Article

Characteristics of nicotine vaping products used by participants in the 2016 ITC Four Country Smoking and Vaping Survey

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Abstract

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.

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... • In the USA, the approach began changing in 2016 since the regulation of all tobacco products became the responsibility of the US Food and Drug Administration (FDA). 52,74,111 The USA presents a somewhat heterogeneous picture owing to the relative autonomy of each single state with regard to taxation and health initiatives. 42 The approach pursued by the European Union with the EU TPD, published in 2014 and implemented by member states between 2016 and 2017, focuses on the reduction of risks for users and non-users who may be at risk if they come into contact with vaping products, e.g., children, 105 and on providing the member states with the necessary guidelines for national policies on tobacco products (European Parliament, 2014). ...
... As highlighted by O'Connor et al., 111 in countries such as Australia the restrictions are circumvented by purchasing nicotine-containing vape liquid online. The role played by the internet in helping vaping users avoid national restrictions had been highlighted in a paper six years previously, 112 l which found that people in Canada and Australia were aware of and using nicotine-containing vaping products, despite national vaping bans. ...
... 112 Furthermore, in Canada, the weaker implementation of vaping regulations means that manufacturers of vaping devices have been able to launch products, with enforcement of vaping regulations targeted primarily at dual manufacturers of tobacco and vaping products. 111 The USA has adopted a less restrictive regulatory approach that allows vaping products to be sold and advertised without specific constraints. 110 However, from 2016 all tobacco products, including e-cigarettes, have been placed under the regulatory authority of the US FDA. ...
Technical Report
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In the programme of work reported here, commissioned and funded by NIHR (National Institute for Health Research), we explored the impact and consequences of policy changes relating to tobacco consumption and supply in England and Scotland over the last decade, as well as the characteristics of e-cigarette use.
... 20 Findings related to preferred nicotine concentrations were similar for both current and former smokers who are current e-cigarette users; that is, they preferred 15 mg/mL followed by 15+ mg/mL nicotine e-liquid concentrations. 21 In other studies, former smokers reported initiating and continuing to use higher nicotine concentrations compared with current smokers or never smokers. 22,23 In another study of e-cigarette users that had recently quit smoking, higher nicotine concentrations were related to stronger perceived cigarette craving reduction and higher e-cigarette satisfaction. ...
... In general, the most preferred/used flavors were fruit, mint/ menthol, and candy/dessert flavors. 21,27,62,64,[68][69][70][71][72][73][74][75] For cigarette smokers who recently bought a JUUL e-cigarette online, mint and mango were the most commonly used flavors. 76 Mint and fruit flavors were also the most preferred JUUL flavors for college student and adult JUUL ever-users. ...
... 63 Compared to former smokers or cigarette-naive e-cigarette users, dual use and/or increasing age were associated with higher tobacco flavor preference, although fruit and/or menthol/mint flavors were still generally more preferred than tobacco even in these populations. 21,27,62,69 Dual users were more likely to begin e-cigarette use with tobacco flavor compared with former smokers. 62 Availability of a variety of flavors and the ability to switch between flavors was a valued aspect of e-cigarettes, and was often cited as a main reason for use-behind health and smoking cessation. ...
Article
Introduction: Many adult cigarette smokers use electronic cigarettes (e-cigarettes) to cut down on or quit smoking cigarettes. E-cigarettes with higher abuse potential and appeal might facilitate complete switching. E-liquid nicotine concentration and flavor are two of the characteristics that may affect the abuse potential and appeal of e-cigarettes. The objective of this systematic review was to compile results from survey, animal, human laboratory, and clinical studies to understand the possible effects of nicotine concentration and flavor on abuse potential and appeal of e-cigarettes in adult current and former cigarette and e-cigarette users. Methods: A comprehensive literature search was conducted in Ovid Medline and PsycINFO followed by citation tracking in Web of Science Core Collection. Peer-reviewed studies published in English between 2007 and August 2020 were selected that analyzed differences between e-liquid nicotine concentration and/or flavors, had outcome measures related to abuse potential and/or appeal, and included adult humans (18+) or animals. 1624 studies were identified and screened. A qualitative synthesis of results was performed. Results: Results from 104 studies included in this review suggest that higher nicotine concentration and access to a variety of flavors are likely to be associated with higher abuse potential and appeal of e-cigarettes for adult current and former cigarette and e-cigarette users. Conclusions: Higher nicotine concentrations and the availability of a variety of flavors in e-cigarettes might facilitate complete substitution for cigarettes. Future e-cigarette regulations should take into account their impact on smokers, for whom e-cigarettes may be a cessation tool or reduced-harm alternative. Implications: E-cigarettes may provide a reduced-harm alternative to cigarettes for smokers unwilling/unable to quit or serve as a path for quitting all nicotine products. Higher nicotine concentrations and flavor variety are associated with higher abuse potential and appeal of e-cigarettes. Higher abuse potential and appeal products may help facilitate complete switching from cigarettes to e-cigarettes. Regulation of nicotine concentration and flavors aimed at decreasing naïve uptake may inadvertently decrease uptake and complete switching among smokers, reducing the harm reduction potential of e-cigarettes. Evidence-based effects of regulating nicotine concentration and flavors must be considered for the population as a whole, including smokers.
... 'Cigalike' NVPs were the most popular products in 2012-2013, 2 though by 2016-2017, tank-style and mod-style (ie, modified) NVPs had supplanted existing products. [3][4][5] JUUL, a high-nicotine pod-style NVP, emerged in 2015 and grew to 40% of the US NVP retail market share by the end of 2017. 6 While high-nicotine NVPs appear to be growing, 7 8 these studies generally use US Nielsen data, which does not capture vape shops and e-commerce purchasing. ...
... Vaping/smoking status. NVP use was dichotomied as daily or non-daily, as was cigarette smoking and combined to create six use status categories: (1) exclusive daily vaper, (2) exclusive non-daily vaper, (3) dual daily (daily NVP/daily cigarette, (4) predominant vaper (daily NVP/non-daily cigarette), (5) predominant smoker (non-daily NVP/daily cigarette) and (6) concurrent non-daily (non-daily NVP/non-daily cigarette). 32 NVP characteristics. ...
... O'Connor et al). 5 Five NVP types were based on two questions about NVP description ('Which of the following best describes the type of e-cigarette/vaping device you currently use most?', that is, disposable, prefilled cartridge, refillable tank) and appearance ('Which of the following best describes the appearance…?', that is, cigarette-like, cigarette-like but different colour, pen-like, box-like, other). ...
Article
Objectives: Regulation of nicotine vaping products (NVPs) varies between countries, impacting the availability and use of these products. This study updated the analyses of O’Connor et al on types of NVPs used and examined changes in NVP features used over 18 months in four countries with differing regulatory environments. Design: Data are from 4734 adult current vapers in Australia, Canada, England and the USA from Waves 1 (2016) and 2 (2018) of the International Tobacco Control Four Country Smoking and Vaping Survey. NVP characteristics included device description, adjustable voltage, nicotine content and tank size. Longitudinal analyses (n=1058) assessed movement towards or away from more complex/modifiable NVPs. A logistic regression was used to examine factors associated with changes in device description from 2016 to 2018. Results: Like 2016, box-tanks were the most popular NVP (37.3%) in all four countries in 2018. Over 80% of vapers continued using the same NVP and nicotine content between waves, though movement tended towards more complex/modifiable devices (14.4% of vapers). Box-tank users, exclusive daily vapers and older vapers were most likely to continue using the same device description. Certain NVPs and features differed by country, such as higher nicotine contents in the USA (11.5% use 21+ mg/mL) and greater device stability over time in Australia (90.8% stability). Conclusions: Most vapers continued using the same vaping device and features over 18 months. Differences in NVP types and features were observed between countries, suggesting that differing NVP regulations affect consumer choices regarding the type of vaping device to use.
... 6 By contrast, MOD users predominantly report using low nicotine contents (eg, <20 mg/ml). 35 Additionally, lactic, benzoic, and levulinic acids have been identified as the most common acids in nicotine salt liquids, 6 which was replicated in the current study. The use of higher VG/lower PG ratios in both MODs and PODs are consistent with research suggesting that PG-dominant liquids may be less pleasant and satisfying to ENDS users, 36 though the VG:PG ratio was more even in POD liquids compared to MOD liquids. ...
... 38 It is likely that this statewide flavor ban will have a larger impact on MOD users, who commonly use fruit and sweet flavors as also observed in national datasets. 35,39 However, fruit flavors were still most popular among POD users, which may be indicative of pre-flavor ban data collection or suggest that retailers and consumers are circumventing this flavor ban. Surprisingly, puff topography did not differ between MOD and POD users despite differences in device and liquid characteristics. ...
Article
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Introduction POD electronic nicotine delivery systems (ENDS), often containing high concentrations of nicotine salts, have replaced MODs (i.e., open/modifiable devices) as the most popular devices. The purpose of this study was to compare device/liquid characteristics, use behavior, and nicotine exposure between POD and MOD users. Methods Data from the initial visit of a prospective observational study of exclusive ENDS users compared MOD (n=48) and POD (n=37) users. Participants completed questionnaires on demographic characteristics, patterns of ENDS use, and ENDS features. A urine sample was collected to test for cotinine and an ENDS liquid sample was collected to test for nicotine and salts. Puff topography was captured during an ad libitum bout at the end of the session. Results MOD and POD users did not differ on demographic characteristics. MOD users reported purchasing more liquid in the past month than POD users (180.4±28.0 vs. 50.9±9.0 ml, p<.001). Differences in characteristics of devices used by MOD and POD users included flavor type (p=.029), nicotine concentration (liquids used by MOD users contained less nicotine than those used by POD users: 8.9±2.0 vs. 41.6±3.2 mg/ml, p<.001), and presence of the nicotine salt (fewer MOD liquids had salts present than POD liquids: 11.9% vs. 77.4%, p<.001). User groups did not differ on urinary cotinine levels or puff topography (ps>.05). Conclusions Despite different characteristics of MOD and POD ENDS, users of those products are exposed to similar amounts of nicotine, likely due to using more liquid among MOD users. IMPLICATIONS This study directly compares ENDS product characteristics, user behavior, and nicotine exposure between MOD and POD ENDS users. Although POD products contained higher nicotine concentrations compared to MOD products, users of PODs reported consuming less liquid than MOD users. Ultimately, MOD and POD users were exposed to similar levels of nicotine, suggesting users behaviorally compensate for differences in product characteristics.
... However, only 41% of Australian e-cigarette users surveyed in that study were confident their vaping products contained nicotine. By contrast, 91% of Australian current vapers surveyed for the International Tobacco Control Four-Country Smoking and Vaping Survey in 2016 used vaping products containing nicotine [15]. ...
... The proportion of vapers sourcing their e-cigarettes from overseas websites, while substantial, was well below proportions of Australian vapers using nicotine in recent studies [15,22]. Reliable information on the proportion of Australian vapers using nicotine ecigarettes and differences in efficacy of e-cigarettes with and without nicotine is needed to understand the impact of Australia's current ecigarette regulations. ...
