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Where Do Vapers Buy Their Vaping Supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey

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International Journal of Environmental Research and Public Health (IJERPH)
Authors:
  • b2: Population Health Solutions

Abstract and Figures

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU). Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons. Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US (1.87, 1.0–3.1). Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.
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International Journal of
Environmental Research
and Public Health
Article
Where Do Vapers Buy Their Vaping Supplies?
Findings from the International Tobacco Control
(ITC) 4 Country Smoking and Vaping Survey
David C. Braak 1, K. Michael Cummings 2, 3,* , Georges J. Nahhas 2,3, Bryan W. Heckman 2,3,
Ron Borland 4,5, Geoffrey T. Fong 6,7,8, David Hammond 9, Christian Boudreau 10,
Ann McNeill 11 , David T. Levy 12 and Ce Shang 13
1Colleges of Graduate Studies and Medicine, Medical University of South Carolina, Charleston, SC 29425,
USA; braak@musc.edu
2Department of Psychiatry & Behavioral Sciences, Medical University of South Carolina, Charleston,
SC 29425, USA; elnahas@musc.edu (G.J.N.); heckmanb@musc.edu (B.W.H.)
3Hollings Cancer Center, Medical University of South Carolina, Charleston, SC 29425, USA
4Nigel Gray Fellowship Group, Cancer Council Victoria, Melbourne 3004, Australia;
Ron.Borland@cancervic.org.au
5School of Psychology, Deakin University, Burwood, Melbourne 3220, Australia
6Department of Psychology and School of Public Health and Health Systems, University of Waterloo,
Waterloo, ON N2L 3G1, Canada; gfong@uwaterloo.ca
7Department of Psychology, University of Waterloo, Waterloo, ON N2L 3G1, Canada
8Ontario Institute for Cancer Research, Toronto, ON M5G 0A3, Canada
9School of Public Health and Health Systems, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
david.hammond@uwaterloo.ca
10 Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, ON N2L 3G1, Canada;
cboudreau@uwaterloo.ca
11 Department of Addictions, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London,
London WC2R 2LS, UK; ann.mcneill@kcl.ac.uk
12 Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University, Washington,
DC 20057, USA; dl777@georgetown.edu
13 Oklahoma Tobacco Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences
Center, Oklahoma City, OK 73104, USA; ce-shang@ouhsc.edu
*Correspondence: cummingk@musc.edu
Received: 19 December 2018; Accepted: 19 January 2019; Published: 26 January 2019


Abstract:
Aim: This study examines where vapers purchase their vaping refills in countries
having different regulations over such devices, Canada (CA), the United States (US), England (EN),
and Australia (AU). Methods: Data were available from 1899 current adult daily and weekly vapers
who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and
Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted
odds ratios and 95% confidence intervals were reported for between country comparisons. Results:
Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought
them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported
using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations
compared to CA (OR = 6.4, 2.3–17.9), the US (OR = 4.1, 1.54–10.7), and EN (OR = 7.9, 2.9–21.8). In the
US, they were more likely to buy from vape shops (OR = 3.3, 1.8–6.2) or online (OR = 1.9, 1.0–3.8) vs
other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at
vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2–10.9) and the US
(1.87, 1.0–3.1). Conclusions: The regulatory environment and enforcement of such regulations appear
to influence the location where vapers buy their vaping products. In AU, banning the retail sale of
nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the
lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.
Int. J. Environ. Res. Public Health 2019,16, 338; doi:10.3390/ijerph16030338 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019,16, 338 2 of 13
Keywords: electronic cigarettes; vaping; vaping policies
1. Introduction
Sales of nicotine vaping products (NVPs), also referred to as electronic cigarettes, have increased
over the past decade, and in some countries they have become the most popular quitting aid used
by smokers [
1
4
]. As vaping prevalence has increased over time, so has the diversity of products
available to consumers [
5
]. NVPs broadly include three types of products: (1) closed systems that are
intended to be thrown out when emptied (closed disposable system), (2) rechargeable devices which
use pre-filled e-liquid cartridges (closed cartridge system); and (3) and rechargeable open system
devices that allow users to refill the e-liquid used (open tank system). Different NVPs differ in how
they deliver nicotine, which influences quitting cigarette-smoking [
6
9
], though individual factors
may contribute as well [
10
]. Some types of products (ex. tank systems) require more accessory parts
than others (ex. disposable), it is possible that some retail locations will be more or less likely to sell
certain products. Users of various products may, therefore, be more or less likely to purchase at certain
locations as well.
A 2014 survey of online sites selling NVPs identified at least 466 brands available in 7764 assorted
flavors, with two types of propellants, offering an average of four to five nicotine strengths [
11
].
Recent evidence reviews suggest that NVPs are likely to have a substantially lower health impact
compared to cigarettes, although these evidence reviews also suggest that nicotine vaping is not done
without some potential health risks and the health risks are likely to be different for smokers who vape
exclusively compared to those who smoke and vape concurrently [
12
,
13
]. Because of their novelty
and the lack of conclusive evidence on their health effects, safety, and cessation efficacy, it has been
unclear whether NVPs should be regulated as tobacco products, therapeutic goods, medical devices,
or consumer lifestyle products [12,13].
Countries have taken different approaches to regulating NVPs, with some banning their sale
at retail without pre-market government authorization, and others allowing their sales with specific
restrictions, primarily age restrictions. Regulation in Australia (AU), and until recently in Canada,
(CA) prohibited the retail sale of NVPs unless government authorization had been obtained prior to
marketing. Non-nicotine vaping products were allowed for sale in all four countries. In CA, the law
restricting the sale of NVPs in retail locations changed in May 2018. However, at the time of this study
in 2016, health authorities in Canada did not enforce the NVP sales ban in retail establishments [
14
].
NVPs could be legally sold to adults at retail locations in England (EN) and the United States (US).
Studies found that government regulations restricting the sale and marketing of NVPs can influence
consumer awareness and use of NVPs [4].
While countries regulated the source of purchase differently, information on where individuals
buy their NVPs is limited. One cross sectional study on California high school students, found that
the most likely purchase location for NVPs was “smoke shops” for those older and younger than 18.
This study did not include “vape shop” in its answer choices, was mainly concerned with tobacco
products in general, and the majority of students surveyed obtained their products from a friend [
15
].
In this study, we reported on where current (daily and/or weekly) vapers purchase their vaping
products and refills, behavioral characteristics of users, and product features by purchase location.
We also compare purchase location by country of residence.
Int. J. Environ. Res. Public Health 2019,16, 338 3 of 13
2. Methods
2.1. Study Participants
Data were available from a sub-sample of the 2016 (Wave 1) International Tobacco Control Four
Country Smoking and Vaping (ITC 4CV1) participants who reported currently vaping daily or weekly.
Details about this survey can be found elsewhere [
16
]. Briefly, the ITC four country survey is an
online panel-based survey which included respondents 18 years or older who had smoked at least 100
cigarettes in their lifetime, who was currently smoking, or who had quit smoking within the last two
years. Recruitment was conducted entirely from web panels. Analyses presented in this paper were
restricted to those who reported purchasing their own vaping device or e-liquid. Those who did not
remember any details of their last purchase and those who did not answer the purchasing question
were excluded. There was a total of 1899 current daily or weekly vapers who reported purchasing
their products within the last 30 days, 456 in CA, 701 in the US, 667 in EN, and 75 in AU. Analyses
presented in this paper were restricted to those who reported purchasing their own vaping device or
e-liquid. Those who did not remember any details of their last purchase and those who did not answer
the purchasing question were excluded. There was a total of 1899 current daily or weekly vapers who
reported purchasing their products within the last 30 days, 456 in CA, 701 in the US, 667 in EN, and 75
in AU.
