Packaging of disposable vaping products and e-liquids in England, Canada and the United States: A content analysis.

BACKGROUND AND AIMS: Vaping product packaging is varied and often features bright colours and novel designs, particularly among recently marketed disposable vapes. This study provides an overview of attributes found on the packaging of popular disposable vapes and e-liquid bottles in England, Canada and the United States (US) and assesses compliance with local packaging regulations. DESIGN: Content analysis. SETTING: Brick-and-mortar and online shops in England (London), Canada (Ontario) and the US (New Hampshire and South Carolina). CASES: 108 vaping products (including packaging) from 76 brands in a range of flavours and nicotine levels. Specifically, 48 disposable vapes (15 from England, 16 from Canada, 17 from the US) and 60 e-liquid bottles (20 per country). MEASUREMENTS: Textual and graphic branding and marketing elements, independently coded by two researchers and checked by a third. FINDINGS: Compliance with local packaging regulations varied across countries. Health warnings were present on the packaging of all but one nicotine-containing product, although 33% of disposables and 17% of e-liquids featuring the warning did not adhere to formatting requirements. Leaflets were seldom included with e-liquid bottles, even in England (45%) where mandatory, and omitted elsewhere. Labelling of nicotine type and batch numbers was inconsistent. Vaping product packaging featured claims relating to sensory perceptions (41%), most often flavours, and some (32%) featured youth-appealing content. Common graphic elements included stylised brand fonts (80%), brand logos (54%), product representations on the external packaging (47%) and abstract graphic elements (64%). Colours on packaging, disposable vapes and e-liquid bottles were associated with product flavour. CONCLUSIONS: In England, Canada and the United States, popular disposable vapes and e-liquid bottles appear to have varying compliance with local packaging regulations and inconsistent labelling of nicotine and product characteristics. The use of colourful designs, evocative descriptors and appealing graphics to promote flavours underscores the need for comprehensive packaging regulations and enforcement.

Harm perceptions across vaping product features: An on-line cross-sectional survey of adults who smoke and/or vape in the United Kingdom.

BACKGROUND AND AIMS: Vaping products are diverse with a wide variety of features, and popular products change rapidly. This study examined the features and types of vaping products that people who smoke and/or vape perceive contribute to the health harms of vaping. DESIGN, SETTING AND PARTICIPANTS: This was a cross-sectional survey co-designed with adults who smoked/vaped and pre-registered. An on-line survey (November 2022) was used of a convenience sample of adults in the United Kingdom who smoked and/or vaped (n = 494). MEASUREMENTS: As primary outcomes, respondents were asked to select any of 15 vaping product features they perceived might have any effect on the health harms of vaping (for each: selected, not selected). Independent variables were smoking/vaping status (smoke and vape; vape, formerly smoked; vape, never regularly smoked; smoke, do not currently vape); relative vaping harm perceptions [less harmful than smoking (accurate), equally/more harmful than smoking or do not know/refused (other)]. Binary logistic regressions were used to compare outcomes by current vaping/smoking status and relative harm perceptions, adjusting for age and sex. FINDINGS: Most people (54.7%) selected between one and three features. The most frequently selected were nicotine concentration (62.2%) and amount of e-liquid consumed (59.1%), followed by nicotine type (e.g. salt or freebase; 33.0%), source/purchase location (25.3%), flavours (24.7%), temperature to heat e-liquid (21.1%), heat produced by device (20.9%), e-liquid brand (20.9%), amount of emissions (18.6%), device type (e.g. disposable, pod, tank; 17.2%), material of tank (17.0%), power/wattage (13.0%), device brand (8.1%), device size (4.1%) and device weight (2.4%). Higher nicotine concentrations, more e-liquid and salt (versus freebase) nicotine were perceived to confer greater harms. Disposables were perceived as slightly more harmful than reusable devices. There were few differences by current vaping/smoking status and between those with accurate (versus other) harm perceptions of vaping relative to smoking (P > 0.05 for most contrasts, adjusting for age and sex). CONCLUSIONS: Certain features and types of vaping products [higher nicotine concentrations, more e-liquid consumed and salt (versus freebase) nicotine] were perceived to confer greater health harms among a sample of UK adults who smoked and/or vaped. Findings are consistent with pervasive misperceptions that nicotine is a major cause of harm, although e-liquid volume is likely to contribute to harms.

Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2022).

BACKGROUND: Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios. METHODS: Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data. RESULTS: Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy. CONCLUSIONS: Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.

