, fat/carbohydrate liking, dietary behaviors, and BMI. In good-fitting models, taste intensity was linked to BMI variation through fat/carbohydrate liking (greater PROP intensity→greater NaCl intensity→greater food liking→higher BMI). Olfactory function tended to predict sweet e-juice liking, which, in turn, partially mediated the food liking and BMI association. The path between smoking-associated dietary behaviors and BMI was direct and independent of chemosensation or liking. These findings indicate that taste associates with BMI in chronic smokers through liking of fats/carbohydrates. Future research should determine if vaping sweet e-juice could improve diet quality and adiposity for smokers.
... However, some research indicates much smaller proportions of e-cigarette advertisements are now endorsing these devices as quit aids [37,42], and cited reasons for use by vapers have significantly shifted away from smoking cessation (43.00%, 1247/2900 in 2012 vs 29.00%, 841/2900 in 2015) toward use to increase social image (21.00%, 609/2900 in 2012 vs 37.00%, 1073/2900 in 2015) [17]. Of concern is that these results suggest that e-cigarette uptake is not solely driven by a desire among smokers to quit smoking [64]. ...
... The use and depiction of vaping for recreation raises questions about the promotion of these devices as a hobby or socializing opportunity [64]. As such, it may be valuable to investigate the degree to which the vaping industry is targeting nonsmoking youth who may have an interest in vaping for enjoyment or as a hobby rather than a smoking cessation tool [37,93]. ...
Background:
There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long-term health consequences. As smoking rates continue to drop or plateau in many well-developed countries, transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence indicates e-cigarettes are being marketed on social media as a harm reduction alternative, with retailers and manufacturers utilizing marketing techniques historically used by the tobacco industry.
Objective:
This study aimed to identify and describe the messages presented in e-cigarette-related social media (Twitter, YouTube, Instagram, and Pinterest) promotions and discussions and identify future directions for research, surveillance, and regulation.
Methods:
Data sources included MEDLINE, Scopus, ProQuest, Informit, the Journal of Medical Internet Research, and Google Scholar. Included studies were published in English between 2007 and 2017, analyzed content captured from e-cigarette-related social media promotions or discussions, and reported results for e-cigarettes separately from other forms of tobacco and nicotine delivery. Database search ceased in October 2017. Initial searches identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full-text articles to determine eligibility and identified 25 studies for inclusion. This process was undertaken with the assistance of the Web-based screening and data extraction tool-Covidence. The review was registered with the Joanna Briggs Institute (JBI) Systematic Reviews database and followed the methodology for JBI Scoping Reviews.
Results:
Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavoring and highlighting the public performance of vaping. Discussion and promotion of these devices appear to be predominantly occurring among the general public and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media.
Conclusions:
The social media landscape is dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly, real-time monitoring and surveillance of how these devices are discussed, promoted, and used on social media is necessary in conjunction with evidence published in academic journals.
... However, some research indicates much smaller proportions of e-cigarette advertisements are now endorsing these devices as quit aids [37,42], and cited reasons for use by vapers have significantly shifted away from smoking cessation (43.00%, 1247/2900 in 2012 vs 29.00%, 841/2900 in 2015) toward use to increase social image (21.00%, 609/2900 in 2012 vs 37.00%, 1073/2900 in 2015) [17]. Of concern is that these results suggest that e-cigarette uptake is not solely driven by a desire among smokers to quit smoking [64]. ...
... The use and depiction of vaping for recreation raises questions about the promotion of these devices as a hobby or socializing opportunity [64]. As such, it may be valuable to investigate the degree to which the vaping industry is targeting nonsmoking youth who may have an interest in vaping for enjoyment or as a hobby rather than a smoking cessation tool [37,93]. ...
BACKGROUND
There has been a rapid rise in the popularity of electronic cigarettes (e-cigarettes) over the last decade, with growth predicted to continue. The uptake of these devices has escalated despite inconclusive evidence of their efficacy as a smoking cessation device and unknown long term health consequences. As tobacco smoking rates continue to drop or plateau in many well developed countries transnational tobacco companies have transitioned into the vaping industry and are now using social media to promote their products. Evidence suggests that e-cigarettes are being marketed on social media as a harm reduction alternative with retailers and manufactures utilising marketing techniques historically used by the tobacco industry.
OBJECTIVE
To identify and describe the messages presented in e-cigarette related social media (Twitter, YouTube, Instagram and Pinterest) promotions and discussions, and identify future directions for research, surveillance and regulation.
METHODS
Data sources included Medline, Scopus, ProQuest, Informit, Journal of Medical Internet Research and Google Scholar. Studies must have been published in English between 2007 and 2017, analyse content captured from e-cigarette related social media promotions or discussions, and report results for e-cigarettes separately to other forms of tobacco and nicotine delivery. Database searching ceased October 2017. Initial searching identified 536 studies. Two reviewers screened studies by title and abstract. One reviewer examined 71 full texts to determine eligibly and identified 25 studies for inclusion. This process was undertaken with the assistance of the online screening and data extraction tool - Covidence. The review was registered with The Joanna Briggs Institute Systematic Reviews database and followed the methodology for JBI Scoping Reviews.
RESULTS
Several key messages are being used to promote e-cigarettes including as a safer alternative to cigarettes, efficacy as a smoking cessation aid, and for use where smoking is prohibited. Other major marketing efforts aimed at capturing a larger market involve promotion of innovative flavouring and highlighting the public performance of vaping. Discussion and promotion of these devices appears to be predominantly occurring among everyday people and those with vested interests such as retailers and manufacturers. There is a noticeable silence from the public health and government sector in these discussions on social media.
CONCLUSIONS
The social media landscape is being dominated by pro-vaping messages disseminated by the vaping industry and vaping proponents. The uncertainty surrounding e-cigarette regulation expressed within the public health field appears not to be reflected in ongoing social media dialogues, and highlights the need for public health professionals to interact with the public to actively influence social media conversations and create a more balanced discussion. With the vaping industry changing so rapidly real time monitoring and surveillance of how these devices are discussed, promoted, and reportedly used on social media is necessary in conjunction with evidence published in academic journals.
... The availability of various flavoured electronic cigarettes is enticing to both new consumers and established users. [1][2][3][4][5] Flavour additives in e-cigarettes have been shown to reduce the perceived harshness of nicotine, which may facilitate increased inhalation, increased nicotine delivery and increased appeal, and ultimately promote experimentation among youth. [6][7][8][9][10][11][12][13] The US Food and Drug Administration (FDA) has expressed concern that certain flavoured e-cigarettes (eg, JUUL) are appealing to youth who may be unaware of the products' addictiveness and otherwise may have never tried a nicotine product. ...
Significance:
Reducing youth e-cigarette use is a New York State (NYS) public health priority. In May 2020, a state-wide restriction on flavoured e-cigarettes, except tobacco flavour, was passed. This study examines changes in nicotine product use behaviour among youth around the time of the state-wide vaping flavour restriction.
Methods:
NYS data from the US International Tobacco Control Policy Evaluation Project Youth Tobacco and E-cigarette Tobacco and Vaping Survey were analysed cross-sectionally from February 2020 (n=955), August 2020 (n=946), February 2021 (n=1030) and August 2021 (n=753). Online surveys were conducted among youth 16-19 years. Weighted descriptive statistics and regression models were used to describe changes in nicotine product use behaviour. Models were adjusted for age, sex, race/ethnicity and perceived family socioeconomic status.
Results:
Significant decreases in past 30-day e-cigarette use (20%-11%), cigarette (7%-4%), and dual use of e-cigarettes and cigarettes (5%-2%) were observed over the 2-year period in NYS. Over 95% of vapers still reported using a non-tobacco-flavoured e-cigarette following the restriction, with fruit-flavoured being the most popular at each time point.
Conclusions:
Nearly all NYS youth continued to vape flavours that were restricted in NYS. While youth past 30-day vaping prevalence decreased significantly from 2020 to 2021, increased flavour restriction compliance could result in an even greater decrease. Continuous monitoring is important to better understand perceptions, use patterns and access at the individual level, retail level and population level to inform future enforcement and restrictions.
... In 2016, Berg reported fruit flavors were preferred among current eCig users, but flavor preferences varied among never, current, and former smokers (Berg, 2016). Soule et al. (2016) used concept mapping to explore reasons for using flavored e-liquids; reasons identified by participants included increased satisfaction/enjoyment, better feel/taste than cigarettes, variety/customization, food craving suppression, and social impacts. Laboratory data in young smokers suggest flavored eCigs have greater subjective reward and reinforcing value, relative to unflavored eCigs, which may increase abuse liability (Audrain-McGovern et al., 2016). ...
Thousands start smoking or vaping daily, despite long-standing efforts by public health authorities to curb initiation and use of nicotine containing products. Over the last 15 years, use of electronic nicotine delivery systems has increased dramatically, with a diverse range of products on the market, including pod-based, disposable, and refillable electronic cigarettes (eCigs). Originally intended for harm reduction and smoking cessation, eCigs may encourage nicotine use among never smokers, given the vast range of appealing flavors that are available. To better understand abuse liability and to facilitate appropriate regulations, it is crucial to understand the science of flavor, and flavor perception within the context of eCig use. Here, we (a) provide a brief primer on chemosensory perception and flavor science for addiction and nicotine researchers, and (b) highlight existing some literature regarding flavor and nicotine use, with specific attention given to individual differences in perception, and interaction between different sensory modalities that contribute to flavor. Dramatic increases in use of eCigs highlights the importance of flavor science in contemporary addiction research, both with regards to public health and regulatory efforts. Other recent work summarizes findings on flavored e-liquids and eCig use, but none have focused explicitly on chemosensory processes or flavor perception as they relate to appeal and use of such products. We argue flavor science needs to be considered as perceptual and behavioral phenomena, and not merely from analytical, toxicological and pharmacological perspectives; we help address this gap here.
... Reports show that appealing flavours are one of the principal reasons for e-cigarette use amongst adolescents and young adults [59,61,62]. Flavourings may make the use of e-cigarettes more desirable and enjoyable [63], especially if sweet-flavoured. Users are more likely to use again and place perceived monetary value on sweet-flavoured versus non-sweet or unflavoured e-cigarettes [59,64]. ...
Since commercial development in 2003, the usage of modern electronic cigarette (e-cigarette) continues to increase amongst people who have never smoked, ex-smokers who have switched to e-cigarettes, and dual-users of both conventional cigarettes and e-cigarettes. With such an increase in use, knowledge of the irritative, toxic and potential carcinogenic effects on the lungs is increasing. This review article will discuss the background of e-cigarettes, vaping devices and explore their popularity. We will further summarise the available literature describing the mechanism of lung injury caused by e-cigarette or vaping use.
... The notion that EC are a harm-reducing alternative to smoking resonates with CC smokers (7). Additionally, some CC smokers prefer the experience of using EC compared to CC, and many find EC more appealing than available cessation pharmacotherapies (14). ...
Smoking remains the leading preventable cause of death and disease in the US. While e-cigarettes (EC) are undeniably harmful when used by adolescents and nonsmokers, the perpetuation of the increasing negative perceptions of EC and widespread false belief that EC are equal or more harmful than combustible cigarettes (CC) represents a significant missed public health opportunity. EC have great potential to serve as a mechanism for smoking harm reduction among hard-to-treat populations of smokers who have failed to quit with currently available treatments. In this paper, we outline why we need to overcome the hostile EC research environment to explore the potential use of EC as a harm-reduction strategy in hard-to-treat populations.
... Also, oral menthol, which did not alter intravenous nicotine administration, reversed oral nicotine aversion (50 and 100 mg/L) in a two-bottle choice test . At the clinical level, studies on e-cigarettes suggest a significant increase of tobacco products palatability by flavors threw masking nicotine's bitter taste and modification of harm perception (Soule, Lopez, Guy, & Cobb, 2016). In order to obtain an addictive effect of nicotine, the reinforcing effect of the drug must be more important than its aversive taste . ...
