Lynne Dawkins

Adolescent Awareness and Use of Electronic Cigarettes: A Review of Emerging Trends and Findings

Adult electronic cigarette (e-cigarette) use is increasing globally, and early studies have suggested that similar trends may be observed among the adolescent population, albeit at lower levels. The current literature review presents data collected since 2014 from 21 cross-sectional studies and one cohort study that were all published in English. In particular, it focuses on awareness, ever use, past 30-day use, and regular use of e-cigarettes. The article suggests that adolescents are nearing complete awareness of e-cigarettes. Furthermore, in relation to ever use and past 30-day use, higher prevalence rates continue to be reported across time, especially in the United States. Nonetheless, reported regular use of e-cigarettes remains much lower than past 30-day use, although conclusions are limited due to inconsistencies with measurement and consequent lack of cross-cultural applicability. The majority of studies do not report whether adolescents use non-nicotine e-cigarettes. There is a current absence of longitudinal studies that explore any association between e-cigarettes and tobacco use and little qualitative data that may illuminate how and why adolescents use e-cigarettes. Through addressing these methodological limitations, future research will be able to inform health care and policy more effectively.

Compensatory Puffing With Lower Nicotine Concentration E-liquids Increases Carbonyl Exposure in E-cigarette Aerosols

Introduction Article 20 of the European Tobacco Products Directive (EU-TPD) specifies that e-liquids should not contain nicotine in excess of 20 mg/mL, thus many vapers may be compelled to switch to lower concentrations and in so doing, may engage in more intensive puffing. This study aimed to establish whether more intensive puffing produces higher levels of carbonyl compounds in e-cigarette aerosols. Methods Using the HPLC-UV diode array method, four carbonyl compounds (formaldehyde, acetaldehyde, acetone, and acrolein) were measured in liquids and aerosols from nicotine solutions of 24 and 6 mg/mL. Aerosols were generated using a smoking machine configured to replicate puffing topography data previously obtained from 12 experienced e-cigarette users. Results Carbonyl levels in aerosols from the puffing regimen of 6 mg/mL were significantly higher (p < .05 using independent samples t tests) compared with those of 24 mg/mL nicotine. For the 6 and 24 mg/mL nicotine aerosols respectively, means ± SD for formaldehyde levels were 3.41 ± 0.94, and 1.49 ± 0.30 µg per hour (µg/h) of e-cigarette use. Means ± SD for acetaldehyde levels were 2.17 ± 0.36 and 1.04 ± 0.13 µg/h. Means ± SD for acetone levels were 0.73 ± 0.20 and 0.28 ± 0.14 µg/h. Acrolein was not detected. Conclusions Higher levels of carbonyls associated with more intensive puffing suggest that vapers switching to lower nicotine concentrations (either due to the EU-TPD implementation or personal choice), may increase their exposure to these compounds. Based on real human puffing topography data, this study suggests that limiting nicotine concentrations to 20 mg/mL may not result in the desired harm minimalization effect. Implications More intensive puffing regimens associated with the use of low nicotine concentration e-liquids can lead to higher levels of carbonyl generation in the aerosol. Although in need of replication in a larger sample outside a laboratory, this study provides pragmatic empirical data on the potential risks of compensatory puffing behaviors in vapers, and can help to inform future regulatory decisions on nicotine e-liquid concentrations. The cap on nicotine concentration at 20 mg/mL set by the EU-TPD may therefore have the unintended consequence of encouraging use of lower nicotine concentration e-liquid, in turn increasing exposure to carbonyl compounds through compensatory puffing.

A qualitative exploration of the role of vape shop environments in supporting smoking abstinence.

E-cigarettes are the most popular method of quitting smoking in England and most are purchased in specialist vape shops. This qualitative study explores how the vape shop environment is experienced by quitters to support smoking abstinence. Semi-structured qualitative interviews were conducted to elicit experiences of e-cigarette use, including experiences of vape shops, in 40 people who had used e-cigarettes in a quit attempt. Observations of six shops in a range of locations were also undertaken. Interview and observation data were analysed using inductive thematic analysis and triangulated. At an individual level, smoking abstinence was supported through shop assistants’ attempts to understand customers’ smoking preferences in order to: (i) tailor advice about the most appropriate product; and (ii) offer an ongoing point of contact for practical help. At an interpersonal level, shops offered opportunity to socialise and reinforce a vaping identity, although the environment was perceived as intimidating for some (e.g., new and female users). At a structural level, shops ensured easy access to products perceived to be good value by customers and had adapted to legislative changes. Vape shops can provide effective behavioural support to quitters to maintain smoking abstinence. Health professionals could capitalise on this through partnership working with shops, to ensure best outcomes for clients wanting to use e-cigarettes to quit smoking.

