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.

Association Between Maternal Depression and Lower Urinary Tract Symptoms in Their Primary School-Age Daughters: A Birth Cohort Study.

PURPOSE: Although maternal depression is associated with adverse outcomes in women and children, its relationship with lower urinary tract symptoms (LUTS) in offspring is less well-characterized. We examined the association between prenatal and postpartum maternal depression and LUTS in primary school-age daughters. DESIGN: Observational cohort study. SUBJECTS AND SETTING: The sample comprised 7148 mother-daughter dyads from the Avon Longitudinal Study of Parents and Children. METHOD: Mothers completed questionnaires about depressive symptoms at 18 and 32 weeks' gestation and 21 months postpartum and their children's LUTS (urinary urgency, nocturia, and daytime and nighttime wetting) at 6, 7, and 9 years of age. Multivariable logistic regression models were used to estimate the association between maternal depression and LUTS in daughters. RESULTS: Compared to daughters of mothers without depression, those born to mothers with prenatal and postpartum depression had higher odds of LUTS, including urinary urgency (adjusted odds ratio [aOR] range = 1.99-2.50) and nocturia (aOR range = 1.67-1.97) at 6, 7, and 9 years of age. Additionally, daughters born to mothers with prenatal and postpartum depression had higher odds of daytime wetting (aOR range = 1.81-1.99) and nighttime wetting (aOR range = 1.63-1.95) at 6 and 7 years of age. Less consistent associations were observed for depression limited to the prenatal or postpartum periods only. CONCLUSIONS: Exposure to maternal depression in the prenatal and postpartum periods was associated with an increased likelihood of LUTS in daughters. This association may be an important opportunity for childhood LUTS prevention. Prevention strategies should reflect an understanding of potential biological and environmental mechanisms through which maternal depression may influence childhood LUTS.

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.

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.

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.

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.

Social Processes Informing Toileting Behavior Among Adolescent and Adult Women: Social Cognitive Theory as an Interpretative Lens.

Little is known about social processes shaping adolescent and adult women's toileting behaviors. The "Study of Habits, Attitudes, Realities, and Experiences" (SHARE) examines adolescent and adult women's experiences related to bladder health across the life course. Forty-four focus groups with 360 participants organized by six age groups were conducted across seven sites. A transdisciplinary team used social cognitive theory as an interpretive lens across a five-stage analysis. The act of observing was identified as the overarching social process informing women's toileting behaviors in three ways: (a) observing others' toileting behavior, (b) being aware that one's own toileting behaviors are monitored by others, and (c) observing oneself relative to others. We found that underlying processes of toileting behaviors, seemingly private are, in fact, highly social. We suggest, given this social embeddedness that health promotion efforts should leverage interpersonal networks for "social norming" interventions and policies to promote healthy toileting behaviors.

Novel (Multilevel) Focus Group Training for a Transdisciplinary Research Consortium.

Health researchers are increasingly turning to qualitative research for a nuanced understanding of complex health phenomena. The quality and rigor of qualitative research relies on individual data collector skills, yet few guidelines exist for training multidisciplinary, multi-institution qualitative research teams. Specific guidance is needed on qualitative research practices that ensure scientific rigor by optimizing diverse experience and expertise across research centers. We describe our systematic approach to training a cohort of 15 focus group moderators from seven universities in the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium's Study of Habits, Attitudes, Realities, and Experiences (SHARE). SHARE's aim was to explore women and girls' experiences, perceptions, beliefs, knowledge, and behaviors related to bladder health and function across the life course. Drawing on adult education and action-learning best practices, a three-phase curriculum was designed to maximize moderator proficiency and qualitative research expertise. The phases involved online, interactive web-based education, in-person didactic training with experiential components, and tailored supplemental online training. Evaluative feedback was collected before, during, and after the training. Feedback was used to identify emergent training needs. This training approach may be used by transdisciplinary research teams conducting multisite research to assure qualitative research credibility and trustworthiness.

I never knew anyone who peed on themselves on purpose: Exploring adolescent and adult women's lay language and discourse about bladder health and function.