Article
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Background and aims: Previous analyses of the effect of e-cigarettes on real world smoking cessation success have mostly been based on surveys undertaken in the US and UK where nicotine e-cigarettes can be readily obtained. In Australia, regulations have made obtaining e-cigarettes containing nicotine difficult. The effectiveness of e-cigarette use as a smoking cessation aid in Australia might therefore be lower than survey-based estimates published to date. This study aimed to estimate the effect of using e-cigarettes for a smoking cessation attempt on past-year smoking cessation success in Australia. Design: Multivariable logistic regression models for past-year smoking cessation success. Setting and participants: Respondents to the 2019 wave of Australia's National Drug Strategy Household Survey who made a smoking cessation attempt in the 12 months leading up to the survey. Measurements: Past-year smoking cessation success was assumed if a smoking cessation attempt resulted in abstinence of more than a month at the time of the survey. Findings: In 2019, Australians that attempted to quit smoking using e-cigarettes achieved greater success than smokers attempting to quit without e-cigarettes (adjusted odds ratio = 1.68; 95% confidence interval (CI): 1.09 - 2.60). If people that only tried e-cigarettes once or twice are considered not to have used e-cigarettes, the estimated effect was slightly stronger (aOR = 1.98; 95% CI: 1.27 - 3.10). Also, the estimated odds ratio was higher among vapers that acquired their e-cigarettes from overseas websites (aOR = 2.24; 95% CI: 1.02 - 4.93). Conclusions: Use of e-cigarettes for a smoking cessation attempt appears to be associated with greater success among Australians who attempted to quit tobacco in 2019 compared with Australians attempting to quit without e-cigarettes, after adjusting for confounding effects.
... 7 Research has also demonstrated that flavours can facilitate smoking cessation. 17,18 Fruit flavours are the most popular among both youth and adult vapers, 5,7,[19][20][21] although, in Canada, tobacco flavours are more commonly used by adults than youth. 4,5 Studies have identified thousands of different e-liquid flavours in the US 22 as well as numerous flavour categories; 23 however, we are unaware of any comprehensive study of the flavour profile of the Canadian e-liquid market. ...
... Third, this study identified a wide range of e-liquid flavours on the Canadian market. The most common flavour category was fruit, consistent with survey data suggesting that fruit is the most popular flavour among both youth and adult vapers, 4,5,[19][20][21] Despite this, "other" flavours had the highest nicotine concentrations. Data suggest an expansion in the availability of flavours since 2014, when the only flavour categories identified were fruit, candy/desserts, drinks and tobacco, 29 compared with the 11 flavour categories identified in this 2020 scan. ...
Article
Introduction The e-cigarette market in Canada has rapidly evolved following the implementation of the Tobacco and Vaping Products Act in May 2018, which liberalized the promotion and sale of vaping products. To date, there is little data on the market profile of key product attributes, including nicotine content, labelling practices and flavours. Methods An online scan of vaping product retailers (manufacturer, two national, five provincial) was conducted in 2020 to assess the e-liquids available on the Canadian market.Data were extracted from websites and product images regarding the nicotine content, labelling and flavours of e-liquids. Results We identified 1746 e-liquids, with a total of 4790 different nicotine concentrations. Approximately half of the e-liquids were offered with salt-base nicotine (46.6%) and half with freebase nicotine (53.2%); the remainder were hybrids (0.2%). The mean nicotine concentration of salt-base e-liquids (3.4%) was higher than freebase e-liquids (0.5%) (p < 0.001). Labels indicating the presence of nicotine were visible on two thirds of e-liquid packaging displayed online (63.2%) while three-quarters of packaging displayed the nicotine concentration (73.7%), and more than half of packaging displayed health warnings (58.9%). A variety of flavours were also identified, with fruit being the most common (43.6%), followed by candy/desserts (27.6%) and non-alcoholic drinks (12.5%). Conclusion Findings demonstrate the diversity of the online e-cigarette market in Canada, including the availability of higher-concentration salt-base nicotine products. Flavour restrictions have the potential to dramatically reduce the number of e-liquid flavours on the market, while restricting nicotine concentrations to < 20 mg/mL will predominantly restrict salt-based e-liquids.
... Products were chosen from brands and styles most commonly reported by current VP users in each country in wave 1 of the ITC Four Country Smoking and Vaping Survey (ITC4CV). 22 Methodological details for each country are available in Thompson et al 23 and via the ITC website (http://www. itcproject. ...
... Tobacco, menthol and cherry (as a representative fruit) flavours were selected as these were reported to be the most commonly reported flavours and were offered by many manufacturers. 22 Labelled nicotine concentrations of 0.5-20 mg/ mL and (in USA) >20 mg/mL were targeted to cover a range of commonly reported values, which also allowed us to evaluate the level of compliance in England with the EU TPD limit of 20 mg/mL nicotine. In total, 245 liquids were purchased across the four sites (166 in England, 54 in the USA, 15 in Australia and 10 in Canada). ...
Article
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Objectives: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs. Methods: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals. Results: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries. Conclusions: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.
... Second, regulations on nicotine vaping products, which could shape the trends in e-cigarette use, vary greatly across countries. In the European Union, e-liquid bottles with nicotine concentrations greater that 20mg/ml are considered as medicinal products and the refillable tank capacity has been limited to 2 mL since 2016 (50). In the UK, selling nicotine products to minors has been forbidden since 2015; in Australia, nicotine vaping products have been banned from retail, while they require special approval in Canada (51). ...
... In France, advertising and sales of these products to minors have been banned since 2016, as well as their use in schools and other public places; furthermore, a warning on the packaging of these e-devices and e-liquids is required, indicating that they are not recommended to non-smokers. Liquids with concentrations of nicotine exceeding 20 mg/ml are prohibited, which is not the case in the USA (52), Canada, the UK or Australia (50). These distinct regulatory environments appear to influence the levels of social acceptability of e-cigarette use, typically lower in Australia compared to the US, Canada, and the UK in 2016 (53). ...
Article
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Background and aims: Most studies in English-speaking countries have found a positive association between e-cigarette experimentation and subsequent daily tobacco smoking among adolescents. However, this result may not be valid in other cultural contexts; in addition, few studies have assessed whether this association varies with the subject's age at the time of e-cigarette experimentation. This study aimed to estimate the association between experimenting first with e-cigarette (rather than tobacco) and subsequent daily smoking according to age at the time of experimentation. Design: Secondary analysis; risk-ratios (RRs) computed using modified Poisson regressions with inverse probability weighting. Setting: A cross-sectional nationwide representative survey performed in 2017 in France. Participants: French adolescents (n=24,111), aged 17 to 18.5 years, who had previously experimented with either e-cigarettes or tobacco. Measures: Exposure was defined as the experimentation with e-cigarettes first (whether or not followed by experimentation with tobacco); the outcome as daily tobacco smoking at the time of data collection. Gender, age, literacy, socioeconomic status, pre-exposure repeat school years and experimentation with 12 other licit and illicit drugs were adjusted for. Uncertainties about the sequence of events defining exposure were handled by the definition of three patterns of exposure, to avoid a misclassification bias. Findings: Exposure reduced the risk of transition to daily smoking: RR=0.58, 95%CI=[0.54, 0.62]. This effect increased in linear manner with age at exposure (RR=0.87, 95%CI=[0.78; 0.98] for 1 year, p<0.001): from RR=1.30 95%CI=[1.09; 1.54] at age 9 to RR=0.38, 95%CI=[0.32; 0.45] at age 17. Conclusions: Experimenting with e-cigarettes first (as opposed to tobacco first) appears to be associated with a reduction in the risk of daily tobacco smoking among French adolescent at ages 17-18.5, but this risk varies negatively with age at experimentation, and early e-cigarette experimenters are at higher risk.
... 14,19 Research showed that flavor use and preferences may differ between user groups. 8,9,[20][21][22] Thus, e-liquid flavors could be regulated in order to maximize public health benefits, and for this, research on flavor preferences among different user groups is needed. ...
... rather than creating an e-cigarette context (eg, how much would you like to try an e-cigarette with this flavor?). Because liking depends on context factors 42 and flavor preference in an e-cigarette context may differ between user groups, 8,9,[20][21][22] differences in hedonic flavor assessment between user groups may have been found if questions were to be asked in an e-cigarette context. In addition, as people are often unable to identify unlabeled flavors without a predefined list of verbal descriptors to choose from 47 and learned associations from previous experiences can influence the hedonic perception, 48 outcomes may have been different if participants would be aware of the specific flavors used in this study. ...
Article
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Introduction: Sensory research on e-liquid flavors can be performed by means of smelling and vaping. However, data comparing smelling versus vaping e-liquid flavors is lacking. This study aims to investigate if smelling could be an alternative to vaping experiments by determining the correlation for hedonic flavor assessment between orthonasal smelling and vaping of e-liquids, for smokers and non-smokers. Methods: Twenty-four young adult smokers (mean age 24.8±9.3) and twenty-four non-smokers (mean age 24.9±7.7) smelled and vaped 25 e-liquids in various flavors. Participants rated liking, intensity, familiarity, and irritation on a 100 mm Visual Analogue Scale. Pearson correlations within and between smelling and vaping were calculated. Differences between user groups were calculated using t-tests. Results: Correlation coefficients between smelling and vaping based on mean group ratings were 0.84 for liking, 0.82 for intensity, 0.84 for familiarity, and 0.73 for irritation. Means of the within-subjects correlation coefficients were respectively 0.51, 0.37, 0.47, and 0.25. Correlations between smelling and vaping varied across individuals (ranging from -0.27 to 0.87) and flavors (-0.33 to 0.81). Correlations and mean liking ratings did not differ between smokers and non-smokers. Conclusions: The strong group-level correlations between orthonasal smelling and vaping e-liquid flavors justify the use of smelling instead of vaping in future research. For example, smelling could be used to investigate differences in e-liquid flavor liking between (potential) user groups such as nicotine-naïve adolescents. The more modest within-subject correlations and variation across individuals and flavors merit caution in using smelling instead of vaping in other types of experiments. Implications: This study supports the use of orthonasal smelling (instead of vaping) e-liquids to measure hedonic flavor perception in some studies where vaping would be inappropriate or not feasible. Examples of research situations where smelling e-liquids may be sufficient are (1) investigating nicotine-naïve individuals (i.e. non-users), (2) investigating individuals under legal age for e-cigarette use (i.e. youth and adolescents), (3) investigating brain responses to exposure of e-liquid flavors using fMRI or EEG, and (4) comparing hedonic flavor assessment between adolescent non-users and current smokers to provide support for future regulations on e-liquid flavors.
... (18,19,43) However, our study was conducted when most people who used NVP were using modifiable tank-style NVP devices (sometimes referred to as 3rd generation devices (44)) with purportedly improved nicotine delivery. (45,46) Differences in TNE-2 levels across various user groups may reflect an actual difference in the ability to deliver nicotine from NVPs versus HTPs and CCs. Farsalinos et al. (47) previously observed lower nicotine yields from a 3 rd generation NVP device than from HTP product IQOS when both devices were puffed for 2 secs. ...
Article
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Background: Comparisons of nicotine and toxicant exposure between people who use different alternative tobacco products remains underexplored. Methods: This cross-sectional, multi-country study analyzed urinary metabolites of nicotine, NNK, and volatile organic compounds (acrolein, acrylamide, acrylonitrile) among established users (n=550) in Japan and Canada. Participants exclusively or concurrently used nicotine vaping products (NVPs; Canada only), heated tobacco products (HTPs; Japan only), and combustible cigarettes (CCs; Japan and Canada), or abstained (Japan and Canada). Results: All product groups showed substantial nicotine exposure. Both HTPs and NVPs exposed exclusive users to lower toxicant levels than exclusive CC use. Canadian participants who exclusively used NVPs exhibited lower NNK and acrolein exposure but higher acrylamide exposure than Japanese participants who exclusively used HTPs. Concurrent use of CCs alongside alternative products exposed users to higher toxicant levels compared to exclusive use of either alternative product. Conclusions: Exclusive use of alternative tobacco products results in significant nicotine exposure but substantially lower toxicant exposure compared to exclusive CC use. People who use HTPs in Japan may experience higher exposure to nicotine and certain toxicants (NNK, acrolein) than people who use NVPs in Canada. Concurrent use results suggest that partially substituting CCs with alternative products may reduce toxicant exposure, but to a lesser extent than completely transitioning to alternative products. Impact: Exposure patterns between two popular alternative tobacco products differ. The overall toxicant exposure from these products is lower than CCs, providing critical data for regulatory decisions and public health considerations.
