#Discreetshipping: Selling E-cigarettes on TikTok.

INTRODUCTION: Youth and young adult use of e-cigarette products continues to remain high despite regulatory approaches to reduce youth access. This study sought to examine TikTok content regarding the sale and distribution of e-cigarettes. AIMS AND METHODS: TikTok videos (n = 475) and metadata posted between June 2022 and August 2023 were scraped using a TikTok application programming interface and popular hashtags used to sell vaping products (ie, #discreetshipping [40.8 million], #puffbundle [14.8 million], #hiddennic [1.0 million]). After watching the 25 most viewed videos (39 600-868 800 views), a codebook was developed. All metadata were annotated using 11 unique codes: Small business, brand, cannabis, bundled, hidden, fake, international sales, no ID, order via Instagram, order via another method, and cost. RESULTS: Overall, 367 videos (with an average of 2017 likes) were deemed relevant. Videos advertised popular vaping brands (50.4%) that included cannabis products (45%). Products were described as bundled (28.6%), hidden (8.7%), and able to be shipped internationally (6%) without age verification (45.2%). Some videos (8.2%) evaded algorithms' detection of illegal activity by describing the post as "Fake." Customers were directed to other social media platforms (most often Instagram, 57.5%) and/or other websites/links (58.3%) to purchase products; 22.1% advertised discounts, free shipping, or low costs (ranging from $25-$35). CONCLUSIONS: Social media platforms, such as TikTok and Instagram, are being used to circumvent e-cigarette regulatory policies. Regulatory agencies should expand enforcement strategies to include social media platforms where users are illegally selling and distributing e-cigarettes internationally to young audiences. IMPLICATIONS: TikTok users across the globe are violating local, state, and federal laws by selling e-cigarettes concealed inside other products or bundled in packages that avoid detection. TikTok videos posted by self-proclaimed small business owners advertise discreet shipping practices that evade age verification in order to sell nicotine and cannabis bundles worldwide. Accounts used phrases describing the post to be "fake" to avoid detection by algorithms or TikTok administrators. E-cigarette regulatory agencies can partner with social media platforms to close regulatory gaps.

Cigarette and E-Cigarette Harm Perceptions During Pregnancy.

BACKGROUND: Research suggests that pregnancy status (prior, current, and future intention) is associated with differences in perceived harm of electronic cigarette (e-cigarette) use during pregnancy. However, perceptions of health outcomes attributed to cigarette and e-cigarette use during pregnancy have not been explored among a sample of pregnant women who smoke. OBJECTIVES: The purpose of this study was to explore differences in perceived harms of cigarette and e-cigarette use and perceived birth and health outcomes associated with cigarette and e-cigarette use during pregnancy among a sample of pregnant women who currently smoked. METHODS: Using a cross-sectional online survey, we examined perceptions about cigarette and e-cigarette use during pregnancy among a sample of U.S. pregnant women ( n = 267) who smoked in the past 30 days. Participants were grouped into categories based on e-cigarette use status (current, past, and never e-cigarette users). Differences between e-cigarette use status and perceived harm (absolute of cigarettes, e-cigarettes, and relative of e-cigarettes) and perceived health outcomes attributed to smoking/e-cigarette use were examined. RESULTS: Among our sample, 45.7%, 39.7%, and 14.6% were current, ever, and never e-cigarette users, respectively. Associations existed between e-cigarette use status and absolute perceived harm of cigarettes, relative perceived harm of e-cigarettes, and perceived health outcomes. Current e-cigarette users believed pregnant women who smoked cigarettes were more likely to lose a child because of miscarriage or sudden infant death syndrome or give birth to a child with low birth weight, reduced lung function, cleft lip, reduced brain function, or attention-deficit/hyperactivity disorder than never e-cigarette users. No associations were found between perceived birth and health outcomes of e-cigarette use by e-cigarette user status. DISCUSSION: Pregnant women who smoked and used e-cigarettes had lower risk perceptions about e-cigarette use during pregnancy than those who only smoked. Health messages and research about the harms of nicotine exposure during pregnancy should address the risks of dual-use versus only e-cigarette use. In addition, messages about the relative harm of e-cigarettes compared to cigarettes are needed for pregnant women who smoke and have trouble quitting.

