A Machine Learning Approach Reveals Distinct Predictors of Vaping Dependence for Adolescent Daily and Non-Daily Vapers in the COVID-19 Era.

Since 2016, there has been a substantial rise in e-cigarette (vaping) dependence among young people. In this prospective cohort study, we aimed to identify the different predictors of vaping dependence over 3 months among adolescents who were baseline daily and non-daily vapers. We recruited ever-vaping Canadian residents aged 16-25 years on social media platforms and asked them to complete a baseline survey in November 2020. A validated vaping dependence score (0-23) summing up their responses to nine questions was calculated at the 3-month follow-up survey. Separate lasso regression models were developed to identify predictors of higher 3-month vaping dependence score among baseline daily and non-daily vapers. Of the 1172 participants, 643 (54.9%) were daily vapers with a mean age of 19.6 ± 2.6 years and 76.4% (n = 895) of them being female. The two models achieved adequate predictive performance. Place of last vape purchase, number of days a pod lasts, and the frequency of nicotine-containing vaping were the most important predictors for dependence among daily vapers, while race, sexual orientation and reporting treatment for heart disease were the most important predictors in non-daily vapers. These findings have implications for vaping control policies that target adolescents at different stages of vape use.

Adolescent E-cigarette use: Rates, concerns, and policy implications

While US consumption of conventional cigarettes has declined steadily, electronic cigarettes have been the most commonly used tobacco product among adolescents since 2014, with a particular surge in use starting in 2017. The 2021 National Youth Tobacco Survey (NYTS) found that even during the COVID-19 pandemic, 2 million adolescents were current e-cigarette users. Just prior to the pandemic in 2020, one in five high school students and one in ten middle school students were using e-cigarettes every day, about the same level as in 2018 when adolescent e-cigarette use was declared an epidemic. Daily use is a strong indicator of nicotine dependence, raising concerns that e-cigarettes will hook a new generation on nicotine, including combustible cigarettes and other tobacco products. E-cigarettes are associated with a number of significant health consequences, including nicotine addiction, toxic effects of flavors, and psychological, social, and educational effects. Adolescents are especially attracted to e-cigarettes because of their youth-friendly flavors and salt-based nicotine which makes the device easier to use with less harsh throat hit, and allows users to more readily inhale large amount of nicotine. Adolescents are also attracted to the appealing designs and ability to conceal the e-cigarette devices;aggressive marketing that targets adolescents;misperceptions about the products' nicotine levels and health effects;and ease of access. Previous successful efforts to reduce tobacco use have been washed away due to the adolescent e-cigarette epidemic. This chapter discusses rates of adolescent e-cigarette use, health effects, why adolescents use e-cigarettes, and then ends with a discussion of the policy implications. © 2023 Elsevier Inc. All rights reserved

The association between risk perceptions, anxiety, and self-reported changes in tobacco and nicotine product use due to COVID-19 in May-June 2020 in Israel.

BACKGROUND: Early in the COVID-19 pandemic, reports about a possible protective effect of nicotine on COVID-19 conflicted with messaging by public health organizations about increased risks of COVID-19 due to smoking. The ambiguous information the public received, combined with COVID-19-induced anxiety, may have led to changes in tobacco or other nicotine product use. This study examined changes in use of combustible cigarettes (CCs), nargila (hookah/waterpipe), e-cigarettes, and IQOS and home-smoking behaviors. We also assessed COVID-19 related anxiety and perceptions regarding changes in risk of COVID-19 severity due to smoking. METHODS: We used cross-sectional data from a population telephone survey that was conducted in Israel in the early phase of the COVID-19 pandemic (May-June 2020) and included 420 adult (age 18+) individuals who reported having ever used CCs (n = 391), nargila (n = 193), and/or electronic cigarettes (e-cigarettes)/heated tobacco products (e.g., IQOS) (n = 52). Respondents were asked about the effect that COVID-19 had on their nicotine product use (quit/reduced use, no change, increased use). We assessed changes in product use, risk perceptions, and anxiety using adjusted multinomial logistic regression analyses. RESULTS: Most respondents did not change their frequency of product use (CCs: 81.0%, nargila: 88.2%, e-cigarettes/IQOS: 96.8%). A small percentage either decreased use (CCs: 7.2%, nargila: 3.2%, e-cigarettes/IQOS:2.4%) or increased use (CCs:11.8%, nargila:8.6%, e-cigarettes/IQOS:+ 0.9%). 55.6% of respondents used a product in the home prior to COVID-19; but during the first lockdown COVID-19 period, a greater percentage increased (12.6%) than decreased (4.0%) their home use. Higher levels of anxiety due to COVID-19 were associated with increased home smoking (aOR = 1.59, 95% CI:1.04-2.42, p = 0.02). Many respondents believed that increased severity of COVID-19 illness was associated with CCs (62.0%) and e-cigarettes/vaping (45.3%), with uncertainty about the association being lower for CCs (20.5%) than for vaping (41.3%). CONCLUSIONS: While many respondents believed that nicotine product use (particularly CCs and e-cigarettes) was associated with increased risk of COVID-19 disease severity, the majority of users did not change their tobacco/nicotine use. The confusion about the relationship between tobacco use and COVID-19 calls for clear evidence-based messaging from governments. The association between home smoking and increased COVID-19-related stress suggests the need for campaigns and resources to prevent smoking in the home, particularly during times of stress.

