Electronic cigarette use intensity measurement challenges and regulatory implications.

Assessing tobacco use intensity allows researchers to examine tobacco use in greater detail than assessing ever or current use only. Tobacco use intensity measures have been developed that are specific to tobacco products, such as asking smokers to report number of cigarettes smoked per day. However, consensus on electronic cigarette use intensity measures that can be used for survey research has yet to be established due to electronic cigarette product and user behavior heterogeneity. While some survey measures that attempt to assess electronic cigarette use intensity exist, such as examining number of 'times' using an electronic cigarette per day, number of puffs taken from an electronic cigarette per day, volume of electronic cigarette liquid consumed per day, or nicotine concentration of electronic cigarette liquid, most measures have limitations. Challenges in electronic cigarette measurement often stem from variations across electronic cigarette device and liquid characteristics as well as the difficulty that many electronic cigarette users have regarding answering questions about their electronic cigarette device, liquid, or behavior. The inability for researchers to measure electronic cigarette use intensity accurately has important implications such as failing to detect unintended consequences of regulatory policies. Development of electronic cigarette use intensity measures, though not without its challenges, can improve understanding of electronic cigarette use behaviors and associated health outcomes and inform development of regulatory policies.

Cigarette Brand Use and Sexual Orientation: Intersections With Gender and Race or Ethnicity.

INTRODUCTION: Lesbian, gay, and bisexual (LGB) populations have higher cigarette smoking rates than heterosexual populations. The tobacco industry has leveraged LGB, gender, and racial or ethnic identities to establish cigarette brand preference. We examined cigarette brand use among smokers by sexual orientation and the implications of gender and race or ethnicity for brand use. METHODS: We used the National Survey on Drug Use and Health (NSDUH; 2015-2017) to conduct weighted bivariate analyses in 2019-2020 of the prevalence of 5 commonly used cigarette brands among adult smokers (N = 24,310) by sexual orientation. We conducted weighted regressions to test relationships between sexual orientation and brand use and interactions between sexual orientation, gender (defined in NSDUH as male or female), and race or ethnicity. RESULTS: LGB smokers were more likely to use Camel (lesbian/gay, OR = 1.7 [95% CI, 1.2-2.3], bisexual, OR = 1.8 [95% CI, 1.5-2.2]) and American Spirit cigarettes (lesbian/gay, OR = 2.8 [95% CI, 1.9-4.1], bisexual, OR = 3.2 [95% CI, 2.5-4.1]) than heterosexual smokers. Lesbian/gay smokers had higher odds of Marlboro cigarette use (OR = 1.2; 95% CI, 1.0-1.4) than heterosexual smokers. Bisexual smokers were more likely to smoke Newport cigarettes (OR = 1.7; 95% CI, 1.4-2.1) than heterosexual smokers. Interactions between LGB and female identities (vs gay or bisexual male) were positively associated with Camel, Marlboro, and Newport use. The interaction between lesbian/gay and Hispanic/Latino ethnicity (vs lesbian/gay White) was also positively associated with Newport use. CONCLUSION: LGB smokers may be more likely to smoke some commonly used cigarette brands than heterosexual smokers, and gender and race or ethnicity may have implications for brand preference. Future research could examine specific contributors to brand use among LGB smokers (eg, tobacco marketing).

Measuring waterpipe tobacco smoking in survey research.

Waterpipe tobacco (WT) smoking remains a significant public health problem. However, few validated measures exist, presenting challenges for obtaining accurate prevalence estimates and making comparisons across studies. We identified items used to measure several WT smoking behaviours in eight US national surveys of youth and adults and two international studies, including the National Youth Tobacco Survey, National Adult Tobacco Survey, Population Assessment of Tobacco and Health Adult and Youth Surveys, Monitoring the Future, National Health Interview Survey, Health Styles, Tobacco Use Supplement: Current Population Survey, Global Adult Tobacco Survey and Global Youth Tobacco Survey. We also identified WT survey items across the first 14 Food and Drug Administration-funded Tobacco Centers of Regulatory Science. Constructs included product description and terminology, ever and current use, quantity and frequency, use of flavours and reasons for use. There was little consistency in WT measurement, highlighting the need for validated measures.

Host-agent-vector-environment measures for electronic cigarette research used in NIH grants.

