E-Cigarette Dependence and Depressive Symptoms Among Youth.

INTRODUCTION: Although the relationship between smoking and depression has been well-established, little is known about the association between use of e-cigarette and depression, particularly among youth and young adults. This study proposes that e-cigarette dependence, rather than simply use, serves as a potential stressor and may interact with pre-existing vulnerabilities to contribute to depression in youth, consistent with the diathesis-stress theory. This study examines the longitudinal association of vaping dependence and vaping frequency on depression symptoms among youth and young adults who have never smoked cigarettes. METHODS: People who used e-cigarettes in the past month who reported never smoking a cigarette (N=1,226) aged between 16 and 25 years were followed longitudinally every 3 months for up to 1 year beginning in 2020. The Penn State E-Cigarette Dependence Index at time t was used to predict depression symptoms assessed using the Center for Epidemiologic Studies Depression Scale at time t+1. RESULTS: A total of 32.1% reported vaping in the past month with the Penn State E-Cigarette Dependence Index score (M=8.5) and a Center for Epidemiologic Studies Depression Scale score (M=15.8). Higher vaping dependence scores were significantly associated with increased depression symptoms scores at follow-up among youth and adults (ß=0.08; 95% CI=0.01, 0.15), controlling for baseline depression symptom scores and covariates. Although vaping dependence was highly associated with vaping frequency level, no significant association between the frequency of vaping and depression was found (ß= -0.33; 95% CI= 1.21, 0.54). CONCLUSIONS: These results are consistent with the diathesis-stress model of the relationship between substance use and depression. Vaping dependence but not vaping frequency was associated with increased depressive symptoms among people who never smoked cigarettes.

Smoking, e-cigarettes and the effect on respiratory symptoms among a population sample of youth: Retrospective cohort study.

INTRODUCTION: E-cigarettes have been steadily increasing in popularity, both as cessation methods for smoking and for recreational and social reasons. This increase in vaping may pose cardiovascular and respiratory risks. We aimed to assess respiratory symptoms in youth users of e-cigarettes and cigarettes. METHODS: A retrospective survey design was utilized to assess Canadian youth aged 16-25 years. Participants were recruited from the Ontario Tobacco Research Unit Youth and Young Adult Research Registration Panel November 2020 to March 2021. A total of 3082 subjects completed the baseline survey. Of these, 2660 individuals who did not have asthma were included in the analysis. The exposure of interest was pack-equivalent years, a novel measure of vaping exposure equivalent conceptually to cigarette pack years incorporating number of puffs per day, number of days vaped per month, and number of years vaped. Respiratory symptoms were measured using the five-item Canadian Lung Health Test. Poisson regression analyses were performed while adjusting for demographic confounders, stratified by smoking status. A non-stratified model tested the interaction of status and vaping dose and the effect of vaping device used was assessed among ever vapers. Analyses controlled for demographic characteristics, use of cannabis and alcohol, and survey date. RESULTS: Each additional puff year increased the rate ratio (RR) of respiratory symptoms by a factor of 11.36 (95% CI: 4.61-28.00; p<0.001) for never smokers, but among current daily smokers higher pack-equivalent years were not associated with more respiratory symptoms (RR=0.83; 95% CI: 0.23-3.11). Among current vapers, those using pod-style devices were more likely to have more respiratory symptoms (RR=1.25; 95% CI: 1.08-1.45) after adjusting for dose. CONCLUSIONS: Vaping is associated with an increased risk of reporting respiratory symptoms among never smoking youth and non-daily ever cigarette smokers. Use of e-cigarettes among non-smokers should be discouraged.

Taking global leadership in banning menthol and other flavours in tobacco: Canada's experience.

Measures to ban or restrict menthol and other flavours in tobacco products are under consideration or newly implemented in an increasing number of jurisdictions across the world. As one of the world leaders, Canada's experience in successfully developing and implementing such measures can be instructive for other jurisdictions. This paper explores the history of how Canada was able to implement tobacco flavour bans including menthol, examines some of the challenges and presents lessons learnt for other jurisdictions. The crucial motivation for these bans emerged from surveillance data showing high rates of flavoured tobacco use by youth, including menthol cigarette smoking, that was publicised by non-governmental organisations. Further data showed that early legislation in 2009 contained loopholes (cigar size exemptions and menthol exemptions) that limited the benefits of the legislation. Leadership by the provinces created an environment in which the federal ban on menthol ingredients in 2017 was a clear and obvious step to ensure implementation across the country. The Canadian measures have been successful at reducing the use of flavoured tobacco including menthol cigarettes and facilitating smoking cessation. Lessons learnt include the downsides of exemptions, the lack of a contraband issue (despite an existing supply in Canada), the benefits of availability of youth flavour prevalence data and the success of subnational regulations to advance national regulation.

