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Purpose: To examine adolescents' perspectives regarding external and internal influences of the e-cigarette initiation process., Design: Semi-structured, in-depth qualitative interviews., Setting: California, remote videoconference., Participants: Adolescents ages 13-17 who currently or previously used e-cigarettes (n = 47)., Method: Interviews occurred from May 2020-February 2021. Two researchers coded transcripts based on a codebook developed inductively. Coded excerpts were reviewed to identify encompassing themes related to adolescent e-cigarette initiation., Results: Adolescents were often near e-cigarette use by peers, family members, and others, creating ample opportunities to try e-cigarettes in response to curiosity, peer pressure, and desires to cope with stress or belong to a group. Adverse first experiences were common (eg, throat irritation, nausea), but many adolescents vaped again or continued to use regularly in attempts to cement friendships or alleviate symptoms of stress and anxiety. Specific characteristics of e-cigarette devices, including low-cost, concealability, and variety in designs and flavors facilitated initiation, continued use, and nicotine dependence., Conclusions: Adolescents progress to e-cigarette use via a multistage process, starting where social expectations and opportunity converge. While individual circumstances vary, many continue to vape as a perceived coping tool for emotional issues, to gain social belonging, or influenced by e-cigarette characteristics that contribute to ongoing use and dependence. Efforts to deter use should address the devices themselves and the social forces driving youth interest in them., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Bonnie Halpern-Felsher is a paid expert scientist in some litigation against the e-cigarette industry and an unpaid scientific advisor and expert regarding some tobacco-related policies.

Background: Adolescents' school engagement, mental health, and substance use have been major concerns during the COVID-19 pandemic, particularly given disruptions to school instruction. We examined how the instructional setting was associated with academic and health-related outcomes within an adolescent cohort followed during the pandemic., Methods: During 3 semi-annual follow-up surveys, adolescents (N = 1066 students; 2242 observations) from 8 California high schools responded to items measuring academic self-efficacy, school connectedness, internalizing and externalizing problems, and use of substances. Separate generalized estimating equation models predicted outcomes based on the instructional setting., Results: Relative to in-person instruction, students in remote instruction reported lower academic self-efficacy (Beta: -0.11; 95% confidence interval [CI]: -0.22, -0.01) and school connectedness (Beta: -0.37; 95% CI: -0.48, -0.25), greater odds of past 30-day internalizing problems (AOR: 1.46; 95% CI: 1.09, 1.95), externalizing problems (AOR: 1.36; 95% CI: 1.02, 1.82), and cigarette, cigar, smokeless tobacco, or hookah use (AOR: 2.50; 95% CI: 1.06, 5.91), but lower odds of past 30-day e-cigarette use (AOR: 0.50; 95% CI: 0.30, 0.86)., Conclusions: Multiple adverse outcomes related to school engagement, mental health, and substance use were associated with remote instruction. To reduce such impacts under future emergencies, schools should rely sparingly on remote instruction and provide appropriate supportive resources., (© 2023, American School Health Association.)

Background:  E-cigarettes are the most-used tobacco product among US adolescents and are associated with nicotine addiction. This qualitative investigation aimed to understand adolescents' experiences and perceptions with nicotine addiction, and related influences of addiction, to inform product regulation, health communication, and cessation resource development., Methods:  Between May 2020 and December 2021, in-depth, semi-structured individual interviews were conducted with 47 California (United States) adolescents ages 13-17 who reported recent tobacco use (primarily e-cigarette use). The topic of addiction both arose organically and followed specific interviewer questions. Researchers used thematic analysis techniques to identify unifying themes related to addiction., Results:  Adolescents described e-cigarette addiction in ways that reflected a loss of control over their routines and activities and as physical symptoms, including reward and withdrawal. While some viewed addiction risk as a reason not to vape, others perceived it possible to use e-cigarettes and avoid or manage addiction. Specific characteristics of e-cigarette devices, particularly disposable nicotine-salt products, including flavors, "cool" designs, concealable size and odor, low price, and ease-of-use, were seen as enhancing addiction risk. Quit attempts were difficult and usually unsupported by adults or formal cessation aids., Conclusions:  For many adolescents, addiction is a major component of their experience with e-cigarettes, often in ways that disrupt their routines and reduce their quality of life. Tobacco control or regulation could target e-cigarette product characteristics to decrease potential for addiction among adolescents. Needed are youth-targeted public communication about nicotine addiction and adolescent-tailored, evidence-based cessation support.

