Rescuing Vapers Versus Rescuing Smokers: The Ethics.

Suppose for the sake of argument that wide access to electronic cigarettes would help a great many smokers quit and others avoid smoking, with a dramatic cumulative effect on population health. But suppose also that nowadays, teenagers rarely benefit from that effect, because most do not smoke and are not expected to smoke as adults. Many teenagers do vape. When the net effect of vaping on general public health is expected to remain very positive, should we nevertheless fight vaping, so as to protect teenagers from the direct risks of vaping? For example, what to do if and when certain targeted regulations that would protect teenagers would also, by making it harder to vape, substantially increase smoking in the general population? This situation may be common, and, by pitting the health interests of the general population against those of teenagers, poses an ethical dilemma. This article argues philosophically that if such tradeoffs between the health interests of adolescents and those of the general population exist, morally it is both permissible and preferable to promote the health of the general population. IMPLICATIONS: In the debate about electronic-cigarette based tobacco harm reduction, some disagreements are factual, for example, disagreements about how harmful vaping is to human lungs, and how much the option of vaping helps smokers quit. However, there is also an ethical debate: if tradeoffs between the health interests of adolescents at risk of vaping and those of the general population (driven by those of smokers) exist, who should be prioritized? This article argues that morally it is sometimes, at least, both permissible and preferable to promote the health of the general population over those of adolescents at risk of vaping.

Predictive Power of Dependence Measures for Quitting Smoking. Findings From the 2016 to 2018 ITC Four Country Smoking and Vaping Surveys.

INTRODUCTION: To test whether urges to smoke and perceived addiction to smoking have independent predictive value for quit attempts and short-term quit success over and above the Heaviness of Smoking Index (HSI). AIMS AND METHODS: Data were from the International Tobacco Control Four Country Smoking and Vaping Wave 1 (2016) and Wave 2 (2018) surveys. About 3661 daily smokers (daily vapers excluded) provided data in both waves. A series of multivariable logistic regression models assessed the association of each dependence measure on odds of making a quit attempt and at least 1-month smoking abstinence. RESULTS: Of the 3661 participants, 1594 (43.5%) reported a quit attempt. Of those who reported a quit attempt, 546 (34.9%) reported short-term quit success. Fully adjusted models showed that making quit attempts was associated with lower HSI (adjusted odds ratio [aOR] = 0.81, 95% confidence interval [CI] = 0.73 to 0.90, p < .001), stronger urges to smoke (aOR = 1.08, 95% CI = 1.04 to 1.20, p = .002), and higher perceived addiction to smoking (aOR = 0.52, 95% CI = 0.32 to 0.84, p = .008). Lower HSI (aOR = 0.57, 95% CI = 0.40 to 0.87, p < .001), weaker urges to smoke (aOR = 0.85, 95% CI = 0.76 to 0.95, p = .006), and lower perceived addiction to smoking (aOR = 0.55, 95% CI = 0.32 to 0.91, p = .021) were associated with greater odds of short-term quit success. In both cases, overall R2 was around 0.5. CONCLUSIONS: The two additional dependence measures were complementary to HSI adding explanatory power to smoking cessation models, but variance explained remains small. IMPLICATIONS: Strength of urges to smoke and perceived addiction to smoking may significantly improve prediction of cessation attempts and short-term quit success over and above routinely assessed demographic variables and the HSI. Stratification of analyses by age group is recommended because the relationship between dependence measures and outcomes differs significantly for younger (aged 18-39) compared to older (aged older than 40) participants. Even with the addition of these extra measures of dependence, the overall variance explained in predicting smoking cessation outcomes remains very low. These measures can only be thought of as assessing some aspects of dependence. Current understanding of the factors that ultimately determine quit success remains limited.

An Exploration of Smoking-to-Vaping Transition Attempts Using a "Smart" Electronic Nicotine Delivery System.