Cannabis vaping among college students

Introduction: Vaping is a growing industry that has gained popularity among college students (Jones, Hill, Pardini, & Meier, 2016). Current trends indicate that college students frequently use these devices to vape cannabis (Kenne, Fischbein, Tan, & Banks, 2017). Detrimental health effects of vaping are emerging, including the cannabis vaping-related inflammatory disease referred to as Electronic-cigarette, or Vaping, Associated Lung Injury (EVALI) (Centers for Disease Control and Prevention, 2020). Research is lacking on the perceptions and attitudes of cannabis vaping among college students. Additionally, the Integrated Behavioral Model may be useful in explaining and predicting cannabis vaping among this population. Both of the aforementioned issues are addressed in this dissertation.Purpose: This alternative dissertation includes two separate studies. The first study was a qualitative design, which was completed with the purpose of exploring factors that influence college students to initiate and continue to vaporize cannabis instead of traditional combustible cannabis practices. The second study was a result of the first and utilized a quantitative design to determine if the IBM is useful in explaining and predicting cannabis vaping among college students.Methods: (Study 1) Individual telephone interviews were conducted, transcribed, and analyzed for common themes (n=21). (Study 2) An online survey was deployed via Amazon Mechanical Turk containing 35 items to measure the primary constructs of the IBM, including Experiential Attitude, Instrumental Attitude, Injunctive Norms, Descriptive Norms, Perceived Control, Self-Efficacy, and Behavioral Intention (n=423). Confirmatory factor analysis and structural equation modeling were used to determine whether the data fit the proposed IBM model. Inclusion criteria for both studies included college undergraduates, aged 18-25, who self-reported vaping cannabis at least once in the past 30 days.Results: (Study 1) Six primary themes and eighteen subthemes were identified. Main themes included 1) Convenience, 2) Discreetness, 3) Euphoric Experience, 4) Social Acceptability, 5) Health and Safety, and 6) COVID-19 Pandemic Impact. (Study 2) Obtained fit indices confirmed that the data fit the proposed model, accounting for 54.2% of the variance. Structural equation modeling demonstrated the strongest path coefficients between Behavioral Intention and Experiential Attitude, Instrumental Attitude, Injunctive Norms, and Descriptive Norms. There was a weak, positive relationship between vaping cannabis and smoking cannabis within the sample.Conclusions: College students who use cannabis tend to both vape and smoke (dual-use), depending largely on social and physical environment. Overall, the participants tended to underestimate the risks associated with both cannabis and vaping. Additionally, the strongest predictors of vaping were descriptive norms and experiential attitude. The findings indicate that the development of interventions and educational programming specific to this demographic is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

The Association of Tobacco Smoking, Second-hand Smoke, and Novel Tobacco Products With COVID-19 Severity and Mortality in Italy: Results From the COSMO-IT Study.