E-cigarette puffing patterns associated with high and low nicotine e-liquid strength: effects on toxicant and carcinogen exposure

BackgroundContrary to intuition, use of lower strength nicotine e-liquids might not offer reduced health risk if compensatory puffing behaviour occurs. Compensatory puffing (e.g. more frequent, longer puffs) or user behaviour (increasing the wattage) can lead to higher temperatures at which glycerine and propylene glycol (solvents used in e-liquids) undergo decomposition to carbonyl compounds, including the carcinogens formaldehyde and acetaldehyde. This study aims to document puffing patterns and user behaviour associated with using high and low strength nicotine e-liquid and associated toxicant/carcinogen exposure in experienced e-cigarette users (known as vapers herein).Methods/designA counterbalanced repeated measures design. Participants: Non-tobacco smoking vapers; have used an e-cigarette for ≥3 months; currently using nicotine strength e-liquid ≥12mg/mL and a second or third generation device. Intervention: This study will measure puffing patterns in vapers whilst they use high and low strength nicotine e-liquid under fixed and user-defined settings, each for a week. The 4 counterbalanced conditions are: i) low strength (6mg/mL), fixed settings; ii) low strength user-defined settings; iii) high strength (18mg/mL) fixed settings; iv) high strength user-defined settings. Biomarkers of exposure to toxicants and carcinogens will be measured in urine. In the second phase of this study, toxicant yields will be measured in aerosol generated using a smoking machine operated to replicate the puffing behaviours of each participant. Primary outcomes: i) Puffing patterns (mean puff number, puff duration, inter-puff interval and mL of liquid consumed) and user behaviour (changes to device settings: voltage and air-flow) associated with using high and low strength nicotine e-liquid. ii) Toxicant/carcinogen exposure associated with the puffing patterns/device settings used by our participants. Secondary outcomes: i) Subjective effects. ii) comparisons with toxicant exposure from tobacco smoke (using documented evidence) and with recommended safety limits. Sample size: Twenty participants.DiscussionThe findings will have important implications for public health messaging regarding the relative risks and subjective effects associated with using high and low strength nicotine e-liquid, and for policy makers regarding regulations on nicotine concentrations in e-liquids.

A pre-post pilot study of electronic cigarettes to reduce smoking in people with severe mental illness.

BACKGROUND Smoking is the largest single contributor to poor physical health and increased mortality in people with serious mental illnesses. The aim of the study was to investigate the utility of electronic cigarettes (e-cigarettes) as a harm reduction intervention in this population. METHOD Fifty tobacco smokers with a psychotic disorder were enrolled onto a 24-week pilot study (ClinicalTrials.gov: NCT02212041) investigating the efficacy of a 6-week free e-cigarette intervention to reduce smoking. Cigarette and e-cigarette use was self-reported at weekly visits, and verified using carbon monoxide tests. Psychopathology, e-cigarette acceptability and adverse effects were assessed using standardised scales. RESULTS There was a significant (⩾50%) reduction in cigarettes consumed per day between baseline and week 6 [F(2.596,116.800) = 25.878, p < 0.001], and e-cigarette use was stable during this period [F(2.932,46.504) = 2.023, p = 0.115]. These changes were verified by significant carbon monoxide reductions between these time points [F(3.335,126.633) = 5.063, p = 0.002]. CONCLUSIONS The provision of e-cigarettes is a potentially useful harm reduction intervention in smokers with a psychotic disorder.

Global and local perspectives on tobacco harm reduction: what are the issues and where do we go from here?

Editorial for a thematic series of Harm Reduction Journal which explores the issues surrounding the current state of tobacco harm reduction at global and local levels. Tobacco harm reduction (THR) refers to strategies designed to reduce the health risks associated with tobacco smoking but which may involve the continued use of nicotine. The health consequences of tobacco smoking are well documented; if current trends continue, it has been estimated that globally, a billion lives will be lost to tobacco smoking in the twenty-first century. However, although some countries have embraced the concept, THR has not been, and is not, widely accepted or implemented, with heavy sanctions on reduced risk nicotine-containing products (including e-cigarettes, snus and heat not burn products) in many countries. Mike Russell famously stated ‘smokers smoke for the nicotine, but die from the tar’. Despite the ringing clarity of this message that it is the thousands of toxicants and numerous carcinogens in tobacco smoke that leads to premature death and disease, many years on, the science of ‘cleaner’ nicotine-containing products remains heavily contested. Nicotine’s long association with combustible tobacco continues to mar social political dialect surrounding the use of nicotine products for harm reduction. A correction was issued on 16 July 2018, also available to download.

The unique contribution of e-cigarettes for tobacco harm reduction in supporting smoking relapse prevention

