RESUMO
OBJECTIVE: This work examines the relationship between local flavor policy exposure and any tobacco product use and flavored tobacco product use among U.S. youth and young adults, as well as the equity potential of these policies by race/ethnicity. METHODS: Participants were aged 15-36 (n = 10,893) surveyed from September-December 2019 using national, address- and probability-based sampling. Local flavor policies enacted before survey completion were linked to participant home address. Weighted cross-sectional multivariable logistic regression examined individual coverage by flavor policy vs. no flavor policy, with current any tobacco or flavored tobacco use, controlling for individual and county-level demographics, psychosocial variables, and other tobacco control policies. Interactions between race/ethnicity and any tobacco use and flavored tobacco use were assessed. RESULTS: Those covered by a flavor policy vs. no policy had lower odds of any tobacco use (aOR = 0.74, 95% CI = 0.55-1.00) and current flavored tobacco use (aOR = 0.67, 95% CI = 0.48-0.93). Compared with Non-Hispanic (NH)-White individuals, NH-Black individuals (aOR = 1.08, CI = 1.04-1.12) had higher odds of any tobacco use, and non-Hispanic Asian individuals had lower odds of any tobacco use (aOR = 0.67, CI = 0.53-0.85). Hispanic individuals exposed to policy had lower odds of flavored tobacco use compared to NH-White peers. CONCLUSIONS: Exposure to flavor restriction policies is associated with lower odds of any tobacco and flavored use among youth and young adults. Flavor restrictions may be beneficial in reducing tobacco use in youth from diverse racial/ethnic backgrounds. However, passing policies covering NH-Black individuals is needed to mitigate disparities in tobacco use by flavor policy coverage over time.
RESUMO
BACKGROUND: The tobacco industry has spent millions of dollars promoting racialised narratives against the US Food and Drug Administration's recently announced ban on menthol as a characterising cigarette flavour. This research investigates racialised narratives in online discourse following the ban's announcement. METHODS: Tweets and users responding to the April 2022 menthol ban announcement were content analysed to examine the influence of tobacco industry affiliates and potentially organic African-American/Black (AA/B) users. Next we investigated the extent to which the menthol ban was discussed on AA/B subreddits and used Latent Dirichlet Allocation topic modelling to provide an overview of the menthol ban discussion on Reddit. RESULTS: Only 28 (13.9%) tweets by 22 users claimed that the menthol ban would lead to police violence and/or racial discrimination. Of users who tweeted about over-policing, eight (36.4%) had financial connections to the tobacco industry. There were only three tweets receiving a combined seven retweets from potentially organic AA/B users. On Reddit, only two posts with one comment discussed the menthol ban on subreddits dedicated to AA/B issues and culture. Topic modelling showed that the most common topic related to the menthol ban involved the social and political implications of the ban followed by illicit markets and protecting youth. CONCLUSION: Tweets claiming a menthol ban will lead to police violence are indicative of industry agenda-setting. The menthol ban was not a prominent topic of discussion in AA/B subreddits although users discussing news and politics expressed concern for how AA/B people would respond to a ban politically.
RESUMO
PURPOSE: This study analyses the Food and Drug Administration (FDA) warning letters sent to e-cigarette companies from 1 January 2020 to 9 September 2021. Study results can inform regulation of e-cigarettes. METHODOLOGY: Warning letters retrieved from FDA's website were coded for company type (retailer, manufacturer or distributor), location (domestic or international), infractions listed (PMTA (premarket tobacco product application), selling to minors, advertising to youth or packaging violation/mislabelling), product type (e-liquid, device or both), flavour (fruit, candy, tobacco, menthol/mint, concept flavour) and consequence (civil money penalties, product seizure and injunction, product detention and refusal of entry to the USA, no-tobacco-sales order, criminal prosecution). RESULTS: Of 303 coded letters (126 from 2020 and 177 from 2021), 97.4% were sent to small online retailers. Overall, 94.1% of the companies cited were located within the USA, 75.2% of the infractions were identified by reviewing a company's website and 70.5% were PMTA violations. In 2020, 55.6% of infractions were PMTA violations; in 2021, nearly all infractions were PMTA violations. The letters cited 880 products; 92.2% of which were e-liquid products, with 32.4% fruit and 31.1% concept flavours. DISCUSSION: Warning letters targeted small online retailers rather than large e-cigarette brands or products most used by youth: pod mods and disposables. The focus of these enforcement actions comprises a small share of the market and the impact on use was likely minimal. With PMTA decisions pending for the largest brands of e-cigarettes, the FDA should use its enforcement powers to target manufacturers, distributors and sellers of the tobacco products that have the greatest impact on youth and products that provide no public health benefit.