BACKGROUND: Despite the robust evidence of an excess risk of coronavirus disease 2019 (COVID-19) severity and mortality in ever smokers, the debate on the role of current and ex-smokers on COVID-19 progression remains open. Limited or no data are available on the link between electronic cigarette (e-cigarette), heated tobacco product (HTP) and second-hand smoke (SHS) exposure and COVID-19 progression. To fill this knowledge gap, we undertook the COvid19 and SMOking in ITaly (COSMO-IT) study. METHODS: A multi-centre longitudinal study was conducted in 2020-2021 in 24 Italian hospitals on a total of 1,820 laboratory-confirmed COVID-19 patients. We estimated multivariable odds ratios (OR) and 95% confidence intervals (CI) to quantify the association between smoking-related behaviours (ie, smoking status, e-cigarette and HTP use, and SHS exposure) and COVID-19 severity (composite outcome: intubation, intensive care unit admission and death) and mortality. RESULTS: Compared to never smokers, current smokers had an increased risk of COVID-19 mortality (OR 2.17; 95% CI, 1.06-4.41). E-cigarette use was non-significantly associated to an increased risk of COVID-19 severity (OR 1.60; 95% CI, 0.96-2.67). An increased risk of mortality was observed for exposure to SHS among non-smokers (OR 1.67; 95% CI, 1.04-2.68), the risk being particularly evident for exposures of ≥6 hours/day (OR 1.99; 95% CI, 1.15-3.44). CONCLUSION: This multicentric study from Italy shows a dismal COVID-19 progression in current smokers and, for the first time, in SHS exposed non-smokers. These data represent an additional reason to strengthen and enforce effective tobacco control measures and to support smokers in quitting.

Factors that influence cannabis vaping habits of college students: A qualitative study.

Objective: The purpose of this study is to examine the attitudes and perceptions of college undergraduates regarding cannabis vaping. Participants: Twenty-one, predominantly male (71.4%; Mage = 22, SD = 2.09), undergraduate college students who reported vaping cannabis in the past 30 days. Methods: Participants were interviewed to determine their attitudes and perceptions regarding cannabis vaping. Findings: Thematic analysis uncovered six primary themes and eighteen subthemes. Main themes included (1) Convenience, (2) Discreetness, (3) Mood-Altering Experience, (4) Social Acceptability, (5) Health and Safety, and (6) COVID-19 Pandemic Impact. Conclusion: College students who use cannabis tend to both vape and use combustible methods, depending upon social and physical environment. This population tends to vaporize cannabis for its perceived mood-altering properties. Additional research is needed to further examine the behaviors and attitudes surrounding cannabis vaping among college undergraduates, as well as the development of interventions specific to this demographic.

Reaching Youth Virtually During a Pandemic: Development and Process Evaluation of #iCANendthetrend, A Peer-Led E-cigarette Prevention and Empowerment Program

Youth e-cigarette use has reached epidemic levels, highlighting a critical need for prevention programming. The COVID-19 pandemic has reinforced the need to support students virtually. In late 2020, #iCANendthetrend, a near-peer school-based intervention, was virtually delivered to 4th-12th graders by trained college facilitators. Data sample includes 383 participants. Outcomes across presentation type and grade levels were compared using Chi-square/Fisher's exact test. Most students found the program beneficial for their age, liked having a near-peer facilitator, and enjoyed the virtual format. Middle schoolers enjoyed the program more than high schoolers (p<.05). Elementary and middle schoolers were more likely to agree that presenters were engaging (p<.05). Our findings suggest 4th-12th grade students are highly receptive to a near-peer approach, even when virtual.

Electronic cigarettes use in COVID-19 era among students of a tertiary institution in Nigeria.

BACKGROUND: Electronic cigarette (e-cigarette) use is becoming popular among undergraduate students in Nigeria with a tendency for escalation because of the coronavirus disease 2019 (COVID-19) pandemic. AIM: The aim of this study was to assess electronic cigarette use in COVID-19 era among undergraduate students of a tertiary institution in Lagos state, Southwestern Nigeria. SETTING: A tertiary institution in Southwestern Nigeria. METHODS: The study design was a descriptive cross-sectional study with a pretested, structured, close- and open-ended self-administered questionnaire used for collection of data on knowledge, attitude and use of e-cigarettes. RESULTS: Data from 183 respondents were analysed. The mean age of respondents was 24.8 ± 3.38 years, most (63%) of whom were males. The prevalence of ever-use of e-cigarettes was 15.3% of which 60.7% reported increased use of e-cigarettes since the COVID-19 pandemic. Age, education, tribe and religion (p 0.001) were significantly associated with higher odds of use of e-cigarettes. CONCLUSION: This study found an increase in the quantity of e-cigarettes used and online purchase of the same by respondents since the COVID-19 pandemic. Paying attention to the rate of use and having control measures in place for online purchase of e-cigarettes by youths in Nigeria may be necessary in the years to come.Contribution: This study addresses a gap in the availability of knowledge of use of e-cigarettes among a growing population of youths in Nigeria.

