No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
A new Classification System for describing concurrent use of Nicotine Vaping Products alongside Cigarettes (so-called “Dual Use”): Findings from the ITC-4 Country Smoking and Vaping Wave 1 Survey t
Abstract
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.
... Of the 96 human studies, (Hammond et al., 2021;Kaplan et al., 2020;Jankowski et al., 2019;Huh et al., 2022;Liu et al., 2017;Vogel et al., 2018;Palmer et al., 2021;Yingst et al., 2022;St Helen et al., 2020;Harvanko et al., 2020;Felicione et al., 2022;Rüther et al., 2018;Hughes et al., 2020;Yingst et al., 2019;Rose et al., 2023;Loukas et al., 2022;Creamer et al., 2019;Strong et al., 2020;Du et al., 2019;Snell et al., 2020;Vogel et al., 2019;Shiffman et al., 2021;Rest et al., 2021;Etter, 2024;Boyd et al., 2022;Do et al., 2023;Pienkowski et al., 2024;Leventhal et al., 2021;Hammond et al., 2023;Tackett et al., 2021;Sargent et al., 2022;Parks et al., 2022;Douglas et al., 2021;Hoyt et al., 2022;Jackson et al., 2021;Wetherill et al., 2023;Winburn and Ofei-Dodoo, 2023;Choi et al., 2018;Zvolensky et al., 2019;Borland et al., 2019;Wade et al., 2022;Sung et al., 2018;Camara-Medeiros et al., 2021;Kim et al., 2021;Pamungkasningsih et al., 2021;Temourian et al., 2022;Douglas et al., 2023;Fearon et al., 2022;Mohd Radzi et al., 2021;Carroll et al., 2017;Chaffee et al., 2022;Perry et al., 2023;Chavez et al., 2021;Saran et al., 2022;Hughes and Callas, 2019;Leventhal et al., 2022;Strong et al., 2017;Odani et al., 2020;Piper et al., 2022;Glantz et al., 2022;Roh et al., 2022;Rhoades et al., 2019;Case et al., 2018;Lin et al., 2022;Case et al., 2020;Boykan et al., 2019;Harvanko et al., 2018;Leavens et al., 2020;Shiffman and Sembower, 2020;Azagba et al., 2019;Johnson et al., 2018;Rycroft et al., 2021;Rudasingwa et al., 2021;Browne and Todd, 2018;Mantey et al., 2021;Zaidi and Shaikh, 2022;Yingst et al., 2021;Kechter et al., 2021;Dobbs et al., 2020;Adjei et al., 2023;Cristol et al., 2024;Buu et al., 2023;Strong et al., 2023;Alshaibani et al., 2023;Parms et al., 2023;Sreeramareddy et al., 2023;Lohner et al., 2023;Tashakkori et al., 2023; 55 % (n = 53) had low risk of bias, 20 % (n = 19) had some concerns or moderate risk of bias, and 25 % (n = 24) had a high or very high risk of bias. Of the 24 high or very high risk of bias studies, 2 were cross-over trials, Harvanko et al., 2020) 3 were non-randomized experimental studies, (Rüther et al., 2018;Hughes et al., 2020;Rose et al., 2023) 11 were longitudinal observational studies, (Creamer et al., 2019;Strong et al., 2020;Du et al., 2019;Snell et al., 2020;Vogel et al., 2019;Shiffman et al., 2021;Rest et al., 2021;Etter, 2024;Boyd et al., 2022;Do et al., 2023;) and 8 were cross-sectional studies (Jankowski et al., 2019;Jackson et al., 2021;Choi et al., 2018;Fearon et al., 2022;Hughes and Callas, 2019;Glantz et al., 2022;Case et al., 2018;Harvanko et al., 2018). ...
... We included 5 cross-sectional studies (Kaplan et al., 2020;Jankowski et al., 2019;Strong et al., 2017;Zaidi and Shaikh, 2022;Cristol et al., 2024) comparing level of dependence and 5 cross-sectional studies (Huh et al., 2022;Liu et al., 2017;Borland et al., 2019;Rudasingwa et al., 2021;Adjei et al., 2023) comparing prevalence of dependence between non-smoker current vapers and non-vaper current smokers in the metaanalyses. All of them had low risk of bias, except two studies (Jankowski et al., 2019;Borland et al., 2019) which had moderate to high risk of bias. ...
... We included 5 cross-sectional studies (Kaplan et al., 2020;Jankowski et al., 2019;Strong et al., 2017;Zaidi and Shaikh, 2022;Cristol et al., 2024) comparing level of dependence and 5 cross-sectional studies (Huh et al., 2022;Liu et al., 2017;Borland et al., 2019;Rudasingwa et al., 2021;Adjei et al., 2023) comparing prevalence of dependence between non-smoker current vapers and non-vaper current smokers in the metaanalyses. All of them had low risk of bias, except two studies (Jankowski et al., 2019;Borland et al., 2019) which had moderate to high risk of bias. Although non-smoker current vapers were found to have lower level of dependence than non-vaper current smokers in the fixed effect model (SMD − 1.828; 95 % CI − 1.915, − 1.741; p = 0; N = 15,546), the random effect model revealed no statistically significant difference in level of dependence (SMD − 5.254; 95 % CI − 15.344, 4.836; p = 0.31; N = 15,546) (Fig. 2). ...
... These classifications are associated with different member characteristics and longitudinal behavior change. For example, in a large multi-country study, Borland et al. [11] applied a rational approach to categorize combustible and/or electronic cigarette users: no use, non-daily use, daily use of each product over the past month. This two-dimensional classification produced eight subtypes of smokers and vapers including four subtypes of dual use (10.8%): predominant smokers (5.6%), daily dual users (3.3%), predominant vapers (0.9%), and nondaily concurrent users (1.1%). ...
... Borland et al.'s [11] attempt at defining subtypes of dual users highlights that even broad divisions using a single dimension of each product created meaningful subtypes. Yet, smoking and vaping behavior is multidimensional (e.g. ...
... We described and compared characteristics of the derived subpopulations using the six FMM variables as well as demographics, smoking and vaping history variables, and variables related to motivation and intentions for future use. This empirical approach with multiple model-input variables may replicate the four subpopulations identified by the rational approach, [9][10][11] but could generate different and/or additional subpopulations. ...
Aims:
To identify subpopulations of dual users of combustible and electronic cigarettes using current smoking and vaping behaviors.
Design:
Secondary analysis of baseline data from a randomized controlled trial testing a smoking cessation intervention for dual users. Finite mixture modeling of frequency, quantity, and dependence on combustible and electronic cigarettes was used to identify classes. Demographics and additional smoking and vaping variables were used to further characterize the classes.
Setting:
United States.
Participants:
A total of 2896 adults who smoked weekly for the past year and vaped weekly for the past month.
Measurements:
Self-report baseline measures assessed demographics and smoking and vaping behaviors and characteristics including days of use per week, frequency of use within a day, time to first use after waking, urges to smoke, smoking cessation motivation, self-efficacy to abstain from smoking, months since vaping initiation, reasons for initiating and maintaining vaping, and future plans to stop vaping.
Findings:
Eight probabilistic classes were identified and well-defined (relative entropy = 0.95, Lo-Mendell-Rubin adjusted likelihood ratio test P < 0.0001; class probabilities 0.89-0.97). In general, classes crossed two levels of smoking with four levels of vaping. The largest class (31%) had relatively high levels of smoking (72% daily, 56% 11+ cigarettes per day [CPD], 96% within 30 minutes of waking) and vaping (74% daily, 100% 20+ electronic-CPD, 74% <30 minutes). The next largest class (27%) had relatively high levels of vaping (93% daily, 100% 20+ electronic-CPD, 82% <30 minutes) and very low levels of smoking (28% daily, 12% 11+ CPD, 0% <30 minutes). The six smaller classes (3%-13%) also had distinct smoking and vaping behaviors. All eight classes exhibited distinguishing characteristics beyond current smoking and vaping behaviors.
Conclusions:
Dual users of combustible and electronic cigarettes are not a homogeneous population, having eight well-defined prospective subpopulations.
... Within-substance, different combinations of smoking and vaping use patterns can yield widely different levels of possible health harms. For instance, data examining dual users of tobacco cigarettes and nicotine-containing e-cigarettes note differences in levels of nicotine dependence according to concurrent daily vs. non-daily use patterns for both smoked and vaped products (Borland et al., 2019). Combined patterns of daily and non-daily dual cigarette/e-cigarette use have also been associated with differential exposure to inhaled toxic compounds linked to chronic disease development (Goniewicz et al., 2018;Smith et al., 2021). ...
... The GAIN-SS is designed to identify individuals who have internalizing, externalizing, and/or substance use disorders that require clinical intervention (Dennis et al., 2006). Measures were drawn from the published literature on substance use (Borland et al., 2019;Collins et al., 1985Collins et al., , 2007Cuttler & Spradlin, 2017;Dennis et al., 2006;Hyland et al., 2017;Lee et al., 2016;Tucker et al., 2019). A detailed description of the measures administered in the survey can be viewed in Table 1. ...
... Bivariate statistical tests were used to determine relationships between variables, including paired samples t-tests and chi-square tests. Due to the literature underscoring health effects occurring alongside daily product use (Borland et al., 2019;Goniewicz et al., 2018;Smith et al., 2021), a series of logistic regression models were fit to determine the contributions of each mode of product use to odds of being: (1) a daily nicotine vaper (vs. non-daily vaper); (2) a daily cannabis vaper (vs. ...
Background
Co-occurring use (co-use) of nicotine and cannabis is common, and represents a broad range of use behaviors, including concurrent use, sequential use, and co-administration. Co-use has primarily been examined through the lens of smoked tobacco and cannabis. Little is known about those who co-use vaped nicotine and cannabis, and the degree to which specific co-use behaviors are associated, based on mode of use and/or substance.
Methods
We conducted an online pilot survey on use behaviors related to inhaled modes of nicotine and cannabis. The survey was administered to 112 concurrent vapers of these substances. Descriptive analyses examined sample characteristics and co-administered vaping and smoking behaviors. Logistic regressions examined associations in use behaviors by mode and substance.
Results
Participants who vaped nicotine and cannabis monthly also reported monthly smoking of cannabis (100%), and cigarettes (58%). Most exhibited moderate-to-high degrees of mental health and substance use problems requiring clinical intervention. Monthly concurrent use exhibited more differences by mode, and more similarities by substance. Specific sequential use practices showed mode-specific associations; with greater frequency of cigarette smoking and nicotine vaping. Co-administration was associated with more frequent tobacco and cannabis smoking.
Conclusions
Those who regularly vape nicotine and cannabis tend to engage in some form of smoking. Different subsets of nicotine and cannabis co-use behaviors showed different associations with patterns of use and modes of drug delivery. Findings underscore the diversity of nicotine and cannabis use behaviors among co-users, and the importance of considering associations by both substance and mode of use.
... 20 To simplify the analysis and because dual use is often unstable, 27-31 dual users of cigarettes and NVPs are included in SAVM as current smokers. 30 Those who vape de novo or who switch from smoking to vaping before age 35 are treated as exclusive vapers, reflecting the minimal smoking-related mortality risks of smokers who quit by age 35. 32 33 Those who switch from smoking to vaping after age 35 become former smokers who vape. ...
... 35 36 Based on our analysis of PATH data (see online supplemental file 2), less than 3% of smokers switch between menthol and nonmenthol cigarettes or initiate smoking after age 30. Using PATH data for ages [25][26][27][28][29][30][31][32][33][34][35]MP 30 is estimated as the average proportion of menthol smokers and is applied to smoker initiation rates at each age a in year t as: ...
... While some studies indicate stable levels of dual use, 65 66 other studies indicate dual use is an unstable use state, with high rates of transition to exclusive NVP use or cigarette smoking. [27][28][29][30][31] Moreover, some studies suggest similar health risks for dual users as for exclusive smokers, 67-69 although others have suggested higher levels. [70][71][72] Further study is warranted on health impacts and patterns of dual use. ...
Introduction
The US Food and Drug Administration most recently announced its intention to ban menthol cigarettes and cigars nationwide in April 2021. Implementation of the ban will require evidence that it would improve public health. This paper simulates the potential public health impact of a ban on menthol in cigarettes and cigars through its impacts on smoking initiation, smoking cessation and switching to nicotine vaping products (NVPs).
Methods
After calibrating an established US simulation model to reflect recent use trends in cigarette and NVP use, we extended the model to incorporate menthol and non-menthol cigarette use under a status quo scenario. Applying estimates from a recent expert elicitation on the behavioural impacts of a menthol ban, we developed a menthol ban scenario with the ban starting in 2021. We estimated the public health impact as the difference between smoking and vaping-attributable deaths and life-years lost in the status quo scenario and the menthol ban scenario from 2021 to 2060.
Results
As a result of the ban, overall smoking was estimated to decline by 15% as early as 2026 due to menthol smokers quitting both NVP and combustible use or switching to NVPs. These transitions are projected to reduce cumulative smoking and vaping-attributable deaths from 2021 to 2060 by 5% (650 000 in total) and reduce life-years lost by 8.8% (11.3 million). Sensitivity analyses showed appreciable public health benefits across different parameter specifications.
Conclusions and relevance
Our findings strongly support the implementation of a ban on menthol in cigarettes and cigars.
... In the next 30 days 6 (43) In the next 6 months 3 (21) No intent to quit in the next 6 months or missing a LGBTQ+: lesbian, gay, bisexual, transgender, and queer or questioning. ...
