Modification of Electronic Nicotine Delivery Systems Among Adolescents and Young Adults.

OBJECTIVES: We assessed awareness and perceptions of, information sources about, and engagement in modifying electronic nicotine delivery systems (ENDS) among adolescents and young adults (AYAs). METHODS: AYAs (N = 1018) endorsing past-month ENDS use completed a survey on awareness and use of the following modifications: (1) refilling rechargeable cartridges/pods or (2) disposable pods, (3) rewicking or (4) recharging disposable pods, (5) modifying nicotine e-liquids (eg, changing propylene glycol/vegetable glycerin, nicotine), (6) combining nicotine and cannabis for simultaneous vaping, and (7) putting cannabis in ENDS designed for nicotine vaping. Logistic regression assessed how sources of information (eg, friends, social media, nonsocial media Web sites, vape shops) about and perceptions of ENDS modifications associated with ENDS modifications. RESULTS: Refilling (69.0% heard, 40.1% tried) and recharging the battery (66.4% heard, 35.8% tried) of disposable pods were most common. Friends (64.4%) and social media (46.7%) were the most common sources of information. Notable significant associations between information sources and modifications were: 1. nonsocial media Web sites and vape shops with rewicking and recharging disposable devices and modifying nicotine e-liquid; 2. nonsocial media Web sites with refilling rechargeable cartridges/pods and disposable pods; and 3. social media with recharging disposable devices and mixing nicotine and cannabis liquids. Perceptions of reduced harm and "coolness" were associated with various modifications. DISCUSSION: AYAs are aware of and modify ENDS for purposes unintended by manufacturers. ENDS policies should consider unintended ENDS use to safeguard public health. Prevention efforts should communicate about the potential harms of ENDS modifications.

E-cigarette dependence and cooling flavor use are linked among youth.

BACKGROUND: E-cigarette flavors that produce cooling sensations may reduce nicotine harshness and enhance appeal among youth. While previous research has shown that use of cooling flavors is associated with more frequent vaping among youth, it is unknown whether the same holds true for e-cigarette dependence. This study examines the relationship between cooling flavor use and e-cigarette dependence among youth accounting for vaping frequency. METHODS: In Fall 2022, a survey was conducted among Connecticut high school students to assess past-month nicotine e-cigarette use, ever use of cooling flavors, cooling flavor types (e.g., fruit-cooling), and e-cigarette dependence. Analyses were restricted to those with past-month nicotine and nicotine-free e-cigarette use and complete data (n=204). Multivariable linear regressions were run to examine the association between cooling flavor use and e-cigarette dependence, adjusting for demographics, e-cigarette use characteristics, and other tobacco product use. RESULTS: 78.4% of the sample used cooling e-cigarette flavors, with 55.0% using mint-cooling flavors and 52.5% using fruit-cooling flavors. Regression results observed that cooling flavor use was associated with higher e-cigarette dependence (ꞵ=1.53, SE=0.63, p=0.017), with those who used cooling flavors having higher e-cigarette dependence than those who did not (M=5.78 [SD=5.33] vs. 2.84 [3.19]). CONCLUSIONS: Our results suggest that cooling flavor use is significantly associated with e-cigarette dependence among youth. While regulations often target menthol flavor, tobacco control agencies should consider restricting any flavor that can produce cooling sensations, even if they are not traditional menthol products, as cooling flavors is associated with youth e-cigarette dependence.

Sources of exposure to non-tobacco nicotine electronic nicotine delivery systems and associations with susceptibility to use and use behaviors among young adults in the United States.

INTRODUCTION: The Electronic Nicotine Delivery Systems (ENDS) industry recently introduced non-tobacco nicotine (NTN), which is not tobacco-derived and is often marketed as "tobacco-free nicotine." Given its novelty, it is important to understand where young adults learn about NTN ENDS. This study examined sources of exposure to NTN ENDS and relationships with NTN ENDS use and susceptibility. METHODS: We analyzed online survey data collected in Fall 2021 from 642 young adults (18-25 years) who had heard of NTN ENDS. We assessed 9 sources of NTN ENDS exposure (e.g., retail stores, social media) and examined associations between sources of exposure and NTN current (past-month) use, lifetime (non-current) use, and susceptibility to use, adjusting for demographics and other tobacco product use. RESULTS: Participants reported current NTN ENDS use (37.4%), lifetime use (12.0%), susceptibility (18.5%), or no susceptibility to use (32.1%). The most common sources of NTN ENDS exposure were retail stores (87.7%) and social media (81.0%). Exposure to NTN ENDS via social media was associated with greater odds of current NTN ENDS use (vs. no susceptibility) (aOR = 1.83, 95%CI: 1.02-3.28). Exposure via online streaming platforms was associated with greater odds of current (aOR = 1.75, 95%CI: 1.08-2.82) and lifetime NTN ENDS use (aOR = 2.42, 95%CI: 1.25-4.68). CONCLUSIONS: Young adults were exposed to and learned about NTN ENDS from diverse sources, primarily retail shops and social media. Further, exposure via social media and streaming platforms were associated with NTN ENDS use. Future studies should explore the content of NTN information from various sources to inform prevention efforts.