Twitter Sentiment About the US Federal Tobacco 21 Law: Mixed Methods Analysis.

BACKGROUND: On December 20, 2019, the US "Tobacco 21" law raised the minimum legal sales age of tobacco products to 21 years. Initial research suggests that misinformation about Tobacco 21 circulated via news sources on Twitter and that sentiment about the law was associated with particular types of tobacco products and included discussions about other age-related behaviors. However, underlying themes about this sentiment as well as temporal trends leading up to enactment of the law have not been explored. OBJECTIVE: This study sought to examine (1) sentiment (pro-, anti-, and neutral policy) about Tobacco 21 on Twitter and (2) volume patterns (number of tweets) of Twitter discussions leading up to the enactment of the federal law. METHODS: We collected tweets related to Tobacco 21 posted between September 4, 2019, and December 31, 2019. A 2% subsample of tweets (4628/231,447) was annotated by 2 experienced, trained coders for policy-related information and sentiment. To do this, a codebook was developed using an inductive procedure that outlined the operational definitions and examples for the human coders to annotate sentiment (pro-, anti-, and neutral policy). Following the annotation of the data, the researchers used a thematic analysis to determine emergent themes per sentiment category. The data were then annotated again to capture frequencies of emergent themes. Concurrently, we examined trends in the volume of Tobacco 21-related tweets (weekly rhythms and total number of tweets over the time data were collected) and analyzed the qualitative discussions occurring at those peak times. RESULTS: The most prevalent category of tweets related to Tobacco 21 was neutral policy (514/1113, 46.2%), followed by antipolicy (432/1113, 38.8%); 167 of 1113 (15%) were propolicy or supportive of the law. Key themes identified among neutral tweets were news reports and discussion of political figures, parties, or government involvement in general. Most discussions were generated from news sources and surfaced in the final days before enactment. Tweets opposing Tobacco 21 mentioned that the law was unfair to young audiences who were addicted to nicotine and were skeptical of the law's efficacy and importance. Methods used to evade the law were found to be represented in both neutral and antipolicy tweets. Propolicy tweets focused on the protection of youth and described the law as a sensible regulatory approach rather than a complete ban of all products or flavored products. Four spikes in daily volume were noted, 2 of which corresponded with political speeches and 2 with the preparation and passage of the legislation. CONCLUSIONS: Understanding themes of public sentiment-as well as when Twitter activity is most active-will help public health professionals to optimize health promotion activities to increase community readiness and respond to enforcement needs including education for retailers and the general public.

Preemption in State Tobacco Minimum Legal Sales Age Laws in the US, 2022: A Policy Analysis of State Statutes and Case Laws.

Preemptive statutory language within tobacco minimum legal sales age (MLSA) laws has prohibited localities from enacting stricter laws than state statutes. With the recent uptake of state Tobacco 21 laws in the US, the current landscape of preempted MLSA laws is unknown. This study sought to update the status of preemption in MLSA laws enacted in US states between 2015-2022. A public health attorney reviewed state tobacco MLSA laws (n = 50) and state tobacco control codes, searching for language regarding preemption. When statutes were unclear, case law was reviewed by examining local ordinances that were invalidated by state court decisions. Overall, 40 states enacted Tobacco 21 laws, seven of which expanded or introduced preemption when they increased the MLSA; a total of 26 states (52%) included preemption. Six states (12%) retained 'savings clauses' included in the MLSA prior to Tobacco 21, and 18 states (36%) did not mention preemption. Based on the precedent set by state courts, eight of these 18 states may preempt localities from raising their MLSA. Historically, preemption has slowed the diffusion of best practices in tobacco control, and once implemented, the laws are difficult to repeal. The recent expansion of preemption could inhibit the evolution, development, and implementation of effective tobacco control policies.

Miscommunication about the US federal Tobacco 21 law: a content analysis of Twitter discussions.