... In addition, young people reported the use of e-cigarettes in times and places where smoking is not allowed or not acceptable, which may lead to increased frequency of vaping [2]. Previous research has shown that dual users are a diverse group with a variety of use patterns (ie, daily use of both cigarettes and e-cigarettes, predominant use of e-cigarettes, predominant use of cigarettes, or nondaily use of both products) and differing levels of nicotine dependence [21]. The variation in the quantity of smoking and vaping among dual users reinforces the need for personalized interventions. ...
Background
Dual use of both e-cigarettes and cigarettes is popular among young adults and may lead to greater nicotine dependence and additive adverse health effects than single-product use. However, existing cessation programs target quitting either e-cigarettes or cigarettes, highlighting a need for interventions to help young adults quit both products (ie, dual tobacco cessation).
Objective
This formative study is part of a larger project to develop a smartphone intervention for dual tobacco cessation among young adults. This study aimed to (1) explore desires for and experiences with quitting both e-cigarettes and cigarettes and (2) identify needs and preferences for dual tobacco cessation intervention programming.
Methods
Semistructured interviews were conducted to elicit the need for and experience with dual tobacco cessation among 14 young adults (18-29 years old) recruited through Instagram (Meta) advertisements in 2023. We conducted a thematic analysis to identify common themes related to quitting experiences and cessation needs.
Results
Participants expressed a strong desire for dual tobacco cessation and had attempted to quit both tobacco products, mostly “cold turkey.” The priority product for quitting first varied by the individual’s perceived harm or level of consumption. Targets for dual tobacco cessation interventions included (1) highlighting the health effects of dual tobacco use compared with single product use, (2) providing cessation support to quit one prioritized product while cutting down the other product with the explicit goal to quit both, (3) emphasizing unique facilitators and barriers to quitting each product (eg, unpleasant smell of cigarettes facilitating smoking cessation and accessibility and flavors of e-cigarettes hindering vaping cessation), and (4) addressing co-use of tobacco with alcohol or cannabis. Participants wanted personalized interventions through smartphone apps that would tailor support to their tobacco use patterns and unique quitting goals and needs. They also suggested presenting intervention content in multimedia (eg, videos, graphic pictures, quizzes, and games) to increase engagement.
Conclusions
This study provides important insights into young adults’ experiences, needs, and preferences for dual tobacco product cessation. We highlight important targets for future smartphone apps to deliver personalized and tailored support to meet the heterogeneous needs and preferences of young people who want to quit using both e-cigarettes and cigarettes.
... These terms refer to individuals who engage in a wide range of hybrid use patterns of novel TNPs and conventional cigarettes. For example, BORLAND et al. published a categorization of "dual use" as four types of concurrent use: 1) predominant smokers (daily smokers with non-daily vaping); 2) dual users (daily use of both products); 3) predominant vapers (daily vapers and non-daily smokers); and 4) non-daily concurrent users (non-daily use of both) based on the frequency of use of both conventional cigarettes and e-vapor products (44). This variability in definition makes it difficult both to compare results across studies and to understand what the patterns mean, but considering the frequency of use of both novel TNPs and conventional cigarettes is important in understanding the implications of different patterns of concurrent use. ...
... This variability in definition makes it difficult both to compare results across studies and to understand what the patterns mean, but considering the frequency of use of both novel TNPs and conventional cigarettes is important in understanding the implications of different patterns of concurrent use. Those who use only one of the novel TNPs or who use only conventional cigarettes are referred to as exclusive or single users (39)(40)(41)(42)(43)(44). We advocate that these terms should also be modified to accommodate people's first language. ...
In recent years, the tobacco- and/or nicotine-containing product (TNP) portfolio has expanded to include products such as e-vapor products, heated tobacco products, and nicotine pouches. Although scientific papers and regulatory requirements/recommendations related to the assessment of product use behavior and exposure to product use have been published for these novel TNPs, there is great diversity in the terminology used to characterize and assess these types of products. The aim of this paper is to define the terms and methods used for assessing product use behavior and exposure, with the objective to suggest a uniform application of terms used by scientists working in this field of research. This publication is the work product of a cross-industry work item commissioned by the Cooperation Centre for Scientific Research Relative to Tobacco (CORESTA) Product Use Behaviour and Biomarkers Subgroups.
... Similarly, the NVP Scenario does not explicitly model short-term NVP use leading to quitting both cigarettes and NVPs, but is indirectly incorporated through a smoking cessation multiplier reflecting the net effect of vaping on smoking cessation rates. In addition, the NVP Scenario does not distinguish dual cigarette and NVP users from exclusive smokers, because dual users have generally been found to either remain dual users or soon transition to either exclusive cigarette or exclusive NVP use [4,8,18,78,86,89] and the health risks of dual users appear to be similar to those of exclusive smokers [36,82,83]. However, transitions from dual use to exclusive NVP use or neither cigarette nor NVP use are reflected in the switching and smoking cessation parameters. ...
... A never smoker who experiments with NVPs and does not transition to smoking is considered a non-user. Because transitions to and from dual use are often particularly unstable [4,8,18,78], we have chosen not to distinguish dual from exclusive cigarette use in the NVP Scenario. In addition, consistent with previous CISNET models [43][44][45], SAVM does not consider relapse, with transitions to former smokers or former NVP users treated as permanent. ...
Background
Nicotine vaping products (NVPs) are increasingly popular worldwide. They may provide public health benefits if used as a substitute for smoking, but may create public health harms if used as a gateway to smoking or to discourage smoking cessation. This paper presents the Smoking and Vaping Model (SAVM), a user-friendly model which estimates the public health implications of NVPs in the USA.
Methods
SAVM adopts a cohort approach. We derive public health implications by comparing smoking- and NVP-attributable deaths and life-years lost under a No-NVP and an NVP Scenario. The No-NVP Scenario projects current, former, and never smoking rates via smoking initiation and cessation rates, with their respective mortality rates. The NVP Scenario allows for smoking- and NVP-specific mortality rates, switching from cigarette to NVP use, separate NVP and smoking initiation rates, and separate NVP and smoking cessation rates. After validating the model against recent US survey data, we present the base model with extensive sensitivity analyses.
Results
The SAVM projects that under current patterns of US NVP use and substitution, NVP use will translate into 1.8 million premature smoking- and vaping-attributable deaths avoided and 38.9 million life-years gained between 2013 and 2060. When the NVP relative risk is set to 5%, the results are sensitive to the level of switching and smoking cessation rates and to a lesser extent smoking initiation rates. When the NVP relative risk is raised to 40%, the public health gains in terms of averted deaths and LYL are reduced by 42% in the base case, and the results become much more sensitive to variations in the base case parameters.
Discussion
Policymakers, researchers, and other public health stakeholders can apply the SAVM to estimate the potential public health impact of NVPs in their country or region using their own data sources. In developing new simulation models involving NVPs, it will be important to conduct extensive sensitivity analysis and continually update and validate with new data.
Conclusion
The SAVM indicates the potential benefits of NVP use. However, given the uncertainty surrounding model parameters, extensive sensitivity analysis becomes particularly important.
... Tobacco use was defined as described below: 1) Based on the Baig & Giovenco classifications described above (Baig & Giovenco, 2020;Borland et al., 2019) W4 past 30-day dual use was categorized into: i) heavy dual use, ii) predominant smoking, iii) predominant ENDS use, and iv) light dual use. ...
Introduction
The study assessed longitudinal transitions among adult (18 and older) past 30-day daily and non-daily dual users of cigarettes and electronic nicotine delivery systems (ENDS).
Methods
Using data from Wave 4 (W4; 2016/17) and Wave 5 (W5; 2018/19) of the Population Assessment of Tobacco and Health (PATH) Study, a nationally representative, longitudinal cohort study of US adults, multivariable regressions were conducted among W4 dual users of cigarettes and ENDS to examine past 30-day cigarette smoking at W5. The study also analyzed changes in frequency of past 30-day smoking and cigarettes smoked per day between W4 and W5, stratified by W4/W5 daily/non-daily ENDS use among W4 daily and non-daily cigarette smokers.
Results
Among W4 dual users, those smoking daily and using ENDS non-daily had higher odds of daily cigarette smoking at W5 than daily users of both products (AOR: 2.32, 95 % CI: 1.38–3.90). W4 daily smokers who used ENDS daily at Wave 5 smoked cigarettes on fewer days at Wave 5 than W4 daily smokers who were either daily ENDS users at Wave 4 (B = −4.59; SE = 1.43, p < 0.01) or non-daily ENDS users at Wave 4 (B = −4.55; SE = 1.24, p < 0.001). Among W4 non-daily cigarette smokers, W4 non-daily ENDS users who used daily at W5 smoked cigarettes on fewer days (B = −4.04, SE = 1.82) at W5 than those who were non-daily ENDS users at W4 and W5.
Conclusions
Findings highlight the importance of frequency of ENDS use in reducing cigarette smoking and could inform smoking cessation interventions among daily cigarette smokers.
... A social practice approach also questions public health narratives that often frame smoking and vaping as a zero-sum competition with winners and losers [18,19]. However, studies of people who smoke and try e-cigarettes suggest many 'dual use' tobacco cigarettes and e-cigarettes [20][21][22]. A social practice approach suggests that it may be more useful to conceptualize smoking and vaping as nesting within the umbrella practice of nicotine inhalation. ...
Background and aim
Social practices such as smoking–drinking co‐use often go ‘hand‐in‐hand’, linked by the coordination of materials, skills and meanings. However, the experience of using e‐cigarettes while drinking among people who smoke (and drink) remains underexplored. We used social practice theory to show how smoking, vaping and drinking intersect and to explain how vaping created two new social practices among people who tried e‐cigarettes to stop smoking: ‘vaping–drinking’ co‐use and ‘smoking–vaping–drinking’ poly‐use.
Methods
We conducted five in‐depth interviews over 18–24 weeks during 2018–19, with each of nine Aotearoa New Zealand young adults aged 20–29 years. Participants smoked daily, did not regularly use e‐cigarettes at entry and wished to try vaping to stop smoking. We analysed participants’ reports of smoking or vaping while drinking using thematic analysis.
Results
Individual participants reported both co‐use and poly‐use occasions throughout the study. Vaping–drinking co‐use arose from practice ‘replacement’ processes, where vaping fully substituted smoking. Smoking–vaping–drinking poly‐use arose from ‘adjacency’ processes where vaping complemented smoking. Participants used both processes flexibly over time, which required new skills in material, temporal, pleasure and social coordination to try to recreate valued meanings of comfort, security and communality associated with well‐established smoking–drinking practices. Unsuccessful coordination attempts maintained smoking–drinking co‐use.
Conclusion
Among Aotearoa New Zealand young adult smokers who want to use vaping to stop smoking, drinking occasions may help to maintain existing smoking–drinking practices and facilitate the development of vaping–drinking co‐use and smoking–vaping–drinking poly‐use practices, potentially prolonging individuals’ exposure to smoking.
... This is the first study to address support for nicotine reduction policies across a broad range of product use histories, including the fourfold classification of 'dual use' from Borland et al. 20 Previously reported estimates of support for VLNCs in Canada, the USA, England and Australia was limited to people who smoked daily. 13 15 Our findings show that support for VLNCs was lowest among people who exclusively smoke daily (ie, those who are highly dependent on nicotine but do not have an alternative source of nicotine besides cigarettes), although the difference was not statistically significant for all smoking/vaping statuses. ...
Introduction
The USA and New Zealand have sought to establish a product standard to set a maximum nicotine level for cigarettes to reduce their addictiveness. This study examined support for very low nicotine cigarettes (VLNCs) in Australia, Canada, England and the USA between 2016 and 2020.
Methods
Repeated cross-sectional data were analysed from participants who currently smoke, formerly smoked or vaped and/or currently vape in the 2016 (n=11 150) and/or 2020 (n=5432) International Tobacco Control (ITC) Four Country Smoking and Vaping Survey. Respondents were asked if they would support a law that reduces the amount of nicotine in cigarettes to make them less addictive. Adjusted and weighted logistic regression analyses estimated the prevalence and predictors of support, such as country, age, sex, education, income, race and smoking/vaping status for VLNCs (support vs oppose/do not know).
Results
A majority of respondents supported a VLNC law, with support highest in Canada (69%; 2016 and 2020 combined), followed by England (61%), Australia (60%) and the USA (58%). Overall, support decreased from 62% in 2016 to 59% in 2020 (p=0.004), which did not differ by country. Levels of support differed by smoking/vaping status, where those who exclusively smoked daily showed the lowest level of support (59%) and those who exclusively vaped non-daily had the highest level of support (72%).
Conclusion
More than half of respondents in all four countries—including those who smoked daily—supported a hypothetical VLNC standard to render cigarettes less addictive. It is important to examine if support is sustained after policies are implemented.
... The potential gateway effect of vaping to smoking occurs through the net NVP and smoking initiation. Because transitions to dual use are often temporary [101][102][103][104] and dual users have risks comparable to smokers [12,13], we chose not to distinguish between exclusive smokers and dual users in the NVP scenario. This assumption implies that dual users will have the same cessation and switching patterns with the same health risks as exclusive smokers. ...
Background
Simulation models play an increasingly important role in tobacco control. Models examining the impact of nicotine vaping products (NVPs) and smoking tend to be highly specialized and inaccessible. We present the Smoking and Vaping Model (SAVM),a user-friendly cohort-based simulation model, adaptable to any country, that projects the public health impact of smokers switching to NVPs.
Methods
SAVM compares two scenarios. The No-NVP scenario projects smoking rates in the absence of NVPs using population projections, deaths rates, life expectancy, and smoking prevalence. The NVP scenario models vaping prevalence and its impact on smoking once NVPs became popular. NVP use impact is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the No-NVP and NVP scenarios. We illustrate SAVM’s adaptation to the German adult ages 18+ population, the Germany-SAVM by adjusting the model using population, mortality, smoking and NVP use data.