Les produits du tabac sont hautement addictifs et leur abus est un problème majeur de santé publique. Chez les humains, cette addiction met en jeu une expérience consommatoire orale avec des composantes sensorielles gustatives et olfactives. De nos jours, le rôle de ces composantes est amplifié avec l’utilisation accrue des produits du tabac non-brûlé, mais aussi les cigarettes électroniques, où la nicotine est associée à des additifs incluant flaveurs et sucres. L’impact des additifs sur le comportement de consommation du tabac doit donc être évalué. Dans ce travail de recherche, notre intérêt se porte sur la nicotine orale et l’interaction bidirectionnelle avec les flaveurs associées. Nous questionnons notamment les propriétés de renforcement secondaire, les effets des arômes sur la palatabilité de la nicotine et son encodage affectif. Dans un premier chapitre, nous avons investigué les propriétés irritantes de la nicotine dans un modèle d’auto-administration orale de nicotine diluée dans de la saccharine chez des souris génétiquement modifiées (knockout) pour le thermorécepteur TRPV1 (Transient receptor potential vanilloid 1), impliqué dans l’échauffement lié au tabagisme et qui a la particularité d’être sensibilisé par la nicotine. Nous mettons en évidence que l’absence de ce récepteur promeut la consommation de nicotine par diminution de son aversion orale. Il n’a cependant pas un rôle spécifique dans les mécanismes de motivation et de rechute. Il a été montré que les stimuli sensoriels non-pharmacologiques deviennent plus salients quand ils sont associés à la nicotine. Ainsi, nous étudions dans un deuxième chapitre, le renforcement secondaire putatif des stimuli oraux par la nicotine. Nous mettons en évidence la nécessité d’association orale de la nicotine à des additifs masquant son goût amer, afin de permettre sa consommation volontaire et la modélisation des différents stades du processus addictif. Ce processus se montre sensible aux stimuli dans la consommation et la rechute, mais insensible aux challenges pharmacologiques malgré l’absorption de nicotine mesurée par la présence de cotinine plasmatique. Les solutions de nicotine à fortes concentrations révèlent des propriétés aversives et réduisent la consommation volontaire. Bien que nous ne montrions pas le renforcement des propriétés incitatives de la vanille par la nicotine, de façon surprenante nous montrons que l’arôme seul peut renforcer le comportement d’auto-administration. Enfin, du fait de l’importance des effets sensoriels oraux dans la consommation de nicotine, nous avons étudié ses propriétés de palatabilité. Les tests de réactivité gustative montrent bien l’aversion gustative pour la nicotine seule et l’amélioration de la palatabilité par l’ajout d’additif aromatique. Ce changement de la palatabilité ne s’est néanmoins pas traduit par des changements du codage neuronal mesuré par le marquage de la protéine c-Fos dans les structures contribuant à l’expression de la valence positive ou négative, notamment le noyau accumbens, le cortex insulaire gustatif, le noyau basolatéral de l’amygdale, l’habenula et la noyau paraventriculaire du thalamus. En revanche, la nicotine, aromatisée ou non, a augmenté l’activation neuronale dans toutes ces structures. L’ensemble de ces résultats met en lumière cette problématique d’association de la nicotine aux additifs pouvant moduler sa perception sensorielle et promouvoir par la suite sa consommation. L’attractivité des nouveaux produits du tabac et leur potentiel d’abus est une question authentique et un problème de santé publique dont l’étude et la régulation sont urgentes.
... Claims that EC are a harm-reducing alternative to smoking resonate among current smokers [61][62][63][64]. In addition, smokers often prefer the experience of using EC compared to CC [65], and there are indications that many smokers find EC more appealing than other smoking cessation aids (such as NRT) [9][10][11]. This preference indicates the population reach and impact of EC could prove greater than traditional pharmacotherapies. ...
Background
Smoking cessation is the most effective means of slowing the decline of lung function associated with chronic obstructive pulmonary disease (COPD). While effective smoking cessation treatments are available, they are underutilized and nearly half of people with COPD continue to smoke. By addressing both nicotine and behavioral dependence, electronic cigarettes (EC) could help people with COPD reduce the harm of combustible cigarettes (CC) through reductions in number of Cigarettes per Day (CPD) or quitting CC completely. The purpose of this pilot study is to identify barriers and facilitators to the use of and assess the preliminary effectiveness of EC as a harm reduction strategy among people with COPD.
Methods
In an open-label two-arm randomized controlled trial pilot study, 60 patients identified as smokers with a COPD diagnosis via electronic health records from a large urban health center are randomized in a 1:1 ratio to either standard care [counseling + nicotine replacement therapy (NRT)] or counseling + EC. The NRT arm will receive nicotine patches and nicotine lozenges for 12 weeks. The EC arm will receive EC for 12 weeks. Both cohorts will receive counseling from a licensed mental health counselor. Using ecological momentary assessment, participants will report their use of CC in both arms and EC use in the EC arm daily via text message. Primary outcomes will be feasibility and acceptability of intervention, and secondary outcomes will be reduction in CPD and change in COPD symptoms as measured by COPD Assessment Tool (CAT) score at 12-weeks. EC displacement of CC. To explore attitudes towards the use of EC as a harm-reduction strategy for patients with COPD, interviews will be performed with a sample of participants from both study arms.
Discussion
Despite decades of availability of smoking cessation medications, nearly half of people with COPD still smoke. This study aims to address the unmet need for feasible and effective strategies for reducing CC use among those with COPD, which has the potential to significantly improve the health of people with COPD who smoke.
Trial Registration ClinicalTrials.gov Identifier: NCT04465318.
... additives are sufficient to drive and maintain consumption of a nicotine-free solution. At the clinical level, while e-cig has been proposed for tobacco abstinence control, increasing body of evidence indicates that the numerous available flavor additives present in e-liquids enhance vape products palatability and attractiveness for new and non-smokers (Soule et al. 2016). ...
Rationale
Tobacco products are very addictive, partly because they contain nicotine which is reinforcing, but also because they include appealing aromas and tastes. Flavor additives are such sensory stimuli which enhance attractiveness, as well as use and abuse of tobacco and vaping products. Yet, the interaction between these flavor additives and nicotine remains poorly understood.
Objectives
We want to understand how flavors may reduce nicotine’ aversive taste and how it may enhance its voluntary oral self-administration in mice.
Methods
We first studied the effect of flavor additives on nicotine solution palatability in a free bottle choice paradigm. Second, we investigated the effect of vanilla flavoring on the different stages of nicotine (40 μg/ml) oral self-administration in mice.
Results
We show that adding flavors increase nicotine palatability and facilitate acquisition and maintenance of oral self-administration when compared to nicotine-alone group. Mice adapt their operant behavior depending on changes in nicotine concentration. All mice reinstate nicotine seeking upon presentation of associated cues. Nevertheless, vanilla-flavored nicotine was not more reinforcing than vanilla-flavored water which was reinforcing enough to drive similar operant response rates.
Conclusions
Flavor additives increase nicotine oral consumption and help maintaining operant behavior in mice. Moreover, flavors can be very attractive and can have high reinforcing value by themselves. Thus, it is crucial that the investigation on how taste signals play an important role in modulating oral nicotine intake in rodent models remains explored.
... Trace levels of ethanol and water are added to e-liquids to enhance the experience for a variety of flavorings that are a major selling point of all ENDS (Berg, 2016). The presence of flavorings may add to the addictive effects of e-cigarettes (Soule, Lopez, Guy, & Cobb, 2016). For example, both vanillin and ethylvanillin have been shown to be monoamine oxidase inhibitors, which are substances present in tobacco smoke that enhance smokers' addiction to nicotine by delaying the catalytic degradation of neurotransmitters by monoamine oxidase enzymes (Truman, Stanfill, Heydari, Silver, & Fowles, 2019). ...
Electronic cigarettes (e-cigarettes) were introduced in the United States in 2007 and by 2014 they were the most popular tobacco product amongst youth and had overtaken use of regular tobacco cigarettes. E-cigarettes are used to aerosolize a liquid (e-liquid) that the user inhales. Flavorings in e-liquids is a primary reason for youth to initiate use of e-cigarettes. Evidence is growing in the scientific literature that inhalation of some flavorings is not without risk of harm. In this review, 67 original articles (primarily cellular in vitro) on the toxicity of flavored e-liquids were identified in the PubMed and Scopus databases and evaluated critically. At least 65 individual flavoring ingredients in e-liquids or aerosols from e-cigarettes induced toxicity in the respiratory tract, cardiovascular and circulatory systems, skeletal system, and skin. Cinnamaldehyde was most frequently reported to be cytotoxic, followed by vanillin, menthol, ethyl maltol, ethyl vanillin, benzaldehyde and linalool. Additionally, modern e-cigarettes can be modified to aerosolize cannabis as dried plant material or a concentrated extract. The U.S. experienced an outbreak of lung injuries, termed e-cigarette, or vaping, product use-associated lung injury (EVALI) that began in 2019; among 2,022 hospitalized patients who had data on substance use (as of January 14, 2020), 82% reported using a delta-9-tetrahydrocannabinol (main psychoactive component in cannabis) containing e-cigarette, or vaping, product. Our literature search identified 33 articles related to EVALI. Vitamin E acetate, a diluent and thickening agent in cannabis-based products, was strongly linked to the EVALI outbreak in epidemiologic and laboratory studies; however, e-liquid chemistry is highly complex, and more than one mechanism of lung injury, ingredient, or thermal breakdown product may be responsible for toxicity. More research is needed, particularly with regard to e-cigarettes (generation, power settings, etc.), e-liquids (composition, bulk or vaped form), modeled systems (cell type, culture type, and dosimetry metrics), biological monitoring, secondhand exposures and contact with residues that contain nicotine and flavorings, and causative agents and mechanisms of EVALI toxicity.
... More than 80% of them use flavored e-cigs, with fruit and menthol flavor being the most preferred ones [5]. While this behavior can lead to tobacco smoking [6], recent data suggest youths also use e-cigs for reasons beyond nicotine [7][8][9][10]. E-cigs are promoted through social media, vape shops, and vaping events [11][12][13]. ...
Purpose of Review
Electronic cigarettes (e-cigs) are a source of metals. Epidemiologic and experimental evidence support that metals are toxic to the cardiovascular system. Little is known, however, about the role that e-cig metals may play as toxicants for the possible cardiovascular effects of e-cig use. The goal of this narrative review is to summarize the evidence on e-cig use and metal exposure and on e-cig use and cardiovascular toxicity and discuss the research needs.
Recent Findings
In vitro studies show cytotoxicity and increased oxidative stress in myocardial cells and vascular endothelial cells exposed to e-liquids and e-cig aerosols, with effects partially reversed with antioxidant treatment. There is some evidence that the heating coil plays a role in cell toxicity. Mice exposed to e-cigs for several weeks showed higher levels of oxidative stress, inflammation, platelet activation, and thrombogenesis. Cross-over clinical experiments show e-cig use alters nitric oxide–mediated flow-mediated dilation, endothelial progenitor cells, and arterial stiffness. Cross-sectional evidence from large nationally representative samples in the USA support that e-cig use is associated with self-reported myocardial infarction. Smaller studies found associations of e-cig use with higher oxidized low-density protein and heart variability compared to healthy controls. Numerous studies have measured elevated levels of toxic metals in e-cig aerosols including lead, nickel, chromium, and manganese. Arsenic has been measured in some e-liquids. Several of these metals are well known to be cardiotoxic.
Summary
Numerous studies show that e-cigs are a source of cardiotoxic metals. Experimental studies (in vitro, in vivo, and clinical studies) show acute toxicity of e-cigs to the vascular system. Studies of long-term toxicity in animals and humans are missing. Longitudinal studies with repeated measures of metal exposure and subclinical cardiovascular outcomes (e.g., coronary artery calcification) could contribute to determine the long-term cardiovascular effects of e-cigs and the potential role of metals in those effects.
