A systematic review of the modelling and economic evaluation studies assessing regulatory options for e-cigarette use.

BACKGROUND: Governments around the world are considering regulating access to nicotine e-cigarettes to prevent uptake among youth however people that smoke tobacco may use them to assist with smoking cessation. The health and cost implications of regulating e-cigarette use among populations are unknown but have been explored in modelling studies. We reviewed health economic evaluation and simulation modelling studies that assessed long-term consequences and interpret their potential usefulness for decision-makers. METHODS: A systematic review with a narrative synthesis was undertaken. Six databases were searched for modelling studies evaluating population-level e-cigarette control policies or interventions restricting e-cigarette use versus more liberalized use. Studies were required to report the outcomes of life years, quality-adjusted life years (QALYs) and/or healthcare costs. The quality of the studies was assessed using two quality assessment tools. RESULTS: In total, 15 studies were included with nine for the United States and one each for the United Kingdom, Italy, Australia, Singapore, Canada, and New Zealand. Three studies included cost-utility analyses. Most studies involved health state transition (or Markov) closed cohort models. Many studies had limitations with their model structures, data input quality and transparency, and insufficient analyses handling model uncertainty. Findings were mixed with 11 studies concluding that policies permitting e-cigarette use lead to net benefits and 4 studies concluding net losses in life-years or QALYs and/or healthcare costs.Five studies had industry conflicts of interest. CONCLUSIONS: While authors did conclude net benefit than net harm in more of the studies so far conducted, the significant limitations that we identified with many of the studies in this review, make it uncertain whether or not countries can expect net population harms or benefits of restrictive versus unrestrictive e-cigarette policies. The generalizability of the findings is limited for decision-makers. In light of the deep uncertainty around the health and economic outcomes of e-cigarettes, simulation modelling methods and uncertainty analyses should be strengthened.

The Association of Frequency of Worry About Financial Debt With Substance Use Among Adults in Ontario, Canada.

BACKGROUND: Financial debt and associated stress might increase the risk of substance use problems or exacerbate existing ones. Little evidence is available about the degree of debt stress and its association with substance use. The objective of this study was to examine the associations of the frequency of worry about debt with heavy episodic drinking (HED), daily smoking, e-cigarette use, and cannabis use in the past 30 days. METHODS: Data were utilized from the 2020/2022 Monitor study, a repeated cross-sectional survey of adults 18 years and older in Ontario, Canada. The surveys employed a web-based panel survey of 6038 adults and collected data on debt-related stress, HED, tobacco smoking, e-cigarettes, and cannabis use in the past 30 days. Odds ratios (OR) were estimated from logistic regression models accounting for sociodemographic factors. RESULTS: Overall, 18.4% of respondents reported that they were worried about their debt most or all of the time. Accounting for household income, educational status, employment status, and other factors, the results revealed that there was a dose-response relationship between the frequency of worry about debt and substance use including daily smoking, e-cigarette use, and cannabis use in the past 30 days compared to those who were not worried at all about their debt. Sex differences were also found in the association between worry about debt and e-cigarette use. CONCLUSIONS: The frequency of worry about debt might have an important role in substance use, which suggests that financial well-being is vital in substance use prevention and harm reduction.

The association between excise taxes and smoking and vaping transitions-Findings from the 2016-2020 ITC United States surveys.

BACKGROUND: While a growing number of studies examined the effect of e-cigarette (EC) excise taxes on tobacco use behaviors using cross-sectional surveys or sales data, there are currently no studies that evaluate the impact of EC taxes on smoking and vaping transitions. METHODS: Using data from the US arm of the 2016-2020 International Tobacco Control Four Country Smoking and Vaping Survey (ITC 4CV), we employed a multinomial logit model with two-way fixed effects to simultaneously estimate the impacts of cigarette/EC taxes on the change in smoking and vaping frequencies. RESULTS: Our benchmark model suggests that a 10 % increase in cigarette taxes led to an 11 % reduction in smoking frequencies (p < 0.01), while EC taxes did not have a significant effect on smoking frequencies. CONCLUSION: Our findings suggest that increasing cigarette taxes may serve as an effective means of encouraging people who smoke to cut back on smoking or quit smoking. The impact of increasing EC taxes on smoking transitions is less certain at this time.

