Young Adult E-cigarette Users Research Articles

ENDS use among college students: Salivary biomarkers and persistent cough

Though e-cigarette aerosol has been associated with altered lung cell function, few studies have examined the effects of use on immune response and respiratory symptoms. The purpose of this study was to examine if recent persistent cough or cytokine levels are related to Electronic Nicotine Delivery Systems (ENDS) use in college students. In April 2019, 61 undergraduate students at the University of Kentucky completed surveys and provided a salivary sample to evaluate cytokine levels (Interleukin (IL-) 2, 4, 6, 8, 10, 12, 13 and TNFα, INFγ), using quota sampling to obtain comparable numbers of ENDS users and non-ENDS users. Data analysis included chi-square tests and multivariable logistic and linear regression. All ENDS users reported JUUL as their primary product. ENDS users were more likely to be younger, use cigarettes and marijuana, and report a persistent cough. Controlling for cigarette and marijuana use, there was a trend toward greater likelihood of persistent cough among ENDS users. Compared with nonusers, salivary IL-2 and INFγ were elevated and IL-4 was decreased, controlling for cigarette and marijuana use. There was a trend toward lower IL-12p70 values among ENDS users with these covariates. Findings reveal dysregulation of salivary immune profiles toward a TH1 phenotype in emerging adult ENDS users and short-term immune function may be dysregulated in young adult e-cigarette users.

Effectiveness of a Quit Vaping Text Message Program in Promoting Abstinence Among Young Adult E-Cigarette Users: Protocol for a Randomized Controlled Trial.

BackgroundMillions of young adults currently vape electronic cigarettes (e-cigarettes), yet little research on vaping cessation interventions exists. Text messaging is a promising, scalable intervention strategy for delivering vaping cessation treatment.ObjectiveThis study evaluates the effectiveness of a text message quit vaping program (This is Quitting) in promoting abstinence from e-cigarettes among young adults; examines changes in self-efficacy, perceived social norms, and social support for quitting as hypothesized mediators of effectiveness; and examines if treatment effectiveness is moderated by gender, race, ethnicity, or sexual minority status.MethodsOverall, 2600 young adult (aged 18-24 years) e-cigarette users in the United States will be recruited via web advertisements to participate in the study. Participants will be randomized to This is Quitting or an assessment-only control condition. The primary outcome measure is 30-day vaping abstinence at 7 months post enrollment.ResultsStudy recruitment began on December 18, 2019, and is projected to be completed by spring 2020. The final 7-month follow-up is anticipated to be completed by fall/winter 2020. Because this is the first-ever evaluation of a quit vaping program, we were unable to draw on existing literature to determine the appropriate sample size. Therefore, we examined abstinence rates among an initial pilot sample of 269 participants (This is Quitting: n=148 and control: n=121) who completed the 1-month follow-up to determine the final sample size. The 1-month response rate was 79.2% (213/269), with no difference between arms. Using intention-to-treat analyses that counted nonresponders as still vaping, 30-day abstinence rates were 16.2% (24/148) among those randomized to This is Quitting and 8.3% (10/121) among those randomized to control. A treatment difference of 16% vs 8% is detectable with 80% power at 2-sided alpha=.05 with 260/group (520 total). To detect treatment differences of this magnitude in a 20% subsample (eg, Hispanic or sexual minority young adult e-cigarette users), we will enroll 1300/group (2600 total).ConclusionsThe scientific, clinical, and public health communities are desperate for cessation resources to address vaping among young people. This study is the first-ever comparative effectiveness trial of an intervention to help young people quit vaping. It focuses on evaluating the effectiveness of a theory-grounded, empirically informed text message intervention among young adults. The study is fully powered to examine potentially important subgroup differences among young people who are more vulnerable to e-cigarette use. Although potentially more challenging from a research ethics and pragmatic standpoint, evaluating quit vaping intervention approaches in teens is an important area for future research. Data from this trial will establish a benchmark of effectiveness for other vaping cessation programs and begin to create a body of evidence focused on how best to help young people break free from e-cigarettes.Trial RegistrationClinicalTrials.gov NCT04251273; https://clinicaltrials.gov/ct2/show/NCT04251273International Registered Report Identifier (IRRID)DERR1-10.2196/18327

Perceived addiction to vaping among youth and young adult regular vapers

BackgroundThe prevalence of e-cigarette use among youth and young adults has increased markedly in recent years; however, little is known about young people’s perceptions of e-cigarette addiction. This study examines...