Adolescents and Young Adults Use of Social Media and Following of e-Cigarette Influencers.

BACKGROUND: With high rates of both e-cigarette and social media use among adolescents and young adults (AYAs), social media influencers who promote e-cigarettes are particularly concerning but are understudied. We examined the association between AYAs' use of 11 different social media platforms (e.g. Facebook, Twitter, Instagram, TikTok, and YouTube) and exposure to social media e-cigarette influencers. OBJECTIVES: From November 2022 to February 2023, we conducted an online, US national survey of AYAs (14-29 years) who endorsed past-30-day e-cigarette use. We used binomial logistic regression to examine associations between the frequency of use of each social media platform and following e-cigarette influencers, controlling for age, sex, race, ethnicity, e-cigarette use frequency, and other tobacco and substance use (i.e., alcohol and cannabis). The model was stratified by adolescents (14-17 years; n = 293) and young adults (18-29 years; n = 654). RESULTS: The most frequently used social media platforms were Snapchat, TikTok and Instagram among adolescents, and YouTube, Instagram and TikTok among young adults. In adjusted models, following e-cigarette influencers was associated with more frequent use of TikTok (adjusted odds ratio [95% CI]; 1.33 [1.05, 1.68]) and Pinterest (1.18 [1.02, 1.38]) among adolescents, and more frequent use of Twitter (1.17 [1.06, 1.29]) among young adults. CONCLUSIONS: The use of different platforms was associated with exposure to e-cigarette influencers: TikTok and Pinterest among adolescents and Twitter among young adults. These findings can inform tobacco regulatory policy and social media platform restrictions of e-cigarette influencers on the platforms that are popular among AYAs.

Development and Psychometric Evaluation of a Novel Measure of Nicotine E-cigarette Withdrawal for use with Adolescents and Young Adults.

INTRODUCTION: Nicotine withdrawal is a well-established construct that prompts continued nicotine product use and contributes to failed cessation efforts. Despite ongoing public health concerns about nicotine e-cigarette use in adolescents and young adults (AYAs), no psychometrically-sound measure of nicotine e-cigarette withdrawal exists for this population. METHODS: A mixed methods approach comprising a literature review to identify existing nicotine withdrawal items; subject matter expert feedback on existing items and novel item generation; cognitive interviews assessing the measure's instructions, items, and response options; and a large quantitative validation survey (N = 997) was employed to develop the novel retrospective measure of nicotine e-cigarette withdrawal. RESULTS: A 25-item solution comprising four subscales - Negative Affect, Negative Physical Symptoms, Craving, and Appetite/Food - and an Overall Withdrawal score was supported. Internal reliability was excellent (mean alpha = 0.91), and scalar measurement invariance was reached for all subgroups tested (e.g., sex, age, exclusive e-cigarette use versus dual tobacco product use, daily versus non-daily nicotine vaping). Overall Withdrawal and its subscales evidenced concurrent validity with time to first vape in the morning, e-cigarette dependence, and previous vaping cessation attempts, although not each subscale was associated with each outcome. Importantly, cross-sectional incremental validity analyses indicated that retrospective withdrawal accounted for variance in each outcome above and beyond e-cigarette dependence. CONCLUSIONS: The novel retrospective AYA Nicotine E-cigarette Withdrawal Scale (AYA NEWS) evidenced strong psychometric properties for use in this population. Future research can determine whether the AYA NEWS can be used to assess acute e-cigarette nicotine withdrawal. IMPLICATIONS: While e-cigarette use remains the most prevalent form of nicotine product use among adolescents and young adults, there are limited options for psychometrically-sound measures of e-cigarette-related constructs in this population. Withdrawal from nicotine is associated with failed cessation attempts and continued use of nicotine-containing products, making it a critical construct within tobacco-related research. This study outlines the development and preliminary psychometric evaluation of a novel, retrospective measure of nicotine e-cigarette withdrawal. Study findings support using the Adolescent and Young Adult Nicotine E-cigarette Withdrawal Scale (AYA NEWS) to assess retrospective withdrawal from nicotine e-cigarettes in young people.