... [12][13][14][15][16][17] It has been reported that flavored tobacco products are viewed as more favorable than unflavored products, as they increase satisfaction, create a better feel and taste, and allow consumers to customize their experience. [18][19][20] Previous studies have shown that young adult ENDS users (generally 18-30 years of age) are more attracted to sweet flavors (eg, fruit and candy). [21][22][23][24][25][26] Similar patterns can be seen among adult vapers, although more bitter flavors (eg, menthol/mint 27 and tobacco [12][13][14][15][16][17] ) are also common among adults, 28,29 especially smokers. ...
Objective: Banning flavors in some tobacco products, while allowing them in others, may shift consumer preferences towards products in which flavors are still allowed. In this study, we examine flavor popularity and inconsistencies in flavor preference across non-cigarette tobacco products among US adults. Methods: We used data from the Population Assessment of Tobacco and Health Study Wave 3 to assess the prevalence of flavor preference for users of non-cigarette tobacco products (N = 9037), as well as flavor inconsistencies between products among polyusers (N = 3183). Results: Most users of flavored tobacco products reported using one flavor category per product. Fruit and tobacco were among the most commonly used flavor categories of ENDS, hookah, traditional cigars, and cigarillo/filtered cigars. Menthol/mint was the most common flavor among snus/smokeless users. Polyusers of ENDS and traditional cigars had the largest inconsistency, where about 68%-76% used different flavors across products. Conversely, polyusers of traditional cigars and cigarillos/filtered cigars had the lowest inconsistency (25%-28%). Conclusions: Flavor preferences differed according to product, suggesting that consumers are not likely to switch across products to maintain a flavor preference. Future research should assess flavor preferences prospectively to improve understanding of the potential benefits of flavor bans.
... There are thousands of e-cigarette flavor products available on the market, each containing a variety of compounds that are effectively transferred via use of ENDS (Allen et al., 2016;DeVito et al., 2019;Tierney, Karpinski, Brown, Luo, & Pankow, 2016;Zhu et al., 2014). Many observational and epidemiological studies found that e-cigarette users, especially youth, prefer eliquids with flavors (Pesko, Kenkel, Wang, & Hughes, 2016;Soule, Lopez, Guy, & Cobb, 2016). ...
Menthol is the only available flavor in combusted tobacco cigarettes; however, e-cigarettes are available in thousands of flavors. Research on flavors and rewarding properties of nicotine is limited. The present study sought to examine the acute rewarding effects of flavors inhaled from an e-cigarette, in combination with intravenous (IV) nicotine among cigarette smokers. In the present study, 24 menthol-preferring young adult (aged 18 to 30) cigarette smokers were tested under 3 different e-cigarette flavor conditions (menthol, green apple, or menthol + green apple) in a within-subject cross-over design. During each test session, each participant received 3 IV infusions (saline, 0.25 mg/70 kg nicotine, 0.5 mg/70 kg nicotine) administered 1 hr apart. The main outcome measures assessed cardiovascular, subjective, and cognitive domains. Compared with green apple or green apple + menthol, menthol produced higher ratings of "cooling" (ps < 0.01). Craving was rated higher following administration of green apple and the combined menthol + apple flavor compared to menthol alone (ps < 0.05). As expected, IV-nicotine dose-dependently increased the ratings of subjective liking/disliking and peak heart rate, improved cognitive performance, and reduced smoking urges (all ps < 0.05). These subjective, cognitive, and physiological effects of nicotine were not affected by any flavor condition. The present findings did not support an interaction between IV-nicotine dose and inhaled flavor for acute effects of nicotine. Green apple flavor, alone or in combination with menthol, could result in higher craving or insufficiently alleviate craving, relative to menthol flavor alone. Additional research is warranted to examine extended exposure to inhaled flavors on the rewarding and addictive effects of nicotine. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... E-cigarettes have been characterized as providing less nicotine than combustible cigarettes [45][46][47][48] although this may be changing as e-cigarettes become more efficient nicotine delivery devices. 49 Further, evidence suggests that sensory features such as flavors might significantly motivate their use, [50][51][52][53][54] and in this sample liking the flavor was significantly positively related to all of the dependence measures. This suggests that the use of e-cigarettes might be more highly related to SDM than is the case for cigarettes (eg, motives such as using for taste or for social reasons). ...
Background:
Electronic cigarettes (e-cigarettes) have drastically changed the nicotine and tobacco product landscape. However, their potential public health impact is still unclear. A reliable and valid measure of e-cigarette dependence would likely advance assessment and prognostication of the public health impact of e-cigarettes. The aim of this research was to examine the internal consistency, structure, and validity of three e-cigarette dependence scales.
Methods:
Adult dual users (smokers who also vape, N = 256) enrolled in an observational cohort study (45.1% women, 70.7% white). At baseline, participants completed the e-cigarette Fagerström Test of Cigarette Dependence (e-FTCD), the e-cigarette Wisconsin Inventory of Smoking Dependence Motives (e-WISDM), and the Penn State Electronic Cigarette Dependence Index (PS-ECDI). All participants provided a urine sample for cotinine analysis and reported e-cigarette use at 1 year.
Results:
The e-WISDM subscales had the highest internal consistency (α = .81-.96), then the PS-ECDI (α = .74) and e-FTCD (α = .51). A single-factor structure for the e-FTCD and an 11-factor structure for the e-WISDM were supported, but the PS-ECDI did not have a single-factor structure. All three e-cigarette dependence scales were highly correlated with validation criteria including continued e-cigarette use at 1 year, but not with e-liquid nicotine concentration or cotinine.
Conclusions:
The e-WISDM and PS-ECDI had stronger internal consistency than did the e-FTCD, despite the e-FTCD's single-factor structure, but all 3 measures appear to be valid measures of e-cigarette dependence as suggested by their significant relations with self-perceived addiction, heavy use, early use after overnight deprivation, and continued use over time.
Implications:
This research provides empirical support for three e-cigarette dependence measures: the e-FTCD, the PS-ECDI, and the e-WISDM among dual users of e-cigarettes and combustible cigarettes. The PS-ECDI and e-WISDM are more reliable, but all three measures were strongly correlated with key dependence constructs such as heavy use and continued use over time.
... Ratings were made on a seven-point Likert-type scale with response anchors ranging from one (Definitely NOT true for me) to seven (Definitely TRUE for me). [17,18] In general, higher rated statements and clusters are "more true" for participants and may suggest these statements and clusters have more importance in promoting e-cigarette to cigarette transition. Rating data were monitored by investigators to ensure they were complete (i.e., ! ...
Purpose:
Longitudinal studies indicate that e-cigarette use among youth and young adults is associated with cigarette smoking initiation. The purpose of this study was to identify reasons why nonsmoking young adults transition from e-cigarette use to cigarette smoking.
Methods:
The study used concept mapping (CM), a mixed-method participatory approach. Fifty-five college students who endorsed initiation of e-cigarettes before cigarettes (lifetime e-cigarette uses ≥ 100 and ≥ 100 cigarettes in lifetime) completed at least one part of the study. In an online program, participants brainstormed (n = 54) statements describing reasons for transition from e-cigarette use to cigarette smoking, sorted statements (n = 46) into conceptually similar categories, and rated (n = 47) how true each statement was for them.
Results:
Participants generated 60 unique statements, and multidimensional scaling analysis generated eight thematic clusters characterizing reasons for transition which included the following: "Sharing with Others," "Psychological Coping," "Cigarette Appeal," "Reinforcing Effects of Cigarettes," "Accessibility," "Social Influence," "Vaping Stigma," and "Vaping Deficiencies." Participants rated "Sharing with Others" and "Psychological Coping" highest (most true) and "Vaping Deficiencies" lowest (least true). For college students, the ability to share cigarettes with peers and access cigarettes from peers and smoking for stress/anxiety management were among the top reasons for transition.
Conclusions:
Results suggest that tailored prevention efforts aimed at reducing cigarette smoking uptake among college students who use tobacco as a means for psychological coping or social facilitation may be warranted. Furthermore, regulatory decisions aimed at limiting cigarette appeal, reinforcing effects, and accessibility may be relevant to reducing transition.
... E-liquid is the solution aerosolized by e-cigarette devices to produce vapor. These liquids come in a variety of flavors (Marynak et al., 2017;Zhu et al., 2014) that are linked with greater perceived enjoyment (Soule, Lopez, Guy, & Cobb, 2016), and lower harm perceptions compared to combustible cigarettes (Pepper, Ribisl, & Brewer, 2016), and ecigarettes initiation in youth (Zare, Nemati, & Zheng, 2018). They also have varied nicotine concentrations (Etter, Zäther, & Svensson, 2013;Goniewicz, Hajek, & McRobbie, 2014;Goniewicz, Kuma, Gawron, Knysak, & Kosmider, 2013), with implications for abuse liability wherein higher concentrations are associated with higher yields of nicotine, an addictive substance (Talih et al., 2017). ...
Introduction:
E-liquid is the solution aerosolized by e-cigarette devices to produce vapor. Continuously evolving e-liquids, and corresponding devices, can affect user experiences associated with these products. Twitter conversations about e-liquids can capture salient behavioral, social, and communicative cues associated with e-liquids. We analyzed Twitter data to characterize key topics of conversation about e-liquids to inform surveillance, and regulatory efforts.
Methods:
Twitter posts containing e-liquid-related terms ("e-liquid(s)," "e-juice(s)") were obtained from 1 January 2018 to 31 December 2018. Text classifiers were used to identify topics of the posts (n = 15,927).
Results:
The most prevalent topic was Promotional at 29.35% followed by Flavors at 24.22%, and Person Tagging at 21.47%. Juice Composition was next most prevalent at 17.61% followed by Cannabis at 16.83%, and Nicotine Health Risks at 6.39%. Quit Smoking was rare at 0.57%.
Conclusion:
These results suggest that flavors, cannabis, health risks of nicotine, and composition warrant consideration as targets in future surveillance, public policy, and interventions addressing the use of e-liquids. Twitter provides ample opportunity to influence the normalization, and uptake, of e-cigarette-related products among non-smokers and youth, unless regulatory restrictions, and counter messaging campaigns are developed to reduce this risk.
... Studies have typically categorized flavors into tobacco, menthol or mint, fruit, candy, other sweet, and coffee (Yingst, Veldheer, Hammett, Hrabovsky, & Foulds, 2017). Flavor is one of the main reasons adults initially try and continue to use e-cigarettes, although other common reasons are using e-cigarettes as a tool for quitting cigarette use, health reasons, and curiosity (Ayers et al., 2017;Patel et al., 2016;Pepper, Ribisl, Emery, & Brewer, 2014;Quisenberry et al., 2018;Simmons et al., 2016;Soule, Lopez, Guy, & Cobb, 2016;Villanti, Richardson, Vallone, & Rath, 2013). ...
Background:
The prevalence of electronic cigarette use has grown over the past decade, with some users reportedly initiating e-cigarette use primarily due to flavors. This study examined the role of flavors in initiation among adult e-cigarette users, as well as the association of flavors with satisfaction and perceived addiction to vaping.
Methods:
The analysis sample consisted of 1492 current e-cigarette users aged 18 or older, drawn from an online quantitative survey conducted in 2016. Multivariable logistic regression and general linear models were used.
Results:
Most current e-cigarette users (62.9%) typically used flavors other than tobacco (including fruit, mint/menthol, sweet, candy, coffee and other), 24.2% typically used tobacco flavors, and 12.9% typically used non-flavored e-cigarettes. Flavor was a common reason for vaping initiation, selected by 29.5% of the sample. Flavor, particularly fruit flavor, was more likely to motivate young adults 18-24 to initiate vaping compared adults 35-44. Those who used flavors, particularly mint/menthol and flavors other than tobacco flavor, had higher odds of reporting high satisfaction with vaping and had higher odds of perceived addiction to vaping than respondents who did not use flavored e-cigarettes.
