IntroductionMicro-influencers (1000–100 000 followers) promote e-cigarettes alongside cannabis on social media. This study examined the association of exposure to such marketing with adolescent perceptions of e-cigarettes and micro-influencers.MethodsIn this 2023–2024 survey-based, in-class repeated-measures experiment, California adolescent e-cigarette and cannabis never-users (n = 1402; Mage = 17 [SD = 0.6]; 51.4% female, 41.7% Hispanic) were randomly shown three pairs of Instagram images featuring micro-influencers promoting: (1) e-cigarettes with cannabis (experimental group), (2) e-cigarettes alone (control), or (3) no substances (placebo). After viewing each image pair, participants rated perceived influencer credibility. After viewing all images, susceptibility to use e-cigarettes was assessed. Three susceptibility sub-items and their composite measure were compared across groups (experimental vs. control; placebo vs. control) and between participants who perceived micro-influencers as credible versus noncredible, using binomial generalized linear mixed effects models. The association of self-reported exposure to micro-influencer e-cigarette or cannabis posts with these outcomes was also assessed.ResultsParticipants in the experimental group had higher odds of e-cigarette use intentions if offered by a friend among all and among those who perceived micro-influencers as credible, compared to controls. Those who self-reported exposure to micro-influencer e-cigarette or cannabis posts were at higher odds of overall susceptibility, intentions to use if a friend offers, and curiosity about e-cigarette use.ConclusionsInfluencer e-cigarette promotion alongside cannabis, and perceptions of influencers as credible, may contribute to e-cigarette use intentions among adolescent never-users. Improvement of social media community guidelines and greater policy attention to e-cigarette and cannabis marketing are needed.ImplicationsThe study showed that influencer promotion of e-cigarettes alongside cannabis, and perceptions of influencers as credible, may contribute to intentions to use e-cigarettes among adolescent never-users. The findings suggest the need for improvement of social media community guidelines and greater policy attention to marketing of e-cigarettes and cannabis.Trial Registrationhttps://clinicaltrials.gov/study/NCT06919263, NCT06919263.

IntroductionThe emergence and rapid increase in sales and use of heated tobacco products (HTPs) in Japan provides a unique case study of their viability as a potentially lower-risk substitute for combustible cigarettes. This review investigates the relationship between HTP and cigarette use in Japan.MethodsWe searched PubMed and Web of Science for studies on HTP and cigarette use, including sales trends, prevalence, and transitions between HTPs and cigarettes from 2010 to 2024. We distinguish results by source of funding and survey design.ResultsOur review included 25 relevant studies, of which 21 reported HTP and/or cigarette prevalence and transitions and 4 reported sales trends. Cigarette sales and use rapidly declined during the national expansion of HTPs. HTP use increased substantially from 2015 to about 2019, then slowed through 2023. Trends from industry-sponsored studies were mostly in line with the government-sponsored estimates. Estimates from government-sponsored (mostly in-person) surveys indicate that cigarette use continuously declined from 2015 to 2023 as HTP growth increased, although at a slower pace since 2018. After decreasing cigarette prevalence from 2015 to 2018, online surveys reported high rates of dual cigarette-HTP use and comparatively low rates of smoking discontinuation from 2018 to 2023.ConclusionsThe rapid decline in cigarette use from 2015 to 2018 in Japan suggests that increasing HTP use may have contributed to this trend. After 2018, slowing HTP sales and mixed estimates of cigarette and HTP use raise uncertainty about the role of HTPs. As such, the evidence remains incomplete, limiting definitive conclusions. The current study highlights the challenges associated with distinguishing the impact of HTPs on displacing cigarettes.ImplicationsThis review provides evidence that HTP use likely contributed to declines in cigarette use in Japan from 2015 to 2018, though recent trends are less conclusive. It highlights differences across data sources and survey types, which can affect how results are interpreted. The study adds to our understanding of how HTPs may or may not replace cigarettes over time and points to the need for better, more consistent data to track these trends.