Seven days in medicine: 16-22 November 2022

Paxlovid, a combination of nirmatrelvir and ritonavir, is strongly recommended by the World Health Organization for people with non-severe covid-19 who are at the highest risk of hospital admission. (Full story doi:10.1136/bmj.o2795) Climate Surgeons advise on sustainable operations The Royal College of Surgeons of Edinburgh, the Royal College of Surgeons of England, and the Royal College of Physicians and Surgeons of Glasgow published a “green theatre checklist” to help surgical teams work more sustainably.1 The recommendations aim to reduce the “triple bottom line” of environmental, social, and economic impacts, they said. Gun violence AMA establishes prevention taskforce The American Medical Association is setting up a taskforce aiming to prevent gun violence, reduce the use of firearms in suicide, and increase collaboration with other organisations in litigation related to firearm safety.

Vaping product access and use among 14-17-year-olds in New South Wales: a cross-sectional study.

OBJECTIVES: We assessed access to vaping products and types of products used and the factors associated with vaping and smoking among young people in the state of New South Wales (NSW), Australia. METHODS: A cross-sectional survey was conducted with a sample of 721 young people aged 14 to 17 years from NSW recruited through online panels. Poisson regression with robust variance was used to estimate relative risks of ever-vaping and ever-smoking. RESULTS: Almost one-third of the sample (32%, n=233) reported being an ever-vaper, of which more than half (54%) had never smoked prior to starting vaping. Ever-vaping was independently associated with age and being Aboriginal or Torres Strait Islander, and ever-smoking was independently associated with being male. Ever-smokers were seven times more likely to be ever-vapers than those who had never smoked, and ever-vapers were 18 times more likely to be ever-smokers than those who had never vaped. Among ever-vapers who reported which type of device they were using, 86% reported the use of disposable products. "Flavourings and taste" was rated as the most important characteristic of vapes. More than half of ever-vapers reported getting the last vape they used from their friends (55%, n=130). More than half of ever-vapers had used a vape that they knew contained nicotine (53%, n=123). CONCLUSIONS: Vaping was the strongest risk factor for smoking, and vice versa, suggesting there is not a straightforward, unidirectional relationship between vaping and smoking in young people. Young people appear to be readily accessing nicotine vaping products, which are often disposable and flavoured, through both social and commercial channels. IMPLICATIONS FOR PUBLIC HEALTH: Stronger enforcement of federal and state policies designed to protect young people from vaping products is urgently needed.

