Exploring the opinions and potential impact of unflavoured e-liquid on smoking cessation among people who smoke and smoking relapse among people who previously smoked and now use e-cigarettes: findings from a UK-based mixed methods study.

BACKGROUND: Although electronic cigarettes (e-cigarettes) appear to be effective in helping people who smoke to stop smoking, concerns about use of e-cigarettes among young people have led to restrictions on non-tobacco flavoured e-liquids in some countries and some US states. These restrictions could reduce the appeal of these products to non-smoking youth but could have negative consequences for people who smoke or use e-cigarettes. METHODS: In this mixed methods study, we recruited UK adults who smoked or used to smoke and subsequently vaped to explore their opinions of unflavoured e-liquids and their beliefs about how they would be impacted by hypothetical e-liquid flavour restrictions. Participants trialled an unflavoured e-liquid instead of their usual nicotine product for four hours and completed a survey and an online interview. RESULTS: Using Interpretive Phenomenological Analysis and graphically presented data, we found differences in participants' opinions of unflavoured e-liquid. If only unflavoured, tobacco flavoured, and menthol flavoured e-liquids remained on the UK market, some people who smoke or vape may be unaffected, but some may relapse to smoking or continue smoking. Despite most wanting to prevent young people from initiating vaping, participants had varying opinions on whether flavour restrictions would be an effective method. CONCLUSIONS: The findings highlight that people who smoke and vape could be impacted by flavour restrictions in a range of ways, some of which could have a potential adverse impact on harm reduction efforts in the UK (e.g., by making smoking more appealing than vaping).

Perspectives on Electronic Nicotine Delivery System Use Cessation Among Adults in Rural Areas: Implications for Future Studies.

INTRODUCTION: More young adults (age 18-24 years) in rural areas versus urban areas use electronic nicotine delivery systems (ENDS) - also known as e-cigarettes. Little is known about young adults' perceptions toward ENDS use and cessation. The objective of this study was to examine barriers and facilitators to ENDS use cessation among young adults living in rural areas, as well as their perceptions about ENDS use and cessation and to determine implications for future cessation studies. METHODS: We administered cross-sectional online surveys to young adults living in rural Midwestern counties. A total of 100 individuals responded to the surveys. Descriptive statistics were used to report their perceptions of ENDS use as well as barriers and facilitators to ENDS use cessation. The content analysis method was used to analyze the answers to an open-ended question regarding perceptions about the ENDS use cessation in the context of rural areas. RESULTS: Barriers to ENDS use cessation included perceived advantages to ENDS use, high nicotine dependence, and the perception that ENDS use was less harmful cigarettes. Facilitators to ENDS use cessation included cost of ENDS use, perceived harm, and high confidence in ability to quit. Participants' perceptions about ENDS use cessation in the context of rural areas were conceptualized under the themes of (1) exposure to and initiation of ENDS use, (2) continuation of ENDS use, and (3) prevention and cessation of ENDS use. CONCLUSIONS: Health care providers, tobacco control researchers, and public health advocates should be aware of barriers and facilitators to ENDS use cessation among young adults for future cessation intervention studies relevant specifically to rural areas.

Forecasting vaping health risks through neural network model prediction of flavour pyrolysis reactions.

Vaping involves the heating of chemical solutions (e-liquids) to high temperatures prior to lung inhalation. A risk exists that these chemicals undergo thermal decomposition to new chemical entities, the composition and health implications of which are largely unknown. To address this concern, a graph-convolutional neural network (NN) model was used to predict pyrolysis reactivity of 180 e-liquid chemical flavours. The output of this supervised machine learning approach was a dataset of probability ranked pyrolysis transformations and their associated 7307 products. To refine this dataset, the molecular weight of each NN predicted product was automatically correlated with experimental mass spectrometry (MS) fragmentation data for each flavour chemical. This blending of deep learning methods with experimental MS data identified 1169 molecular weight matches that prioritized these compounds for further analysis. The average number of discrete matches per flavour between NN predictions and MS fragmentation was 6.4 with 92.8% of flavours having at least one match. Globally harmonized system classifications for NN/MS matches were extracted from PubChem, revealing that 127 acute toxic, 153 health hazard and 225 irritant classifications were predicted. This approach may reveal the longer-term health risks of vaping in advance of clinical diseases emerging in the general population.