... Nicotine, a highly addictive and hazardous psychoactive substance, can have detrimental effects on various organs in the human body. 1 Unsurprisingly, tobacco consumption, a primary source of nicotine, continues to contribute significantly to global mortality and morbidity rates. 2 In Canada, cigarette smoking and e-cigarette use are the predominant modes of nicotine consumption. 3 According to Statistics Canada, 4 the number of individuals smoking cigarettes aged 12 years and older decreased from 5.3 million in 2015 to 3.8 million in 2021. However, there has been a significant surge in e-cigarette usage in recent years. ...
Article
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Many Canadians use nicotine products such as cigarettes and e-cigarettes. A particular subpopulation of concern is post-secondary students given they have a higher prevalence of use. Many correlates of cigarette smoking and e-cigarette use have been identified. However, less focus has been on examining the correlates of cigarette smoking, e-cigarette use and dual use. This study explores the correlates of different nicotine modality use in post-secondary students. Using data from the Canadian Campus Wellbeing Survey (CCWS; n = 27,164), a multi-level nominal regression assessed the correlates of nicotine modality use. In comparison to individuals who were <20, individuals 20-24 (OR = .448, 95% CI .321, .625), 25-29 (OR = .140, 95% CI .093, .212), 30-34 (OR = .076, 95% CI .046, .125) and over 35 (OR = .041, 95% CI .024, .071) had lower odds of e-cigarette use compared to cigarette smoking. Identifying as a woman (OR = 1.553, 95% CI 1.202, 2.006), non-heterosexual (OR = .642, 95% CI = .485,0.851), current cannabis user (OR = 1.651, 95% CI 1.296, 2.104), and being an international student (OR = .350, 95% CI .251, .487) also impacted the odds of e-cigarette use vs only cigarette smoking. When considering dual use vs cigarette smoking, individuals aged 20-24 (OR = .491, 95% CI .337, .717), 25-29 (OR = .221, 95% CI .137, .357), 30-34 (OR = .163, 95% CI .091, .292) and over 35 (OR = .122, 95% CI .065, .230) had lower odds than individuals <20. Current cannabis use (OR = 1.680, 95% CI = 1.209, 2.138), binge drinking (OR = 1.885, 95% CI 1.384, 2.568), and international student status (OR = .689, 95% CI .476, .996) also impacted cigarette smoking vs dual-use. Overall, a minority of young adults (11.5%) at post-secondary institutions in our sample use nicotine products, and the higher prevalence of e-cigarette use warrants continued monitoring. Health promotion campaigns addressing e-cigarette use are required. Additionally, tailored intervention efforts could prioritize the treatment needs of international students studying in Canada.
... Nevertheless, regulations on nicotine form and strength may need to balance both the harm-reducing and harm-inducing uses of e-cigarettes by weighing potentials to reduce youth addiction vs. harm-reducing transitions to e-cigarettes. Given that youth and young e-cigarette users prefer either pod systems (e.g., JUUL) or disposables (e.g., puff bars) to e-liquid products, our findings on nicotine salt preference may be particularly relevant to adult e-liquid or opensystem e-cigarette users [49,50]. In addition, existing evidence shows that open systems may help adult smokers to quit smoking [51]. ...
Article
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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.
... Accordingly, Australia's regulatory framework is based on the precautionary principle: the purchase of nicotine-containing e-cigarettes and e-liquids without a prescription from a medical practitioner is prohibited in all Australian States and Territories. However, such e-liquids can easily be accessed online (Yong et al., 2014;O'Connor et al., 2019;Wood, 2021) and non-nicotine e-liquids remain legal despite evidence suggesting that the risks associated with e-cigarette use are not limited to nicotine exposure (Goniewicz et al., 2014;Tobore, 2019;Korfei, 2018). ...
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Increases in e-cigarette use are of concern to public health authorities given the harms associated with vaping. Understanding people's perceptions of the risks and benefits of e-cigarette use has the potential to assist with prevention efforts. However, research assessing the perceptions of Australian adolescents and any differences in perceptions between adolescents, young adults, and adults is limited. Additionally, research exploring perceptions of various types of e-cigarettes is lacking. To inform the development of prevention and intervention programs and policies, this study aimed to explore Australians' perceptions of the risks and benefits associated with e-cigarette use and whether perceptions differ by age and user status. A sample of 4,617 Australians aged 12 + years completed an online survey that assessed (i) smoking and e-cigarette user status, (ii) e-cigarette risk perceptions, (iii) beliefs about e-cigarettes as a smoking cessation tool, and (iv) positive e-cigarette outcome expectancies. Across all age groups, respondents perceived non-nicotine and flavoured e-cigarettes as less harmful than nicotine e-cigarettes. Significantly more adolescents and young adults than adults held positive outcome expectancies, and a substantial minority of non-users and never users in all age groups believed that using e-cigarettes confers social and mental health benefits. Given the potential benefits they perceived to be associated with e-cigarette use, a substantial proportion of adolescent and young adult never users may be vulnerable to initiation. These findings highlight the importance of (i) adequately communicating the risks associated with non-nicotine e-cigarette use and (ii) addressing misperceptions about use, especially among youth.
... 7 Technological innovations in the mid-to-late 2010s sparked considerable increases in NVP popularity, among not only current and former adult cigarette smokers 8 but also youth and young adults in a handful of Western countries. 9 10 This fast-paced evolution has transformed NVPs into an expansive product category encompassing devices of all shapes, sizes and user modifiability, 11 in addition to thousands of unique flavours added to nicotine solutions. 12 NVP devices and nicotine solutions are manufactured by multinational corporations and independent companies. ...
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The introduction of electronic inhalable products, such as nicotine vaping products (NVPs) and heated tobacco products (HTPs), has further diversified the nicotine market landscape. This poses unique challenges in measuring self-reported nicotine use behaviours, which have been the hallmark of tobacco surveillance systems. This paper raises concerns of potential measurement error for electronic inhalable product use in surveys due to similarities in product design between NVPs and HTPs, as well as changing trends in cannabis administration. We identify several strategies for addressing this issue (eg, including descriptive preambles in surveys that differentiate product classes from one another; incorporating survey questions that probe beyond an initial question regarding product use). In the absence of comprehensive validation studies, caution is warranted when interpreting survey results that rely on self-reported HTP use.
... Troisièmement, cette étude a permis de présenter le large éventail d'arômes de liquides à vapoter offerts sur le marché canadien. La catégorie d'arômes la plus courante était celle des fruits, ce qui concorde avec les données d'enquêtes, qui ont révélé que les fruits sont l'arôme le plus populaire chez les jeunes et les adultes qui vapotent4,5,[19][20][21] . Les arômes de la catégorie « autres » affichaient quant à eux les concentrations en nicotine les plus élevées. ...
Article
Introduction Le marché de la cigarette électronique au Canada a évolué rapidement depuis la mise en œuvre de la Loi sur le tabac et les produits de vapotage en mai 2018, qui a libéralisé la promotion et la vente des produits de vapotage. On dispose actuellement de peu de données sur le profil du marché en fonction des principales caractéristiques des produits, que ce soit la teneur en nicotine, les pratiques d’étiquetage ou les arômes. Méthodologie Une analyse en ligne des détaillants de produits de vapotage (deux fabricants à l’échelle nationale et cinq fabricants à l’échelle provinciale) a été effectuée en 2020 pour étudier les liquides à vapoter offerts sur le marché canadien. Les données ont été extraites de sites Internet et d’images de produits concernant la teneur en nicotine, l’étiquetage et les arômes des liquides à vapoter. Résultats Nous avons répertorié 1746 liquides à vapoter, totalisant 4790 concentrations en nicotine. Environ la moitié des liquides à vapoter contenaient des sels de nicotine (46,6 %) et l’autre moitié contenait de la nicotine épurée (53,2 %), le reste contenant une combinaison des deux (0,2 %). La concentration moyenne en nicotine des liquides à base de sels de nicotine (3,4 %) était supérieure à celle des liquides à base de nicotine épurée (0,5 %) (p < 0,001). Les deux tiers (63,2 %) des emballages de liquides à vapotage affichés en ligne avaient des étiquettes indiquant la présence de nicotine, les trois quarts (73,7 %) affichaient la concentration en nicotine et plus de la moitié (58,9 %) affichaient des mises en garde concernant la santé. Nous avons également relevé une variété d’arômes parmi les liquides, les plus courants étant les fruits (43,6 %), suivis des bonbons et desserts (27,6 %) et des boissons non alcoolisées (12,5 %). Conclusion Ces résultats montrent la diversité du marché de la cigarette électronique en ligne au Canada, dont une offre de produits avec sels de nicotine à forte concentration. Les restrictions relatives aux arômes pourraient réduire considérablement le nombre d’arômes de liquides à vapoter sur le marché et le fait de limiter les concentrations en nicotine à moins de 20 mg/ml aurait une incidence principalement sur les liquides à base de sels de nicotine.
... In the past few years, youth vaping prevalence has increased in Canada (Government of Canada, 2020a) and flavours play an important role in attracting youth to vaping products. Recent evidence suggests that youth prefer flavour categories such as fruit, confectionary and dessert (Government of Canada, 2018a;O'Connor et al., 2019). The chemicals detected in products are used to better understand flavour chemicals and their role in imparting intended or declared product flavours. ...
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Currently, there is a lack of comprehensive data on the diversity of chemicals present in vaping liquids. To address this gap, a non-targeted analysis of 825 vaping liquids collected between 2017 and 2019 from Canadian retailers was conducted. Prior to mass spectrometry analysis, samples were diluted 1:500 v/v with methanol or acetonitrile. Chemical compound separation and analysis was carried out using gas chromatography and triple quadrupole mass spectrometry (GC-MS/MS) systems operated in the full scan mode and mass range of 35–450 m/z. Mass spectrum for each sample was obtained in electron ionization at 70 eV and processed. Non-targeted identification workflow included use of automated mass spectral deconvolution and identification system (AMDIS), where required, as well as a number of commercially available spectral libraries. In order to validate identities, an in-house database of expected compounds previously detected in vaping liquids was used along with genuine analytical standards for compounds of interest. This resulted in a dataset of over 1,500 unique detected chemicals. Approximately half of these chemical compounds were detected only once in a single product and not in multiple products analyzed. For any sample analyzed, on average, 40% of the chemical constituents appeared to have flavouring properties. The remainder were nicotine and related alkaloids, processing, degradation or indirect additives, natural extractives and compounds with unknown roles. Data published here from the project on the Open Characterization of vaping liquids is unique as it offers a detailed understanding of products’ flavour chemical profiles, the presence and frequency of chemicals of potential health concern, as well as trends and changes in products’ chemical complexity over a three-year period. Non-targeted chemical surveillance such as this present valuable tools to public health officials and researchers in responding to emergent issues such as vaping associated lung injury or informing chemical based strategies which may be aimed at addressing product safety or appeal.
... Early focus groups indicated that cigalike users expressed limited knowledge and were unable to describe differences between NVPs though they were familiar with basic features such as the ability to refill or recharge [4]. Researchers have used formal terms such as Electronic Nicotine Delivery Systems [5] and NVPs [6], or classified products into generations [2,7]. By contrast, some NVP users may use less technical terms such as 'e-cigarette' and 'vape', and less commonly use details such as brand name [5], though identification via brand name (e.g., JUUL) has become more common recently [8]. ...