Conclusions:
Users of flavored e-cigarettes reported greater satisfaction and self-perceived addiction than users of non-flavored e-cigarettes. The appeal of flavors, particularly among young adults, has implications for regulatory policy regarding the marketing and promotion of flavored products. These findings may provide direction for the Food and Drug Administration's plans to restrict flavors other than menthol, mint, and tobacco.
... All ECIG liquids were labeled as 70% propylene glycol/30% vegetable glycerin (identical to Hiler et al., 2017). To determine the specific ECIG liquid flavors within the Food/Dessert/Spice and Fruit flavor categories, a content analysis of preferred ECIG liquid flavors among adult ECIG users (age 18+ and used an ECIG for at least 1 month) from a previous study was performed (N=114 total flavor responses from N=41/46 participants included in Soule et al., 2016; see Supplementary Material * ). Four unique liquid flavors at the solvent and nicotine concentration ratios specified above were sourced from a local ECIG vendor (AVAIL Vapor, LLC, Richmond, VA): Food/Dessert/Spice (Cream), Fruit (Tropical Fruit), Tobacco, and Menthol (see Table 1). ...
Background:
A rapidly evolving tobacco marketplace highlights the timeliness of the FDA's authority to regulate tobacco, specifically the role that flavorings in nicotine-containing electronic cigarette (ECIG) liquids have on public health. This study aimed to evaluate the extent to which ECIG liquid flavor and nicotine concentration influenced subjective measures of abuse liability among young adult cigarette (cig) smokers.
Methods:
Young adult (18-21 y.o.) smokers (M = 10.1 cig/day, no regular ECIG use history) completed 7 Latin-square ordered conditions each preceded by 12 h. nicotine/tobacco abstinence. Conditions were own brand cig (OB) and eGo-style ECIG paired with three liquid flavors (cream, tropical fruit, tobacco/menthol) varying in nicotine concentration (0 or 36 mg/ml). Products were administered in two 10-puff bouts in each condition. Heart rate/blood pressure (HR/BP) and tobacco/nicotine abstinence symptoms, nicotine/general drug effects, and acceptability measures were assessed repeatedly throughout sessions. Mixed linear models were followed-up with Tukey's HSD t-tests.
Results:
HR/BP indicated nicotine exposure during nicotine-containing conditions. OB and tobacco/menthol 36 mg/ml conditions produced significant decreases in ratings of cig smoking urges. Nicotine/drug effects were elevated significantly for OB and 36 mg/ml ECIG conditions with one exception noted for the tobacco/menthol 0 mg/ml condition. OB had the highest acceptability ratings, and ECIG condition results varied by acceptability item.
Conclusions:
Among young adult smokers, ECIG conditions containing nicotine were positively associated with several subjective measures of abuse liability but not all. Flavors did not consistently mask/enhance effects observed. Results reinforce continued examination of ECIG-delivered nicotine and liquid flavors in relationship to abuse liability.
... We need therefore to understand whether regulations may be acting as a deterrent for some smokers. Indeed, regulations which go further such as by prohibiting flavours will be a deterrent, given the importance of flavours in masking the taste of e-liquids [20]. Another concern is that increasing the burden of regulations for e-cigarettes favours the tobacco industry and we would all agree, that a diversity of manufacturers for e-cigarettes is likely to ensure that the market continues to evolve to best support more smokers to stop. ...
... 28 Flavorings may make the use of e-cigarettes more enjoyable, satisfying, and appealing. 29 Flavors may also increase the rewarding and relative reinforcing value of e-cigarettes. 30 Sweet-flavored e-cigarettes increased appeal, willingness to use again, and perceived monetary value compared with nonsweet or unflavored e-cigarettes. ...
Objectives:
The use of flavored electronic cigarettes (e-cigarettes) is common among e-cigarette users, but little is known about the potential harms of flavorings, the extent to which the concurrent use of multiple flavor types occurs, and the correlates of flavor type use. The objective of this study was to assess the types of e-cigarette flavors used by adolescent (aged 12-17), young adult (aged 18-24), and older adult (aged ≥25) e-cigarette users.
Methods:
We assessed the prevalence of flavored e-cigarette use within the past month by flavor types and concurrent use of multiple flavor types among past-month e-cigarette users sampled during Wave 2 (2014-2015) of the Population Assessment for Tobacco and Health Study among 414 adolescents, 961 young adults, and 1711 older adults. We used weighted logistic regression models for the use of fruit-, candy-, mint/menthol-, tobacco-, or other-flavored e-cigarettes and concurrent use of multiple flavor types. Covariates included demographic characteristics, e-cigarette use frequency, cigarette smoking status, current use of other tobacco products, and reasons for e-cigarette use.
Results:
The leading e-cigarette flavor types among adolescents were fruit, candy, and other flavors; among young adults were fruit, candy, and mint/menthol; and among older adults were tobacco or other flavors, fruit, and mint/menthol. Compared with older adults, adolescents and young adults were more likely to use fruit-flavored e-cigarettes (adjusted odds ratio [aOR] = 3.35; 95% confidence interval [CI], 2.56-4.38; and aOR = 2.31; 95% CI, 1.77-3.01, respectively) and candy-flavored e-cigarettes (aOR = 3.81; 95% CI, 2.74-5.28; and aOR = 2.95; 95% CI, 2.29-3.80, respectively) and concurrently use multiple flavor types (aOR = 4.58; 95% CI, 3.39-6.17; and aOR = 2.28; 95% CI, 1.78-2.91, respectively).
Conclusions:
Regulation of sweet e-cigarette flavors (eg, fruit and candy) may help reduce the use of e-cigarettes among young persons without substantially burdening adult e-cigarette users.
... The e-cigarettes market has at the same time evolved from early brands highlighting advantages over traditional cigarettes to present products with multiple flavours and product versatility (Zhu et al. 2014). E-cigarettes come in a range of models, along with a wide variety of e-liquids and levels of nicotine (Goniewicz et al. 2014, Soule et al. 2016. ...
The use of e‐cigarettes is increasing, a practice denoted as vaping. We explore user motives, self‐identity as vapers and involvement in vaping subcultures, drawing on sociological theory of stigma, subcultures and symbolic boundaries. Based on analyses of semi‐structured interviews with 30 Norwegian vapers, we find that there is a vaping subculture in Norway. We identify two dominant vaper identities. The first is labelled cloud chasers. These were dedicated vapers who identified with symbols and values in the subculture. Many were politically engaged in improving vaping regulation regimes and felt a sense of belonging to a vaping community. The second group is labelled substitutes. These were former daily smokers who used e‐cigarettes for smoking cessation in a more pragmatic and defensive manner, to avoid health risks, to escape the stigma of smoking and to manage nicotine addiction. In this group, self‐identity as a vaper was generally lacking. Vaping was often symbolically linked to the stigmatised smoker identity they wanted to escape, and was restricted to private contexts. The perceived symbolic meaning of e‐cigarettes varies: for some, they are a symbol of pleasure and community. For others, they connote the stigmatised status of the addicted smoker seeking an alternative to cigarettes.
... Participants were instructed to review the statements provided previously and to avoid duplicating the content of the statements generated by other participants. [28][29][30][31][32][33] The lead author monitored the statements as they were entered by participants. Statements were displayed in the order in which they were entered, allowing for easier comparison of new statements to previously entered statements. ...
... 24 In one longitudinal study, researchers found that the proportion of youth that did not know if they were using an e-cigarette with nicotine doubled from 2013 to 2015 (11.1% versus 20%). 25 This is particularly concerning because nicotine, along with flavors, 26,27 plays an important role in e-cigarette experimentation, 25 transitions from e-cigarettes to cigarette use, [28][29][30] and dual use of e-cigarettes with traditional cigarettes. [31][32][33][34][35][36] E-cigarette liquids can be purchased easily by the gallon or in eye-drop size or larger bottles from the Internet or retail stores. ...
... The reasons for initiation of ENDS, particularly as it relates to sweet taste or flavors, need to be further explored among young adults. A concept mapping study among adults found that five clusters for reasons for using flavored ENDS included satisfaction/ enjoyment, better taste than cigarettes, variety, food craving suppression, and social impacts [35]. Adults who use ENDS for weight control were more likely to prefer flavors [36]. ...
Objective
With the rise in electronic cigarette (ENDS) use among US young adults, more research is needed on expectations for use and perceptions related to body image, weight control, and stress relief.
Methods
College students (N = 230; modal age 21 years; 68% female) completed an online survey assessing cigarette smoking and ENDS, dieting and body image, perceptions about flavors, stress, weight gain prevention, and appetite regulation.
Sample characteristics
Dual use (cigarette and ENDS) was reported by n = 69 (30.0%). Exclusive cigarette smoking was endorsed by n = 53 (23%) with exclusive ENDS use reported by n = 15 (6.5%). Ninety-three participants (40.5%) reported not using either product.
Results
Among those using ENDS, < 33% reported using as a stress management tool, < 15% reported using ENDS to control appetite, and > 70% reported using cartridges that tasked like sweets. There was a positive correlation between dieting behaviors and body concern, suggesting those who reported higher use of ENDS for weight and appetite regulation also had higher pathological eating scores and concern over body shape and size.
Conclusion
Prevention and education related to weight, body image, and tobacco are needed to address misperceptions of tobacco products.
Level of evidence
Level V, cross-sectional descriptive study.
... In adolescents and young adults, e-cigarette use has increased sharply (10) and could lead to cigarette smoking (11). However, young people also enjoy e-cigarettes for reasons beyond nicotine (12), with flavorings found to enhance e-cigarette use (13)(14)(15)(16). E-cigarette use is increasing despite critical knowledge gaps regarding their toxicity and health effects. ...
Tobacco use and exposure to tobacco smoke remain major but avoidable causes of premature mortality and disease worldwide. Although the age-standardized prevalence of daily smoking has declined for both men and women in many countries, the number of smokers continues to increase because of global population growth. Although cigarettes are the most commonly used tobacco product, the tobacco epidemic has become tremendously complex with the emergence and popularity of alternative products such as waterpipes and electronic cigarettes (also known as e-cigarettes). Exposure sciences play a major role in characterizing the tobacco epidemic as well as in the promotion, enactment, and implementation of tobacco control initiatives including legislation and voluntary measures in countries worldwide. We reviewed several studies in Latin America and other regions, showing how high-quality exposure assessment has contributed to smoke-free policies. Although there are many toxicants in tobacco products, metals could be playing an important role in tobacco-related disease. Tobacco plants accumulate cadmium and lead from soil. In e-cigarettes, a metallic coil heats the e-liquid to produce the aerosol that is inhaled by the vaper, and studies have found high aerosol levels of nickel, chromium, lead, and zinc. Despite many tobacco control successes, including the enactment of the Framework Convention on Tobacco Control, which has been ratified by 181 countries, tobacco control faces many challenges globally. Given the continuing increase in the number of smokers worldwide and the rapid emergence of new tobacco products, additional creative efforts are needed to achieve a smoke-free world, help smokers to quit, and protect youth from initiating tobacco use.
... To better understand existing measurement items, we collected, reviewed, and categorized 371 survey items on e-cigarette perceptions from across seven of the fourteen Tobacco Centers of Regulatory Science (TCORS) sites funded by a partnership between the National Institutes of Health and the U.S. Food and Drug Administration (Camenga, Kong, Cavallo, & Krishnan-Sarin, 2016;Chaffee et al., 2015;Cooper et al., 2016;Cooper, Loukas, Harrell, & Perry, 2017;Gorukanti et al., 2016;Harrell et al., 2017;Majeed et al., 2016;Pechacek, Nayak, Gregory, Weaver, & Eriksen, 2016;Roditis, Delucchi, Cash, & Halpern-Felsher, 2016;Soule, Lopez, Guy, & Cobb, 2016;Soule, Maloney, Guy, Eissenberg, & Fagan, 2017;Yang, Liu, Lochbuehler, & Hornik, in press). As members of the TCORS Measurement Workgroup, we considered the varied ways to measure e-cigarette perceptions and identified strategies that may enhance measure validity, and strategies that researchers may consider avoiding. ...
