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.

An Introduction and Practical Guide to Strategies for Analyzing Longitudinal Data in Clinical Trials of Smoking Cessation Treatment: Beyond Dichotomous Point-Prevalence Outcomes.

Conceptualizing tobacco dependence as a chronic relapsing condition suggests the need to use analytic strategies that reflect that premise. However, clinical trials for smoking cessation typically define the primary endpoint as a measure of abstinence at a single timepoint distal to the intervention, typically 3-12 months. This reinforces the concept of tobacco outcomes as a dichotomous state-one is, or is not, abstinent. Fortunately, there are several approaches available to handle longitudinal data that reflect the relapsing and remitting nature of tobacco use during treatment studies. In this paper, sponsored by the Society for Research on Nicotine and Tobacco's Treatment Research Network, we present an introductory overview of these techniques and their application in smoking cessation clinical trials. Topics discussed include models to examine abstinence outcomes (eg, trajectory models of abstinence, models for transitions in smoking behavior, models for time to event), models that examine reductions in tobacco use, and models to examine joint outcomes (eg, examining changes in the use of more than one tobacco product). Finally, we discuss three additional relevant topics (ie, heterogeneity of effects, handling missing data, and power and sample size) and provide summary information about the type of model that can be used based on the type of data collected and the focus of the study. We encourage investigators to familiarize themselves with these techniques and use them in the analysis of data from clinical trials of smoking cessation treatment. Implications Clinical trials of tobacco dependence treatment typically measure abstinence 3-12 months after participant enrollment. However, because smoking is a chronic relapsing condition, these measures of intervention success may not accurately reflect the common trajectories of tobacco abstinence and relapse. Several analytical techniques facilitate this type of outcome modeling. This paper is meant to be an introduction to these concepts and techniques to the global nicotine and tobacco research community including which techniques can be used for different research questions with visual summaries of which types of models can be used for different types of data and research questions.

A randomized controlled trial of potential tobacco policies prohibiting menthol flavor in cigarettes and e-cigarettes: a study protocol.

BACKGROUND: Menthol cigarette use remains a large public health problem and disproportionately affects Black adults in the United States. The Food and Drug Administration has proposed prohibiting menthol flavor in cigarettes to protect public health. However, e-cigarettes are available in menthol flavor and are a popular alternative product adults might switch to if menthol is prohibited in cigarettes. Research is needed to understand how availability of menthol (vs. tobacco) flavored e-cigarettes could impact cigarette use among adults who smoke menthol cigarettes. METHODS: We will recruit 150 adults who currently smoke menthol cigarettes and will randomize them to 1 of 3 conditions modeling different regulatory scenarios. We will recruit equal numbers of participants identifying as Black vs. non-Black and will stratify randomization by race. To promote standardization and adherence, cigarette and e-cigarette products will be provided for 8 weeks based on the assigned condition: (A) no menthol restriction (menthol cigarette and menthol flavored e-cigarette), (B) menthol prohibited in cigarettes only (non-menthol cigarette and menthol flavored e-cigarette), (C) menthol prohibited in both cigarettes and e-cigarettes (non-menthol cigarette and tobacco flavored e-cigarette). A follow-up visit will occur at week 12 to assess tobacco use status. The study aims are to (1) examine the impact of prohibiting menthol flavor in cigarettes and e-cigarettes on smoking behavior and (2) investigate whether outcomes differ by race to understand the impact of menthol policies on Black (vs. non-Black) individuals given high rates of menthol cigarette use in this population. The primary outcome will evaluate changes in the number of cigarettes smoked per day during the 8-week study period and will examine differences by regulatory scenario. Secondary outcomes will compare percent days smoke-free, changes in nicotine dependence, and motivation, confidence, and intentions to quit smoking by the regulatory scenarios. We will examine whether changes in the outcomes differ by Black vs. non-Black participants to compare the magnitude of the effect of the various menthol policy scenarios by race. DISCUSSION: Results will contribute critical information regarding menthol in cigarettes and e-cigarettes to inform regulatory policies that maximize reductions in cigarette smoking and reduce tobacco-related health disparities. TRIAL REGISTRATION: NCT05259566. Yale IRB protocol #2000032211, last approved 12/8/2023.

The Scientific Basis for the Regulation of Flavors in Tobacco Products.