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Nicotine vaping products (NVPs) have evolved rapidly, and some vapers have difficulty reporting about their NVP. NVP knowledge may be important for providing accurate survey data, understanding the potential risks of NVP use, and assessing legal and regulated products. This paper examines current vapers who responded “don’t know” (DK) regarding their NVP features. Data are from adult daily/weekly vapers in Waves Two (2018, n = 4192) and Three (2020, n = 3894) of the ITC Four Country Smoking and Vaping Survey. Analyses assessed DK responses for NVP features (e.g., type/appearance, nicotine) and consumption. A DK index score was computed based on the percent of all features with DK responses, which was tested for associations with demographics, smoking/vaping status, NVP features, purchase location, and knowledge of NVP relative risks. NVP description and appearance were easily identified, but DK was more common for features such as nicotine content (7.3–9.2%) and tank/cartridge volume capacity (26.6–30.0%). DK responses often differed by vaping/smoking status, NVP type/appearance, purchase location, and country. Vapers who are younger, use box-shaped NVPs, purchase online, and exclusive daily vapers were associated with lower DK index scores. Higher DK index scores were associated with poorer knowledge of relative health risks of NVP use. The diversity of the NVP market and wide variation in how products are used makes it challenging to capture information from users about device features, such as nicotine content and capacity, in population surveys.
... There were statistically significant differences across the 6 tobacco use categories overall for doctor visitations at each wave (χ 2 p <0.001), however the absolute differences in proportions between groups were for not especially large. Finally, the e-cigarette marketplace has evolved since the time of this survey to include devices of varying power as well as substantial ranges in nicotine concentration [56,57]. It will be important to re-evaluate associations with health outcomes as e-cigarette technology continues to evolve. ...
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Following their introduction a decade ago, electronic cigarettes (e-cigarettes) have grown in popularity. Given their novelty, knowledge of the health consequences of e-cigarette use remains limited. Epidemiologic studies have not comprehensively explored associations between e-cigarette use and hypertension, a highly prevalent health condition and major contributor to cardiovascular disease burden. In this study, cross-sectional associations of cigarette smoking and e-cigarette use (vaping) with self-reported diagnosed hypertension were evaluated among 19,147 18–55 year old respondents in Wave 3 (2015–2016) of the Population Assessment of Tobacco and Health Study. Multivariable analyses first modeled smoking and vaping as separate 2-category variables, then as a 6-category composite variable accounting for former smoking. After adjusting for potential confounders, current vaping (aOR = 1.31; 95%CI: 1.05–1.63) and current smoking (aOR = 1.27; 95%CI: 1.10–1.47) were both associated with higher odds of hypertension. In analyses modeling smoking and vaping compositely, respondents who were concurrently smoking and vaping had the highest odds of hypertension (aOR = 1.77; 95%CI: 1.32–2.39 [referent: never smokers]). These results differ somewhat from prior epidemiologic studies of vaping and respiratory outcomes, which consistently report smaller point estimates for current vaping than for current smoking. Our findings reinforce the uncertainty surrounding long-term health consequences of vaping, as well as highlight important distinctions between respiratory and cardiovascular outcomes when considering the harm reduction potential of e-cigarettes.
... Exclusive, daily vapers were more likely to use refillable pen-shaped or box-shaped devices than disposable cig-a-like devices, when compared with other (non-daily/dual) users. Cartridge-based (closed) systems, typically marketed by tobacco companies, were more common among respondents from the US and England [8]. ...
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Country-level differences in nicotine vaping products used and biomarkers of exposure among long-term e-cigarette users and dual users remain understudied. This cross-sectional study was conducted in 2014 in the United States (n = 166), United Kingdom (n = 129), and Poland (n = 161). We compared patterns of tobacco product use and nicotine and toxicant exposure among cigarette-only smokers (n = 127); e-cigarette-only users (n = 124); dual users of tobacco cigarettes and e-cigarettes (n = 95); and non-users (control group, n = 110) across three countries using mixed-effects linear regression. Compared with cigarette smokers, e-cigarette-only users had lower levels of toxicant biomarkers, but higher levels of nicotine biomarkers. Dual users had higher levels of toxicant biomarkers than e-cigarette-only users but similar levels to cigarette-only smokers. E-cigarette users in Poland, who overwhelmingly used refillable tank devices, exhibited greater levels of nicotine, and toxicant biomarkers relative to e-cigarette users in US/UK. Despite smoking fewer cigarettes, dual users from Poland exhibited similar levels of nicotine biomarkers compared with UK dual users, but higher than US dual users. Country-level differences in e-cigarette devices used and smoking behaviors (e.g., intensity) may contribute to differences in biomarker levels among users of the same products residing in different countries.
... Additional support for the interest in flavors moderating differences in individual factors related to vaping is provided by the different patterns of e-liquid flavors used by dual users and exclusive vapers. In line with previous research, both groups mostly used tobacco and mint flavored ecigarettes at initiation, but exclusive vapers currently used more fruit and sweet e-liquid flavors than dual users [5,34,[61][62][63]. This could be interpreted as vapers switching from tobacco to non-tobacco flavors over time, which is supported by a previous study [5]. ...
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Appealing product characteristics, such as flavors, may stimulate e-cigarette use. While switching to e-cigarettes may reduce harm for smokers, concerns exist about e-cigarette use among never-smokers. The role of flavors in the decision to switch to or refrain from vaping is unclear. This study used a bottom–up approach to investigate the relation between flavor preferences and individual factors related to vaping between various user groups. A cross-sectional survey was conducted among never-users (n = 407), smokers (n = 138), dual users (n = 122), and exclusive vapers (n = 61) in the Netherlands. Demographics, attractiveness of product characteristics, flavor preferences, and individual factors related to vaping (knowledge, trust, perceived susceptibility, attitude, social influence, deliberation, and intention) were assessed. The availability of different flavors was the most attractive characteristic of e-cigarettes. Dual users and exclusive vapers had most often used tobacco and menthol/mint flavors when they first started vaping. Compared to dual users, exclusive vapers currently used more fruit and sweet flavors. Never-users who were interested in trying an e-liquid flavor had more knowledge about and a more positive attitude towards e-cigarettes. Smokers who were interested in trying a flavor had a more positive attitude towards e-cigarettes and experienced the social influence towards not using e-cigarettes as less strong than those who did not want to try any flavor. Hence, individual factors related to vaping differed depending on whether never-users and smokers wanted to try an e-liquid flavor. This means that flavors may moderate differences found in individual factors related to vaping, or vice versa.
... This issue contains 13 different papers spanning a wide range of topics from broad descriptions of NVPs and usage patterns, motivations for using vaping products, beliefs and attitudes about nicotine vaping, and the impact of various policies on vaping and smoking behaviors, and the likely impact they will have on population health outcomes (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) These 13 papers point out some of limitations of the data available on vaping, smokingvaping transitions, and health risks and highlight the challenges in predicting how the evolving nicotine delivery market in different jurisdictions might impact population health. ...
... Nicotine vaping products (NVPs), sometimes called electronic cigarettes, are products designed to deliver nicotine without tobacco smoke by heating solutions containing distilled nicotine to create an aerosol (colloquially called 'vapour') [1]. NVPs should be distinguished from heated tobacco products which create an aerosol by heating volatile chemicals in tobacco. ...
Article
Aims To determine whether a simple combination of level of smoking and level of vaping results in a useful typology for characterising smoking and vaping behaviours. Methods Cross‐sectional data from adults (≥18 years) in the 2016 Wave 1 ITC Four Country Smoking and Vaping Survey in the United States (n=2291), England (n=3591), Australia (n=1376), and Canada (n=2784) were used. Participants who either smoked, vaped or concurrently used both at least monthly were included and divided into 8 groups based on use frequency of each product (daily, non‐daily, no current use). This resulted in 4 concurrent use groups (predominant smokers, dual daily users, predominant vapers and concurrent non‐daily users). These groups were compared with each other and with the 4 exclusive use groups, on socio‐demographics, nicotine dependence, beliefs and attitudes about both products, and quit‐related measures using data weighted to reference population surveys in each country. Results 10.8% of the sample were concurrent users, with daily smokers vaping non‐daily (predominant smokers) constituting 51.6% of this group. All 8 categories differed from other categories on at least some measures. Concurrent daily nicotine users reported higher levels of indicators of nicotine dependence, and generally more positive attitudes toward both smoking and vaping than concurrent non‐daily users. Among daily nicotine users, compared with exclusive daily smokers, reports of interest in quitting were higher in all concurrent use groups. Dual daily users had the most positive attitudes about smoking overall, and saw it as the least denormalised, and at the same time were equally interested in quitting as other concurrent users and were most likely to report intending to continue vaping. Conclusions In Australia, Canada, England and the United States in 2016, daily nicotine users differed considerably from non‐daily nicotine users. Among daily nicotine users, dual daily users (those who smoke and vape concurrently) should be treated as a distinct grouping when studying relationships between smoking and vaping. The 8 level typology characterising concurrent and exclusive use of smoking and vaping should be considered when studying both products.
Article
Background Comparisons of nicotine and toxicant exposures between people who use different alternative tobacco products remain underexplored. Methods This cross-sectional, multicountry study analyzed urinary metabolites of nicotine, tobacco-specific nitrosamines [4-methylnitrosamino-1-3-pyridyl-1-butanone (NNK)], and volatile organic compounds (acrolein, acrylamide, and acrylonitrile) among established users (n = 550) in Japan and Canada. Participants exclusively or concurrently used nicotine vaping products (NVP; Canada only), heated tobacco products (HTP; Japan only), and combustible cigarettes (CC; Japan and Canada) or abstained (Japan and Canada). Results All product groups showed substantial nicotine exposure. Both HTPs and NVPs exposed exclusive users to lower toxicant levels than exclusive CC use. Canadian participants who exclusively used NVPs exhibited lower NNK and acrolein exposure but higher acrylamide exposure than Japanese participants who exclusively used HTPs. Concurrent use of CCs alongside alternative products exposed users to higher toxicant levels compared with exclusive use of either alternative product. Conclusions Exclusive use of alternative tobacco products results in significant nicotine exposure but substantially lower toxicant exposure compared with exclusive CC use. People who use HTPs in Japan may experience higher exposure to nicotine and certain toxicants (NNK and acrolein) than people who use NVPs in Canada. Concurrent use results suggest that partially substituting CCs with alternative products may reduce toxicant exposure but to a lesser extent than completely transitioning to alternative products. Impact Exposure patterns between two popular alternative tobacco products differ. The overall toxicant exposure from these products is lower than from CCs, providing critical data for regulatory decisions and public health considerations.
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Objective This study estimated prevalence of current electronic nicotine delivery systems (ENDS) used by US adults who smoked cigarettes or formerly smoked in 2022 and assessed ENDS flavors, devices, and brands used most often. Methods Data are from the 2022 US ITC Smoking and Vaping Survey. Respondents were recruited from a web panel of a nationally representative sample of US adults ages 18+ who smoked, formerly smoked, and/or vaped ENDS. Using weighted data, we estimated prevalence of current vaping among adults who smoke or formerly smoked (N = 2,016). Among the subset who vaped (n = 554), we assessed flavors and devices used most often. Using unweighted data, we assessed the frequency (count) of reported brands used most often. Results In 2022, 22.0 % of US adults who smoked or formerly smoked were vaping at least monthly. A significantly higher proportion of adults who formerly smoked and/or were younger (18–39) were vaping than adults who were smoking and/or were older (40+) (both p < 0.001). Tank devices were used most often (34.7 %), followed by disposables (27.4 %), pre-filled pods/cartridges (23.0 %), and refillable pods/cartridges (14.9 %). The five most commonly used flavors were fruit (33.9 %), tobacco (20.1 %), menthol (12.2 %), candy/sweets (10.8 %), and mixed ice flavors (10.0 %). The top 5 brands were JUUL, Smok, Vuse, Geekvape, and Blu. Conclusions In 2022, a majority of adults who smoked cigarettes or who had quit smoking used a variety of flavors and devices that go beyond the choices that FDA currently has authorized for sale.