Objective: Xerostomia (subjective experience of dry mouth), while less common in younger populations, can contribute to caries and oral discomfort. Use of e-cigarettes and cannabis among adolescents is increasing and may be a xerostomia risk factor. This study evaluates xerostomia prevalence in an adolescent population, overall and by e-cigarette, cannabis and combustible tobacco use., Methods: Cross-sectional analyses of 12-month follow-up data (N=976; collected 2020-2021) from a cohort of adolescents recruited from public high schools in Northern California (USA) compared self-reported past 30-day e-cigarette, cannabis and other tobacco use and dry mouth (overall dry mouth experience; shortened xerostomia inventory, SXI). Dry mouth experience (never, occasionally, frequently/always) was modelled using ordered logistic regression with school-level clustering and adjustment for gender, race/ethnicity, alcohol use, asthma, physical activity and mutually for e-cigarette, cannabis and tobacco use., Results: Past 30-day use prevalence was 12% for e-cigarettes, 16% for cannabis and 3% for combustible tobacco. Occasional dry mouth experience (54%) was more common than frequent/always experience (5%). Frequent/always dry mouth was more prevalent among frequent (>5 days/month) e-cigarette (14%) and cannabis (19%) users and combustible tobacco users (19%) than non-users of those respective products (all comparisons p < 0.001). In covariable-adjusted models, frequent e-cigarette use was no longer significantly associated with dry mouth experience (OR: 1.40; 95% CI: 0.69, 2.84), while frequent cannabis use (OR: 3.17; 95% CI: 1.47, 6.82) and combustible tobacco use (OR: 1.92; 95% CI: 1.38, 2.68) were associated with greater odds of reporting more frequent dry mouth. Findings were qualitatively similar using the SXI., Conclusions: In this study, xerostomia was not independently associated with e-cigarette use but was one potential health concern of adolescent cannabis and combustible tobacco use., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Purpose: This study compares access to flavoured JUUL and other e-cigarettes from retail, online and social sources among underage and young adult e-cigarette users who live in California jurisdictions that restrict sales of flavoured tobacco with the rest of the state., Methods: An online survey used social media advertisements to recruit participants (n=3075, ages 15-29) who lived in one of nine jurisdictions that restrict sales (n=1539) or in the rest of state, and oversampled flavoured tobacco users. Focusing on past-month e-cigarette users (n=908), multilevel models tested whether access to flavoured JUUL and other e-cigarettes from retail, online and social sources differed by local law (yes/no) and age group (15-20 or older), controlling for other individual characteristics., Results: The percent of underage users who obtained flavoured JUUL and other e-cigarettes in the past month was 33.6% and 31.2% from retail, 11.6% and 12.7% online, and 76.0% and 70.9% from social sources, respectively. Compared with underage and young adult users in the rest of California, those in localities that restrict the sales of flavoured tobacco were less likely to obtain flavoured JUUL from retail sources (Adjusted OR=0.54, 95% CI 0.36 to 0.80), but more likely to obtain it from social sources (Adjusted OR=1.55, 95% CI 1.02 to 2.35). The same pattern was observed for other brands of flavoured e-cigarettes., Conclusion: Although local laws may reduce access to flavoured e-cigarettes from retail sources, more comprehensive