Non-tobacco nicotine E-cigarette use and flavored E-cigarette use among young adults in the United States.

BACKGROUND: E-cigarette flavors can create sensations of sweetness and coolness while masking the aversiveness of nicotine. Recently, non-tobacco nicotine (NTN) products were introduced to the market, but little is known about flavors in NTN e-cigarette use. We examined associations between flavors (i.e., sweet, mint/menthol) and susceptibility to and use of NTN e-cigarettes. METHODS: 1239 US young adults (18-25 years) completed an anonymous, online survey in Fall 2021. The analytic sample included 520 participants who had used e-cigarettes and heard of NTN. Multinomial logistic regression models analyzed associations of flavored e-cigarette use (sweet and mint/menthol) with NTN e-cigarette use status (i.e., current [past-month] use, past [ever but not current] use, susceptible to use, and non-susceptible to use [reference]). RESULTS: Overall, 46.2% of participants reported current NTN use, 14.8% reported past use, 16.7% were susceptible to use, and 22.3% reported no susceptibility. Participants reported dual-use of sweet and mint/menthol NTN e-cigarette flavors (56.5%), sweet flavors use (24.8%), and mint/menthol flavor use (1.7%). Ever dual use of sweet and mint/menthol flavors was associated with current (OR = 9.64, 95%CI: 3.21-28.98) and past NTN e-cigarette use (8.30, [2.10-32.80]). Ever sweet flavor use was associated with current NTN use (3.80, 95%CI: 1.44-10.03) and susceptibility to future use (4.25, [1.53-11.81]). Similar findings were observed for mint/menthol flavors (current: 5.03, [1.41-17.99]; susceptible: 5.65, [1.64-19.51]). CONCLUSION: The use of sweet and mint/menthol flavors was significantly associated with NTN e-cigarette use among US young adults, highlighting the need for ongoing surveillance of flavored NTN e-cigarettes and appropriate regulations to discourage use.

Psychometric Evaluation of the Modified E-cigarette Evaluation Questionnaire for use with High School Adolescents and Young Adults.

INTRODUCTION: The subjective experience of positive and negative effects of e-cigarette use has been shown to relate to e-cigarette use outcomes in adults, but no validated measure of e-cigarette subjective response exists for adolescents and young adults (AYAs). In the current study, the psychometric properties of the Modified E-cigarette Evaluation Questionnaire (MECEQ) were evaluated for use with AYAs. METHODS: 997 AYAs who endorsed using nicotine e-cigarettes at least 4 days per week completed an anonymous, online survey in 2022 (51.1% male; 17.39 [1.88] years old; 33.9% Hispanic; 68% White). Analyses included factor analysis to determine the latent structure of the MECEQ, internal consistency, measurement invariance, between-group differences, and test-criterion relationships with vaping frequency and dependence. RESULTS: The originally-proposed, five-factor structure and a novel four-factor structure were supported, and each subscale was internally consistent. Both models reached scalar invariance for all participant subgroups tested (e.g., sex, daily vaping status), and several between-groups differences were observed. For instance, compared to less frequent vaping, daily vaping was associated with increased Craving Reduction (5-factor), reduced Stimulant Effects (4-factor), and reduced Aversion (5-factor; 4-factor). Adjusted relationships between both MECEQ versions and vaping frequency and dependence provided evidence of concurrent validity. CONCLUSIONS: Similar to adults, a five-factor and four-factor version of the MECEQ were supported and evidenced internal consistency, scalar measurement invariance, and concurrent relationships with vaping frequency and dependence. Moving forward, researchers are encouraged to include the MECEQ in future studies to better understand the importance of subjective response in AYA vaping behavior. IMPLICATIONS: The Modified E-cigarette Evaluation Questionnaire (MCEQ), an e-cigarette-adapted version of the Modified Cigarette Evaluation Questionnaire (MCEQ), recently was validated to assess subjective e-cigarette effects among adults. Here, we demonstrate that the MECEQ can be used among adolescents and young adults (AYAs). The MECEQ can be scored using the original, five-factor MCEQ structure or using a novel, four-factor structure. Both versions were internally consistent, reached scalar measurement invariance, and evidenced concurrent relationships with vaping frequency and dependence. In sum, this study provides the field with the first psychometrically-sound measure of subjective effects of e-cigarette use for use with AYAs.