OBJECTIVE: Tobacco 21 is a law that sets the minimum legal sales age of tobacco products to 21. On 20 December 2019, the USA passed a federal Tobacco 21 law. The objective of this study is to explore Twitter discussions about the federal Tobacco 21 law in the USA leading up to enacted. METHODS: Twitter messages about Tobacco 21 posted between September and December 2019 were collected via RITHM software. A 2% sample of all collected tweets were double coded by independent coders using a content analysis approach. RESULTS: Findings included three content categories of tweets (news, youth and young adults and methods of avoiding the law) with eight subcodes. Most news tweets incorrectly described the law as a purchase law (54.7%). However, Tobacco 21 is in fact a sales law-it only includes penalties for tobacco retailers who sell to under-age purchasers. About one-fourth (27%) of the tweets involved youth and young adults, with some claiming the law would reduce youth smoking and others doubting its ability to limit youth access to tobacco products. Few tweets (2.5%) mentioned methods of circumventing the policy, such as having an older peer purchase tobacco. CONCLUSIONS: As several countries explore raising their age of sale of tobacco laws to 21, they should couple policy enactment with clear and accurate communication about the law. Compliance agencies at all levels (eg, local, regional, national) can use social media to identify policy loopholes and support vulnerable populations throughout the policy implementation process.

Components in tobacco-free school policies-A coding tool for assessment.

OBJECTIVE: To develop an instrument to examine tobacco-free campus policy components. PARTICIPANTS: Missouri two- and four-year, specialized/technical, and religious colleges and universities (N = 76). Methods: The instrument was informed via literature review and expert interviews. Coder agreement was strong (κ = .80). Qualitative policy language examples were identified. RESULTS: Model policy components including consideration for population, prohibited products, location restrictions, enforcement, consequences, promotions, communications, cessation, designated smoking areas and exemptions; comprehensive policies included all populations, for all tobacco products, and at all locations on the campus. Nineteen campuses had comprehensive tobacco-free policies, five had comprehensive smoke-free policies (cigarettes and e-cigarettes), and no policy included all model components. Fifty-two were non-comprehensive. CONCLUSIONS: This instrument can allow campuses to identify components for comprehensive and model tobacco-free campus policies and assist officials in improving policy language. Future research can use this instrument to examine the effectiveness of components and their impact on tobacco use outcomes.

Policy and Behavior: Comparisons between Twitter Discussions about the US Tobacco 21 Law and Other Age-Related Behaviors.

To combat the e-cigarette epidemic among young audiences, a federal law was passed in the US that raised the minimum legal sales age of tobacco to 21 years (commonly known as Tobacco 21). Little is known about sentiment toward this law. Thus, the purpose of our study was to systematically explore trends about Tobacco 21 discussions and comparisons to other age-restriction behaviors on Twitter. Twitter data (n = 4628) were collected from September to December of 2019 that were related to Tobacco 21. A random subsample of identified tweets was used to develop a codebook. Two trained coders independently coded all data, with strong inter-rater reliability (κ = 0.71 to 0.93) found for all content categories. Associations between sentiment and content categories were calculated using χ2 analyses. Among relevant tweets (n = 955), the most common theme­the disjunction between ages for military enlistment and tobacco use­was found in 17.8% of all tweets. Anti-policy sentiment was strongly associated with the age of military enlistment, alcohol, voting, and adulthood (p < 0.001 for all). Opposition to Tobacco 21 propagates on social media because the US federal law does not exempt military members. However, the e-cigarette epidemic may have fueled some support for this law.

Exploring Factors That Predict Marketing of e-Cigarette Products on Twitter: Infodemiology Approach Using Time Series.