IntroductionThe tobacco industry’s marketing efforts have successfully recruited a new generation of tobacco users, with flavored e-cigarette use becoming increasingly prevalent among young adults (YAs). Media campaigns continue to be an effective and cost-efficient approach to counteract the strong negative influence of marketing. Identifying salient beliefs underlying YAs’ flavored e-cigarette use serves as the first step in designing effective anti-vaping campaigns.MethodsAn elicitation survey was conducted among 396 YAs (18–25 years; M = 19.66, SD = 1.45) who have ever vaped, with the majority (70.3%) having vaped in the past 6 months. Open-ended questions were used to probe perceptions of flavored e-cigarette use, including benefits, consequences, social norms, facilitators, and barriers of continued use. Thematic analysis was conducted by two coders (α = 0.81–1.00) to identify commonly held and novel beliefs.ResultsThe most shared benefits of flavored e-cigarette use included facilitating stress relief and addressing mental health concerns. While participants shared many health-related disadvantages of flavored vaping, including shortness of breath and addiction, our findings illuminate misperceptions and knowledge gaps about the safety of these products. Participants emphasized the influence of marketing on their use of flavored e-cigarettes, as appealing ads on social media were commonly cited as facilitating factors. Our findings also underscore the glorious social perceptions of flavored vaping.ConclusionsThe findings of this study provide a comprehensive list of potential themes for anti-vaping campaigns targeting flavored e-cigarette use among YAs, ranked by prevalence. Novel, salient beliefs generated directly from the target audience provide fresh, innovative angles to fuel prevention efforts.ImplicationsThis study fills an important gap in understanding about YAs’ beliefs and perceptions of flavored vaping products. Our findings reveal salient and novel attitudinal, normative, and control beliefs about flavored vaping. These beliefs will serve as a springboard for inspiring effective campaigns that seek to change YAs’ beliefs and to subsequently curb their flavored vaping behavior.

IntroductionWaterpipe smoking has become popular in East Asia and other regions. However, few studies have investigated the indoor air quality, including the presence of carcinogens, in waterpipe bars (WBs). This study aimed to compare indoor air quality between WBs and non-WBs in Hong Kong, focusing on differences observed during weekdays and weekends.MethodsAir samples from 8 WBs and 6 non-WBs were collected to investigate levels of fine particulate matter (PM2.5), carbon monoxide (CO), nicotine, volatile organic compounds (VOCs), and polycyclic aromatic hydrocarbons (PAHs) in the ambient air of these bars. Samples were collected for 2 h in each bar during both a weekday and a weekend evening. Data were analyzed using descriptive statistics, the Wilcoxon rank-sum test, and Wilcoxon signed-rank test.ResultsThe median PM2.5 levels in WBs was 332.1 μg/m3 on weekdays and 1001 μg/m3 on weekends. Similarly, CO levels in WBs were 22.5 ppm on weekdays 27.9 ppm on weekends. The comparison showed that PM2.5 (p = .0019) and CO (p = .0019) levels in WBs were significantly higher than those in non-WBs on weekdays. Airborne nicotine levels were 3.2 μg/m3 on weekdays and 16.1 μg/m3 on weekends. Most VOCs and PAHs levels were higher during weekends, with benzo[a]pyrene at 15.3 ng/m3 (weekday) and 22.5 ng/m3 (weekend), and Formaldehyde at 57 μg/m3 (weekday) and 66.5 μg/m3 (weekend)—Group 1 carcinogens.ConclusionThis study revealed alarmingly high levels of airborne PM2.5, CO, nicotine, and carcinogens such as Benzo[a]pyrene and Formaldehyde in WBs in Hong Kong, especially on weekends.ImplicationsThis study provides the first evidence of air quality in waterpipe establishments in Asia, demonstrating extremely poor air quality that pose significant health risks to both patrons and staff. These results can serve as evidence for the strict enforcement of tobacco control policies, such as total waterpipe bans. It is also crucial to assess compliance with occupational safety regulations in WBs and to ensure employees exposed to high levels of harmful substances such as PM2.5, CO, nicotine, and carcinogens are offered education and health screenings and education. These measures are vital to ensuring the safety and health of workers.

