AAP eBooks

eCigarettes

By American Academy of Pediatrics

More data continues to emerge on teen use of eCigarettes that leads to smoking. Renowned AAP journal editors have created this new, first-in-series, Pediatric Collection with high-impact articles that address the public health trend among adolescents and young adults, and the unintended nicotine poisonings among younger children.

https://shop.aap.org/pediatric-collections-ecigarettes-paperback/

  1. Page 1
  2. Page 4
    Abstract

    Electronic nicotine delivery systems (ENDS) are rapidly growing in popularity among youth. ENDS are handheld devices that produce an aerosolized mixture from a solution typically containing concentrated nicotine, flavoring chemicals, and propylene glycol to be inhaled by the user. ENDS are marketed under a variety of names, most commonly electronic cigarettes and e-cigarettes. In 2014, more youth reported using ENDS than any other tobacco product. ENDS pose health risks to both users and nonusers. Nicotine, the major psychoactive ingredient in ENDS solutions, is both highly addictive and toxic. In addition to nicotine, other toxicants, carcinogens, and metal particles have been detected in solutions and aerosols of ENDS. Nonusers are involuntarily exposed to the emissions of these devices with secondhand and thirdhand aerosol. The concentrated and often flavored nicotine in ENDS solutions poses a poisoning risk for young children. Reports of acute nicotine toxicity from US poison control centers have been increasing, with at least 1 child death reported from unintentional exposure to a nicotine-containing ENDS solution. With flavors, design, and marketing that appeal to youth, ENDS threaten to renormalize and glamorize nicotine and tobacco product use. There is a critical need for ENDS regulation, legislative action, and counter promotion to protect youth. ENDS have the potential to addict a new generation of youth to nicotine and reverse more than 50 years of progress in tobacco control.

  3. Page 15
    Abstract

    Nicotine is the primary pharmacologic component of tobacco, and users of tobacco products seek out its effects. The highly addictive nature of nicotine is responsible for its widespread use and difficulty with quitting. This technical report focuses on nicotine and discusses the stages of use in progression to dependence on nicotine-containing products; the physiologic characteristics, neurobiology, metabolism, pharmacogenetics, and health effects of nicotine; and acute nicotine toxicity. Finally, some newer approaches to cessation are noted.

  4. Page 28
    Abstract

    Tobacco use and tobacco smoke exposure are among the most important health threats to children, adolescents, and adults. There is no safe level of tobacco smoke exposure. The developing brains of children and adolescents are particularly vulnerable to the development of tobacco and nicotine dependence. Tobacco is unique among consumer products in that it causes disease and death when used exactly as intended. Tobacco continues to be heavily promoted to children and young adults. Flavored and alternative tobacco products, including little cigars, chewing tobacco, and electronic nicotine delivery systems are gaining popularity among youth. This statement describes important evidence-based public policy actions that, when implemented, will reduce tobacco product use and tobacco smoke exposure among youth and, by doing so, improve the health of children and young adults.

  5. Page 38
    Abstract

    Tobacco dependence starts in childhood. Tobacco exposure of children is common and causes illness and premature death in children and adults, with adverse effects starting in the womb. There is no safe level of tobacco smoke exposure. Pediatricians should screen for use of tobacco and other nicotine delivery devices and provide anticipatory guidance to prevent smoking initiation and reduce tobacco smoke exposure. Pediatricians need to be aware of the different nicotine delivery systems marketed and available. Parents and caregivers are important sources of children’s tobacco smoke exposure. Because tobacco dependence is a severe addiction, to protect children’s health, caregiver tobacco dependence treatment should be offered or referral for treatment should be provided (such as referral to the national smoker’s quitline at 1-800-QUIT-NOW). If the source of tobacco exposure cannot be eliminated, counseling about reducing exposure to children should be provided.