E-Cigarette Dependence in Youth.

INTRODUCTION: The majority of e-cigarette vaping youth use nicotine when vaping. Some then become dependent on the nicotine, which can result in subsequent health effects. There has been limited evaluation of convergent validity of e-cigarette dependence measures for use specifically in youth. The aim of this study was to investigate and validate various e-cigarette dependence measures for use in youth populations. AIMS AND METHODS: One thousand two hundred and five Canadian youth aged 16-24 who completed a cross-sectional online survey reported vaping at least monthly and were thus included in the analysis. E-cigarette dependence was assessed using a modified Penn State Electronic Cigarette Dependence Index (PS-ECDI), the E-Cigarette Dependence Scale (EDS), a self-perceived vaping dependence question, and time to first vape after waking. Internal consistency, convergent validity, and concurrent validity of the measures were assessed. RESULTS: Both the PS-ECDI and the EDS exhibited a good degree of internal consistency (α = 0.8472 and 0.8405, respectively). All measures exhibited convergent validity against each other and against time to first vape upon waking (p < .001), as well as concurrent validity against vaping frequency and nicotine concentration (p < .001). The PS-ECDI was inferior to the EDS, self-perceived measure, and time from waking when predicting daily vaping frequency, but, along with the self-perceived measure, was superior to the EDS and time from waking when predicting monthly vaping. CONCLUSIONS: All measures exhibit convergent and concurrent validity, as well as internal consistency. Depending on the needs of the study, it would be appropriate to use any of these measures when assessing e-cigarette dependence in adolescent and young-adult populations. IMPLICATIONS: The PS-ECDI and the self-perceived measure are equally effective in predicting monthly vaping, but the self-perceived measure was superior in predicting daily vaping. Thus, the one-item self-perceived measure of dependence is appropriate for use and preferable to the 11-item PS-ECDI or the 4-item EDS in situations of limited time or where subjects are at risk of respondent fatigue, and is superior to time to first vape after waking to predict vaping frequency.

Smoking cessation strategies used by former menthol cigarette smokers after a menthol ban.

INTRODUCTION: Menthol cigarettes were banned in Ontario, Canada on January 1st, 2017. We used concept mapping, a mixed-method approach, to describe how menthol cigarette smokers quit smoking after the Ontario menthol ban. METHODS: Pre-ban daily and non-daily menthol cigarette smokers who reported smoking abstinence 24 months after the ban (n = 62; 53.2% women; mean age = 43.6, SD = 12.5) generated statements describing reasons and strategies for smoking cessation/reduction after the menthol ban. Participants sorted a final list of 57 statements into groups of similar content and rated statements on how true each statement was for them and multidimensional scaling analysis identified thematic clusters. RESULTS: Six clusters were identified: Mental and Environment Changes, Direct Ban Impacts, Health Reasons, Cues to Action, Family and Friends, and Cessation Strategies. The highest rated statements (i.e., most true) suggested many participants were motivated to quit smoking before or after the ban and 30.7% of participants believed the menthol ban helped with smoking cessation. Some of the lowest rated statements included using nicotine replacement therapy products, medication (i.e., Champix), or other tobacco products suggesting these strategies were less common. Statement ratings suggested many smokers quit without using replacement products or medication, but modifying cognitions and avoiding smoking cues were common. CONCLUSIONS: The menthol ban aided some menthol smokers to quit, while others reported the ban did not play a role in smoking cessation. These data suggest the menthol ban had direct and indirect effects on smoking reduction behavior. Campaigns supporting similar bans that target both types of effects will likely be most effective for smoking reduction.

The effect of MPOWER on smoking prevalence.

OBJECTIVE: To examine the effect of varying levels of comprehensive tobacco control on smoking in a global context. METHODS: Using data from WHO's Reports on the Global Tobacco Epidemic, scatter plots were produced to visualise the relationship between comprehensive tobacco control policy (2008 MPOWER composite score) and change in current tobacco smoking between 2006 and 2009. Fixed-effect regression models assessed the effect of changes in each MPOWER measure on changes in current tobacco smoking between 2006 and 2009. All analyses were stratified by sex. RESULTS: Overall, countries with higher MPOWER composite scores experienced greater decreases in current tobacco smoking between the years 2006 and 2009. Regression analyses revealed that the M and R measures showed a negative association with current tobacco smoking over time. Current tobacco smoking decreased (1.07 percentage points for males, 1.04 percentage points for females) with each increase in score value for monitoring tobacco use (M). Also, current tobacco smoking decreased (0.95 percentage points for males, 0.41 percentage points for females) with each increase in score value for raising taxes on tobacco (R). The effect of the MPOWER measures on current tobacco smoking varied by country income status (P measure in the female analysis; p<0.05) and/or by WHO region (M, P and O measures in the male analysis; p<0.05). CONCLUSIONS: Higher levels of MPOWER combined, as well as continued and frequent monitoring of tobacco use (M) and increasing taxation (R), were associated with a decrease in current tobacco smoking over time.