state or federal restrictions are recommended to close the loopholes for online sources. Dedicated efforts to curtail access from social sources are needed., Competing Interests: Competing interests: BH-F provides expert witness testimony for some e-cigarette litigation., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The Hooked on Nicotine Checklist (HONC) has been used to assess nicotine dependence (loss of autonomy over tobacco) among adolescents. Existing HONC validation studies for non-cigarette products, such as electronic cigarettes (e-cigarettes), have generally not considered biomarkers of nicotine exposure., Methods: Within a cross-sectional sample of California (USA) high school students (total N = 1396; mean age 15.2 years; 56% female; 54% Hispanic/Latinx), self-reported past 30-day users of any tobacco (including e-cigarettes) completed a modified 10-item HONC questionnaire and provided saliva samples (N = 318 samples, including N = 234 exclusive past 30-day e-cigarette users). Samples were analyzed for cotinine using liquid chromatography-tandem mass spectrometry (lower limit of quantification: 1.0 ng/mL)., Results: Across four categories of HONC score corresponding to an increasing number of reported dependence symptoms (scores: 0, 1, 2-4, 5-10), the prevalence of quantifiable salivary cotinine increased among past 30-day tobacco users (20%, 21%, 38%, 55%, respectively, P-for-trend < 0.001) and among past 30-day exclusive e-cigarette users (15%, 22%, 31%, 42%, respectively, P-for-trend = 0.001). Among participants with quantifiable cotinine levels, HONC total score and cotinine were positively correlated among past 30-day tobacco users (n = 89; Spearman rho = 0.449; P < 0.001) and past 30-day exclusive e-cigarette users (n = 49; Spearman rho = 0.520; P < 0.001). HONC score was also associated with past 30-day frequency of tobacco product use and reported use of tobacco within 30 min of waking., Conclusions: These results support the validity of HONC to assess nicotine dependence among adolescents. Dependence symptoms may be experienced at low levels of nicotine exposure., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

To determine if cigarette smoking, electronic cigarette use, and rate of consumption of these products differed before and after a pandemic lockdown order, two convenience samples of adults in Central California were recruited and surveyed before (March 2020) and after (May 2020) COVID-19 lockdown orders were implemented in California ( n = 2571). Multivariable logistic and negative binomial regression models tested the association between adults recruited pre- or post-California lockdown and past month cigarette use, past month electronic cigarette use, past month cigarette consumption, and past month e-cigarette consumption among current users, controlling for demographic differences. Adults pre- and post-lockdown had equal odds of using cigarettes during the past month. Cigarette users who responded post-lockdown had higher cigarette consumption rates compared to cigarette users who responded pre-lockdown (IRR = 1.13, 95% CI = 1.15, 1.23). Adults who responded post-lockdown had lower odds of using electronic cigarettes during the past month compared to participants surveyed before the order (OR = 0.66, 95% CI: 0.55, 0.78). Cigarette users may be using more cigarettes during the state mandated lockdown. Possible causes for this increase in cigarette use may include increased stress, the change in workplace smokefree protections coverage, and increased opportunities for smoking or vaping.