Results
Assuming that the excess NVP mortality risk is 5% that of smoking, Germany-SAVM projected 4.7 million LYLs and almost 300,000 SVADs averted associated with NVP use from 2012 to 2060. Increasing the excess NVP mortality risk to 40% with other rates constant resulted in averted 2.8 million LYLs and 200,000 SVADs during the same period.
Conclusions
SAVM enables non-modelers, policymakers, and other stakeholders to analyze the potential population health effects of NVP use and public health interventions.
... Given that most adult e-cigarette users concurrently use cigarettes and other tobacco products such as cigars, smokeless tobacco, and pipes, (Creamer et al., 2019;Sung et al., 2018) and that cigarette smoking and other tobacco product use have been shown to be associated with poorer mental health, (Boksa, 2017;Carter et al., 2014;Forman-Hoffman et al., 2017;Hagman et al., 2008;King et al., 2018;Kulik and Glantz, 2017;Plurphanswat et al., 2017;Streck et al., 2020) it is important to tease out the potential confounding impact of cigarette smoking and other non-ecigarette tobacco product use on the association between e-cigarette use and psychological distress. Furthermore, studies (Azagba et al., 2019;Borland et al., 2019) have found that nicotine dependence among dual users of e-cigarettes and cigarettes (hereafter "dual users") varied by their use frequencies. Given that nicotine dependence is linked to psychological distress, (Prochaska et al., 2017) it is plausible that varying levels of nicotine dependence may contribute to different probabilities of psychological distress within subgroups of dual users. ...
This observational study examines the association of current e-cigarette use and dual use of e-cigarettes and cigarettes (dual use) with psychological distress among U.S. adults. We differentiate dual use based on the smoking frequency and compare the relationship between dual use and psychological distress to that of exclusive cigarette smoking with the same smoking frequency.
Using data from the 2015–2018 National Health Interview Surveys, we analyzed adults aged 18+ (N = 55,780) who currently use e-cigarettes or/and cigarettes and have no history of using other tobacco products, and adults who never used any tobacco. Multinomial logistic regression models estimate the association of current e-cigarette use and dual use with psychological distress severity (no/mild, moderate, and severe).In the sample, 15.3% and 2.9% of adults experienced moderate and severe psychological distress. Compared to never tobacco users, current exclusive e-cigarette users and dual users who smoke daily had higher odds of moderate and severe psychological distress. Dual users who smoke nondaily had higher odds of moderate, but not severe psychological distress than never tobacco users. Compared to exclusive daily smokers, dual users with daily smoking had higher odds of moderate and severe psychological distress. Compared to exclusive nondaily smokers, dual users with nondaily smoking had higher odds of moderate but not severe psychological distress.
Our findings suggest that exclusive e-cigarette use is associated with psychological distress severity. Dual use is associated with higher odds of psychological distress severity compared to never tobacco users and exclusive cigarette smoking, and this association differs by smoking frequency.
... No entanto, também destaca a necessidade de mais pesquisas para entender melhor os fatores complexos envolvidos no tabagismo e desenvolver intervenções mais eficazes para reduzir o tabagismo entre os estudantes universitários. Elsaieh, A. M., Shohaimi, S., Nadzir, M. N. H. M., Puad, M. H. M., Rahman, A. H. A., Elsaihi, F. M. (2023) International organizations have divergent views on these issues, with some advocating for strict regulations while others lean towards a more lenient approach A study by Borland et al. (2019) revealed that individuals who use nicotine daily expressed a higher interest in quitting than exclusive daily smokers. Dual daily users exhibited more favourable attitudes towards smoking in general. ...
Objective: In order to develop effective interventions and policies to address the growing trend of dual tobacco and e-cigarette use among Malaysia's younger generation, it is crucial to understand the socio-demographic factors that influence this behaviour. This study aimed to bridge this knowledge gap by examining the relationship between socio-demographic characteristics and smoking status among university students in the Klang Valley region of Malaysia. Method: The researchers used a cross-sectional field survey approach to collect data through a questionnaire administered to 386 university students in the Klang Valley region of Malaysia. The selected universities included Universiti Putra Malaysia (UPM), Universiti Kebangsaan Malaysia (UKM), Universiti Malaya (UM), and Sunway University, providing a diverse representation of the country's young population. Results: The findings highlight the complex nature of factors influencing smoking behaviours, revealing that socio-demographic variables have a limited impact on an individual's smoking status. However, gender emerged as a notable exception, strongly associated with smoking status. This suggests that gender dynamics may play a significant role in shaping tobacco and e-cigarette use among students. Furthermore, the study identified additional influences, such as peer pressure, accessibility of tobacco products, and perceptions towards smoking, which are likely to affect smoking behaviours. Although these aspects were not the primary focus of the study, their importance is evident. Conclusions: The study provides valuable information that can help policymakers, health professionals, and educators develop effective strategies to reduce smoking among young Malaysians. However, it also highlights the need for further research to better understand the complex factors involved in smoking and to develop more effective interventions to reduce smoking among university students. Research Implications: The study's findings can guide the development of targeted interventions, educational campaigns, and policies aimed at reducing tobacco and e-cigarette use among university students. The strong association between gender and smoking status may also guide tailored interventions for different gender groups. Originality/value: The originality of this study lies in its focused investigation of socio-demographic factors influencing dual tobacco and e-cigarette use among university students in Malaysia. The research not only reveals the limited influence of socio-demographic variables but also highlights the significance of gender and other unexplored factors, providing a nuanced understanding of smoking behaviours within this specific context.
... The Statement raises concerns about dual use (concurrent smoking and vaping) in a large RCT by Hajek at study completion [26]. Dual users are a heterogenous group, consisting of predominant smokers, dual daily users and predominant vapers [74]. Only dual users with sustained daily smoking and vaping are of potential concern, but the frequency of smoking and vaping are not mentioned in the paper or supplementary materials. ...
This paper critically analyses a statement by Australia's National Health and Medical Research Council (NHMRC) on e‐cigarettes in May 2022 that will be used to guide national policy. We reviewed the evidence and the conclusions drawn in the NHMRC Statement. In our view, the Statement is not a balanced reflection of the benefits and risks of vaping because it exaggerates the risks of vaping and fails to compare them to the far greater risks of smoking; it uncritically accepts evidence of harms from e‐cigarettes while adopting a highly sceptical attitude towards evidence of their benefits; it incorrectly claims that the association between adolescent vaping and subsequent smoking is causal; and it understates the evidence of the benefits of e‐cigarettes in assisting smokers to quit. The Statement dismisses the evidence that vaping is probably already having a positive net public health effect and misapplies the precautionary principle. Several sources of evidence supporting our assessment were published after the NHMRC Statement's publication and are also referenced. The NHMRC Statement on e‐cigarettes does not present a balanced assessment of the available scientific literature and fails to meet the standard expected of a leading national scientific body.
... Given the finding of different tobacco use and cessation behaviors among daily and intermittent users of any type of tobacco products in Table 4, it is presumed that there were different degrees of nicotine dependence among them-higher in dual users than single users and in daily users than intermittent ones, which is similar to the study by Borland et al., 9) except that it dealt with ECs rather than HTPs. ...
Background:
After the advent of heated tobacco products (HTPs) in 2017, domestic cigarette sales declined until 2019, but have increased in South Korea since 2020. This study aimed to analyze tobacco use and cessation behavior among HTP users compared with conventional cigarette (CC) users.
Methods:
We analyzed data from the eighth Korea National Health and Nutrition Examination Survey (2019). Of 6,188 study participants, 1,181 were current tobacco product users (single, dual, and triple), including all combinations of CCs, HTPs, and electronic cigarettes (ECs). Tobacco use and cessation behaviors among single and dual users of CCs and HTPs were assessed using various categorical methods.
Results:
In 2019, proportions of HTP use in men and women aged ≥19 years in South Korea were 8.8% and 1.5%, respectively, and those of single, dual, and triple users were 23.6%, 58.0%, and 18.4%, respectively. Dual users had more tobacco use than CC only and HTP only users (all P<0.001). Each daily user accounted for a lower percentage of attempt and preparation stages for cessation than intermittent users (all P<0.001, except for dual users).
Conclusion:
In this study, we analyzed the differences in tobacco use and cessation behavior among CC and HTP users in various populations in South Korea. Additionally, we found that all novel tobacco product users had already experienced CCs in adulthood. Further studies that address HTP's harmful effects in humans are necessary.
... Our study corroborates the findings regarding BOEs reported by Smith et al. [28], indicating that a clear pattern is emerging. As suggested by Borland et al. [32] product use frequency is an important indicator for identifying subsets of people who both smoke and vape. We demonstrate that among the four subgroups, those who vape frequently and those who infrequently smoke and vape, smoked fewer cigarettes and therefore, are lower on the continuum of exposure relative to people who frequently smoke and infrequently vape and people who frequently smoke and vape. ...
Introduction
People who both smoke cigarettes and vape are often considered as a homogenous group even though multiple subgroups may exist. We examined biomarkers of exposure (BOE) and biomarkers of potential harm (BOPH) to differentiate between subgroups of people who smoke and vape based on PATH Study Wave 1 (2013–2014) data.
Methods
We compared people who only smoke cigarettes everyday (Group A, n = 2442) and people who only vape everyday (Group C, n = 169) against people who smoke and vape segmented into subgroups of people who frequently smoke and vape (Group B1, n = 169), frequently smoke and infrequently vape (Group B2, n = 678), frequently vape and infrequently smoke (Group B3, n = 57), and infrequently smoke and vape (Group B4, n = 66). Eighteen BOEs (representing exposure to TSNAs, nicotine, heavy metals, PAHs, and volatile organic compounds) and four BOPHs (representing inflammation and oxidative stress) were compared within the subgroups.
Results
Levels of many BOEs/BOPHs were higher among Group B2 relative to Groups B1, B3, and B4. Compared to Group A, many BOEs were significantly lower in Groups B3 (15/18) and B4 (17/18), and some BOEs were higher among B2 (4/18). Compared to Group C, significantly lower BOEs were observed for Group B4 (2/18).
Conclusions
Overall, the levels of BOEs and BOPHs in people who smoke and vape are associated with frequency of cigarette smoking. Our findings indicate that not all people who smoke and vape are the same, and tobacco product use frequency should be considered when categorizing people who smoke and vape.
... Furthermore, dual use of ENDS with combusted cigarettes is commonplace, and the extent of reduced exposure and potential harm in ENDS users who continue to smoke cigarettes is difficult to assess. (Goniewicz et al., 2018;Borland et al., 2019;Piper et al., 2019;Smith et al., 2021) In short term studies of acute effects of novel products such as ENDS, (Hajek et al., 2017;St Helen et al., 2020a) it is important to determine recent use of tobacco products as well as the extent of dual use of both products. For exposure assessment, self-reported use of particular products can be useful, but they are of limited utility for obtaining quantitative data. ...
Biomarkers for the use of electronic nicotine delivery systems (ENDS) are desirable for studies of the health effects of electronic cigarettes and related devices. However, the aerosols inhaled from these devices do not contain substances that are unique to this class of products, i.e., substances that are not present in cigarette smoke or those that do not have common environmental or dietary sources. Consequently, identifying selective biomarkers for ENDS use remains a challenge. If co-use of conventional tobacco products can be definitively ruled out, then nicotine and its metabolites are suitable for assessing exposure. Self-reports from questionnaires are often used to obtain information on product use. But self-reports may not always be accurate, and are not amenable to obtaining quantitative information on exposure. An alternative approach is to use selective biomarkers for conventional tobacco products to definitively rule out their use. In this article, we describe two new LC-MS/MS methods for the minor tobacco alkaloids anabasine, anatabine, nicotelline, anatalline, and 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), a tobacco-specific nitrosamine metabolite, all biomarkers that are selective for the use of conventional tobacco products. Applications of these biomarkers in studies of ENDS use and dual use of ENDS and conventional tobacco products are also discussed.
... Most vapers do not exclusively use e-cigarettes; rather, these individuals vape and use one or more additional tobacco products (dubbed dual-and polyusers, respectively) (174). Thus, evaluating the health risks associated with exclusive e-cigarette use has been challenging, as the preference in choosing a secondary tobacco product can vary with location, access to tobacco products, and nicotine craving (175,176). ...
Since the spread of tobacco from the Americas hundreds of years ago, tobacco cigarettes and, more recently, alternative tobacco products have become global products of nicotine addiction. Within the evolving alternative tobacco product space, electronic cigarette (e-cigarette) vaping has surpassed conventional cigarette smoking among adolescents and young adults in the United States and beyond. This review describes the experimental and clinical evidence of e-cigarette toxicity and deleterious health effects. Adverse health effects related to e-cigarette aerosols are influenced by several factors, including e-liquid components, physical device factors, chemical changes related to heating, and health of the e-cigarette user (e.g., asthmatic). Federal, state, and local regulations have attempted to govern e-cigarette flavors, manufacturing, distribution, and availability, particularly to underaged youths. However, the evolving e-cigarette landscape continues to impede timely toxicological studies and hinder progress made toward our understanding of the long-term health consequence of e-cigarettes.
Expected final online publication date for the Annual Review of Pharmacology and Toxicology, Volume 62 is January 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
... NVP and cigarette use were dichotomized as daily or nondaily (i.e., weekly). These variables were combined to create six use status categories: (1) exclusive daily vaper, (2) exclusive nondaily vaper, (3) dual daily user (daily NVP/daily cigarette), (4) predominant vaper (daily NVP/nondaily cigarette), (5) predominant smoker (nondaily NVP/daily cigarette), and (6) concurrent nondaily user (nondaily NVP/nondaily cigarette) [23]. ...
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.