Effective tobacco policies are important for reducing the harm of tobacco use and can have a broad impact at the population level. This review provides an overview of how clinical science can inform tobacco policies with a focus on policies related to flavored tobacco products, using menthol cigarettes as an illustrative example. Specifically, this review summarizes the role of flavors in tobacco use and the history of regulation of flavored tobacco products by the US Food and Drug Administration (FDA), provides an overview of clinical research methods used to contribute to the scientific evidence to inform FDA tobacco policies, discusses key findings related to menthol tobacco products using these methods, and proposes future directions for clinical research. As the tobacco marketplace continues to evolve with new products and flavor chemicals, ongoing clinical science will be essential for establishing evidence-based policies to protect public health and reduce tobacco-related health disparities.

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.

"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.

Common Measures to Evaluate Flavored Tobacco Products: Recommendations From the Tobacco Centers for Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee.

INTRODUCTION: Flavored electronic nicotine delivery systems (ENDS) and tobacco products are associated with the initiation and progression of tobacco use. With recent restrictions around flavored products, it is critical to measure both the product and the flavor being used. The Tobacco Centers of Regulatory Science (TCORS) Flavored Tobacco Products Measurement Subcommittee (FTPMS) was established to develop core measures to assess flavored tobacco and ENDS product usage, facilitate data harmonization, replicability, and comparisons across studies. AIMS AND METHODS: The FTPMS used a mixed-method approach to inform the development of recommended measures (first use, current use, reasons for use) to assess tobacco and ENDS product flavors. This included reviewing existing surveys, identifying priority areas, developing new measures, cognitive testing, and finalization of recommended measures. RESULTS: Recommended measures were selected from national surveys (e.g. PATH study) and survey items used in TCORS studies to evaluate first use, current use, and reasons for use of tobacco and ENDS products. Response options were expanded for questions about specific flavors and adapted to allow for assessments relevant to recent federal policies. Supplemental measures were developed for researchers conducting more in-depth research around flavored products. CONCLUSIONS: Using an expert consensus process supplemented with cognitive testing, the FTPMS developed recommendations for core and supplemental measures for flavored tobacco and ENDS products. Harmonizing data on these factors for flavored tobacco and ENDS products are critical for researchers and may provide actionable evidence to federal, state, and local regulators and policymakers, as well as support evaluations of policies restricting flavors in these products. IMPLICATIONS: The development of core measures to assess first use, current use, and reasons for use of flavored tobacco and ENDS products will facilitate data harmonization, replicability, and comparisons across studies conducted in different samples or across communities with varying levels of regulation for these products. Use of these standardized measures will allow for a greater understanding of the role of flavors and helps to build a more robust evidence base to inform regulatory decisions to reduce tobacco and ENDS use at the population level.

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.

Smartphone Apps for Smoking Cessation: Systematic Framework for App Review and Analysis.

BACKGROUND: Cigarette smoking is a leading cause of preventable death, and identifying novel treatment approaches to promote smoking cessation is critical for improving public health. With the rise of digital health and mobile apps, these tools offer potential opportunities to address smoking cessation, yet the functionality of these apps and whether they offer scientifically based support for smoking cessation are unknown. OBJECTIVE: The goal of this research was to use the American Psychiatric Association app evaluation model to evaluate the top-returned apps from Android and Apple app store platforms related to smoking cessation and investigate the common app features available for end users. METHODS: We conducted a search of both Android and iOS app stores in July 2021 for apps related to the keywords "smoking," "tobacco," "smoke," and "cigarette" to evaluate apps for smoking cessation. Apps were screened for relevance, and trained raters identified and analyzed features, including accessibility (ie, cost), privacy, clinical foundation, and features of the apps, using a systematic framework of 105 objective questions from the American Psychiatric Association app evaluation model. All app rating data were deposited in mindapps, a publicly accessible database that is continuously updated every 6 months given the dynamic nature of apps available in the marketplace. We characterized apps available in July 2021 and November 2022. RESULTS: We initially identified 389 apps, excluded 161 due to irrelevance and nonfunctioning, and rated 228, including 152 available for Android platforms and 120 available for iOS platforms. Some of the top-returned apps (71/228, 31%) in 2021 were no longer functioning in 2022. Our analysis of rated apps revealed limitations in accessibility and features. While most apps (179/228, 78%) were free to download, over half had costs associated with in-app purchases or full use. Less than 65% (149/228) had a privacy policy addressing the data collected in the app. In terms of intervention features, more than 56% (128/228) of apps allowed the user to set and check in on goals, and more than 46% (106/228) of them provided psychoeducation, although few apps provided evidence-based support for smoking cessation, such as peer support or skill training, including mindfulness and deep breathing, and even fewer provided evidence-based interventions, such as acceptance and commitment therapy or cognitive behavioral therapy. Only 12 apps in 2021 and 11 in 2022 had published studies supporting the feasibility or efficacy for smoking cessation. CONCLUSIONS: Numerous smoking cessation apps were identified, but analysis revealed limitations, including high rates of irrelevant and nonfunctioning apps, high rates of turnover, and few apps providing evidence-based support for smoking cessation. Thus, it may be challenging for consumers to identify relevant, evidence-based apps to support smoking cessation in the app store, and a comprehensive evaluation system of mental health apps is critically important.