Background: Electronic nicotine delivery systems (known as electronic cigarettes or e-cigarettes) increase risk for adverse health outcomes among naïve tobacco users, particularly youth and young adults. This vulnerable population is also at risk for exposed brand marketing and advertisement of e-cigarettes on social media. Understanding predictors of how e-cigarette manufacturers conduct social media advertising and marketing could benefit public health approaches to addressing e-cigarette use. Objective: This study documents factors that predict changes in daily frequency of commercial tweets about e-cigarettes using time series modeling techniques. Methods: We analyzed data on the daily frequency of commercial tweets about e-cigarettes collected between January 1, 2017, and December 31, 2020. We fit the data to an autoregressive integrated moving average (ARIMA) model and unobserved components model (UCM). Four measures assessed model prediction accuracy. Predictors in the UCM include days with events related to the US Food and Drug Administration (FDA), non-FDA-related events with significant importance such as academic or news announcements, weekday versus weekend, and the period when JUUL maintained an active Twitter account (ie, actively tweeting from their corporate Twitter account) versus when JUUL stopped tweeting. Results: When the 2 statistical models were fit to the data, the results indicate that the UCM was the best modeling technique for our data. All 4 predictors included in the UCM were significant predictors of the daily frequency of commercial tweets about e-cigarettes. On average, brand advertisement and marketing of e-cigarettes on Twitter was higher by more than 150 advertisements on days with FDA-related events compared to days without FDA events. Similarly, more than 40 commercial tweets about e-cigarettes were, on average, recorded on days with important non-FDA events compared to days without such events. We also found that there were more commercial tweets about e-cigarettes on weekdays than on weekends and more commercial tweets when JUUL maintained an active Twitter account. Conclusions: e-Cigarette companies promote their products on Twitter. Commercial tweets were significantly more likely to be posted on days with important FDA announcements, which may alter the narrative about information shared by the FDA. There remains a need for regulation of digital marketing of e-cigarette products in the United States.

Potential risk factors for cigarette use among a sample of college JUUL users.

Objective: To examine the relationship between demographics, other tobacco use, and JUUL dependency on combustible cigarette use among college JUUL users. Participants: Undergraduates (n = 595) at a large southwestern university who used JUUL weekly completed a cross-sectional online survey in March 2019. Methods: Logistic regressions examined associations between covariates and ever use/past 30-day use of cigarettes. Results: As age increased, odds of ever trying a cigarette increased (AOR = 1.87; 95% CI = 1.45-2.41); however, as age of JUUL initiation increased, odds of ever (AOR = 0.80; 95% CI = 0.65-0.99) or past 30-day (AOR = 0.78; 95% CI = 0.63-0.97) cigarette use decreased. Those moderately (AOR = 2.03; 95% CI = 1.07-3.82) or highly (AOR = 8.01; 95% CI = 3.08-20.83) dependent on JUUL were more likely to have tried cigarettes than those not dependent. However, dependence was not associated with past 30-day use. Conclusions: JUUL users may not transition to combustible cigarettes during college. Longitudinal studies are needed to examine transitions in JUUL users' tobacco product use after college.

Human papillomavirus (HPV) knowledge, beliefs, and vaccine uptake among United States and international college students.

Objective: The purpose of this study was to compare knowledge about human papillomavirus (HPV) and HPV vaccine, college student's beliefs toward HPV, and HPV vaccine uptake between US and international college students studying in the US. Participants: The study was conducted using a sample (N = 588) of college students from a university in the South Central US. Methods: Study measures was derived from previously validated measures. Data were collected via an online survey using Qualtrics. Results: Significant differences were found in HPV awareness, HPV vaccine awareness, and HPV vaccine uptake between US and international college students. Conclusion: This study showed existing disparities between US and international college students regarding HPV and HPV vaccine awareness, and HPV vaccine uptake. College health centers can play a crucial role in raising awareness of HPV and HPV vaccination rates by organizing various intervention programs to reduce these disparities.

Association of psychological distress and current cigarette smoking among Native Hawaiian and Pacific Islander adults and compared to adults from other racial/ethnic groups: Data from the National Health Interview Survey, 2014.

Cigarette smoking is the leading cause of preventable deaths worldwide. Research has documented an association between psychological distress and smoking among certain racial/ethnic groups but has not examined this association among Native Hawaiian and Pacific Islander (NHPI) adults. Data from the 2014 general and the NHPI-specific National Health Interview Surveys were analyzed at the University of Arkansas for Medical Sciences Regional Campus (Fayetteville, AR) in April 2021 to determine the association between current cigarette smoking and levels of psychological distress among NHPI adults and to assess the difference in the magnitude of that association among NHPI adults compared to adults of other racial/ethnic groups in the United States. The final analytic sample (n = 34,782) included 1,916 NHPI, 20,430 White, 4,725 Black, 2,001 Asian, and 5,710 Hispanic adults. A significant association between current cigarette smoking and psychological distress levels was found among NHPI adults as well as among adults from other racial/ethnic groups. There was no significant difference in the magnitude of the detected association among NHPI adults compared to the magnitude of the same association detected among adults of other racial/ethnic groups. However, this finding indicates race/ethnicity does not moderate the association between psychological distress and current cigarette smoking. Future studies should explore factors that may further explain the variation in current cigarette smoking within and across all racial/ethnic groups.