Availability of substances for use in personal vaporisers on three online cryptomarkets.

BACKGROUND: Personal vaporisers are gaining popularity as an alternative route of administration for a range of substances. Online cryptomarkets are becoming increasingly popular among people who use substances due to their perceived anonymity, ease of use, and reduced risk of violence compared to traditional face-to-face dealers. We examined the diversity of substances marketed for use in a personal vaporiser on these marketplaces. METHODS: Vaping related listings were extracted from three online cryptomarkets ('Agartha', 'Cryptonia', and 'Tochka') using The Onion Router browser. Data collection occurred between October and November 2019. RESULTS: We identified 1929 listings from 201 unique sellers. The top product on Agartha, Cryptonia, and Tochka were vape cartridges prefilled with the e-liquid (70.4 %, 39.4 %, 52.3 % respectively). The most common substance in these products was cannabis oil (96.1 %, 82.1 %, 87.8 %), followed by synthetic cannabinoids (3.7 %, 9.7 %, 9.8 %) and psychedelic substances (0.2 %, 6.4 %, 1.2 %). Vendors were primarily from the USA. Many products offered worldwide shipping (96.3 %, 42.4 %, 51.2 %). CONCLUSION: Vaping products listed on online cryptomarkets in 2019 primarily contained cannabis oils. Future studies should continue to examine cryptomarkets to identify emerging trends of substances that can be used in personal vaporisers.

Validation of an E-cigarette Purchase Task in Advanced Generation Device Users.

INTRODUCTION: Behavioral economic purchase tasks are used to estimate the reinforcing value of drugs by asking participants how much they would purchase across a range of increasing prices. We sought to validate such a task for e-cigarettes in experienced users of advanced generation, tank-style devices. METHODS: Dual users of cigarettes and e-cigarettes (N = 54) and exclusive e-cigarette users (N = 59) attended one session during which they completed assessments including two versions of the E-cigarette Purchase Task: one that asked how many puffs of their e-cigarette they would purchase in 24 hours at varying prices and one that asked how many mLs of e-liquid they would purchase. We correlated purchase task outcomes with other measures of e-cigarette use. We also compared the tasks across dual and exclusive users. RESULTS: Indices derived from the mLs-based task were more likely to be correlated with self-reported use rates, e-cigarette dependence, and cotinine levels than the puffs-based task. Exclusive users showed greater demand on than dual users only on the mLs version when using an F-test comparison method, while multivariate analysis of variance (MANOVA) results showed that dual users showed greater demand only on the puffs task. CONCLUSIONS: Results indicate that the mLs version had greater validity than the puffs version in terms of clinical indices. Dual users may still be on a trajectory to fully switching to e-cigarettes; thus, puffs as a measure may be more intuitive, as this measure is shared by cigarettes and e-cigarettes. For exclusive users, the unit they purchase their e-liquid in may be the most relevant unit and better capture their demand for that product. IMPLICATIONS: Behavioral economic purchase tasks have been widely used to understand nicotine use. We have developed two versions of a purchase task for e-cigarette use and compared the two versions in users of advanced generation e-cigarette devices. We found that the mLs version of the task better-reflected use patterns relative to a puffs version, which suggests that participants struggle to place monetary value on a unit of consumption (ie, puffs). Validated measures of e-cigarette reinforcement will be important as researchers and regulators determine which features of these products contribute to reinforcing efficacy.

Neighborhood Disadvantage and Tobacco Retail Outlet and Vape Shop Outlet Rates.