RESUMO
BACKGROUND: Electronic cigarettes (e-cigarettes) are a common tobacco product in the US. Despite lacking Food and Drug Administration (FDA) approval for cessation, e-cigarettes, including JUUL, a popular device, have been viewed by some as a potential tool for tobacco users seeking to quit combustible tobacco use. It is unknown how current and former smokers report using these products for cigarette smoking cessation. METHODS: Online surveys were collected from a probability-based panel of US adults aged 18-64, with an oversample of past 12-month JUUL users (n=3415). Weighted past 12-month and past 30-day use of popular e-cigarette brands were measured. Former smokers with a quit attempt in the past 4 years and current smokers with a quit attempt in the past 12 months were asked about methods for smoking cessation, including e-cigarettes and nicotine replacement therapies (NRTs) use. RESULTS: Among former smokers (n=157), 21.2% used e-cigarettes and/or NRTs to help them quit. Specifically, 2.2% used JUUL only, compared with 10.3% who used NRTs only, and 6.9% used other e-cigarettes only to quit. Among current smokers with a quit attempt (n=308), 24.0% used any product (NRT or e-cigarettes) to quit, and only 1.1% used JUUL only. Current smokers reported relatively low use of NRTs only (10.1%), other e-cigarettes only (5.6%) and other e-cigarettes and NRTs (5.1%). CONCLUSIONS: Data suggest that few smokers in the US use e-cigarettes, and JUUL specifically, for cessation, and NRTs use is relatively low. All e-cigarettes should undergo FDA review to minimise recreational use and understand their cessation efficacy.
Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Abandono do Hábito de Fumar , Produtos do Tabaco , Adulto , Humanos , Fumantes , Dispositivos para o Abandono do Uso de TabacoRESUMO
BACKGROUND: The electronic nicotine delivery system (ENDS) JUUL has quickly captured the ENDS market, representing 74.6% of the total dollar share for this category as of November 2018. Although JUUL is marketed as an alternative to cigarettes intended for current adult smokers, evidence suggests that a majority of ENDS users are concurrently current cigarette smokers. Little is known about the dual use of JUUL and cigarettes, as well as the reasons for trying JUUL among adult tobacco users. METHODS: A survey fielded via web and phone of 1332 current cigarette, cigar, little cigar or cigarillo (CLCC), and ENDS users aged 18-54 years was conducted from March to May 2018. Weighted descriptive and bivariate analyses examined JUUL use and reasons for trying JUUL by demographics, combustible tobacco use, ENDS use and intention to quit. RESULTS: Approximately 81% of our sample reported current use of two or more tobacco products, including cigarettes, CLCCs or ENDS. Among current tobacco users, 15% ever used JUUL and 12% used JUUL in the past 30 days. Most individuals (74%) reporting ever JUUL use indicated using it for 5 days or fewer in the past 30 days. The most common reason for trying JUUL was trying to quit smoking cigarettes (37%), followed by family, friends or colleagues using the product (32%). CONCLUSION: Although some tobacco users may be initiating JUUL to decrease combustible use, most were using the product infrequently and concurrently with other products. Findings have significant implications for cessation intervention efforts and policy development to help smokers quit.