INTRODUCTION: Electronic nicotine delivery systems (ENDS) are used to aid smoking cessation attempts; however, many smokers continue to smoke while using an ENDS (dual use). Although uncertainty remains regarding whether specific ENDS patterns hinder or support successful smoking cessation, recent advances in "smart" technology allow passive and active recording of behaviors in real time, enabling more detailed insights into how smoking and vaping patterns may coevolve. We describe patterns of ENDS initiation, and subsequent use, including any changes in cigarette consumption, among daily smokers using a "smart" ENDS (S-ENDS) to quit smoking. METHOD: An 8-week long mixed-methods feasibility study used Bluetooth-enabled S-ENDS that passively recorded real-time device use by participants (n = 11). Daily surveys administered via smartphones collected data on self-reported cigarette consumption. RESULTS: All 11 participants were dual users, at least initially, during their quit attempt. We observed three provisional vaping and smoking patterns: immediate and intensive ENDS initiation coupled with immediate, dramatic, and sustained smoking reduction, leading to smoking abstinence; gradual ENDS uptake with gradual smoking reductions, leading to daily dual use throughout the study period; and ENDS experimentation with return to exclusive smoking. For six participants, the patterns observed in week 1 were similar to the vaping and smoking patterns observed throughout the rest of the study period. CONCLUSION: Technological advances now allow fine-grained description of ENDS use and smoking patterns. Larger and longer studies describing smoking-to-vaping patterns, and estimating associations with smoking outcomes, could inform ENDS-specific cessation advice promoting full transition from smoking to exclusive ENDS use. IMPLICATIONS: The use of an S-ENDS that recorded real-time device use among daily smokers engaged in a quit attempt provides insight into patterns and trajectories of dual use (continuing to smoke while using ENDS), and the possible associations between ENDS initiation, subsequent use, and smoking cessation outcomes. Such work could support more targeted cessation counseling and technical advice for smokers using ENDS to quit smoking, reduce the risk of users developing long-term dual use patterns, and enhance the contributions ENDS may make to reducing smoking prevalence.

"They're thinking, well it's not as bad, I probably won't get addicted to that. But it's still got the nicotine in it, so ": Maturity, Control, and Socializing: Negotiating Identities in Relation to Smoking and Vaping-A Qualitative Study of Young Adults in Scotland.

Objective: To explore the understandings of and engagement with e-cigarettes, of young adults from disadvantaged backgrounds, and how these may have an impact on existing smoking identities. Methods: Twenty-two small group and 11 individual qualitative interviews were conducted in Central Scotland with 72 16-24 year olds between September 2015 and April 2016. Participants were mostly smokers and ex-smokers from socioeconomically disadvantaged backgrounds. Results: Although most participants had tried e-cigarettes, they generally held ambivalent views about e-cigarettes and vaping. Two overarching themes were identified which helped in understanding this. Firstly, e-cigarettes were understood by the participants in relation to their existing smoking identities. Vaping was viewed as less controllable and more addictive than smoking, which did not fit with their self-identity as controlled smokers. Secondly, they felt that vaping could not replace the social and cultural importance that smoking had in their lives. Conclusion: This study suggests that though young adults from disadvantaged areas are trying e-cigarettes for various reasons, vaping is rarely sustained. Through their own experiences of vaping and their observations of others vaping, the participants perceive the behavior as endangering an existing acceptable and controlled smoking identity. Additionally, e-cigarettes were considered to be a jarring presence in existing social situations where smoking was valued. This study, therefore, provides insights into how young adults may be rationalizing their continued smoking in the face of potentially less harmful alternatives. Implications: As new and novel nicotine delivery devices, and due to their similarity to smoking, e-cigarettes have the potential to help smokers in their quit attempts. However, the findings from this study raise questions about whether e-cigarettes are regarded as having this potential by young adult smokers from disadvantaged socioeconomic environments where smoking is more commonplace and acceptable.

E-cigarettes and smoking cessation: a prospective study of a national sample of pregnant smokers.