Neighborhood-level socioeconomic variables, such as the proportion of minority and low-income residents, have been associated with a greater density of tobacco retail outlets (TROs), though less is known about the degree to which these neighborhood indicators are related to vape shop outlet (VSO) density. Many studies of TROs and neighborhood characteristics include only a small set of variables and also fail to take into account the correlation among these variables. Using a carefully curated database of all TROs and VSOs in Virginia (2016-2018), we developed a Bayesian model to estimate a neighborhood disadvantage index and examine its association with rates of outlets across census tracts while also accounting for correlations among variables. Models included 12 census tract variables from the American Community Survey. Results showed that increasing neighborhood disadvantage was associated with a 63% and 64% increase in TRO and VSO risk, respectively. Important variables associated with TRO rates included % renter occupied housing, inverse median gross rent, inverse median monthly housing costs, inverse median monthly housing costs, and % vacant housing units. Important variables associated with VSO rates were % renter occupied housing and % Hispanic population. There were several spatial clusters of significantly elevated risk for TROs and VSOs in western and eastern Virginia.

Flavored E-Cigarette Sales in the United States Under Self-Regulation From January 2015 Through October 2019.

Objectives. To describe the evolution of flavored e-cigarette sales since the expansion of the JUUL brand, and to describe the effect of JUUL's November 2018 decision to self-regulate the flavors it sold in stores on flavored e-cigarette sales.Methods. We used Scantrack data on sales of e-cigarettes in the United States from January 2015 to October 2019 provided by The Nielsen Company. National sales values were aggregated monthly in 5 flavor categories (fruit, menthol/mint, sweet, tobacco, and other).Results. The expansion of JUUL sales coincided with an expansion in fruit-flavor sales through October 2018. Once JUUL withdrew fruit and sweet flavors from stores, menthol/mint came to dominate the e-cigarette market, but through 2019, a new surge in fruit-flavor sales by non-JUUL brands was observed.Conclusions. After a decline in sales following JUUL's decision to withdraw some flavored products from stores, JUUL sales recovered within weeks and surpassed their previous maximum in those same channels, as consumption shifted to the menthol/mint and tobacco flavors that remained on shelves.Public Health Implications. These trends suggest shortcomings of self-regulation and highlight the utility of government regulation.

Socioeconomic Disparities in Vape Shop Density and Proximity to Public Schools in the Conterminous United States, 2018.

We conducted an environmental justice assessment examining the distribution of specialty vape shops in relation to where minority and low-income youth live and attend school. We collated and examined the density of vape shops in public school districts in 2018 throughout the conterminous United States using geographic information systems. We calculated the proximity of vape shops to public middle and high schools through nearest neighbor analysis in QGIS software. We examined the statistical relationships between the density of vape shops in school districts, and proximity to schools, with the proportion of racial/ethnic minorities and those living in poverty. We found that vape shops are more densely distributed, and are in closer proximity to schools, in school districts with higher proportions of Asian and Black or African American populations. However, vape shops were further away from schools in school districts with higher proportions of the population in poverty. The proximity and higher density of vape shops in relationship to schools in Asian and Black or African American communities may result in disproportionate health impacts due to greater access and exposure to vape products and advertisements. Our results may help school district administrators prioritize and target efforts to curb youth vaping (e.g., health education curricula) in these school districts with high density and closer proximity of vape shops to schools. Policy efforts, such as local ordinances restricting the promotion and sale of vaping products close to schools, could help prevent disproportionate human and environmental health impacts to minorities.

Impact of e-cigarette and cigarette prices on youth and young adult e-cigarette and cigarette behaviour: evidence from a national longitudinal cohort.

INTRODUCTION: Understanding the impact of prices for tobacco and nicotine products is critical for creating policies to prevent use among young people. This study examines the impact of electronic cigarette (e-cigarette) and cigarette prices on current e-cigarette and cigarette use among youth and young adults. METHODS: Data were from a national probability-based sample aged 15-21 collected in 2014 and followed every 6 months for 2.5 years through 2016. We conducted separate conditional likelihood logistic regression models with past 30-day e-cigarette use and past 30-day cigarette use outcomes on the sample of individuals who participated in at least two survey waves (n=11 578) with linked Nielsen market-level price data for rechargeable e-cigarettes and cigarettes. Models controlled for time-varying variables at the individual and state policy levels, and fixed effects at the individual, wave and market levels. RESULTS: Higher cigarette prices were associated with increased past 30-day e-cigarette use, indicating e-cigarettes may serve as a substitute for cigarettes. We did not find a statistically significant relationship between rechargeable e-cigarette prices and past 30-day e-cigarette use; neither did we find a significant relationship between rechargeable e-cigarette prices and past 30-day cigarette smoking. CONCLUSION: This is the first study to examine e-cigarette and cigarette prices on e-cigarette and cigarette behaviour longitudinally among young people. Findings suggest the need for better measuring the costs associated with e-cigarette use among this population, as well as a careful assessment of price and tax policies that takes into account cross-product impact to sufficiently discourage e-cigarette and cigarette use among young people.