Assuntos
Sistemas Eletrônicos de Liberação de Nicotina/estatística & dados numéricos , Produtos do Tabaco/estatística & dados numéricos , Uso de Tabaco/epidemiologia , Vaping/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fumantes/estatística & dados numéricos , Abandono do Hábito de Fumar/estatística & dados numéricos , Inquéritos e Questionários , Adulto JovemRESUMO
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.
Assuntos
Negro ou Afro-Americano/psicologia , Sistemas Eletrônicos de Liberação de Nicotina/métodos , Mentol , Pesquisa Qualitativa , Fumantes/psicologia , Vaping/psicologia , Adulto , Idoso , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Masculino , Mentol/administração & dosagem , Pessoa de Meia-Idade , Abandono do Hábito de Fumar/métodos , Abandono do Hábito de Fumar/psicologia , Inquéritos e Questionários , Produtos do Tabaco , Fumar Tabaco/epidemiologia , Fumar Tabaco/psicologia , Fumar Tabaco/terapia , Vaping/epidemiologia , Vaping/terapiaRESUMO
Oral nicotine pouches are gaining popularity, yet national-level research on youth and young adult use is still needed. We examined characteristics of those who use oral nicotine pouches and trends in use over time in a sample of U.S. youth and young adults. Data were obtained from a weekly, national, online, continuous tracking survey of approximately 315 unique participants (aged 15-24) per week. Bivariate analyses were conducted on those surveyed December 2021 to May 2022 (n = 7,832) summarizing demographic and tobacco product use characteristics of those currently using oral nicotine pouches, those who had ever used oral nicotine pouches, but not currently, and those who never used pouches. From December 2021 to May 2022, 16% of participants ever used nicotine pouches and 12% currently used the product. Participants who currently used oral nicotine pouches were more likely to report being aged 21+, male, and lower income. Seventy-three percent of those who currently used pouches and 33% of those who ever, but not currently, used pouches reported current cigarette smoking. Results suggest that many young people who smoke cigarettes are concurrently using oral nicotine pouches. We also examined current and ever use in respondents surveyed between September 2020 and May 2022 to assess trends over the two-year period (n = 25,944) and findings indicate stable oral nicotine product use rates over time among adolescents and young adults. Appropriate regulation is needed so nicotine naïve individuals do not initiate use and those currently using tobacco do not use oral nicotine pouches concurrently with other products.
RESUMO
INTRODUCTION: Although the relationship between tax and price and youth cigarette use is well established, little is known about these associations and youth e-cigarette use. This research examines U.S. youth sensitivity to changes in e-cigarette prices and tax using standardized measures of e-cigarette taxes and prices. METHODS: This analysis uses national data on past 30-day use and the number of days using e-cigarettes (i.e., the intensity of use) from the repeat cross-sectional 2015-2019 Youth Risk Behavior Survey, in combination with inflation-adjusted standardized e-cigarette price and tax data to understand whether changes in e-cigarette price and tax were associated with changes in e-cigarette use. Two-part demand regression models controlling for demographics and e-cigarette restriction policies were conducted to calculate price and tax elasticities of demand, in addition to $0.50 and $1.00 price and tax increase simulations. RESULTS: Increased e-cigarette prices and taxes were associated with significant reductions in past 30-day use. Prices were also significantly associated with decreases in the intensity of use. A $0.50 and $1.00 tax increase leads to a 6.3% and 12.2% decrease in past 30-day use and a 4.7% and 9.3% decrease in intensity, respectively. A $0.50 and $1.00 price increase leads to a 4.1% and 8.2% decrease in past 30-day use and a 4.2% and 8.3% decrease in intensity, respectively. CONCLUSIONS: Higher prices and taxes reduce youth current e-cigarette use and days using e-cigarettes. Policies increasing e-cigarette prices, such as excise taxes, can reduce youth current e-cigarette use and days using e-cigarettes.
Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Produtos do Tabaco , Vaping , Adolescente , Humanos , Fumar/epidemiologia , Vaping/epidemiologia , Estudos Transversais , Comércio , ImpostosRESUMO
OBJECTIVE: To examine the role of social media in promoting recall and belief of distorted science about nicotine and COVID-19 and whether recall and belief predict tobacco industry beliefs. DESIGN: Young adults aged 18-34 years (N=1225) were surveyed cross-sectionally via online Qualtrics panel. The survey assessed recall and belief in three claims about nicotine and COVID-19 and three about nicotine in general followed by assessments of industry beliefs and use of social media. Ordinal logistic regression with robust standard errors controlling for gender, race/ethnicity, education, current e-cigarette use and age was used to examine relationships between variables. RESULTS: Twitter use was associated with higher odds of recall (OR=1.21, 95% CI=1.01 to 1.44) and belief (OR=1.26, 95% CI=1.04 to 1.52) in COVID-19-specific distorted science. YouTube use was associated with higher odds of believing COVID-19-specific distorted science (OR=1.32, 95% CI=1.09 to 1.60). Reddit use was associated with lower odds of believing COVID-19-specific distorted science (OR=0.72, 95% CI=0.59 to 0.88). Recall (OR=1.26, 95% CI=1.07 to 1.47) and belief (OR=1.28, 95% CI=1.09 to 1.50) in distorted science about nicotine in general as well as belief in distorted science specific to COVID-19 (OR=1.61, 95% CI=1.34 to 1.95) were associated with more positive beliefs about the tobacco industry. Belief in distorted science about nicotine in general was also associated with more negative beliefs about the tobacco industry (OR=1.18, 95% CI=1.02 to 1.35). CONCLUSIONS: Use of social media platforms may help to both spread and dispel distorted science about nicotine. Addressing distorted science about nicotine is important, as it appears to be associated with more favourable views of the tobacco industry which may erode public support for effective regulation.
Assuntos
COVID-19 , Sistemas Eletrônicos de Liberação de Nicotina , Mídias Sociais , Indústria do Tabaco , Atitude , COVID-19/epidemiologia , Comunicação , Humanos , Nicotina , Adulto JovemRESUMO
BACKGROUND: Anti-industry sentiments are protective against smoking, but the relationship between industry beliefs and e-cigarette use remains unknown. METHODS: A nationally representative survey of U.S. youth and young adults in Fall 2019 (n = 9554) assessed knowledge that e-cigarette and cigarette companies are the same, belief that e-cigarette companies lie about harm, and belief that tobacco companies want young people to vape. Weighted multivariate logistic regression models estimated odds of current use and susceptibility to use (among ever and never users) by industry knowledge and beliefs. Additional models assess association between industry knowledge and industry beliefs. All models controlled for harm perceptions, friend use, sensation seeking, combustible use, and demographic characteristics. RESULTS: Disagreement that companies lie about harm (adjusted odds ratio (aOR)= 1.94, 95% CI: 1.43-2.63) and companies want young people to vape (aOR=1.72, 95% CI: 1.36-2.17) was associated with increased odds of current use. Belief that e-cigarette and cigarette companies were different entities was associated with increased odds of current use (aOR=1.45, 95% CI: 1.12-1.88). Disagreement or not knowing that companies are the same was associated with lower odds of believing companies lie about harm (disagreement aOR=0.37, 95% CI: 0.27-0.52; don't know aOR=0.47, 95% CI: 0.35-0.65) and belief that companies want young people to vape (disagreement aOR=0.36, 95% CI: 0.28-0.46; don't know aOR=0.54, 95% CI: 0.42-0.68). CONCLUSION: Similar to cigarettes, e-cigarette industry beliefs were associated with current use among young people. Highlighting e-cigarettes' connection to Big Tobacco may be an important strategy to prevent youth and young adult e-cigarette use.