Measuring perceptions associated with e-cigarette use can provide valuable information to help explain why youth and adults initiate and continue to use e-cigarettes. However, given the complexity of e-cigarette devices and their continuing evolution, measures of perceptions of this product have varied greatly. Our goal, as members of the working group on e-cigarette measurement within the Tobacco Centers of Regulatory Science (TCORS) network, is to provide guidance to researchers developing surveys concerning e-cigarette perceptions. We surveyed the 14 TCORS sites and received and reviewed 371 e-cigarette perception items from seven sites. We categorized the items based on types of perceptions asked, and identified measurement approaches that could enhance data validity and approaches that researchers may consider avoiding. The committee provides suggestions in four areas: (1) perceptions of benefits, (2) harm perceptions, (3) addiction perceptions, and (4) perceptions of social norms. Across these 4 areas, the most appropriate way to assess e-cigarette perceptions depends largely on study aims. The type and number of items used to examine e-cigarette perceptions will also vary depending on respondents' e-cigarette experience (i.e., user vs. non-user), level of experience (e.g., experimental vs. established), type of e-cigarette device (e.g., cig-a-like, mod), and age. Continuous formative work is critical to adequately capture perceptions in response to the rapidly changing e-cigarette landscape. Most important, it is imperative to consider the unique perceptual aspects of e-cigarettes, building on the conventional cigarette literature as appropriate, but not relying on existing conventional cigarette perception items without adjustment.
... Flavors (e.g., menthol, coffee) also increased perceived efficacy of e-cigarettes as cessation aids in the sample overall, while the exact flavors differed across subgroups [82]. Within a sample of adult ecigarette users, the most common reported reasons for using flavors were increased satisfaction/enjoyment and better feel/taste than cigarettes (including statements indicating that users perceived flavors as increasing palatability by seeming to mask aversive effects of nicotine or other aversive tastes associated with cigarettes), while other common responses included Variety/Customization and Food Craving Suppression [83]. ...
Background:
Electronic cigarette (e-cigarette) use has increased substantially in recent years. While e-cigarettes have been proposed as a potentially effective smoking cessation tool, dualuse in smokers is common and e-cigarettes are widely used by non-smokers, including youth and young-adult non-smokers. Nicotine, the primary addictive component in cigarettes, is present at varying levels in many e-liquids. E-cigarettes may lead to initiation of nicotine use in adult and youth non-smokers, re-initiation of nicotine dependence in ex-smokers or increased severity of nicotine dependence in dual-users of cigarettes and e-cigarettes. As such, there are important clinical and policy implications to understanding factors impacting nicotine exposure from e-cigarettes. However, the broad and rapidly changing range of e-liquid constituents and e-cigarette hardware which could impact nicotine exposure presents a challenge. Recent changes in regulatory oversight of e-cigarettes underscore the importance of synthesizing current knowledge on common factors which may impact nicotine exposure.
Methods:
This review focuses on factors which may impact nicotine exposure by changing e-cigarette use behavior, puff topography, altering the nicotine yield (amount of nicotine exiting the e-cigarette mouth piece including nicotine exhaled as vapor) or more directly by altering nicotine absorption and bioavailability.
Results:
Topics reviewed include e-liquid components or characteristics including flavor additives (e.g., menthol), base e-liquid ingredients (propylene glycol, vegetable glycerin), components commonly used to dissolve flavorants (e.g., ethanol), and resulting properties of the e-liquid (e.g., pH), e-cigarette device characteristics (e.g., wattage, temperature, model) and user behavior (e.g., puff topography) which may impact nicotine exposure.
Conclusion:
E-liquid characteristics and components, e-cigarette hardware and settings, and user behavior can all contribute substantially to nicotine exposure from e-cigarettes.
... Surprisingly, older adults also frequently used candy and fruit flavors in their e-cigarettes. The use of flavors may lead to more enjoyment, better taste, and food craving, 25 but there is concern that some flavor additives, such as benzaldehyde, common in cherry-flavored liquid, may cause increased airway irritation. 26 Other flavors also contain diacetyl, which has been associated with bronchiolitis obliterans, or Bpopcorn workers lung.^2 ...
Background:
Electronic cigarettes (e-cigarettes) are battery-operated nicotine-delivery devices used by some smokers as a cessation tool as well as by never smokers.
Objective:
To determine the usage of e-cigarettes in older adults at risk for or with chronic obstructive pulmonary disease (COPD).
Design:
Prospective cohorts.
Participants:
COPDGene (N = 3536) and SPIROMICS (N = 1060) subjects who were current or former smokers aged 45-80.
Main measures:
Participants were surveyed to determine whether e-cigarette use was associated with longitudinal changes in COPD progression or smoking habits.
Key results:
From 2010 to 2016, participants who had ever used e-cigarettes steadily increased to 12-16%, but from 2014 to 2016 current use was stable at ~5%. E-cigarette use in African-Americans (AA) and whites was similar; however, AA were 1.8-2.9 times as likely to use menthol-flavored e-cigarettes. Current e-cigarette and conventional cigarette users had higher nicotine dependence and consumed more nicotine than those who smoked only conventional cigarettes. E-cigarette users had a heavier conventional cigarette smoking history and worse respiratory health, were less likely to reduce or quit conventional cigarette smoking, had higher nicotine dependence, and were more likely to report chronic bronchitis and exacerbations. Ever e-cigarette users had more rapid decline in lung function, but this trend did not persist after adjustment for persistent conventional cigarette smoking.
Conclusions:
E-cigarette use, which is common in adults with or at risk for COPD, was associated with worse pulmonary-related health outcomes, but not with cessation of smoking conventional cigarettes. Although this was an observational study, we find no evidence supporting the use of e-cigarettes as a harm reduction strategy among current smokers with or at risk for COPD.
... The researchers conducted subsequent analyses to determine the individual and cluster average ratings of importance for past 30-day cigarette smoking, past 30-day cigar smoking, initiation of cigarette smoking, and initiation of cigar smoking. Following procedures employed by other CM studies, ratings were averaged for each item, followed by a cluster average of the items' averages (Frye et al. 2012, Johnson et al. 2011, Ries et al. 2010, Soule et al. 2016a, Soule et al. 2016b. Differences in cluster means by cigarettes and cigars were examined using t-tests. ...
Background: African American young adults are at high risk for dual use of cigarettes and cigars. Limited work has explored and characterized the reasons for use in this population and their relative importance for initiation and current smoking of these products.
Method: Reasons for cigarette and cigar use were systematically explored and categorized using a mixed methods participatory approach called concept mapping. A series of in-person group sessions were held with 30 African American young adult (ages 18–29) current smokers of both cigarettes and cigars in Prince George’s County, MD and Washington, DC. Participants brainstormed, sorted, rated, and interpreted their reasons for initiation and past 30-day use of cigarettes and cigars. A cluster map was generated using multi-dimensional scaling, and t-tests were used to explore differences in ratings by background characteristics.
Results: Participants generated 64 reasons for smoking cigarettes and cigars, and categorized these reasons into six groups: emotions, urges, access, product characteristics, lifestyle, and outside pressure. Emotions and urges were the most important motivations for initiation and current smoking of both products. Product characteristics were significantly more important for cigar initiation and smoking than for cigarettes, and outside pressure was more important for current smoking of cigars than cigarettes. Ratings differed by gender, socioeconomic status, and smoking characteristics.
Conclusions: Cigarette and cigar smoking have several overlapping motivations, but key differences were also found, most notably for product characteristics. The FDA’s regulation of cigars and cigarettes should focus on addressing key characteristics appealing to young adults to curb dual use.
Background:
Characterizing the appeal of flavored e-cigarette solutions by tobacco product use status can inform regulations to reduce vaping in those who never smoked without discouraging adopting e-cigarettes as a quit-smoking aid.
Methods:
Adults aged 21+ who currently use tobacco products (N = 119) self-administered standardized puffs of eight non-tobacco flavored and two tobacco-flavored e-cigarette solutions using a pod-style device. Participants rated appeal (0-100 scale) following each administration. Mean differences in flavor appeal ratings were compared between four groups: people who never smoked/currently vape, formerly smoked/currently vape, currently smoke/currently vape, and currently smoke/do not vape (with interest in vaping).
Results:
The Global Flavor (all non-tobacco vs. tobacco)×Group interaction (p = .028) revealed higher appeal for non-tobacco vs. tobacco flavors in adults who never smoked/currently vape (B[95 %CI] = 13.6[4.1-23.1]), formerly smoked/currently vape (B[95 %CI] = 11.6[4.2-18.9]), and currently smoke/currently vape (B[95 %CI] = 9.3[2.5-11.6]), but not adults who currently smoke/never vaped (B[95 %CI] = -0.1[-5.1 to 4.9]). In flavor-specific analyses, adults who never smoked/currently vape rated strawberry (p = .022), peppermint (p = .028), and menthol (p = .028) more appealing than tobacco flavors. Among adults who formerly smoked/currently vape, strawberry (p < .001), peppermint (p = .009), and vanilla (p = .009), were more appealing than tobacco. Adults who currently smoked/currently vape rated peppermint (p = .022) and vanilla (p = .009) as more appealing than tobacco. No non-tobacco flavors were more appealing than tobacco in adults who currently smoke/never vaped.
Conclusions:
E-cigarette sales restrictions on non-tobacco flavors, including menthol, may eliminate products preferred by adults who vape, including those who never smoked, without discouraging adults who currently smoke and never vaped from trying e-cigarettes.
The chemosensory experiences evoked by flavors encompass a number of unique sensations that include olfactory stimuli (smell), gustatory stimuli (taste, i.e., salty, sweet, sour, bitter, and umami (also known as "savoriness")), and chemesthesis (touch). As such, the responses evoked by flavors are complex and, as briefly stated above, involve multiple perceptive mechanisms. The practice of adding flavorings to tobacco products dates back to the 17th century but is likely much older. More recently, the electronic cigarette or "e-cigarette" and its accompanying flavored e-liquids emerged on to the global market. These new products contain no combustible tobacco but often contain large concentrations (reported from 0 to more than 50 mg/mL) of nicotine as well as numerous flavorings and/or flavor chemicals. At present, there are more than 400 e-cigarette brands available along with potentially >15,000 different/unique flavored products. However, surprisingly little is known about the flavors/flavor chemicals added to these products, which can account for >1% by weight of some e-liquids, and their resultant chemosensory experiences, and the US FDA has done relatively little, until recently, to regulate these products. This article will discuss e-cigarette flavors and flavor chemicals, their elicited responses, and their sensory effects in some detail.
Objective:
The present study evaluated the effects of nicotine concentration (0-10 mg/ml) and flavor (gummy bear vs unflavored) on the subjective experiences of vaporized nicotine in young adult low-dose nicotine (3 mg/ml) ECIG users.
Participants:
Eight young adult ECIG users were recruited.
Methods:
A single blinded crossover study was used. Participants were instructed to take ten 1.5 second puffs, each separated by 20 seconds. After self-administration, heart rate was recorded, and participants completed the Drug Effects, Direct Effects of Nicotine, and Direct Effects of ECIG questionnaires.
Results:
ECIG user's standard daily nicotine dose influenced the rewarding and aversive effects of nicotine as the 10 mg/ml dose was found to be aversive in this user group. The combination of flavor and nicotine increased the subjective effects of ECIGs.
Conclusions:
Flavored e-liquids contribute to the reinforcing properties of nicotine by enhancing the subjective effects, which may lead to continued ECIG use.