AIMS: This analysis explored and characterized adolescent and adult women's lay language and discourse related to bladder health/function. METHODS: Forty-four focus groups were conducted across seven United States research centers with 360 adolescents and adult women, organized by six age categories. Multilevel content analyses classified emergent themes. A transdisciplinary lens and inductive approach guided data interpretation. Interpretive insights were validated by a community engagement panel. RESULTS: A repertoire of bladder function terms emerged, including explicit functional terms, formal and polite euphemistic terms, and informal familiar terms, as well as cultural and regional metaphors and idioms. Terminology usage was historically grounded, developmental, and cumulative across the life course. Lay discourse was contextual and affectively valent, suggesting unspoken, commonly understood, situation-based "rules" for talking about bladder function. Discourse appeared to be siloed within family and friendship circles. Adolescents and adult women often described, rather than named, bladder sensations or problems. Terminology for bladder issues tended to minimize severity and frequency, with medical language only relevant to extreme examples and not applicable to mild episodes. CONCLUSIONS: A definitional discordance between medical and lay views of bladder problems was identified, signifying a need to clarify the meaning of medical terms for lay persons. Adolescents and adult women do not have or use standardized precise terminology for bladder health and function, relying instead on social convention and interpersonal context. Findings can be used to foster shared understandings between lay persons and health professionals, informing development of clinical, research, and public health initiatives to promote bladder health.

Applying concepts of life course theory and life course epidemiology to the study of bladder health and lower urinary tract symptoms among girls and women.

AIMS: Although lower urinary tract symptoms (LUTS) may occur at different periods during the life course of women, a little research on LUTS has adopted a life course perspective. The purpose of this conceptual paper is to demonstrate how life course theory and life course epidemiology can be applied to study bladder health and LUTS trajectories. We highlight conceptual work from the Prevention of Lower Urinary Tract Symptoms Research Consortium to enhance the understanding of life course concepts. METHODS: Consortium members worked in transdisciplinary teams to generate examples of how life course concepts may be applied to research on bladder health and LUTS in eight prioritized areas: (a) biopsychosocial ecology of stress and brain health; (b) toileting environment, access, habits, and techniques; (c) pregnancy and childbirth; (d) physical health and medical conditions; (e) musculoskeletal health; (f) lifestyle behaviors; (g) infections and microbiome; and (h) hormonal status across the life span. RESULTS: Life course concepts guided consortium members' conceptualization of how potential risk and protective factors may influence women's health. For example, intrapartum interventions across multiple pregnancies may influence trajectories of bladder health and LUTS, illustrating the principle of life span development. Consortium members also identified and summarized methodologic and practical considerations in designing life course research. CONCLUSIONS: This paper may assist researchers from a variety of disciplines to design and implement research identifying key risk and protective factors for LUTS and bladder health across the life course of women. Results from life course research may inform health promotion programs, policies, and practices.

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."

Youth generated prevention messages about electronic cigarettes.

Rates of e-cigarette use are high among youth, and there is little known about the long-term health effects of e-cigarettes. Since peer influence is a powerful determinant of tobacco use, we aimed to identify message themes about e-cigarettes that youth would use to encourage or discourage peers from using e-cigarettes. We conducted 10 focus groups (N = 69) with non-smokers and smokers from one middle school, high school and college in Connecticut. Participants engaged in a discussion about e-cigarettes, and each participant created one written message to encourage e-cigarette use and one to discourage use among peers. We content-analyzed the messages and identified three main themes and 12 encouraging and discouraging sub-themes. Encouraging themes included health benefits of e-cigarettes relative to cigarettes, attractive product characteristics (e.g. flavors) and social advantages (e.g. positive social image) of using e-cigarettes. Discouraging messages included health risks of e-cigarettes relative to cigarettes, unattractive product characteristics (e.g. cost) and social disadvantages (e.g. negative social image of using an e-cigarette). Overall, there were no differences by sex, age group or smoking status in generation of encouraging and discouraging message themes. This study identified youth-generated themes that may aid in e-cigarette prevention among youth.

Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health.

AIM: The study purpose is to explore adolescent and adult women's experiences, perceptions, beliefs, knowledge and behaviors related to bladder health across the life course using a socioecological perspective. Lower urinary tract symptoms affect between 20-40% of young adult to middle-aged women, with symptoms increasing in incidence and severity with aging. There is limited evidence to address bladder health promotion and prevention of dysfunction. This first study of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is designed to address gaps in existing qualitative research in this area. DESIGN: This focus group study will be implemented across seven geographically diverse United States research centers using a semi-structured focus group guide informed by a conceptual framework based on the socioecological model. METHODS: The study was approved in July 2017. A total of 44 focus groups composed of 6-8 participants representing six different age categories (ranging from 11 to over 65 years) will be completed. We aim to recruit participants with diverse demographic and personal characteristics including race, ethnicity, education, socioeconomic status, urban/rural residence, physical/health conditions and urinary symptom experience. Up to 10 of these focus groups will be conducted in Spanish. Focus group transcripts will undergo content analysis and data interpretation to identify and classify themes and articulate emerging themes. DISCUSSION: This foundational qualitative study seeks to develop an evidence base to inform future research on bladder health promotion in adolescent and adult women. IMPACT: This study has the potential to provide new insights and understanding into adolescent and adult women's lived experience of bladder health, the experience of lower urinary symptoms and knowledge and beliefs across the life course. This article is protected by copyright. All rights reserved.