E-cigarette device power moderates the effects of non-tobacco flavors and nicotine on product appeal in young adults

BackgroundIdentifying e-cigarette product characteristics that moderate the effects of non-tobacco flavors and nicotine on user appeal can inform regulations issued in tandem with e-cigarette nicotine and flavor policies aimed to protect young adult health. An e-cigarette device’s electrical power affects the amount of solution aerosolized per puff, leading to more concentrated or diluted aerosol, which may alter product appeal. This laboratory experiment tested whether e-cigarette device power moderated the independent and interactive effects of non-tobacco flavors and nicotine on appeal in young adults. MethodIn a within-subject design single-visit protocol, young adult e-cigarette users (N = 100) administered standardized doses of e-cigarette solutions varying in flavor (fruit, menthol, tobacco) and nicotine (nicotine-containing [6 mg/mL], nicotine-free). Solutions were administered via a variable-voltage tank-style device at low (7.3 W[3.3 V@1.5 Ω resistance]) and high (12.3 W[4.3 V@1.5 Ω resistance]) power settings. Participants rated each dose’s appeal (0–100 scale). ResultsThe high (vs. low) power setting attenuated the appeal-enhancing effects of menthol (vs. tobacco) flavors (Menthol × Power, estimate = −5.44, P = .03). Power did not moderate the appeal-enhancing effects of fruit flavors. High (vs. low) power amplified the appeal-reducing effects of nicotine-containing (vs. nicotine-free) solutions (Nicotine × Power, estimate = 6.69, P < .001) and augmented the extent to which fruit and menthol flavors suppressed nicotine’s appeal-reducing effects (Flavor × Nicotine × Power, estimates = 9.40–14.85, Ps≤0.03). ConclusionE-cigarette device power appears to moderate flavor- and nicotine-induced changes in product appeal in nuanced ways, including by augmenting the ability of non-tobacco flavors to mask nicotine’s appeal-reducing effects. Regulatory restrictions on high-powered e-cigarette devices warrant consideration in efforts to protect young adult health.

Sex differences in the appeal of flavored e-cigarettes among young adult e-cigarette users.

Experimental evidence suggests that females (vs. males) may be more sensitive to and derive greater reinforcement from the sensory aspects of combustible cigarette smoking (e.g., flavor, taste). However, it is unknown if there are similar sex differences in the appeal of flavored e-cigarettes. Young adult male (N = 65) and female (N = 35) e-cigarette users (mean age = 25.4; 53% current smokers) attended 1 laboratory session in which they self-administered standardized e-cigarette doses according to a Flavor (fruit vs. tobacco vs. menthol) × Nicotine (6 mg/mL vs. 0 mg/mL) × Voltage (3.3 V vs. 4.3 V) within-participant fully crossed factorial design. Following each trial, participants completed ratings of appeal (mean of liking, disliking [reverse scored], and willingness-to-use-again ratings). Sex was tested as a between-subjects moderator of the effects of flavor on appeal. There was a significant interaction between sex and flavor for e-cigarette appeal (p < .001). In males, fruit-flavored e-cigarettes generated greater appeal than menthol and tobacco (ps < .001). In females, both fruit- and menthol-flavored e-cigarettes generated greater appeal than tobacco (ps < .001), but there was no significant difference between fruit- and menthol-flavored e-cigarettes (p = .40). The findings of this study suggest that males prefer fruit-flavored e-cigarettes, and females prefer both menthol- and fruit-flavored e-cigarettes. The impact of regulatory policies targeting e-cigarette flavors in the population may vary by sex. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Compliance in Controlled E-cigarette Studies.

