A New Study Examines Stealthy Vapor Devices Popular With Youth

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A newly published article examined stealthy vapor devices, as well as low-odor and low-vapor e-juices, via a comprehensive online search between March and June 2018. As evidence of their popularity, a search for ‘stealth vaping’ on YouTube found 18,200 videos. A variety of cleverly designed vapor devices disguised as USB sticks, pens, remote controls, car fobs, smart phones, sweatshirt drawstrings and even asthma inhalers are on the market. JUUL, which resembles a USB stick, is the archetype of these devices and is especially popular among youth. A search of ‘JUUL’ on YouTube yielded 148 000 videos with 57 videos having >100 000 views. Searches on ‘JUUL at school’ (15 500), ‘JUUL in class’ (6840), ‘hiding JUUL in school’ (2030) and ‘JUUL in school bathroom’ (1040) illustrate the product’s popularity among students. Some e-juices promote themselves as having low visibility plumes while others profess to be of subtle odor to avoid detection. Numerous techniques have been described to hide the exhaled vapor plume such as by swallowing it or blowing it into one’s clothing or into a backpack.

The researchers concluded that the vaping industry has demonstrated much ingenuity in devising discreet vaporizers and de-emphasizing exhaled vapor plumes and their aroma. The US market for vaping devices with stealthy characteristics is anything but inconspicuous, with JUUL alone accounting for 70.5% of sales (July 2018).

Source: Ramamurthi et al. (2018). JUUL and other stealth vaporizers: hiding the habit from parents and teachers. Tobacco Control, Sep 15. piitobaccocontrol-2018-054455. doi: 10.1136/tobaccocontrol-2018-054455. [Epub ahead of print]

Did You Know: That Higher SES is Linked To Higher Electronic Nicotine Delivery System Use?

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A newly published study investigated the association between socioeconomic status (SES) (education, income, and employment status) and current and former electronic nicotine delivery system (ENDS) use. Researchers analyzed data from the American Heart Association Tobacco Regulatory and Addiction Center (A-TRAC) online survey.

Findings included:

  • College educated persons (vs. those with less than a high school diploma) had a 37% greater prevalence of current ENDS use and a 16% greater prevalence of former ENDS use.
  • Persons with household incomes above $90K (vs. less than $20,000) had a greater prevalence of current and former ENDS use.
  • Those who were employed (vs. not employed) had a 13% greater prevalence of current ENDS use.
  • Higher SES (vs. lower SES) persons were more likely to use ENDS.
Source: Glover et al. (2018). The social patterning of electronic nicotine delivery system use among US adults. Preventive Medicine, Aug 29;116:27-31. doi: 10.1016/j.ypmed.2018.08.038. [Epub ahead of print]

Newly Published: Literature Review of Hookah Use among Youth

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This systematic review summarizes and assesses the literature related to hookah use among adolescents (11 to 18 years of age) in the U.S. from 2009 to 2017. Authors reviewed 461 articles for inclusion and included 55 articles which were coded for study themes, study quality and their relevance to FDA’s research priorities.

Findings included:

·         The following themes were identified: (1) prevalence of hookah use (n=42); (2) tobacco use transitions (n=7); (3) sociodemographic correlates (n=35); (4) psychosocial risk factors (n=21); (5) concurrent use of other tobacco products (n=31); (6) concurrent use of other substances (n=9); and (7) other (n=15) which includes low prevalence themes.

·         Older age, male gender, positive social normative beliefs, higher peer use as well as lower perceived risk were associated with hookah use.

·         Longitudinal studies of youth hookah use showed bidirectional relationships between use of hookah and other tobacco products.

·         All articles fell within FDA’s research priority related to “behavior.” Three priorities (“impact analysis,” “health effects,” and “toxicity”) have not been explored for hookah use among U.S. youth since 2009.

The researchers concluded that the prevalence of hookah use among youth in the U.S. is increasing, thus more research is needed to inform policies targeted to protect this vulnerable population.