... While current marketing related to these products, where available and allowed, emphasize the potential for reduced health risk 27 , there is no evidence to suggest that these products are any less addictive. Currently, concurrent use of both cigarettes and vaping devices is common 28 , and there is no robust evidence available to help understand whether removing nicotine from smoked products will decrease or increase concurrent use with vaping devices. Furthermore, these products are not universally available, with some countries banning or heavily restricting access due to valid health and safety concerns 8 . ...
... 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. Questions and response options regarding NVPs were similar between W1 and W2 and asked participants to describe the NVP they currently use most (cf. ...
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.
... Past-30-day use (≥1 day), daily past-30-day use and non-daily use in the past 30 days have been employed in other tobacco cohort studies that describe patterns of exclusive, dual product and polytobacco use. [24][25][26] Together with the distribution of responses to the survey question (see online supplemental material 2), we categorised the following types of tobacco use, among those who reported smoking 1+days in the past 30 days: (1) exclusive, nondaily (<30 days) cigarette; (2) exclusive HTP (≥1 day); (3) dual HTP (≥1 day) and non-daily cigarette; (4) dual HTP (≥1 day) and daily (30 days) cigarette; and (5) exclusive, daily cigarette. ...
Objectives
Japan is currently the biggest market of heated tobacco products (HTPs) in the world. Little is known about nicotine dependence among HTP users. Thus, the objective was to assess the association of type of tobacco use and time-to-first-use, a marker of nicotine dependence.
Methods
A cross-sectional analysis of the 2019 data from an internet cohort study was conducted. The analytical sample consisted of 2147 current (≥1 day use in the past 30 days) HTP and/or conventional cigarette users, aged 25+ years. Marginal structural binomial regression was used to estimate nicotine dependence prevalence ratios (PRs) for each category of tobacco use (exclusive daily cigarette, exclusive HTP (≥1 day), dual HTP+daily cigarette, dual HTP+non-daily cigarette), relative to exclusive, non-daily cigarette smoking.
Results
Using a 5 min cut-off for time-to-first-use, the prevalence of nicotine dependence was higher among dual users of HTP and daily cigarettes (PR=1.38; 95% CI: 1.05 to 1.82) and exclusive, daily cigarette users (PR=1.48; 95% CI: 1.15 to 1.91), relative to exclusive, non-daily cigarette users. However, nicotine dependence among exclusive HTP users, and dual HTP+non-daily cigarette users, did not differ from that of exclusive, non-daily cigarette users. When using 15 and 30 min cut-offs, all types of users, including exclusive HTP, had higher levels of nicotine dependence relative to exclusive, non-daily cigarette users.
Conclusions
Regardless of HTP use, daily cigarette users had higher prevalence of nicotine dependence compared with non-daily cigarette users. Exclusive HTP users had similar (or potentially higher) dependence compared with exclusive, non-daily cigarette users. Longitudinal studies are needed to interrogate the public health implications of growing HTP use worldwide.
... Earlier population data from the United States indicates that multiple product use (ie, using two or more products) is common among adult cigarette/tobacco users. 1 Some research has showed that over half of current cigar users and chewing tobacco users reported multiple product use. 2 Concurrent use of vaping products with cigarettes also appears to be common, although perhaps declining. 1,3 A study looked into the dual use of combustible tobacco, smokeless tobacco, and NVPs, and found that dual use was an unstable state with users being more likely to transition to exclusive combustible use than to remain in the dual use categories. 4 In Japan, the introduction of HTPs is associated with a lot of concurrent use with smoking. ...
Introduction
This study explores patterns of use of non-cigarette tobacco and nicotine products among adult cigarette smokers and recent ex-smokers. Along with cigarette smoking status we explore differences as a function of countries with different product regulations, gender and age.
Methods
Data came from the ITC Four Country Smoking and Vaping Wave 3 Survey conducted between February-June 2020. The analytic sample consisted of 9112 current cigarette smokers (at least monthly) and 1184 recent ex-smokers (quit cigarettes ≤ 2 years) from Australia, Canada, England, and the US. Respondents were asked about their cigarette smoking and current use of the following non-cigarette products: combustible tobacco (cigars, cigarillos, pipe, waterpipe); non-combustible tobacco (smokeless tobacco, and heated tobacco products (HTPs)); and non-tobacco nicotine products (nicotine vaping products (NVPs), nicotine replacement therapy (NRT), and nicotine pouches)).
Results
Overall, NVPs (13.7%) and NRT (10.9%) were the most reported nicotine products used, followed by cigars (5.3%), cigarillos (4.2%), and HTPs (3.5%). More than 21% current and recent ex-smokers of cigarettes reported using a non-tobacco nicotine product and non-combustible product, with respondents in England reporting the highest levels of use (>26%). Males, younger respondents, and current non-daily cigarette smokers were more likely to use non-cigarette nicotine products. Notably, 11.6% of ex-cigarette smokers were using other combustible tobacco.
Conclusion
Considerable percentages of current cigarette smokers and ex-smokers use non-cigarette nicotine products, and there are unexpectedly high levels of use of other combustible products by those recent ex-smokers of cigarettes which is concerning and has important implications for definitions of smoking cessation.
Implications
The tobacco product market has evolved to include new products which add to existing non-cigarette tobacco products creating a much more diverse nicotine market. This brief report provides a snapshot of use of various combustible and non-combustible nicotine containing products among current cigarette smokers and recent ex-smokers in four western countries. Our results indicate that use of non-cigarette tobacco and nicotine products among these cigarette smokers and recent ex-smokers is not low, particularly among males, younger and non-daily cigarette smokers. Use of other combustible tobacco among respondents that recently quit cigarette smoking is concerning and has important implications for definitions of smoking cessation. Increased emphasis on researching non-cigarette nicotine product use is warranted in tobacco control generally and smoking cessation in particular.
Background/Aims
E‐cigarettes are frequently used by people who smoke. This study measured how the prevalence and patterns of smoking and vaping (‘dual use’) in England have changed as the vaping market has rapidly evolved.
Design
Representative monthly cross‐sectional survey, July 2016 to April 2024.
Setting
England.
Participants
128 588 adults (≥18y).
Measurements
Logistic regression estimated associations between survey wave and dual use. Descriptive statistics were used to analyse patterns of smoking and vaping, overall and by sociodemographic, smoking and vaping characteristics and harm perceptions of e‐cigarettes vs. cigarettes.
Findings
Across the period, the overall prevalence of dual use increased non‐linearly from 3.5% to 5.2% of adults [prevalence ratio (PR) = 1.49 (1.25–1.76)]. Among adults who smoked, the proportion who also vaped was relatively stable up to mid‐2021, at an average of 18.6% between July 2016 and May 2021, then increased rapidly to 34.2% by April 2024 [PR = 1.76 (1.48–2.09)]. This increase was greatest at younger ages [e.g. from 19.6% to 59.4% among 18‐ to 24‐year‐olds; PR = 3.04 (2.28–4.23)]. The most common pattern of dual use across the period was daily cigarette smoking with daily vaping [49.0% (47.3–50.8%)]. Over time, the proportion of dual users reporting daily cigarette smoking with non‐daily vaping decreased [from 35.2% to 15.0%; PR = 0.43 (0.29–0.63)], offset primarily by an increase in the proportion reporting non‐daily cigarette smoking with daily vaping [from 7.6% to 21.5%; PR = 2.84 (1.71–4.72)]. Daily cigarette smoking with daily vaping was more common (and non‐daily cigarette smoking with daily vaping less common) among dual users who were older, less advantaged, mainly smoked hand‐rolled cigarettes, had stronger urges to smoke and had been vaping for ≤6 months. Daily vaping was more common among dual users who thought e‐cigarettes were less/equally harmful as cigarettes, or were unsure.
Conclusions
In England, vaping prevalence has increased rapidly among adults who smoke since 2021, which was when disposable e‐cigarettes started to become popular. Since 2016, patterns of dual use have shifted away from more frequent smoking towards more frequent vaping. This may be the result of increasing prevalence of dual use among younger adults, who are more likely than older dual users to smoke non‐daily and vape daily.
Introduction
Dual use of cigarettes and e-cigarettes is especially prevalent among lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ+) adults in the US. This is concerning as health risks of dual use may be as high or higher than exclusive smoking. We sought to learn about people who dual use and identify as LGBTQ+’s perspectives about dual use, quitting, and cessation ads.
Methods
Nineteen LGBTQ+ adults who dual use participated in virtual semi-structured interviews in North Carolina in 2022. We asked about perceptions of smoking and vaping in LGBTQ+ communities, their thoughts about quitting, and their opinions on four cessation ads. The ads advocated quitting one or both products. Transcripts were coded using ATLAS.ti and reviewed using a thematic content analysis approach.
Results
Participants described how within LGBTQ+ communities, smoking and vaping are common and accepted and are used to cope or to socialize. Most participants made past quit attempts. Many said they were not ready to quit both products, but some were open to quitting smoking. Some thought e-cigarettes may be as harmful as cigarettes, reducing their motivation to quit smoking cigarettes due to the lack of perceived health benefits. Participants sought cessation ads that explicitly address dual use and are representative and supportive. They disliked ads that felt stereotypical or patronizing.
Conclusions
Dual use in LGBTQ+ communities appears driven by both internal and external pressures. Participants were generally open to quitting cigarettes, and LGBTQ+ smoking cessation may be best encouraged with authentic ads that explicitly address both products.
Implications
These qualitative findings about smoking and vaping among LGBTQ+ individuals provide guidance for communication ad campaign design to help reduce the high dual use rates among LGBTQ+ young adults.
INTRODUCTION
Limited data exist on factors associated with concurrent use patterns of electronic nicotine delivery systems (ENDS) and cigarettes. We examined longitudinally perceptions and experiences with ENDS in relationship to concurrent use patterns among established, recent smokers who recently initiated ENDS.
METHODS
Participant recruitment took place using paid digital advertisements on social media. Between December 2020 and October 2021, 303 adults aged ≥21 years from across the US who currently or recently smoked and had initiated ENDS use within the past 30 days or reinitiated ENDS use after more than one year of non-use were surveyed. Multinomial logistic regressions were conducted to analyze association between the outcome of current use pattern at follow-up at 1 month [rejectors (discontinued ENDS, continued smoking), primary smokers (concurrent users, mostly smoke), dual user (similar smoking and ENDS use), primary vapers (concurrent users, mostly vape), and switchers (discontinued smoking, continued using ENDS) or quitters (discontinued both smoking and ENDS] and perceptions of and experiences with ENDS predictors at baseline.
RESULTS
At follow-up at 1 to 2 months after initiating ENDS, 20% were rejectors, 31% were primary smokers, 13% were dual users, 19% were primary vapers, and 17% were switchers/quitters. Perceiving ENDS as less harmful than smoking or being uncertain and as equally or more enjoyable smoking, experiencing a lot or complete reduction in cravings to smoking and in irritability with ENDS use, liking the taste of ENDS, and being satisfied with vaping were associated with higher odds of quitting smoking compared to rejecting ENDS or mostly smoking at follow-up at 1 month.
CONCLUSIONS
Findings highlight the importance of initial ENDS perceptions and experiences when examining tobacco outcomes and potentially for developing policies and interventions targeting smoking cessation. ENDS initiators are differentiating into distinct use patterns based on these factors within a short period of time.
Background and Aims
Pathways of transitioning from tobacco smoking to vaping after receiving an e‐cigarette‐based smoking cessation intervention have been minimally explored. Study aims: 1) identify pathways between intervention delivery and final follow‐up; 2) describe baseline and post‐intervention statistical data in relation to smoking/vaping behaviour of the different pathway groups; 3) explore qualitative participant perspectives contextualising pathway groups.
Design
Embedded mixed‐methods analysis of data collected for the Cessation of Smoking Trial in the Emergency Department (COSTED) randomised controlled trial.
Setting
Recruitment from 6 Emergency Departments (5 in England and 1 in Scotland) between January and August 2022.
Participants
366 adult smokers who were randomised to receive the COSTED intervention and provided data at 6‐month follow‐up. Qualitative subsample of 24 participants interviewed after follow‐up.
Interventions
Brief smoking cessation advice, provision of an e‐cigarette starter kit and referral to the local Stop Smoking Service.
Measurements
Descriptive statistical reporting of identified pathways and smoking/vaping behaviour at baseline and 6‐month follow‐up. Semi‐structured phone/video interviews analysed thematically.
Findings
13.4% ( n = 49) of participants quit smoking within 1 month of receiving the intervention, 19.1% ( n = 70) quit between 1 and 6 months, 24.9% ( n = 91) reduced cigarettes per day (CPD) by at least 50%, and 42.6% did not experience a significant smoking reduction. Approximately a third of participants who quit reported not vaping at follow‐up. Reporting dual use was associated with a reduction in CPD. Appoximately a third reported experimenting with a different device to the one provided as part of the intervention. Quitters reported themes of satisfaction with vaping, changes in environment facilitating quitting and motivation to quit.
Conclusions
Dual use of cigarettes and e‐cigarettes can result in a reduction of smoking and may preclude quitting smoking. Sustained e‐cigarette use is not always necessary for quitting success. Success depends on personal context as well satisfaction with vaping.
Objective:
This study measured anatalline and nicotelline, two minor tobacco alkaloids, to discriminate between exclusive smokeless tobacco (SLT) use, exclusive electronic nicotine delivery systems (ENDS) use, exclusive cigarette use, dual SLT and cigarette use, and dual ENDS and cigarette use.
Methods:
N = 664 urine samples from participants in the Population Assessment of Tobacco and Health Study were analyzed for anatalline and nicotelline. Geometric means and 95% confidence intervals were calculated for biomarker levels and their ratios. Non-parametric Receiver Operating Characteristic analyses were used to determine optimal cut-points of natural log-transformed biomarker ratios for distinguishing between tobacco use groups.