2.2. Measures
The outcome measure was where vapers reported purchasing their vaping products (online,
vape shop, other location). Participants were asked “Now thinking about the LAST TIME you
purchased disposable e-cigarettes, cartridges, or e-liquid, where did you make this last purchase?”
Responses were grouped into online, vape shop, or other (i.e., “tobacco specialty shop/tobacconist”,
“newsagent/off-license/corner shop/convenience shop”, “convenience store including petrol station”,
“gas/petrol station”, “supermarket”, “pharmacy”, “chemist”, “pub or bar”, “temporary mobile
sales location”, “some other kind of Shop”, “from outside the country”, or “from somewhere else”).
The independent variable was country of purchase (CA, the US, EN, and AU).
User characteristics included, smoking frequency (i.e., daily, non-daily, not at all), vaping
frequency (i.e., daily or weekly), vaping duration (i.e., <1 month, 1–3 months, >3 months). We also
examined how demographic characteristics, and vaping product features varied by purchase location
in each of the four countries.
Participant demographic characteristics included age (i.e., 18–24 years, 25–39 years, 40–54 years,
55+ years), gender (i.e., male vs female), race (i.e., white or non-white), and educational level (i.e.,
low = high school or less, moderate = technical degree or some university, high = completed university).
In addition, participants in each country were asked, “which of the following categories best describes
your annual household income, that is the total income before taxes, or gross income, of all persons
in your household combined, for one year?” Because currencies and standards for defining income
status varied between countries we categorized respondents as either low, moderate, or high income
as follows: US: low = less than 30,000 USD, moderate = 30,000–59,999 USD, and high = 60,000 USD,
and AU: low = less than 30,000 AUD, moderate = 30,000–59,999 AUD, and high = 60,000 CAD. For EN,
low = less than 30,000 GBP, moderate = 30,000–45,999 GBP, and high = 45,000 GBP or more.
Vaping product characteristics included self-reported e-liquid nicotine strength which was
collapsed into three groups: (1) no nicotine, (2) contains nicotine; and (3) don’t know, e-liquid
flavor (i.e., tobacco, menthol or mint, fruit, candy/deserts/sweets, and other), product type (i.e.,
disposable, cartridge, and tank systems), and product modifiability (i.e., power not modifiable, power
adjustment possible—but not used, power adjustment possible—and used, and don’t know), following
the approach suggested by O’Connor et al [5].
Int. J. Environ. Res. Public Health 2019,16, 338 4 of 13
2.3. Data Analysis
Weighted generalized logistic regression for survey data (i.e., proc surveylogistic) was performed
using SAS 9.4 (SAS Institute, Cary, NC, USA), accounting for missing data being missing not at
random (i.e., nomcar option) with purchasing location as the dependent variable and country as
the independent variable. The model was adjusted for smoking and vaping frequency, age, gender,
ethnicity, household income, educational level, e-liquid flavor, and type of vaping device. Those who
refused or did not report ethnicity, household income, and educational level were excluded along with
those who reported buying nicotine-free e-liquid. Frequencies and percentages were reported as well
as odds ratios with 95% confidence intervals for pair-wise comparisons between countries (i.e. country
vs country by location vs location).
2.4. Ethics Approval
The survey protocols and all materials, including the survey questionnaires, were cleared for
ethics by Institutional Review Board, Medical University of South Carolina (ORE #: 20803); Research
Ethics Office, King’s College London, UK (ORE #: 20803 and RESCM-17/18-2240); Office of Research
Ethics, University of Waterloo, Canada (ORE #: 20803 and ORE #: 21609); and Human Research Ethics,
Cancer Council Victoria, Australia (ORE #: 21609 and HREC 1603).
3. Results
Overall, in all four countries the majority of current vapers were white, and male. The ages of
the participants were fairly evenly distributed, though in the US and AU the largest age category was
25–39 (US: 33.4%, AU: 40.8%). In England and in Canada the ages of the participants skewed a little
older with the largest category in England being 55+ (38.3%) and the largest category in Canada being
40–45 (38.6%). In all four countries, most current vapers were categorized as daily vapers; in EN and
AU greater than 50% of current vapers did not smoke at all, whereas in Canada the largest category of
smoking frequency was daily smoking (45.2% of current vapers). Current vapers in all four countries
reported having a high household income the most often, and a moderate education level (except
in the US where the largest category of education level was “low”). In total 41.4% of current vapers
bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail
locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids; 90.3% in
CA, 90.2% in the US, 94.6% in EN, and 88.5% in.
In CA and the US, the majority of vapers bought their vaping products from vape shops, 65.3%
and 43.3%, respectively. In EN, most vapers bought their products from other retail locations (37.7%),
and in AU, mostly from online sources (65.2%). In all four countries, the majority of NVP users who
were purchasing their own products reported using tank system NVPs (67.6% in CA, 59.4% in US,
75.1% in EN, and 82.4% in AU), followed by cartridge systems (19.1% in CA, 29.6% in US, 20.7% in EN,
and 10.1% in AU), and disposables (13.2% in CA, 11% in US, 4.2% in EN, and 7.6% in AU). With the
exception of NVP users in EN (42.5%), the majority of survey participants reported using NVP that
allowed for adjustable power (61.7% in CA, 59.1% in the US, and 57.9% in AU), though this question
did not assess the 259 participants who reported using disposable systems.
Table 1a–d display the bi-variate descriptive characteristics of NVP users by purchase location
separately within each of the four countries. Overall, user characteristics and product characteristics
were fairly similar across the four countries.
Int. J. Environ. Res. Public Health 2019,16, 338 5 of 13
Table 1.
Sample characteristics by e-cigarette purchase location in (
a
) Canada (n= 456); (
b
) the United
States (n= 701); (c) England (n= 667); (d) Australia (n= 75).