Article
Background: Vaping is an increasingly popular mode of cannabis use. Few studies have characterized the role of flavors in cannabis e-liquids.Objectives: To explore the prevalence of flavored vaping liquids, including differences between countries and correlates of use.Methods: Data were from Wave 4 (2021) of the International Cannabis Policy Study with national samples aged 16-65 in Canada, the United States (US), Australia, and New Zealand. The sample comprised 52,938 respondents, including 6,265 who vaped cannabis e-liquids in the past 12-months (2,858 females, 3,407 males). Logistic regression models examined differences in the use of flavored e-liquids between countries and sociodemographic characteristics.Results: The prevalence of vaping cannabis e-liquids was highest in the US (15.3%) and Canada (10.7%) compared to Australia (4.0%) and New Zealand (3.7%). Among past 12-month cannabis consumers, 57.5% reported using flavored vaping liquids, 34.2% used unflavored vaping products and 8.3% did not know. People who vape in Australia were most likely to report using flavored liquids compared to New Zealand (OR = 2.29), Canada (OR = 3.14), and the US (OR = 3.14) (p < .05 for all). Fruit was the most reported vaping flavor (40.8%), followed by candy/dessert (20.4%) and vanilla (15.2%). Use of flavored vapes was greater among younger, ethnic minorities, female, higher education and income adequacy, and more frequent consumers (p < .05).Conclusion: Many cannabis consumers reported using flavored e-liquids, with highest levels among young people aged 16-35. Given the high prevalence of vaping in legal markets, regulators should consider the role of flavored vaping products in promoting cannabis use among this group.
Article
Objectives. To examine the impact of US restrictions implemented in February 2020 prohibiting flavors other than menthol and tobacco in cartridge-based e-cigarettes. Methods. We analyzed 5 cross-sectional waves of the International Tobacco Control Policy Evaluation Project Youth Tobacco and Vaping Surveys, conducted online with youths aged 16 to 19 years in the United States, Canada, and England, for differences in usual e-cigarette flavor, device, and brand reported by past-30-day vapers (n = 9512) before (2017, 2018, 2019), during (February 2020), and after (August 2020) implementation of US flavor restrictions. Results. In August 2020, 78.7% of vapers in the United States reported using a flavor prohibited in cartridges or pods, versus 86.3% in Canada (adjusted odds ratio [AOR] = 1.73; 95% CI = 1.25, 1.40) and 79.8% in England (AOR = 1.10; 95% CI = 0.78, 1.55). Disposable e-cigarettes (exempt from flavor restrictions) increased to a greater extent among vapers in the United States (13.2% to 36.8%) versus Canada (7.7% to 14.2%; AOR = 2.01; 95% CI = 1.33, 3.04) and England (10.8% to 16.4%; AOR = 2.33; 95% CI = 1.52, 3.57). Puff Bar (disposable) emerged as the most popular brand in the United States. Conclusions. Usual flavors used by youth vapers in the United States were unchanged after 2020 restrictions on cartridge-based e-cigarettes. Youths used brands and devices exempt from the restrictions. (Am J Public Health. Published online ahead of print May 26, 2022: e1–e11. https://doi.org/10.2105/AJPH.2022.306780 )
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Smoking prevalence in several high-income countries is steadily declining but remains persistently high in ‘lower’ socioeconomic position (SEP) groups, contributing to inequities in morbidity and mortality. Smoking to relieve stress is a commonly endorsed motive for continued smoking; however, it remains unclear whether smoking to relieve stress has a negative impact on motivation to stop and future quit attempts and if so, whether associations are moderated by SEP. This was an observational study with cross-sectional and prospective survey data from the nationally representative Smoking Toolkit Study in England. A total of 1,135 adult smokers were surveyed at baseline, with 153 (13.5%) respondents followed up at 12 months. Respondents provided information on demographic, social and smoking characteristics. A series of multivariable logistic regression analyses was conducted. Bayes Factors (BFs) were calculated to explore non-significant associations. Smoking to relieve stress was commonly endorsed by respondents from both ‘lower’ (43.2% [95% CI = 39.4%, 47.0%]) and ‘higher’ (40.5% [95% CI = 35.9%, 45.1%]) SEP groups (p = 0.39). Smoking to relieve stress was associated with high motivation to stop at baseline (ORadj = 1.48, 95% CI = 1.03–2.12, p = 0.035) but not significantly with the odds of making a quit attempt at a 12-month follow-up, although the magnitude and direction of the effect was similar to that observed for high motivation to stop (ORadj = 1.49, 95% CI = 0.69–3.20, p = 0.3). Data were insensitive to detect moderation effects of SEP (BF = 0.90 and BF = 1.65, respectively). Smoking to relieve stress is a commonly endorsed motive and is associated with high motivation to stop but not significantly with the odds of making a quit attempt in the next 12 months, although the magnitude and direction of the effect was similar for both outcomes. There was no clear evidence of moderation by SEP, although data were insensitive to distinguish the alternative from the null hypothesis.
Article
Implications: The electronic cigarette (ECIG) research community faces several challenges when it comes to regulatory science; not only is the ECIG market changing at a rapid pace, but the terms used by researchers, health organizations, ECIG users, and ECIG manufacturers/distributors to describe devices are inconsistent. These discrepancies make it difficult to advance science and develop regulations. Although researchers have used "generations" to categorize ECIG device types based on various characteristics, with the constantly evolving ECIG market, it is unclear where one "generation" of devices ends and the next begins.
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Electronic cigarettes (E‐cigarettes) have become increasingly popular around the world. Currently, dental professionals’ knowledge and attitudes are varied with many clinicians unclear regarding the impact of E‐cigarette products on the oral and general health of their patients. With developing social and health related challenges, advice of dental and medical associations and other regulatory bodies on E‐cigarette use is changing. Growing evidence demonstrating the risks of E‐cigarette usage has prompted a review of legislation in the United Kingdom (UK), United States of America (USA), Australia and Canada to include the sale and availability of E‐cigarettes, particularly those containing nicotine. Further consideration within the scientific and public health community is being given to assessing demographic usage patterns particularly uptake by non‐smokers and adolescents, efficacy as a cessation tool, the impact of vapour on bystanders and direct injuries via explosions as well as emerging lung injuries. This article aims to provide a summary of the most up to date evidence relating to E‐cigarette use, the latest position of dental associations and the oral health implications of E‐cigarettes compared to conventional smoking. The article also aims to collate this information in order to provide dental clinicians with guidance on how to advise patients, specifically in answering common questions posed regarding E‐cigarette use.
Article
Introduction: Little is known about why males are more likely to use electronic cigarettes (ECs) compared to females. This study examined gender differences in reasons for vaping and characteristics of EC used (device type, device capacity, e-liquid nicotine strength, and flavour). Methods: Data from 3938 current adult (18+ years) at-least-weekly EC users who participated in Wave 2 (2018) ITC Four Country Smoking and Vaping Survey in Canada, the United States, England, and Australia. Results: Of the sample, 54% were male. The most commonly cited reasons for vaping in females were 'less harmful to others' (85.8%) and in males were 'less harmful than cigarettes' (85.5%), with females being more likely to cite 'less harmful to others' (adjusted odds ratio (aOR)=1.64, p=0.001) and 'help cut down on cigarettes' (aOR=1.60, p=0.001) than males. Significant gender differences were found in EC device type used (χ2=35.05, p=0.043). Females were less likely to report using e-liquids containing >20 mg/ml of nicotine, and tank devices with >2ml capacity (aOR=0.41, p<0.001 and aOR=0.65, p=0.026, respectively) than males. There was no significant gender difference in use of flavoured e-liquids, with fruit being the most common flavour for both males (54.5%) and females (50.2%). Conclusion: There were some gender differences in reasons for vaping and characteristics of the product used. Monitoring of gender differences in patterns of EC use would be useful to inform outreach activities and interventions for EC use. Implications: Our findings provide some evidence of gender differences in reasons for vaping and characteristics of EC used. The most common reason for vaping reported by females was 'less harmful to others', which may reflect greater concern by female vapers about the adverse effects of second-hand smoke compared to male vapers. Gender differences might be considered when designing gender sensitive smoking cessation policies. Regarding characteristics of EC products used, we found gender differences in preferences for e-liquid nicotine strength and device capacity. Further studies should examine whether the observed gender differences in EC use reasons and product characteristics are predictive of smoking cessation. Furthermore, studies monitoring gender-based marketing of ECs may be considered.
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Objectives Flavours increase attractiveness of electronic cigarettes and stimulate use among vulnerable groups such as non-smoking adolescents. It is important for regulators to monitor the market to gain insight in, and regulate the range of e-liquid flavours that is available to consumers. E-liquid manufacturers are required to report key product information to authorities in the European Member States in which they plan to market their products. This information was used to provide an overview of e-liquid flavour descriptions marketed in the Netherlands in 2017. Methods Two researchers classified 19 266 e-liquids into the 16 main categories of the e-liquid flavour wheel, based on information from four variables in the European Common Entry Gate system. Flavour descriptions were further specified in subcategories. Results For 16 300 e-liquids (85%), sufficient information was available for classification. The categories containing the highest number of e-liquids were fruit (34%) , tobacco (16%) and dessert (10%). For all e-liquids, excluding unflavoured ones, 245 subcategories were defined within the main categories. In addition to previously reported subcategories, various miscellaneous flavours such as sandwich, buttermilk and lavender were identified. Conclusions In 2017, ~20 000 e-liquids were reported to be marketed in the Netherlands, in 245 unique flavour descriptions. The variety of marketed flavour descriptions reflects flavour preference of e-cigarette users as described in literature. Our systematic classification of e-liquids by flavour description provides a tool for organising the huge variety in market supply, serves as an example for other countries to generate similar overviews and can support regulators in developing flavour regulations.
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Introduction and aims: Despite regulatory barriers for accessing nicotine liquid, use of nicotine vaping products (NVPs) has increased rapidly in Australia. Legal use of NVPs to aid smoking cessation requires a prescription, and pharmacies report receiving enquiries about the use of and access to NVPs. In this study, we assessed vaping product use, harm perception and policy support among community pharmacy customers. Design and methods: A cross-sectional survey was conducted among customers (n = 470) from a large community pharmacy chain in Brisbane, Australia. Multivariable logistic regression was used to examine perception of NVPs as less harmful than combustible cigarettes and regulatory recommendations in relation to demographics, smoking status and NVP use. Results: Almost one-third of the sample (31%) had either tried NVPs in the past (16%) or were current vapers (15%), the majority of them being current smokers (67%) who are trying to quit (31%) or substitute smoking (41%). Vapers primarily depended on family/friends as a source of information (76%). Current smokers and vapers were more likely to perceive NVPs as less harmful than cigarettes than non-smokers and non-vapers. Perceiving NVPs as safer than cigarettes was correlated with a recommendation to regulate as a tobacco product. Discussion and conclusions: There was widespread misperception about relative risk of nicotine-containing products, with 37% of respondents perceiving nicotine-containing NVPs to be as harmful as combustible cigarettes. Community pharmacies represent an ideal setting for educating smokers about smoking and vaping. Thus, pharmacy staff needs educational support to ensure that they are equipped to provide current evidence-based information to customers.
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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.