E-cigarette studies have found that the use of a variety of flavors and customizable devices results in greater use frequency and user satisfaction. However, standardized research e-cigarettes are being developed as closed systems with limited flavor options, potentially limiting user satisfaction. In this study, we explore protocol compliance in an e-cigarette study using a standardized, assigned device with puff time and duration tracking (controlled e-cigarette) and potential limitations that controlled devices and e-liquids can introduce. In a crossover study, 49 young adult e-cigarette users were recruited using convenience sampling and assigned a controlled e-cigarette device and flavored or unflavored e-liquids on standardized protocols. E-cigarette use frequency (number of puffs per day, collected from the device) and serum cotinine levels were obtained at each of three study visits over 3 weeks. The correlation of cotinine and e-cigarette use over the preceding week was calculated at each study visit. Correlation of nicotine intake, as measured by serum cotinine, and puff time, as measured by puffs count and duration from the e-cigarette device, as an indicator of study protocol compliance, substantially declined after the first week of the study and were no longer correlated in the remaining study weeks (R2 = 0.53 and p ≤ .01 in week 1, R2 < 0.5 and p > .05 for remaining weeks). There is an emerging need for controlled e-cigarette exposures studies, but low compliance in the use of assigned devices and e-liquids may be a limitation that needs to be mitigated in future studies. This study is the first to analyze compliance with instructions to use a standardized e-cigarette device with puff time and duration tracking (controlled e-cigarette) across all subjects and an assigned e-liquid flavor over a 3-week period. We find that protocol compliance, as measured by correlations between e-cigarette use measures and cotinine levels, was only achieved in the first week of the study and declined thereafter. These findings indicate that the assignment of a study device and instruction to only use the study device with assigned e-liquid flavor may not be sufficient to ensure participant compliance with the study protocol. We suggest that additional measures, including behavioral and biological markers, are needed to ensure sole use of the study e-cigarette and e-liquid and to be able to interpret results from controlled e-cigarette studies.

Expectancies and reasons for use of e-cigarettes among young adults: A longitudinal analysis.

Use of electronic cigarettes, or e-cigarettes, has increased exponentially in recent years. Mechanisms that might underlie this increase include expectancies and reasons for e-cigarette use. This study was designed to identify and evaluate changes in expectancies and reasons for e-cigarette use among young adults over time and to determine whether such changes were associated with changes in e-cigarette use. Data for these analyses were collected from a sample of 137 young adult e-cigarette users who completed electronic surveys 5 times over a 12-month period. Results yielded five e-cigarette use expectancy and reason factors: Affect-Related Reasons, Social Reasons, Positive Social Expectancies, Positive Internal Expectancies, and Negative Expectancies. Linear mixed models showed that Negative Expectancies significantly increased over time (p = .004), whereas Affect-Related Reasons significantly decreased over time (p = .001). Additional linear mixed models indicated that, whereas both frequency and quantity of e-cigarette use decreased over time, changes in Positive Internal Expectancies were positively associated with changes in frequency of e-cigarette use (p = .032) and changes in Positive Social Expectancies were positively associated with changes in both frequency (p = .007) and quantity (p = .026) of e-cigarette use. These findings suggest that young adults' expectancies and reasons for using e-cigarettes fluctuate over time, and changes in expectancies seem to be longitudinally associated with changes in e-cigarette use. Positive expectancies for e-cigarette use represent targets for clinical, prevention, and intervention efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Some Young Adult E-Cigarette Users Report Seizures.

The FDA is investigating nicotine poisoning as a possible cause.

The relationship between family history of tobacco use and progression to tobacco use among young adult e-cigarette users.

Family history of tobacco use and use of e-cigarettes have both been associated with increased tobacco use among young adults. However, to our knowledge, these variables have not been considered simultaneously. This study was designed to evaluate the hypothesis that family history of tobacco use would predict tobacco product use over time among young adult e-cigarette users with limited combustible tobacco use experience. A sample of 124 participants were recruited online from across the United States, completed five surveys over 12 months, and reported use of nicotine and tobacco products over the previous two weeks at each survey. Family history of nicotine and tobacco use was reported at the 6-month assessment, and data were collected in 2017 and 2018. Regression models indicated that family history was associated with likelihood of cigarette use (odds ratio = 1.02 [95% confidence interval = [1.00, 1.04]). Significant interactions between family history and linear (OR = 1.05 [1.01, 1.10]) and quadratic (OR = 0.99 (0.98, 1.00)] time terms indicated that the association between family history and likelihood of combustible product use shifted over time. In both cases, more extensive family histories predicted greater use frequency, and follow-up analyses showed that more extensive family history was associated with greater combustible tobacco product use 3, 6, and 9 months following baseline. Family history of nicotine/tobacco use may promote initiation of tobacco use among e-cigarette users. These results suggest family history of tobacco use may comprise a risk factor for combustible tobacco use within the evolving tobacco product landscape.