Purpose: The aim of the study was to describe young adult use and perceptions of different brands of pod-based electronic cigarettes (e-cigarettes) and compare with earlier types of non-pod-based e-cigarettes (e.g., mods and tanks)., Methods: Data were collected from January to March 2019 and derive from the final wave of a cohort study recruited in 2013-2014 using a convenience sample from 10 large California high schools with racially/ethnically and socioeconomically diverse populations. A total of 445 participants completed an online survey (mean age = 20.1 years [SD = 1.66], 64.8% female [n = 278], 38.8% white [n = 161], 23.9% each for Asian and "more than one race" [n = 99], 13.5% other [n = 56], and 36.9% Hispanic [n = 160]). The main outcomes were description of and reasons to use pods, perceived nicotine content, and use patterns., Results: Although <25% of participants reported smoking cigarettes and using non-pod-based e-cigarettes, >25% reported ever use of JUUL. Similarly, <33% of cigarette smokers and non-pod-based e-cigarette users reported use in the past 30 days, and >50% of JUUL ever users did. The most agreed upon reason (58%) for using pods was because they are "easy to hide." About half of pod users "do not know" if they mix brands of e-juice and pods, the nicotine concentration in their e-juice cartridges, nor time to finish a cartridge. Of the 50% of participants who shared their pod, 23 (15%) did "sometimes," 20 (13%) "always," and 16 (11% each) "about half the time" or "often." There was no consensus about how to refer to different brands of pods., Conclusions: Our findings indicate young adults harbor confusion about pod-based e-cigarettes, including nicotine content, usage patterns, and labeling, and that pod use is largely because of the ease with which they can "stealth" vape. The findings suggest needed regulation and education about these products., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of the study was to assess adolescent and young adult support for banning the sale of various tobacco and marijuana products and describe whether support varies by tobacco or marijuana use status., Methods: We analyzed data from a California school-based survey (N = 450) on tobacco access, perceptions, social norms, marketing, and use., Results: We found a majority of respondents favored gradually banning the sale of cigarettes (76%); e-cigarettes other than JUULs (55%); JUULs (59%); cigars, cigarillos, and little cigars (70%); and hookah (54%). A majority of ever and never users favored immediately banning the sale of cigarettes. Support for gradual, immediate, and drugstore bans was higher among never users for every policy except an immediate ban on cigarette sales, for which there was no difference between the 2 groups., Conclusions: There is broad support for aggressive tobacco control interventions, especially for combustible tobacco products, among a sample of California youth and young adults., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Limited research among adolescents and young adults (AYA) has assessed tobacco and marijuana co-use in light of specific products. We examined the patterns of past 30-day co-use of tobacco and marijuana products, and the product-specific associations among past 30-day use of these substances., Methods: Data from three school-based convenience samples of California AYA (aged 15-22) (Sample 1 = 3008; Sample 2 = 1419; Sample 3 = 466) were collected during 2016-2017. Proportions of past 30-day co-use of tobacco (e-cigarettes, cigarettes, hookah, cigars) and marijuana (combustible, vaporized, edible, blunt) were estimated. Multivariable logistic regression analyses examined associations between use of each tobacco and marijuana product for individual samples, then the pooled analysis calculated combined ORs., Results: In the three samples, 7.3-11.3% of participants reported past 30-day co-use. Combinations of e-cigarettes or cigarettes and combustible marijuana were the most common co-use patterns. Past 30-day use of e-cigarettes or cigarettes (vs. non-use) increased the odds of past 30-day use of all marijuana products [e-cigarettes: ORs (95%CI) ranging from 2.5 (1.7, 3.2) for edible marijuana to 4.0 (2.8, 5.2) for combustible marijuana; cigarettes: from 3.2 (2.1, 4.2) for vaporized marijuana to 5.5 (3.8, 7.3) for combustible marijuana]. Past 30-day use of hookah or cigars was positively associated with past 30-day use of three of four marijuana products, except for hookah and vaporized marijuana, and for cigars and combustible marijuana., Conclusions: Given various co-use patterns and significant associations among tobacco and marijuana products, interventions targeting AYA should address co-use across the full spectrum of specific products for both substances., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Importance: Use of alternative tobacco products (ATPs) such as electronic cigarettes, chewing tobacco, pipes, cigars, cigarillos, little cigars, and hookah is rapidly increasing. Although marketing restrictions exist for cigarettes, marketing of ATPs is not yet fully regulated, and studies have not assessed the association