(a)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Smoking frequency
Daily 49 (13.8) 139 (53.6) 87 (32.6) 275 (45.2)
Nondaily 14 (10.6) 79 (67.2) 23 (22.2) 116 (16.9)
Not at all 6 (11.4) 54 (78.5) 5 (10.2) 65 (37.9)
Vaping frequency
Daily 37 (10.9) 152 (72.8) 51 (16.3) 240 (59.4)
Nondaily 32 (14.4) 120 (54.4) 64 (31.2) 216 (40.6)
Been vaping for
Less than 1 month 3 (9.2) 16 (75.9) 6 (15) 25 (5.5)
1–3 months 9 (9.3) 39 (65.9) 17 (24.8) 65 (11.5)
>3 months 55 (12.6) 217 (64.8) 92 (22.6) 364 (82.7)
No answer 2 (100) 0 (0) 0 (0) 2 (0.3)
Age
18–24 18 (14.6) 58 (61.5) 27 (23.9) 103 (15.4)
25–39 29 (19.9) 100 (58.8) 36 (21.3) 165 (30.3)
40–45 19 (9.0) 84 (69.1) 38 (21.9) 141 (38.6)
55+ 3 (3.8) 30 (72.3) 14 (23.9) 47 (15.7)
Sex
Female 29 (11.1) 131 (71.2) 47 (17.7) 207 (46.5)
Male 40 (13.4) 141 (60.2) 68 (26.4) 249 (53.5)
Race
White 43 (10.1) 227 (67.4) 89 (22.5) 359 (86)
Nonwhite 26 (26.4) 43 (51.7) 26 (21.8) 95 (13.8)
Refused 0 (0) 2 (100) 0 (0) 2 (0.2)
Don’t know 0 (0) 0 (0) 0 (0) 0 (0) (0)
Household Income
Low 13 (15.6) 53 (61.7) 25 (22.6) 91 (18.7)
Moderate 20 (8.2) 81 (67.5) 34 (24.3) 135 (29.3)
High 36 (15.4) 116 (62.9) 50 (21.7) 202 (45.5)
No answer 0 (0) 22 (82.6) 6 (17.4) 28 (6.5)
Educational level
Low 10 (4.9) 81 (69.2) 31 (26) 122 (30)
Moderate 27 (10.2) 120 (71) 42 (18.7) 189 (45.2)
High 32 (25.4) 69 (49.7) 42 (24.8) 143 (24.5)
No answer 0 (0) 2 (100) 0 (0) 2 (0.3)
E-liquid flavor
Tobacco flavor 16 (10.7) 59 (64.2) 33 (25) 108 (22.3)
Menthol or mint 6 (4.9) 38 (53.9) 18 (41.3) 62 (15.2)
Fruit flavor 22 (17.2) 89 (68.3) 27 (14.5) 138 (31)
Candy, desserts, sweets 5 (4.6) 45 (82.2) 9 (13.2) 59 (12.2)
Other 20 (17) 41 (60.2) 28 (22.7) 89 (19.3)
E-liquid containing nicotine
No 2 (2.6) 14 (71.9) 8 (25.4) 24 (7.8)
Yes 65 (12.4) 254 (65.5) 105 (22.2) 424 (90.3)
Refused 0 (0) 1 (100) 0 (0) 1 (0.1)
Don’t know 2 (52.8) 3 (26.5) 2 (20.7) 7 (1.8)
Product type
Disposable 9 (13.1) 12 (17.4) 40 (69.4) 61 (13.2)
Cartridge 24 (15.2) 61 (61) 32 (23.8) 117 (19.1)
Tank 36 (11.4) 199 (75.9) 43 (12.7) 278 (67.6)
Int. J. Environ. Res. Public Health 2019,16, 338 6 of 13
Table 1. Cont.
(a)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Product power modifiability
Missing 9 (13.1) 12 (17.4) 40 (69.4) 61 (13.2)
Power not adjustable 13 (9.9) 62 (72.6) 21 (17.5) 96 (22)
Power adjustable but I don’t change it 23 (16.2) 78 (65.1) 27 (18.8) 128 (26.6)
Power adjustable and I change it 23 (10.9) 110 (77.1) 26 (12) 159 (35.1)
Don’t know 1 (9.7) 10 (86.2) 1 (4.1) 12 (3.1)
Total 69 (12.3) 272 (65.3) 115 (22.4) 456
(b)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Smoking frequency
Daily 107 (23.4) 168 (36.8) 190 (39.7) 465 (40.1)
Nondaily 33 (28.7) 61 (48.9) 38 (22.4) 132 (13.2)
Not at all 22 (29.2) 52 (47.3) 30 (23.5) 104 (46.7)
Vaping frequency
Daily 111 (27.7) 198 (45.6) 159 (26.8) 468 (78.2)
Nondaily 51 (23.7) 83 (35.3) 99 (40.9) 233 (21.8)
Been vaping for
Less than 1 month 27 (22.2) 30 (53.4) 43 (24.4) 100 (13.2)
1–3 months 14 (10.4) 32 (35.5) 34 (54) 80 (7.1)
>3 months 120 (29.0) 219 (42.5) 178 (28.5) 517 (79.4)
No answer 1 (44.5) 0 (0) 3 (55.5) 4 (0.3)
Age
18–24 33 (27.8) 71 (48.2) 65 (24) 169 (16)
25–39 78 (24.4) 120 (43.9) 120 (31.7) 318 (33.4)
40–45 28 (29) 36 (40.8) 30 (30.2) 94 (27)
55+ 23 (27) 54 (42.2) 43 (30.8) 120 (23.5)
Sex
Female 70 (26.3) 124 (45.8) 94 (27.9) 288 (42.4)
Male 92 (27.2) 157 (41.5) 164 (31.3) 413 (57.6)
Race
White 128 (27.3) 236 (44.5) 203 (28.2) 567 (89.8)
Nonwhite 34 (22.5) 43 (32.8) 55 (44.7) 132 (10.1)
Refused 0 (0) 2 (100) 0 (0) 2 (0.1)
Don’t know 0 (0) 0 (0) 0 (0) 0 (0) (0)
Household Income
Low 31 (31.3) 58 (43.3) 55 (25.5) 144 (32.8)
Moderate 36 (19) 74 (43.7) 54 (37.3) 164 (23.5)
High 95 (28.5) 145 (42.2) 146 (29.2) 386 (42.3)
No answer 0 ((.)) 4 (72.1) 3 (27.9) 7 (1.3)
Educational level
Low 43 (33.8) 72 (41.8) 55 (24.4) 170 (46)
Moderate 43 (24.6) 86 (46.9) 65 (28.6) 194 (26.4)
High 76 (17.3) 123 (42.5) 138 (40.2) 337 (27.6)
No answer 0 (0) 0 (0) 0 (0) 0 (0) (0)
Int. J. Environ. Res. Public Health 2019,16, 338 7 of 13
Table 1. Cont.