Current Pharmacotherapies for Smoking Cessation and Promising Emerging Drugs.

OBJECTIVE: Pharmacotherapy is commonly used during quit attempts and has shown an increase in the likelihood of achieving abstinence. However, with established pharmacotherapies, abstinence rates following a quit attempt remain low, and relapse is common. This review aims to investigate the efficacy and harm profiles of current and emerging pharmacotherapies. METHODS: Literature review of current and emerging pharmacotherapies for smoking cessation and tobacco use disorder. RESULTS: Emerging pharmacotherapies include new formulations of existing therapies, drug repurposing and some new treatments. New treatments are welcome and may incorporate different mechanisms of action or different safety and tolerability profiles compared to existing treatments. However, emerging pharmacotherapies have yet to demonstrate greater efficacy compared to existing treatments. The emergence of Electronic Nicotine Delivery Systems (ENDS) or 'vaping' is a feature of the current debate around tobacco use disorder. ENDS appear to facilitate switching but not quitting and are controversial as a harm minimisation strategy. LIMITATIONS: Studies included a broad range of therapies and trial designs that should be compared with their differences taken into consideration. CONCLUSION: Strategies to successfully quit smoking vary between individuals and may extend beyond pharmacotherapy and involve complex psychosocial factors and pathways.

E-cigarette use among university students in Palestine: Prevalence, knowledge, and determinant factors.

BACKGROUND: Recent reports indicated accelerated rates of e-cigarette use, especially among youth in various Middle Eastern countries, including Palestine. Nevertheless, little is known about knowledge, attitudes, and perceptions regarding this topic in Palestine. This study aimed to assess the prevalence of e-cigarette use among Palestinian university students, along with their knowledge, attitudes, and perceptions about e-cigarette use. METHODS: An observational cross-sectional study, utilizing an online self-administered questionnaire, was conducted on Palestinian students from five universities between 17/04/2023 and 04/11/2023. RESULTS: A total of 1002 Palestinian university students completed the questionnaire. The prevalence of e-cigarette use among students was 18.1%. The mean knowledge score about e-cigarettes was significantly lower among the users of e-cigarettes compared to non-users. E-cigarette use was significantly associated with the participants' smoking status. Among e-cigarette users, 43.6% were also current traditional cigarette users, and 66.9% were current waterpipe users. E-cigarette use was significantly associated with having a friend who is a smoker and/ or a smoking mother. Binary logistic regression revealed a significant positive effect between the participant's smoking status, the mother's smoking status, knowledge about e-cigarettes, and the use of e-cigarettes (p-value < 0.05). Among e-cigarette users, 18.8% used them in indoor places at the university, and 25% reported using them daily in the past month. Affordability of e-cigarettes was the most reported reason for their use (47.5%). CONCLUSION: This study concluded that e-cigarette use is prevalent and rapidly rising among university students in Palestine. This is worrisome as it is significantly associated with insufficient knowledge about the adverse health effects of E-cigarette use, and its addictive nature. These findings focus on the importance of improving the students' knowledge about e-cigarette use by implementing educational campaigns and considering age regulations on e-cigarette availability and use.

Sources of exposure to non-tobacco nicotine electronic nicotine delivery systems and associations with susceptibility to use and use behaviors among young adults in the United States.

