The Role of Flavors in Electronic Cigarette Abuse Liability in Tobacco-Naïve Young Adults

A primary public health concern associated with the use of electronic cigarettes (ECIGS) has been the risk of product initiation by vulnerable young adults who are largely naïve to tobacco. The use of ECIGs among such individuals may be influenced by the wide variety of sweet flavored liquids available for purchase. Previous work suggests that one flavor, menthol, increases the likelihood of abuse of cigarettes. Thus, the United States Food and Drug Administration has requested input from the research community regarding the abuse liability of flavored ECIGs in order to inform future product regulation. Using a double-blind, within-subject study design, 30 young adults (aged 18-24 years, M = 19.43, 63.3% female, 83.3% Caucasian) who are largely tobacco-naïve experienced two sessions that differed by the flavor of ECIG liquid used: tobacco or fruit (choice of fruit medley or mango). Within each session, participants used the flavor assigned ECIG during two separate puffing bouts and rated product effects via subjective questionnaires (e.g., nicotine delivery, product acceptability) pre- and post-bouts. Participants also rated subjective product appeal and engaged in both a progressive ratio and probability-based purchase task to assess willingness to work for and spend money on each flavor of ECIG. Smoking topography (i.e., puff number, duration, and inter-puff interval) was also analyzed. Heart rate and subjective measures of nicotine delivery (e.g., lightheadedness, nausea, headache) were significantly higher post- bout compared to pre-bout, indicating nicotine delivery during puffing bouts. However, few significant effects of flavor emerged across subjective, physiological, behavioral economic, or puffing topography outcomes. Recruited participants had very low levels of lifetime ECIG use (M = 12.37 uses; range = 3 - 50 uses) and reported not enjoying ECIG use. Rather, the majority of participants reported social motivations as a primary reason for product use. While this study is the first to experimentally assess abuse liability of flavor among a sample of tobacco naïve young adults, results suggest that there may be factors other than flavor which motivate initial product use and susceptibility among naïve users with low lifetime use

Cannabis Legalization in State Legislatures: Public Health Opportunity and Risk

Forthcoming in the Marquette Law Revie

Addictiveness and sttractiveness of tobacco additives

SCENIHR (Scientific Committee on Emerging and Newly Identified Health Risks): et al.The Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) has been asked to evaluate the role of tobacco additives in the addictiveness and attractiveness of tobacco products. The criteria for dependence established in humans indicate that tobacco has a high addictive potential, but it remains difficult to assess the addictiveness of individualadditives. In animal studies the addictive potency of the final tobacco product cannot be assessed. The reinforcing potency of drugs is measured after intravenous injections and suggests that the abuse liability of pure nicotine is weaker than the addictive potential of tobacco products in humans. The currently used methods to define addictiveness of nicotine and additives are thus not considered adequate. In humans, the positive correlation between tobacco consumption and dependence suggests that individuals with high nicotine levels in their blood are more dependent. In animal studies using self-administration, an inverted U-shaped dose-response curve has generally been revealed suggesting that the addictiveness of nicotine is not directly linearwith the dose. There is however substantial variation in the response to nicotine in both animals and humans, and genetic factors probably play an important role. No tobacco additives which are addictive by themselves have so far been identified. However, sugars, polysaccharides and cellulose fibres which are naturally present in tobacco, or sugars added in high quantities to most tobacco products, give rise to numerous aldehydes, such as acetaldehyde, in tobacco smoke. Acetaldehyde given intravenously is self-administered and enhances the addictiveness of nicotine in experimental animals. Additives that facilitate deeper inhalation (e.g. menthol) or inhibit the metabolism of nicotine may enhance the addictiveness of nicotine indirectly. Substances such as ammonia that increase the pH of the tobacco and the smoke, result in higher amounts of uncharged nicotine. However, it is uncertain if more nicotine isabsorbed with higher smoke pH. For smokeless tobacco it seems that an increased pH enhances nicotine absorption in the mouth.The methods used to quantify the addictive potency of additives have limitations because of technical challenges in experimentally manipulating the presence or absence of anadditive in a tobacco product. Such experiments require large technical and financial resources. In addition, there are ethical issues if testing in humans is considered. Due to these limitations, the available methodologies are not considered adequate. A number of technical characteristics of cigarettes (paper, filter, packing, geometry) influence the content of different substances in the smoke and the size of smoke particles. Many smokers compensate for a lower dose of nicotine by increasing puff volume and frequency, and by deeper inhalation. The particle size of the smoke aerosol does not seem to substantially influence the exposure to nicotine. The technical characteristics of cigarettes may thus modulate smoking behaviour but it is uncertain if this leads to a higher risk of addiction. Attractiveness is defined as the stimulation to use a product. The attractiveness of tobacco products may be increased by a number of additives but is also influenced by external factors such as marketing, price etc. Animal models do not currently exist for the assessment of attractiveness. In humans, the attractiveness of individual tobaccoproducts may be compared in panel studies, surveys, and by experimental measures. Another method is to experimentally adjust tobacco products to exclude or include individual additives and test responses to them. However, this type of research is difficult due to ethical considerations that will usually preclude human testing of tobacco products, particularly among non-users or children. The use of fruit and candy flavours seems to favour smoking initiation in young people. Menthol also attracts a number of smokers, in particular African Americans. Some additives decrease the harshness and increase the smoothness of the smoke. Certain additives yield a full and white smoke and other additives reduce the lingering odour of the smoke in order to favour the acceptability of smoking to people around. Additives considered attractive may in principle lead to brand preference or a higher consumption of tobacco products. However, it remains difficult to distinguish the direct effects of these additives from indirect effects such as the marketing towards specific groups.Peer Reviewe