Assuntos
Sistemas Eletrônicos de Liberação de Nicotina , Produtos do Tabaco , Vaping , Adolescente , Humanos , Fumar/epidemiologia , Uso de Tabaco , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: To understand the relationship between exposure to online tobacco advertising and current smokeless tobacco use in the context of tobacco control policies. METHODS: Three waves of a national probability-based sample of (n = 15,985) youth and young adults were used. Analysis consisted of GEE logistic models controlling for social media use, demographics, tobacco use, average price of smokeless tobacco inclusive of taxes, smoke-free indoor air laws (SFIA) and state tobacco control expenditures. RESULTS: Frequent exposure to tobacco advertising on social media is associated with greater odds of current smokeless use (aOR: 2.05, 95% CI: 1.62, 2.60). Higher prices and SFIA coverage were associated with reduced current smokeless use when examined separately from other tobacco policy variables (aOR: 0.79, CI: 0.73, 0.85; aOR: 0.44, CI: 0.28, 0.70). CONCLUSIONS: Greater exposure to tobacco advertising online is associated with greater odds of smokeless use among surveyed youth and young adults. This effect of social media marketing exposure on smokeless use outweighs the mitigating impact of existing tobacco control policies. The findings underscore the need for strong advertising regulation of evolving tobacco products, including smokeless products, on social media and surveillance of digital marketing tactics to young people.
Assuntos
Produtos do Tabaco , Tabaco sem Fumaça , Adolescente , Publicidade , Humanos , Nicotiana , Uso de Tabaco/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: Morbidity and mortality from smoking-related diseases among people living with HIV (PLWH) in the U.S. surpasses that due to HIV itself. Conventional smoking cessation treatments have not demonstrated strong efficacy among PLWH. We conducted a pilot randomized controlled trial (RCT) to evaluate a tailored smoking cessation intervention based on the minority stress model. We compared standard of care counseling (SOC) to a tailored intervention (TI) including one face-to-face counseling session incorporating cognitive behavioral therapy to build resilience, and 30 days of 2-way text messaging. RESULTS: The primary outcome was smoking cessation. Secondary outcomes included cigarettes per day (CPD), exhaled carbon monoxide (CO), and cessation self-efficacy. A total of 25 participants were enrolled (TI:11, SOC:14), and 2 were lost to follow-up. There were no significant differences in quit rates between study groups. However, there was a significantly greater decrease in CPD in the TI versus SOC (13.5 vs. 0.0, p-value:0.036). Additionally, self-efficacy increased in both groups (TI p-value:0.012, SOC p-value:0.049) and CO decreased in both groups (TI p-value: < 0.001, SOC p-value:0.049). This intervention shows promise to support smoking cessation among PLWH. A larger study is needed to fully evaluate the efficacy of this approach. CLINICAL TRIAL: Trial Registration: Retrospectively registered (10/20/2020) NCT04594109.
Assuntos
Infecções por HIV , Abandono do Hábito de Fumar , District of Columbia , Infecções por HIV/terapia , Humanos , Projetos Piloto , FumarRESUMO
OBJECTIVES: More than 250 US localities restrict sales of flavoured tobacco products (FTPs), but comprehensiveness varies, and many include retailer-based exemptions. The purpose of this study is to examine resulting changes in the US retail environment for FTPs if there was a hypothetical national tobacco control policy that would prohibit FTP sales in all retailers except (1) tobacco specialty stores or (2) tobacco specialty stores and alcohol outlets. DESIGN AND SETTING: A cross-sectional analysis of the FTP retail environment in every US Census tract (n=74 133). FTP retailers (n=3 10 090) were enumerated using nine unique codes from a national business directory (n=296 716) and a national vape shop directory (n=13 374). OUTCOME MEASURES: We assessed FTP availability using static-bandwidth and adaptive-bandwidth kernel density estimation. We then calculated the proportion of FTP stores remaining and the mean density of FTP retailers under each policy scenario for the overall population, as well as across populations vulnerable to FTP use. RESULTS: Exempting tobacco specialty stores alone would leave 25 276 (8.2%) FTP retailers nationwide, while exempting both tobacco specialty stores and alcohol outlets would leave 54 091 (17.4%) retailers. On average, the per cent remaining FTP availability per 100 000 total population was 7.1% for a tobacco specialty store exemption and 18.1% for a tobacco specialty store and alcohol outlet exemption. Overall, density estimate trends for remaining FTP availability among racial/ethnic populations averaged across Census tracts mirrored total population density. However, estimates varied when stratified by metropolitan status. Compared with the national average, FTP availability would remain 47%-49% higher for all racial/ethnic groups in large metropolitan areas. CONCLUSIONS: Retailer-based exemptions allow greater FTP availability compared with comprehensive policies which would reduce FTP availability to zero. Strong public policies have the greatest potential impact on reducing FTP availability, particularly among urban, and racial/ethnic minority populations.