(b)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
E-liquid flavor
Tobacco flavor 44 (30.4) 48 (28.5) 82 (41.1) 174 (26.1)
Menthol or mint 24 (18.2) 58 (38.6) 57 (43.3) 139 (14)
Fruit flavor 29 (20.9) 76 (55) 46 (24) 151 (29.3)
Candy, desserts, sweets 15 (37.7) 35 (53.5) 10 (8.8) 60 (13.9)
Other 50 (29.7) 64 (41.5) 63 (28.8) 177 (16.7)
E-liquid containing nicotine
No 5 (47.8) 12 (49.9) 2 (2.3) 19 (3.3)
Yes 156 (27.6) 263 (45.1) 231 (27.3) 650 (90.2)
Refused 0 (0) 0 (0) 1 (100) 1 (0)
Don’t know 1 (5.3) 6 (16.5) 24 (78.2) 31 (6.5)
Product type
Disposable 35 (34.9) 21 (19) 60 (46.2) 116 (11)
Cartridge 55 (24.6) 77 (16.7) 148 (58.7) 280 (29.6)
Tank 72 (26.4) 183 (61.1) 50 (12.5) 305 (59.4)
Product power modifiability
Missing 35 (34.9) 21 (19) 60 (46.2) 116 (11)
Power not adjustable 26 (23.8) 45 (29.8) 67 (46.4) 138 (29.1)
Power adjustable but I don’t change it 38 (20.7) 73 (63.4) 46 (15.9) 157 (19.4)
Power adjustable and I change it 61 (29.9) 140 (50.4) 79 (19.7) 280 (39.7)
Don’t know 2 (19.4) 2 (30.6) 6 (50) 10 (0.8)
Total 162 (26.8) 281 (43.3) 258 (29.9) 701
(c)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Smoking frequency
Daily 100 (26.2) 124 (31.3) 130 (42.5) 354 (23.7)
Nondaily 55 (23.3) 61 (40.7) 58 (36) 174 (12.5)
Not at all 52 (36) 40 (27.7) 47 (36.3) 139 (63.8)
Vaping frequency
Daily 157 (33.6) 160 (29.9) 160 (36.6) 477 (86)
Nondaily 50 (23) 65 (32.1) 75 (45) 190 (14)
Been vaping for
Less than 1 month 13 (39.2) 11 (37.6) 11 (23.3) 35 (3.3)
1–3 months 23 (43) 30 (17.5) 30 (39.5) 83 (10.7)
>3 months 171 (30.6) 183 (31.2) 194 (38.2) 548 (85.8)
No answer 0 (0) 1 (100) 0 (0) 1 (0.3)
Age
18–24 61 (22) 80 (56.2) 54 (21.8) 195 (7.1)
25–39 49 (26.1) 61 (32.7) 73 (41.2) 183 (25.6)
40–45 37 (34.5) 37 (26.1) 47 (39.3) 121 (29)
55+ 60 (36.2) 47 (26.7) 61 (37.1) 168 (38.3)
Sex
Female 77 (30.8) 79 (33.7) 80 (35.5) 236 (48)
Male 130 (33.3) 146 (26.9) 155 (39.8) 431 (52)
Int. J. Environ. Res. Public Health 2019,16, 338 8 of 13
Table 1. Cont.
(c)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Race
White 176 (31) 198 (30.2) 213 (38.9) 587 (92.1)
Nonwhite 24 (49.4) 21 (18.2) 18 (32.3) 63 (5.2)
Refused 1 (17.3) 2 (68) 2 (14.7) 5 (1.2)
Don’t know 6 (54.9) 4 (41.7) 2 (3.4) 12 (1.5)
Household Income
Low 26 (18.6) 39 (32.3) 62 (49) 127 (17.3)
Moderate 59 (30.7) 62 (32.1) 66 (37.2) 187 (31.7)
High 107 (37) 106 (26.4) 97 (36.7) 310 (42.9)
No answer 15 (40.7) 18 (37.9) 10 (21.3) 43 (8.1)
Educational level
Low 41 (29.8) 54 (35.3) 48 (34.9) 143 (19.9)
Moderate 83 (29.7) 87 (29.2) 102 (41.1) 272 (60.2)
High 79 (48.2) 81 (23.9) 82 (27.9) 242 (15.7)
No answer 4 (18.1) 3 (42.8) 3 (39.1) 10 (4.3)
E-liquid flavor
Tobacco flavor 69 (35.2) 56 (23.2) 82 (41.6) 207 (33.8)
Menthol or mint 38 (29.8) 41 (20.5) 53 (49.7) 132 (26.7)
Fruit flavor 58 (28.5) 87 (50.6) 51 (21) 196 (26.1)
Candy, desserts, sweets 9 (16.8) 16 (29.8) 13 (53.4) 38 (3.9)
Other 33 (43.9) 25 (26.3) 36 (29.9) 94 (9.5)
E-liquid containing nicotine
No 7 (70) 4 (18.5) 3 (11.5) 14 (3.2)
Yes 193 (31.0) 219 (31.0) 217 (38.0) 629 (94.6)
Refused 2 (21.4) 0 (0) 2 (78.6) 4 (0.4)
Don’t know 5 (24.4) 2 (14.2) 13 (61.4) 20 (1.8)
Product type
Disposable 19 (18.2) 17 (21) 34 (60.9) 70 (4.2)
Cartridge 67 (36.6) 44 (12.2) 83 (51.2) 194 (20.7)
Tank 121 (31.7) 164 (35.6) 118 (32.7) 403 (75.1)
Product power modifiability
Missing 19 (18.2) 17 (21) 34 (60.9) 70 (4.2)
Power not adjustable 82 (33.5) 66 (24.3) 95 (42.1) 243 (51.7)
Power adjustable but I don’t change it 43 (32.3) 55 (28.9) 41 (38.8) 139 (14.9)
Power adjustable and I change it 57 (31) 84 (43.1) 59 (25.9) 200 (27.6)
Don’t know 6 (40.4) 3 (31.3) 6 (28.3) 15 (1.6)
Total 207 (32.1) 225 (30.2) 235 (37.7) 667
(d)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Smoking frequency
Daily 15 (44.3) 6 (8.5) 21 (47.2) 42 (32.6)
Nondaily 8 (73.8) 0 (0) 4 (26.2) 12 (10.5)
Not at all 15 (75.5) 6 (24.5) 0 (0) 21 (57)
Vaping frequency
Daily 32 (67.9) 12 (20.1) 16 (12) 60 (83)
Nondaily 6 (52.1) 0 (0) 9 (47.9) 15 (17)
Int. J. Environ. Res. Public Health 2019,16, 338 9 of 13
Table 1. Cont.