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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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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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Aims This paper presents updated prevalence estimates of awareness, ever‐use, and current use of nicotine vaping products (NVPs) from 14 International Tobacco Control Policy Evaluation Project (ITC Project) countries that have varying regulations governing NVP sales and marketing. Design, setting, participants and measurements A cross‐sectional analysis of adult (≥18 years) current smokers and ex‐smokers from 14 countries participating in the ITC Project. Data from the most recent survey questionnaire for each country were included, which spanned the period 2013 to 2017. Countries were categorized into four groups based on regulations governing NVP sales and marketing (allowable or not), and level of enforcement (strict or weak where NVPs are not permitted to be sold): (1) most restrictive policies (MRPs): not legal to be sold or marketed with strict enforcement: Australia, Brazil, Uruguay; (2) restrictive policies (RPs): not approved for sale or marketing with weak enforcement: Canada, Malaysia, Mexico, New Zealand (NZ); (3) less restrictive policies (LRPs): legal to be sold and marketed with regulations: England, Netherlands, Republic of Korea, United States (US); (4) no regulatory policies (NRPs): Bangladesh, China, Zambia. Countries were also grouped by World Bank Income Classifications. Country‐specific weighted logistic regression models estimated adjusted NVP prevalence estimates for: awareness, ever/current use, and frequency of use (daily vs. non‐daily). Findings NVP awareness and use were lowest in NRP countries. Generally, ever‐ and current use of NVPs were lower in MRP countries [ever‐use: 7.1% to 48.9%; current use: 0.3% to 3.5%] relative to LRP countries [ever‐use: 38.9% to 66.6%; current use: 5.5% to 17.2%] and RP countries [ever‐use: 10.0% to 62.4%; current use: 1.4% to 15.5%]. NVP use was highest among high income countries, followed by upper‐middle income countries, and then by lower‐middle income countries. Conclusions With a few exceptions, awareness and use of nicotine vaping products (NVPs) varies by the strength of national regulations governing NVP sales/marketing, and by country income. In countries with no regulatory policies, use rates were very low, suggesting that there was little availability, marketing and/or interest in NVPs in these countries where smoking populations are predominantly poorer. The higher awareness and use of NVPs in high income countries with moderately (e.g., Canada, NZ) and less (e.g., England, US) restrictive policies, is likely due to the greater availability and affordability of NVPs.
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Aims To compare the effects of i) high versus low nicotine concentration e‐liquid, ii) fixed versus adjustable power and iii) the interaction between the two on: a) vaping behaviour, b) subjective effects, c) nicotine intake, and d) exposure to acrolein and formaldehyde in e‐cigarette users vaping in their everyday setting. Design Counterbalanced, repeated measures with four conditions: i) low nicotine (6 mg/mL)/fixed power; ii) low nicotine/adjustable power; iii) high nicotine (18 mg/mL)/fixed power; iv) high nicotine/adjustable power. Setting London and the South East, England. Participants Twenty experienced e‐cigarette users (recruited between September 2016 and February 2017) vaped ad libitum using an eVic Supreme™ with a ‘Nautilus Aspire’ tank over four weeks (one week per condition). Measurements Puffing patterns (daily puff number [PN], puff duration [PD], inter‐puff interval [IPI]), mL of e‐liquid consumed, changes to power (where permitted), and subjective effects (urge to vape, nicotine withdrawal symptoms) were measured in each condition. Nicotine intake was measured via salivary cotinine. 3‐hydroxypropylmercapturic acid (3‐HPMA), a metabolite of the toxicant acrolein, and formate, a metabolite of the carcinogen formaldehyde, were measured in urine. Findings There was a significant nicotine concentration x power interaction for PD (p<0.01). PD was longer with low nicotine/fixed power compared with i) high nicotine/fixed power (p< 0.001 and ii) low nicotine/adjustable power (p< 0.01). PN and liquid consumed were higher in the low versus high nicotine condition (main effect of nicotine, p<0.05). Urge to vape and withdrawal symptoms were lower, and nicotine intake was higher, in the high nicotine condition (main effects of nicotine: p<0.01). Whilst acrolein levels did not differ, there was a significant nicotine x power interaction for formaldehyde (p<0.05). Conclusions Use of a lower nicotine concentration e‐liquid may be associated with compensatory behaviour (e.g., higher number and duration of puffs) and increases in negative affect, urge to vape, and formaldehyde exposure.
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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.
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Objectives: We tested the substitutability of nicotine replacement therapy (NRT), electronic cigarettes (ECs), and very low nicotine cigarettes (VLNCs) in the context of an online experimental tobacco marketplace (ETM) that was designed to mimic the choices of smokers under 4 policy scenarios. Methods: Dutch cigarette smokers (N = 840) completed an online survey in July 2015. The ETM was comprised of conventional cigarettes, VLNCs, ECs (disposable/cartridge/tank systems), and NRT (lozenges/patches/tabs). All participants completed a scenario in which conventional cigarettes were banned. To test additional policy scenarios participants were randomized to one of 3 experiments: (1) no VLNCs; (2) all products available; or (3) no ECs. Hypothetical weekly purchases were made when the cost for conventional cigarettes was one-half market price (MP), MP, 2x MP, and 4x MP. We measured substitutability by the change in estimated consumption as cigarette prices increased. Results: Tank and cartridge ECs and VLNCs were stronger cigarette substitutes than disposable ECs and NRT products. Substitution of ECs and NRT for cigarettes was dampened when VLNCs were available. Conclusions: The ETM offers a method to predict how smokers might respond to policies that alter the availability of potentially substitutable products available in the marketplace.
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Background Electronic cigarette (e-cigarette) use in the USA is increasing. As such, it is critical to understand who uses e-cigarettes, how e-cigarettes are used and what types of products are prevalent. This study assesses patterns of current e-cigarette use among daily and non-daily adult users in the 2013–2014 Population Assessment of Tobacco and Health (PATH) Study. Methods We examined the proportion of current adult e-cigarette users (n=3642) reporting infrequent use (use on ‘some days’ and use on 0–2 of the past 30 days), moderate use (use on ‘some days’ and use on >2 of the past 30 days) and daily use. We examined demographic characteristics, use of other tobacco products and e-cigarette product characteristics overall and by use category. Adjusted prevalence ratios (aPRs) were calculated using Poisson regression to assess correlates of daily e-cigarette use. Results Among the 5.5% of adult current e-cigarette users in the PATH Study, 42.2% reported infrequent use, 36.5% reported moderate use and 21.3% reported daily use. Cigarette smokers who quit in the past year were more likely to report daily e-cigarette use, compared with current smokers (aPR=3.21, 95% CI=2.75 to 3.76). Those who reported using rechargeable or refillable devices were more likely to report daily use compared with those who did not use these devices (aPR=1.95, 95% CI=1.44 to 2.65 and aPR=2.10, 95% CI=1.75 to 2.52, respectively). Conclusions The majority of e-cigarette users in this study reported less than daily use. Compared with non-daily use, daily use was associated with being a former smoker; however, cross-sectional data limits our ability to establish the temporality or directionality of such associations.
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Background: Given the rapid increase in the popularity of e-cigarettes and the paucity of associated longitudinal health-related data, the need to assess the potential risks of long-term use is essential. Objective: To compare exposure to nicotine, tobacco-related carcinogens, and toxins among smokers of combustible cigarettes only, former smokers with long-term e-cigarette use only, former smokers with long-term nicotine replacement therapy (NRT) use only, long-term dual users of both combustible cigarettes and e-cigarettes, and long-term users of both combustible cigarettes and NRT. Design: Cross-sectional study. Setting: United Kingdom. Participants: The following 5 groups were purposively recruited: combustible cigarette-only users, former smokers with long-term (≥6 months) e-cigarette-only or NRT-only use, and long-term dual combustible cigarette-e-cigarette or combustible cigarette-NRT users (n = 36 to 37 per group; total n = 181). Measurements: Sociodemographic and smoking characteristics were assessed. Participants provided urine and saliva samples and were analyzed for biomarkers of nicotine, tobacco-specific N-nitrosamines (TSNAs), and volatile organic compounds (VOCs). Results: After confounders were controlled for, no clear between-group differences in salivary or urinary biomarkers of nicotine intake were found. The e-cigarette-only and NRT-only users had significantly lower metabolite levels for TSNAs (including the carcinogenic metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol [NNAL]) and VOCs (including metabolites of the toxins acrolein; acrylamide; acrylonitrile; 1,3-butadiene; and ethylene oxide) than combustible cigarette-only, dual combustible cigarette-e-cigarette, or dual combustible cigarette-NRT users. The e-cigarette-only users had significantly lower NNAL levels than all other groups. Combustible cigarette-only, dual combustible cigarette-NRT, and dual combustible cigarette-e-cigarette users had largely similar levels of TSNA and VOC metabolites. Limitation: Cross-sectional design with self-selected sample. Conclusion: Former smokers with long-term e-cigarette-only or NRT-only use may obtain roughly similar levels of nicotine compared with smokers of combustible cigarettes only, but results varied. Long-term NRT-only and e-cigarette-only use, but not dual use of NRTs or e-cigarettes with combustible cigarettes, is associated with substantially reduced levels of measured carcinogens and toxins relative to smoking only combustible cigarettes. Primary funding source: Cancer Research UK.
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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.
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Electronic cigarettes (e-cigs) are becoming increasingly popular but little is known about how e-cig users'transition between the different device types and what device characteristics and preferences may influence the transition. 4421 experienced e-cig users completed an online survey about their e-cig use, devices, and preferences. Participants included in analysis were ever cigarette smokers who used an e-cig at least 30 days in their lifetime and who reported the type of their first and current e-cig device and the nicotine concentration of their liquid. Analyses focused on transitions between "first generation" devices (same size as a cigarette with no button) and "advanced generation" devices (larger than a cigarette with a manual button) and differences between current users of each device type. Most e-cig users (n=2603, 58.9%) began use with a first generation device, and of these users, 63.7% subsequently transitioned to current use of an advanced generation device. Among users who began use with an advanced generation device (n=1818, 41.1%), only 5.7% transitioned to a first generation device. 77% of current advanced generation e-cig users switched to their current device in order to obtain a "more satisfying hit". Battery capabilities and liquid flavor choices also influenced device choice. E-cig users commonly begin use with a device shaped like a cigarette and transition to a larger device with a more powerful battery, a button for manual activation and a wider choice of liquid flavors. © 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.
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Introduction: Some electronic cigarette (ECIG) users attain tobacco cigarette-like plasma nicotine concentrations while others do not. Understanding the factors that influence ECIG aerosol nicotine delivery is relevant to regulation, including product labeling and abuse liability. These factors may include user puff topography, ECIG liquid composition, and ECIG design features. This study addresses how these factors can influence ECIG nicotine yield. Methods: Aerosols were machine generated with 1 type of ECIG cartridge (V4L CoolCart) using 5 distinct puff profiles representing a tobacco cigarette smoker (2-s puff duration, 33-ml/s puff velocity), a slow average ECIG user (4 s, 17 ml/s), a fast average user (4 s, 33 ml/s), a slow extreme user (8 s, 17 ml/s), and a fast extreme user (8 s, 33 ml/s). Output voltage (3.3-5.2 V or 3.0-7.5 W) and e-liquid nicotine concentration (18-36 mg/ml labeled concentration) were varied. A theoretical model was also developed to simulate the ECIG aerosol production process and to provide insight into the empirical observations. Results: Nicotine yields from 15 puffs varied by more than 50-fold across conditions. Experienced ECIG user profiles (longer puffs) resulted in higher nicotine yields relative to the tobacco smoker (shorter puffs). Puff velocity had no effect on nicotine yield. Higher nicotine concentration and higher voltages resulted in higher nicotine yields. These results were predicted well by the theoretical model (R (2) = 0.99). Conclusions: Depending on puff conditions and product features, 15 puffs from an ECIG can provide far less or far more nicotine than a single tobacco cigarette. ECIG emissions can be predicted using physical principles, with knowledge of puff topography and a few ECIG device design parameters.