OBJECTIVE: The purpose of this study is to describe the focus and comprehensiveness of domains measured in e-cigarette research. METHODS: A portfolio analysis of National Institutes of Health grants focusing on e-cigarette research and funded between the fiscal years 2007 and 2015 was conducted. Grant proposals were retrieved using a government database and coded using the Host-Agent-Vector-Environment (HAVE) model as a framework to characterise the measures proposed. Eighty-one projects met the criteria for inclusion in the analysis. RESULTS: The primary HAVE focus most commonly found was Host (73%), followed by Agent (21%), Vector (6%) and Environment (0%). Intrapersonal measures and use trajectories were the most common measures in studies that include Host measures (n=59 and n=51, respectively). Product composition was the most common area of measurement in Agent studies (n=24), whereas Marketing (n=21) was the most common (n=21) area of Vector measurement. When Environment measures were examined as secondary measures in studies, they primarily focused on measuring Peer, Occupation and Social Networks (n=18). Although all studies mentioned research on e-cigarettes, most (n=52; 64%) did not specify the type of e-cigarette device or liquid solution under study. CONCLUSIONS: This analysis revealed a heavy focus on Host measures (73%) and a lack of focus on Environment measures. The predominant focus on Host measures may have the unintended effect of limiting the evidence base for tobacco control and regulatory science. Further, a lack of specificity about the e-cigarette product under study will make comparing results across studies and using the outcomes to inform tobacco policy difficult.

The association between perceived e-cigarette and nicotine addictiveness, information-seeking, and e-cigarette trial among U.S. adults.

Perceptions of harm and addictiveness are associated with smoking combusted cigarettes, but these factors have not been fully explored for e-cigarettes. Specifically, little is known about the perceived harm and addictiveness of e-cigarettes, or whether information-seeking about e-cigarettes is related to trying e-cigarettes. We aimed to determine the relationship between (1) perceived e-cigarette harm and addictiveness and trying e-cigarettes; (2) nicotine perceptions and trying e-cigarettes; and (3) e-cigarette information-seeking, Internet use, and trying e-cigarettes. We used data from the nationally representative 2015 Health Information National Trends Survey-FDA (HINTS-FDA 2015). Weighted multivariable logistic regression models assessed independent associations between perceived e-cigarette harm, perceived e-cigarette addictiveness, nicotine perceptions, e-cigarette information-seeking, personal Internet use, and trying e-cigarettes, among 3195 adults. Compared to people who believed e-cigarettes were equally or more addictive than combusted cigarettes, those who believed e-cigarettes were less addictive had 2.49 times the odds of trying e-cigarettes (95% confidence interval [CI]: 1.30, 4.74). Perceived e-cigarette harm and nicotine perceptions were not associated with trying e-cigarettes. The positive association between e-cigarette addictiveness and trying e-cigarettes coupled with the lack of an association between nicotine perceptions and trying e-cigarettes suggests people do not fully understand that e-cigarettes contain nicotine and therefore could be addictive. People most frequently reported searching for information about potential health effects of e-cigarettes (37.9%), indicating that people are interested in learning about the potential impact of e-cigarette use on their health. People who searched for information about e-cigarettes had 10.23 higher odds of trying e-cigarettes (CI: 5.41, 19.33).

Advancing Tobacco Product Warning Labels Research Methods and Theory: A Summary of a Grantee Meeting Held by the US National Cancer Institute.

BACKGROUND: The World Health Organization's Framework Convention on Tobacco Control recommends prominent pictorial health warnings on tobacco products. To advance research methods, theory and understanding of how tobacco product warning labels (TPWLs) work, the US National Cancer Institute convened a grantee meeting. Our article describes the key insights that emerged from the meeting, situated within the context of the scientific literature. RESULTS & RECOMMENDATIONS: First, presentations confirmed that large, pictorial TPWLs motivate people to try to quit and encourage smoking cessation. Second, pictorial TPWLs increase attention, knowledge, negative affect, and thinking about the warning. Third, TPWL studies have primarily used brief-exposure laboratory studies and observational studies of sustained exposure through national policy implementation, with a few randomized trials involving several weeks of exposure-with generally consistent results found across study designs. Fourth, novel assessment methods include brain imaging, eye tracking and "best-worst" discrete choice experiments. To make TPWL even more effective, research is needed to confirm the mechanisms of their influence, their impact across vulnerable populations, and their effect on social media posts about tobacco products. Research is also needed on the effect of trial design choices, the predictive validity of new measurement approaches, and warning labels for non-cigarette tobacco products. IMPLICATIONS: To improve scientific understanding of TPWL effects, this grantee meeting summary describes emerging research methods, theory and study results. Directions for future research include examination of the mechanisms of how warning labels work across diverse tobacco products and across different populations and contexts.

Psychometric Evaluation of the E-cigarette Dependence Scale.