Use of Flavored E-Cigarettes Among Adolescents, Young Adults, and Older Adults: Findings From the Population Assessment for Tobacco and Health Study.

The use of flavored electronic cigarettes (e-cigarettes) is common among e-cigarette users, but little is known about the potential harms of flavorings, the extent to which the concurrent use of multiple flavor types occurs, and the correlates of flavor type use. The objective of this study was to assess the types of e-cigarette flavors used by adolescent (aged 12-17), young adult (aged 18-24), and older adult (aged ≥25) e-cigarette users. We assessed the prevalence of flavored e-cigarette use within the past month by flavor types and concurrent use of multiple flavor types among past-month e-cigarette users sampled during Wave 2 (2014-2015) of the Population Assessment for Tobacco and Health Study among 414 adolescents, 961 young adults, and 1711 older adults. We used weighted logistic regression models for the use of fruit-, candy-, mint/menthol-, tobacco-, or other-flavored e-cigarettes and concurrent use of multiple flavor types. Covariates included demographic characteristics, e-cigarette use frequency, cigarette smoking status, current use of other tobacco products, and reasons for e-cigarette use. The leading e-cigarette flavor types among adolescents were fruit, candy, and other flavors; among young adults were fruit, candy, and mint/menthol; and among older adults were tobacco or other flavors, fruit, and mint/menthol. Compared with older adults, adolescents and young adults were more likely to use fruit-flavored e-cigarettes (adjusted odds ratio [aOR] = 3.35; 95% confidence interval [CI], 2.56-4.38; and aOR = 2.31; 95% CI, 1.77-3.01, respectively) and candy-flavored e-cigarettes (aOR = 3.81; 95% CI, 2.74-5.28; and aOR = 2.95; 95% CI, 2.29-3.80, respectively) and concurrently use multiple flavor types (aOR = 4.58; 95% CI, 3.39-6.17; and aOR = 2.28; 95% CI, 1.78-2.91, respectively). Regulation of sweet e-cigarette flavors (eg, fruit and candy) may help reduce the use of e-cigarettes among young persons without substantially burdening adult e-cigarette users.

Journal Club-Electronic Cigarettes and Vaping as a Harm Reduction Alternative: Really?

Journal Club-Electronic Cigarettes and Vaping as a Harm Reduction Alternative: Really?

Polytobacco Use Among a Nationally Representative Sample of Adolescent and Young Adult E-Cigarette Users

PurposeElectronic nicotine delivery systems (ENDS) are adolescents’ most commonly used tobacco product and young adults’ second most used. Little is known about ENDS use alongside other tobacco products (polytobacco use) and whether exclusive ENDS users differ from polytobacco ENDS users. MethodsIn spring 2016, we surveyed a nationally representative sample of 3,517 13–25-year olds (36.9% 13–17-year olds), and examined sociodemographic and relative risk perceptions between two groups of past 30-day ENDS users: exclusive (only ENDS) and polytobacco (ENDS and at least one other tobacco product). Results4.5% of adolescents and 10% of young adults reported past 30-day ENDS use (n = 281; analytic sample). ENDS users were 38.8% female and 70.6% white. Over half (55.9%) were polytobacco ENDS users. The most common patterns of polytobacco ENDS use were ENDS and cigarettes (11.5%), ENDS and cigars (7.7%), and ENDS, cigars, and waterpipe (5.2%). Those who perceived ENDS to be less harmful than cigarettes were more likely to be exclusive ENDS users than those who perceived ENDS to be as or more harmful than cigarettes (adjusted odds ratio = 2.6, confidence interval = 1.2, 5.7). There were no differences between ENDS groups on age, race, sex, parental education, sexual orientation, or ENDS use frequency. ConclusionsJust over half of ENDS users also used other tobacco products, increasing their risk for nicotine addiction and other health harms. The Food and Drug Administration is responsible for communicating product risk to consumers and should consider common patterns of use and relative risk perceptions in its ENDS public education efforts.