INTRODUCTION: The Electronic Nicotine Delivery Systems (ENDS) industry recently introduced non-tobacco nicotine (NTN), which is not tobacco-derived and is often marketed as "tobacco-free nicotine." Given its novelty, it is important to understand where young adults learn about NTN ENDS. This study examined sources of exposure to NTN ENDS and relationships with NTN ENDS use and susceptibility. METHODS: We analyzed online survey data collected in Fall 2021 from 642 young adults (18-25 years) who had heard of NTN ENDS. We assessed 9 sources of NTN ENDS exposure (e.g., retail stores, social media) and examined associations between sources of exposure and NTN current (past-month) use, lifetime (non-current) use, and susceptibility to use, adjusting for demographics and other tobacco product use. RESULTS: Participants reported current NTN ENDS use (37.4%), lifetime use (12.0%), susceptibility (18.5%), or no susceptibility to use (32.1%). The most common sources of NTN ENDS exposure were retail stores (87.7%) and social media (81.0%). Exposure to NTN ENDS via social media was associated with greater odds of current NTN ENDS use (vs. no susceptibility) (aOR = 1.83, 95%CI: 1.02-3.28). Exposure via online streaming platforms was associated with greater odds of current (aOR = 1.75, 95%CI: 1.08-2.82) and lifetime NTN ENDS use (aOR = 2.42, 95%CI: 1.25-4.68). CONCLUSIONS: Young adults were exposed to and learned about NTN ENDS from diverse sources, primarily retail shops and social media. Further, exposure via social media and streaming platforms were associated with NTN ENDS use. Future studies should explore the content of NTN information from various sources to inform prevention efforts.

Associations between vaping and self-reported respiratory symptoms in young people in Canada, England and the US.

BACKGROUND: Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours. METHODS: Participants (n = 39,214) aged 16-19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s). RESULTS: Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85-1.10)], those who both smoked and vaped had higher odds [1.26 (1.12-1.42)], and those who had done neither, lower odds [0.67 (0.61-0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22-1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07-1.93)], multiple [1.76 (1.30-2.39)] and 'other' [2.14 (1.45-3.16)] flavours with higher odds. All device types were associated with similar odds. CONCLUSIONS: Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

A systematic review and meta-analysis of the association between e-cigarette use among non-tobacco users and initiating smoking of combustible cigarettes.

INTRODUCTION: The rapid increase in e-cigarette use over the past decade has triggered an important public health question on the potential association between e-cigarette use and combustible cigarette smoking. Following AMSTAR 2 and PRISMA guidelines, this evidence synthesis sought to identify and characterize any associations between e-cigarette use among individuals not smoking cigarettes and initiation of cigarette smoking. METHODS: The protocol was registered on September 24, 2018 (PROSPERO 2018 CRD42018108540). Three databases were queried from January 01, 2007 to April 26, 2023. Search results were screened using the PICOS review method. RESULTS: Among 55 included studies (40 "good" and 15 "fair"; evidence grade: "high") that adjusted for gender, age, and race/ethnicity between groups, generally, there was a significant association between non-regular e-cigarette use and initiation of cigarette smoking, further supported by the meta-analytic results (AOR 3.71; 95% CI 2.86-4.81). However, smoking initiation was most often measured as ever/current cigarette smoking. Two studies (quality: 2 "good") evaluated progression to regular cigarette smoking among individuals with regular use of e-cigarettes, and generally found no significant associations. One study ("good") evaluated smoking initiation among individuals with regular use of e-cigarettes, finding an increasing probability of ever smoking cigarettes with increased e-cigarette use. Twelve studies (10 "good" and two "fair") examining progression to regular smoking among individuals with non-regular use of e-cigarettes reported inconsistent findings. CONCLUSIONS: Numerous methodological flaws in the body of literature limit the generalizability of these results to all individuals who are not smoking cigarettes with few studies measuring established/regular use/smoking of e-cigarettes and cigarettes. Further, studies did not control adequately for specific confounding variables representing common liabilities between e-cigarette use and cigarette smoking, nor did they account for sufficient follow-up durations. Collectively, these flaws limit the generalizability of findings to the question of an association between e-cigarette use and cigarette smoking initiation.