BACKGROUND: Smoking during pregnancy has adverse health consequences for the mother and fetus. E-cigarettes could aid with smoking cessation but there is limited research on the prevalence and patterns of e-cigarette use, and their association with smoking cessation among pregnant smokers. METHODS: We conducted a secondary analysis of a randomized controlled trial of a text-messaging program for smoking cessation among a U.S. national cohort of pregnant smokers (n = 428). Outcomes assessed were trajectories of e-cigarettes use from baseline to one-month follow-up, and longitudinal association between e-cigarette use at baseline and smoking cessation at one-month follow-up. RESULTS: At baseline, 74 (17.29%) pregnant smokers used e-cigarettes in the past 30 days and 36 (8.41%) used e-cigarettes in the past 7 days. The primary reason stated for using e-cigarettes during pregnancy was for quitting. E-cigarette use between baseline and 1-month was inconsistent. Of 36 dual-users at baseline, 20 (55.56%) stopped using e-cigarettes by the 1-month follow-up and 14 initiated e-cigarette use. There was no evidence of an association between e-cigarette use at baseline and the primary smoking cessation outcome, 7-day point prevalence abstinence [adjusted odds ratio = 0.79, 95% confidence intervals = 0.33-1.92]. CONCLUSIONS: A secondary analysis of a national sample of pregnant smokers indicates that use of e-cigarettes is inconsistent and is not associated with improved smoking cessation outcomes. There is an urgent need to further examine the risk and benefits of e-cigarette use, especially during pregnancy.

E-cigarette Use Among US Adults: Population Assessment of Tobacco and Health (PATH) Study.

Introduction: In 2011 the US Food and Drug Administration launched the Population Assessment of Tobacco and Health (PATH) Study to gather information for regulatory activities authorized by the Family Smoking Prevention and Tobacco Control Act (TCA). Methods: Data were drawn from the first wave of the PATH survey, involving interviews of 32 320 civilian and non-institutionalized adults. In addition to conventional classifications for current, former and never smoking and e-cigarette use, we used PATH questions to classify former and current triers of these products. Descriptive statistics were used to describe the prevalence, patterns of, and reasons for e-cigarette use, and the perceptions of nicotine and e-cigarettes among user groups, according to smoking status. Results: The prevalence of current smoking was 18%; an additional 3.1% of participants were current triers. The prevalence of current e-cigarette use was 2.4% (1.0% every day, 1.4% some days), with another 3.2% as current triers. The majority of nonsmokers who were current e-cigarette users were already current (56%) or former (34%) cigarette triers. Reasons for e-cigarette use were similar across subgroups, but patterns of use were different. Majorities of participants believed that nicotine is the main substance driving tobacco use, that nicotine causes most cancers, and that e-cigarettes were less harmful than cigarettes. Conclusions: E-cigarettes were used primarily by current smokers and recent former smokers. The main reasons for use center around perceptions that e-cigarettes are less harmful than cigarettes to users and others. Implications: This study reports detailed information about the prevalence, patterns of, and reasons for e-cigarette use in the first (baseline) wave of the PATH Study in 2014. In addition to conventional categories for current, former and never smoking and e-cigarette use, the PATH questionnaire facilitated classification of new usage groups consisting of current and former triers of these products, which may impact prevalence estimates.

The Relationship of E-Cigarette Use to Cigarette Quit Attempts and Cessation: Insights From a Large, Nationally Representative U.S. Survey.

Objectives: While cessation from cigarettes is a top priority for public health, controversy surrounds the role of e-cigarettes for quitting cigarettes. This study examines the role of e-cigarettes in quit attempts and 3-month cigarette abstinence using a large, recent nationally representative US sample. Methods: Data from the 2014/15 Tobacco Use Supplement-Current Population Survey (TUS-CPS) on cigarette and e-cigarette use and individual characteristics were supplemented with information on state tobacco control policies. We estimated frequencies and multivariate logistic equations for making a quit attempt among those who smoked 1 year earlier and for remaining abstinent at least 3 months among those making a quit attempt. These two outcomes were related to demographic characteristics, tobacco control policies and different frequency measures of e-cigarette use (ever, at least 1, 5, 20 of the last 30 days, a continuous measure of days use). Results: Having made a quit attempt was more likely among smokers using e-cigarettes than non-users. Among those making at least one quit attempt, quit success was lower among ever users, but higher among those with at least 5 days use of e-cigarettes in the last month. Both quit attempts and quit success were linearly related to the frequency of e-cigarette use. Conclusions: Consistent with randomized trials and those observational studies that measure frequency of e-cigarette use, both quit attempts and quit success were positively associated with increased frequency of e-cigarette use. Frequency of e-cigarette use was important in gauging the nature of these relationships. Implications: Previous studies have obtained mixed results regarding the relationship of e-cigarette use to cigarette smoking cessation. This study provides a more precise methodology for considering the relationship of e-cigarette use to quit attempts and to quit success, and finds that quit attempts and quit success increase with the number of days use in the past month.