Young adult e-cigarette use outcome expectancies: Validity of a revised scale and a short scale

The revised youth e-cigarette outcome expectancies measure adds new items informed by recent qualitative research with young adult e-cigarette users, especially in the domain of positive “smoking” experience. Positive “smoking” experience represents beliefs that use of e-cigarettes provides outcomes associated with a better “smoking” alternative: for example, an alternative that is more socially approved, more suitable for indoor use, and that provides a safer means of enjoying nicotine. In addition, we tested a short, 8-item version of the measure which may be more easily incorporated into surveys. We tested the validity of the revised measure, both long and short versions, in terms of factor structure and associations of the expectancy factors with current e-cigarette use, e-cigarette use susceptibility, and e-cigarette use dependence. Participants were young adults (N=470; 65% women; mean age=20.9, SD=2.1). Results replicated the findings of the previous study as well as highlighted the importance of the added domain of positive “smoking” experience and the validity of the short scale. Furthermore, results showed that positive outcome expectancies are strongly associated with e-cigarette use dependence. The long and short versions of the revised youth e-cigarette outcome expectancies scale appear to be valid and useful for application not only among cigarette smokers and e-cigarette users but also among never smokers and never e-cigarette users.

Type of E-Cigarette Device Used Among Adolescents and Young Adults: Findings From a Pooled Analysis of Eight Studies of 2166 Vapers.

A recent study of adult smokers who vape found that disposable/cigalike electronic (e-) cigarette devices were more commonly used than later generation devices. However, whether these trends reflect patterns among adolescents and young adults, many of whom have limited or no history of combustible cigarette use, has not been studied. Participants were drawn from eight locally, regionally, and US nationally representative studies. Surveys took place between Fall 2014 and Spring 2016; participants were residents of California (3 studies), Texas (2 studies), Connecticut (1 study), or randomly selected from the US population (2 studies). Data were collected from middle and high school students (4 studies), young adults under 30 (3 studies), or a mixture (1 study) to assess type of e-cigarette device used among past-30 day e-cigarette users: disposable/cigalike, or later generation e-cigarette device. Fewer than 15% of participants in each study reported primarily using a disposable/cigalike device in the past month (across all studies: 7.5%; 95%CI: 4.9%, 10.5%). The proportion using later generation devices ranged from 58% to 86% across studies; overall, 77.0% (95%CI: 70.5%, 82.9%) reported primary use of a later generation device. Combined, 13.2% (95%CI: 5.9%, 22.8%) reported "don't know" or were missing data. Among adolescent and young adult e-cigarette users, primary use of disposable/cigalike devices was rare. Future research should continue to evaluate the type of device used by adolescents and young adults, as these data may be relevant to regulatory oversight of e-cigarettes recently acquired by the Food and Drug Administration Center for Tobacco Products. In this pooled analysis of adolescent and young adult vapers, primary use of later generation e-cigarette devices was substantially more common than use of disposable/cigalike devices. The type of device predominantly used by adolescents and young adults has regulatory implications for policy to reduce adolescent use of e-cigarettes.

Comparing Twitter and Online Panels for Survey Recruitment of E-Cigarette Users and Smokers.