Socioeconomic status and adolescent e-cigarette use: The mediating role of e-cigarette advertisement exposure.

Among adolescents, low socioeconomic status (SES) is associated with greater exposure to tobacco cigarette advertising and cigarette use. However, associations among SES, e-cigarette advertising and e-cigarette use are not well understood. This study examined exposure to e-cigarette advertisements as a mediator of the relationship between SES and adolescent e-cigarette use. Adolescents (N = 3473; 51% Female) from 8 high schools in Connecticut completed an anonymous survey in Spring 2015. Mediation analysis was used to examine whether the total number of sources of recent e-cigarette advertising exposure (e.g., TV, radio, billboards, magazines, local stores [gas stations, convenience stores], vape shops, mall kiosks, tobacco shops, social media) mediated the association between SES (measured by the Family Affluence Scale) and past-month frequency of e-cigarette use. We clustered for school and controlled for other tobacco product use, age, sex, race/ethnicity and perceived social norms for e-cigarette use in the model. Our sample recently had seen advertisements via 2.1 (SD = 2.8) advertising channels. Mediation was supported (indirect effect: ß = 0.01, SE = 0.00, 95% CI [0.001, 0.010], p = 0.02), such that higher SES was associated with greater recent advertising exposure, which, in turn, was associated with greater frequency of e-cigarette use. Our study suggests that regulations to reduce youth exposure to e-cigarette advertisement may be especially relevant to higher SES youth. Future research should examine these associations longitudinally and evaluate which types of advertisements target different SES groups.

Current and Former Smokers' Use of Electronic Cigarettes for Quitting Smoking: An Exploratory Study of Adolescents and Young Adults.

BACKGROUND: This exploratory study examines the prevalence and predictors of current and former smokers' use of electronic (e-) cigarettes for smoking cessation among a sample of adolescent and young adult established smokers. METHODS: We conducted school-wide surveys in two middle (n = 1166) and four high schools (n = 3614) in fall 2013 and one public college (n = 625) in spring 2014. We analyzed data from 189 established smokers (reported smoking 100 cigarettes in their lifetime) who also reported ever-use of e-cigarettes (50.7% female, 89.4% White race, Mage 18.3 [SD = 2.8]). We further classified participants as current smokers (reported past-month cigarette smoking) and former smokers (no past-month smoking). Adjusted logistic regression assessed associations of using e-cigarettes to quit smoking with demographic, cigarette and e-cigarette use patterns, e-cigarette flavor preference, and risk perception variables. RESULTS: Overall, 41.8% of the sample reported that they "have used an e-cigarette to quit smoking." In adjusted models, older age, White race, higher e-cigarette frequency, and preference for using a combination of e-cigarette flavors predicted increased odds of having used e-cigarettes to quit smoking (p < .05). Using e-cigarettes to quit smoking was not associated with current or former cigarette smoking status or perceptions that "e-cigarettes help people quit smoking" or "e-cigarettes are safer than quit smoking medications." CONCLUSIONS: Adolescents and young adults who report more frequent e-cigarette use and preference for using flavor combinations are more likely to use e-cigarettes for smoking cessation. Future studies are needed to determine whether e-cigarette use leads to tobacco abstinence in youth smokers. IMPLICATIONS: Among young established smokers, more frequent e-cigarette use and preference for using flavors mixed together, but not perceptions of harmfulness of e-cigarettes or comparative safety of e-cigarettes compared with cigarettes or other smoking cessation medications or helpfulness of e-cigarettes in quitting smoking, are associated with using e-cigarettes for smoking cessation.

E-Cigarette Susceptibility as a Predictor of Youth Initiation of E-Cigarettes.

INTRODUCTION: Identifying youth at risk for future e-cigarette use is critical for informing prevention efforts. Prior research established measures of susceptibility to conventional cigarettes, and this study aimed to examine whether items adapted for e-cigarette susceptibility predicted subsequent e-cigarette use among never e-cigarette users. METHODS: Longitudinal school-wide survey data were collected from middle and high school students in Fall 2013 (wave 1) and Spring 2014 (wave 2). Among never e-cigarette users at wave 1 (n = 1720), e-cigarette susceptibility was measured by two items assessing anticipation of experimenting with e-cigarettes in the future and willingness to use an e-cigarette if offered by a best friend. Logistic regression models examined susceptibility as a predictor of e-cigarette initiation and past 30-day use 6 months later at wave 2. Models were clustered by school and controlled for sex, age, race, SES, and other substance use (alcohol, marijuana, and other tobacco). RESULTS: In total, 8.9% (n = 153) of youth initiated e-cigarettes and 3.7% (n = 63) reported past 30-day use at wave 2. E-cigarette susceptibility was a significant independent predictor of subsequent initiation (OR = 4.27, 95% CI = 3.12-5.85) and past 30-day e-cigarette use (OR = 5.10, 95%CI = 3.38-7.68) 6 months later. Susceptible youth were more likely to be male, older, and have used alcohol, marijuana, or other tobacco products. CONCLUSIONS: These findings provide initial support for adapting two susceptibility items to identify adolescents at risk for future e-cigarette use. Identifying strategies that are effective for targeting susceptible youth and preventing future e-cigarette use will be critical areas for future research. IMPLICATIONS: More than a quarter of the sample who reported both a willingness to try e-cigarettes if offered by a best friend and anticipation of experimenting with e-cigarettes in the future went on to try e-cigarettes within the academic year, suggesting that targeting this group will be critical for preventing youth e-cigarette initiation. There were notable demographic differences between susceptible and non-susceptible youth, suggesting targeting e-cigarette prevention efforts to male students who have used other substances may be especially important for preventing future e-cigarette use. Research is needed to determine the most effective prevention strategies to reach susceptible youth.