Why young adults use tobacco-free nicotine E-cigarettes: An analysis of qualitative data.

BACKGROUND: Tobacco-free nicotine (TFN) is often marketed as being better tasting and healthier than tobacco-derived nicotine (TDN). Studies have yet to systematically characterize subjective experiences using TFN e-cigarettes. This qualitative study explored young adults' reasons for using TFN e-cigarettes and perceptions of differences between using TFN and TDN e-cigarettes. METHOD: We conducted a national online Qualtrics survey of U.S. young adults aged 18-25 years in October 2021. Respondents who reported lifetime TFN e-cigarette use (n = 317, mean age: 20.8 (SD:2.2), 53.9 % female) provided write-in responses to open-ended questions assessing reasons for using TFN e-cigarettes and perceptions of differences between TFN and TDN e-cigarettes. Responses from participants were thematically analyzed by independent raters. RESULTS: Reasons for using TFN e-cigarettes included product taste/flavor, health reasons (e.g. believing TFN was healthy), and product accessibility. Perceptions of differences between TFN and TDN e-cigarettes included differences in taste/ flavor and acute psychoactive and physical effects (e.g., nicotine buzz, throat hit), with TFN e-cigarettes being described as generally stronger and superior relative to TDN e-cigarettes. CONCLUSION: These qualitative data suggest that taste and perceived health benefits are primary reasons that young adults try TFN e-cigarettes. Compared to TDN, young adults perceive TFN as better tasting with different psychoactive and less aversive effects. Determining if these perceived reasons for use and differences occur in blinded human experimental studies is a necessary next step to understanding TFN e-cigarette use. Additionally, understanding why young adults use TFN e-cigarettes is important in the development of prevention communication about these products.

Psychometric evaluation of the sensory e-cigarette expectancies scale for use with adolescents.

BACKGROUND: The Sensory E-cigarette Expectancies Scale (SEES) has demonstrated solid psychometric properties for use with adults. It assesses expectancies for enjoying the taste and smell of vaping, experiencing pleasurable physical sensations, and enjoying creating vapor clouds. We evaluated psychometric properties of the SEES for use with adolescents. METHODS: In Fall 2022, 4,855 students from eight Connecticut high schools completed an anonymous, cross-sectional, online survey. Our analytic sample (n = 724) endorsed lifetime e-cigarette use and completed the SEES. Psychometric analyses included factor analyses, internal reliability, measurement invariance, between-groups differences, and relationships with vaping outcomes. RESULTS: The three-factor SEES structure was confirmed. Internal reliability of each subscale was excellent (range: 0.88-0.95). The SEES was invariant by sex (male/female), race (Black/White/Other), Hispanic ethnicity (no/yes), nicotine e-cigarette use (no/yes), any past-month vaping (no/yes), daily vaping (no/yes), and vaping status (a variable created based on the distribution of past-month vaping frequency [0; 1-4; 5-20; 21+ days]). Those who reported using nicotine e-cigarettes, past-month vaping, daily vaping, and vaping on 21+ days in the past month reported stronger scores on each subscale compared to their respective counterparts. In adjusted models, expecting Pleasurable Physical Sensations was associated with total flavors used, past-month vaping frequency, and e-cigarette dependence. Enjoyment of Taste and Smell was positively associated with total flavors used and e-cigarette dependence. Enjoyment of Vapor Clouds was positively associated with total flavors used and past-month vaping frequency. CONCLUSIONS: Given its strong psychometric properties, the SEES can be used in future research to assess sensory-related vaping expectancies in youth.

Prioritizing common terminology and measures to advance research on oral nicotine product use.

This commentary calls for consistent measurement of oral nicotine product use by the scientific community, recommends specific measures where possible, and emphasizes areas in need of further research. We hope to expedite the use of consistent measures of oral nicotine product use so that this area of tobacco research can advance quickly.

Accurately classifying cannabis blunt use as tobacco-cannabis co-use versus exclusive cannabis use.