Early Subjective Sensory Experiences with "Cigalike" E-cigarettes Among African American Menthol Smokers: A Qualitative Study.

Introduction: Despite smoker interest in e-cigarettes as a harm reduction or cessation aid, many smokers prematurely discontinue vaping after trying a product. This study explored the role of early subjective sensory experiences in vaping persistence and desistance. Methods: African American menthol cigarette smokers aged ≥18 years (N = 15; M = 54.1 years; SD = 8.2), motivated to quit smoking, and interested in trying e-cigarettes were recruited in Washington, DC. Participants were followed for 3 weeks and provided menthol cigalike e-cigarettes after Week 1. Participants completed three interviews about their vaping experiences. Thematic analysis of responses was designed to understand the sensory aspects of vaping. Results: During the first 2 weeks of vaping, four participants reported a positive vaping experience while 11 reported decreased satisfaction. Salient sensory attributes of dissatisfaction included poor taste, insufficient throat hit, difficulty pulling, and a lack of "whole body" satisfaction compared to their preferred cigarette brand. Conclusions: The sensory experiences with a specific cigalike e-cigarette were related to vaping persistence and desistence. Although this was a small volunteer sample of African American menthol smokers motivated to quit smoking, 27% (N = 4) of participants with a positive vaping experience continued using the product, while 73% (N = 11) of participants' vaping experience was unsatisfactory across several experiential categories. In future research of e-cigarettes' efficacy as a smoking cessation or reduction aid, both device characteristics and smokers' expectations for these devices should be considered, so vapers do not expect the same taste sensations, throat sensations, and "whole body" satisfaction as they experienced with their menthol cigarettes. Implications: The subjective sensory experiences associated with initial e-cigarette product use are associated with use patterns. Subjective sensory experiences may also help understand the differences in the appeal, satisfaction, and harm-reduction potential of the rapidly evolving diverse types of products emerging in the marketplace. How products meet the sensory needs of smokers wanting to switch or quit smoking may influence adherence and success rates.

Predicting Short-Term Uptake of Electronic Cigarettes: Effects of Nicotine, Subjective Effects, and Simulated Demand.

Introduction: E-cigarettes have potential to support tobacco cessation or reduction, but how nicotine content affects smokers' subjective perceptions and use of e-cigarettes, rather than tobacco, is unclear. Method: Thirty-five adult daily smokers who had not previously tried e-cigarettes were recruited from two cities in New Zealand in 2016-2017. Smokers were given four e-cigarette cartridges (0, 6, 12, and 18 mg nicotine) in a randomized, blinded order over four 2-week periods. Daily cigarette smoking and e-cigarette use was monitored using ecological momentary analysis and participants completed the modified Cigarette Evaluation Questionnaire after each 2-week period. Results: Mean cigarettes per day decreased by 37% (9.69 to 6.09) when e-cigarettes were available relative to baseline (p = .008). Nicotine-containing cartridges (>0 mg) were associated with greater use (p = .023) and craving reduction (p = .026) than 0 mg. Alleviation of withdrawal symptoms (p = .048) and taste and enjoyment factors (p = .039) predicted e-cigarette use. Conclusion: Availability of e-cigarettes reduced cigarette smoking behavior regardless of nicotine content, and e-cigarette use was greater with nicotine-containing cartridges. First-time users' e-cigarette use can be predicted using subjective ratings and more research is required to clarify the effect of nicotine content on subjective perceptions and use. Implications: For low-moderate dependence smokers, availability of e-cigarettes may reduce cigarette smoking behavior regardless of nicotine content, but the availability of nicotine-containing cartridges may promote greater e-cigarette use. First response to trialing e-cigarettes is an important factor in determining subsequent experimental and possibly longer-term use.