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.

The Modified E-Cigarette Evaluation Questionnaire: Psychometric Evaluation of an Adapted Version of the Modified Cigarette Evaluation Questionnaire for Use With Adults Who Use Electronic Nicotine Delivery Systems.

INTRODUCTION: The subjective experience of positive and negative effects likely contributes to e-cigarette use, and the Modified Cigarette Evaluation Questionnaire (MCEQ) previously has been adapted to assess the reinforcing and aversive effects of vaping. However, the psychometric properties of the MCEQ for use with e-cigarettes have not been established. AIMS AND METHODS: We examined the psychometric properties of the Modified E-cigarette Evaluation Questionnaire (MECEQ) within a sample of 857 adults who recently used e-cigarettes in a smoking cessation attempt (52.4% male; 40.84 [12.25] years old; 62.8% non-Hispanic white; 22.4% daily e-cigarette users). Analyses included confirmatory factor analysis of the original structure, exploratory/confirmatory factor analyses to identify the alternate latent structure(s), internal consistency, measurement invariance, between-group differences, and test-criterion relationships with vaping-related outcomes. RESULTS: The original five-factor structure and a novel four-factor structure were supported. Each was scalar invariant across several participant subgroups (eg, current smoking status, daily vaping status). All multi-item subscales were internally consistent. Both versions detected several between-group differences. For example, current smokers reported stronger aversive effects than did exclusive e-cigarette users. Finally, adjusted relationships between both MECEQ versions and vaping-related outcomes provided evidence for concurrent validity. CONCLUSIONS: The five-factor and four-factor versions of the MECEQ evidenced good-to-excellent internal consistency, scalar measurement invariance, and concurrent relationships with vaping-related outcomes. While both versions could be used to assess subjective vaping effects in adults with histories of cigarette smoking and vaping, additional research is needed to evaluate the applicability of these factor structures to other samples (eg, e-cigarette users with no smoking history, youth). IMPLICATIONS: Although the MCEQ has been adapted in previously published studies to assess the subjective reinforcing and aversive effects of vaping, the psychometric foundation necessary for doing so had not been established. We showed that the MECEQ can be scored using the original five-factor MCEQ format or using a newly identified four-factor structure. Both versions evidenced construct validity, internal consistency, measurement invariance (permitting between-group comparisons), and concurrent validity with vaping-related outcomes. Results strengthen the interpretability of previously published work using the five-factor MCEQ structure and provide an alternative scoring approach for vaping-specific subjective effects.

Psychometric Evaluation of the Short-Form Vaping Consequences Questionnaire for Use With High School Adolescents Who Use and Do Not Use E-cigarettes.