E-cigarette Use Among High School and Middle School Adolescents in Connecticut.

INTRODUCTION: There is limited evidence on electronic cigarette (e-cigarette) use among U.S. adolescents. METHODS: Cross-sectional, anonymous surveys conducted in 4 high schools (HS; n = 3,614) and 2 middle schools (MS; n = 1,166) in Connecticut in November 2013 examined e-cigarette awareness, use patterns, susceptibility to future use, preferences, product components used (battery type, nicotine content, flavors), and sources of marketing and access. RESULTS: High rates of awareness (MS: 84.3%; HS: 92.0%) and of lifetime (3.5% MS, 25.2 % HS) and current (1.5% MS, 12% HS) use of e-cigarettes was observed. Among those who had not tried e-cigarettes, 26.4% of MS and 31.7% of HS students reported being susceptible to future use. Males (OR = 1.70, p < .01), older students (OR = 1.39, p < .05), Caucasians (OR = 2.01, p < .001), ever cigarette smokers (OR = 13.04, p < .001), and current cigarette smokers (OR = 65.11, p < .001) were more likely to be lifetime e-cigarette users and to report greater future susceptibility (males: OR = 1.30; Caucasians: OR = 1.14; ever cigarette smokers; OR = 3.85; current cigarette smokers; OR = 9.81; ps < .01-.001). Among MS students who were lifetime e-cigarette users, 51.2% reported that e-cigarette was the first tobacco product they had tried. E-cigarettes that were rechargeable and had sweet flavors were most popular. Smokers preferred e-cigarettes to cigarettes. Current cigarette smokers were more likely to initiate with nicotine-containing e-cigarettes, and ever and never cigarette smokers to initiate with e-cigarettes without nicotine. Primary sources for e-cigarette advertisements were televisions and gas stations and, for acquiring e-cigarettes, were peers. CONCLUSIONS: Longitudinal monitoring of e-cigarette use among adolescents and establishment of policies to limit access are imperatively needed.

Reasons for Electronic Cigarette Experimentation and Discontinuation Among Adolescents and Young Adults.

INTRODUCTION: Understanding why young people try and stop electronic cigarette (e-cigarette) use is critical to inform e-cigarette regulatory efforts. METHODS: We conducted 18 focus groups (N = 127) in 1 middle school (MS), 2 high schools (HSs), and 2 colleges in Connecticut to assess themes related to e-cigarette experimentation and discontinuation. We then conducted surveys to evaluate these identified themes in 2 MSs, 4 HSs, and 1 college (N = 1,175) to explore whether reasons for e-cigarette experimentation and/or discontinuation differed by school level or cigarette smoking status. RESULTS: From the focus groups, we identified experimentation themes (i.e., curiosity, flavors, family/peer influence, easy access, and perceptions of e-cigarettes as "cool" and as a healthier/better alternative to cigarettes) and discontinuation themes (i.e., health concerns, loss of interest, high cost, bad taste, and view of e-cigarettes as less satisfying than cigarettes). The survey data showed that the top reasons for experimentation were curiosity (54.4%), appealing flavors (43.8%), and peer influences (31.6%), and the top reasons for discontinuation were responses related to losing interest (23.6%), perceiving e-cigarettes as "uncool" (16.3%), and health concerns (12.1%). Cigarette smokers tried e-cigarettes because of the perceptions that they can be used anywhere and to quit smoking and discontinued because they were not as satisfying as cigarettes. School level differences were detected. CONCLUSIONS: E-cigarette prevention efforts toward youth should include limiting e-cigarette flavors, communicating messages emphasizing the health risks of use, and changing social norms surrounding the use of e-cigarettes. The results should be interpreted in light of the limitations of this study.