Patterns of cigarillo use among Canadian young adults in two urban settings.

OBJECTIVES: Current estimates indicate that cigarillo use has become commonplace among young adults in Canada despite the established risks to health. However, little else is known about patterns of cigarillo use in this subpopulation. The intent of this research was to examine the patterns, attitudes, and beliefs regarding cigarillo use and co-use of cigarillos and cigarettes among Canadian young adults. METHODS: Canadians aged 19-29 years from the Greater Toronto Area, Ontario and Edmonton, Alberta were recruited from September 2009 to February 2010 and in June 2010, respectively (n=133). Eligible participants completed questionnaires assessing cigarillo, cigarette, and cannabis use; social influence of usage; and beliefs about cigarillo use. RESULTS: Cigarillo use was common in social settings, with friends, and during leisure time. The majority of participants were co-users of cigarillos and cigarettes (82%), and currently used cannabis (72%). Respondents reported "replacing cigarette smoking" and "flavour" as main reasons for smoking cigarillos; and half (52%) believed they were not at all addicted to cigarillos. Disconcertingly, participants perceived the risk of cancer attributed to smoking cigarillos as significantly less than the risk of cancer attributed to smoking cigarettes (p<0.0001). CONCLUSION: These findings highlight the social nature of cigarillo use, and suggest a lack of awareness of the health risks associated with cigarillo and polytobacco use in this small convenience sample of Canadian young adults. Population-level analyses are needed to further investigate cigarillo, polytobacco and concurrent cannabis use patterns and beliefs among Canadian young adults.

Understanding the impact of the Smoke-Free Ontario Act on hospitality establishments' outdoor environments: a survey of restaurants and bars.

BACKGROUND: The Smoke-Free Ontario Act (SFOA) came into effect in May 2006 and included restrictions to outdoor hospitality areas by only permitting smoking on a patio if the area had no roof. OBJECTIVES: (1) To assess the impact of the SFOA on the prevalence of smoke-free patios in Ontario and (2) to determine the proportion of venues where structural alterations were made rather than going smoke-free in order to achieve compliance with the SFOA. METHODS: A telephone survey of 403 hospitality sector operators/owners in four clustered samples of Ontario, Canada. RESULTS: Based on completed surveys, the SFOA resulted in an increase in prevalence of smoke-free patios, from 5% (n=21) to 25% (n=99). Of the patios where smoking was permitted before the SFOA (n=382), 42% (n=161) had physical structures that would make smoking not permissible under the new act. Operators of half of these venues (n=80) made their patios smoke-free, with most indicating they had no choice given the costs or physical limitations to changing their outdoor environment. The other half (n=81) reported making physical changes, including removing roof structures to achieve compliance. CONCLUSION: The SFOA resulted in greater protection from outdoor secondhand smoke; however, most patios still permitted smoking. Half of the venues that complied with the SFOA by going smoke-free did so involuntarily because of structural and/or financial limitations. The majority of venue operators preferred to permit smoking on their patios, and only made their patios smoke-free when they were required to do so by law.

Vendor compliance with Ontario's tobacco point of sale legislation.

OBJECTIVE: On May 31, 2006, Ontario joined a small group of international jurisdictions to implement legislative restrictions on tobacco point of sale promotions. This study compares the presence of point of sale promotions in the retail tobacco environment from three surveys: one prior to and two following implementation of the legislation. METHOD: Approximately 1,575 tobacco vendors were randomly selected for each survey. Each regionally-stratified sample included equal numbers of tobacco vendors categorized into four trade classes: chain convenience, independent convenience and discount, gas stations, and grocery. Data regarding the six restricted point of sale promotions were collected using standardized protocols and inspection forms. Weighted estimates and 95% confidence intervals were produced at the provincial, regional and vendor trade class level using the bootstrap method for estimating variance. RESULTS: At baseline, the proportion of tobacco vendors who did not engage in each of the six restricted point of sale promotions ranged from 41% to 88%. Within four months following implementation of the legislation, compliance with each of the six restricted point of sale promotions exceeded 95%. Similar levels of compliance were observed one year later. Grocery stores had the fewest point of sale promotions displayed at baseline. Compliance rates did not differ across vendor trade classes at either follow-up survey. Point of sale promotions did not differ across regions in any of the three surveys. CONCLUSION: Within a short period of time, a high level of compliance with six restricted point of sale promotions was achieved.