Results:
The anatalline/nicotelline ratio distinguished exclusive cigarette from exclusive SLT use (threshold = 18.1, sensitivity = 89.3%, specificity = 86.4%, AUC = 0.90), and exclusive SLT from exclusive ENDS use (threshold = 12.8, sensitivity = 96.4%, specificity = 76.3%, AUC = 0.90) very well, but had reduced sensitivity and specificity when distinguishing exclusive cigarette from exclusive ENDS or any dual use with cigarettes.
Conclusions:
This research fills a gap in understanding the public health consequences of SLT and ENDS use by providing objective measures that can signal use of these products alone or in combination with cigarettes.
Importance
Population-level health outcomes associated with e-cigarettes depend in part on the association between e-cigarettes and combustible cigarette cessation. The US Food and Drug Administration has authority to regulate e-cigarette characteristics, including flavor and device type.
Objective
To investigate whether e-cigarette characteristics are associated with cigarette cessation behaviors among adults in the US population who use e-cigarettes.
Design, Setting, and Participants
This cohort study was conducted using longitudinal data collected in 2014 to 2021 by the Population Assessment of Tobacco and Health Study, a population-based, US nationally representative study. Participants were sampled from the civilian noninstitutionalized population using a 4-staged, stratified sampling design. Data were weighted and analyzed from 1985 adults ages 21 or older who smoked cigarettes daily and had used e-cigarettes in the past 30 days. Data were analyzed in May 2021 to May 2024.
Exposures
The following e-cigarette characteristics were assessed: use frequency (daily and nondaily), flavor type (tobacco, menthol or mint, sweet, and combination), device type (disposable, cartridge, and tank), and year of data collection as a proxy for the evolving e-cigarette marketplace.
Main Outcomes and Measures
The following cigarette cessation behaviors were assessed: making a cigarette quit attempt, cigarette cessation among individuals who made a quit attempt, and overall cigarette discontinuation regardless of quit attempts. Associations were evaluated between e-cigarette characteristics (assessed at baseline in 1 approach and assessed at follow-up in another approach) and cigarette cessation outcomes, controlling for demographic, cigarette smoking, and other e-cigarette use characteristics.
Results
The study sample consisted of 1985 participants representing adults in the population (mean age, 40.0 years [95% CI, 39.2-40.9 years]; 49.4% [95% CI, 46.3%-52.6%] male; 11.4% [95% CI, 9.6%-13.4%] Black, 80.7% [95% CI, 77.8%-83.3%] White, and 8.0% [95% CI, 6.3%-10.0%] other race; 9.2% [95% CI, 7.5%-11.2%] Hispanic). Daily vs nondaily e-cigarette use was associated with greater overall cigarette discontinuation rates (12.8% [95% CI, 9.1%-17.7%] vs 6.1% [95% CI, 4.8%-7.7%]; adjusted odds ratio [aOR], 2.26 [95% CI, 1.34-3.81]), and use of e-cigarettes in 2019 to 2021 vs 2014-2015 to 2015-2016 was also associated with greater overall cigarette discontinuation rates (12.0% [95% CI, 8.8%-16.0%] vs 5.3% [95% CI, 2.9%-9.3%]; aOR, 2.75 [95% CI, 1.13-6.67]). Use of menthol or mint vs tobacco flavor e-cigarettes was associated with greater overall cigarette discontinuation rates (9.2% [95% CI, 6.6%-12.8%] vs 4.7% [95% CI, 3.0%-7.1%]; aOR, 2.63 [95% CI, 1.32-5.27]) only when assessing e-cigarette use at baseline. E-cigarette device type was not associated with cigarette discontinuation rates in adjusted analyses.
Conclusions and Relevance
In this study, daily e-cigarette use and use of e-cigarettes in 2019 to 2021 were consistently associated with greater cigarette discontinuation rates. These findings suggest that research focused on e-cigarettes marketed in recent years is needed to inform product regulation and public health policy decisions.
Objective
Dual use of combustible cigarettes and e-cigarettes is common among U.S. tobacco users, yet mis-perceptions about the harm of dual use persist, often oversimplifying its multifaceted exposure and health impacts. To address this gap, we evaluated the association of prolonged dual use (consecutive use for more than 1 year) with psychosocial factors, including perceptions of absolute and relative harm of e-cigarettes, social norms, and intentions to quit smoking, among U.S. adult smokers over time.
Methods
Using the data from Waves 1 to 5 (2013–2019) from the Population Assessment of Tobacco and Health (PATH) Study, we characterized dual use and prolonged dual use by sociodemographics and psychosocial factors among U.S. adult smokers. We examined the association between dual use, including prolonged dual use, and psychosocial factors over time using logistic regression.
Results
Dual use of smokers decreased from 19.8 % in 2013 to 16.4 % in 2019, and prolonged dual use among dual users decreased from 40.0 % in 2013 to 27.4 % in 2019. Prolonged dual users, independent of frequency of use, presented significantly higher cigarette dependence than temporary dual users. The perception of absolute e-cigarette harm (perceiving e-cigarettes as very or extremely harmful) was negatively associated with prolonged dual use. No significant association was found between prolonged dual use and perception of relative e-cigarette harm (perceiving e-cigarettes are less harmful than cigarettes) as well as with intentions to quit smoking and beliefs that most people disapprove of e-cigarette use.
Conclusion
Increased perceptions of absolute harm of e-cigarettes, rather than relative harm, appear to decrease prolonged dual use. Public health strategies should consider further emphasis in educating users of the absolute harm, as opposed to endorsing e-cigarette use as a harm reduction alternative, in their tobacco cessation efforts to further discourage dual use.
Background and Objectives
The use of both electronic and combustible cigarettes is related to greater rates of cannabis use. Further, cannabis use is associated with worse combustible smoking‐related outcomes, yet little research has identified mechanisms underlying such relations. It may be that negative‐affect‐related transdiagnostic factors such as emotion dysregulation, anxiety sensitivity, and/or distress intolerance play a mechanistic role in the cannabis–tobacco interrelations.
Methods
The current study tested this hypothesis among 400 adults who endorsed dual use, 33% of whom endorsed current (past 3 months) cannabis use. We conducted analyses of variance and indirect effects model using the PROCESS v4.1 macro in SPSS version 29.
Results
Results indicated that participants who use cannabis reported greater difficulty with emotion regulation, anxiety sensitivity, and cigarette dependence severity. Cannabis use was related to cigarette dependence severity indirectly via difficulty with emotion regulation and anxiety sensitivity.
Discussion and Conclusions
These results indicate that specific transdiagnostic negative‐affect‐related factors of difficulty with emotion regulation and anxiety sensitivity are associated with cannabis use among adults who smoke combustible and electronic cigarettes.
Scientific Significance
Given that these transdiagnostic factors are malleable, these findings suggest targeting and engaging such mechanisms may offer novel behavioral change strategies for this high‐risk population.
Background:
E-cigarette advertising, which often includes various features, may prompt e-cigarette use and product switching. This study examined the associations between noticing e-cigarette ad features and perceived product appeal and interest in completely switching from cigarettes to advertised e-cigarettes among young adult dual users of both products.
Methods:
We analyzed data from an online heatmap experiment among young adult dual users defined as established cigarette smokers who currently used e-cigarettes (ages 18-34 years; n = 1,821). Participants viewed 12 e-cigarette ads, clicked on ad features (e.g., fruit flavors, nicotine warnings, price promotions, smoker-targeted claims) that attracted their attention (defined as "noticing"), and answered questions about e-cigarette product appeal and interest in completely switching from cigarettes to the e-cigarettes shown. We examined within-person associations between noticing specific ad features and outcomes, controlling for demographic and tobacco use-related characteristics.
Results:
Noticing fruit flavors (AOR = 1.67 and 1.28) and fruit images (AOR = 1.53 and 1.21) was positively associated with having any e-cigarette product appeal and switching interest. Noticing price promotions (AOR = 1.23) was positively associated with product appeal. In contrast, noticing nicotine warnings (AOR = 0.74 and 0.86), smoker-targeted claims (AOR = 0.78 and 0.89), and tobacco flavors (AOR = 0.92 and 0.90) was negatively associated with product appeal and switching interest.
Conclusions:
Noticing certain e-cigarette ad features (e.g., fruit flavors and nicotine warnings) may be associated with product appeal and/or switching interest among young adult dual users. More research is needed to assess the influence of e-cigarette ad features that promote product switching interests among cigarette smokers while discourage interests among tobacco-naïve individuals.
Background
Next generation of nicotine/tobacco products (NGPs) include electronic cigarettes (ECs), heated tobacco products (HTPs), oral nicotine pouches (NPs) and smokeless tobacco (SLT) products (in particular snus). These products commonly contain nicotine and are intended to replace combustible cigarettes (CCs) and thus can be regarded as tobacco harm reduction products. To fulfill this role, it is essential that nicotine, which has well established addictive properties, is not causally related to health risks upon chronic use.
Objectives
The purpose of this review is to evaluate the scientific literature to answer the question, whether nicotine is involved in the development of any diseases or disorders associated with the acute, short, mid- and long-term use of NGPs. Appropriate results from studies with nicotine replacement therapy (NRT) products (gum, patches, inhalers, lozenges) are included as reference basis for inferring the health effects of NGPs. Furthermore, suggestions for filling identified gaps and for avoiding or minimizing limitations and weaknesses in study design are provided.
Methods
Literature databases such as MEDLINE, Google Scholar and an in-house ABF library (containing about 180,000 articles) were searched for relevant articles. Furthermore, pertinent monographs (such as the US Surgeon General Reports) and recent reviews were screened for further publications. Inclusion criteria were: all human studies investigating the association between use (preferably chronic use) of the nicotine/tobacco products mentioned above and health effects, including diseases, disorders, changes in biomarkers of biological effect (BOBEs). In vivo (animal) and in vitro studies were also considered, provided effects of NGPs in the presence and absence of nicotine or in relation to the nicotine exposure dose were reported. Also, reference lists of recent suitable articles were screened. In total, about 500 articles were retrieved by this approach. The role of nicotine was evaluated by considering the article authors’ statements and their cited references as well as by own judgement of reported results. Human studies are presented in a standardized table format.
Results
In total, 183 human studies were evaluated, with cardiovascular diseases (CVD) ranking highest (N = 75 studies), followed by respiratory diseases (43), oral health disorders (23), cancer (10), metabolic syndrome (7), reproduction disorders (5) and several other diseases (< 5). The majority of studies do not provide evidence for a participation of nicotine in the pathogenesis. Some (weak) evidence was found that nicotine might be involved in some CVD-related effects and metabolic syndrome. This would be also supported by results from animal and in vitro studies.
Discussion
Human studies showed some severe limitations and weaknesses with respect to the study design and time of availability of NGPs on the market. A severe flaw is the insufficient consideration of dual use (NGP + CC), particularly in studies on chronic use, which could have led to erroneously increased risks for NGPs with direct consequences also for the role of nicotine. Additionally, prior effects from using CC have an impact. Both circumstances could have led to inaccurate conclusions in terms of elevated risk levels, which require changes in method designs. Suggestions for methodological improvements are provided for future studies.
Conclusions
A final evaluation of the role of nicotine in disease development in NGP users is currently not possible because use durations are too short. Chronic studies often suffer from insufficient separation between NGP only and dual use together with CCs, which may falsely increase the observed health risk. There is some limited evidence that nicotine may be involved in CVD-related effects, which, however, has to be verified in well controlled long-term studies. The potential involvement of nicotine in other patho-mechanisms also requires further research.
Introduction
Little is known about patterns of dual use of tobacco and electronic cigarettes (e-cigarettes), especially regarding the factors that lead people to choose either product in particular situations. Identifying contextual factors that are associated with product use would enhance understanding of the maintenance of dual product use.
Methods
Individuals who dual use (N=102) completed ecological momentary assessment surveys via text message regarding recent use of tobacco and e-cigarettes for two weeks. Product legality, availability, craving, the presence of other people who smoke/vape, and social disapproval were assessed. Data were analyzed using hierarchical logistic regression to identify factors associated with likelihood of tobacco versus e-cigarette use.
Results
Contexts associated with increased likelihood of using tobacco rather than e-cigarettes included being in the presence of other people who smoke (OR=2.74, p<.0001) and experiencing elevated tobacco cigarette craving (OR=3.51, p<.0001). Decreased likelihood of tobacco over e-cigarette use was associated with smoking restrictions (OR=0.26, p=.003), the presence of other people who vape (OR=0.46, p<.0001), and experiencing elevated e-cigarette craving (OR=0.23, p<.0001). The legality of e-cigarettes, social disapproval, and the availability of the alternative product were not significantly associated with use of one product over the other. An individual difference score of relative tobacco (vs. e-cigarette) use pattern did not significantly moderate these effects.
Conclusions
This study provided essential information regarding behavioral patterns of dual use, which informs our understanding of people who dual use. Contexts such as smoking restrictions, craving, and social context significantly differentiated between use of tobacco and e-cigarettes. This suggests product-specific motivations for dual use of tobacco and e-cigarettes in people who use both.
Implications
This study assessed the relationship between momentary contextual factors and dual use in a nationally recruited sample of people who dual use. Assessments of dual use in daily life provided novel information regarding patterns of dual use as well as differential use-motivations for each product. This information will be essential to build a theoretical framework of dual use of tobacco and e-cigarettes.
Background:
Smoking exposes people to high levels of Tobacco-Specific Nitrosamines (TSNAs), which include potent carcinogens. We systematically reviewed TSNA exposure between people smoking, vaping and doing neither.
Methods:
Databases were searched between August 2017-March 2022, using vaping related terms. Peer-reviewed articles reporting TSNA metabolites (NNAL,NNN,NAB,NAT) levels in bio-samples among adults exclusively vaping, exclusively smoking, or doing neither were included. Where possible, meta-analyses were conducted.