Electronic cigarette use—vaping—is increasingly popular. Various product factors may influence an individual’s choice of e-cigarette. To provide an evidence base for e-cigarette regulation, a better understanding of the role different product attributes play in product preferences is needed. Here, we used conjoint analysis to quantify different factors that influence e-cigarettes choices, including flavors, nicotine level, customizability, or use of e-cigarettes to manage appetite/food craving. Young adults completed a set of choice-based conjoint tasks online. Choice Based Conjoint analysis (CBC) was used to determine utility scores for each attribute. Young adults (n = 587) who vaped at least once per week were included in analyses; gender differences were explored. Flavor was the most important attribute (48.1%), followed by product messaging (21.0%) and nicotine level (15.3%). Within flavor, confectionery and fruit flavors had the highest utility scores, while classic menthol and tobacco flavors had the lowest. Men and women differed in flavors, nicotine levels, and product messaging that appealed most. Among young adults who vape weekly, flavor is the most important factor in e-cigarette preferences. Gender also factors into e-cigarette preferences, especially for preferred nicotine level. Understanding why individuals choose particular e-cigarette products will help inform public health efforts and policy making.
Background
Few studies assess whether electronic cigarette (e-cigarette) device characteristics or flavours impact longitudinal patterns of cigarette and e-cigarette use.
Design
We examined data from waves 2–4 of the Population Assessment of Tobacco and Health Study (2014–2018). Among adult (≥18 years) current e-cigarette users at wave 2 who were current smokers (dual users; n=1759) and former smokers (exclusive e-cigarette users; n=470), we classified participants into four use patterns at wave 3 (~12 months later) and wave 4 (~24 months later): (1) dual use of e-cigarettes and cigarettes; (2) exclusive cigarette smoking; (3) exclusive e-cigarette use; (4) non-use of both products. We used multinomial logistic regression to assess correlates of changing use patterns at 24 months, relative to no change, adjusting for sociodemographic factors.
Results
At 24 months, 26.5% of baseline exclusive e-cigarette users, and 9% of baseline dual users, abstained from both vaping and smoking. Participants who vaped non-tobacco flavours (vs tobacco flavours), and used refillable tank or modifiable devices (vs disposable, cartridges and other devices) were less likely to transition to non-use of both products and to exclusive cigarette smoking. Baseline daily vaping (vs non-daily) was positively associated with exclusive e-cigarette use at 24 months for baseline daily cigarette smokers, but negatively associated with exclusive e-cigarette use and non-use of both products at 24 months for baseline non-daily smokers.
Conclusions
Non-tobacco flavours, daily vaping and modifiable e-cigarette devices may help some smokers abstain from cigarette smoking via transitioning to exclusive e-cigarette use, but are also associated with ongoing exclusive e-cigarette use.
Background
The FDA’s policies restricting sale of sweet flavored cartridge-based and disposable electronic nicotine delivery systems (ENDS) comprise important steps toward curbing adolescent ENDS use. However, additional evidence is needed about the contribution of specific flavors to adolescents’ ENDS use. This study investigated the effects of flavor use on same day vaping behaviors, and next day intentions and willingness.
Methods
We collected ecological momentary assessments (EMA) from 50 adolescent past two-week vapers (ages 14–17) over 14 days. Daily EMA data were collected on vaping occasions, total puffs, vaping intentions, vaping willingness, and flavor used.
Results
On average, data were obtained on 13.4 days per participant (670 observations). Participants vaped flavors on 87% of days (fruit = 55%; mint = 30%; tobacco = 6%; menthol = 5%, and candy, sweets, or chocolate = 5%). On days when participants vaped fruit flavors, they took more puffs (r = 0.13, p = .030). On days when they vaped tobacco flavor, they reported more vaping occasions (r = 0.20, p = .005) and more puffs (r = 0.15, p = .033). On days when they vaped because of flavor appeal, they reported more vaping occasions (r = 0.19, p = .001) and more puffs (r = 0.24, p < .001). On days when they vaped menthol flavor, they were less likely to report willingness to vape the next day (r = -0.14, p = .042). Adolescents who reported vaping due to flavor appeal were more likely to report intentions (OR = 5.63, p = .035) and willingness to vape the next day (r = 0.23, p < .001)
Conclusion
These findings provide additional support for policies restricting the sale of flavored ENDS products to adolescents.
Rationale:
There is limited understanding regarding how various e-cigarette flavorings may influence the behavior of non-regular e-cigarette users who are regular cigarette smokers.
Objectives:
To assess differences in nicotine delivery, puffing topography, subjective effects, and user satisfaction from different flavored e-liquids.
Methods:
Eighteen daily smokers (average age, 44.1 ± 7.0; 9 males; average CPD, 13.0 ± 5.8) smoked their tobacco cigarettes during an initial visit and returned five times to try an e-cigarette (eGo type) refilled with a nicotine solution (24 mg/ml) of five different flavors: cherry, tobacco, espresso, menthol, and vanilla (randomized order). Assessments at each visit included puffing topography, blood samples for nicotine analysis, and subjective reports of nicotine effects and flavor satisfaction.
Results:
Vaping different flavors resulted in different levels of plasma nicotine. The flavor producing the highest plasma nicotine concentration (Cmax) was cherry (median 21.2 ng/ml), which was not significantly different than nicotine delivery from a combustible cigarette (29.2 ng/ml, p > .05). Vanilla e-liquid produced the lowest Cmax (9.7 ng/ml), and participants tended to puff less frequently on vanilla compared to tobacco flavor (p = .013). Flavors did not differ significantly in the speed of nicotine delivery (Tmax). During controlled use, puff duration for all flavors was significantly longer than a combustible cigarette (p < 0.05). After controlling for nicotine delivery, significant differences in flavor enjoyment were detected. Menthol flavored e-liquid was rated as more enjoyable than vanilla and tobacco flavored e-liquids (p < 0.05).
Conclusions:
Flavors tested in this study yielded different patterns of nicotine delivery and led to differences in reduction in smoking urges.
Trial registration:
ClinicalTrials.gov Identifier: #NCT02575885.
Background and Aims
Vaporized nicotine products (VNPs) can vary in important characteristics including size, shape, flavor and nicotine yield. We examined whether complex interactions among these characteristics could affect smokers’ VNP perceptions and usage patterns.
Design
A within‐subject randomized cross‐over trial.
Setting
Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
Participants
Eighteen daily cigarette smokers.
Measurements
Participants attended eight weekly visits during which they sampled six different VNPs (disposable, rechargeable, eGO, mod, e‐Cigar and e‐Pipe) with tobacco‐flavored e‐liquid. Prior to device use, participants completed product‐ranking questionnaires. Participants completed controlled puffing sessions during each of the six trials, after which satisfaction questionnaires were completed and blood samples were taken.
Findings
Initial perceptions showed that the smallest device (disposable) was ranked as safer compared with a larger device (e‐Pipe) (P < 0.05). Participants rated the eGO and mod devices higher on satisfaction and enjoyment from use, taste, pleasantness, harshness (‘throat hit’) and speed of effect, but lower on perceived health risk and embarrassment from use (P < 0.05). All devices had a lower Cmax than the combustible cigarette (P < 0.05), but there were differences among devices (P < 0.05). The mod, e‐Pipe and eGO provided the highest amount of perceived smoking urge relief, and this correlated strongly with Cmax across all devices (R² = 0.8614, P = 0.007). The perceived speed of urge relief was not correlated with Tmax (R² = 0.0035, P = 0.911)
Conclusions
Daily cigarette smokers testing six types of vaporized nicotine products (VNPs) reported that they varied in taste, amount of withdrawal relief, harshness, embarrassment from use, perceived health risk and subjective and objective nicotine delivery. The eGO and mod models have properties that may make them most effective for cigarette substitution among smokers who intend to switch to a VNP.
Introduction:
Open electronic cigarette (e-cigarette) systems are customizable by consumers and often allow for potential "unorthodox" use of the product; that is, use not as intended by the manufacturer. Little is known about the types and prevalence of unorthodox uses and how these practices are transmitted via popular social media.
Methods:
Monthly searches of YouTube were conducted from June through November 2016 using the search terms: "e-cigarettes", "vaping", and "e-juice". After collecting static and dynamic data on the 150 videos identified, two coders independently coded videos for general information, unorthodox use behaviors, health claims, and production quality and characteristics for orthodox and unorthodox use. Inter coder reliability was high (Cohen's κ 0.81, p < .001).
Results:
One hundred fifty videos were included in the study with a total of 115,551,563 views. We identified nine categories of unorthodox uses of e-cigarettes. Unorthodox use was three times as prevalent as orthodox use. Seventy-seven percent of the unorthodox use videos included recreational e-cigarette use, 57% included modification of mechanical parts and components, and 44.6% included unorthodox substance application (dripping). There were more than twice as many social media links in videos depicting unorthodox compared to orthodox use, but the level of engagement was lower for unorthodox use.
Conclusions:
E-cigarette unorthodox use on YouTube is more prevalent than orthodox use, suggesting the need to further investigate the prevalence of unorthodox use among e-cigarette users and the influence of social media on consumer uptake of unorthodox and orthodox uses of e-cigarettes.
Implications:
The U.S. Food and Drug Administration (FDA) has regulatory authority over e-cigarettes, parts and components. Many e-cigarettes currently marketed are open systems. Closed systems may allow less manipulation and may influence the safety of these products. This study provides valuable information on ways that open system e-cigarettes are used and it can inform safety tests that can be conducted by the FDA to determine whether or not these products should remain on the market. Additionally, our definitions of unorthodox use can be incorporated into the Population Assessment of Tobacco on Health Study to better understand the prevalence of these behaviors.
Introduction:
Electronic cigarettes (ECIGs) aerosolize a liquid that usually contains propylene glycol and/or vegetable glycerin, flavorants, and the dependence-producing drug nicotine in various concentrations. This study examined the extent to which ECIG liquid nicotine concentration is related to user plasma nicotine concentration in ECIG-naïve tobacco cigarette smokers.
Methods:
Sixteen ECIG-naïve cigarette smokers completed four laboratory sessions that differed by the nicotine concentration of the liquid (0, 8, 18, or 36mg/ml) that was placed into a 1.5 Ohm, dual coil "cartomizer" powered by a 3.3V battery. In each session, participants completed two, 10-puff ECIG use bouts with a 30-second inter-puff interval; bouts were separated by 60 minutes. Venous blood was sampled before and after bouts for later analysis of plasma nicotine concentration; puff duration, volume, and average flow rate were measured during each bout.
Results:
In bout 1, relative to the 0mg/ml nicotine condition (mean = 3.8ng/ml, SD = 3.3), plasma nicotine concentration increased significantly immediately after the bout for the 8 (mean = 8.8ng/ml, SD = 6.3), 18 (mean = 13.2ng/ml, SD = 13.2), and 36mg/ml (mean = 17.0ng/ml, SD = 17.9) liquid concentration. A similar pattern was observed after bout 2. Average puff duration in the 36mg/ml condition was significantly shorter compared to the 0mg/ml nicotine condition. Puff volume increased during the second bout for 8 and 18mg/ml conditions.
Conclusions:
For a given ECIG device, nicotine delivery may be directly related to liquid concentration. ECIG-naïve cigarette smokers can, from their first use bout, attain cigarette-like nicotine delivery profiles with some currently available ECIG products.
Implications:
Liquid nicotine concentration can influence plasma nicotine concentration in ECIG-naïve cigarette smokers, and, at some concentrations, the nicotine delivery profile of a 3.3V ECIG with a dual coil, 1.5-Ohm cartomizer approaches that of a combustible tobacco cigarette in this population. Finding a product that delivers nicotine as effectively as a tobacco cigarette, as we report here, may be essential for smokers who want to replace completely their combustible tobacco cigarettes with ECIGs.
AIMS: Here, we present results from a prospective pilot study that was aimed at surveying changes in daily cigarette consumption in smokers making their first purchase at vape shops. Modifications in products purchase were also noted.