Cannabis vaping among college students

Introduction: Vaping is a growing industry that has gained popularity among college students (Jones, Hill, Pardini, & Meier, 2016). Current trends indicate that college students frequently use these devices to vape cannabis (Kenne, Fischbein, Tan, & Banks, 2017). Detrimental health effects of vaping are emerging, including the cannabis vaping-related inflammatory disease referred to as Electronic-cigarette, or Vaping, Associated Lung Injury (EVALI) (Centers for Disease Control and Prevention, 2020). Research is lacking on the perceptions and attitudes of cannabis vaping among college students. Additionally, the Integrated Behavioral Model may be useful in explaining and predicting cannabis vaping among this population. Both of the aforementioned issues are addressed in this dissertation.Purpose: This alternative dissertation includes two separate studies. The first study was a qualitative design, which was completed with the purpose of exploring factors that influence college students to initiate and continue to vaporize cannabis instead of traditional combustible cannabis practices. The second study was a result of the first and utilized a quantitative design to determine if the IBM is useful in explaining and predicting cannabis vaping among college students.Methods: (Study 1) Individual telephone interviews were conducted, transcribed, and analyzed for common themes (n=21). (Study 2) An online survey was deployed via Amazon Mechanical Turk containing 35 items to measure the primary constructs of the IBM, including Experiential Attitude, Instrumental Attitude, Injunctive Norms, Descriptive Norms, Perceived Control, Self-Efficacy, and Behavioral Intention (n=423). Confirmatory factor analysis and structural equation modeling were used to determine whether the data fit the proposed IBM model. Inclusion criteria for both studies included college undergraduates, aged 18-25, who self-reported vaping cannabis at least once in the past 30 days.Results: (Study 1) Six primary themes and eighteen subthemes were identified. Main themes included 1) Convenience, 2) Discreetness, 3) Euphoric Experience, 4) Social Acceptability, 5) Health and Safety, and 6) COVID-19 Pandemic Impact. (Study 2) Obtained fit indices confirmed that the data fit the proposed model, accounting for 54.2% of the variance. Structural equation modeling demonstrated the strongest path coefficients between Behavioral Intention and Experiential Attitude, Instrumental Attitude, Injunctive Norms, and Descriptive Norms. There was a weak, positive relationship between vaping cannabis and smoking cannabis within the sample.Conclusions: College students who use cannabis tend to both vape and smoke (dual-use), depending largely on social and physical environment. Overall, the participants tended to underestimate the risks associated with both cannabis and vaping. Additionally, the strongest predictors of vaping were descriptive norms and experiential attitude. The findings indicate that the development of interventions and educational programming specific to this demographic is warranted. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Seven days in medicine: 31 Aug to 6 Sep 2022

3 Pensions Consultation begins on NHS pension changes The UK government has launched a consultation on pension changes to make it easier for retired and partially retired NHS staff to return to the workforce or continue working over winter. Since March 2020 some of the pension scheme’s rules on retiring and returning have been suspended, but these measures apply only until 31 October. E-cigarettes are becoming especially popular with young people: 11% of 18-24 year olds use them, the highest rate by age group.6 Food safety Listeria is linked to ready-to-eat smoked fish The Food Standards Agency, Food Standards Scotland, and the UK Health Security Agency are reinforcing advice to vulnerable groups such as over 65s, anyone pregnant, or people with weakened immune systems, to ensure that ready-to-eat smoked fish is thoroughly cooked before they eat it. 9 Life expectancy US sees steepest decline in a century Life expectancy in the US fell for the second year running in 2021, said the Centers for Disease Control and Prevention.

A Pilot Feasibility Study of an Online Youth Tobacco Survey Administration among High School Students.

The COVID-19 pandemic restrictions forced many schools to shift to remote or hybrid learning, disrupting surveillance systems such as the New Jersey Youth Tobacco Survey, traditionally administered in schools by paper and pencil. In spring 2021, we conducted a feasibility study among a convenience sample of six public high schools to assess the use of an online survey to allow for remote participation. In each school, 4 to 6 classes were selected randomly, and all students within a sampled class were selected to participate in the survey. A total of 702 students completed surveys. School contacts were asked to provide qualitative feedback about the survey administration. Feedback was generally positive, with a few suggestions for improvement. Approximately 19% of students reported the ever use of e-cigarettes. Among current e-cigarette users, there was a shift in popularity from prefilled or refillable pods or cartridges (23.3%) to disposable e-cigarettes (53.5%). Less than 10% of current e-cigarette users reported using tobacco-flavored e-cigarettes, despite a statewide flavor ban on all other flavors.

E-cigarette use among high school students in the United States prior to the COVID-19 pandemic: Trends, correlates, and sources of acquisition.