Assisting young people aged 12-25 years to cease e-cigarette use in general practice.

BACKGROUND: Increasing numbers of young people (adolescents aged 12-17 years and young adults aged 18-25 years) are using e-cigarettes. Although the extent of the health effects is currently unknown, young people are at risk of developing nicotine dependence and, as a result, find it difficult to cease use of e-cigarettes. They might seek help from their general practitioner (GP) to do so. OBJECTIVE: This article summarises the available evidence for e-cigarette cessation in young people and suggests a rational approach to assist GPs seeing young people seeking help for e-cigarette cessation. DISCUSSION: There is limited evidence to support best treatment options for e-cigarette cessation in young people. An approach based on the experience from tobacco cessation in adults and adapted for young people might assist. Management that supports family and school engagement, with behavioural interventions, nicotine replacement therapy, other pharmacological interventions and ongoing review as appropriate for the young person's age and developmental milestones, might help successful e-cigarette cessation.

How healthcare providers and the right information may play a critical role in quitting success among smokers interested in using e-cigarettes for quitting: Results from a survey of U.S adults.

INTRODUCTION: Promoting smoking cessation is a global public health priority. E-cigarettes are increasingly being used by individuals to try quitting smoking. Identifying sources and types of information available to adults who are trying to quit, and the impact of this information during a quit attempt, is critical to augment the potential public health benefit of e-cigarettes for reducing cigarette smoking. METHODS: US adults (N = 857) who reported using e-cigarettes in a recent smoking cessation attempt completed an anonymous, cross sectional, online survey. We examined sources of information and type of information received when using e-cigarettes to quit smoking and their associations with the duration of abstinence achieved. RESULTS: The two most commonly reported information sources were friends (43.9%) and the internet (35.2%), while 14.0% received information from a healthcare provider. People received information on type of device (48.5%), flavor (46.3%), and nicotine concentration (43.6%). More people received information about gradually switching from smoking to vaping (46.7%) than abruptly switching (30.2%). Obtaining information from healthcare providers (ß (SE) = 0.16 (0.08), p = 0.04), getting information about abruptly switching to e-cigarettes (ß (SE) = 0.14 (0.06), p = 0.01) and what nicotine concentrations to use (ß (SE) = 0.18 (0.05), p = 0.03) were associated with longer quit durations. CONCLUSIONS: Amidst the growing popularity of e-cigarettes use for quitting smoking, our results highlight common sources of information and types of information received by individuals. Few people received information from healthcare providers indicating a gap in cessation support that can be filled. Providing information about immediate switching to e-cigarettes and nicotine concentrations to use may help in increasing quit rates and duration.

Feasibility of restricting e-cigarettes to prescription only for smoking cessation.

E-cigarette use among youth in Canada has risen to epidemic proportions. E-cigarettes are also moderately useful smoking cessations aids. Restricting e-cigarettes to prescription only smoking cessation aids could help limit youth's access to them while keeping them available as therapies for patients who smoke conventional cigarettes. In Canada, drugs or devices must be approved by regulatory bodies such as Health Canada in order to become licensed prescription medications. A similar situation is underway in Australia, where e-cigarettes have been restricted to prescription only. This commentary explores the feasibility of a similar regulation for e-cigarettes in Canada as prescription smoking cessation aids.

Puffing to Persistent Smoking Cessation.

Nicotine e-cigarettes are a safe and effective way to help patients stop smoking.

Association between health-related social media use and E-cigarette use among current cigarette users: the roles of anti-tobacco messages and harm perception.