Results:
Of 12,781 identified studies, 22 were included. TSNA levels fell substantially when people who smoke switched to vaping in longitudinal studies and were lower among people who vaped compared to smoked in cross-sectional studies. Levels of TSNAs were similar when comparing people who switched from smoking to vaping, to those who switched to no use of nicotine products, in longitudinal studies. Levels were higher among people who vaped compared to people who neither vaped nor smoked in cross-sectional studies.When comparing people who vaped to smoked: pooled urinary NNAL was 79% lower across three randomised controlled trials and 96% lower across three cross-sectional studies; pooled NAB was 87% lower and NAT 94% lower in two cross-sectional studies. When comparing people who neither vaped nor smoked to people who vaped, pooled urinary NNAL was 80%, NAB 26%, and NAT 27% lower in two cross-sectional studies. Other longitudinal data, and NNN levels could not be pooled.
Conclusions:
Exposure to all TSNAs was lower among people who vaped compared to people who smoked. Levels were higher among people who vaped compared to people who neither vaped nor smoked.
This study examined differences in quit attempts, 1-month quit success, and vaping status at follow-up among a cohort of 3709 daily smokers with and without depression, anxiety, and regular alcohol use who participated in both the 2018 and 2020 International Tobacco Control Four Country Smoking and Vaping (ITC 4CV) Surveys. At baseline, a survey with validated screening tools was used to classify respondents as having no, or one or more of the following: 1) depression, 2) anxiety, and 3) regular alcohol use. Multivariable adjusted regression analyses were used to examine whether baseline (2018) self-report conditions were associated with quit attempts; quit success; and vaping status by follow-up (2020). Results showed that respondents who reported depressive symptoms were more likely than those without to have made a quit attempt (aOR = 1.32, 95% CI:1.03–1.70, p = 0.03), but were less likely to have quit (aOR = 0.55, 95% CI:0.34–0.89, p = 0.01). There were no differences in quit attempts or quit success between those with and without self-reported anxiety diagnoses or regular alcohol use. Among successful quitters, respondents with baseline depressive symptoms and self-reported anxiety diagnoses were more likely than those without to report vaping at follow-up (aOR = 2.58, 95% CI:1.16–5.74, p = 0.02, and aOR = 3.35 95% CI:1.14–9.87, p = 0.03). In summary, it appears that smokers with depression are motivated to quit smoking but were less likely to manage to stay quit, and more likely to be vaping if successfully quit. As smoking rates are higher among people with mental health conditions, it is crucial for healthcare professionals to identify these vulnerable groups and offer tailored smoking cessation support and continued support during their quit attempt.
Purpose of Review: E-cigarette use (vaping) among adults has increased, and various patterns of concurrent smoking and vaping (i.e., "dual use") have emerged. Understanding dual use is important for mitigating tobacco-related harm. This narrative review summarizes recent research on dual use, including prevalence and types of dual use, sociodemographic and psychiatric characteristics, nicotine dependence, reasons for dual use, harm perceptions, toxicant exposure, trajectories of dual use, and emerging treatments for dual use.
Recent Findings: Nearly half of e-cigarette users concurrently use cigarettes, and many smoke more frequently than they use e-cigarettes. This is concerning because dual users are exposed to both cigarette and potential e-cigarette toxicants and the data are mixed regarding the ability of e-cigarettes to promote smoking cessation.
Summary: Further work is needed to identify ways to increase complete smoking abstinence and optimize harm reduction among dual users, including strategies to encourage e-cigarette cessation after stopping smoking.
Background
Dual use of combustible cigarettes and e-cigarettes is an emerging phenomenon among U.S. adults. Literature suggests two primary reasons for this emerging use (i.e., to help quit smoking and to stealth vape). This study investigated user profiles based on use intensity and the reasons for dual use.
Methods
A total of 1,151 U.S. adult dual users were drawn from the 2018-2019 Tobacco Use Supplement to the Current Population Survey. We divided them into four groups: daily dual users (n=189), predominant smokers (n=608), predominant vapers (n=143), and non-daily dual users (n=211). We performed weighted multivariable logistic regressions to identify factors associated with the two primary reasons for dual use.
Results
3 in 10 of U.S. adult dual users used e-cigarettes to help quit smoking while 2 in 10 of U.S. adult dual users used e-cigarettes to stealth vape. Compared to daily dual users, predominant smokers [adjusted odds ratio (AOR) = 0.61, 95% CI = 0.23, 0.62] were less likely to use e-cigarettes to help quit smoking whereas predominant vapers (AOR = 1.80, 95% CI = 1.04, 3.13) were more likely to use e-cigarettes to help quit smoking and less likely to use e-cigarettes to stealth vape (AOR = 0.30, 95% CI = 0.10, 0.89).
Conclusions
There was notable heterogeneity among the four groups of dual users. As the landscape of tobacco use is rapidly changing with an increasing popularity of e-cigarettes, reasons as well as behaviors of dual users need to be regularly monitored for effective tobacco control.
Background
We model the potential impact of relaxing current nicotine vaping product (NVP) restrictions on public health in Australia.
Methods
A Restricted NVP Scenario was first developed to project current smoking and vaping rates, where a US smoking model was calibrated to recent Australian trends. To model less restrictive NVP policies, a Permissive NVP Scenario applied rates of switching from smoking to vaping, initiation into NVP and cigarette use, and cessation from smoking and vaping based on US trends. The model measures vaping risk relative to the excess mortality rate of smoking. The public health impacts are measured as the difference between smoking- and vaping-attributable deaths (SVADs) and life years lost (LYLs) in the Restricted and Permissive NVP Scenarios with sensitivity analysis regarding the NVP excess risk and other factors.
Results
Assuming an NVP excess risk of 5% that of smoking, 104.2 thousand SVADs (7.7% reduction) and 2.05 million LYLs (17.3% reduction) are averted during 2017-2080 in the Permissive NVP Scenario compared to the Restricted NVP Scenario. Assuming 40% NVP excess risk, 70 thousand SVADs and 1.2 million LYLs are averted. The impact is sensitive to the rate at which smokers switch to NVPs and quit smoking, and relatively insensitive to the smoking initiation and NVP initiation and cessation rates.
Conclusions
The model suggests the potential for public health gains to be achieved by relaxing NVP access regulations. However, the model would benefit from better information regarding the impact of NVPs on smoking under a relaxation of current restrictions.
Implications
Australia has implemented a strong array of cigarette-oriented policies, but has restricted access to nicotine vaping products (NVPs). The Smoking and Vaping Model offers a framework for modeling hypothetical policy scenarios. The Australian model shows the potential for public health gains by maintaining cigarette-oriented policies while relaxing the current restrictive NVP policy. Modeling results under a permissive NVP policy are particularly sensitive to the estimated rates of smoking cessation and switching to vaping, which are not well established and will likely depend on past and future cigarette-oriented policies and the specific NVP policies implemented in Australia.
Introduction
In observational studies, vaping daily is positively associated with cigarette smoking abstinence, while non-daily vaping is associated with less smoking abstinence (versus no e-cigarette use). It remains unknown whether cigarette smokers who vape daily have different motivations for using e-cigarettes than those who vape non-daily.
Methods
Using latent class analysis and 10 self-reported reasons for vaping, we identified sub-groups of participants based on vaping motivations among 1,544 adult (≥18 y) dual users of e-cigarettes and cigarettes at wave 4 of the Population Assessment of Tobacco and Health (2016-2018). We examined the association of motivation sub-groups with vaping frequency at wave 4, and subsequent cigarette smoking abstinence at wave 5 (2018-2019). Additional analyses examined the association of vaping frequency with smoking abstinence before and after adjustment for motivation sub-groups.
Results
Four distinct sub-groups of e-cigarette users emerged, including 54% of participants who were “Vaping Enthusiasts”, 20% who vaped for “Convenience and Social Acceptability”, 10% classified as “Experimenters”, and 16% who vaped for “Quitting Smoking and Harm Reduction.” The Convenience and Social Acceptability sub-group were less likely than “Vaping Enthusiasts” (AOR=0.29, 95%CI[0.20-0.42]) and “Quitting Smoking and Harm Reduction” (AOR=0.41, 95%CI[0.24-0.71]) classes to vape daily (versus non-daily). Sub-groups were not associated with smoking abstinence after one year. Adjustment for motivation sub-groups did not attenuate a positive association of daily vaping with smoking abstinence.
Conclusions
Cigarette smokers who vaped for convenience and social acceptability were less frequent e-cigarette users than those with other vaping motivations. Vaping motivations were not associated with subsequent smoking abstinence.
Electronic cigarettes (E-cigarettes) use is an emerging public health problem. Trying to assess the independent associations between E-cigarettes use and whole blood cell in a nationally representative sample of the US adults is very important for the smoking population. Using E-cigarettes data from NHANES (National Health and Nutrition Examination Survey) 2013-2018, 17,180 adults were included in this cross-sectional analysis. All participants were stratified into four different groups (non-smoke group N=10087, E-cigarettes group N=52, dual-smoke group N=249, cigarettes group N=6792) based on questions SMQ020 (smoked at least 100 cigarettes in life) and SMQ690H (used last 5 days E-cigarettes). Whole blood cell tests included white blood cell (WBC) with differentials, red blood cell (RBC) with characteristics, and platelet variables. With adjusted by age, gender, and race ethnicity, multivariate logistic regression analyses were used to assess independent associations between E-cigarettes group and other groups for different whole blood cell variables. A total of 17,180 participants were included in the study; 47.9% were males, with a mean age of 46.99 (±0.29). In WBC-related variables, non-smoke group had the lowest value in WBC counts (7.15±0.05), lymphocyte (2.15±0.02), and monocyte (0.57±0.01), among the four different groups. In RBC-related variables, non-smoke group had the lowest value in mean cell volume (MCV, 88.46±0.14, p<0.05) and mean cell hemoglobin (MCH, 29.73±0.06, p<0.05), among the four different groups. In adjusted analysis, WBC (OR = 0.97, 95% CI: 0.96-0.98, p<0.001), especially lymphocyte (OR = 0.97, 95% CI: 0.96-0.98, p<0.001) and monocyte (OR = 0.11, 95% CI: 0.02-0.66, p<0.001) of non-smoke group, showed negative significant effect for E-cigarettes group. Meanwhile, lower odds of MCV (OR = 0.91, 95% CI: 0.81-1.04, p<0.05) and MCH (OR = 0.81, 95% CI: 0.65-1.00, p<0.05) in non-smoke group were observed compared to E-cigarettes group. Conversely, for dual-smoke group and cigarette group, there was no significant results in all whole blood cell variables compared to E-cigarettes group. E-cigarettes use might be associated with a systemic response that could lead to an increase in WBC, especially lymphocytes and monocytes, in the US adults. Meanwhile, the properties of RBC might also be influenced simultaneously; MCV and MCH in E-cigarettes population were bigger than the non-smoke population.
Background
The scientific term for the substance people inhale and exhale from a vaping device is ‘aerosol’, but whether the public uses this term is unclear. To inform tobacco control communication efforts, we sought to understand what tobacco users call e-cigarette aerosols.
Methods
Participants were a national convenience sample of 1628 US adults who used e-cigarettes, cigarettes or both (dual users). In an online survey, conducted in spring 2021, participants described what ‘people inhale and exhale when they vape’, using an open-ended and then a closed-ended response scale. Participants then evaluated warning statements, randomly assigned to contain the term ‘aerosol’ or ‘vapor‘ (eg, ‘E-cigarette aerosol/vapor contains nicotine, which can lead to seizures’).
Results
In open-ended responses, tobacco users most commonly provided the terms ‘vapor’ (31%) and ‘smoke’ (23%) but rarely ‘aerosol’ (<1%). In closed-ended responses, the most commonly endorsed terms were again ‘vapor’ (57%) and ‘smoke’ (22%) but again infrequently ‘aerosol’ (2%). In closed-ended responses, use of the term ‘vapor’ was more common than other terms among people who were older; white; gay, lesbian or bisexual; college educated; or vape users only (all p <0.05). In the experiment, warnings using the terms ‘aerosol’ and ‘vapor’ were equally effective (all p >0.05).
Conclusions
The public rarely uses the term ‘aerosol’ to describe e-cigarette output, potentially complicating educational efforts that use the term. Future studies should explore public knowledge and understanding of the terms ‘aerosol’ and the more popular ‘vapor’ to better inform vaping risk communication.
Introduction
With the US Food and Drug Administration recently proposing to implement a ban on menthol cigarettes, it is critical to estimate the potential public health effects of such a ban. With high rates of menthol cigarette use and important smoking-related health disparity implications, the impact of the ban on the non-Hispanic black (NHB) population merits strong consideration.
Methods
We apply the previously developed Menthol Smoking and Vaping Model to the NHB population. A status quo scenario is developed using NHB-specific population, smoking and vaping initiation, cessation and death rates. Estimates from a recent expert elicitation on behavioural impacts of a menthol cigarette ban on the NHB population are used to develop a menthol ban scenario implemented in 2021. The public health impacts of the menthol ban are estimated as the difference between smoking and vaping attributable deaths (SVADs) and life years lost (LYLs) in the status quo and the menthol ban scenarios from 2021 to 2060.
Results
Under the menthol ban scenario, overall smoking is projected to decline by 35.7% in 2026 and by 25.3% in 2060 relative to the status quo scenario. With these reductions, SVADs are estimated to fall by about 18.5% and LYLs by 22.1%, translating to 255 895 premature deaths averted, and 4.0 million life years gained over a 40-year period.
Conclusions
A menthol cigarette ban will substantially reduce the smoking-associated health impact on the NHB population, thereby reducing health disparities.