Ten Years of FDA Tobacco Regulation: Lessons for Public Health Stakeholders.

In the 10 years that the U.S. Food and Drug Administration (FDA) has been regulating tobacco products, the agency has been plagued with setbacks, some of its own making, and some the result of outside forces. What has been consistently true is that the public health community has not had as much of a voice as it should have until public health groups began filing lawsuits against the FDA. This article examines four areas of FDA regulation over the last decade in an attempt to qualitatively describe the work of the Center for Tobacco Products and identify opportunities for public health groups to have greater advocacy success in the future.

Expenditure on smoking and alternative nicotine delivery products: a population survey in England.

BACKGROUND AND AIMS: The expense associated with using non-combustible nicotine products as an alternative to smoking may deter smoking reduction or cessation. This study aimed to estimate (i) how much adults in England spend each week on smoking and alternative nicotine products and (ii) the potential cost saving that could be achieved by switching from smoking to using an alternative nicotine delivery product. DESIGN AND SETTING: Data came from September to November 2018 waves of the Smoking Toolkit Study, a series of national household surveys of the adult population in England. PARTICIPANTS: A total of 859 adults (aged ≥ 16 years) who reported current smoking or current use of an alternative nicotine product. MEASUREMENTS: Participants reported their average weekly expenditure on smoking and alternative nicotine products [nicotine replacement therapy (NRT) or e-cigarettes]. FINDINGS: Current smokers who did not use any alternative nicotine delivery products (n = 602) reported spending on average £23.09 [95% confidence interval (CI) = £21.64-24.54] on smoking each week. Ex-smokers who used alternative nicotine products (n = 91) reported spending on average £8.59 (95% CI = £6.80-10.39) on these products each week; £8.03 (95% CI = £6.03-10.03) on e-cigarettes and £10.05 (95% CI = £5.62-14.47) on NRT. People who both smoked and used alternative nicotine products (dual users, n = 166) spent on average £24.54 (95% CI = £21.78-27.29) on smoking and £7.49 (95% CI = £6.00-8.99) on alternative nicotine products each week. Expenditure on smoking was higher among heavier, more addicted smokers and lower among those with routine/manual occupations, non-daily smokers and roll-your-own tobacco users. Expenditure on e-cigarettes was higher among men, users from central and southern versus northern England and smokers who had tried to quit in the past year, and lower among current smokers. Expenditure on NRT was lower among roll-your-own tobacco users. CONCLUSIONS: In England, expenditure among e-cigarette and nicotine replacement therapy users is approximately one-third of the expenditure of smokers. The average smoker may save an estimated £15.06 per week by switching completely to e-cigarettes or £13.04 per week by switching to nicotine replacement therapy, although this is likely to differ according to individual usage patterns.

The impact of e-cigarette price changes on vaping and smoking behaviors.