BACKGROUND: The popularity of e-cigarettes is on the rise among current cigarette users. Therefore, there are concerns about their health implications. This study examined the impact of health-related social media use on e-cigarette use among current cigarette users. It assesses the mediating influence of online anti-tobacco messages and the moderating role of the harm perception of e-cigarettes. METHODS: This study was focused on 563 current cigarette users from the 2022 Health Information National Trends Survey (HINTS). Three tasks were performed: (1) assessing the direct and indirect impacts of health-related social media use on e-cigarette use among current cigarette users, (2) exploring the mediating role of exposure to online anti-tobacco messages, and (3) examining the moderating influence of e-cigarette harm perception on the path from anti-tobacco messages to e-cigarette use. RESULTS: Health-related social media use was positively associated with current cigarette users' e-cigarette use directly (bp = 0.183, p < .01) and indirectly through exposure to online anti-tobacco messages (bp = 0.023, 95% CI: [0.001, 0.051]). Harm perception of e-cigarettes moderated the relationship between online exposure to anti-tobacco messages and e-cigarette use (bp=-0.467, p < .01). The relationship appeared weaker for individuals who perceived greater harm from e-cigarettes. CONCLUSIONS: Health-related social media use positively correlates with e-cigarette use among current cigarette users through exposure to online anti-tobacco messages. The perceived harm of e-cigarettes moderates this indirect path. These findings have implications for public health interventions aimed at smoking cessation.

The case of young people who use e-cigarettes infrequently: Who is this population? What becomes of them?

BACKGROUND: Emerging data indicate that many adolescents and young adults ("youth") engage in infrequent, or occasional, e-cigarette use. However, little is known about this population as they are often subsumed into the broader "any past-30-day use" category used to define youth "current use." This study aimed to focus on infrequent e-cigarette use by youth, examining its correlates and transitional outcomes. METHODS: Participants were from a prospective cohort study of youth (aged 15-24 at baseline). Among youth who had used e-cigarettes, we classified "infrequent use" as using e-cigarettes ≤5 days in the last 30 days (n=273) and "frequent use" as using e-cigarettes ≥6 days in the last 30 days (n=278). Descriptive statistics, Markov modeling, and logistic regression were utilized. RESULTS: By the 12-month follow-up, 76.8% of those using infrequently at baseline remained in the "infrequent use" category, 6.3% reported no recent use, and 16.8% had escalated to the "frequent use" category. Among the youth using infrequently at baseline, those who did (vs. did not) escalate to frequent use by follow-up had higher baseline nicotine dependence and were more likely to have family members who used tobacco. CONCLUSIONS: Infrequent e-cigarette use is extremely common, and often fairly stable, among young people. Prevention efforts must certainly attempt to reduce escalation and attend to both individual and interpersonal factors (e.g., nicotine dependence, family use). Yet prevention efforts must additionally attend to the case of continued infrequent use, given the high prevalence of people in this category and their regular exposure to e-cigarette harms.

Comparison of bladder carcinogenesis biomarkers in the urine of traditional cigarette users and e-cigarette users.