Effectiveness of a Vaping Cessation Text Message Program Among Young Adult e-Cigarette Users: A Randomized Clinical Trial.

Importance: e-Cigarettes are the most commonly used tobacco product among young adults (YAs). Despite the harms of nicotine exposure among YAs, there are few, if any, empirically tested vaping cessation interventions available. Objective: To determine the effectiveness of a text message program for vaping cessation among YAs vs assessment-only control. Design, Setting, and Participants: A parallel, 2-group, double-blind, individually randomized clinical trial was conducted from December 2019 to November 2020 among YA e-cigarette users. Eligible individuals were US residents aged 18 to 24 years who owned a mobile phone with an active text message plan, reported past 30-day e-cigarette use, and were interested in quitting in the next 30 days. Participants were recruited via social media ads, the intervention was delivered via text message, and assessments were completed via website or mobile phone. Follow-up was conducted at 1 and 7 months postrandomization; follow-up data collection began January 2020 and ended in November 2020. The study was prespecified in the trial protocol. Interventions: All participants received monthly assessments via text message about e-cigarette use. The assessment-only control arm (n = 1284) received no additional intervention. The active intervention arm (n = 1304) also received This is Quitting, a fully automated text message program for vaping cessation that delivers social support and cognitive and behavioral coping skills training. Main Outcomes and Measures: The primary outcome was self-reported 30-day point prevalence abstinence (ppa) at 7 months analyzed under intention-to-treat analysis, which counted nonresponders as vaping. Secondary outcomes were 7-day ppa under intention-to-treat analysis and retention weighted complete case analysis of 30-day and 7-day ppa. Results: Of the 2588 YA e-cigarette users included in the trial, the mean (SD) age was 20.4 (1.7) years, 1253 (48.4%) were male, 2159 (83.4%) were White, 275 (10.6%) were Hispanic, and 493 (19.0%) were a sexual minority. Most participants (n = 2129; 82.3%) vaped within 30 minutes of waking. The 7-month follow-up rate was 76.0% (n = 1967), with no differential attrition. Abstinence rates were 24.1% (95% CI, 21.8%-26.5%) among intervention participants and 18.6% (95% CI, 16.7%-20.8%) among control participants (odds ratio, 1.39; 95% CI, 1.15-1.68; P < .001). No baseline variables moderated the treatment-outcome relationship, including nicotine dependence. Conclusions and Relevance: Results of this randomized clinical trial demonstrated that a tailored and interactive text message intervention was effective in promoting vaping cessation among YAs. These results establish a benchmark of intervention effectiveness. Trial Registration: ClinicalTrials.gov Identifier: NCT04251273.

Patterns of cigarette, e-cigarette, and cannabis use among adult smokers in primary care 2014-2015.

BACKGROUND: Poly-use of tobacco, cannabis, and electronic cigarettes (e-cigarettes) is an emerging problem in the general population. The current study investigated poly-use of these products and receipt of smoking cessation counseling in a primary care setting. METHODS: We conducted a cross-sectional secondary data analysis from a trial of a tablet intervention to increase provider delivery of the 5As (Ask, Advise, Assess, Assist, Arrange follow-up), a brief counseling intervention for smoking cessation, in 3 diverse primary care clinics in San Francisco, CA from 2014 to 2015. Participants were currently smoking cigarettes (N = 601; mean age = 50.8; 38.1% female) and reported information on past 30-day cigarette and e-cigarette use and past 3-month cannabis use. We classified participants into 4 groups: (1) cigarette-only, (2) dual-use of cigarettes and e-cigarettes, (3) dual-use of cigarettes and cannabis, (4) poly-use of cigarettes, e-cigarettes, and cannabis, and examined correlates of use. RESULTS: Only cigarette smoking was reported by 48.6% of participants, 30.4% reported use of cigarettes and cannabis, 10.5% reported use of cigarettes and e-cigarettes, and 10.5% reported use of cigarettes, e-cigarettes, and cannabis. Cigarette-only smokers did not differ from other groups by cigarette smoking behavior and motivation to quit. Patients reporting dual-use of cigarettes and e-cigarettes had a higher likelihood of receiving the Arrange step and all 5As compared to cigarette-only smokers. CONCLUSIONS: Providers should screen for co-use of cigarettes and other nicotine/cannabis products and consider co-use when delivering smoking cessation treatment and evaluating treatment outcomes. Development of guidelines to help facilitate provider training is needed.