Background: Understanding the relations between e-cigarette prices and e-cigarette/cigarette use may shed light on the possible impact of e-cigarette regulations on public health. Objectives: This study aimed to assess potential impacts of e-cigarette price changes on vaping and smoking behaviors by smoking status (current, former, and never smokers) and e-cigarette type (pre-filled only vs. refillable). Methods: A total of 918 US-based adult e-cigarette users completed an online survey, designed to assess behavioral intention of e-cigarette/cigarette use in hypothetical situations with varying prices of e-cigarettes, in 2017. Results: With reduction in e-cigarette prices, more than 50% of current smokers reported they would reduce or quit smoking, but with greater increases in price, the rates of not only those who would quit (12.5-19.4%), but also those who would increase smoking rose (15.1-25.1%). Current smokers (vs. former/never) were more likely to increase e-cigarette use at reduced e-cigarette prices. Among current smokers, pre-filled users were less likely to quit smoking with reduced prices. At higher prices, pre-filled users were more likely to quit e-cigarettes (former smokers), but also more likely to start smoking (never smokers). Among former smokers, recent quitters were more likely to restart smoking with any e-cigarette price changes, and less likely to reduce or quit e-cigarettes with increased prices. Conclusions: Both smoking and e-cigarette use seem to be sensitive to e-cigarette price changes. Increases in e-cigarette price may have both positive and negative effects on smoking behavior, and e-cigarette price changes may disproportionately affect pre-filled users and recent quitters.

Tobacco Retail Licensing and Youth Product Use.

BACKGROUND: Restricting youth access to tobacco is a central feature of US tobacco regulatory policy, but impact of local tobacco retail licensing (TRL) regulation on cigarette smoking rates remains uncertain. Effects of TRL on other tobacco product use and use as adolescents reach the age to legally purchase tobacco products has not been investigated. METHODS: Prevalences of ever and past 30-day cigarette, electronic cigarette (e-cigarette), cigar, and hookah use were assessed in a survey of a cohort of 1553 11th- and 12th-grade adolescents (mean age: 17.3 years); rates of initiation were evaluated 1.5 years later. An American Lung Association (2014) youth access grade was assigned to each of 14 political jurisdictions in which participants lived on the basis of the strength of the local TRL ordinance. RESULTS: At baseline, participants living in 4 jurisdictions with "A" grades (ie, with most restrictive ordinances) had lower odds of ever cigarette use (odds ratio [OR] 0.61; 95% confidence interval [CI] 0.41-0.90) and of past 30-day use (OR 0.51; 95% CI 0.29-0.89) than participants in 10 D- to F-grade jurisdictions. At follow-up at legal age of purchase, lower odds of cigarette use initiation (OR 0.67; 95% CI 0.45-0.99) occurred in jurisdictions with stronger TRL policy. Lower odds of e-cigarette initiation at follow-up (OR 0.74; 95% CI 0.55-0.99) and of initiation with past 30-day use (OR 0.45; 95% CI 0.23-0.90) were also associated with better regulation. CONCLUSIONS: Strong local TRL ordinance may lower rates of cigarette and e-cigarette use among youth and young adults.

Prices, use restrictions and electronic cigarette use-evidence from wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey.

AIMS: To determine if there are associations between changes in the explicit (i.e. price) and implicit (i.e. use restrictions in public places) costs of cigarettes and nicotine vaping products (NVPs) and their use patterns in the United States. METHODS: Data came from wave 1 (2016) US data of the ITC Four Country Smoking and Vaping Survey (ITC US 4CV1) and Nielsen Scanner Track database. A multiple logistic regression model was applied to estimate the likelihoods of NVP use (vaping at least monthly), cigarette/NVP concurrent use (vaping and smoking at least monthly) and switch from cigarettes to NVPs (had quit smoking < 24 months and currently vape) among ever smokers, conditioning upon cigarette/NVP prices, use restrictions and socio-demographics. RESULTS: Living in places where vaping is allowed in smoke-free areas was significantly associated with an increase in the likelihood of vaping [marginal effect (ME) = 0.17; P < 0.05] and the concurrent use of cigarettes and NVPs (ME = 0.11; P < 0.05). Higher NVP prices were associated with decreased likelihood of NVP use, concurrent use, and complete switch (P > 0.05). Higher cigarette prices were associated with greater likelihood of cigarette and NVP concurrent use (P > 0.05). Working in places where vaping is banned is associated with lower likelihood of vaping and NVP and cigarette concurrent use (P > 0.05). CONCLUSIONS: Higher prices for nicotine vaping products (NVPs) and vaping restrictions in public places are associated with less NVP use and less concurrent use of vaping and smoking. Public policies that increase prices for vaping devices and supplies (i.e. regulations, taxes) and restrict where vaping is allowed are likely to suppress vaping.