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.

Evaluation of a hospital-initiated tobacco dependence treatment service: uptake, smoking cessation, readmission and mortality.

BACKGROUND: The National Health Service in England aims to implement tobacco dependency treatment services in all hospitals by 2024. We aimed to assess the uptake of a new service, adapted from the Ottawa Model of Smoking Cessation, and its impact on 6-month quit rates and readmission or death at 1-year follow-up. METHODS: We conducted a pragmatic service evaluation of a tobacco dependency service implemented among 2067 patients who smoked who were admitted to 2 acute hospitals in London, England, over a 12-month period from July 2020. The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence specialists, provision of pharmacotherapy and behavioural support throughout the hospital stay, and telephone support for 6 months after discharge. The outcomes were (i) patient acceptance of the intervention during admission, (ii) quit success at 6 months after discharge, (iii) death, or (iv) readmission up to 1 year following discharge. Multivariable logistic regression was used to estimate the impact of a range of clinical and demographic variables on these outcomes. RESULTS: The majority (79.4%) of patients accepted support at the first assessment. Six months after discharge, 35.1% of successfully contacted patients reported having quit smoking. After adjustment, odds of accepting support were 51-61% higher among patients of all non-White ethnicity groups, relative to White patients, but patients of Mixed, Asian, or Other ethnicities had decreased odds of quit success (adjusted odds ratio (AOR) = 0.32, 95%CI = 0.15-0.66). Decreased odds of accepting support were associated with a diagnosis of cardiovascular disease or diabetes; however, diabetes was associated with increased odds of quit success (AOR = 1.88, 95%CI = 1.17-3.04). Intention to make a quit attempt was associated with a threefold increase in odds of quit success, and 60% lower odds of death, compared to patients who did not intend to quit. A mental health diagnosis was associated with an 84% increase in the odds of dying within 12 months. CONCLUSIONS: The overall quit rates were similar to results from Ottawa models implemented elsewhere, although outcomes varied by site. Outcomes also varied according to patient demographics and diagnoses, suggesting personalised and culturally tailored interventions may be needed to optimise quit success.

Use of 'Elf Bar' among youth and young adults who currently vape in England: cross-sectional associations with demographics, dependence indicators and reasons for use.

BACKGROUND AND AIMS: Elf Bar is currently the leading e-cigarette (vape) brand in Great Britain. This study examined youth and young adults' use of Elf Bar, socio-demographic characteristics and dependence indicators and reasons for use over other brands. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: Online 2022 International Tobacco Control Project Youth Tobacco and Vaping Survey (N = 1355 16-29-year-olds in England who had vaped in the past 30 days). MEASUREMENTS: Currently using Elf Bar most often (versus other brands) and associations with: socio-demographics, owning a vaping device, dependence indicators and reasons for brand choice. Logistic regressions were used. FINDINGS: Among 16-29-year-olds who vaped in the past 30 days, 48.4% (n = 732) reported Elf Bar as the brand they used most often. Among 16-17-year-olds, 40.7% used Elf Bar over other brands; this was lower than among 18-19-year-olds (60.1%) and 20-29-year-olds (47.4%) (P ≤ 0.002). Using Elf Bar over other brands was higher among those who were female (55.2 versus 41.5% male), identified as White (53.1 versus 30.9% other/mixed), a student (54.5 versus 44.3% not), did not own a vape (66.7 versus 44.4% who did) and typically vaped 5-8 hours after waking (62.7 versus 36.8% within 5 min) (P ≤ 0.044). Most who vaped but had never smoked used Elf Bar (64.3%), although use did not significantly differ from those who currently (45.4%), formerly (42.3%) or experimentally (48.7%) smoked (all P ≥ 0.060). Popular reasons for choosing Elf Bar over other brands were better flavour/taste (47.5%), less expensive (28.7%), easier to get (26.1%), smoother to inhale (24.0%) and popularity (23.1%). 'Better for quitting smoking' (10.1%) was least frequently selected reason for choosing Elf Bar over other brands. CONCLUSIONS: Elf Bar brand e-cigarettes were used by approximately half of 16-29-year-olds who vaped in England in 2022 and was mainly chosen over other brands for subjective responses (e.g. flavour/taste), rather than for quitting smoking.

Noticing education campaigns or public health messages about vaping among youth in the United States, Canada and England from 2018 to 2022.

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16-19 year-olds in United States, Canada and England (2018-2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.