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A growing body of scientific studies show that e-cigarettes may serve as an acceptable substitute for smoking tobacco cigarettes, thereby reducing or eliminating exposure to harmful elements in smoke. The success of e-cigarettes is such that sales of these products are rapidly gaining on traditional cigarettes. The rapidly evolving phenomenon is raising concerns for the health community, pharmaceutical industry, health regulators and state governments. Obviously, these products need to be adequately regulated, primarily to protect users. Depending on the form and intended scope, certain regulatory decisions may have diverse unintended consequences on public health and may face many different challenges. Ideally, before any regulations are enacted, the regulatory body will require sufficient scientific research to verify that a problem does exist, quantify the problem, explore all potential solutions including making no change at all, determine the possible consequences of each, and then select the solution that is best for public health. Here we present an overview on the existing and deeming regulatory decisions for electronic cigarettes. We challenge them, based on the mounting scientific evidence with the ultimate goal of proposing appropriate recommendations while minimizing potential unintended consequences of ill-informed regulation.
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This paper describes the conceptual model that underlies the International Tobacco Control Policy Evaluation Project (ITC Project), whose mission is to measure the psychosocial and behavioural impact of key policies of the Framework Convention on Tobacco Control (FCTC) among adult smokers, and in some countries, among adult non-smokers and among youth. The evaluation framework utilises multiple country controls, a longitudinal design, and a pre-specified, theory-driven conceptual model to test hypotheses about the anticipated effects of specific policies. The ITC Project consists of parallel prospective cohort surveys of representative samples of adult smokers currently in nine countries (inhabited by over 45% of the world's smokers), with other countries being added in the future. Collectively, the ITC Surveys constitute the first-ever international cohort study of tobacco use. The conceptual model of the ITC Project draws on the psychosocial and health communication literature and assumes that tobacco control policies influence tobacco related behaviours through a causal chain of psychological events, with some variables more closely related to the policy itself (policy-specific variables) and other variables that are more downstream from the policy, which have been identified by health behaviour and social psychological theories as being important causal precursors of behaviour (psychosocial mediators). We discuss the objectives of the ITC Project and its potential for building the evidence base for the FCTC.
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This paper outlines the design features, data collection methods and analytic strategies of the International Tobacco Control (ITC) Four Country Survey, a prospective study of more than 2000 longitudinal respondents per country with yearly replenishments. This survey possesses unique features that sets it apart among surveys on tobacco use and cessation. One of these features is the use of theory-driven conceptual models. In this paper, however, the focus is on the two key statistical features of the survey: longitudinal and "quasi-experimental" designs. Although it is often possible to address the same scientific questions with a cross-sectional or a longitudinal study, the latter has the major advantage of being able to distinguish changes over time within individuals from differences among people at baseline (that is, differences between age and cohort effects). Furthermore, quasi-experiments, where countries not implementing a given new tobacco control policy act as the control group to which the country implementing such a policy will be compared, provide much stronger evidence than observational studies on the effects of national-level tobacco control policies. In summary, application of rigorous research methods enables this survey to be a rich data resource, not only to evaluate policies, but also to gain new insights into the natural history of smoking cessation, through longitudinal analyses of smoker behaviour.
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Background: Although several countries, including Canada, have prohibited the sale of nicotine-containing e-cigarettes, there is little evidence examining the impact of such regulatory measures on nicotine content and labelling. Methods: E-cigarettes were systematically purchased at 80 retail outlets across 4 cities in Ontario, Canada in January-February 2015. Products' nicotine content and labelling accuracy were assessed using gas chromatography. Results: A total of 166 e-cigarette products were purchased, including disposable products (33%), refillable products (14%), and e-liquids (53%). Similar proportions of products were labelled as 'without nicotine' (41%), and 'with nicotine' (44%), while 15% of products were unlabelled. Analyses revealed that almost half the products (48%) contained nicotine. With respect to the presence of nicotine, 10 products (6%) were mislabelled. Just over one-quarter (27%) of products labelled as 'with nicotine' (n = 73) fell outside their labelled concentration. All of the mislabelled products were e-liquids (100%) and the vast majority were sold in vape shops (90%). Conclusion: Despite a prohibition, nicotine-containing e-cigarettes are commonly sold in Canada. While many e-cigarettes were correctly labelled, inaccuracies were common, particularly among nicotine-containing products sold in vape shops. The findings reflect limitations regarding the design and enforcement of the current e-cigarette regulatory framework.
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Background The experimental tobacco marketplace (ETM) provides a method to estimate, prior to implementation, the effects of new products or policies on purchasing across various products in a complex tobacco marketplace. We used the ETM to examine the relationship between nicotine strength and substitutability of alternative products for cigarettes to contribute to the literature on regulation of e-liquid nicotine strength. Methods The present study contained four sampling and four ETM purchasing sessions. During sampling sessions, participants were provided 1 of 4 e-liquid strengths (randomised) to sample for 2 days followed by an ETM purchasing session. The nicotine strength sampled in the 2 days prior to an ETM session was the same strength available for purchase in the next ETM. Each participant sampled and could purchase 0 mg/mL, 6 mg/mL, 12 mg/mL and 24 mg/mL e-liquid, among other products, during the study. Results Cigarette demand was unaltered across e-liquid strength. E-liquid was the only product to substitute for cigarettes across more than one e-liquid strength. Substitutability increased as a function of e-liquid strength, with the 24 mg/mL displaying the greatest substitutability of all products. Conclusions The present study found that e-liquid substitutability increased with nicotine strength, at least up to 24 mg/mL e-liquid. However, the effects of e-liquid nicotine strength on cigarette purchasing were marginal and total nicotine purchased increased as e-liquid nicotine strength increased.
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Introduction Electronic cigarettes are widely variable devices, typically with user definable liquid and device parameters. Yet, little is known about how regular users manipulate these parameters. There is also limited understanding of what factors drive electronic cigarette use and liquid purchasing, and whether two common ingredients, propylene glycol and vegetable glycerin, alter the subjective effects of these devices. Methods During the spring of 2016 522 adults, who reported daily use of electronic cigarettes containing nicotine, completed a survey on electronic cigarettes. Survey questions included an electronic cigarette dependence questionnaire, questions on tobacco and electronic cigarette use, and device and liquid preferences. Results Fifty-nine percent of respondents reported using another tobacco product, which was positively associated with level of nicotine dependence. On average, devices were set to 28.3 (SD = 24.2) watts. Ability to change device voltage, and level of resistance typically used, was significantly associated with level of nicotine dependence. Amount of liquid consumed, nicotine concentration, and milligrams of nicotine used per week, were positively associated with nicotine dependence. Participants rated ‘good taste’ as the most important consideration when using and purchasing liquids, and propylene glycol is associated with undesirable effects and vegetable glycerin with desirable effects. Conclusions These data indicate that electronic cigarette users utilize a wide range device parameter settings and liquid variables, and that individuals with greater nicotine dependence favor voltage control devices, and lower resistance heating elements. Taste is a key factor for electronic cigarette selection, and concentrations of propylene glycol and vegetable glycerin may have a significant impact on the reinforcing effects of liquids.
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E‐cigarettes are used by millions of people despite the fact that the harmful effect of aerosol emitted from these products to the human organism is still not clear. In this paper, toxicity of vapor generated using different solutions and battery output voltage on A549 cells viability is presented. The obtained EC50 values for commercially available propylene glycol/glycerol solution 1:1 e‐liquids based on 3.2 V (0.127%), 4.0 V (0.112%) and 4.8 V (0.038%) were about 1.5–4.5 times higher than in tobacco smoke (0.0086%). Furthermore, it was shown that the increase of battery output voltage decreased A549 cell viability. In addition, commercially available extracts were more cytotoxic than laboratory made extracts. Owing to the expansiveness of e‐cigarettes, it is very important to estimate their impact on public health. Our results not only confirm less cytotoxicity of e‐liquid aerosol than cigarette smoke, but also demonstrate that solutions used in e‐liquids and, for the first time, battery output voltage have a significant impact on cytotoxicity of e‐cigarette vapor. Thus, the results of this study are very important for the current and future legal regulations on e‐cigarettes. KEYWORDS battery output voltage, electronic cigarettes, human lung adenocarcinoma A549, vapor, viability
Article
Background: Electronic cigarettes (ECIGs) aerosolize liquids for user inhalation that usually contain nicotine. ECIG nicotine emission is determined, in part, by user behavior, liquid nicotine concentration, and electrical power. Whether users are able to report accurately nicotine concentration and device electrical power has not been evaluated. This study's purpose was to examine if ECIG users could provide data relevant to understanding ECIG nicotine emission, particularly liquid nicotine concentration (mg/ml) as well as battery voltage (V) and heater resistance (ohms, Ω) - needed to calculate power (watts, W). Methods: Adult ECIG users (N=165) were recruited from Los Angeles, CA for research studies examining the effects of ECIG use. We asked all participants who visited the laboratory to report liquid nicotine concentration, V, and Ω. Results: Liquid nicotine concentration was reported by 89.7% (mean=9.5mg/ml, SD=7.3), and responses were consistent with the distribution of liquids available in commonly marketed products. The majority could not report voltage (51.5%) or resistance (63.6%). Of the 40 participants (24.8%) who reported voltage and resistance, there was a substantial power range (2.2-32,670W) the upper limit of which exceeds that of the highest ECIG reported by any user to our knowledge (i.e., 2512W). If 2512W is taken as the upper limit, only 30 (18.2%) reported valid results (mean 237.3W, SD=370.6; range=2.2-1705.3W). Conclusions: Laboratory, survey, and other researchers interested in understanding ECIG effects to inform users and policymakers may need to use methods other than user self-report to obtain information regarding device power.
Article
Background: A recent study of adult smokers who vape found that disposable/cigalike electronic (e-) cigarette devices were more commonly used than later generation devices. However, whether these trends reflect patterns among adolescents and young adults, many of whom have limited or no history of combustible cigarette use, has not been studied. Methods: Participants were drawn from 8 locally, regionally, and U.S. nationally representative studies. Surveys took place between Fall 2014 and Spring 2016; participants were residents of California (3 studies), Texas (2 studies), Connecticut (1 study), or randomly selected from the United States population (2 studies). Data were collected from middle and high school students (4 studies), young adults under 30 (3 studies), or a mixture (1 study) to assess type of e-cigarette device used among past-30 day e-cigarette users: disposable/cigalike, or later generation e-cigarette device. Results: Fewer than 15% of participants in each study reported primarily using a disposable/cigalike device in the past month (across all studies: 7.5%; 95%CI: 4.9%, 10.5%). The proportion using later generation devices ranged from 58% to 86% across studies; overall, 77.0% (95%CI: 70.5%, 82.9%) reported primary use of a later generation device. Combined, 13.2% (95%CI: 5.9%, 22.8%) reported "don't know" or were missing data. Conclusions: Among adolescent and young adult e-cigarette users, primary use of disposable/cigalike devices was rare. Future research should continue to evaluate the type of device used by adolescents and young adults, as these data may be relevant to regulatory oversight of e-cigarettes recently acquired by the Food and Drug Administration Center for Tobacco Products. Implications: In this pooled analysis of adolescent and young adult vapers, primary use of later generation e-cigarette devices was substantially more common than use of disposable/cigalike devices. The type of device predominantly used by adolescents and young adults has regulatory implications for policy to reduce adolescent use of e-cigarettes.