    Health care delivery systems should facilitate the effective prevention, identification, and treatment of tobacco dependence in children and adolescents, their parents, and other caregivers. Health care facilities should protect children from tobacco smoke exposure and tobacco promotion. Tobacco dependence prevention and treatment should be part of medical education, with knowledge assessed as part of board certification examinations.

  6. Page 50
    Abstract
    Address correspondence to Gary A. Smith, MD, DrPH, Center for Injury Research and Policy, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH 43205. E-mail: gary.smith@nationwidechildrens.org

    OBJECTIVES To investigate the epidemiologic characteristics and outcomes of exposures to electronic cigarettes (e-cigarettes), nicotine, and tobacco products among young children in the United States.

    METHODS A retrospective analysis of exposures associated with nicotine and tobacco products among children younger than 6 years old was conducted by using National Poison Data System data.

    RESULTS From January 2012 through April 2015, the National Poison Data System received 29 141 calls for nicotine and tobacco product exposures among children younger than 6 years, averaging 729 child exposures per month. Cigarettes accounted for 60.1% of exposures, followed by other tobacco products (16.4%) and e-cigarettes (14.2%). The monthly number of exposures associated with e-cigarettes increased by 1492.9% during the study period. Children <2 years old accounted for 44.1% of e-cigarette exposures, 91.6% of cigarette exposures, and 75.4% of other tobacco exposures. Children exposed to e-cigarettes had 5.2 times higher odds of a health care facility admission and 2.6 times higher odds of having a severe outcome than children exposed to cigarettes. One death occurred in association with a nicotine liquid exposure.

    CONCLUSIONS The frequency of exposures to e-cigarettes and nicotine liquid among young children is increasing rapidly and severe outcomes are being reported. Swift government action is needed to regulate these products to help prevent child poisoning. Prevention strategies include public education; appropriate product storage and use away from children; warning labels; and modifications of e-cigarette devices, e-liquid, and e-liquid containers and packaging to make them less appealing and less accessible to children.

  7. Page 61
    Abstract
    Address correspondence to Suchitra Krishnan-Sarin, PhD, Department of Psychiatry, Yale University School of Medicine, Connecticut Mental Health Center, S-208, 34 Park St, New Haven, CT 06519. E-mail: suchitra.krishnan-sarin@yale.edu

    BACKGROUND Electronic cigarettes (e-cigarettes) electrically heat and vaporize e-liquids to produce inhalable vapors. These devices are being used to inhale vapors produced by dripping e-liquids directly onto heated atomizers. The current study conducts the first evaluation of the prevalence rates and reasons for using e-cigarettes for dripping among high school students.

    METHODS In the spring of 2015, students from 8 Connecticut high schools (n = 7045) completed anonymous surveys that examined tobacco use behaviors and perceptions. We assessed prevalence rates of ever using e-cigarettes for dripping, reasons for dripping, and predictors of dripping behaviors among those who reported ever use of e-cigarettes.

    RESULTS Among 1080 ever e-cigarette users, 26.1% of students reported ever using e-cigarettes for dripping. Reasons for dripping included produced thicker clouds of vapor (63.5%), made flavors taste better (38.7%), produced a stronger throat hit (27.7%), curiosity (21.6%), and other (7.5%). Logistic regression analyses indicated that male adolescents (odds ratio [OR] = 1.64), whites (OR = 1.46), and those who had tried multiple tobacco products (OR = 1.34) and had greater past-month e-cigarette use frequency (OR = 1.07) were more likely to use dripping (Ps < .05).

    CONCLUSIONS These findings indicate that a substantial portion (~1 in 4) of high school adolescents who had ever used e-cigarettes also report using the device for dripping. Future efforts must examine the progression and toxicity of the use of e-cigarettes for dripping among youth and educate them about the potential dangers of these behaviors.

  8. Page 68
    Abstract
    Address correspondence to Hongying Dai, PhD, Division of Health Services and Outcomes Research, Children’s Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108. E-mail: hdai@cmh.edu

    BACKGROUND AND OBJECTIVE Flavored electronic cigarettes (e-cigarettes) are not prohibited in the United States, and e-cigarette flavors proliferate on the market. This study sought to examine flavored e-cigarette use and its association with smoking among youth.