Detailed description of the prevalence and sources of e-cigarettes among youth is needed to inform effective regulatory policies. We used the Youth Risk Behavior Surveillance System data (2015-2019) to assess trends in current (past-30-day-use) and frequent (≥10 days in past-30-days) e-cigarette use among United States high schoolers before the COVID-19 pandemic. First, we assessed trends overall and then stratified by participants' sociodemographic characteristics, use of other tobacco products, and experiences of psychosocial stress. We also evaluated past year quit attempts and the changing sources of e-cigarettes. Our sample size was 41,021 (15,356-2015; 12,873-2017; 12,792-2019). The prevalence of current e-cigarette use increased from 24.0% (95%CI:21.9%-26.3%) in 2015 to 32.7% (30.4%-35.1%) in 2019. The proportion of current users who reported frequent use also increased significantly from 22.6% (20.4%-24.8%) to 45.4% (42.7%-48.2%). Thus, an increasing proportion of US high school students who use e-cigarettes reported frequent use, indicating greater nicotine dependence. The increase in current and frequent e-cigarette use was more pronounced in youth who reported other substance use and psychosocial stressors such as bullying. Between 2017 and 2019, there was a decline in the proportion of youth who bought e-cigarettes online (6.9% to 3.2%) or from convenience stores (22.0% to 16.6%). Conversely, there was an increase in the proportion who borrowed (34.5% to 40.1%) or purchased e-cigarettes through other people (10.7% to 18.0%), indicating that most youth are evading age-related restrictions by obtaining e-cigarettes from other people. Finally, a considerable proportion of youth tobacco users are making quit attempts; 47.6% (45.1%-50.1%) in 2019.

E-cigarette or Vaping Product Associated Lung Injury (EVALI) Presenting As Cardiac Arrest.

E-cigarettes or vaping products became available in the market in 2004. Since then, their use has rapidly increased in all sections of society. They have been increasingly used as a "safer" alternative for combustible cigarettes and as an aid toward smoking cessation. Over time, the acceptability of e-cigarettes in public spaces increased. Lack of regulatory control also led to a rapid rise in the rate of e-cigarette/vaping product users. We report a case of a 35-year-old female who recently switched from conventional cigarettes to e-cigarette usage, and who presented to the emergency department after an out-of-hospital cardiac arrest. She was found to have bilateral extensive nodular ground-glass opacities on a CT angiogram of the chest. She needed non-invasive ventilation and was initially started on broad-spectrum antibiotic treatment for possible pneumonia. Due to a worsening clinical status, e-cigarette or vaping product associated lung injury (EVALI) diagnosis was considered, and she was started on parenteral steroid therapy, leading to rapid recovery in respiratory status. With a tapering course of steroid therapy and cessation of e-cigarette use, there was complete clinical and radiological recovery. This case highlights that EVALI can have varied clinical presentations, and the diagnosis should be considered in anyone who presents with an acute cardio-pulmonary decline and a concomitant history of e-cigarette use.

Analytic modeling and risk assessment of aerial transmission of SARS-CoV-2 virus through vaping expirations in shared micro-environments.

It is well known that airborne transmission of COVID-19 in indoor spaces occurs through various respiratory activities: breathing, vocalizing, coughing, and sneezing. However, there is a complete lack of knowledge of its possible transmission through exhalations of e-cigarette aerosol (ECA), which is also a respiratory activity. E-cigarettes have become widely popular among smokers seeking a much safer way of nicotine consumption than smoking. Due to restrictive lockdown measures taken during the COVID-19 pandemic, many smokers and vapers (e-cigarette users) were confined to shared indoor spaces, making it necessary to assess the risk of SARS-CoV-2 virus aerial transmission through their exhalations. We summarize inferred knowledge of respiratory particles emission and transport through ECA, as well as a theoretical framework for explaining the visibility of exhaled ECA, which has safety implications and is absent in other respiratory activities (apart from smoking). We also summarize and briefly discuss the effects of new SARS-CoV-2 variants, vaccination rates, and environmental factors that may influence the spread of COVID-19. To estimate the risk of SARS-CoV-2 virus aerial transmission associated with vaping exhalations, we adapt a theoretical risk model that has been used to analyze the risks associated with other respiratory activities in shared indoor spaces. We consider home and restaurant scenarios, with natural and mechanical ventilation, with occupants wearing and not wearing face masks. We consider as "control case" or baseline risk scenario an indoor space (home and restaurant) where respiratory droplets and droplet nuclei are uniformly distributed and aerial contagion risk might originate exclusively from occupants exclusively rest breathing, assuming this to be the only (unavoidable) respiratory activity they all carry on. If an infected occupant uses an e-cigarette in a home or restaurant scenarios, bystanders not wearing face masks exposed to the resulting ECA expirations face a [Formula: see text] increase of risk of contagion with respect the control case. This relative added risk with respect to the control case becomes [Formula: see text] for high-intensity vaping, [Formula: see text], and over [Formula: see text] for speaking for various periods or coughing (all without vaping). Infectious emissions are significantly modified by mechanical ventilation, face mask usage, vaccination, and environmental factors, but given the lack of empiric evidence, we assume as a working hypothesis that all basic parameters of respiratory activities are equally (or roughly equally) affected by these factors. Hence, the relative risk percentages with respect to the control state should remain roughly the same under a wide range of varying conditions. By avoiding direct exposure to the visible exhaled vaping jet, wearers of commonly used face masks are well protected from respiratory droplets and droplet nuclei directly emitted by mask-less vapers. Compared to the control case of an already existing (unavoidable) risk from continuous breathing, vaping emissions in shared indoor spaces pose just a negligible additional risk of COVID-19 contagion. We consider that it is not necessary to take additional preventive measures beyond those already prescribed (1.5 m separation and wearing face masks) in order to protect bystanders from this contagion.