DESIGN: Participants were instructed how to charge, fill, activate and use their e-cigarettes (e-cigs). Participants were encouraged to use these products in the anticipation of reducing the number of cig/day smoked.
SETTINGS: Staff from LIAF contacted 10 vape shops in the province of the city of Catania (Italy) that acted as sponsors to the 2013 No Tobacco Day.
PARTICIPANTS: 71 adult smokers (≥18 years old) making their first purchase at local participating vape shops were asked by professional retail staff to complete a form.
MEASUREMENTS: Their cigarette consumption was followed-up prospectively at 6 and 12 months. Details of products purchase (i.e., e-cigs hardware, e-liquid nicotine strengths and flavours) were also noted.
FINDINGS: Retention rate was elevated, with 69% of participants attending their final follow-up visit. At 12 month, 40.8% subjects could be classified as quitters, 25.4% as reducers and 33.8% as failures. Switching from standard refillables (initial choice) to more advanced devices (MODs) was observed in this study (from 8.5% at baseline to 18.4% at 12 month) as well as a trend in decreasing thee-liquid nicotine strength, with more participants adopting low nicotine strength (from 49.3% at baseline to 57.1% at 12 month).
CONCLUSIONS: We have found that smokers purchasing e-cigarettes from vape shops with professional advice and support can achieve high success rates.
Recent youth trends in the prevalence of e-cigarette and traditional cigarette use in Florida were examined in a cross-sectional, representative state sample from 2011 to 2014. Traditional cigarette use among youth declined during the study period. Experimentation with and past 30-day use of e-cigarettes among Florida youth tripled over 4 years. Past 30-day e-cigarette use exceeded traditional cigarette use in 2014; 10.8% of high school and 4.0% of middle school students reported recent e-cigarette use, compared with 8.7% of high school and 2.9% of middle school students for traditional cigarettes (P<0.001). By 2014, 20.5% of high school and 8.5% of middle school students reported ever use of e-cigarettes. Among ever e-cigarette users in 2014, 30.3% of high school and 42.2% of middle school students had never smoked traditional cigarettes. Given the concern that significant rates of e-cigarette use by U.S. adolescents may have a negative effect on public health, further review of e-cigarette advertising, marketing, sales, and use among U.S. youth is warranted.
Electronic cigarettes (e-cigarettes) are a relatively recent phenomenon, serving dual roles as an alternative vehicle for nicotine delivery and a smoking-cessation tool. The purpose of this study was to determine pregnant women's knowledge, attitudes, and practice regarding electronic cigarettes.
A voluntary, anonymous survey was distributed to a convenience sample of pregnant women presenting to a university-based outpatient clinic. After survey completion, participants received information about smoking cessation and e-cigarettes. Data were examined using χ and Fisher exact tests and analysis of variance. Stata was used for the analysis.
Of the 326 surveys distributed, 316 were completed (97%). Of the 316 participants, 42 (13%) reported having ever used e-cigarettes. Only 2 (0.6%) reported current daily use. Ever users were slightly older (27.3 years vs 25.4 years; P = 0.007) and more likely to be current smokers (43% vs. 14%; P < 0.001) compared with women who had never used electronic cigarettes. Knowledge of the harms of smoking was similar between the 2 groups. Overall, 57% of all respondents believed that e-cigarettes contain nicotine, 61% that e-cigarettes can be addictive, and 43% that e-cigarettes are less harmful to a fetus than traditional cigarettes. Among ever users, the most common reasons given for the use of e-cigarettes were the perception of less harm than traditional cigarettes (74%) and help with smoking cessation (72%).
Misconceptions about e-cigarettes are common among pregnant women, potentially motivating use that may pose risks to both maternal and child health. Screening and education regarding e-cigarettes should be included in prenatal care. Future research in this area is necessary, including research examining pregnancy outcomes among women who use e-cigarettes.
Although there is increasing attention to the prevalence of new and emerging tobacco products in the civilian population, remarkably little is known about the current prevalence of these products in a military population.
The current investigation was designed to determine the prevalence of tobacco and nicotine containing products (TNCP) and correlates of use across multiple cohorts of trainees undergoing Technical Training in the US Air Force between April 2013 and December 2014. Chi-square test, Cochran-Armitage test for linear trend, and logistic regression models were applied to test differences and linear trends across time for TNCP use as well as correlates of use in a cross-sectional sample of 13,685 Airmen (final analytic sample).
Over a quarter (26.9%) of Airmen reported regular use of a TNCP. The two most prevalent products were cigarettes (11.2%) and hookah (10.5%). Among correlates of use, Airmen that regularly use TNCPs were more likely to be male, younger, non-Hispanic White, and single with a high school degree or GED. Hookah was the most endorsed for intentions to use, and along with e-cigarettes, had the lowest perception of harm. While prevalence of most products remained constant across entering cohorts, the prevalence of e-cigarettes showed significant linear increase.
The prevalence of TNCP use is high across cohorts of Airmen. Remarkably high estimates of future intentions to use and low perceptions of harm for emerging products suggest that intervention efforts should be directed at multiple forms of TNCP use to address this important public health issue.
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
E-cigarettes can be categorized into two basic types, (1) cigalikes, that are disposable or use pre-filled cartridges and (2) tanks, that can be refilled with liquids. The aims of this study were to examine: (1) predictors of using the two e-cigarette types, and (2) the association between type used, frequency of use (daily vs. non-daily vs. no use), and quitting.
Online longitudinal survey of smokers in Great Britain was first conducted in November 2012. Of 4064 respondents meeting inclusion criteria at baseline, this study included (N = 1643) current smokers followed-up 1 year later. Type and frequency of e-cigarette use were measured at follow-up.
At follow-up, 64% reported no e-cigarette use, 27% used cigalikes, and 9% used tanks. Among e-cigarette users at follow-up, respondents most likely to use tanks versus cigalikes included: 40-54 versus 18-24 year olds and those with low versus moderate/high education. Compared to no e-cigarette use at follow-up, non-daily cigalike users were less likely to have quit smoking since baseline (P = .0002), daily cigalike or non-daily tank users were no more or less likely to have quit (P = .3644 and P = .4216, respectively), and daily tank users were more likely to have quit (P = .0012).
Whether e-cigarette use is associated with quitting depends on type and frequency of use. Compared with respondents not using e-cigarettes, daily tank users were more likely, and non-daily cigalike users were less likely, to have quit. Tanks were more likely to be used by older respondents and respondents with lower education.
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
Because electronic cigarettes are relatively new, data on usage patterns and factors which influence them are sparse. Hence, this study aims at assessing awareness, beliefs about electronic cigarettes and experimentation with them among university students from Romania- a country where the sales and marketing of these products are widespread. Secondly, correlates of electronic cigarette experimentation will also be investigated.
A cross-sectional study was performed by means of anonymous questionnaires among 480 students, aged 19-24, from Cluj-Napoca, Romania, between April-May 2013.
The results show that 92.5% of the students have heard about e-cigarettes; out of these, one quarter (53.3% of the smokers, 25% of the ex-smokers, 5.5% of the non-smokers) have tried electronic cigarettes at least once during lifetime. The results of the multinomial logistic regression point out that the correlates of electronic cigarette experimentation were: male gender, being a smoker of traditional cigarettes, having friends who experimented with electronic cigarettes, having stronger beliefs that electronic cigarettes could help them quit smoking and being less convinced that they are used only by smokers. The explained variance was 59%.
The results underline the importance of addressing the issue of e-cigarette use through health education programs and regulatory interventions, since e-cigarettes are a reality faced by the Romanian youth.
Tobacco use and addiction most often begin during youth and young adulthood. Youth use of tobacco in any form is unsafe. To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6-8) and high school (grades 9-12) students, CDC and the Food and Drug Administration (FDA) analyzed data from the 2011-2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development, causes addiction, and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States.
We examined whether smokers who used e-cigarettes are more likely to quit after 1 year than smokers who had never used e-cigarettes.
We surveyed California smokers (n = 1000) at 2 time points 1 year apart. We conducted logistic regression analyses to determine whether history of e-cigarette use at baseline predicted quitting behavior at follow-up, adjusting for demographics and smoking behavior at baseline. We limited analyses to smokers who reported consistent e-cigarette behavior at baseline and follow-up.
Compared with smokers who never used e-cigarettes, smokers who ever used e-cigarettes were significantly less likely to decrease cigarette consumption (odds ratio [OR] = 0.51; 95% confidence interval [CI] = 0.30, 0.87), and significantly less likely to quit for 30 days or more at follow-up (OR = 0.41; 95% CI = 0.18, 0.93). Ever-users of e-cigarettes were more likely to report a quit attempt, although this was not statistically significant (OR = 1.15; 95% CI = 0.67, 1.97).
Smokers who have used e-cigarettes may be at increased risk for not being able to quit smoking. These findings, which need to be confirmed by longer-term cohort studies, have important policy and regulation implications regarding the use of e-cigarettes among smokers. (Am J Public Health. Published online ahead of print April 16, 2015: e1-e7. doi:10.2105/AJPH.2014.302482).
Most studies on e-cigarettes have come from population-based surveys. The current research aimed to provide initial data on e-cigarette awareness, perceptions, use, and reasons for use among adults seeking substance use treatment.
A survey was conducted among 198 participants ≥18 years old in a community-based outpatient substance use treatment program.
Of the 198 participants, 69% currently smoked cigarettes, 92% were aware of e-cigarettes, and 58% had ever used e-cigarettes. The proportion of the number of participants who had ever used e-cigarettes to the number who currently smoked (89.7%) appeared higher than the corresponding proportion in the 2012-13 National Adult Tobacco Survey (78.3%). Almost half of the sample who reported ever using e-cigarettes endorsed quitting or reducing smoking as a reason for use, and 32% endorsed reasons for use relating to curiosity/experimentation. A greater likelihood of e-cigarette ever-use was significantly associated with younger age (adjusted odds ratio [AOR] = 0.94, 95%confidence interval [CI] = 0.90, 0.98) and perceptions related to using e-cigarettes in public places where smoking cigarettes is not allowed (AOR = 2.96, 95%CI = 1.18, 7.42) but was not associated with primary drug of choice.
E-cigarette use in adults seeking substance use treatment appears higher than it is in the US general population of smokers. The high frequency of use may be due to curiosity/experimentation or attempts to quit or reduce smoking.
Future research may consider how e-cigarettes interact with other substance use and affect high rates of nicotine and tobacco use in this population. (Am J Addict 2015;XX:1-7).
© American Academy of Addiction Psychiatry.
There is strong interest in the use of electronic cigarettes (e-cigarettes) globally. This paper is the first to report population-based data on ever-use and current use of e-cigarettes among New Zealand adults. The paper also extends previous international studies by exploring the reasons for trying e-cigarettes, ever users' recall of brand(s) they have ever tried, and current users' recall of their current brand.
The Health and Lifestyles Survey (HLS) is a biennial face-to-face in-house survey of New Zealand adults aged 15years or over. In 2014, 2594 participants completed the survey.
Ever-use and current use of e-cigarettes were 13.1% and 0.8% respectively. Tobacco smoking status predicted the use of e-cigarettes, with current smokers reporting the highest rate of use (50% ever-use and 4% current use). Among current smokers who had tried an e-cigarette, curiosity (49%) and desire to quit smoking (37%) were the most common reasons for trying. About half of the ever-users could not name any of the brand(s) they had ever tried, and one-fifth of current users could not name their current brand.
Compared with other countries, New Zealand has a high rate of ever-use. Among current smokers, one in two had tried an e-cigarette. However, progression to regular use appears to be rare. The finding that 18% of current e-cigarette users could not name their current brand highlights the importance of investigating users' knowledge of e-cigarettes in general and assessing the factors that influence brand choice such as advertising, price, and accessibility.