Introduction: Dual users of cigarettes and e-vapor products (EVP) are often considered as a homogenous group even though multiple subgroups may exist. We examined biomarkers of exposure (BOE) and biomarkers of potential harm (BOPH) to differentiate between subgroups of dual users based on PATH Study Wave 1 (2013-2014) data.
Methods: We segmented adult dual users (n=970) into four subgroups based on the number of days of product used in past 30 days – frequent dual users of both products (FreqDU, n=169), frequent smokers who vape infrequently (SMVP, n=678), frequent vapers who smoke infrequently (VPSM, n=57), and infrequent dual users of both products (InfreqDU, n=66). Eighteen BOEs (representing exposure to TSNAs, nicotine, heavy metals, PAHs, and volatile organic compounds), and four BOPHs (representing inflammation and oxidative stress) were analyzed within the subgroups, versus exclusive daily cigarette smokers (ESM, n=2,442) and exclusive daily e-cigarette users (EVP, n=169).
Results: Levels of many BOEs and BOPHs were higher among SMVP relative to FreqDU, VPSM and InfreqDU. Compared to ESM, many BOEs were significantly lower in VPSM (15/18) and InfreqDU (17/18), and some BOEs were higher among SMVP (4/18). InfreqDU showed significantly lower levels of 2/18 BOEs than EVP, and lower levels of 2/4 BOPHs than ESM.
Conclusions: Overall, the levels of BOEs and BOPHs in dual users are associated with frequency of cigarette smoking. Our findings indicate that not all dual users are the same, and tobacco product use frequency should be considered when categorizing dual users.
Introduction:
Most adult cigarette smokers who use e-cigarettes are dual cigarette and e-cigarette (CC-EC) users, yet little is known about relative consumption of cigarettes to e-cigarettes and any associated harm reduction.
Methods:
Rate of substitution from cigarettes to e-cigarettes at week 6 and change in biomarkers of exposure and potential harm were examined among dual CC-EC users [64/114 (56%); 35 Black, 29 Latino] in an e-cigarette switching randomized trial.
Results:
Dual users averaged 79% substitution of cigarettes for e-cigarettes at week 6, resulting in a reduction from baseline of 70.0 ± 54.1 cigarettes per week (p < .001). Total nicotine consumption remained stable (baseline: 1160.5 ± 1042.1 pg/mL of cotinine, week 6: 1312.5 ± 1725.9 pg/mL of cotinine, p = .47), while significant reductions were seen in the potent lung carcinogen 4-(methylnitrosamino)-1-(3-pyridul)-1-butanol (NNAL) (-55.9 ± 88.6 ng/ml, p < .001), carbon monoxide (-6.3 ± 8.6 ppm, p < .001), and self-reported respiratory symptoms (-3.3 ± 8.0, p = .002). No significant changes were found in blood pressure or spirometry. Greater substitution from cigarettes to e-cigarettes was associated with larger reductions in NNAL (r = -.29, p = .02).
Conclusions:
The predominant dual use pattern was characterized by regular e-cigarette and intermittent cigarette use. Findings demonstrate the short-term harm reduction potential of this dual use pattern in Black and Latino smokers and suggest that the greatest benefit, aside from cessation of both products, is achieved by higher substitution of e-cigarettes for cigarettes. Findings need confirmation in a larger sample with longer follow-up in dual users with greater variability in rate of substitution.
Inhalation of the toxic smoke produced by combusting tobacco products, primarily cigarettes, is the overwhelming cause of tobacco-related disease and death in the United States and globally. A diverse class of alternative nicotine delivery systems (ANDS) has recently been developed that do not combust tobacco and are substantially less harmful than cigarettes. ANDS have the potential to disrupt the 120-year dominance of the cigarette and challenge the field on how the tobacco pandemic could be reversed if nicotine is decoupled from lethal inhaled smoke. ANDS may provide a means to compete with, and even replace, combusted cigarette use, saving more lives more rapidly than previously possible. On the basis of the scientific evidence on ANDS, we explore benefits and harms to public health to guide practice, policy, and regulation. A reframing of societal nicotine use through the lens of harm minimization is an extraordinary opportunity to enhance the impact of tobacco control efforts. Expected final online publication date for the Annual Review of Public Health Volume 39 is April 1, 2018. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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.
Background:
While some smokers use e-cigarettes and stop smoking, a substantial proportion try e-cigarettes and later discontinue or use them concurrently with smoking (current dual users). The aim was to assess factors associated with ongoing e-cigarette use and discontinuation among smokers.
Methods:
Secondary analysis of data of 1489 currently smoking adults, 18 and above, from a GB population-based online survey conducted in March 2016. A multivariable logistic regression assessed motivation to stop smoking among never e-cigarette users, past triers (<weekly use), past users (≥weekly use), and current dual users. A multinomial logistic regression assessed associations of e-cigarette use status with motivation to stop smoking, reasons for use, age, gender, social grade, heaviness of smoking, and type of first e-cigarette used. Reasons for discontinuing use were assessed.
Results:
Current dual users were more motivated to stop smoking than past users (AOR=1.95, 95% CI: 1.10-3.46); never users' or past triers' motivation did not differ from past users'. Dual users were less dependent on cigarettes (AOR=0.54, 95% CI: 0.35-0.86) and more likely to use e-cigarettes as an aid to reduce smoking (AOR=2.40, 95% CI: 1.59-3.64) and to deal with smoking restrictions (AOR=2.03, 95% CI: 1.22-3.38) than past users. Smokers mostly discontinued e-cigarettes because they did not feel like smoking, did not help with cravings, or respondents had just wanted to try them.
Conclusion:
Among smokers, ongoing use of e-cigarettes is associated with reasons for reducing smoking and dealing with smoking restrictions, heightened motivation to stop smoking, and lower dependence on smoking.
Background
Noncigarette tobacco products are evolving rapidly, with increasing popularity in the United States.
Methods
We present prevalence estimates for 12 types of tobacco products, using data from 45,971 adult and youth participants (≥12 years of age) from Wave 1 (September 2013 through December 2014) of the Population Assessment of Tobacco and Health (PATH) Study, a large, nationally representative, longitudinal study of tobacco use and health in the United States. Participants were asked about their use of cigarettes, e-cigarettes, traditional cigars, cigarillos, filtered cigars, pipe tobacco, hookah, snus pouches, other smokeless tobacco, dissolvable tobacco, bidis, and kreteks. Estimates of the prevalence of use for each product were determined according to use category (e.g., current use or use in the previous 30 days) and demographic subgroup, and the prevalence of multiple-product use was explored.
Results
More than a quarter (27.6%) of adults were current users of at least one type of tobacco product in 2013 and 2014, although the prevalence varied depending on use category. A total of 8.9% of youths had used a tobacco product in the previous 30 days; 1.6% of youths were daily users. Approximately 40% of tobacco users, adults and youths alike, used multiple tobacco products; cigarettes plus e-cigarettes was the most common combination. Young adults (18 to 24 years of age), male adults and youths, members of racial minorities, and members of sexual minorities generally had higher use of tobacco than their counterparts.
Conclusions
During this study, 28% of U.S. adults were current users of tobacco, and 9% of youths had used tobacco in the previous 30 days. Use of multiple products was common among tobacco users. These findings will serve as baseline data to examine between-person differences and within-person changes over time in the use of tobacco products. (Funded by the National Institute on Drug Abuse and the Food and Drug Administration.)
Context:
Rapid developments in e-cigarettes, or electronic nicotine delivery systems (ENDS), and the evolution of the overall tobacco product marketplace warrant frequent evaluation of the published literature. The purpose of this article is to report updated findings from a comprehensive review of the published scientific literature on ENDS.
Evidence acquisition:
The authors conducted a systematic review of published empirical research literature on ENDS through May 31, 2016, using a detailed search strategy in the PubMed electronic database, expert review, and additional targeted searches. Included studies presented empirical findings and were coded to at least one of nine topics: (1) Product Features; (2) Health Effects; (3) Consumer Perceptions; (4) Patterns of Use; (5) Potential to Induce Dependence; (6) Smoking Cessation; (7) Marketing and Communication; (8) Sales; and (9) Policies; reviews and commentaries were excluded. Data from included studies were extracted by multiple coders (October 2015 to August 2016) into a standardized form and synthesized qualitatively by topic.
Evidence synthesis:
There were 687 articles included in this systematic review. The majority of studies assessed patterns of ENDS use and consumer perceptions of ENDS, followed by studies examining health effects of vaping and product features.
Conclusions:
Studies indicate that ENDS are increasing in use, particularly among current smokers, pose substantially less harm to smokers than cigarettes, are being used to reduce/quit smoking, and are widely available. More longitudinal studies and controlled trials are needed to evaluate the impact of ENDS on population-level tobacco use and determine the health effects of longer-term vaping.
To use a unique longitudinal data set to assess the association between e-cigarette use while smoking with smoking cessation attempts, cessation and substantial reduction, taking into account frequency of use and key potential confounders.
Web-based survey, baseline November/December 2012, 1-year follow-up in December 2013.
Great Britain.
National general population sample of 4064 adult smokers, with 1759 (43%) followed-up.
Main outcome measures were cessation attempt, cessation and substantial reduction (≥50% from baseline to follow-up) of cigarettes per day (CPD). In logistic regression models, cessation attempt in the last year (analysis n = 1473) and smoking status (n = 1656) at follow-up were regressed on to baseline e-cigarette use (none, non-daily, daily) while adjusting for baseline socio-demographics, dependence and nicotine replacement (NRT) use. Substantial reduction (n = 1042) was regressed on to follow-up e-cigarette use while adjusting for baseline socio-demographics and dependence and follow-up NRT use.
Compared with non-use, daily e-cigarette use at baseline was associated with increased cessation attempts [odds ratio (OR) = 2.11, 95% confidence interval (CI) = 1.24-3.58, P = 0.006], but not with cessation at follow-up (OR = 0.62, 95% CI = 0.28-1.37, P = 0.24). Non-daily use was not associated with cessation attempts or cessation. Daily e-cigarette use at follow-up was associated with increased odds of substantial reduction (OR = 2.49, 95% CI = 1.14-5.45, P = 0.02), non-daily use was not.
Daily use of e-cigarettes while smoking appears to be associated with subsequent increases in rates of attempting to stop smoking and reducing smoking, but not with smoking cessation. Non-daily use of e-cigarettes while smoking does not appear to be associated with cessation attempts, cessation or reduced smoking.
© 2015 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.
Aims:
Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit.
Methods:
Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice).
Results:
At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up.
Conclusions:
Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.
To identify the predictors of attempts to stop smoking and the predictors of quit attempt success in adult general population samples.
We performed an electronic search of EMBASE, Pubmed, Web of Science, PsychINFO and the Cochrane Tobacco Addiction Group specialized register for articles that examined, in prospective adult general population samples, predictors of quit attempts and the success of quit attempts. Experts were contacted for knowledge of other relevant studies. Eight studies met the inclusion criteria and results were extracted independently by two researchers.
There was considerable methodological heterogeneity between studies. Motivational factors dominated the prediction of quit attempts, whereas only cigarette dependence consistently predicted success after an attempt had been made. Social grade also appeared to predict success but was only examined in two studies. None of the other socio-demographic factors consistently predicted making a quit attempt or success.
Population-level studies from a number of countries show that past quit attempts and measures of motivation to stop are highly predictive of quit attempts, whereas only measures of dependence are consistently predictive of success of those attempts. Gender, age and marital status and educational level are not related consistently to quit attempts or quit success across countries.
An inability to maintain abstinence is a key indicator of tobacco dependence. Unfortunately, little evidence exists regarding the ability of the major tobacco dependence measures to predict smoking cessation outcome. This paper used data from four placebo-controlled smoking cessation trials and one international epidemiological study to determine relations between cessation success and the Fagerström Test for Nicotine Dependence (FTND), the Heaviness of Smoking Index, the Nicotine Dependence Syndrome Scale, and the Wisconsin Inventory of Smoking Dependence Motives. Results showed that much of the predictive validity of the FTND could be attributed to its first item, time to first cigarette in the morning, and this item had greater validity than any other single measure. Thus the time-to-first-cigarette item appears to tap a pattern of heavy, uninterrupted, and automatic smoking and may be a good single-item measure of nicotine dependence.
The goal of this article is to determine whether reducing cigarette consumption increases the likelihood of future cessation. Data from 3,385 participants who originally took part in the Community Intervention Trial for Smoking Cessation completed detailed tobacco use phone surveys in 1988, 1993, and 2001. Between 1988 and 1993, 15% of smokers reduced their daily cigarette consumption by 50% or more, and 9% of the entire baseline sample maintained this reduction in 2001. Those who reduced more than 50% were 1.7 times more likely to quit smoking by 2001 compared with those who did not reduce. Few smokers are able to reduce their consumption by 50% or more, although those who do are more likely to quit compared with those who do not.
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.
Aims
To examine current and ex‐ smokers’ reasons for continuing or discontinuing regular use of nicotine vaping products (NVPs).
Design and participants
Cross‐sectional study of 2,722 current daily/weekly, and 921 ex‐daily/weekly, adult vapers who were either current or ex‐cigarette smokers when surveyed.
Setting
2016 ITC Four Country Smoking and Vaping Wave 1 (4CV1) surveys conducted in the United States (n=1159), England (n=1269), Canada (n=964), and Australia (n=251).