Harm perceptions, JUUL dependence, and other tobacco product use among young adults who use JUUL.

INTRODUCTION: The study identified groups of JUUL using young adults based on their use patterns and compared harm perceptions, JUUL dependence, and other tobacco product use among these groups. METHODS: Online cross-sectional survey data were gathered in March 2019 from 667 undergraduate students who used JUUL weekly (50.4% females, average age: 20.3 years) at a southwest U.S. university. RESULTS: Latent class analysis identified four groups of young adults who used JUUL: 1) Light Social JUUL Using Young Adults (LS, 52.5%) who used JUUL occasionally with friends when drinking alcohol, 2) Daily Sensation Seekers (DSS, 16.2%) who used JUUL daily with alcohol, 3) Daily Activity Driven JUUL Using Young Adults (DAD, 26.0%) who used JUUL daily while drinking, watching media, or studying, and 4) Daily All Occasion JUUL Using Young Adults (DAO, 5.3%) who used JUUL heavily, daily and in various occasions. While all four groups reported some extent of JUUL dependence, DAO reported the highest dependence and were more likely than LS to have used cigarettes and other e-cigarettes besides JUUL. They also tended to believe different pod flavors could cause different types of lung damage while the other groups were unsure/disagreed with this belief. LS were more likely than DSS and DAD to believe that JUUL use indicated openness to new experiences. CONCLUSION: Young adults with different JUUL use patterns perceived JUUL harms differently and faced varied risks of JUUL dependence and other tobacco product use. Effective cessation interventions should be adapted to meet the needs of these groups.

Pregnant Smokers' Intention to Switch From Cigarettes to E-Cigarettes: A Reasoned Action Approach.

INTRODUCTION: This study used the reasoned action approach (RAA) to examine 1) factors associated with pregnant smokers' intention to switch from cigarettes to e-cigarettes and 2) the influence that intention to switch had on future expectations to resume cigarette use postpartum. METHODS: U.S. pregnant women (N = 267) who reported past 30-day use of cigarettes completed an online cross-sectional survey between November and December 2019. A 30-item scale measured RAA constructs (intention, instrumental attitudes, experiential attitudes, injunctive norms, descriptive norms, perceived autonomy, and perceived capacity). A confirmatory factor analysis confirmed and structural equation modeling tested the RAA constructs' association with intention to switch and the relationship between intention to switch and future expectations to resume smoking after pregnancy. RESULTS: The confirmatory factor analysis confirmed the seven-factor measurement model. Structural equation modeling found instrumental attitudes (ß = 0.43; p < .001) and descriptive norms (ß = 0.53; p < .001) were associated with intention to switch from cigarettes to e-cigarettes. However, there were differences between the constructs' relationships with intention between those who did and did not use e-cigarettes in the past 30 days. Intention to switch was inversely related with future expectations to resume smoking postpartum (ß = -0.13; p < .001). CONCLUSIONS: This study examined multiple facets of behavioral decision-making that may influence pregnant smokers' intention to switch to e-cigarettes during pregnancy. In this sample, pregnant people who believed switching from cigarettes to e-cigarettes was important and that other smokers commonly switched during pregnancy reported greater intention to switch. Novel theories, such as the RAA, may provide an optimal lens to understand pregnant smokers' behavioral decision-making process as they consider switching from cigarettes to e-cigarettes.

College Students' Reasons for Using JUULs.