    METHODS Estimates of flavored e-cigarette use from the 2014 National Youth Tobacco Survey were investigated. A logistic regression model was used to assess whether flavored e-cigarette use was associated with (1) intention to initiate cigarette use among never-smoking youth (n = 16 471), (2) intention to quit tobacco use among current-smoking youth (n = 1338), and (3) perception of tobacco’s danger among all respondents (n = 21 491).

    RESULTS A total of 2017 respondents reported using e-cigarettes in the last 30 days, of whom 1228 (60.9%) reported using flavored e-cigarettes. Among never-smoking youth, 55.6% (288) of current e-cigarette users reported using flavored e-cigarettes. Among current smokers, 68.4% (495) of current e-cigarette users reported using flavored e-cigarettes. Compared with not using e-cigarettes in the past 30 days, using flavored e-cigarettes was associated with higher odds of intention to initiate cigarette use among never-smoking youth (adjusted odds ratio [aOR] = 5.7; P < .0001), lower odds of intention to quit tobacco use among current-smoking youth (aOR = 0.6; P = .006), and a lower prevalence of perception of tobacco’s danger among all respondents (aOR = 0.5; P < .0001).

    CONCLUSIONS Flavored e-cigarette use is associated with increased risks of smoking among youth. Comprehensive tobacco control and prevention strategies that address flavored e-cigarette products are critically needed to reduce tobacco use among youth.

  9. Page 77
    Abstract
    Address correspondence to Jessica Barrington-Trimis, PhD, 2001 N. Soto St, 230-D, Los Angeles, CA 90089. E-mail: jtrimis@usc.edu

    BACKGROUND There has been little research examining whether e-cigarette use increases the risk of cigarette initiation among adolescents in the transition to adulthood when the sale of cigarettes becomes legal.

    METHODS The Children’s Health Study is a prospectively followed cohort in Southern California. Data on e-cigarette use were collected in 11th and 12th grade (mean age = 17.4); follow-up data on tobacco product use were collected an average of 16 months later from never-smoking e-cigarette users at initial evaluation (n = 146) and from a sample of never-smoking, never e-cigarette users (n = 152) frequency matched to e-cigarette users on gender, ethnicity, and grade.

    RESULTS Cigarette initiation during follow-up was reported by 40.4% of e-cigarette users (n = 59) and 10.5% of never users (n = 16). E-cigarette users had 6.17 times (95% confidence interval: 3.30–11.6) the odds of initiating cigarettes as never e-cigarette users. Results were robust to adjustment for potential confounders and in analyses restricted to never users of any combustible tobacco product. Associations were stronger in adolescents with no intention of smoking at initial evaluation. E-cigarette users were also more likely to initiate use of any combustible product (odds ratio = 4.98; 95% confidence interval: 2.37–10.4), including hookah, cigars, or pipes.

    CONCLUSIONS E-cigarette use in never-smoking youth may increase risk of subsequent initiation of cigarettes and other combustible products during the transition to adulthood when the purchase of tobacco products becomes legal. Stronger associations in participants with no intention of smoking suggests that e-cigarette use was not simply a marker for individuals who would have gone on to smoke regardless of e-cigarette use.

  10. Page 88
    Abstract
    Address correspondence to Zewditu Demissie, PhD, Division of Adolescent and School Health, Centers for Disease Control and Prevention, 1600 Clifton Rd, MS E-75, Atlanta, GA 30329. E-mail: izj5@cdc.gov

    BACKGROUND Adolescent use of tobacco in any form is unsafe; yet the use of electronic cigarettes and other electronic vapor products (EVPs) has increased in recent years among this age group. We assessed the prevalence and frequency of cigarette smoking and EVP use among high school students, and associations between health-risk behaviors and both cigarette smoking and EVP use.