BACKGROUND: Historically, blunt use constituted tobacco-cannabis co-use based on the products available for creating blunts (e.g., hollowed-out cigars filled with cannabis). With the introduction of tobacco-free blunt wraps (e.g., hemp wraps), blunt use now may constitute tobacco-cannabis co-use or exclusive cannabis use. We examined adolescents' use of tobacco and tobacco-free blunt products and highlighted how misclassification of tobacco-cannabis co-use versus exclusive cannabis use may occur if products used to make blunts are not assessed. METHODS: 4855 students from eight Connecticut high schools completed an online survey in 2022. Use of tobacco products for making blunts (e.g., cigarillos, tobacco blunt wraps) and tobacco-free blunt wraps were assessed as was the use of other tobacco products (e.g., e-cigarettes, cigarettes, hookah). The analytic sample comprised 475 students who endorsed lifetime blunt use. RESULTS: Tobacco-free blunt wraps (72.6%) were the most popular product for making blunts, followed by cigarillos (56.5%), tobacco blunt wraps (49.2%), and large cigars (13.0%). When classified into mutually exclusive groups, students reported exclusive tobacco-free blunt use (32.3%), exclusive tobacco product blunt use (27.4%), or use of both tobacco product and tobacco-free blunts (40.3%). Among those exclusively using tobacco-free blunts, 13.4% endorsed no tobacco product use. CONCLUSIONS: Tobacco-free blunt wraps were very popular among high school adolescents, highlighting the importance of assessing products used for making blunts. Assuming that blunts contain tobacco without considering tobacco-free blunts can lead to misclassification of blunt use as tobacco-cannabis co-use when it actually reflects exclusive cannabis use, potentially leading to inflated estimates of tobacco use. DATA AVAILABILITY: Data will be made available upon reasonable request to the corresponding author.

Qualitative exploration of longer versus shorter quit attempts among adults using E-Cigarettes for combustible cigarette cessation.

Empirical evidence about the effectiveness of using e-cigarettes to quit smoking cigarettes remains inconclusive, yet e-cigarettes are commonly used for smoking cessation. Moreover, people who have longer duration quit attempts are likely to have even longer quit attempts in the future. Researchers analyzed 40 qualitative interviews to assess adults' experiences using e-cigarettes during their longest duration quit attempt. Interviewees quit smoking for ≥ one month (n = 20) or for shorter durations (n = 20). Thematic and comparative content analyses were used to analyze interview transcripts for factors facilitating or impeding the duration of quit attempts when using e-cigarettes. Participant narratives were mostly similar irrespective of their quit attempt duration. Six themes common across groups as well as themes more often discussed by people with shorter quit attempts are described. Most participants discussed using e-cigarette devices and flavors to either replace sensations similar to smoking combustible cigarettes (e.g., inhaling from a cylindrical object) or to distract themselves from cravings to smoke. E-cigarettes also were described by the majority of participants as useful for smoking cessation because they approximate combustible cigarette use, potentially reduce health-related harms, save money, and lead to reduced social stigma compared to smoking cigarettes. Those who reported shorter duration quit attempts shared e-cigarette product challenges, health concerns, needs for support. Study findings demonstrate the need for additional research on the factors that may increase the likelihood that using e-cigarettes will result in longer and sustained e-cigarette-based quit attempts among adults.

The first nicotine product tried is associated with current multiple nicotine product use and nicotine dependence among a nationally representative sample of U.S. youths.

This study examines the demographic factors associated with youths' first product tried (i.e., cigarettes, e-cigarettes, cigars, hookah, or smokeless tobacco). This study also evaluates whether the first product tried is associated with future nicotine product use (i.e., no use, single product use, and multiple product use) and nicotine dependence. Participants were 1999 youths (ages 12-17 years) who had ever tried a nicotine product and completed the Population Assessment of Tobacco Health study's Wave 1 (2013-2014) and Wave 4 (2016-2018) assessments. Two separate multinomial logistic regression models examined the association between 1) demographic factors and the first product tried at Wave 1 and 2) the first product tried at Wave 1 and past-30-day product use status at Wave 4. A two-part multivariable model examined the association between the first product tried and nicotine dependence, with part 1 modeling the presence (or absence) of any symptom of dependence and part 2 modeling the degree of dependence among those with any symptom of dependence. The first product tried was associated with sex, race, urbanicity, and parent education. First trying smokeless tobacco (vs. e-cigarettes) was associated with a greater likelihood of multiple product use (vs. no use and vs. single product use). Regarding the degree of nicotine dependence (n = 713), first trying smokeless tobacco (vs. e-cigarettes) was associated with higher nicotine dependence scores among those with any symptom of dependence. Youths who first try smokeless tobacco (vs. e-cigarettes) may be at higher risk for future multiple product use and more symptoms nicotine dependence. Research should explore tailored interventions for smokeless tobacco users.