between ownership of ATP promotional materials and subsequent ATP or cigarette initiation among adolescents and young adults., Objective: To estimate the association between marketing receptivity measured at baseline and ATP and any tobacco initiation 1 year later, including cigarettes, among adolescents and young adults., Design, Setting, and Participants: Longitudinal cohort study of adolescents and young adults aged 13 to 19 years recruited at high schools in California from July 2014 to October 2015, with follow-up 1 year later. Data were analyzed from January to March 2018., Exposures: Ownership of ATP-specific promotional material and ownership of any tobacco promotional materials (eg, samples, coupons, branded caps, t-shirts, or posters) assessed in wave 1., Main Outcomes and Measures: Outcomes were (1) ATP initiation and (2) either ATP or cigarette initiation in wave 2., Results: Of 757 participants (mean [SD] age at wave 1, 16.1 [1.1] years; 481 [63.5%] female; 166 [21.9%] Asian or Pacific Islander, 202 [26.7%] white, and 276 [36.4%] Latino), 129 (17.0%) initiated ATP use and 141 (18.6%) initiated ATP or cigarette use 1 year later. In unadjusted models, wave 2 ATP initiation was found to be significantly associated with wave 1 ownership of ATP promotional materials (odds ratio, 2.23; 95% CI, 1.26-3.97). After adjustment for wave 1 demographic covariates, the association between ownership of ATP promotional material and ATP initiation 1 year later yielded similar results (odds ratio, 2.13; 95% CI, 1.16-3.91). Results of models assessing a combined outcome variable of either ATP or cigarette ever use were not statistically significant., Conclusions and Relevance: Ownership of ATP promotional materials was associated with subsequent initiation of ATPs. The results of this study are consistent with the suggestion that current marketing restrictions for cigarettes, including restrictions of the distribution of samples, coupons, and other promotional material, should extend to ATPs.

Importance: Electronic cigarettes (e-cigarettes) are the most commonly used tobacco product among adolescents and young adults, and the new pod-based e-cigarette devices may put adolescents and young adults at increased risk for polytobacco use and nicotine dependence., Objective: To build an evidence base for perceptions of risk from and use of pod-based e-cigarettes among adolescents and young adults., Design, Setting, and Participants: In a survey study, a cross-sectional analysis was performed of data collected from April 6 to June 20, 2018, from 445 California adolescents and young adults as part of an ongoing prospective cohort study designed to measure the use and perceptions of tobacco products., Exposures: Use of pod-based e-cigarettes, e-cigarettes, and cigarettes., Main Outcomes and Measures: Ever use, past 7-day use, and past 30-day use and co-use of pod-based e-cigarettes, e-cigarettes, and cigarettes; use of flavors and nicotine in pod-based e-cigarettes and e-cigarettes; and associated perceptions of risks, benefits, and nicotine dependence., Results: Among 445 adolescents and young adults (280 females, 140 males, 6 transgender individuals, and 19 missing data; mean [SD] age, 19.3 [1.7] years) who completed wave 6 of the ongoing prospective cohort study, ever use information was provided by 437 respondents, of which 68 (15.6%) reported use of pod-based e-cigarettes, 133 (30.4%) reported use of e-cigarettes, and 106 (24.3%) reported use of cigarettes. The mean (SD) number of days that pod-based e-cigarettes were used in the past 7 days was 1.5 (2.4) and in the past 30 days was 6.7 (10.0). The mean (SD) number of days that other e-cigarettes were used in the past 7 days was 0.8 (1.8) and in the past 30 days was 3.2 (7.4). The mean (SD) number of days that cigarettes were used in the past 7 days was 0.7 (1.8) and in the past 30 days was 3.0 (7.6). Among ever users of pod-based e-cigarettes, 18 (26.5%) reported their first e-liquid was flavored menthol or mint and 19 (27.9%) reported fruit (vs 13 [9.8%] and 50 [37.6%] for other e-cigarettes). The mean perceived chance of experiencing social risks and short-term and long-term health risks from the use of either pod-based e-cigarettes or other e-cigarettes was 40% and did not differ statistically by e-cigarette type. Among 34 adolescents and young adults reporting any loss of autonomy from nicotine, there was no difference in mean (SD) Hooked On Nicotine Checklist scores between those using pod-based e-cigarettes (2.59 [3.14]) and other e-cigarettes (2.32 [2.55])., Conclusions and Relevance: Use by adolescents and young adults of newer types of e-cigarettes such as pod-based systems is increasing rapidly, and adolescents and young adults report corresponding misperceptions and lack of knowledge about these products. Rapid innovation by e-cigarette manufacturers suggests that public health and prevention efforts appear to be needed to include messages targeting components common to all current and emerging e-cigarette products to increase knowledge and decrease misperceptions, with the goal to try to ultimately reduce e-cigarette use among adolescents and young adults.