INTRODUCTION: Assessing youth vaping expectancies using a psychometrically sound measure can improve understanding of e-cigarette susceptibility and use. AIMS AND METHODS: We evaluated the psychometric properties of the Short-Form Vaping Consequences Questionnaire (SF-VCQ), an expectancy measure previously validated with adults, within a sample of 1753 high school adolescents who completed an online, school-based survey in Fall 2020 (51.6% female; 15.56 [1.22] years old; 46.6% non-Hispanic white; 26.9% reported lifetime but no past-30-day vaping; 12.6% reported past-30-day vaping). Analyses included confirmatory factor analysis, internal consistency, measurement invariance, between-group differences, and test-criterion relationships. RESULTS: The four-factor structure was confirmed and was scalar invariant by lifetime and past-month vaping status, sex, and race. All subscales were internally reliable (mean α = 0.94). The subscales were sensitive to differences based on sex, race, vaping susceptibility among never users, and lifetime and past-month vaping status. For example, students who vaped in the past-month held weaker expectancies for negative consequences but stronger expectancies for positive reinforcement, negative reinforcement, and appetite/weight control compared to lifetime vapers. Unadjusted relationships within the subsamples of lifetime and past-month vapers provided evidence of convergent validity. Evidence for concurrent validity was observed for all samples after accounting for covariates. For example, expectancies for positive reinforcement, negative reinforcement, and appetite/weight control remained significantly associated with past-month vaping frequency. CONCLUSIONS: The SF-VCQ evidenced excellent internal reliability, scalar measurement invariance, and construct, convergent, and concurrent validity in samples of never, lifetime, and past-month adolescent e-cigarette users. Findings support using the SF-VCQ for assessing youths' vaping-related expectancies. IMPLICATIONS: The current study established the psychometric properties of the SF-VCQ for use among adolescents with and without vaping experience, including measurement invariance that permits direct comparisons of expectancies across these two groups. When considered in concert with previously published research in adults, the SF-VCQ provides researchers with a measure that can be used with both youth and adult samples. Observed relationships between positive expectancies and vaping susceptibility in vaping naïve youth and indices of vaping frequency in youth with vaping experience suggest that challenging positive expectancies may be a valuable addition to prevention and intervention efforts to reduce youth vaping.

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.

Differences in JUUL Appeal Among Past and Current Youth JUUL Users.

INTRODUCTION: JUUL, a closed system e-cigarette with disposable pods, is popular among youth, with positive attributes of this product linked to current use by youth. However, many youth try JUUL and do not continue using; understanding differences in the appeal of this device between current users and those who chose not to continue use can inform regulation and prevention efforts. The aim of the current study is to compare JUUL appeal in youth among past users (ie, used, but not in past month) and current users (ie, used in past month). METHODS: A cross-sectional survey was conducted in four Connecticut high schools in Spring 2018. This survey assessed JUUL use and reasons for liking/disliking JUUL, including its' pharmacological effects (eg, nicotine "buzz"), product characteristics (eg, flavors), peer influence, appeal compared to other e-cigarettes, and concealability. Logistic regressions were conducted to examine differences in liking/disliking JUUL by use status (past vs. current). RESULTS: Among JUUL users (N = 1374; 43% of total sample), 30.4% were past users and 69.6% were current users. Compared to current users, past users were less likely to like JUUL for positive pharmacological effects (eg, nicotine "buzz"), product characteristics (eg, flavors), and peer use and more likely to dislike JUUL for the adverse pharmacological effects (eg, headache), product characteristics (eg, flavors), and for "other" reasons (open-ended response; eg, perceived harm). CONCLUSIONS: Findings suggest that altering JUUL appeal through regulating nicotine content and flavors may be key in policy aimed at shifting youth to become past JUUL users. IMPLICATIONS: This study investigates how current and past youth JUUL users differ in their report of the appeal of JUUL. Past users are less likely to report experiencing positive pharmacological effects and product characteristics of JUUL and are less likely to report appeal due to peer use. Understanding how appeal of JUUL may differ among past and current users can aid in our understanding of how to regulate these products so that they are less appealing to current youth users.

E-cigarette use perceptions that differentiate e-cigarette susceptibility and use among high school students.

BACKGROUND: E-cigarette use among adolescents is increasingly popular and a growing public health concern. OBJECTIVES: To examine how individual e-cigarette use perceptions differ between adolescents based on e-cigarette use status and susceptibility to future use of e-cigarettes. METHODS: Data were collected using surveys administered across eight Connecticut high schools (grades 9-12), Spring 2015. N = 2592 students (Mage = 16.01, SD = 1.28, Female = 51.7%) reported e-cigarette use and susceptibility and were categorized into non-susceptible never-users (57.8%), susceptible never-users (16.9%) and ever-users (25.4%). Youth also responded to 12 e-cigarette use perceptions describing perceived benefits and risks of e-cigarette use. RESULTS: A multinomial logistic regression model was used. Eight use perceptions were related to susceptibility or use of e-cigarettes. The benefit-related use perception "feel relaxed" was the only item associated with greater odds of being both susceptible (vs. non-susceptible, p <.001) and an ever-user (vs. susceptible; p <.05). Two other benefit-related use perceptions were related to higher odds of being susceptible to e-cigarette use ("control your weight"; AOR = 1.82, p <.05; "look cool"; AOR = 3.13, p <.05). Results also identified key risk-related use perceptions that related to lower odds of either being susceptible to e-cigarette use ("have a heart attack"; AOR =.43, p <.001) or of ever-use ("have bad breath"; AOR =.28, p <.001; "get lung cancer"; AOR =.58, p <.05). CONCLUSION: E-cigarette use perceptions among youth differ by e-cigarette use and susceptibility status. Findings could help identify youth who are vulnerable to e-cigarette use and inform prevention, for example by developing counter-messaging for benefit perceptions associated with susceptibility and ever-use.