Source: Cooper et al. (2018). Hookah Use among U.S. Youth: A Systematic Review of the Literature from 2009-2017. Nicotine & Tobacco Research, Jun 28. doi: 10.1093/ntr/nty135. [Epub ahead of print].

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Who Is More Likely To Initiate Tobacco Product Use: Youth or Young Adults?

A recently published study examined the initiation of tobacco product use, including cigarettes, e-cigarettes, cigar products, and hookah, among contemporary youth and young adults, to determine whether the developmental timing (youth vs. young adulthood) of initiation has changed. Researchers analyzed data from the national Population Assessment of Tobacco and Health Study, and two Texas cohort studies, the Texas Adolescent Tobacco and Marketing Surveillance System (TATAMS), and the Marketing and Promotions Across Colleges in Texas (M-PACT) project. Findings indicate that young adults who were never users began to ever and currently use all tobacco products more than youth in these samples, a marked departure from prior decades of research.

Source:  Perry et al. (2018). Youth or Young Adults: Which Group Is at Highest Risk for Tobacco Use Onset? The Journal of Adolescent Health, Jul 7. pii: S1054-139X(18)30188-5. doi: 10.1016/j.jadohealth.2018.04.011. [Epub ahead of print]

Did You Know? Receptivity to Tobacco Advertising Is Associated With Progression Toward Use In Adolescents


A newly published study investigated whether receptivity to tobacco advertising among youth and young adults is associated with progression (being a susceptible never user or ever user) to use of the product advertised, as well as conventional cigarette smoking. For that purpose, researchers analyzed data from the Population Assessment of Tobacco and Health (PATH) Study at wave 1 (2013-2014) and 1-year follow-up at wave 2 (2014-2015) which was conducted in a US population-based sample of never tobacco users aged 12 to 24 years from wave 1 of the PATH Study (N = 10,989).

Findings included:

  • Receptivity to any tobacco advertising at wave 1 was high for those aged 12 to 14 years but highest for those aged 18 to 21 years.
  • E-Cigarette advertising had the highest receptivity among all age groups.
  • For those aged 12 to 17 years, susceptibility to use a product at wave 1 was significantly associated with product use at wave 2 for conventional cigarettes, e-cigarettes, cigars, and smokeless tobacco products.
  • Among committed never users aged 12 to 17 years at wave 1, any receptivity was associated with progression toward use of the product at wave 2.

 The researchers concluded that receptivity to tobacco advertising was significantly associated with progression toward use in adolescents. Receptivity was highest for e-cigarette advertising and was associated with trying a cigarette.


Source: Pierce et al. (2018). Association Between Receptivity to Tobacco Advertising and Progression to Tobacco Use in Youth and Young Adults in the PATH Study. JAMA Pediatrics, Mar 26. doi: 10.1001/jamapediatrics.2017.5756. [Epub ahead of print]



Did You Know? A Quarter Of Youth Who Have Never Used Tobacco Products Are Open To Using E-Cigarettes

A newly published study examined how e-cigarette harm perceptions and advertising exposure are associated with openness and curiosity among tobacco naive youth. Findings from the 2015 National Youth Tobacco Survey were analyzed.

Findings included:

  • Among respondents who never used tobacco products, 24% were open to using e-cigarettes and 25% were curious.
  • Respondents that perceived e-cigarettes to cause a lot of harm had lower odds of both openness and curiosity about e-cigarettes compared to those with lower harm perception.
  • Respondents who reported high exposure to e-cigarette advertising in stores had greater odds of being open to e-cigarette use and highly curious compared to those not highly exposed.


The researchers concluded that youth exposed to e-cigarette advertising are open and curious to e-cigarette use. These findings could help public health practitioners better understand the interplay of advertising exposure and harm perceptions with curiosity and openness to e-cigarette use in a rapidly changing marketplace.