A Combination of Factors Related to Smoking Behavior, Attractive Product Characteristics, and Socio-Cognitive Factors are Important to Distinguish a Dual User from an Exclusive E-Cigarette User.

Although total cessation of nicotine and tobacco products would be most beneficial to improve public health, exclusive e-cigarette use has potential health benefits for smokers compared to cigarette smoking. This study investigated differences between dual users and exclusive e-cigarette users provide information to optimize health communication about smoking and vaping. A cross-sectional survey (n = 116) among 80 current, adult dual users and 36 current, adult-exclusive e-cigarette users was conducted in the Netherlands. The questionnaire assessed four clusters of factors: (1) Past and current smoking and vaping behavior, (2) product characteristics used, (3) attractiveness and reasons related to cigarettes and e-cigarettes, and (4) socio-cognitive factors regarding smoking, vaping, and not smoking or vaping. We used random forest-a machine learning algorithm-to identify distinguishing features between dual users and e-cigarette users. We are able to discern a dual user from an exclusive e-cigarette user with 86.2% accuracy based on seven factors: Social ties with other smokers, quantity of tobacco cigarettes smoked in the past (e-cigarette users) or currently (dual users), self-efficacy to not vape and smoke, unattractiveness of cigarettes, attitude towards e-cigarettes, barriers: accessibility of e-cigarettes, and intention to quit vaping (A). This combination of features provides information on how to improve health communication about smoking and vaping.

Nicotine Use Disorders in Adolescents.

Rates of certain tobacco products have decreased over the past decade, but nicotine use disorder is still prevalent among adolescents. New trends in tobacco use, such as in the use of electronic cigarettes, are creating alarm. This article reviews nicotine addiction and measurement in adolescents, along with potential health risks and comorbidities. Various psychosocial and pharmacologic interventions are reviewed along with novel interventions that show promise for reducing tobacco use in this vulnerable population.

Comparison of pharmacy students' self-efficacy to address cessation counseling needs for traditional and electronic cigarette use.

BACKGROUND AND PURPOSE: This study assessed pharmacy students' self-rated ability to provide cessation counseling for e-cigarette use and traditional cigarette smoking. EDUCATIONAL ACTIVITY AND SETTING: A cross-sectional study was conducted in spring 2014 at The University of Texas at Austin. Participants included first through fourth year (P1-P4) doctor of pharmacy (PharmD) students. Perceived confidence and knowledge to counsel on cigarette smoking cessation and e-cigarette cessation were self-rated and based on the Ask-Advise-Assess-Assist-and Arrange (5 A's) follow-up model as well as general counseling skills for recreational nicotine product use cessation. Comparisons were made between students' confidence to counsel patients on traditional cigarette smoking cessation and e-cigarette cessation and by class level. FINDINGS: Compared to cigarette smoking cessation counseling, students were less confident in their ability to counsel on e-cigarette cessation using the 5 A's model and general counseling skills. Students perceived themselves to be less knowledgeable about the harmful effects of e-cigarettes, pharmacists' role in counseling on e-cigarette cessation, and how patients can benefit from e-cigarette cessation counseling. A higher proportion of students reported having no training on e-cigarette cessation compared to cigarette smoking cessation (59% vs 9%). SUMMARY: Targeted training on how to counsel patients on e-cigarette cessation should be included in pharmacy curricula. Such training is expected to increase the confidence of pharmacists-in-training to address the needs of patients who use e-cigarettes.