PURPOSE: To identify reasons that college students use JUUL and explore associations between reasons for using JUUL and social and behavioral (tobacco use) factors. DESIGN: On-line, cross-sectional survey. SETTING: Large southwestern university in the US. SUBJECTS: Undergraduate students (n = 605) who owned JUUL and used it weekly. MEASURES: The study measured age of JUUL initiation, JUUL dependence, and use of other e-cigarettes and other tobacco products. Participants described reasons for JUUL use as brief open-ended responses. ANALYSIS: Responses were categorized by 2 researchers using an inductive procedure. Logistic regressions examined associations between demographics and use frequency and categorized reasons for using JUUL. RESULTS: Four reasons for using JUUL emerged: self-help (48.4%), social (30.4%), experience (42.8%), and substance use/addiction (42.3%). Daily JUUL users were 1.66 (95% CI: 1.05-2.63) times as likely to use JUUL for self-help than those who used JUUL 1-3 days/week. Those who had never tried a cigarette were twice (OR = 2.08; 95% CI: 1.22-3.54) as likely as cigarette-first users to use JUUL for social reasons. Males (OR = 1.87; 95% CI: 1.32-2.65) had higher odds of using JUUL for the experience than females, and JUUL and other e-cigarettes users were 4.37 (95% CI: 1.83-10.45) times as likely as JUUL-only users to use JUUL due to substance use/addiction. CONCLUSION: JUUL users report unique reasons for use (e.g., addiction) not previously reported for older models of e-cigarette devices.

Tobacco 21 Policies in the U.S.: The Importance of Local Control With Federal Policy.

INTRODUCTION: In December 2019, the U.S. raised the minimum legal sales age of tobacco to 21 years, a law commonly known as Tobacco 21. This study examines local Tobacco 21 policies for the inclusion of model policy components: comprehensive tobacco definition, age verification and tobacco access, enforcement measures, tobacco retail license, and violation penalties. METHODS: A document analysis of Tobacco 21 local policies passed in the U.S. before July 1, 2019 (N=477) was conducted in May 2020 using a Tobacco 21 policy assessment tool. Policies were coded by 2 independent coders for the inclusion of components. RESULTS: Many localities included model component: comprehensive tobacco definition (65%), appearance age (70.9%), local tobacco retail license (72%), a graduated monetary penalty structure (93%), and tobacco retail license suspensions or revocations (74%) for repeated violations. However, only 17.4% of policies included an appearance age in compliance with federal law (30 years). Furthermore, few policies included enforcement components, such as a mandatory number of inspections (5.9%) or compliance checks (6.7%) per year, or a minimum age for the underage purchasers used during compliance checks (8.4%). CONCLUSIONS: Local policies can play an important role in tobacco control by providing an added layer to ensure adequate enforcement of age-restriction policies and allow an avenue to introduce strict measures that may diffuse into higher branches of government for policy adoption. Although many local Tobacco 21 policies fill regulatory gaps within the state and federal laws, often there is a lack of model components to ensure that policies are implemented as intended.

Interventions using mHealth strategies to improve screening rates of cervical cancer: A scoping review.

MHealth interventions are extensively used to inform and remind women about cervical cancer and their upcoming screening appointments. Our scoping review aims to examine the effectiveness these interventions targeted to increase the uptake of cervical cancer screening along with its barriers and facilitators. We searched 4 databases (PsycINFO. PUBMED, CINAHL, and MEDLINE) for studies that were published between January 1, 2009 and October 2019. References were further screened manually for additional papers. Studies were included in the review if they used interventions including phone calls, text messages and mobile applications as their primary strategy to contact women. We identified 12 unique studies that met the inclusion criteria; seven were international studies. Most studies sent multiple messages (informative and reminder) and/or made numerous phone calls (manual/automated) to inform participants about cervical cancer screening, their nearest screening clinic, and their upcoming appointments. Five studies documented a significant increase in the uptake of cervical cancer screenings during the follow-ups conducted within 12 months. Qualitative studies suggested participants prefer particular communication mediums, and they were concerned about privacy and confidentiality issues when text messages were sent with their health information. Findings suggest mHealth interventions may be an effective strategy to reach women for improving their cervical cancer uptake. Barriers including transportation cost, inaccessibility, and inability to come for walk-in appointments in the health clinics need to be addressed, beyond reminders, in mobile phone-based interventions to facilitate their presence in their next appointment.

Young Adult JUUL Users' Beliefs About JUUL.