Source: Margolis et al. (2018). E-cigarette openness, curiosity, harm perceptions and advertising exposure among U.S. middle and high school students. Preventive Medicine, Apr 17, 112:119-125. doi: 10.1016/j.ypmed.2018.04.017. [Epub ahead of print]

Did You Know? Youth Exposure to E-Cigarette Advertising is Highest in Retail Stores

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A newly published Morbidity and Mortality Report (CDC, March 2018) focused on the exposure to electronic cigarette advertising among middle and high school students. To assess patterns of self-reported exposure to four e-cigarette advertising sources (retail stores, the Internet, television, and newspapers and magazines), CDC researchers analyzed data from the 2014, 2015, and 2016 National Youth Tobacco Surveys (NYTSs).

Findings included:

  • Overall, exposure to e-cigarette advertising from at least one source increased each year during 2014-2016 (2014: 68.9%; 2015: 73.0%; 2016: 78.2%).
  • In 2016, exposure was highest for retail stores (68.0%), followed by the Internet (40.6%), television (37.7%), and newspapers and magazines (23.9%).
  • During 2014-2016, youth exposure to e-cigarette advertising increased for retail stores (54.8% to 68.0%), decreased for newspapers and magazines (30.4% to 23.9%), and did not significantly change for the Internet or television.


Recommendations include reducing youth exposure to e-cigarette advertising from a range of sources, including retail stores, television, the Internet, and print media such as newspapers and magazines.

Source: Marynak et al. (2018). Exposure to Electronic Cigarette Advertising Among Middle and High School Students – United States, 2014-2016. MMWR Morb Mortal Wkly Rep. 2018 Mar16, 67(10), 294-299.

Did You Know? Hookah Smoking is Common Among College Students

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A recently published study reported on the first nicotine product used among undergraduates who had ever tried tobacco, and explores correlates of hookah as that first product. Participants included a convenience sample of undergraduate students (n = 1538) at four universities in upstate New York during fall 2013. 
Findings included: 
  • Among the 832 students who reported ever use of any nicotine product, 25.4% reported hookah as their first product smoked; only combustible cigarettes (39.5%) were reported more frequently. 
  • Among students who ever smoked cigarettes, most reported cigarettes as their introductory product. 
  • Among students who never smoked cigarettes, nearly half reported hookah as their introductory product. 
  • Among ever nicotine users, current hookah smoking was common (34.9%), and greater than current e-cigarette (25.9%) and current combustible cigarette (26.4%) use. 
  • Never users of cigarettes, females, and non-Hispanic African Americans, had higher adjusted odds of reporting hookah as their introductory product.
The researchers’ recommendations include broadening prevention efforts beyond a focus on combustible cigarettes.
Source: Kulak et al. (2018). Examining Hookah as an Introduction to Nicotine Products among College Students. Substance Use & Misuse, Mar 13:1-9. doi: 10.1080/10826084.2018.1441308. [Epub ahead of print]

Lack of Public Health Messages About Hookah Use Maybe Interpreted As Sign That Hookah Use is Safe

The rate of Hookah use among college students during the last decade is about 30%. Presently, the US Food and Drug Administration (FDA) has little regulation for the manufacture, distribution, or sale of hookah. A recently published review of the scientific literature assessed hookah use while focusing on the consequences for regulatory policy.
Findings included:
  • Hookah use may initiate smoking among tobacconaïve college students.
  • College students who use hookah are generally not aware of the increased risks for tobacco related diseases as it relates to their behavior.
  • Few public health messages target college-age adults with anti-hookah messages.
  • A lack of information regarding the dangers and potential harms of hookah use may be misinterpreted as a sign of “safety” which inadvertently may imply a suggestion of no need for safety measures.
Source: Fevrier et al. (2018). Policy Implications and Research Recommendations: A Review of Hookah Use Among US College Students. Journal of Community Health, Mar 30. doi: 10.1007/s10900-018-0502-4. [Epub ahead of print]

Did You Know? Among California Youth, Prevalence of E-Cigarette Use is Highest Among Non-Hispanic White Boys and Asian Girls


A newly published study sought to determine e-cigarette use prevalence and its relation to alcohol use as a potential gateway drug, and how this may differ by sex and ethnicity in a multi-ethnic sample of California adolescents. The researchers analyzed data from 1806 adolescents aged 12-17 in the 2014 and 2015 California Health Interview Survey (CHIS) cycles.