Background: During the use of electronic cigarettes (e-cigarettes), users are still exposed to carcinogens similar to those found in tobacco products. Since these carcinogens are metabolized and excreted in urine, they may have carcinogenic effects on the bladder urinary tract epithelium. This meta-analysis aimed to compare bladder cancer carcinogens in the urine of tobacco users and e-cigarette users using a large number of samples. Methods: A systematic meta-analysis was performed using data obtained from several scientific databases (up to November 2023). This cumulative analysis was performed following the Preferred Reporting Items for Systematic Evaluation and Meta-Analysis (PRISMA) and Assessing the Methodological Quality of Systematic Evaluations (AMSTAR) guidelines, according to a protocol registered with PROSPERO. This study was registered on PROSPERO and obtained the unique number: CRD42023455600. Results: The analysis included 10 high-quality studies that considered polycyclic aromatic hydrocarbons (PAHs), volatile organic compounds (VOCs) and tobacco-specific nitrosamines (TSNAs). Statistical indicators show that there is a difference between the tobacco user group and the e-cigarette user group in terms of 1-Hydroxynaphthalene (1-NAP) [weighted mean difference (WMD)10.14, 95% confidence interval (CI) (8.41 to 11.88), p < 0.05], 1-Hydroxyphenanthrene (1-PHE) [WMD 0.08, 95% CI (-0.14 to 0.31), p > 0.05], 1-Hydroxypyrene (1-PYR) [WMD 0.16, 95% CI (0.12 to 0.20), p < 0.05], 2-Hydroxyfluorene (2-FLU) [WMD 0.69, 95% CI (0.58 to 0.80), p < 0.05], 2-Hydroxynaphthalene (2-NAP) [WMD 7.48, 95% CI (4.15 to 10.80), p < 0.05], 3-Hydroxyfluorene (3-FLU) [WMD 0.57, 95% CI (0.48 to 0.66), p < 0.05], 2-Carbamoylethylmercapturic acid (AAMA) [WMD 66.47, 95% CI (27.49 to 105.46), p < 0.05], 4-Hydroxy-2-buten-1-yl-mercapturic acid (MHBMA) [WMD 287.79, 95% CI (-54.47 to 630.04), p > 0.05], 4-(Methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNAL) [WMD 189.37, 95% CI (78.45 to 300.29), p < 0.05], or N0-nitrosonornicotine (NNN) [WMD 11.66, 95% CI (7.32 to 16.00), p < 0.05]. Conclusion: Urinary bladder cancer markers were significantly higher in traditional tobacco users than in e-cigarette users.Systematic review registration: PROSPERO (CRD42023455600: https://www.crd.york.ac.uk/PROSPERO/).

Injuries from electronic cigarettes, and cigarette/cigar-related paraphernalia, NEISS, 2012-2022.

There is a need to determine the role of smoking/vaping related products in Emergency Department (ED) product-related injuries by age and sex to determine if interventions are warranted. These products include the combustible tobacco products' paraphernalia to light them (CTPP), electronic nicotine delivery systems (ENDS), and electronic non-nicotine delivery system (ENNDS). Data from the National Electronic Injury Surveillance System (NEISS), years 2012-2022, were examined for injury data associated with CTPP and ENDS/ENNDS. Bivariate comparisons were conducted. There were an estimated 3,142 (95%CI: 2,384-3,975) ED-treated ENDS/ENNDS product-related injuries and 46,116 (95%CI: 38,712-53,520) CTPP product-related injuries. Males were more likely to have an ED-treated ENDS/ENNDS product-related injury than females (proportion 0.93 [95%CI: 0.82, 0.98] versus 0.70 [95%CI: 0.02, 0.19]) as well as a CTPP product-related injury than females (proportion, 0.60 [95%CI: 0.56, 0.64] versus 0.40 [95%CI: 0.37, 0.44]). There were more ED-treated ENDS/ENNDS product-related injuries among persons ≥18 years than <18 years (proportion, 0.89 [95%CI: 0.75, 0.96] versus 0.11 [95% CI: 0.4, 0.35]). There were also more ED-treated CTPP product injuries among persons ≥ 18 years than <18 years (proportion, 0.73 [95%CI: 0.68, 0.78] versus 0.27 [95%CI: 0.22, 0.32]). No change in the proportion of injuries in our sample associated with END/ENNDS over time were observed. There is a need to consider injuries related to ENDS/ENNDS and CTPP product-related injuries in the discussion of the risks associated with smoking/vaping. Although ENDS/ENNDS have had fewer ED-treated injuries, the number of such injuries has remained stable, rather than declined over the previous decade. Injury prevention is a public health imperative and targeted interventions by healthcare providers during routine care, and the use of public service announcements could specifically target adults ≥18 years. Providing peer-to-peer educational programs, and initiating similar programs targeted at males who use CTP and ENDS/ENNDS have the potential to decrease injury risk.