(d)
Online Vape Shop Other Retail Total
N(row %) N(row %) N(row %) N(col %)
Been vaping for
Less than 1 month 3 (63.6) 1 (5.3) 4 (31.1) 8 (6.4)
1–3 months 3 (33.3) 1 (7.5) 7 (59.2) 11 (12.6)
>3 months 32 (86.6) 10 (19.0) 14 (10.7) 56 (80.9)
No answer 0 (0) 0 (0) 0 (0) 0 (0)
Age
18–24 1 (21.1) 2 (71.3) 1 (7.7) 4 (10.6)
25–39 12 (66.1) 3 (14.2) 7 (19.6) 22 (40.8)
40–45 17 (64.3) 5 (9.2) 13 (26.4) 35 (27.5)
55+ 8 (86.6) 2 (3.8) 4 (9.6) 14 (21.1)
Sex
Female 7 (55.8) 8 (30.7) 11 (13.5) 26 (42.2)
Male 31 (72) 4 (6.5) 14 (21.5) 49 (57.8)
Race
White 35 (70.8) 8 (17.3) 18 (11.9) 61 (88.2)
Nonwhite 3 (22.9) 4 (12.5) 7 (64.6) 14 (11.8)
Refused 0 (0) 0 (0) 0 (0) 0 (0) (0)
Don’t know 0 (0) 0 (0) 0 (0) 0 (0) (0)
Household Income
Low 5 (80.1) 0 (0) 4 (19.9) 9 (8.1)
Moderate 7 (72.8) 2 (11.2) 6 (16) 15 (28.9)
High 26 (63.4) 9 (21.9) 14 (14.7) 49 (59.5)
No answer 0 (0) 1 (13) 1 (87) 2 (3.6)
Educational level
Low 11 (66.1) 3 (27) 3 (6.9) 17 (32.6)
Moderate 12 (65.9) 4 (11.5) 10 (22.6) 26 (43.8)
High 15 (62.5) 5 (12.1) 12 (25.3) 32 (23.6)
No answer 0 (0) 0 (0) 0 (0) 0 (0) (0)
E-liquid flavor
Tobacco flavor 14 (72.8) 1 (2.1) 7 (25.1) 22 (16.3)
Menthol or mint 1 (36.1) 2 (13) 5 (51) 8 (7.2)
Fruit flavor 6 (40.2) 3 (36.1) 5 (23.7) 14 (20)
Candy, desserts, sweets 5 (66.3) 2 (33.7) 0 (0) 7 (18.2)
Other 12 (80) 4 (5.4) 8 (14.6) 24 (38.3)
E-liquid containing nicotine
No 1 (8.1) 1 (10.6) 6 (81.3) 8 (6.5)
Yes 34 (68.6) 11 (18.1) 17 (13.3) 62 (88.5)
Refused 0 (0) 0 (0) 0 (0) 0 (0) (0)
Don’t know 3 (78.5) 0 (0) 2 (21.5) 5 (5)
Product type
Disposable 2 (10.3) 0 (0) 10 (89.7) 12 (7.6)
Cartridge 6 (40.2) 4 (14.6) 8 (45.2) 18 (10.1)
Tank 30 (73.2) 8 (18.5) 7 (8.3) 45 (82.4)
Product power modifiability
Missing 2 (10.3) 0 (0) 10 (89.7) 12 (7.6)
Power not adjustable 11 (75.2) 2 (3.1) 9 (21.8) 22 (33.7)
Power adjustable but I don’t change it 8 (88) 2 (9.6) 1 (2.5) 11 (10.2)
Power adjustable and I change it 16 (61.3) 8 (30.8) 5 (7.9) 29 (47.7)
Don’t know 1 (100) 0 (0) 0 (0) 1 (0.9)
Total 38 (65.2) 12 (16.7) 25 (18.1) 75
Int. J. Environ. Res. Public Health 2019,16, 338 10 of 13
Table 2compares the likelihood of purchasing locations of NVPs between all countries. In AU,
vapers were 6.4 times more likely to buy online vs other locations compared to vapers in CA (95%
CI: 2.3–17.1), 4.1 times more likely than in the US (95% CI: 1.5–10.7), and 7.9 times more likely than
respondents in EN (95% CI: 2.9–21.8). In the US, they were 3.3 times more likely to buy from vape
shops (95% CI: 1.8–6.2) and 1.9 times more likely to buy online (95% CI: 1.0–3.7) vs other retail locations
when compared to those in EN. Additionally, in CA, vapers were 5.1 times more likely to purchase at
vape shops than at other retail locations when compared to vapers in EN (95%CI: 3.2–10.9) and 1.8
times more likely than in the US (95% CI: 1.0–3.1).
Table 2. Adjusted analyses of purchase location (n= 1508).
Online vs Other Vape Shop vs Other Vape Shop vs Online
AOR (95% CI) AOR (95% CI) AOR (95% CI)
Australia vs Canada 6.4 (2.3–17.9) * 0.3 (0.1–1.1) 0.1 (0.01–0.2) *
Australia vs England 7.9 (2.9–21.8) * 2.0 (0.6–6.6) 0.2 (0.1–0.9) *
Australia vs United States 4.1 (1.5–10.7) * 0.6 (0.2–2.1) 0.1 (0.1–0.6) *
Canada vs England 1.2 (0.6–2.6) 5.9 (3.2–10.9) * 4.8 (2.4–9.3) *
Canada vs United States 0.6 (0.3–1.3) 1.8 (1.0–3.1) 2.8 (1.5–5.3) *
England vs United States 0.5 (0.3–1.0) 0.3 (0.2–0.6) * 0.6 (0.3–1.1)
Adjusted for smoking status, vaping status, age, sex, ethnicity, education, income, e-liquid flavor, and device type;
excludes race (refused, don’t know), educational level (no answer), household income (no answer), and nicotine
concentration (0, refused, don’t know). * indicates 95% CI does not include 1.0.
4. Discussion
Differences in how governments regulate and enforce laws regulating the legal points-of-sale
of NVPs appeared to influence where vapers obtained their vaping products and supplies. In CA,
Vape shops were the most preferred location for products purchase. In the US and EN the purchase
locations were fairly evenly distributed among vape shops, online, and other. In AU, most participants
reported purchasing their products online.
In this survey the vaping products that were assessed, aside from the vaping device themselves
were refills (i.e. pods, cartridges, e-liquid). In AU, the ban of sale of NVPs appears to have led to current
vapers relying mainly on online purchasing sources, unless they are buying non-nicotine containing
e-liquid, in which case, other retail outlets were the primary purchase location. The frequent purchase
from vape shops in CA was a surprise since technically the sale of NVPs was prohibited in retail
outlets without prior government approval. Up to 2016, no NVPs had received approval. It was widely
reported that Canadian authorities were not aggressively enforcing the rules preventing the sale of
NVPs in retail establishments, which may explain the reporting of vape shops as the primary source of
NVPs [
14
]. The law prohibiting the sale of NVPs in CA appears to have discouraged the marketing of
NVPs manufactured by cigarette companies and other vaping manufacturers who primarily market
their products in traditional cigarette selling outlets [
17
]. However, the lax enforcement of the law
may have allowed independently owned vape shops to flourish. As of May 2018, NVPs can be legally
sold in retail outlets in Canada that is likely to change where Canadian vapers will report buying their
NVPs in the future [18]. NVP users in the US and EN reported a wider variety of purchasing sources
for their NVPs, although vape shops were a popular location especially for exclusive NVP users using
tank systems.
While it appears that the regulatory environment in different countries can influence vaping
prevalence, even in restricted environments, such as AU, vaping is still happening with consumers
relying on online sources to purchase their nicotine vaping devices and supplies [
4
]. What is less clear
is how the diversity of NVP points of sale influences vaping and/or smoking behaviors. One might
expect that having a greater diversity of purchasing sources would provide more product options
for consumers at lower prices, thereby increasing vaping prevalence and perhaps contributing to an
accelerated decline in cigarette use. On the other hand, it is possible that by having a greater diversity
Int. J. Environ. Res. Public Health 2019,16, 338 11 of 13
of NVP selling outlets would have the unfortunate effect of encouraging the uptake of vaping by
nonsmokers, including teenagers. The apparent growing popularity of JUUL and other pod type
vaping products in the US and more recently in Canada has raised concerns about how NVPs are
marketed and to whom they are sold [1923].
Vape shops permit the purchase of NVPs in an environment where cigarettes are typically
not available. Two previous studies have suggested that smokers getting their NVPs from vape
shops were more likely to stop smoking cigarettes completely [
24
,
25
]. Although, it remains unclear
if the devices and information received in vape shops account for the higher quit rates or if it is
something about those who purchase vaping products from vape shops which make them more
likely to discontinue smoking. It is well established in the smoking cessation treatment literature that
combining pharmacotherapy with behavioral counseling increases the odds of smoking cessation over
pharmacotherapy or counseling alone [
26
]. In theory, one might expect that smokers purchasing their
NVPs from a vape shop would get better instruction on how to vape to maximize nicotine delivery
compared to those purchasing their NVPs online or in a cigarette selling retail store. Additionally,
since vape shops are typically not in the business of selling cigarettes or other tobacco products, there
would be an incentive for the vape shop owners to encourage consumers to completely switch away
from cigarettes [
27
]. On the other hand, vape shops remain unregulated, so it is unclear if consumers
would get accurate information about the NVPs they are purchasing [
28
]. While vape shops will likely
need to be regulated to some extent, the form and extent of regulatory oversight have not yet been
defined in the US [29].