INTRODUCTION: Psychometrically sound measures of e-cigarette dependence are lacking. METHODS: We modified the PROMIS Item Bank v1.0-Smoking: Nicotine Dependence for All Smokers for use with e-cigarettes and evaluated the psychometrics of the 22-, 8-, and 4-item adapted versions, referred to as The E-cigarette dependence scale (EDS). Adults (1009) who reported using e-cigarettes at least weekly completed an anonymous survey in summer 2016 (50.2% male, 77.1% White, mean age 35.81 [10.71], 66.4% daily e-cigarette users, 72.6% current cigarette smokers). Psychometric analyses included confirmatory factor analysis, internal consistency, measurement invariance, examination of mean-level differences, convergent validity, and test-criterion relationships with e-cigarette use outcomes. RESULTS: All EDS versions had confirmable, internally consistent latent structures that were scalar invariant by sex, race, e-cigarette use (nondaily/daily), e-liquid nicotine content (no/yes), and current cigarette smoking status (no/yes). Daily e-cigarette users, nicotine e-liquid users, and cigarette smokers reported being more dependent on e-cigarettes than their counterparts. All EDS versions correlated strongly with one another, evidenced convergent validity with the Penn State E-cigarette Dependence Index and time to first e-cigarette use in the morning, and evidenced test-criterion relationships with vaping frequency, e-liquid nicotine concentration, and e-cigarette quit attempts. Similar results were observed when analyses were conducted within subsamples of exclusive e-cigarette users and duals-users of cigarettes and e-cigarettes. CONCLUSIONS: Each EDS version evidenced strong psychometric properties for assessing e-cigarette dependence in adults who either use e-cigarette exclusively or who are dual-users of cigarettes and e-cigarettes. However, results indicated little benefit of the longer versions over the 4-item EDS, which provides an efficient assessment of e-cigarette dependence. IMPLICATIONS: The availability of the novel, psychometrically sound EDS can further research on a wide range of questions related to e-cigarette use and dependence. In addition, the overlap between the EDS and the original PROMIS that was developed for assessing nicotine dependence to cigarettes provides consistency within the field.

Philip Morris research on precursors to the modern e-cigarette since 1990.

BACKGROUND: Use of electronic cigarettes (e-cigarettes) is increasing rapidly. Chinese pharmacist Hon Lik is frequently cited as inventing the modern e-cigarette in 2003. However, tobacco companies have developed electronic nicotine delivery systems since at least 1963. METHODS: We searched the University of California San Francisco Truth (formerly Legacy) Tobacco Industry Documents beginning with the terms 'electric cigarette' and 'electronic cigarettes', 'e-cigarette', 'smokeless cigarettes', 'nicotine aerosol', 'tobacco aerosol', and 'vaping' and then expanded the search using snowball sampling. We focused our analysis on Philip Morris (PM) documents discussing technology that aerosolised a nicotine solution because these devices resembled modern e-cigarettes. Over 1000 documents were reviewed; 40 were included in the final analysis. RESULTS: PM started developing a nicotine aerosol device in 1990 to address the health concerns and decreased social acceptability of smoking that were leading smokers to switch to nicotine replacement therapy. PM had developed a capillary aerosol generator that embodied basic e-cigarette technology in 1994, but in the mid-to-late 1990s focused on applying its aerosol technology to pharmaceutical applications because of uncertainty of how such products might affect potential Food and Drug Administration regulation of tobacco products. In 2001, PM resumed its work on a nicotine aerosol device, and in 2013, NuMark (a division of Altria, PM's parent company) released the MarkTen, a nicotine aerosol device. CONCLUSIONS: Rather than a disruptive technology, PM developed e-cigarette technology to complement, not compete with, conventional cigarettes and evade tobacco control regulations.

Adolescent Smoking Cessation With Bupropion: The Role of Adherence.

INTRODUCTION: While many medications can be effective aids to quitting tobacco, real world adherence to smoking cessation medications may render a potentially effective medication ineffective. The present study investigated the role of adherence on treatment outcomes in a bupropion dose-response study among adolescent smokers trying to quit smoking. METHODS: Three hundred twelve adolescent boys (n = 143) and girls (n = 169) between the ages of 14-17 were enrolled in the study, and were randomly assigned to use either 300 mg, 150 mg or placebo bupropion to quit smoking. Among the eligibility criterion, participants had to smoke at least six cigarettes per day, be motivated to quit smoking (self report), have an exhaled carbon monoxide level greater than or equal to 10 ppm, and report at least two previous quit attempts. Adherence to medication was determined by both self-report and actual counts of unused medication and empty medication packaging. Smoking status was determined by a combination of self-report and biochemical verification (breath carbon monoxide and urine cotinine). RESULTS: Cotinine-confirmed quit rates were significantly higher as a function of high adherence (20.69%) relative to low adherence (0.00%) in the 300-mg Bupropion Sustained Release group. Overall adherence in all study conditions in this highly controlled study was high (74%), but was significantly lower in non-white participants. CONCLUSIONS: Effectiveness of bupropion for adolescent smoking cessation is contingent on achieving high rates of medication adherence, but considerable variations in adherence impacted outcomes. IMPLICATIONS: Few studies have assessed the safety and efficacy of medications to help adolescent smokers quit, and we conducted one such study assessing bupropion. In this analysis of that original study, we assess the role of adherence in use of medication and quit rates. We found that adherence was related to outcomes, particularly in the 300-mg dose of bupropion.