    METHODS We used 2015 national Youth Risk Behavior Survey data (N = 15 624) to classify students into 4 mutually exclusive categories of smoking and EVP use based on 30-day use: nonuse, cigarette smoking only, EVP use only, and dual use. Prevalence of cigarette smoking and EVP use were assessed overall and by student demographics and frequency of use. Prevalence ratios were calculated to identify associations with health risk-behaviors.

    RESULTS In 2015, 73.5% of high school students did not smoke cigarettes or use EVPs, 3.2% smoked cigarettes only, 15.8% used EVPs only, and 7.5% were dual users. Frequency of cigarette smoking and EVP use was greater among dual users than cigarette-only smokers and EVP-only users. Cigarette-only smokers, EVP-only users, and dual users were more likely than nonusers to engage in several injury, violence, and substance use behaviors; have ≥4 lifetime sexual partners; be currently sexually active; and drink soda ≥3 times/day. Only dual users were more likely than nonusers not to use a condom at last sexual intercourse.

    CONCLUSIONS EVP use, alone and concurrent with cigarette smoking, is associated with health-risk behaviors among high school students.

  11. Page 101
    Abstract
    Address correspondence to Jessica L. Barrington-Trimis, PhD, MS, MA, University of Southern California, 2001 North Soto St, 230-D, Los Angeles, CA 90089. E-mail: jtrimis@usc.edu

    BACKGROUND Use of electronic cigarettes (e-cigarettes) among adolescents has increased since their introduction into the US market in 2007. Little is known about the role of e-cigarette psychosocial factors on risk of e-cigarette or cigarette use in adolescence.

    METHODS Information on e-cigarette and cigarette psychosocial factors (use and attitudes about use in the home and among friends) was collected from 11th- and 12th-grade participants in the Southern California Children’s Health Study during the spring of 2014.

    RESULTS Of 2084 participants, 499 (24.0%) had used an e-cigarette, including 200 (9.6%) current users (past 30 days); 390 participants (18.7%) had smoked a combustible cigarette, and 119 (5.7%) were current cigarette smokers. Cigarette and e-cigarette use were correlated. Nevertheless, 40.5% (n = 81) of current e-cigarette users had never smoked a cigarette. Psychosocial factors (home use of each product, friends’ use of and positive attitudes toward e-cigarettes and cigarettes) and participant perception of the harm of e-cigarettes were strongly positively associated both with e-cigarette and cigarette use. Most youth who reported e-cigarette use had friends who used e-cigarettes, and almost half of current users reported that they did not believe there were health risks associated with e-cigarette use.

    CONCLUSIONS Longitudinal studies of adolescents are needed to determine whether the strong association of e-cigarette psychosocial factors with both e-cigarette and cigarette use will lead to increased cigarette use or dual use of cigarettes and e-cigarettes, or whether e-cigarettes will serve as a gateway to cigarette use.

  12. Page 114
    Abstract
    Address correspondence to Stanton A. Glantz, PhD, Center for Tobacco Control Research and Education, Room 366 Library, 530 Parnassus Ave, University of California, San Francisco, CA 94143-1390. E-mail: glantz@medicine.ucsf.edu

    BACKGROUND E-cigarette use is rapidly increasing among adolescents in the United States, abstract with some suggesting that e-cigarettes are the cause of declining youth cigarette smoking. We hypothesized that the decline in youth smoking changed after e-cigarettes arrived on the US market in 2007.

    METHODS Data were collected by using cross-sectional, nationally representative school-based samples of sixth- through 12th-graders from 2004–2014 National Youth Tobacco Surveys (samples ranged from 16 614 in 2013 to 25 324 in 2004). Analyses were conducted by using interrupted time series of ever (≥1 puff) and current (last 30 days) cigarette smoking. Logistic regression was used to identify psychosocial risk factors associated with cigarette smoking in the 2004–2009 samples; this model was then applied to estimate the probability of cigarette smoking among cigarette smokers and e-cigarette users in the 2011–2014 samples.