Article
Introduction Electronic cigarettes’ (e-cigarettes) viability as a public health strategy to end smoking will likely be determined by their ability to mimic the pharmacokinetic profile of a cigarette while also exposing users to significantly lower levels of harmful/potentially harmful constituents (HPHCs). The present study examined the nicotine delivery profile of third- (G3) versus second-generation (G2) e-cigarette devices and their users' exposure to nicotine and select HPHCs compared with cigarette smokers. Methods 30 participants (10 smokers, 9 G2 and 11 G3 users) completed baseline questionnaires and provided exhaled carbon monoxide (eCO), saliva and urine samples. Following a 12-hour nicotine abstinence, G2 and G3 users completed a 2-hour vaping session (ie, 5 min, 10-puff bout followed by ad libitum puffing for 115 min). Blood samples, subjective effects, device characteristics and e-liquid consumption were assessed. Results Smokers, G2 and G3 users had similar baseline levels of cotinine, but smokers had 4 and 7 times higher levels of eCO (p<0.0001) and total 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanol (i.e., NNAL, p<0.01), respectively, than G2 or G3 users. Compared with G2s, G3 devices delivered significantly higher power to the atomiser, but G3 users vaped e-cigarette liquids with significantly lower nicotine concentrations. During the vaping session, G3 users achieved significantly higher plasma nicotine concentrations than G2 users following the first 10 puffs (17.5 vs 7.3 ng/mL, respectively) and at 25 and 40 min of ad libitum use. G3 users consumed significantly more e-liquid than G2 users. Vaping urges/withdrawal were reduced following 10 puffs, with no significant differences between device groups. Discussion Under normal use conditions, both G2 and G3 devices deliver cigarette-like amounts of nicotine, but G3 devices matched the amount and speed of nicotine delivery of a conventional cigarette. Compared with cigarettes, G2 and G3 e-cigarettes resulted in significantly lower levels of exposure to a potent lung carcinogen and cardiovascular toxicant. These findings have significant implications for understanding the addiction potential of these devices and their viability/suitability as aids to smoking cessation.
Article
The Food and Drug Administration (FDA) is issuing this final rule to deem products meeting the statutory definition of "tobacco product,'' except accessories of the newly deemed tobacco products, to be subject to the Federal Food, Drug, and Cosmetic Act (the FD&C Act), as amended by the Family Smoking Prevention and Tobacco Control Act (Tobacco Control Act). The Tobacco Control Act provides FDA authority to regulate cigarettes, cigarette tobacco, roll-your-own tobacco, smokeless tobacco, and any other tobacco products that the Agency by regulation deems to be subject to the law. With this final rule, FDA is extending the Agency's "tobacco product'' authorities in the FD&C Act to all other categories of products that meet the statutory definition of "tobacco product" in the FD&C Act, except accessories of such newly deemed tobacco products. This final rule also prohibits the sale of "covered tobacco products" to individuals under the age of 18 and requires the display of health warnings on cigarette tobacco, roll-your own tobacco, and covered tobacco product packages and in advertisements. FDA is taking this action to reduce the death and disease from tobacco products. In accordance with the Tobacco Control Act, we consider and intend the extension of our authorities over tobacco products and the various requirements and prohibitions established by this rule to be severable.
Article
Aims: To assess prevalence of electronic cigarette (e-cigarette) use, reported changes in smoking status due to e-cigarette use and correlates of e-cigarette use in the European Union (EU) member states in 2014. Design: Cross-sectional survey of EU citizens representative of the population (Special Eurobarometer 429). Setting: All 28 member states of the EU. Participants: 27,460 EU citizens aged ≥ 15 years (after excluding those who responded "Do not know" to the questions about smoking status and e-cigarette use). Measurements: Descriptive analysis (%, 95%CI) of e-cigarette use prevalence (current use, past use and past experimentation) according to smoking status, self-reported changes in smoking status according to patterns of e-cigarette use, and logistic regression analysis to examine correlates of e-cigarette use, especially sociodemographic factors and smoking status. Findings: Ever e-cigarette use was reported by 31.1% (30.0-32.2%) of current smokers, 10.8% (10.0-11.7%) of former smokers, and 2.3% (2.1-2.6%) of never smokers. Past experimentation [7.2% (6.9-7.5%)] was more common than current [1.8% (1.6-1.9%)] and past use [2.6% (2.4-2.8%)]. Extrapolated to the whole population, about 48.5 million EU citizens were ever e-cigarette users, with 76.8% using nicotine-containing e-cigarettes. Initiation with e-cigarettes was reported by 0.8% (0.6-0.9%) of participants who reported ever use of any tobacco-related product. Only 1.3% (1.1-1.5%) of never smokers used nicotine-containing e-cigarettes, with 0.09% (0.04-0.14%) reporting daily nicotine use. Smoking cessation due to e-cigarette use was reported by 35.1% (30.7-39.5%) of current e-cigarette users, while a further 32.2% (29.9-36.5%) reported smoking reduction. An estimated 6.1 and 9.2 million EU citizens had quit and reduced smoking with the use of e-cigarettes respectively. Being current (OR: 21.23, 95%CI: 18.32-24.59) or former smokers (OR: 6.49, 95%CI: 5.49-7.67) were the strongest correlates of ever e-cigarette use. Conclusions: E-cigarette use in the European Union appears to be largely confined to current or former smokers, while current use and nicotine use by people who have never smoked is rare. Over 30% of current e-cigarette users polled reported smoking cessation and reduction.
Article
AimsStudying users of e-cigarettes is important to help determine whether these devices aid smoking cessation. Obtaining data in representative samples is difficult, but online surveys of users may begin to build a picture. Therefore, this study aimed, through a large online survey, to describe usage and characteristics of users of e-cigarettes. DesignCross-sectional internet survey between 2012 and 2014. Setting and participantsA total of 2807 current e-cigarette users enrolled via e-cigarette and smoking cessation websites, who lived in France (n=988), the United States (n=579), Switzerland (n=310), the United Kingdom (n=143) and other countries (n=787). MeasurementsType of e-cigarette used: pre-filled cartridges (n=71), unmodified refillable tanks (n=758), modified refillable tanks (n=392), patterns of use, perceived effects. FindingsPre-filled models were perceived to be less effective than unmodified refillable tanks for smoking cessation by former smokers (definitely helped': 74% vs. 94%, P<0.001) and by current smokers for smoking reduction (definitely helped': 37% vs. 78%, P<0.001). Users modified their e-cigarettes mainly to obtain a better taste (very true' 60%, 55.5-64.5%). Modified tanks were perceived to make it easier to abstain from smoking than unmodified tanks 95% vs. 89%, P<0.001); 34% of users of pre-filled cartridges, 60% of users of unmodified tanks and 83% of users of modified tanks were men (P<0.001). Conclusions Newer-generation e-cigarettes were perceived to be more satisfactory and more effective for refraining from smoking than older models. Women tended to use pre-filled, unmodified models, which were perceived by participants to be the least effective in terms of abstaining from smoking.
Article
Introduction: We evaluated the accuracy of nicotine concentration labeling on electronic cigarette refill products. Methods: The nicotine concentration of 71 electronic cigarette refill fluid products and 1 related do-it-yourself (DIY) product was quantified using high-performance liquid chromatography. Quantified data were compared with manufacturers labeled concentrations. Duplicate refill fluid products purchased at different times were evaluated by visual comparison of fluid coloration and quantified nicotine concentration. Results: Thirty-five of the 54 nicotine-containing fluids had quantified nicotine concentrations that deviated by more than ± 10% from the manufacturer labels, with 46 of 50 being in excess of labeled values. Refill fluids labeled as 0 nicotine had no detectable nicotine. Of the 5 products that were unlabeled for nicotine concentration, 3 contained no detectable nicotine, whereas the remaining 2 contained nicotine in excess of 100mg/ml and may have been intended for DIY use. Sixteen of the 18 duplicate bottles of refill fluid varied greatly in their nicotine concentrations. One of the 5 companies showed significant improvement in labeling accuracy among the most recently purchased products. Of the 23 total duplicate pairs, 15 of 23 varied in coloration from their mates. Conclusions: Nicotine concentration labeling on electronic cigarette refill products was often inaccurate but showed improvement recently in products from 1 company. To ensure the safety of refill fluids and DIY products, it is necessary to establish quality control guidelines for the manufacturing and labeling and to monitor products longitudinally.
Article
This study investigated the performance of electronic cigarettes (e-cigarettes), compared different models within a brand, compared identical copies of the same model within a brand, and examined performance using different protocols. Airflow rate required to generate aerosol, pressure drop across e-cigarettes, and aerosol density were examined using three different protocols. First 10 puff protocol: The airflow rate required to produce aerosol and aerosol density varied among brands, while pressure drop varied among brands and between the same model within a brand. Total air hole area correlated with pressure drop for some brands. Smoke-out protocol: E-cigarettes within a brand generally performed similarly when puffed to exhaustion; however, there was considerable variation between brands in pressure drop, airflow rate required to produce aerosol, and the total number of puffs produced. With this protocol, aerosol density varied significantly between puffs and gradually declined. CONSECUTIVE TRIAL PROTOCOL: Two copies of one model were subjected to 11 puffs in three consecutive trials with breaks between trials. One copy performed similarly in each trial, while the second copy of the same model produced little aerosol during the third trial. The different performance properties of the two units were attributed to the atomizers. There was significant variability between and within brands in the airflow rate required to produce aerosol, pressure drop, length of time cartridges lasted, and production of aerosol. Variation in performance properties within brands suggests a need for better quality control during e-cigarette manufacture.
Article
Electronic nicotine delivery systems (ENDS) purport to deliver nicotine to the lungs of smokers. Five brands of ENDS were evaluated for design features, accuracy and clarity of labelling and quality of instruction manuals and associated print material supplied with products or on manufacturers' websites. ENDS were purchased from online vendors and analysed for various parameters. While the basic design of ENDS was similar across brands, specific design features varied significantly. Fluid contained in cartridge reservoirs readily leaked out of most brands, and it was difficult to assemble or disassemble ENDS without touching nicotine-containing fluid. Two brands had designs that helped lessen this problem. Labelling of cartridges was very poor; labelling of some cartridge wrappers was better than labelling of cartridges. In general, packs of replacement cartridges were better labelled than the wrappers or cartridges, but most packs lacked cartridge content and warning information, and sometimes packs had confusing information. Used cartridges contained fluid, and disposal of nicotine-containing cartridges was not adequately addressed on websites or in manuals. Orders were sometimes filled incorrectly, and safety features did not always function properly. Print and internet material often contained information or made claims for which there is currently no scientific support. Design flaws, lack of adequate labelling and concerns about quality control and health issues indicate that regulators should consider removing ENDS from the market until their safety can be adequately evaluated.
Evidence Review of E-Cigarettes and Heated Tobacco Products 2018. A report commissioned by Public Health England
  • A Mcneill
  • L S Brose
  • R Calder
  • L Bauld
  • D Robson
McNeill A., Brose L. S., Calder R., Bauld L., Robson D. Evidence Review of E-Cigarettes and Heated Tobacco Products 2018. A report commissioned by Public Health England. London: Public Health England; 2018.
Rapid Review of Nicotine Inhaling Product Compliance with the Tobacco Product and Related Products Regulations: 2017. MacGregor Consulting Limited for the Chartered Trading Standards Institute
  • Macgregorj
MacGregor J. Rapid Review of Nicotine Inhaling Product Compliance with the Tobacco Product and Related Products Regulations: 2017. MacGregor Consulting Limited for the Chartered Trading Standards Institute; 2018 May. Available at: https://www.tradingstandards.uk/media/documents/ news--policy/tobacco-control/rr1-phase-3-final-report-fordhsc.pdf (accessed 5 March 2019) (Archived at http://www. webcitation.org/76eEfkXz1 on 5 March 2019).
Awareness, trial, and use of electronic cigarettes among adult current smokers and ex‐smokers in 14 countries with differing EC regulatory polices: results from the International Tobacco Control Policy Evaluation Project
  • Gravely S.
Awareness, trial, and use of electronic cigarettes among adult current smokers and ex-smokers in 14 countries with differing EC regulatory polices: results from the International Tobacco Control Policy Evaluation Project
  • S Gravely
  • P Driezen
  • J Ouimet
  • A C K Quah
  • K Cummings
  • M Thompson
Gravely, S., Driezen, P., Ouimet, J., Quah, A. C. K., Cummings, K., Thompson, M. et al. Awareness, trial, and use of electronic cigarettes among adult current smokers and ex-smokers in 14 countries with differing EC regulatory polices: results from the International Tobacco Control Policy Evaluation Project. Addiction 2019; https://doi.org/10.1111/add.14558.