The importance of product definitions in US e-cigarette laws and regulations.

BACKGROUND: How electronic cigarettes and similar products (e-cigarettes) are defined affects how they are regulated, particularly whether existing laws for cigarettes apply, including sales and marketing, youth access, smoke-free and taxation laws. METHODS: We examined the text of 46 bills that define e-cigarettes enacted in 40 states and characterised how e-cigarettes and similar products were defined. RESULTS: States enact laws creating new product categories for e-cigarettes separate from the 'tobacco product' category (eg, 'alternative nicotine product,' 'vapour product,' 'electronic nicotine device'), with four states explicitly excluding e-cigarettes from 'tobacco products.' Twenty-eight states do not include e-cigarettes in their definitions of 'tobacco products' or 'smoking,' eight include e-cigarettes as 'tobacco products,' three include e-cigarettes in 'smoking.' Sixteen states' definitions of e-cigarettes require nicotine, and five states pre-empt more stringent local laws. Tobacco and e-cigarette industry representatives tried to shape laws that benefit their interests. CONCLUSIONS: Definitions separating e-cigarettes from other tobacco products are common. Similar to past 'Trojan horse' policies, e-cigarette policies that initially appear to restrict sales (eg, limit youth access) may actually undermine regulation if they establish local pre-emption or create definitions that divide e-cigarettes from other tobacco products. Comparable issues are raised by the European Union Tobacco Products Directive and e-cigarette regulations in other countries. Policymakers should carefully draft legislation with definitions of e-cigarettes that broadly define the products, do not require nicotine or tobacco, do not pre-empt stronger regulations and explicitly include e-cigarettes in smoke-free and taxation laws.

A content analysis of electronic cigarette manufacturer websites in China.

OBJECTIVE: The goal of this study was to summarise the websites of electronic cigarette (e-cigarette) manufacturers in China and describe how they market their products. METHODS: From March to April 2013, we used two search keywords 'electronic cigarette' (Dian Zi Xiang Yan in Chinese) and 'manufacturer' (Sheng Chan Chang Jia in Chinese) to search e-cigarette manufacturers in China on Alibaba, an internet-based e-commerce business that covers business-to-business online marketplaces, retail and payment platforms, shopping search engine and data-centric cloud computing services. A total of 18 websites of 12 e-cigarette manufacturers in China were analysed by using a coding guide which includes 14 marketing claims. RESULTS: Health-related benefits were claimed most frequently (89%), followed by the claims of no secondhand smoke (SHS) exposure (78%), and utility for smoking cessation (67%). A wide variety of flavours, celebrity endorsements and e-cigarettes specifically for women were presented. None of the websites had any age restriction on access, references to government regulation or lawsuits. Instruction on how to use e-cigarettes was on 17% of the websites. CONCLUSIONS: Better regulation of e-cigarette marketing messages on manufacturers' websites is needed in China. The frequent claims of health benefits, smoking cessation, strategies appealing to youth and women are concerning, especially targeting women. Regulators should prohibit marketing claims of health benefits, no SHS exposure and value for smoking cessation in China until health-related, quality and safety issues have been adequately addressed. To avoid e-cigarette use for initiation to nicotine addiction, messages targeting youth and women should be prohibited.

Use of E-Cigarettes Among Current Smokers: Associations Among Reasons for Use, Quit Intentions, and Current Tobacco Use.