Copyright © 2015 Elsevier Ltd. All rights reserved.
We examined 1) changes in smoking and vaping behavior and associated cotinine levels and health status among regular smokers who were first-time e-cigarette purchasers and 2) attitudes, intentions, and restrictions regarding e-cigarettes.
We conducted a pilot longitudinal study with assessments of the aforementioned factors and salivary cotinine at weeks 0, 4, and 8. Eligibility criteria included being ≥18 years old, smoking ≥25 of the last 30 days, smoking ≥5 cigarettes per day (cpd), smoking regularly ≥1 year, and not having started using e-cigarettes. Of 72 individuals screened, 40 consented, 36 completed the baseline survey, and 83.3% and 72.2% were retained at weeks 4 and 8, respectively.
Participants reduced cigarette consumption from baseline to week 4 and 8 (p's < 0.001); 23.1% reported no cigarette use in the past month at week 8. There was no significant decrease in cotinine from baseline to week 4 or 8 (p's = ns). At week 8, the majority reported improved health (65.4%), reduced smoker's cough (57.7%), and improved sense of smell (53.8%) and taste (50.0%). The majority believed that e-cigarettes versus regular cigarettes have fewer health risks (97.2%) and that e-cigarettes have been shown to help smokers quit (80.6%) and reduce cigarette consumption (97.2%). In addition, the majority intended to use e-cigarettes as a complete replacement for regular cigarettes (69.4%) and reported no restriction on e-cigarette use in the home (63.9%) or car (80.6%).
Future research is needed to document the long-term impact on smoking behavior and health among cigarette smokers who initiate use of e-cigarettes.
E-cigarette use has increased rapidly over the past decade. There is growing concern about e-cigarette use and advertising given limited regulation of these products. This cross-sectional study reports on data collected at baseline from hospitalized cigarette smokers (N = 944) recruited in monthly cohorts between December 2012 and September 2013. Participants were queried regarding e-cigarette awareness and use, and number and sources of e-cigarette advertisement exposures in the previous 6 months. Most Whites (99 %) reported ever hearing of an e-cigarette compared to 96 % of Blacks (p < 0.001). Over two thirds (64 %) of Whites reported ever using an e-cigarette compared to 30 % of Blacks (p < 0.001). There were significant trends in increasing e-cigarette use for both racial groups with an average increase of 13 % each month (p < 0.005) and in increasing e-cigarette advertisement exposure reported for the previous 6 months, with a 14 % increase each month (p < 0.0001). Whites reported 56 % greater advertisement exposure than Blacks (mean = 25 vs. 8 in month 1 to 79 vs. 45 in month 9, respectively; p < 0.0001). For Blacks, advertisement exposure was significantly associated with e-cigarette use (p < 0.001). Whites reported more advertisement exposure from stores and the Internet, and Blacks reported more advertisement exposure from radio or television. Results suggest that e-cigarette marketing is beginning to breach the Black population who are, as a consequence, "catching up" with Whites with regard to e-cigarette use. Given the significant disparities for smoking-related morbidity and mortality between Blacks and Whites, these findings identify new areas for future research and policy.
Introduction:
There is limited evidence on electronic cigarette (e-cigarette) use among U.S. adolescents.
Methods:
Cross-sectional, anonymous surveys conducted in 4 high schools (HS; n = 3,614) and 2 middle schools (MS; n = 1,166) in Connecticut in November 2013 examined e-cigarette awareness, use patterns, susceptibility to future use, preferences, product components used (battery type, nicotine content, flavors), and sources of marketing and access.
Results:
High rates of awareness (MS: 84.3%; HS: 92.0%) and of lifetime (3.5% MS, 25.2 % HS) and current (1.5% MS, 12% HS) use of e-cigarettes was observed. Among those who had not tried e-cigarettes, 26.4% of MS and 31.7% of HS students reported being susceptible to future use. Males (OR = 1.70, p < .01), older students (OR = 1.39, p < .05), Caucasians (OR = 2.01, p < .001), ever cigarette smokers (OR = 13.04, p < .001), and current cigarette smokers (OR = 65.11, p < .001) were more likely to be lifetime e-cigarette users and to report greater future susceptibility (males: OR = 1.30; Caucasians: OR = 1.14; ever cigarette smokers; OR = 3.85; current cigarette smokers; OR = 9.81; ps < .01-.001). Among MS students who were lifetime e-cigarette users, 51.2% reported that e-cigarette was the first tobacco product they had tried. E-cigarettes that were rechargeable and had sweet flavors were most popular. Smokers preferred e-cigarettes to cigarettes. Current cigarette smokers were more likely to initiate with nicotine-containing e-cigarettes, and ever and never cigarette smokers to initiate with e-cigarettes without nicotine. Primary sources for e-cigarette advertisements were televisions and gas stations and, for acquiring e-cigarettes, were peers.
Conclusions:
Longitudinal monitoring of e-cigarette use among adolescents and establishment of policies to limit access are imperatively needed.
Objectives:
We assessed trends in use of electronic cigarettes among U.S. adults, demographic predictors of use, and smoking status of current electronic cigarette users.
Methods:
Mixed-mode surveys were used to obtain representative, cross-sectional samples of U.S. adults in each of 4 years.
Results:
Sample sizes for 2010, 2011, 2012, and 2013 were 3,240, 3,097, 3,101, and 3,245, respectively. Ever use of electronic cigarettes increased from 1.8% (2010) to 13.0% (2013), while current use increased from 0.3% to 6.8%, p < .001. Prevalence of use increased significantly across all demographic groups. In 2013, current use among young adults 18-24 (14.2%) was higher than adults 25-44 (8.6%), 45-64 (5.5%), and 65+ (1.2%). Daily smokers (30.3%) and nondaily smokers (34.1%) were the most likely to currently use e-cigarettes, compared to former smokers (5.4%) and never-smokers (1.4%), p < .001. However, 32.5% of current electronic cigarette users are never- or former smokers.
Conclusions:
There has been rapid growth in ever and current electronic cigarette use over the past 4 years. Use is highest among young adults and current cigarette smokers. Although smokers are most likely to use these products, almost a third of current users are nonsmokers, suggesting that e-cigarettes contribute to primary nicotine addiction and to renormalization of tobacco use. Regulatory action is needed at the federal, state, and local levels to ensure that these products do not contribute to preventable chronic disease.
Electronic cigarettes (e-Cigs) are an attractive long-term alternative nicotine source to conventional cigarettes. Although they may assist smokers to remain abstinent during their quit attempt, studies using first generation e-Cigs report low success rates. Second generation devices (personal vaporisers - PVs) may result in much higher quit rates, but their efficacy and safety in smoking cessation and/or reduction in clinical trials is unreported.
We conducted a prospective proof-of-concept study monitoring modifications in smoking behaviour of 50 smokers (unwilling to quit) switched onto PVs. Participants attended five study visits: baseline, week-4, week-8, week-12 and week-24. Number of cigarettes/day (cigs/day) and exhaled carbon monoxide (eCO) levels were noted at each visit. Smoking reduction/abstinence rates, product usage, adverse events and subjective opinions of these products were also reviewed.
Sustained 50% and 80% reduction in cigs/day at week-24 was reported in 15/50 (30%) and 7/50 (14%) participants with a reduction from 25cigs/day to 6cigs/day (p < 0.001) and 3cigs/day (p < 0.001), respectively. Smoking abstinence (self-reported abstinence from cigarette smoking verified by an eCO ≤10 ppm) at week-24 was observed in 18/50 (36%) participants, with 15/18 (83.3%) still using their PVs at the end of the study. Combined 50% reduction and smoking abstinence was shown in 33/50 (66%) participants. Throat/mouth irritation (35.6%), dry throat/mouth (28.9%), headache (26.7%) and dry cough (22.2%) were frequently reported early in the study, but waned substantially by week-24. Participants’ perception and acceptance of the products was very good.
The use of second generation PVs substantially decreased cigarette consumption without causing significant adverse effects in smokers not intending to quit.
Trial registration
(ClinicalTrials.gov Identifier: NCT02124200)
Introduction:
There are limited data on the use of electronic cigarettes (e-cigarettes) among youth, particularly with regard to the use of nicotine versus nonnicotine products. This study investigates ever use of nicotine and nonnicotine e-cigarettes and examines the demographic and behavioral correlates of e-cigarette use in Ontario, Canada.
Methods:
Data for 2,892 high school students were derived from the 2013 Ontario Student Drug Use and Health Survey. This province-wide school-based survey is based on a 2-stage cluster design. Bivariate and multivariate analyses were used to investigate the factors associated with ever use of e-cigarettes. Ever use of e-cigarettes was derived from the question, "Have you ever smoked at least one puff from an electronic cigarette?" All analyses included appropriate adjustments for the complex study design.
Results:
Fifteen percent of high school students reported using e-cigarettes in their lifetime. Most students who ever used e-cigarettes reported using e-cigarettes without nicotine (72%), but 28% had used e-cigarettes with nicotine. Male, White/Caucasian, and rural students, as well as those with a history of using tobacco cigarettes, were at greater odds of e-cigarette use. Seven percent of students who had never smoked a tobacco cigarette in their lifetime reported using an e-cigarette. Five percent of those who had ever used an e-cigarette had never smoked a tobacco cigarette.
Conclusion:
More students reported ever using e-cigarettes without nicotine than with nicotine in Ontario, Canada. This underscores the need for greater knowledge of the contents of both nicotine and nonnicotine e-cigarettes to better guide public health policies.
Background:
Smoking reduction remains a pivotal issue in public health policy, but quit rates obtained with traditional quit-smoking therapies remain disappointingly low. Tobacco Harm Reduction (THR), aiming at less harmful ways of consuming nicotine, may provide a more effective alternative. One promising candidate for THR are electronic cigarettes (e-cigs). The aim of this study was to investigate the efficacy of second-generation e-cigs both in terms of acute craving-reduction in the lab and in terms of smoking reduction and experienced benefits/complaints in an eight-month Randomized Controlled Trial (RCT).
Design:
RCT with three arms.
Methods:
Participants (N = 48) unwilling to quit smoking were randomized into two e-cig groups and one control group. During three lab sessions (over two months) participants, who had been abstinent for four hours, vaped/smoked for five minutes, after which we monitored the effect on craving and withdrawal symptoms. eCO and saliva cotinine levels were also measured. In between lab sessions, participants in the e-cig groups could use e-cigs or smoke ad libitum, whereas the control group could only smoke. After the lab sessions, the control group also received an e-cig. The RCT included several questionnaires, which repeatedly monitored the effect of ad libitum e-cig use on the use of tobacco cigarettes and the experienced benefits/complaints up to six months after the last lab session.
Results:
From the first lab session on, e-cig use after four hours of abstinence resulted in a reduction in cigarette craving which was of the same magnitude as when a cigarette was smoked, while eCO was unaffected. After two months, we observed that 34% of the e-cig groups had stopped smoking tobacco cigarettes, versus 0% of the control group. After five months, the e-cig groups demonstrated a total quit-rate of 37%, whereas the control group showed a quit rate of 38% three months after initiating e-cig use. At the end of the eight-month study, 19% of the e-cig groups and 25% of the control group were totally abstinent from smoking, while an overall reduction of 60% in the number of cigarettes smoked per day was observed (compared to intake). eCO levels decreased, whereas cotinine levels were the same in all groups at each moment of measurement. Reported benefits far outweighed the reported complaints.
Conclusion:
In a series of controlled lab sessions with e-cig naïve tobacco smokers, second generation e-cigs were shown to be immediately and highly effective in reducing abstinence induced cigarette craving and withdrawal symptoms, while not resulting in increases in eCO. Remarkable (>50 pc) eight-month reductions in, or complete abstinence from tobacco smoking was achieved with the e-cig in almost half (44%) of the participants.
Aims:
Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit.
Methods:
Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice).
Results:
At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up.
Conclusions:
Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.