The Food and Drug Administration's e-Cigarette Flavor Restrictions Have Not Gone Far Enough to Curb the Youth e-Cigarette Use Epidemic

Driven by targeted marketing, high nicotine content, and the availability of flavors appealing to youths,1 past 30-day use surged among high school students from 1.5% in 2011 to 27.5% in 2019.2 To curb youth access and use, the US Food and Drug Administration (FDA) issued an enforcement policy against any flavored, cartridge-based e-cigarettes with tobacco and menthol flavor exemptions in February 2020. Because of the concern of the comparability of the August 2020 data collected during the pandemic, Hammond etal. did not assess the potential impact of the policy on the accessibility of vaping devices or e-cigarette use prevalence. Studies that exploited the variation in the comprehensiveness of flavor restrictions between state and local jurisdictions indicated a reduction in flavored and total e-cigarette sales associated with more stringent flavor restrictions.9 However, other studies have raised an important concern that reducing youth access to flavored e-cigarettes may motivate substitution of e-cigarettes with traditional cigarettes.10 Moreover, flavor is also a primary driver of e-cigarette initiation among adult cigarette smokers and may be critical for adult smokers who are otherwise unable to quit cigarette smoking to switch to a potentially safer alternative.

Flavors Remain a Major Driver of Youth E-Cigarette Use

Over the past decade, the landscape ofyouth e-cigarette use has been dynamic.1,2 E-cigarettes have been the most commonly used tobacco product among US youths since 2014,1 and in 2019, current (past30-day) e-cigarette use prevalence reached a peak among middle-school (10.5%) and high-school (27.5%) students.3 During 2020 to 2021, the COVID-19 pandemic resulted in virtual learning for students, which impacted youth access to e-cigarettes, including from social sources;in 2020, before COVID-19 was declared a pandemic, more than half of youths who currently used e-cigarettes reported getting their e-cigarettes from a friend.3 Nonetheless, in 2021, more than 2 million US middle- and high-school students used e-cigarettes.2 POLICIES TO REDUCE YOUTH E-CIGARETTE USE Flavors remain a major driver ofyouth e-cigarette use.2 A majority of youths who currently use e-cigarettes report flavors are a reason they used the products, and, in 2021,84.7% of youths who used e-cigarettes reported using a flavored product2;the most commonly used flavor types among youths were fruit (71.6%), followed by candy, desserts, or other sweets (34.1 %);mint (30.2%);and menthol (28.8%).2 Public health concerns over youth e-cigarette use have fueled the adoption of policies focused on flavored e-cigarettes. [...]as of February 2022, seven statesand more than 300communities have enacted restrictions on the sale of at least some flavored e-cigarettes;many of these laws include mentholflavored products.4 Research suggests these local laws are associated with reduced availability, marketing, and sales of restricted products.5 However, there is variation inthe specificproducts, flavors, and store types covered by these laws.4 FACTORS THAT DIMINISH POLICY IMPACT Noncomprehensive policies, such as those that exempt certain flavors, can lead to shifts in behaviors by consumers that might diminish the policy's intended effects.5 For example, following the January 2020 national restriction on the sale of certain flavored cartridge-based e-cigarettes (excluding menthol and tobacco), increases occurred in US sales of mentholflavored e-cigarettes and disposable e-cigarettes, the latter of which were still available for sale with fruit, candy, mint, and other flavors.6 Disposable e-cigarette use increased among US youths during 2019 to 2020, and in 2020, among youths who used flavored e-cigarettes, menthol use was 34.3% among those who used disposable e-cigarettes and 48.4% among those who used prefilled cartridges or pods.3 Actions by manufacturers can diminish the impact of flavored e-cigarette restrictions. CORRESPONDENCE Correspondence should be sent to Brian A. King, PhD, MPH, Office on Smoking and Health, Centers for Disease Control and Prevention, 4770 Buford Highway NE, MS S107-7, Atlanta, GA 30341 (e-mail: baking@cdc.gov).