Using Latent Class Analysis to Examine Susceptibility to Various Tobacco Products Among Adolescents.

INTRODUCTION: Most tobacco use is initiated during adolescence and susceptibility is an important predictor of initiation. Research is needed to understand susceptibility across tobacco products among youth to inform prevention efforts. AIMS AND METHODS: We surveyed 2945 students from four Southeastern Connecticut high schools in 2017. We assessed susceptibility to future use of seven different tobacco products (ie, cigarettes, e-cigarettes, hookah, cigars, cigarillos, blunts, and smokeless tobacco) among youth who had never used a tobacco product. Susceptibility was coded as any response other than "definitely not" to three items assessing (1) curiosity, (2) willingness to experiment with the product in the future, and (3) willingness to try if offered by a friend. Latent class analysis was used to identify patterns of susceptibility across multiple tobacco products and sociodemographic predictors of these classes. RESULTS: Among n = 1246 youth who had never tried a tobacco product, 51.2% (n = 638) were susceptible to at least one product and 29.1% (n = 363) were susceptible to two or more products (average among susceptible youth: M = 2.4 products, SD = 1.7, range 1-7). Latent class analysis identified three classes: youth who were: (1) susceptible to all products (5.6%), (2) susceptible to e-cigarettes, hookah, and blunts (23.6%), and (3) mostly non-susceptible to all products (70.8%). In a multivariable model, demographic variables and peer tobacco use predicted class membership. CONCLUSIONS: We observed high rates of susceptibility to non-traditional tobacco products among youth, and many youth were susceptible to more than one product. Targeting susceptibility across multiple tobacco products may be important for reducing youth tobacco use. IMPLICATIONS: Patterns of polytobacco use susceptibility were identified among youth who had never previously used tobacco products. Many youth were susceptible to more than one product and we observed three distinct classes of susceptibility among youth: those who were mostly non-susceptible, those who were susceptible to alternative or non-traditional tobacco products (e-cigarettes, hookah, and blunts), and those who were susceptible to all tobacco products. These findings suggest the importance of addressing susceptibility across multiple tobacco products.

Querying About the Use of Specific E-Cigarette Devices May Enhance Accurate Measurement of E-Cigarette Prevalence Rates Among High School Students.

INTRODUCTION: Prevalence estimates of electronic cigarette (e-cigarette) use may underestimate actual use in youth. Confusion resulting from the fact that a multitude of devices (eg, vape pens, JUULs) fall under the umbrella term "e-cigarettes," the use of different names to refer to e-cigarettes (eg, vapes, electronic vaping devices), and the use of different terminology to refer to e-cigarette use (eg, "vaping," "JUULing"), may lead some young e-cigarette users to incorrectly indicate nonuse. Therefore, we compared rates of endorsing lifetime e-cigarette use when adolescents were asked about lifetime e-cigarette use in two different ways. METHODS: In May to June 2018, a total of 1960 students from two high schools in Connecticut completed a computerized, school-based survey. Participants first reported on lifetime "e-cigarette" use and, subsequently, on lifetime use of five different e-cigarette devices: disposables, cig-a-likes, or E-hookahs; vape pens or Egos; JUULs; pod systems other than JUULs such as PHIX or Suorin; and advanced personal vaporizers or mods. RESULTS: In total, 35.8% of students endorsed lifetime "e-cigarette" use, whereas 51.3% endorsed lifetime use of at least one e-cigarette device. The kappa statistic indicated only 66.6% agreement between the methods of assessing e-cigarette use. Overall, 31.5% of adolescents who endorsed lifetime device use did not endorse lifetime "e-cigarette" use, although rates of discordant responding varied across subgroups of interest (eg, sex, race). CONCLUSIONS: Assessing adolescents' use of specific e-cigarette devices likely yields more accurate results than assessing the use of "e-cigarettes." If these findings are replicated in a nationally representative sample, regulatory efforts requiring all e-cigarette devices to be clearly labeled as "e-cigarettes" may help to reduce confusion. IMPLICATIONS: Different prevalence estimates of lifetime e-cigarette use were obtained depending on the way that prevalence was assessed. Specifically, fewer adolescents (35.8%) endorsed lifetime e-cigarette use when they were asked "Have you ever tried an e-cigarette, even one or two puffs?" than when they were queried about lifetime use of five different e-cigarette devices (51.3%). Among those who endorsed lifetime use of at least one specific e-cigarette device, 31.5% did not endorse lifetime "e-cigarette" use. These findings suggest that when assessing adolescents' lifetime e-cigarette use, using of terms referring to specific devices likely produces more accurate prevalence estimates than using the term "e-cigarettes."