Findings included:

  • The prevalence of e-cigarette use was 9.1% overall in California adolescents but highest in boys among non-Hispanic Whites (15.1%) and in Asian girls (13.3%).
  • Among e-cigarette users, 61.3% of boys and 71.0% of girls reported using alcohol as well.

The researchers concluded that attention needs to be paid to the high prevalence of e-cigarette smoking, as well as its potential as a gateway drug for alcohol drinking in adolescents.

Source: Wong & Fan, (2018). Ethnic and sex differences in E-cigarette use and relation to alcohol use in California adolescents: the California Health Interview Survey. Public Health, Mar 7;157:147-152. doi: 10.1016/j.puhe.2018.01.019. [Epub ahead of print]

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Literature Review Of Characteristics Of Adolescent E-Cigarette Users
A newly published article reviewed the existing e-cigarette literature for the characteristics of adolescents most likely to become e-cigarette users. A total of 100 articles were found, and 25 were finally included in the present review. The researchers found that older age, male gender, conventional smokers, peer influence, daily smoking, and heavier smoking are the most common characteristics of adolescent e-cigarette users. Since e-cigarette use is increasing and considering that the long-term health effects are still under investigation, targeted interventions towards more susceptible individuals may be an effective prevention strategy.
Source: Perikleous et al. (2018). E-Cigarette Use Among Adolescents: An Overview of the Literature and Future Perspectives. Frontiers in Public Health, Mar 26;6:86. doi: 10.3389/fpubh.2018.00086.
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Did You Know? Majority of Youth who Use Electronic Vaping Products Use Advanced Models that Deliver Nicotine More Effectively

Advanced models of electronic vaping products (EVPs) likely pose a greater risk to adolescent health than basic or intermediate models because advanced models deliver nicotine more effectively and heat e-liquid to higher temperatures, producing more harmful chemical emissions. A newly published study (Nicotine & Tobacco Research, December 2017) examined adolescents’ risk factors for using different device types. Researchers used social media to recruit an online sample of 1,508 U.S. adolescents aged 15-17 who reported past 30-day use of e-cigarettes. The study assessed tobacco use, beliefs and knowledge about EVPs, and EVP use behavior, including the device type participantsuse most frequently. 
Findings included:
  • Most respondents usually used modifiable advanced devices (56.8%) rather than basic “cigalike” (14.5%) or pen-style intermediate (28.7%) devices.
  • Use of multiple device types was common, particularly among those who primarily used basic devices.
  • Younger age and less frequent vaping were associated with mainly using basic devices.
  • Adolescents who were older, male, personally bought their main device, and had ever mixed e-liquids were at elevated risk for usually using advanced devices.
The researchers concluded that adolescents who primarily use basic devices may be newer users who are experimenting with multiple devices. Future research should examine which adolescents are most likely to transition to advanced devices in order to develop targeted interventions. Recommendations include that regulators should consider strategies to reduce access to all types of EVPs, such as better enforcement of the current ban on sales to minors.
Source: Pepper et al. (2017). Adolescents’ Use of Basic, Intermediate, and Advanced Device Types for Vaping. Nicotine & Tobacco Research, Dec 23, [Epub ahead of print]
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Did You Know That African Americans, Compared To Whites And Hispanics, Are Less Likely To View E-Cigarettes As Addictive?

A recently published study examined racial/ethnic differences in e-cigarette knowledge, risk perceptions, and social norms among current and former smokers.

Findings included:

  • White participants scored significantly higher on e-cigarette knowledge, compared to both Hispanics and African Americans/Blacks.
  • Knowledge was lower among African Americans/Blacks compared to Hispanics.
  • Compared to both Whites and Hispanics, African American/Black participants held lower perceptions regarding e-cigarette health risks and were less likely to view e-cigarettes as addictive.
  • Normative beliefs did not differ by race/ethnicity.

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