Measurements
Current vapers were asked about the following reasons for regular NVP use: less harmful to others, social acceptance, enjoyment, use in smoke‐free areas, affordability, and managing smoking behaviour. Ex‐vapers were asked about the following reasons for discontinuing regular NVP use: addiction concerns, affordability, negative experiences, perceived social unacceptability, safety concerns, product dissatisfaction, inconvenience, unhelpfulness for quitting, unhelpfulness for managing cravings, and not needed for smoking relapse prevention. Possible correlates of NVP use and discontinuation, including smoking status, smoking/vaping frequency, quit duration (ex‐smokers only), country, age, and type of NVP device used, were examined using multivariate logistic regression models.
Findings
For current smokers, the top three reasons for current regular NVP use were: helpful for cutting down smoking (86%), less harmful to others (78%), and helpful for quitting smoking (77%). The top three reasons for discontinuing vaping were: not being satisfying (78%), unhelpfulness for cravings (63%), and unhelpfulness for quitting smoking (52%). For ex‐smokers, the top three reasons for current vaping were: enjoyment (91%), less harmful to others (90%) and affordability (90%); and for discontinuing were: not needed to stay quit (77%), not being satisfying (50%) and safety concerns (44%). Reported reasons varied by user characteristics, including age, country and NVP device‐type.
Conclusions
Regular use of nicotine vaping products is mainly motivated by its perceived benefits, especially for reducing or quitting smoking, whereas its discontinuation is motivated by perceived lack of such benefits, with some variation by user characteristics.
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.
Aim
To describe the methods of the 2016 International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey, conducted in 2016 in Australia (AU), Canada (CA), England (EN), and the United States (US).
Methods
The respondents were cigarette smokers, former smokers (quit within the previous two years), and at‐least‐weekly vapers, aged 18 and older. Eligible cohort members from the ITC Four Country Survey (4C) were retained. New respondents were sampled by commercial firms from their panels. Where possible, ages 18‐24 and vapers were over‐sampled. Data were collected online, and respondents were remunerated. Survey weights were calibrated to benchmarks from nationally representative surveys.
Results
Response rates by country for new recruits once invited ranged from 15.2% to 49.6%; cooperation rates were above 90%. Retention rates from the 4C cohort ranged from 35.7% to 44.2%. Sample sizes for smokers/former smokers were 1504 in AU, 3006 in CA, 3773 in EN, and 2239 in the US. Sample sizes for additional vapers were 727 in CA, 551 in EN, and 494 in the US.
Conclusion
The International Tobacco Control Four Country Smoking and Vaping Survey design and data collection methods allow analyses to examine prospectively the use of cigarettes and nicotine vaping products in jurisdictions with different regulatory policies. The effects on the sampling designs and response quality of recruiting the respondents from commercial panels are mitigated by the use of demographic and geographic quotas in sampling; by quality control measures; and by the construction of survey weights taking into account smoking/vaping status, sex, age, education, and geography.
Introduction
This study assessed patterns of e-cigarette and cigarette use from Wave 1 to Wave 2 among adult e-cigarette users at Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study.
Methods
We examined changes in e-cigarette use frequency at Wave 2 among adult e-cigarette users at Wave 1 (unweighted n=2835). Adjusted prevalence ratios (aPR) were calculated using a predicted marginal probability approach to assess correlates of e-cigarette discontinuance and smoking abstinence at Wave 2.
Results
Half (48.8%) of adult e-cigarette users at Wave 1 discontinued their use of e-cigarettes at Wave 2. Among dual users of e-cigarettes and cigarettes at Wave 1, 44.3% maintained dual use, 43.5% discontinued e-cigarette use and maintained cigarette smoking and 12.1% discontinued cigarette use at Wave 2, either by abstaining from cigarette smoking only (5.1%) or discontinuing both products (7.0%). Among dual users at Wave 1, daily e-cigarette users were more likely than non-daily users to report smoking abstinence at Wave 2 (aPR=1.40, 95% CI 1.02 to 1.91). Using a customisable device (rather than a non-customisable one) was not significantly related to smoking abstinence at Wave 2 (aPR=1.14, 95% CI 0.81 to 1.60).
Conclusions
This study suggests that e-cigarette use patterns are highly variable over a 1-year period. This analysis provides the first nationally representative estimates of transitions among US adult e-cigarette users. Future research, including additional waves of the PATH Study, can provide further insight into long-term patterns of e-cigarette use critical to understanding the net population health impact of e-cigarettes in USA.
Introduction:
Amid decreasing rates of cigarette smoking and a rise in e-cigarette use, there is a need to understand population patterns of use to inform tobacco control efforts and evaluate whether e-cigarettes may play a role in tobacco harm reduction.
Methods:
This study merged data from the 2014 and 2015 National Health Interview Survey (NHIS) and restricted the sample to recent smokers [i.e., current smokers and former smokers who quit in 2010 or later (n=15,532)]. Log-binomial regression estimated adjusted prevalence ratios (aPR) for being quit by e-cigarette use status (i.e., daily, some day, former trier, never). All analyses controlled for factors traditionally correlated with smoking cessation.
Results:
A quarter of the sample (25.2%) were former smokers. The prevalence of being quit was significantly higher among daily e-cigarette users compared to those who had never used e-cigarettes [52.2% vs. 28.2%, aPR: 3.15 (2.66, 3.73)]. Those who used e-cigarettes on some days were least likely to be former smokers (12.1%). These relationships held even after accounting for making a quit attempt and use of other tobacco products.
Conclusions:
Among those with a recent history of smoking, daily e-cigarette use was the strongest correlate of being quit at the time of the survey, suggesting that some smokers may have quit with frequent e-cigarette use or are using the products regularly to prevent smoking relapse. However, the low prevalence of cessation among infrequent e-cigarette users highlights the need to better understand this subgroup, including the individual factors and/or product characteristics that may inhibit cessation.
Introduction
The public health impact of vaporized nicotine products (VNPs) such as e-cigarettes is unknown at this time. VNP uptake may encourage or deflect progression to cigarette smoking in those who would not have otherwise smoked, thereby undermining or accelerating reductions in smoking prevalence seen in recent years.
Methods
The public health impact of VNP use are modeled in terms of how it alters smoking patterns among those who would have otherwise smoked cigarettes and among those who would not have otherwise smoked cigarettes in the absence of VNPs. The model incorporates transitions from trial to established VNP use, transitions to exclusive VNP and dual use, and the effects of cessation at later ages. Public health impact on deaths and life years lost is estimated for a recent birth cohort incorporating evidence-informed parameter estimates.
Results
Based on current use patterns and conservative assumptions, we project a reduction of 21% in smoking-attributable deaths and of 20% in life years lost as a result of VNP use by the 1997 US birth cohort compared to a scenario without VNPs. In sensitivity analysis, health gains from VNP use are especially sensitive to VNP risks and VNP use rates among those likely to smoke cigarettes.
Conclusions
Under most plausible scenarios, VNP use generally has a positive public health impact. However, very high VNP use rates could result in net harms. More accurate projections of VNP impacts will require better longitudinal measures of transitions into and out of VNP, cigarette and dual use.
Implications
Previous models of VNP use do not incorporate whether youth and young adults initiating VNP would have been likely to have been a smoker in the absence of VNPs. This study provides a decision-theoretic model of VNP use in a young cohort that incorporates tendencies toward smoking and shows that, under most plausible scenarios, VNP use yields public health gains. The model makes explicit the type of surveillance information needed to better estimate the effect of new products and thereby inform public policy.
Background:
Smokers increasingly use e-cigarettes for many reasons, including attempts to quit combustible cigarettes and to use nicotine where smoking is prohibited. We aimed to assess the association between e-cigarette use and cigarette smoking cessation among adult cigarette smokers, irrespective of their motivation for using e-cigarettes.
Methods:
PubMed and Web of Science were searched between April 27, 2015, and June 17, 2015. Data extracted included study location, design, population, definition and prevalence of e-cigarette use, comparison group (if applicable), cigarette consumption, level of nicotine dependence, other confounders, definition of quitting smoking, and odds of quitting smoking. The primary endpoint was cigarette smoking cessation. Odds of smoking cessation among smokers using e-cigarettes compared with smokers not using e-cigarettes were assessed using a random effects meta-analysis. A modification of the ACROBAT-NRSI tool and the Cochrane Risk of Bias Tool were used to assess bias. This meta-analysis is registered with PROSPERO (number CRD42015020382).
Findings:
38 studies (of 577 studies identified) were included in the systematic review; all 20 studies with control groups (15 cohort studies, three cross-sectional studies, and two clinical trials) were included in random effects meta-analysis and sensitivity analyses. Odds of quitting cigarettes were 28% lower in those who used e-cigarettes compared with those who did not use e-cigarettes (odds ratio [OR] 0·72, 95% CI 0·57-0·91). Association of e-cigarette use with quitting did not significantly differ among studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarettes) compared with studies of only smokers interested in cigarette cessation (OR 0·63, 95% CI 0·45-0·86 vs 0·86, 0·60-1·23; p=0·94). Other study characteristics (design, population, comparison group, control variables, time of exposure assessment, biochemical verification of abstinence, and definition of e-cigarette use) were also not associated with the overall effect size (p≥0·77 in all cases).
Interpretation:
As currently being used, e-cigarettes are associated with significantly less quitting among smokers.
Funding:
National Institutes of Health, National Cancer Institute, FDA Center for Tobacco Products.
Objective:
The aim of this study is to describe electronic cigarette use in Kansas adults and its relationship with cigarette cessation.
Methods:
The Kansas Adult Tobacco Survey (ATS) is a 2012-2013 phone survey of non-institutionalized Kansas adults (N=9656). The ATS was analyzed to create a profile of cigarette and e-cigarette users, and demonstrate associations between e-cigarette use and cigarette cessation attempts and cigarette abstinence.
Results:
In 2013, 45% of adult cigarette smokers had tried e-cigarettes and 14% had used e-cigarettes in the past month. The prevalence of current cigarette smoking was 76.5% among past-month e-cigarette users. Adults who only use e-cigarettes are younger and more affluent than adults who only smoke cigarettes. The prevalence of past-month e-cigarette use among smokers who made a quit attempt in the past year is more than double that of smokers who did not. E-cigarette use was negatively associated with past-month (aPOR=0.21, 95% CI: 0.11-0.38) and past-year cigarette abstinence (aPOR=0.14, 95% CI: 0.10-0.22).
Conclusions:
E-cigarette use is common among cigarette smokers. E-cigarette use is more common among smokers who made a recent quit attempt and many smokers report using smokeless tobacco or e-cigarettes to help quit. Recent cigarette abstinence, however, is negatively associated with e-cigarette use.
This study explores the behavior of tobacco "chippers"--very light smokers who regularly use tobacco without developing dependence. Eighteen chippers (CHs) who averaged a maximum of five cigarettes per day, but who smoked at least 4 days per week, were compared to 29 dependent smokers (DSs). Laboratory data showed that CHs inhale cigarette smoke and are exposed to nicotine. In both experimental and retrospective self-report data, CHs showed no signs of tobacco withdrawal when abstinent. CHs also differed from DSs in their pattern of smoking: their smoking was less linked with mood states. However, the hypothesis that they were "social" smokers was contradicted. CHs also differed on psychosocial variables relevant to a stress-coping model of smoking: they reported less stress, better coping, and more social support, but these differences were small. Although the two groups were demographically similar, smoking behavior differences between CHs and DSs were long-standing: the two groups differed in their responses to initial smoking and in their family histories of smoking and cessation. CHs' smoking behavior challenges classical theories of dependence; further research is needed on the factors that may protect CHs from addiction.
We examined whether cigarette smokers in the United States can significantly reduce their smoking and maintain this reduction and, if so, whether this predicts an increase or decrease in the probability of smoking cessation in the future.
Longitudinal observation study.
The 22 US cities of the Community Intervention Trial for smoking cessation (COMMIT).
The 1410 subjects who smoked at both baseline and at 2-year follow-up.
Public health efforts to prompt cessation in half the communities.
Self-reported cigarettes/day and abstinence at baseline, 2-year and 4-year follow-ups.
At 2-year follow-up, 60% of the subjects had either not changed or increased their smoking, 17% had decreased their smoking by 5-25%, 15% by 24-49% and 8% by > or = 50%. Among the 40% who had reduced > or = 5% at 2-year follow-up, 52% reported maintaining that reduction at 4-year follow-up. Reduction in smoking at year 2 did not prospectively predict an increase or decrease in the probability of making a quit attempt; nor did it predict eventually quitting by year 4.
A substantial minority of US smokers are able to reduce their smoking and maintain this for long periods of time. Smoking reduction neither promotes nor undermines cessation.
Harm minimization and tobacco control: reframing societal views of nicotine use to rapidly save lives
- D B Abrams
- A M Glasser
- J L Pearson
- A C Vilanti
- L K Collins
- R S Niaura
Abrams D. B., Glasser A. M., Pearson J. L., Vilanti A. C., Collins
L. K., Niaura R. S. Harm minimization and tobacco control:
reframing societal views of nicotine use to rapidly save lives.
Annu Rev Public Health 2018; 1: 193-213.
- K Stratton
- L Y Kwan
- D L Eaton
National Academies of Sciences Engineering and Medicine. In: Public health consequences of E-cigarettes
- K Stratton
- L Y Kwan
- D L Eaton
Stratton K., Kwan L. Y., Eaton D. L., editors. National Academies of Sciences Engineering and Medicine. In: Public health
consequences of E-cigarettes. Washington, DC: The National
Academies Press; 2018, p. 680.
The application of a decision-theoretic model to estimate the public health impact of vaporized nicotine product initiation in the united states
- D T Levy
- R Borland
- A C Vilanti
- R Niaura
- Z Yuan
- Y Zhang
Levy D. T., Borland R., Vilanti A. C., Niaura R., Yuan Z., Zhang
Y. et al. The application of a decision-theoretic model to estimate the public health impact of vaporized nicotine product
initiation in the united states. Nicotine Tob Res 2017; 19:
149-59.