Evaluating the effect of switching to non-menthol cigarettes among current menthol smokers: an empirical study of a potential ban of characterising menthol flavour in cigarettes.

INTRODUCTION: Menthol cigarette use remains a serious public health problem, prompting the consideration of tobacco regulatory efforts to ban menthol cigarettes. The current study uses a novel empirical design to model the potential effects of a ban of menthol cigarettes on smoking behaviour among current menthol smokers. METHODS: 29 non-treatment-seeking adults who smoked menthol cigarettes were recruited in Connecticut in 2017-2018 (n=15 female; n=17 Black, n=10 White, n=5 Hispanic). Repeated-measures analyses examined within-person changes in smoking behaviour when participants were switched from smoking their usual brand menthol cigarettes to a matched-brand non-menthol cigarette for 2 weeks to model a potential ban of menthol cigarettes. RESULTS: Participants smoked significantly fewer non-menthol (vs menthol) cigarettes per day (mean decrease=2.2 cigarettes, SD=3.2, p<0.001), confirmed by significant reductions in urine cotinine levels (p=0.013). After switching to non-menthol cigarettes, participants had significantly lower nicotine dependence scores (reduced by >18%, p<0.001) and greater increases in quitting motivation and confidence (rated 1-10) (motivation: mean increase=2.1, SD=2.8, p<0.001; confidence: mean increase=1.3, SD=3.3, p=0.04). Exploratory analyses indicated significant interactions by race (p=0.004); Black smokers had greater reductions in cigarettes per day (mean decrease=3.5 cigarettes, SD=2.8) versus non-Black smokers (mean decrease=0.2, SD=2.6). CONCLUSIONS: Banning menthol as a characterising flavour in cigarettes may decrease smoking and reduce the addictive potential of cigarettes among current smokers. Results provide additional support for tobacco regulatory policies banning menthol flavour in an effort to improve public health. TRIAL REGISTRATION: NCT03075839.

Longitudinal Findings from a Randomized Clinical Trial of Varenicline for Alcohol Use Disorder with Comorbid Cigarette Smoking.

BACKGROUND: This study is the first to examine longitudinal posttreatment outcomes of a placebo-controlled trial of varenicline for alcohol use disorder (AUD) with comorbid cigarette smoking. METHODS: Participants were 131 adults (n = 39 female) seeking alcohol treatment in a randomized, double-blind, parallel group, placebo-controlled, 16-week multisite trial of varenicline combined with medical management (MM). Timeline follow-back assessments of alcohol and smoking behavior were conducted at the end of treatment (4 months), with follow-ups at 6, 9, and 12 months. Outcomes were percentage of heavy drinking days (PHDD), percent of participants with no heavy drinking days (NHDD), cotinine-confirmed prolonged smoking abstinence (PA), and good clinical outcome on either NHDD or PA. RESULTS: Treatment improvements were maintained posttreatment. For the sample overall, PHDD or NHDD did not differ significantly by treatment condition (ps > 0.13), but varenicline produced higher rates of PA versus placebo at 4, 9, and 12 months (p < 0.05). Significant differences were observed by sex: Males had higher rates of NHDD with varenicline (28.9%) versus placebo (6.4%) at the end of treatment (p = 0.004), and these effects were maintained at 12 months (varenicline: 40.0% vs. placebo: 19.2%, p = 0.03). Higher rates of PA were seen for varenicline in both males (8.9%) and females (21.1%) versus placebo (males/females: 0%) at the end of treatment (p = 0.05), and this effect was maintained at 12 months for females (varenicline: 21.1% vs. placebo, 0.0%, p = 0.05). CONCLUSIONS: Varenicline treatment combined with MM appears to have enduring benefits for patients with co-occurring AUD and cigarette smoking, and these effects may differ by sex.