INTRODUCTION: Research has documented growing availability and use of e-cigarettes in the United States over the last decade. METHODS: We conducted a national panel survey of current adult cigarette smokers to assess attitudes, beliefs, and behaviors relating to e-cigarette use in the United States (N = 2,254). RESULTS: Among current cigarette smokers, 20.4% reported current use of e-cigarettes on some days and 3.7% reported daily use. Reported reasons for e-cigarette use included: quit smoking (58.4%), reduce smoking (57.9%), and reduce health risks (51.9%). No significant differences in sociodemographic characteristics between e-cigarette users and nonusers were observed. Prior quit attempts were reported more frequently among e-cigarette users (82.8%) than nonusers (74.0%). Intention to quit was reported more frequently among e-cigarette users (64.7%) than nonusers (46.8%). Smokers intending to quit were more likely to be e-cigarette users than those not intending to quit (odds ratio [OR] = 1.90, CI =1.36-2.65). Those who used e-cigarettes to try to quit smoking (OR = 2.25, CI = 1.25-4.05), reduce stress (OR = 3.66, CI = 1.11-12.09), or because they cost less (OR = 3.42, CI = 1.64-7.13) were more likely to report decreases in cigarette smoking than those who did not indicate these reasons. Smokers who reported using e-cigarettes to quit smoking (OR = 16.25, CI = 8.32-31.74) or reduce stress (OR = 4.30, CI = 1.32-14.09) were significantly more likely to report an intention to quit than those who did not indicate those reasons for using e-cigarettes. CONCLUSIONS: Nearly a quarter of smokers in our study reported e-cigarettes use, primarily motivated by intentions to quit or reduce smoking. These findings identify a clinical and public health opportunity to re-engage smokers in cessation efforts.

'To quarterback behind the scenes, third-party efforts': the tobacco industry and the Tea Party.

BACKGROUND: The Tea Party, which gained prominence in the USA in 2009, advocates limited government and low taxes. Tea Party organisations, particularly Americans for Prosperity and FreedomWorks, oppose smoke-free laws and tobacco taxes. METHODS: We used the Legacy Tobacco Documents Library, the Wayback Machine, Google, LexisNexis, the Center for Media and Democracy and the Center for Responsive Politics (opensecrets.org) to examine the tobacco companies' connections to the Tea Party. RESULTS: Starting in the 1980s, tobacco companies worked to create the appearance of broad opposition to tobacco control policies by attempting to create a grassroots smokers' rights movement. Simultaneously, they funded and worked through third-party groups, such as Citizens for a Sound Economy, the predecessor of AFP and FreedomWorks, to accomplish their economic and political agenda. There has been continuity of some key players, strategies and messages from these groups to Tea Party organisations. As of 2012, the Tea Party was beginning to spread internationally. CONCLUSIONS: Rather than being a purely grassroots movement that spontaneously developed in 2009, the Tea Party has developed over time, in part through decades of work by the tobacco industry and other corporate interests. It is important for tobacco control advocates in the USA and internationally, to anticipate and counter Tea Party opposition to tobacco control policies and ensure that policymakers, the media and the public understand the longstanding connection between the tobacco industry, the Tea Party and its associated organisations.

State-wide dissemination of a school-based nutrition education programme: a RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis.

OBJECTIVE: The current study evaluated the overall public health impact of the 'Shaping Up My Choices' (SMC) programme, a 10-week school-based nutrition education curriculum developed for third-grade students, using the RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework. DESIGN: Randomized controlled trial to evaluate the programme and secondary analysis of archival data to describe dissemination. Data were collected from programme records, teacher surveys and student pre-, post- and 3-month follow-up surveys. SETTING: Public elementary schools in California. SUBJECTS: An evaluation sample (938 students and nineteen teachers) and a dissemination sample (195 245 students and 7359 teachers). RESULTS: In the evaluation sample, differences between the control and intervention groups were observed for nutrition knowledge, self-efficacy, outcome expectancies, and intakes of vegetables, fruit (girls only), soda, and low-nutrient high-energy foods from pre- to post-survey. Group differences in change in knowledge, outcome expectancies and vegetable intake were sustained through the 3-month follow-up (efficacy). One hundred per cent of intervention teachers in the evaluation sample implemented all of the lessons (implementation). The dissemination sample represented 42% of third-grade students (reach) and 39% of third-grade classrooms in public elementary schools in California during 2010-2011 (adoption). Thirty-seven per cent of third-grade teachers in the dissemination sample reordered SMC materials during the subsequent school year (2011-2012; maintenance). CONCLUSIONS: The SMC programme demonstrates the potential for moderate to high public health impact.

Forbidden fruit and the prediction of cigarette smoking.

The concept of "forbidden fruit" has been popularly associated with adolescent cigarette smoking in the US. However, only a few empirical studies have been conducted to investigate how this construct operates among adolescents. We examined the concurrent and prospective relationships between two related concepts of forbidden fruit and adolescent cigarette smoking behavior and intention. We found some support for forbidden fruit attitudes as concurrent and longitudinal predictors of smoking and intention to smoke. Implications of these findings are discussed.