Where Do Vapers Buy Their Vaping Supplies? Findings from the International Tobacco Control (ITC) 4 Country Smoking and Vaping Survey.

Aim: This study examines where vapers purchase their vaping refills in countries having different regulations over such devices, Canada (CA), the United States (US), England (EN), and Australia (AU). Methods: Data were available from 1899 current adult daily and weekly vapers who participated in the 2016 (Wave 1) International Tobacco Control Four Country Smoking and Vaping. The outcome was purchase location of vaping supplies (online, vape shop, other). Adjusted odds ratios and 95% confidence intervals were reported for between country comparisons. Results: Overall, 41.4% of current vapers bought their vaping products from vape shops, 27.5% bought them online, and 31.1% from other retail locations. The vast majority of vapers (91.1%) reported using nicotine-containing e-liquids. In AU, vapers were more likely to buy online vs other locations compared to CA (OR = 6.4, 2.3⁻17.9), the US (OR = 4.1, 1.54⁻10.7), and EN (OR = 7.9, 2.9⁻21.8). In the US, they were more likely to buy from vape shops (OR = 3.3, 1.8⁻6.2) or online (OR = 1.9, 1.0⁻3.8) vs other retail locations when compared to those in EN. In CA, vapers were more likely to purchase at vape shops than at other retail locations when compared to vapers in EN (5.9, 3.2⁻10.9) and the US (1.87, 1.0⁻3.1). Conclusions: The regulatory environment and enforcement of such regulations appear to influence the location where vapers buy their vaping products. In AU, banning the retail sale of nicotine vaping products has led vapers to rely mainly on online purchasing sources, whereas the lack of enforcement of the same regulation in CA has allowed specialty vape shops to flourish.

The impact of vaping and regulatory environment on cigarette demand: behavioral economic perspective across four countries.

BACKGROUND AND AIMS: Government regulations of nicotine vaping products (NVP) have evolved rapidly during the past decade. The impact of NVP regulatory environment and vaping on cigarette demand is unknown. The current study aims to investigate whether or not respondents' reported cigarette demand, as measured by a hypothetical cigarette purchase task, varies with (1) smoking status, (2) vaping status or (3) NVP regulatory environment (country used as proxy). DESIGN: Cross-sectional survey data from wave 1 of the International Tobacco Control (ITC) Four Country Smoking and Vaping (4CV) Survey (2016). SETTING: Australia, Canada, England and the United States. PARTICIPANTS: A total of 10 316 adult smokers. MEASUREMENTS: A hypothetical purchase task asked smokers to estimate how many cigarettes they would purchase for consumption in a single day across multiple cigarette prices. Responses were used to derive measures of cigarette demand. Overall sensitivity of cigarette consumption to price increases was quantified to index cigarette demand elasticity, whereas estimated consumption when cigarettes are free was used to index cigarette demand intensity. FINDINGS: A majority of the non-daily smokers had previously smoked daily (72.3%); daily vapers were more likely to be former daily smokers (89.9%) compared to non-daily vapers (70.1%) and non-vapers (69.2%) (P < 0.001). The smoking status × vaping status interaction was significant for cigarette demand intensity (F = 4.93; P = 0.007) and elasticity (F = 7.30; P = 0.001): among non-daily smokers, vapers reported greater intensity but lower elasticity (i.e. greater demand) relative to non-vapers (Ps < 0.05). Among daily smokers, daily vapers reported greater intensity relative to non-vapers (P = 0.005), but vaping status did not impact elasticity (Ps > 0.38). Intensity was higher in Australia compared with all other countries (Ps < 0.001), but elasticity did not vary by country (F = 2.15; P = 0.09). CONCLUSIONS: In a hypothetical purchase task, non-daily smokers showed lower price elasticity if they used e-cigarettes than if they did not, while there was no clear difference in elasticity between e-cigarette users and non-users among daily smokers or according to regulatory environment of their country with regard to e-cigarettes.