    RESULTS Youth cigarette smoking decreased linearly between 2004 and 2014 (P = .009 for ever smoking and P = .05 for current smoking), with no significant change in this trend after 2009 (P = .57 and .23). Based on the psychosocial model of smoking, including demographic characteristics, willingness to wear clothing with a tobacco logo, living with a smoker, likelihood of smoking in the next year, likelihood of smoking cigarettes from a friend, and use of tobacco products other than cigarettes or e-cigarettes, the model categorized <25% of current e-cigarette–only users (between 11.0% in 2012 and 23.1% in 2013) as current smokers.

    CONCLUSIONS The introduction of e-cigarettes was not associated with a change in the linear decline in cigarette smoking among youth. E-cigarette–only users would be unlikely to have initiated tobacco product use with cigarettes.

  13. Page 124
    Abstract
    Address correspondence to Thomas A. Wills, PhD, Epidemiology Program, University of Hawaii Cancer Center, 701 Ilalo St, 5th Floor, Honolulu, HI 96813. E-mail: Twills@cc.hawaii.edu

    OBJECTIVE To describe electronic cigarette (e-cigarette) use and cigarette use among adolescents abstract and determine whether established risk factors for smoking discriminate user categories.

    METHODS School-based survey of 1941 high school students (mean age 14.6 years) in Hawaii; data collected in 2013. The survey assessed e-cigarette use and cigarette use, alcohol and marijuana use, and psychosocial risk and protective variables (eg, parental support, academic involvement, smoking expectancies, peer smoking, sensation seeking). Analysis of variance and multinomial regression examined variation in risk and protective variables across the following categories of ever-use: e-cigarette only, cigarette only, dual use (use of both products), and nonuser (never used either product).

    RESULTS Prevalence for the categories was 17% (e-cigarettes only), 12% (dual use), 3% (cigarettes only), and 68% (nonusers). Dual users and cigarette-only users were highest on risk status (elevated on risk factors and lower on protective factors) compared with other groups. E-cigarette only users were higher on risk status than nonusers but lower than dual users. E-cigarette only users and dual users more often perceived e-cigarettes as healthier than cigarettes compared with nonusers.

    CONCLUSIONS This study reports a US adolescent sample with one of the largest prevalence rates of e-cigarette only use in the existing literature. Dual use also had a substantial prevalence. The fact that e-cigarette only users were intermediate in risk status between nonusers and dual users raises the possibility that e-cigarettes are recruiting medium-risk adolescents, who otherwise would be less susceptible to tobacco product use.

  14. Page 133
    Abstract
    Address correspondence to Jennifer C. Duke, PhD, RTI International, 3040 East Cornwallis Road, Research Triangle Park, NC 27709. E-mail: jduke@rti.org.

    BACKGROUND AND OBJECTIVE Currently, the US Food and Drug Administration does not regulate electronic cigarette (e-cigarette) marketing unless it is advertised as a smoking cessation aid. To date, the extent to which youth and young adults are exposed to e-cigarette television advertisements is unknown. The objective of this study was to analyze trends in youth and young adult exposure to e-cigarette television advertisements in the United States.

    METHODS Nielsen data on television household audiences’ exposure to e-cigarette advertising across US markets were examined by calendar quarter, year, and sponsor.

    RESULTS Youth exposure to television e-cigarette advertisements, measured by target rating points, increased 256% from 2011 to 2013. Young adult exposure increased 321% over the same period. More than 76% of all youth e-cigarette advertising exposure occurred on cable networks and was driven primarily by an advertising campaign for 1 e-cigarette brand.

    CONCLUSIONS E-cigarette companies currently advertise their products to a broad audience that includes 24 million youth. The dramatic increase in youth and young adult television exposure between 2011 and 2013 was driven primarily by a large advertising campaign on national cable networks. In the absence of evidencebased public health messaging, the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health. If current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults.