Assuntos
Nicotiana , Produtos do Tabaco , Comércio , Estudos Transversais , Etnicidade , Humanos , Grupos MinoritáriosRESUMO
The effectiveness of tobacco control policies that create smoke-free healthcare facilities and encourage the delivery of tobacco dependence treatment may be undermined by the availability of retail tobacco in the surrounding environments. This study examined the availability of retail tobacco in relation to: federally qualified health centers and look-a-like (FQHC/LAL) healthcare facilities (nâ¯=â¯706) as well as substance abuse and addiction treatment centers (nâ¯=â¯953) across New York State (NYS) in 2018. A statewide tobacco retailer density surface using static-bandwidth kernel density estimation was constructed from geocoded licensed tobacco vendors (nâ¯=â¯21,314). For each healthcare facility, tobacco retailer density (retailers per square mile) was extracted from the underlying NYS density surface. Proximity from each healthcare facility to the nearest tobacco vendor was calculated in walkable miles. Across NYS, tobacco retailer density ranged from 0 to 41.02 retailers per square mile. The availability of retailer tobacco near FQHC/LAL healthcare facilities and substance abuse and addiction treatment centers was higher in metropolitan areas than less urban areas as expected. School-based FQHC/LAL healthcare facilities had higher density than all other FQHC/LAL healthcare facilities types (Meanâ¯=â¯20.82 vs. 17.04, pâ¯=â¯0.0042), while opioid abuse and addiction treatment centers had on average higher density (Meanâ¯=â¯20.42 vs. 9.81, pâ¯<â¯0.0001) and closer proximity to a tobacco vendor (Meanâ¯=â¯0.14 vs. 0.36, pâ¯<â¯0.0001) than other substance abuse and addiction treatment centers. State and local tobacco control retailer reduction policies should be considered to reduce the availability of retail tobacco surrounding these facilities.
RESUMO
INTRODUCTION: Evidence indicates that one reason cigarette smokers value e-cigarettes is the ability to use them in places where smoking is not permitted. We sought to: 1) explore adult daily smokers' experiences using e-cigarettes in the context of smoke-free places; and 2) describe smokers' perceptions of bystanders' reactions. METHODS: Twenty adult daily smokers in Washington, DC initiated e-cigarettes for three weeks and completed in semi-structured interviews at the end of each week. All interviews (n=60) were digitally-recorded, transcribed verbatim, imported into NVivo 10.0, and analyzed using thematic analysis methodology. RESULTS: The sample had a mean age of 37.9 years and 18 participants reported having smoked their first cigarette by age 18. Common themes included descriptions of: 1) uncertainty about whether smoke-free policies included e-cigarettes; 2) using e-cigarettes in smoke-free places (e.g. restaurants, workplace, public transit-bus and rail); 3) approaches to e-cigarette use in smoke-free places as part of a complex decision-making process, ranging from testing and establishing the social and spatial boundaries of e-cigarette use, to confining e-cigarette use to inside their home; and 4) favorable, unfavorable, and impartial reactions from bystanders facilitated or impeded e-cigarette use, indicating social approval/social disapproval. CONCLUSIONS: Results suggest a continuum of factors, including smoke-free policies and reactions from bystanders may facilitate or impede e-cigarette use among smokers in environments where a smoke-free imperative is well-established. As e-cigarette use evolves, study findings indicate the importance of the social environment and how it could affect those switching from cigarettes to e-cigarettes.