PURPOSE: The purpose of this study was to test beliefs (risks to individual health, tobacco industry affiliation, and harm to others) with young adult current JUUL users to prompt decreased JUUL use. METHODS: An explanatory sequential mixed-method design was used. Undergraduates aged 18-24 years at a large southwest university who owned and used a JUUL at least once a week completed an online survey (n = 667) in March 2019. Participant reactions to 6 JUUL-specific statements (harm to lungs and brain, tobacco industry ownership, communication device inside JUUL, harm to others and the environment) were assessed. Then, 51 participants completed an in-person interview 1-2 weeks later to explain what influenced their responses. RESULTS: Across beliefs, females were more likely and those who used other tobacco products were less likely to say they would reduce JUUL use. Beliefs about harm to the brain, others, and the environment had the most influence on interview participants. Tobacco industry affiliation with JUUL was not viewed negatively and likely would not affect participant decisions. CONCLUSIONS: Messaging developed for other tobacco products may not have the same impact with young adult JUUL users. These findings provide guidance to tobacco use regulators by informing marketing message regulations to prevent initiation or prolonged use of JUUL and other pod-based products.

Gestational Women's Perceptions About the Harms of Cigarette and E-Cigarette Use During Pregnancy.

OBJECTIVES: The purpose of this study was to examine differences between perceived harm of cigarette and electronic cigarette (e-cigarette) use while pregnant and differences between healthcare providers' communication about these products during pregnancy. METHODS: A convenience sample of gestational women (n = 218; ages 18-45) living in the US completed an online survey between May and December 2017. Participants reported perceived likelihood of adverse health outcomes (e.g., low birth weight, sudden infant death syndrome) among infants/children born to mothers who used cigarettes/e-cigarettes. T-tests and two-way ANOVAs examined differences between risk perceptions of using cigarettes/e-cigarettes while pregnant based on pregnancy status (previously pregnant, currently pregnant, future pregnant). Chi-square analyses examined differences between healthcare provider communication about cigarette/e-cigarette use during pregnancy. RESULTS: Overall, participants believed adverse health outcomes were significantly more likely to be caused by maternal use of cigarettes than e-cigarettes. Participants who planned to be pregnant reported higher endorsement that smoking combustible cigarettes would cause a miscarriage (p < .05) or increased blood pressure (p < .05) for a child than currently pregnant participants. Participants reported healthcare providers asked about (p < .05), advised them not to use (p < .001), and talked to them about health effects of smoking combustible cigarettes while pregnant (p < .001) significantly more than e-cigarettes. CONCLUSIONS FOR PRACTICE: Healthcare providers working with pregnant women should perform the 5As behavioral intervention method to provide pregnant women with tobacco cessation care. They should also discuss the absolute harm nicotine exposure (via cigarettes or e-cigarettes) can have on fetal health and development.

Addiction vs. dependence: A mixed methods analysis of young adult JUUL users.

OBJECTIVE: JUUL-brand electronic cigarettes (e-cigarettes) contain higher levels of nicotine than other e-cigarettes. The current study examined the relationship between young adults' self-reported addiction and measured JUUL dependence. METHODS: This study used a sequential, explanatory mixed methods design. Data were collected from a large, southwestern college in the US. College students who were weekly JUUL users and owned a JUUL device (n = 595) completed a cross-sectional online survey, then a subsample (n = 51) participated in in-person interviews. All data were collected between March-April 2019. T-tests were used to examine differences between JUUL dependence and self-reported addiction, and logistic regressions were employed to examine factors that may influence self-reported addiction to JUUL, nicotine, and other e-cigarettes. Interviews were independently coded by 2 coders (kappa ranged from 0.46 to 0.99) then analyzed for corresponding themes. RESULTS: Participants who had a higher JUUL dependence were more likely to report addiction to several substances/products, including nicotine, JUULs, cigarettes, other e-cigarettes, alcohol, and marijuana. Interview participants minimized JUUL addiction by comparing JUUL to other socially acceptable addictions and describing JUUL addiction as a habit. Interview participants suggested addiction to nicotine was more stigmatizing than JUUL. The number of days participants used JUUL per week, use of traditional tobacco products, and measured JUUL dependence were each associated with self-reported JUUL addiction. CONCLUSIONS: Social construction of self-reported addictions may be changing young audiences' views of addiction to JUUL. Research is needed to see if using the phrase 'nicotine dependence' rather than 'JUUL addiction' influences young adults' JUUL use.