BackgroundWe have little understanding of how vapers use e-cigarettes beyond cessation. E-cigarettes may have a role to play in reducing the health-related harms of tobacco smoking, through not only assisting smoking cessation attempts but also supporting long-term abstinence from smoking. However, there are fears that vaping may lead to the ‘renormalisation’ of smoking type behaviours. This study aimed to explore patterns of use and reported experiences of vapers quitting smoking using an e-cigarette in relation to long-term smoking status (abstinence or relapse).MethodsA purposive sample of 40 UK vapers was matched to a sampling frame of demographic characteristics from a representative sample of UK quitters. Following full informed consent, semi-structured qualitative interviews were conducted. Data were thematically analysed by two members of the research team. Final thematic analysis was verified and agreed by consensus.ResultsThe sample self-reported long histories of tobacco use and multiple previous quit attempts which had eventually resulted in relapse back to smoking, although a small but important group had never before attempted to quit. Initiating e-cigarette use was experienced as a revelation for some, who were quickly able to fully switch to using e-cigarettes as an alternative to tobacco smoking. For others, periods of dual use or smoking relapse combined with attempts at vaping that were not initially satisfactory. Many of these chose a cheaper ‘cig-a-like’ device which they found to be inadequate. Experimentation with different devices and different setups, over time, resulted in some ‘sliding’ rather than switching to vaping. This involved periods of ‘dual use’. Some settled on patterns of vaping as a direct substitute of previous tobacco smoking, whereas others reported ‘grazing’ patterns of vaping throughout the day that were perceived to support tobacco smoking abstinence.ConclusionsOur data demonstrates that e-cigarettes may be a unique harm reduction innovation for smoking relapse prevention. E-cigarettes meet the needs of some ex-smokers by substituting physical, psychological, social, cultural and identity-related aspects of tobacco addiction. Some vapers reported that they found vaping pleasurable and enjoyable—being more than a substitute but actually preferred, over time, to tobacco smoking. This clearly suggests that vaping is a viable long-term substitute for smoking, with substantial implications for tobacco harm reduction.

Correction to: Global and local perspectives on tobacco harm reduction: what are the issues and where do we go from here?

After publication of the original article [1], the authors noticed an error in the Competing interests section.

Nicotine absorption from e-cigarettes over 12 months

BACKGROUND Research indicates that, over time, exclusive e-cigarette users (vapers) gradually reduce the nicotine concentration in their e-liquid and transition to more sophisticated devices. Alongside this, consumption of e-liquid increases and constant cotinine levels are maintained. AIMS We aimed to confirm these observations in 27 experienced vapers tested at baseline and 12 months later, by measuring nicotine absorption (via salivary levels of the nicotine metabolite cotinine; ng/mL), nicotine concentrations in e-liquid (mg/mL), volume of e-liquid consumed (mL per day), device types and flavours used, both at baseline and 12 months. RESULTS Vapers reduced both their nicotine concentrations in e-liquid over 12 months (from 13.83 mg/mL at baseline to 9.91 at follow up) but significantly increased their e-liquid consumption (from 4.44 to 6.84 mL). No significant changes in salivary cotinine concentrations (370.88 ng/mL at baseline and 415.78 ng/mL at follow up) were observed. There was an increase in sub-ohming (using an atomiser coil with resistance of <1 Ω with increased power) at 12 months, and in the use of fruit flavoured e-liquids. CONCLUSIONS Our sample of experienced vapers reduced the concentration of nicotine in their e-liquid over time, but maintained their nicotine intake possibly through self-titration via more intensive puffing. Findings suggest there may be little benefit in reducing nicotine e-liquid concentration since this appears to result in higher e-liquid consumption which may incur both a financial and health cost. Gaining an understanding of underlying reasons for lowering e-liquid concentration would be a useful line of empirical enquiry.

Predictors of heroin abstinence in opiate substitution therapy in heroin-only users and dual users of heroin and crack

AIMS To analyse predictors of heroin abstinence in opiate substitution therapy (OST) based on frequency of crack use and its interactions with other predictors in a clinical non-experimental setting. DESIGN Retrospective study. SETTING A community drug service in London, UK. PARTICIPANTS 325 clients starting OST between 2010 and 2014 (197 methadone and 128 buprenorphine). MEASUREMENTS Logistic regression models (a general model and separate models for methadone and buprenorphine) assessed demographic and clinical data as predictors of heroin abstinence at one year after treatment start (or at the date of transfer to another service). FINDINGS For the general model participants choosing methadone were more likely to use heroin at follow up (OR=2.36, 95% CI: 1.40-3.17) as were daily crack users on methadone (OR=2.62, 95% CI: 0.96-7.16). For the methadone model only daily crack use predicted heroin use at follow up (OR=2.62, 95% CI: 0.96-7.16). For buprenorphine, higher amounts of baseline heroin use, lower buprenorphine dose and daily drinking predicted heroin use at follow up (OR=0.85, 95% CI: 0.75-0.95; OR=1.31, 95% CI: 1.06-1.60 and OR=6.04, 95% CI: 1.26-28.92). Both use of cannabis and depression increased likelihood of heroin abstinence for clients not using crack compared to occasional (OR=6.68, 95% CI: 0.37-119.59; OR=106.31, 95% CI: 3.41-3313.30) and daily (OR=57.49 (95% CI: 2.37-1396.46; OR=170.99 (95% CI: 4.61-6339.47) users. CONCLUSIONS Most of the predictors in the general model were found significant only in the buprenorphine but not in the methadone model, suggesting that a general model has little predictive value. Crack use was a significant predictor of heroin abstinence at follow up in all models, however for buprenorphine only when depression or cannabis use was present. Further research is needed to assess effective treatment approaches for the growing population of dual users.