This study has important limitations to consider. First, this is a descriptive study based on the
first wave of data collection making it impossible to draw firm conclusions about the temporality
of the associations. Second, this study only reports on the purchasing behaviors of current daily or
weekly vapers, whose purchasing patterns may be different for those who vape less frequently or
those who did not purchase their products. Third, the vaping product marketplace is rapidly changing
so that product features common to those NVP users in 2016 may not hold for those vaping today or
in the future. Finally, the small number of participants reporting the use of non-nicotine-containing
e-liquid limited the ability to compare them to those who use nicotine-containing liquid, furthermore
the “other” location in our analysis was a very heterogeneous group of purchase locations due to low
participant counts.
In summary, the findings from this study show that government regulations restricting where
NVPs can be legally sold, and how the regulations are enforced, influence both the location where
current NVP users report purchasing their NVPs and the types of product the report purchasing.
The AU retail sales ban of NVPs appears to have led vapers to rely on online purchasing sources.
In contrast, in CA, the lack of enforcement of this law has allowed vape shops to flourish limiting
access to NVPs sold alongside cigarettes. In the US and EN, NVP users reported a greater diversity of
purchase locations. Future studies should consider longitudinal data in order to elucidate the effects
of policy changes over time. For example, as the US considers limiting the sale of product categories
in certain locations, proceeding waves of the ITC project will be well positioned to capture an effect
on behavior.
Author Contributions:
The authors of this paper attest to their contributions to the paper in the following areas:
conceptualization: D.C.B., K.M.C., G.J.N., B.W.H., R.B., G.T.F., D.H., C.B., A.M., D.T.L. and C.S.; survey design and
execution: K.M.C., R.B., G.T.F., A.M. and C.B.; data analysis: D.C.B., K.M.C., G.J.N., B.W.H. and C.B.; data curation:
G.T.F., and C.B.; writing—original draft preparation: D.C.B., K.M.C., G.J.N., B.W.H. and C.B.; writing—review
and editing: D.C.B., K.M.C., G.J.N., B.W.H., R.B., G.T.F., D.H., C.B., A.M., D.T.L., and C.S.; project administration,
K.M.C., R.B., G.T.F., and A.M.; and funding acquisition: K.M.C., R.B., and G.T.F.
Funding:
This study was supported by grants from the National Cancer Institute of the US P01CA200512,
the Canadian Institutes of Health Research (FDN 148477), and by the National Health and Medical Research
Council of Australia APP1106451. Core support was provided in part through the biostatistics shared resource at
the Hollings Cancer Center, Medical University of South Carolina (P30 CA138313). GTF was supported in part
from a Senior Investigator Award from the Ontario Institute for Cancer Research. BWH was supported by NIDA
(K23 DA041616). DCB supported by NIH/NIDA GM-T32008716.
Int. J. Environ. Res. Public Health 2019,16, 338 12 of 13
Conflicts of Interest:
KMC has received payment as a consultant to Pfizer, Inc., for service on an external advisory
panel to assess ways to improve smoking cessation delivery in health care settings. KMC also has served as paid
expert witness in litigation filed against the tobacco industry.
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... The studies of adolescents largely used public school samples, limiting generalisability to adolescents who left school and private school students. ENP sales data from Nielsen do not capture vape shop or online sales while approximately 70% US vapers buy products online or from vape shops [100]. Outcome measurements were also often subject to participants' possible inaccurate recollection of ENP related experiences in the past 30 days, such as use, exposure to marketing, and noticing warning labels. ...
... Several prominent features that manufacturers often manipulate include nicotine concentration, nicotine form, flavors, and the ratio of vegetable glycerin (VG) to propylene glycol (PG), or VG/PG ratio [1,[6][7][8][9][10][11][12][13]. Nicotine concentration and form are the key factors that drive the exponential growth of the e-cigarettes online [39,40]. Online stores provide an easy-to-access retail environment for vapers especially during the COVID-19 pandemic [41,42]. ...
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Given the increase in electronic cigarette use during the past decade, the objectives of this study are to obtain comprehensive product-level information from online vape shops, which are one of the most common outlets for e-cigarette users to purchase vaping products, especially e-liquid products, and to examine the appeal of various e-liquid product attributes to consumers. We used web scraping and estimation of generalized estimating equation (GEE) models to obtain and analyze data from five popular online vape shops that sell nationwide across the US. The outcome measures are e-liquid pricing for the following e-liquid product attributes: nicotine concentration (in mg/ml), nicotine form (nicotine-free, freebase, or salt), vegetable glycerin/propylene glycol (VG/PG) ratio, and a variety of flavors. We find that the pricing for freebase nicotine and nicotine salt products are 1% (p<0.001) lower and 12% higher (p<0.001), respectively, than that for products that do not contain nicotine. For nicotine salt-based e-liquid products specifically, the pricing for a 50/50 VG/PG ratio is 10% (p<0.001) higher than the pricing for a more common 70/30 VG/PG ratio, and the pricing for fruity flavors is 2% (p<0.05) higher than that for tobacco/unflavored products. Regulating the nicotine form in all e-liquid products and fruity flavor in nicotine salt-based products will have a great impact on the market and consumers. The preference for VG/PG ratio varies by product nicotine form. More evidence on typical user patterns of a certain nicotine form (i.e., freebase or salt nicotine) is needed to assess the public health consequences of these regulations.
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Aims To explore where people in England typically buy e‐cigarettes/vaping products, how their characteristics and the types of products purchased differ according to the source of purchase and whether this is changing over time. Design This was a nationally representative monthly cross‐sectional survey. Setting The study was conducted in England, 2016–23. Participants A total of 6507 adults (≥ 18 years) who reported current vaping. Measurements Participants were asked where they usually buy their vaping products: vape shops, supermarkets/convenience stores, on‐line or other sources (‘other’ or cheap from friends). Findings Up to 2020, vape shops were the most common source of purchase (mean monthly proportion = 43.3%), followed by supermarkets/convenience stores (29.7%) and on‐line retailers (20.5%). In 2020, these purchasing patterns shifted: on‐line purchasing increased and vape‐shop purchasing fell. The rise in on‐line purchasing was short‐lived, peaking at 33.6% [95% confidence interval (CI) = 31.0–36.5%] in July 2021, and soon returned to baseline levels. However, the fall in vape‐shop purchasing persisted, remaining below 31% from July 2021 onwards, displaced by a rapid rise in purchasing from supermarkets and convenience stores from 31.6% (95% CI = 29.6–33.7%) in January 2021 to 48.5% (95% CI = 42.9–54.8%) by April 2023. This rise was most pronounced among younger adults (aged 18–35 years; P interaction < 0.001) and those mainly using disposable devices ( P interaction = 0.013). Purchasing from other sources was relatively rare, and declined from 9.1% (95% CI = 6.6–12.7%) in July 2016 to 4.3% (95% CI = 2.6–7.1%) in April 2023. Conclusions Supermarkets and convenience stores have recently overtaken vape shops to become the most popular places to buy vaping products in England. This change appears to have been driven by the rising popularity of new disposable e‐cigarettes among younger adults, who tend to buy these products from supermarkets/convenience stores.