Awareness, susceptibility, and use of oral nicotine pouches and comparative risk perceptions with smokeless tobacco among young adults in the United States.

BACKGROUND: Oral nicotine pouches (NPs) that contain nicotine but no tobacco leaves are rapidly gaining popularity. However, there is limited research on NPs, including within priority populations. In the current study, we examined awareness of, susceptibility to, and use of NPs in young adults as well as comparative risk perceptions with smokeless tobacco. METHODS: In 2021, 609 young adults (18-25 years) completed an online survey. Participants reported on NP awareness, susceptibility, and use as well as on comparative product perceptions for NPs versus smokeless tobacco. We ran unadjusted between-groups comparisons and an adjusted multinomial logistic regression to identify relationships between product perceptions and NP susceptibility and use. RESULTS: 41.5% of participants had heard of NPs before. Participants were non-susceptible (66.2%), susceptible (23.5%), or had used NPs (10.3%). Comparative product perceptions between NPs and smokeless tobacco suggested that young adults, as a whole, expressed uncertainty about the relative risk/benefit of using NPs versus smokeless tobacco. However, as expected, unadjusted and adjusted findings indicated that favorable perceptions of NPs versus smokeless tobacco were disproportionately observed among susceptible participants and NP users compared to non-susceptible individuals. Demographic differences were also observed (e.g., NP users were more likely than non-susceptible and susceptible individuals to have used smokeless tobacco). CONCLUSIONS: Young adults reported awareness of, susceptibility to, and use of NPs, with findings indicating that favorable perceptions of NPs versus smokeless tobacco may contribute to NP susceptibility and use beyond known correlates like smokeless tobacco use. However, further research is needed to understand the full range of factors that are associated with NP susceptibility and use. It will be important to disentangle factors that are associated with potential positive public health impacts (e.g., switching from smokeless tobacco to exclusive NP use) from those associated with negative public health impacts (e.g., initiation among nicotine naïve individuals).

"Tobacco-free" Nicotine Pouches: Risk Perceptions, Awareness, Susceptibility, and Use Among Young Adults in the United States.

BACKGROUND: Nicotine pouches containing synthetic nicotine or tobacco-derived nicotine (TDN) are available in the United States. Synthetic nicotine pouches are often marketed as "tobacco-free nicotine" (TFN), which may alter risk perceptions and product appeal. This study examined young adults' perceptions of TFN versus TDN pouches and the associations between product perceptions and TFN pouch awareness, susceptibility, and use, respectively. AIMS AND METHODS: In total 630 young adults (18-25 years) completed an online Qualtrics panels survey in 2021. Participants were informed that TFN pouches contain synthetic nicotine as opposed to TDN. Participants reported on comparative risk perceptions for TFN versus TDN pouches and on TFN pouch awareness, susceptibility, and use. Unadjusted between-group comparisons and adjusted binary logistic regressions were run to examine relationships between product perceptions and TFN pouch awareness, susceptibility, and use. RESULTS: Participants were aware of (37.3%), susceptible to (29.2%), or had used TFN pouches (3.8%). In unadjusted comparisons, TFN pouch awareness, susceptibility, and use were associated with disproportionately perceiving TFN pouches as less harmful or otherwise better than TDN pouches. In adjusted models, relationships between favorable perceptions and both TFN pouch awareness and susceptibility remained significant. CONCLUSIONS: The descriptor "tobacco-free" may impact risk perceptions and the appeal of nicotine pouches among young adults. While no direct relationship was observed between TFN perceptions and TFN pouch use in the adjusted model, perceptions remained related to product awareness and susceptibility, which may be linked to future use. Continued surveillance is needed to fully determine how the term "tobacco-free" on product packaging and advertising impacts longitudinal public health outcomes. IMPLICATIONS: Nicotine pouches originally contained TDN. Today, numerous brands of synthetic nicotine pouches, which are often marketed as "tobacco-free," are available on the market. We informed participants that "tobacco-free nicotine" pouches contain synthetic nicotine and examined comparative risk perceptions (i.e. tobacco-free vs. TDN pouches) and TFN pouch awareness, susceptibility, and use. Perceiving tobacco-free nicotine pouches as less harmful than tobacco-derived pouches was associated with product awareness, susceptibility, and use in unadjusted models and with awareness and susceptibility in adjusted models. Restricting the term "tobacco-free" may become necessary if the term inaccurately reduces product risk perceptions or increases product appeal.