  15. Page 141
    Abstract
    Address correspondence to Jessica L. Barrington-Trimis, PhD, MS, MA, University of Southern California, 2001 North Soto St, 230-D, Los Angeles, CA 90089. E-mail: jtrimis@usc.edu

    BACKGROUND Use of electronic cigarettes (e-cigarettes) among adolescents has increased since their introduction into the US market in 2007. Little is known about the role of e-cigarette psychosocial factors on risk of e-cigarette or cigarette use in adolescence.

    METHODS Information on e-cigarette and cigarette psychosocial factors (use and attitudes about use in the home and among friends) was collected from 11th- and 12th-grade participants in the Southern California Children’s Health Study during the spring of 2014.

    RESULTS Of 2084 participants, 499 (24.0%) had used an e-cigarette, including 200 (9.6%) current users (past 30 days); 390 participants (18.7%) had smoked a combustible cigarette, and 119 (5.7%) were current cigarette smokers. Cigarette and e-cigarette use were correlated. Nevertheless, 40.5% (n = 81) of current e-cigarette users had never smoked a cigarette. Psychosocial factors (home use of each product, friends’ use of and positive attitudes toward e-cigarettes and cigarettes) and participant perception of the harm of e-cigarettes were strongly positively associated both with e-cigarette and cigarette use. Most youth who reported e-cigarette use had friends who used e-cigarettes, and almost half of current users reported that they did not believe there were health risks associated with e-cigarette use.

    CONCLUSIONS Longitudinal studies of adolescents are needed to determine whether the strong association of e-cigarette psychosocial factors with both e-cigarette and cigarette use will lead to increased cigarette use or dual use of cigarettes and e-cigarettes, or whether e-cigarettes will serve as a gateway to cigarette use.

  16. Page 154
    Abstract
    Address correspondence to Meghan E. Morean, PhD, Department of Psychology, Oberlin College, 120 W Lorain Street #219, Oberlin, OH 44074. E-mail: meghan.morean@gmail.com

    BACKGROUND AND OBJECTIVES Electronic cigarette (e-cigarette) use is increasing rapidly among high abstract school (HS) students. Of concern, e-cigarettes can be used to vaporize cannabis, although use rates among adolescents are unknown. We evaluated lifetime rates of using e-cigarettes to vaporize cannabis among all lifetime e-cigarette users (27.9%), all lifetime cannabis users (29.2%), and lifetime users of both e-cigarettes and cannabis (18.8%); common means of vaporizing cannabis including hash oil, wax infused with D-9-tetrahydrocannabinol (THC), and dried cannabis; and demographic predictors of using e-cigarettes to vaporize cannabis.

    METHODS In the spring of 2014, 3847 Connecticut HS students completed an anonymous survey assessing e-cigarette and cannabis use.

    RESULTS Vaporizing cannabis using e-cigarettes was common among lifetime e-cigarette users, lifetime cannabis users, and lifetime dual users (e-cigarette 18.0%, cannabis 18.4%, dual users 26.5%). Students reported using e-cigarettes to vaporize hash oil (e-cigarette 15.4%, cannabis 15.5%, dual users 22.9%) and wax infused with THC (e-cigarette 10.0%, cannabis 10.2%, dual users 14.8%) and using portable electronic vaporizers to vaporize dried cannabis leaves (e-cigarette 19.6%, lifetime cannabis 23.1%, lifetime dual users 29.1%). Binary logistic regression indicated that male students (odds ratio [OR] = 2.05), younger students (OR = 0.64), lifetime e-cigarette users (OR = 5.27), and lifetime cannabis users (OR = 40.89) were most likely to vaporize cannabis using e-cigarettes. Rates also differed by HS attended.

    CONCLUSIONS Rates of vaporizing cannabis using e-cigarettes were high. These findings raise concerns about the lack of e-cigarette regulations and the potential use of e-cigarettes for purposes other than vaping nicotine.

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