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Background In response to the growing awareness and use of electronic nicotine delivery systems (ENDS), or e-cigarettes, the U.S. Food and Drug Administration asserted its regulatory authority over ENDS in May 2016. Federal, state, and local regulatory action on ENDS may have significant and unique impacts on specialty ENDS retailers, including tobacco and vape shops. The purpose of this study is to describe the commercial motivations of vape shops in minority communities as business entities whose financial interests and actions may be particularly impacted by regulation of ENDS. Methods Specialty tobacco and vape retail stores in three minority communities were identified through an online search and community canvassing. Key informant interviews were conducted with tobacco and vape shop owners or managers discussing the business interests and tactics of selling ENDS for their store. Interview data were coded and analyzed for major themes. Results Interviews with 18 tobacco shops and 9 vape shops were completed. Tobacco shops’ reasons for carrying e-cigarettes were business oriented, focused on maintaining their customer base. In comparison, vape shops opened because of the owner’s positive experiences with e-cigarettes and belief in the potential of e-cigarettes to help people quit or reduce smoking. Tobacco shops mainly see their customers as using e-cigarettes to quit smoking whereas vape shops reported their customers using e-cigarettes for more varied reasons. Tobacco shops are much more limited in their marketing than vape shops, which rely heavily on social media and experimentation with other forms of marketing. Conclusions Tobacco shops and vape shops differ in their rationale and approaches to the business of e-cigarettes. Vape shops engage in a wide range of activities that stabilize their financial interest and increase their influence with customers and within the vape community. In order for regulatory policymaking and tobacco control interventions to maximize effectiveness, the actions of vape shops in promoting ENDS use and influencing policy debates must be taken into account.
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Background While national surveys showed declines in e-cigarette use in the USA between 2015 and 2016, recent reports indicate that JUUL, a sleekly designed e-cigarette that looks like a USB drive, is increasingly being used by youth and young adults. However, the extent of JUUL’s growth and its marketing strategy have not been systematically examined. Methods A variety of data sources were used to examine JUUL retail sales in the USA and its marketing and promotion. Retail store scanner data were used to capture the retail sales of JUUL and other major e-cigarette brands for the period 2011–2017. A list of JUUL-related keywords was used to identify JUUL-related tweets on Twitter; to identify JUUL-related posts, hashtags and accounts on Instagram and to identify JUUL-related videos on YouTube. Results In the short 3-year period 2015–2017, JUUL has transformed from a little-known brand with minimum sales into the largest retail e-cigarette brand in the USA, lifting sales of the entire e-cigarette category. Its US$150 million retail sales in the last quarter of 2017 accounted for about 40% of e-cigarette retail market share. While marketing expenditures for JUUL were moderate, the sales growth of JUUL was accompanied by a variety of innovative, engaging and wide-reaching campaigns on Twitter, Instagram and YouTube, conducted by JUUL and its affiliated marketers. Conclusions The discrepancies between e-cigarette sales data and the prevalence of e-cigarette use from surveys highlight the challenges in tracking and understanding the use of new and emerging tobacco products. In a rapidly changing media environment, where successful and influential marketing campaigns can be conducted on social media at little cost, marketing expenditures alone may not fully capture the influence, reach and engagement of tobacco marketing.
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Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among U.S. middle and high school students (1). Exposure to e-cigarette advertisements is associated with higher odds of current e-cigarette use among middle and high school students (2-4). To assess patterns of self-reported exposure to four e-cigarette advertising sources (retail stores, the Internet, television, and newspapers and magazines), CDC analyzed data from the 2014, 2015, and 2016 National Youth Tobacco Surveys (NYTSs). Overall, exposure to e-cigarette advertising from at least one source increased each year during 2014-2016 (2014: 68.9%, 18.3 million; 2015: 73.0%, 19.2 million; 2016: 78.2%, 20.5 million). In 2016, exposure was highest for retail stores (68.0%), followed by the Internet (40.6%), television (37.7%), and newspapers and magazines (23.9%). During 2014-2016, youth exposure to e-cigarette advertising increased for retail stores (54.8% to 68.0%), decreased for newspapers and magazines (30.4% to 23.9%), and did not significantly change for the Internet or television. A comprehensive strategy to prevent and reduce youth use of e-cigarettes and other tobacco products includes efforts to reduce youth exposure to e-cigarette advertising from a range of sources, including retail stores, television, the Internet, and print media such as newspapers and magazines (5).
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Background and aims The regulatory environment for nicotine vaping products (NVPs) varies widely across countries and this will likely affect the devices used, nicotine content, and usage and hence the ability of NVPs to substitute for cigarettes. We aimed to describe the types of NVPs used by current vapers in four countries with varying regulatory and enforcement approaches toward the marketing and sale of NVPs. Methods Data are from Wave 1 (July‐November 2016) of the ITC Four Country Smoking and Vaping Survey (4CV1), conducted among a cohort of current and former smokers, and current NVP users (n=5,147 adults; ≥18 years) in Australia (AU), Canada (CA), England (EN), and the United States (US) reporting either current daily, weekly, or occasional NVP use. Devices were described by type, brand, voltage variability, and refill capacity. Refill solutions were described by flavour and nicotine content. Descriptive statistics and bivariate analyses were conducted on the overall sample and stratified by country. A multinomial logistic regression examined factors associated with device preference across the whole sample. Results The types of NVPs used differed by pattern of use and country. Exclusive, daily vapers were more likely to use refillable pen‐shaped devices (OR=10.0) or refillable box‐shaped devices (OR=5.4) than disposable cigalike devices, when compared with other (non‐daily/dual) users. Nearly all respondents reported using flavoured NVPs, fruit (28%) being the most common flavour. Refillable devices were the most popular: Refillable box‐shaped devices were more commonly reported by vapers in AU (36.8%) and US (31.4%), whereas in EN (47.4%) and CA (29.7%), vapers more often reported using refillable pen‐style devices. Most users also reported that their products contained nicotine, even in CA (87.8%) and AU, (91.2%) where vaping products containing nicotine were technically illegal. Conclusions In Australia, Canada, England, and the United States in 2016, refillable nicotine vaping products (NVP) were the most common type of NVP used by daily vapers. Most daily vapers reported using flavoured e‐liquids/refills (with variance across countries) and most reported using products that contain nicotine, even where vaping products with nicotine were banned.
Article
Aim To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN), and the United States (US). Methods The respondents were cigarette smokers, former smokers (quit within the previous two years), and at‐least‐weekly vapers, aged 18 and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18‐24 and vapers were over‐sampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys. Results Response rates by country for new recruits once invited ranged from 15.2% to 49.6%; cooperation rates were above 90%. Retention rates from the 4C cohort ranged from 35.7% to 44.2%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN, and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN, and 494 in the US. Conclusion The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education, and geography.