Use and Product Characteristics of "Tobacco Free Nicotine" E-Cigarettes Among Young Adults.

INTRODUCTION: E-cigarettes are increasingly being marketed as containing tobacco-free nicotine (TFN). There is no data examining use of TFN e-cigarettes by young adults and how use may differ from non-TFN e-cigarettes. The current study aims to characterize young adult TFN e-cigarette use and examine differences between those who report using TFN and non-TFN e-cigarettes. METHOD: U.S. young adults (18-25) with lifetime e-cigarette use (n = 927) were recruited via online panels in Fall 2021 and answered questions about TFN and non-TFN e-cigarettes. Participants were categorized by lifetime TFN e-cigarette use status (yes vs. no; 34% yes). Bivariate comparisons examined differences in e-cigarette characteristics (device type, flavors, nicotine concentration) between the TFN and non-TFN groups. Binary logistic regression models examined associations between lifetime frequency of vaping (<100 vs. ≥100 times), and other tobacco product, cannabis, and/or alcohol use and lifetime TFN e-cigarette use (yes vs. no). Adjusted models include age, race/ethnicity, vaping onset age, and sex. RESULTS: In multivariable adjusted models, lifetime TFN e-cigarette use was associated with younger age, greater lifetime vaping, and nicotine pouch use. Young adults who used TFN e-cigarettes were more likely to report fruit, mint, menthol, and beverage flavors and know their e-liquid nicotine concentration compared with those who used non-TFN e-cigarettes. CONCLUSION: Among young adults who have used e-cigarettes, more frequent e-cigarette use and use of nicotine pouches, which can also contain TFN, were associated with TFN e-cigarette use. Understanding behaviors and characteristics of those using TFN e-cigarettes is critical to regulation of TFN containing products. IMPLICATIONS: This study characterizes young adults who report experience with tobacco free nicotine (TFN) e-cigarettes and compares them to those who have not used TFN e-cigarettes. Young adults with more frequent e-cigarette use and use of nicotine pouches are more likely to report TFN e-cigarette use.

Examining associations of e-cigarette flavour restrictions with e-cigarette use and success quitting smoking among US adults.

INTRODUCTION: Restricting available e-cigarette flavours to only tobacco and menthol may reduce appeal among youth; it is unknown how flavour restrictions impact adults using e-cigarettes to quit smoking cigarettes. METHODS: Online US survey data were collected in summer 2021 from 857 adults who reported using e-cigarettes in a recent attempt to quit smoking. Survey items assessed e-cigarette flavours used during their quit attempt, whether e-cigarette flavour bans restricted access to flavours they like, and what impact the restrictions had on e-cigarette behaviour. Multivariable logistic regression models were used to examine the associations of flavour bans with success quitting smoking for 1 month or longer. RESULTS: 30.2% (N=259) reported restricted access to e-cigarette flavours they like. During their quit attempt, 64.9% (N=168) used tobacco or menthol-flavoured e-cigarettes, and 90.7% (N=235) used another flavour that could be affected by restrictions, most commonly fruit, mint, and candy/dessert. Responses to flavour restrictions included switching devices to continue using preferred flavours (39.4%), using the same device only with available flavours (35.9%), buying preferred flavours elsewhere (eg, online) (19.3%), making flavours (3.5%) and 'other' (eg, no longer using e-cigarettes) (1.9%). The odds of quitting smoking for 1 month or longer were not significantly different between those experiencing flavour restrictions (vs not), preferring tobacco/menthol (vs restricted) flavour, or switching flavours in response to the bans (vs finding another way to obtain restricted flavours) (p>0.11). CONCLUSION: Experiencing e-cigarette flavour restrictions was not associated with success quitting smoking among adults using e-cigarettes to try to quit.

The Modified Cigarette Evaluation Questionnaire: Psychometric properties of the originally-proposed five-factor structure and a novel four-factor structure for use with adults who currently smoke cigarettes.