To determine Latino parents' beliefs on the health effects of beverages on infants and toddlers, their sources of information on beverages and perceived barriers to following guidelines for healthy beverage consumption by children. We conducted 29 interviews with parents of Latino children ages 6-36 months. Parents were recruited in three community health centers in Northern California. The interviews were recorded, transcribed and analyzed using standard qualitative methods. The following dominant themes emerged. Parents believed that water and milk were healthy beverages for children and that sugar-sweetened beverages (SSBs) were unhealthy. Views on 100% fruit juice were mixed. Parents distinguished between homemade beverages such as "agua fresca" which they considered healthy, despite containing added sugar, and beverages from stores which were viewed as unhealthy. Participants' main source of information on beverages was the federal nutrition program for Women, Infants, and Children (WIC). Parents were confused, however, as to why WIC provides juice yet counseled parents to avoid giving their children juice. Parents preferred to receive information on beverages from experts. Differing practices among family members regarding which beverages they provide to children was the most important barrier to following beverage guidelines. Our study suggests that Latino parents are receptive to counseling on beverages from expert sources. Such counseling should address both store-bought and homemade beverages. The WIC program is a key source of information on beverages for Latino parents; thus counseling offered by WIC should be evidence-based and avoid mixed messages.

Purpose: To examine whether there are differences between adolescents and adults in their interpretation of probability terms., Methods: Participants were 20 fifth graders, 54 seventh graders, 45 ninth graders, and 34 young adults (mean adult age = 26.24 years, standard deviation = 2.09) from the San Francisco Bay area. They completed a self-administered survey asking them to assign percentage estimates (0% to 100%) to 30 randomly ordered probability terms., Results: Significant age differences in the mean percentage estimates for 8 of the 30 terms were shown. Moreover, we found large variation in the interpretation of most probability terms studied, with larger variation among the adolescents than adults. Finally, all age groups had some difficulty correctly differentiating between "possibly" and "probably"., Conclusions: Owing to wide variation in the interpretation of probability terms, both within and across age groups, we suggest health practitioners use percentages rather than probability terms to convey risk to both adolescents and adults.

Objective: To determine whether pediatricians in managed care settings adhere to national guidelines concerning the provision of clinical preventive services., Design: Surveys were mailed between September 1996 and April 1997 to all pediatricians practicing in a California group-model health maintenance organization. The survey asked pediatricians about their screening and education practices on 34 recommended services and the actions taken with adolescent patients who have engaged in risk behavior., Results: The response rate was 66.2% (N = 366). Pediatricians, on average, screened 92% of their adolescent patients for immunization status and blood pressure; 85% for school performance; 60% to 80% for obesity, sexual intercourse, cigarette use, alcohol use, drug use, and seat belt and helmet use; 30% to 47% for access to handguns, suicide, eating disorders, depression, and driving after drinking alcohol; fewer than 20% for use of smokeless tobacco, sexual orientation, sexual and physical abuse, and riding a bike or swimming after drinking alcohol; and 26% to 41% for close friends' engagement in risk behavior. Pediatricians' assessment and education with adolescent patients who screened positive for risk behavior was particularly low. Female physicians, physicians who saw a greater proportion of older adolescents, and recent medical school graduates were more likely to provide preventive services., Conclusions: Pediatricians in this health maintenance organization provide preventive services to adolescent patients at rates below recommendations but at rates greater than physicians in other practice settings. Improvement is especially needed in the areas that contribute most to adolescent mortality and for patients who screen positive for a risk behavior.