E-Cigarette Flavors, Devices, and Brand Preferences Among Youths in Canada, England, and the United States: The Value and Challenges of Comparing International Survey Data

First-generation e-cigarettes were visually more like traditional tobacco cigarettes but lacked choice in flavors, whereas newer versions have evolved, looking less like their predecessors and gaining flavor alternatives. Equally, however, choice of flavors plays an important role in potentially supporting adults who use e-cigarettes as a smoking cessation aid.4 It has therefore been a challenge for policymakers in different jurisdictions to balance actions that reduce pathways of harm for young people's health and actions that minimize disruption of smoking cessation efforts among adults, a choice often made within a limited supply of evidence. [...]comparing findings from different countries can present challenges given the international divergence in e-cigarette use, which likely reflects differences in the regulatory landscape over the past decade.7 For example, Hammond et al. highlighted that, unlike in the United States and Canada, cartridge and pod e-cigarettes remain less prevalent than refillable tank devices among youth and adult vapers in the United Kingdom. Since 2016, there has been a plateauing of e-cigarette use in the United Kingdom, in contrast to the large growth seen in the United States during this period.8 European Union legislation such as the Tobacco Products Directive likely delayed the entry of products such asJUUL into UK markets as a result of the restrictions on e-liquids with a nicotine strength of more than 20 milligrams per milliliter. [...]our later research showed that the proliferation of e-cigarette use in the United Kingdom likely contributed to hardening attitudes toward smoking amongyoung people.10 In contrast to the United States, the majority of users of nicotine-based vaping products in the United Kingdom are adults.11 After implementation of the Tobacco Products Directive, e-cigarette flavor remained an important reason for e-cigarette experimentation among young people in the United Kingdom.3 Attraction to flavors continues to be a strong reason in more recent Englandbased surveys.11 Efforts to address vaping flavor enticement among young people may thus take different forms moving forward, with North America highlighting the role of nicotine-based products and England focusing more attention on the role of non-nicotine products.

Experimental Forum 2: Two Years After the 2020 Food and Drug Administration Guidance on E-Cigarette Flavors

Putatively, flavorings afford adult cigarette smokers options to switch to vaping.1 But the flavorings are also perceived to be attractive to people who have never smoked cigarettes, with particular concern about nicotine initiation by underage youths.2 In particular, the flavor and type of device on which nicotine use is initiated may influence later nicotine dependence in young adults.3 In the United States, three broad classes of vaping device are common: (1) single-unit disposable devices roughly equivalent to a pack of cigarettes;(2) homemade devices with, for example, customizable nicotine liquid tanks, batteries, and mouthpieces;and (3) devices with a rechargeable battery and replaceable cartridges containing nicotine liquid. Creating complicated relationships, and further limiting possible benefits to smoking cessation in the public health audience's eyes, Altria (formerly Philip Morris) purchased a major stake in JUUL in 2018. In addition to stay-at-home mandates, fear of contracting the respiratory illness was noted to increase motivation to quit cigarette smoking.8 Interestingly, e-cigarette users also reported greater quit attempts (41 %) than did cigarette smokers (26%) because of COVID-19 fears.9 In addition, various state and local prohibitions against public vaping and fluctuations in product cost have also occurred. Because of changes in sampling necessitated by the COVID-19 pandemic, data quality in large population-based surveys remains an area of active investigation, including potential discontinuities that could limit comparisons overtime. [...]we note that one or two time points since the Guidance was released may not portend sustained changes in behavior.