BackgroundE-cigarettes have rapidly increased in popularity in recent years, driven, at least in part, by marketing and word-of-mouth discussion on Twitter. Given the rapid proliferation of e-cigarettes, researchers need timely quantitative data from e-cigarette users and smokers who may see e-cigarettes as a cessation tool. Twitter provides an ideal platform for recruiting e-cigarette users and smokers who use Twitter. Online panels offer a second method of accessing this population, but they have been criticized for recruiting too few young adults, among whom e-cigarette use rates are highest.ObjectiveThis study compares effectiveness of recruiting Twitter users who are e-cigarette users and smokers who have never used e-cigarettes via Twitter to online panelists provided by Qualtrics and explores how users recruited differ by demographics, e-cigarette use, and social media use.MethodsParticipants were adults who had ever used e-cigarettes (n=278; male: 57.6%, 160/278; age: mean 34.26, SD 14.16 years) and smokers (n=102; male: 38.2%, 39/102; age: mean 42.80, SD 14.16 years) with public Twitter profiles. Participants were recruited via online panel (n=190) or promoted tweets using keyword targeting for e-cigarette users (n=190). Predictor variables were demographics (age, gender, education, race/ethnicity), e-cigarette use (eg, past 30-day e-cigarette use, e-cigarette puffs per day), social media use behaviors (eg, Twitter use frequency), and days to final survey completion from survey launch for Twitter versus panel. Recruitment method (Twitter, panel) was the dependent variable.ResultsAcross the total sample, participants were recruited more quickly via Twitter (incidence rate ratio=1.30, P=.02) than panel. Compared with young adult e-cigarette users (age 18-24 years), e-cigarette users aged 25 to 34 years (OR 0.01, 95% CI 0.00-0.60, P=.03) and 35 to 44 years (OR 0.01, 95% CI 0.00-0.51, P=.02) were more likely to be recruited via Twitter than panel. Smokers aged 35 to 44 years were less likely than those aged 18 to 24 years to be recruited via Twitter than panel (35-44: OR 0.03, 95% CI 0.00-0.49, P=.01). E-cigarette users who reported a greater number of e-cigarette puffs per day were more likely to be recruited via Twitter than panel compared to those who reported fewer puffs per day (OR 1.12, 95% CI 1.05-1.20, P=.001). With each one-unit increase in Twitter usage, e-cigarette users were 9.55 times (95% CI 2.28-40.00, P=.002) and smokers were 4.91 times (95% CI 1.90-12.74, P=.001) as likely to be recruited via Twitter than panel.ConclusionsTwitter ads were more time efficient than an online panel in recruiting e-cigarette users and smokers. In addition, Twitter provided access to younger adults, who were heavier users of e-cigarettes and Twitter. Recruiting via social media and online panel in combination offered access to a more diverse population of participants.

Contexts of cigarette and e-cigarette use among dual users: a qualitative study.

BackgroundNot much is currently understood regarding the contexts of cigarette and e-cigarette use among dual users. Proper application of e-cigarettes to smoking cessation or tobacco harm reduction would require an understanding of when and why dual users use cigarettes versus e-cigarettes. This study sought to elucidate the contexts of cigarette versus e-cigarette use among dual users.MethodsTwelve focus group discussions were conducted with 62 young adult current daily e-cigarette users [63 % men; mean age = 25.1 (Standard Deviation = 5.5)]. Almost all participants either concurrently smoked cigarettes or had been recent dual users. Data were analyzed following principles of inductive deduction.ResultsResults indicated that dual users’ use of cigarettes is influenced by particular activities (e.g., before/after eating), strong craving or need for stimulation (e.g., in response to stress), places/situations (e.g., when cigarette smokers are nearby; outdoors), use of other substances (alcohol, coffee), and unavailability of an e-cigarette when needed. In addition to particular activities and places/situations that are conducive to e-cigarette use, use of e-cigarette when cigarette is not available or where cigarette smoking is not permitted emerged as contexts specific to e-cigarette use.ConclusionsFor habitual cigarette smokers wanting to quit tobacco smoking, switching over completely to e-cigarettes may require skills of cognitive-behavioral management. Future research needs to ascertain the characteristics of dual users who use e-cigarettes as cessation aids versus as cigarette alternative when cigarette is unavailable or smoking is not permitted.

Young adult e-cigarette users’ reasons for liking and not liking e-cigarettes: A qualitative study

Objective: To gain an in-depth understanding of what young adult electronic- or e-cigarette users like or dislike about e-cigarettes. We aimed to determine the reasons that may encourage young adults to use e-cigarettes or discourage them from using e-cigarettes.Design: Twelve focus group discussions were conducted with 62 current daily e-cigarette users (63% men) of mean age = 25.1 years (standard deviation = 5.5). Data were analysed following principles of inductive content analysis.Results: Results indicated 12 categories of reasons for liking e-cigarettes (e.g. recreation, smoking cessation) and 6 categories of reasons for not liking e-cigarettes (e.g. poor product quality, poor smoking experience).Conclusions: Young adults’ motives for using or not using e-cigarettes appear to be varied and their relative importance in terms of predicting e-cigarette use initiation, dependence, and cigarette/e-cigarette dual use needs to be carefully studied in population-based, empirical studies. The current findings suggest that e-cigarettes may serve social, recreational, and sensory expectancies that are unique relative to cigarettes and not dependent on nicotine. Further, successful use of e-cigarettes in smoking cessation will likely need higher standards of product quality control, better nicotine delivery efficiency and a counselling component that would teach smokers how to manage e-cigarette devices while trying to quit smoking cigarettes.