IntroductionNicotine dependence measures often rely on self-reported cigarette consumption, which has declined over time and may not accurately reflect nicotine intake. We developed a brief two-item Short Nicotine Dependence Index (SNDI) assessing urge to use and difficulty abstaining, and examined its association relative to that of the established Heaviness of Smoking Index (HSI) with saliva cotinine, a biomarker of nicotine exposure.MethodsData were drawn from the Health Survey for England (HSE; 2000–2021) and a London General Practice Survey (GP Survey; 1989) (n = 14 244 current cigarette smokers aged ≥16 with valid cotinine data). Dependence was assessed using two questions: time to first cigarette after waking (scored 1–6) and perceived difficulty going a whole day without smoking (scored 0–3). Scores were summed to produce a total SNDI score (range 1–9). Mean cotinine levels were estimated across item responses and total scores in each sample.ResultsCotinine concentrations increased consistently with higher scores on both individual items and the total SNDI score. In the HSE, cotinine ranged from 83 [95% CI = 77% to 88%] ng/mL for those with the lowest total score to 387 [377–396] ng/mL for those with the maximum score. A similar gradient was observed in the GP Survey (from 92 [75–110] to 431 [399–463]), despite higher overall cigarette consumption. In both datasets, the SNDI explained more variance in cotinine than the HSI: R2 = 0.304 vs. 0.278; GP Survey: 0.283 vs. 0.250.ConclusionsThe SNDI is a brief self-report measure that outperforms existing short tools in predicting nicotine exposure. It offers a practical alternative for research and community surveillance in evolving nicotine use landscapes.ImplicationsThe Short Nicotine Dependence Index offers an efficient and practical alternative to traditional dependence measures that rely on cigarette consumption. Its brevity and strong correlation with biochemical markers make it well-suited for use in large-scale surveys and clinical settings. By focusing on observed behavior (time to first cigarette) and self-reported difficulty abstaining, it remains relevant as smoking and nicotine use patterns shift. In addition, because it does not use reported cigarettes smoked per day, it may be useful for assessing dependence on other nicotine products (eg, e-cigarettes). Further research is needed to evaluate its validity among users of other nicotine products.

IntroductionEmergency departments (EDs) offer a valuable opportunity to deliver smoking cessation interventions. Long-term abstinence confers the maximum health benefits.MethodsAdults attending UK EDs who currently smoked were randomized to an intervention (brief advice, e-cigarette, and referral to local stop smoking services) or control (contact details for local stop smoking services). Participants were followed up at 1, 3, and 6 months as part of the main trial. Participants who consented to long-term follow-up were also contacted at approximately 18 months post randomization. For an “all participants” analysis, those who did not consent to long-term follow-up had their smoking status set at the value of the 6-month outcome. Those who did not respond were assumed to be smoking.ResultsLong-term follow-up occurred between 14 and 22 months, mean = 18 months. Long-term follow-up for those who consented to this was 35% in the intervention group (n = 145) and 34% in the control group (n = 143). For those who consented to long-term follow-up self-reported 7-day abstinence at 18 months was 12.8% in the intervention group (n = 53) and 8.33% in the control group (n = 35) (RR = 1.56, 95% CI = 1.04%−2.32%, p = .031). For all participants self-reported 7-day abstinence at long-term follow-up was 13.8% in the intervention group (n = 67) and 8.6% in the control group (n = 42) (RR = 1.61, 95% CI = 1.12%−2.31%, p = .010).ConclusionsAdults who smoke attending the ED who received a smoking cessation intervention were significantly more likely to report abstinence 18 months after randomization.ImplicationsEmergency Departments should be considered as a location for smoking cessation interventions in order to increase long-term abstinence.

IntroductionThis study aims to provide prevalence data on dual-use (one additional product) and poly-use (two or more products) of inhaled nicotine and tobacco products (cigarettes, e-cigarettes and/or heated tobacco products (HTP)) among current waterpipe (WP) users in Germany over recent years, and explores specific person characteristics associated with such co-use.MethodsA series of cross-sectional, nationwide, representative, face-to-face household surveys in Germany between 2019 and 2023. Samples were selected using multistratified random sampling (50%) combined with quota sampling (50%). The current analysis included 61 713 respondents (aged ≥14 years) of which 1303 reported current WP use.ResultsWP use in Germany fluctuated between 1.5% and 2.8% from 2019 and 2023. The prevalence rate for 2023 was 1.5% (95%CI = 1.2,1.7). Among users, exclusive WP use declined from 41.8% (95%CI = 35.3,48.5) in 2019 to 26.3% (95%CI = 20.2,33.3) in 2023. Over this period, dual-use increased from 49.3% (95%CI = 42.6,56.1) to 62.3% (95%CI = 55.0,69.3), and poly-use rose from 8.9% (95%CI = 5.5,13.4) to 11.2% (95%CI = 7.1,16.7). Multivariable analyses confirmed a significant decline in exclusive WP use over time (OR per year = 0.90, 95%CI = 0.81–0.99), while the increases in dual-use was not statistically robust after adjustment. Among dual users, the majority (94.2%) reported also smoking cigarettes. The likelihood of using at least one additional product alongside WP was positively associated with increasing age, and with low and middle compared with high educational attainment.ConclusionAmong current WP users in Germany, exclusive WP use has decreased in recent years, with potential commensurate increase in dual- and poly-use.ImplicationThese novel data help inform on the consumption behavior of current WP users and highlights the need for targeted public health interventions that address not only exclusive product use but also the rising combination of different products.