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Introduction: JUUL has emerged as the leading brand in a rapidly evolving e-cigarette market. JUUL is distinctive for its novel nicotine delivery method that results in high nicotine concentrations, as well as its sleek, discreet design. The current study examined national estimates of JUUL among youth in the United States (US), including whether JUUL users report different patterns of use compared to users of other e-cigarettes. Methods: Data was analyzed from the US arm of the ITC Youth Tobacco and E-cigarette Survey, an online survey conducted in July/August 2017 with youth aged 16 through 19 recruited from consumer panels (n=4086). Results: Overall, 14.2% of respondents had used an e-cigarette in the past 30 days. JUUL was the second-most popular brand reported by past-30-day e-cigarette users (9.7%). Compared to e-cigarette users of other brands, JUUL users were significantly older [adjusted Odds Ratio (aOR)=2.50, 95% Confidence Interval (CI): 1.56-4.01] and reported a greater number of computers in the household (a socioeconomic status proxy; aOR=1.55, 95% CI: 1.22-1.96), with no differences by sex, race/ethnicity, or student status. Controlling for sociodemographic variables, JUUL users were more likely than other e-cigarette users to have ever tried to quit e-cigarettes (aOR=2.65, 95% CI: 1.12-6.30), with no differences observed by smoking status, frequency of e-cigarette use, urges to use e-cigarettes, or perceived addiction to e-cigarettes. Conclusions: JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between users of JUUL and other e-cigarette brands. Implications: The current study examined national estimates of JUUL e-cigarette use among youth in the United States, during the early phase of JUUL's popularity. JUUL was among the most popular e-cigarette brands among youth, and there were few differences in sociodemographic profile or patterns of use between JUUL and other e-cigarette brands. The findings help to characterize the rapid rise of this new product category within the rapidly evolving e-cigarette market at a time when the FDA and public health community are seeking to understand JUUL and its appeal among young people.
Article
Objective To estimate the prevalence of JUUL use and identify demographic and psychosocial correlates of use among youth and young adults in the USA. Methods A national, probability-based sample was recruited via address-based sampling, with subsamples recruited from an existing probability-based online panel. Participants (N=14 379) ages 15–34 were surveyed about JUUL use, tobacco use, electronic nicotine delivery system (ENDS) harm perceptions, sensation seeking and demographic characteristics. Data were collected February–May 2018. Χ ² analyses assessed differences in JUUL use by demographic and psychosocial characteristics. Logistic regressions identified significant correlates of ever and current JUUL use. Results Overall, 6.0% reported ever JUUL use, and 3.3% reported past 30-day (ie, current) use. Rates were higher among participants aged 15–17 and 18–21 years, with 9.5% and 11.2% reporting ever use, and 6.1% and 7.7% reporting current use, respectively. Among current users aged 15–17 years, 55.8% reported use on 3 or more days in the past month, and over a quarter reported use on 10–30 days. Significant correlates of use included younger age, white race, greater financial comfort, perceptions of ENDS as less harmful than cigarettes, household ENDS use, high sensation seeking and current combustible tobacco use. Conclusion JUUL use was significantly higher among young people, with those under 21 having significantly higher odds of ever and current use. Frequency of use patterns suggest youth may not be experimenting with the device but using it regularly. Given the high nicotine content of JUUL, there is concern over the potential for addiction and other serious health consequences among young people. Findings suggest strong regulatory actions are needed to prevent youth and young adult uptake.
Article
Background: Most studies of electronic nicotine delivery systems (ENDS) compare self-selected users versus nonusers. The few randomized studies to date generally support a positive impact on reducing smoking behavior, but these studies are focused on guided ENDS use. This study presents a randomized, naturalistic trial of ENDS with prospective outcomes of uptake and behavioral changes in smoking. Methods: Adult smokers with minimal ENDS history were randomized in a 2:1 ratio to receive product for 3 weeks (n = 46), or not (n = 22). Changes in nicotine delivery (16 vs. 24 mg), midway through the study allowed a compelling opportunity to examine two ENDS products compared with the control group. Primary outcomes, assessed via daily diaries during sampling period and in-person laboratory visits over 4 months, included uptake and usage of ENDS, cessation-related outcomes, and exposure to smoke constituents. Results: All ENDS participants tried product at least once, with 48% of 24 mg and 30% of 16 mg using their assigned product for the entire sampling period. Within the 24 mg ENDs group, 57% made an independent purchase of ENDS, versus 28% of 16 mg, and 14% of control participants (P = 0.01). Smokers in both ENDS groups significantly reduced their smoking, whereas control participants did not (P = 0.03). Cessation behaviors (quit attempts, biologically verified abstinence) numerically but not statistically favored ENDS participants. Conclusions: Results suggest that cigarette smokers are willing to use ENDS with trends toward reduced cigarette smoking and positive changes in cessation-related behaviors. Impact: Randomized, naturalistic trials such as presented herein are needed to understand the population impact of e-cigarettes. Cancer Epidemiol Biomarkers Prev; 26(12); 1795–803. ©2017 AACR.
Article
Purpose The purpose of the study was to determine from whom and where adolescents obtained tobacco, including cigarettes, e-cigarettes, and hookah. Methods California adolescents (N = 772; 63.19% female; mean age = 16.13 years, SD = 1.61; 26.44% white, 22.12% Asian/Pacific Islander, 36.65% Hispanic, and 14.79% other) were surveyed about their access to different tobacco products. Results Adolescents were significantly more likely to obtain tobacco from friends (54.9%) than family members or direct purchasing (p < .001). Smoke shops were the most common purchase location across products (44.3%), with adolescents significantly more likely to purchase hookah and e-cigarettes from smoke shops than gas stations, liquor stores, or drug stores (p < .02). Conclusions The effective characterization of tobacco access patterns is critical to the development of comprehensive tobacco control. By demonstrating peers and smoke shops as the primary social and retail outlets, this study identifies targets for the optimization of regulation and messaging aimed at reducing adolescents' access to tobacco.
Article
Objectives To describe the effect of e-liquid flavors on nicotine intake and pharmacology of e-cigarettes. Methods 11 males and 3 females participated in a 3-day inpatient crossover study with strawberry, tobacco, and their usual flavor e-liquid. Nicotine levels were nominally 18 mg/ml in the strawberry (pH 8.29) and tobacco (pH 9.10) e-liquids and ranged between 3–18 mg/ml in the usual brands (mean pH 6.80). Each day consisted of a 15-puff session followed by 4 hours of abstinence, then 90 minutes of ad libitum use. Subjects used a KangerTech mini ProTank 3. Results After 15 puffs, the amount of nicotine inhaled and systemically retained were not significantly different between the strawberry and tobacco e-liquids but plasma AUC(0 → 180) was significantly higher with the strawberry e-liquid. While not significantly different, Cmax was 22% higher and various early time point AUCs to measure rate of rise of nicotine in blood ranged between 17-23% higher with the strawberry e-liquid compared to the tobacco e-liquid. During ad libitum use, systemic exposure to nicotine (AUC(0 → 90)) was the same for the tobacco and usual brand e-liquids but were both significantly lower than after using the strawberry e-liquid. The usual flavors were more liked and satisfying than the strawberry and tobacco e-liquids. Conclusion Flavors influence nicotine exposure through flavor liking, may affect rate of nicotine absorption possibly through pH effects, and contribute to heart rate acceleration and subjective effects of e-cigarettes. E-cigarette users titrate their nicotine exposure but the extent of titration may vary across flavors.