Reducing the smoking-related health burden in the USA through diversion to electronic cigarettes: a system dynamics simulation study

Background Electronic cigarettes (“e-cigarettes”) have altered tobacco smoking trends, and their impacts are controversial. Given their lower risk relative to combustible tobacco, e-cigarettes have potential for harm reduction. This study presents a simulation-based analysis of an e-cigarette harm reduction policy set in the USA. Methods A system dynamics simulation model was constructed, with separate aging chains representing people in different stages of use (both of combustible cigarettes and e-cigarettes). These structures interact with a policy module to close the gap between actual (simulated) and goal numbers of individuals who smoke, chosen to reduce the tobacco-attributable death rate (i.e., mostly combustible cigarette-attributable, but conservatively allowing e-cigarette-attributable deaths) to that due to all accidents in the general population. The policy is two-fold, removing existing e-liquid flavor bans and providing an informational campaign promoting e-cigarettes as a lower-risk alternative. Realistic practical implementation challenges are modeled in the policy sector, including time delays, political resistance, and budgetary limitations. Effects of e-cigarettes on tobacco smoking occur through three mechanisms: (1) diversion from ever initiating smoking; (2) reducing progression to established smoking; and (3) increasing smoking cessation. An important unintended effect of possible death from e-cigarettes was conservatively included. Results The base-case model replicated the historical exponential decline in smoking and the exponential increase in e-cigarette use since 2010. Simulations suggest tobacco smoking could be reduced to the goal level approximately 40 years after implementation. Implementation obstacles (time delays, political resistance, and budgetary constraints) could delay and weaken the effect of the policy by up to 62% in the worst case, relative to the ideal-case scenario; however, these discrepancies substantially decreased over time in dampened oscillations as negative feedback loops stabilize the system after the one-time “shock” introduced by policy changes. Conclusions The simulation suggests that the promotion of e-cigarettes as a harm-reduction policy is a viable strategy, given current evidence that e-cigarettes offset or divert from smoking. Given the strong effects of implementation challenges on policy effectiveness in the short term, accurately modeling such obstacles can usefully inform policy design. Ongoing research is needed, given continuing changes in e-cigarette use prevalence, new policies being enacted for e-cigarettes, and emerging evidence for substitution effects between combustible cigarettes and e-cigarettes.publishedVersio

Prev Chronic Dis

IntroductionAn understanding of the real-world use of electronic cigarettes (e-cigarettes) is needed to inform surveillance efforts and future state and federal regulation. This study investigates the behavioral aspects of e-cigarette use.MethodsWe used qualitative methods to examine salient characteristics of e-cigarette use. The lead investigator (M.C.) conducted in-depth, semistructured individual interviews to explore patterns and behaviors associated with e-cigarette use among a purposive sample of 50 current adult users. Thematic content analysis was used to analyze qualitative data and document themes.ResultsSeveral important themes emerged. Although most users started with \u201cclosed system\u201d products, the majority switched from that type of e-cigarette to \u201copen system\u201d devices. Responses were diverse on preferred flavors, although mixing flavors was a common practice. Many users had difficulty estimating the total amount of e-liquid they used within a given period and described an iterative process in which they experimented with different nicotine levels to determine their preferred concentration. Reported frequency of use and puffing behaviors varied greatly between users and also differed from the way traditional cigarettes are smoked.ConclusionResults from this study have implications for developing appropriate survey metrics for e-cigarette surveillance, the regulation of flavorings, and reporting of e-cigarette product constituents.2016P50 CA180906/CA/NCI NIH HHS/United States1 P50 CA180906-01/CA/NCI NIH HHS/United States26766848PMC4714939672