BACKGROUND: The Modified Cigarette Evaluation Questionnaire (MCEQ) measures self-reported, subjective reinforcing and aversive effects of smoking. The MCEQ is proposed as comprising five factors. However, its latent factor structure has been confirmed in only one published study, and key psychometric properties like measurement invariance and test-criterion validity have not been formally examined. METHODS: We examined the latent structure of the MCEQ using confirmatory and exploratory factor analysis and evaluated internal consistency, measurement invariance, between-group differences, and relationships with smoking-related characteristics in a sample of 764 adults who smoke cigarettes. As a secondary test of construct validity, we fit identified latent factor structures to a sample of 131 adults from a prior trial who were biochemically-confirmed to currently smoke. RESULTS: A four-factor structure that recently was validated for an e-cigarette-adapted version of the MCEQ outperformed the originally-proposed five-factor structure in several ways: it uniquely evidenced good model fit both within the primary and replication samples, reached scalar invariance for all participant subgroups tested, was sensitive to detecting numerous between-groups differences in subsamples of interest, and each of its subscales was associated with at least one smoking characteristic assessed. CONCLUSIONS: The four-factor MCEQ structure evidenced stronger psychometric properties in our sample than did the original five-factor MCEQ. However, until additional research is conducted on the utility of the five- and four-factor solutions in other samples, neither the five- nor the four-factor MCEQ structure should be assumed. In the meantime, researchers should examine the MECQ's latent structure in their data prior to conducting subsequent analyses.

Curiosity, use, and perceptions of "tobacco-free nicotine" E-cigarettes among U.S. young adults.

This study determined whether young adults perceptions of how tobacco free nicotine (TFN) compared to tobacco-derived nicotine (TDN) were associated with curiosity to try or use TFN e-cigarettes. U.S. young adults aged 18-25 years (n = 1176) completed an online survey in October 2021. Survey questions assessed TFN awareness, curiosity, use, and perceptions of how flavor, taste, ease of access, cost, and harm compared between TFN and TDN. Participants were categorized into 3 groups: not curious to try TFN (n = 511, 43.5%), curious to try TFN (n = 348, 29.6%), and ever used TFN (n = 317, 27%). Multinomial logistic regression measured associations between perceptions and TFN curiosity and use (vs. not curious to try), with total number tobacco products used and demographics as covariates. Compared to young adults who were not curious to try TFN e-cigarettes, those who were curious perceived TFN as less addictive than TDN (aOR = 2.27; 95% CI =1.34-3.86). Those who had used TFN e-cigarettes perceived TFN as having flavors that tasted better (aOR = 1.80; 95% CI = 1.63-1.99), "smoother" (aOR = 1.88; 95% CI =1.18-2.99), and less like tobacco (aOR 1.94; 95% CI 1.23-3.05). Adjusted models did not show differences in perceptions between those who had tried TFN and those who were curious to try TFN. Young adults who were curious to try or had used TFN had more positive perceptions of TFN. As it is currently unclear whether synthetic nicotine carries the same health risks as TDN, ongoing surveillance of TFN uptake among young adults is warranted.

Association of youth impulsivity and use of e-cigarette devices, flavors, and frequency of use.

INTRODUCTION: Given high youth e-cigarette use, it is important to investigate how traits, like impulsivity, may be associated with youth e-cigarette use behaviors. The study aim is to determine if impulsivity is associated with trying more e-cigarette flavors and device types, and greater frequency of e-cigarette use. METHOD: Cross sectional survey data from CT high schoolers (n = 4875, 6 schools) were collected in 2019. Lifetime (ever) e-cigarette users (n = 2313) completed the Brief Barrett Impulsivity Scale, which contains two subscales; behavioral impulsivity and impaired self-control. Among lifetime users, associations between impulsivity subscales and number of e-cigarette flavors tried, e-cigarette devices tried, and past 30-day frequency of e-cigarette use were examined using regression models. Additionally, associations of impulsivity and use frequency were examined among only current e-cigarette users (≥1 day of use in past 30; n = 1327). School, age, race/ethnicity, vaping initiation age, other tobacco product use, and sex were included as covariates in models. RESULTS: Higher behavioral impulsivity was associated with greater number of e-cigarette flavors tried (AOR: 1.06, 95% CI: 1.02, 1.11, p <.008) and higher frequency of past 30-day use both among ever and current e-cigarette users (AOR: 1.26, 95%CI:1.10,1.44, p <.001; AOR: 1.12, 95%CI:1.02,1.22, p <.02), but not number of e-cigarette devices tried. Impaired self-control was not associated with any outcomes. CONCLUSION: Youth with higher behavioral impulsivity may be more at risk for using more e-cigarette flavors and using e-cigarettes more frequently. Regulations aimed at reducing flavor availability among youth and interventions targeting impulsive behavior may be important for this population.