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Objectives: To examine the prevalence and characteristics of dual users of cigarettes and waterpipes by comparing them with individuals who use either product exclusively. Participants: Cross-sections of undergraduate students at a public university recruited each spring semester from 2006 to 2011 (total N = 2,998). Methods: Participants completed an Internet survey that assessed demographics, tobacco use, perceptions, and norms concerning various tobacco products. Individuals who reported exclusive cigarette, exclusive waterpipe, and dual (waterpipe + cigarette) use were examined. Results: Across years, 22% reported exclusive cigarette, 6.1% exclusive waterpipe, and 9.3% dual cigarette and waterpipe use. Dual users differed in demographics and social influences from their exclusive counterparts. Conclusions: Findings suggest that dual waterpipe and cigarette use was more prevalent than exclusive waterpipe use, and dual users may differ from individuals who use either product alone. These results warrant the inclusion of waterpipe-specific content in state and national surveys as well as tobacco prevention and intervention efforts. (Contains 2 tables and 1 figure.)

Objectives: In this study, we examined the concordance of manufacturers' labeled nicotine concentration on flavored electronic cigarette (e-cigarette) liquids with lab measured nicotine concentrations and how nicotine is marketed on product labels. Methods: The top 10 selling flavored e-cigarette liquids for 7 brands were purchased from 7 vape shops in 2 major US cities - Richmond, Virginia and Honolulu, Hawaii, in 2015. We examined the nicotine concentration using liquid chromatography mass spectrometry (.05mg/mL limit of quantification) and descriptive information on the e-cigarette bottles (N = 40). Results: All nicotine-based samples showed discordance between the labeled and lab measured nicotine concentrations. Overall, 27% showed a higher mean level of measured nicotine, and Richmond, VA samples showed the highest levels of discordance (-60% [pipe tobacco]; 39% [green goblin]). Additionally, 90% of the 6 different types of nicotine-related warning statements indicated that the product "may" contain nicotine ("e-liquid may contain nicotine") even when the product contained nicotine. Moreover, 20% of the e-cigarette liquids included descriptors (low, medium, high nicotine). Conclusions: The findings show that e-cigarette manufacturers provided inaccurate information about nicotine on product labels. Studies are needed to determine what quality control standards are needed to protect the public from the harms of nicotine. [ABSTRACT FROM AUTHOR]

Background: This study is a systematic evaluation of a novel tobacco product, electronic cigarettes (ECIGs) using a two-site, four-arm, 6-month, parallel-group randomized controlled trial (RCT) with a follow-up to 9 months. Virginia Commonwealth University is the primary site and Penn State University is the secondary site. This RCT design is important because it is informed by analytical work, clinical laboratory results, and qualitative/quantitative findings regarding the specific ECIG products used.Methods: Participants (N = 520) will be randomized across sites and must be healthy smokers of >9 cigarettes for at least one year, who have not had a quit attempt in the prior month, are not planning to quit in the next 6 months, and are interested in reducing cigarette intake. Participants will be randomized into one of four 24-week conditions: a cigarette substitute that does not produce an inhalable aerosol; or one of three ECIG conditions that differ by nicotine concentration 0, 8, or 36 mg/ml. Blocked randomization will be accomplished with a 1:1:1:1 ratio of condition assignments at each site. Specific aims are to: characterize ECIG influence on toxicants, biomarkers, health indicators, and disease risk; determine tobacco abstinence symptom and adverse event profile associated with real-world ECIG use; and examine the influence of ECIG use on conventional tobacco product use. Liquid nicotine concentration-related differences on these study outcomes are predicted. Participants and research staff in contact with participants will be blinded to the nicotine concentration in the ECIG conditions.Discussion: Results from this study will inform knowledge concerning ECIG use as well as demonstrate a model that may be applied to other novel tobacco products. The model of using prior empirical testing of ECIG devices should be considered in other RCT evaluations.Trial Registration: TRN: NCT02342795 , registered December 16, 2014. [ABSTRACT FROM AUTHOR]

This study examined the psychosocial risk characteristics of former smokers in comparison to nonsmokers, experimental smokers, and established smokers. Adolescents reported their tobacco use beliefs, attitudes, and behaviors via the Virginia Youth Tobacco Survey in 2007 (N = 2,067) and 2009 (N = 3,928). Multinomial logistic regression results showed former smokers had greater susceptibility to tobacco-related influences (peer smoking, industry advertising) and alternative tobacco use (smokeless tobacco, waterpipe/hookah) than nonsmokers and early experimenters and fewer psychosocial differences compared to advanced experimenters and established smokers. Findings highlight the need for addressing adolescents who are former smokers as a distinct group in prevention and cessation efforts. Implications and limitations are noted. [ABSTRACT FROM PUBLISHER]

Introduction A revised indoor air quality law has been implemented in Virginia to protect the public from the harmful effects of secondhand smoke exposure. This legislation contains exemptions that include allowances for smoking in a room that is structurally separated and separately ventilated. The objective of the current study was to examine the impact of this law on air quality in waterpipe cafe´s, as well as to compare the air quality in these cafés to restaurants that allow cigarette smoking and those where no smoking is permitted. Methods Indoor air quality in 28 venues (17 waterpipe cafés, five cigarette smoking-permitted restaurants and six smoke-free restaurants (five with valid data)) in Virginia was assessed during 4 March to 27 May 2011. Real-time measurements of particulate matter (PM) with 2.5 mm aerodynamic diameter or smaller (PM2.5) were obtained and occupant behaviour/venue characteristics were assessed. Results The highest mean PM2.5 concentration was observed for waterpipe cafe´ smoking rooms (374 μg/m3, n=17) followed by waterpipe cafe´ non-smoking rooms (123 mg/m3, n=11), cigarette smoking-permitted restaurant smoking rooms (119 μg/m3, n¼5), cigarette smoking-permitted restaurant non-smoking rooms (26 mg/m3, n=5) and smoke-free restaurants (9 mg/m3, n¼5). Smoking density was positively correlated with PM2.5 across smoking rooms and the smoke-free restaurants. In addition, PM2.5 was positively correlated between smoking and non-smoking rooms of venues. Conclusions The PM2.5 concentrations observed among the waterpipe cafés sampled here indicated air quality in the waterpipe cafe´ smoking rooms was worse than restaurant rooms in which cigarette smoking was permitted, and state-required non-smoking rooms in waterpipe cafés may expose patrons and employees to PM2.5 concentrations above national and international air quality standards. Reducing the health risks of secondhand smoke may require smoke-free establishments in which tobacco smoking sources such as water pipes are, like cigarettes, prohibited [ABSTRACT FROM AUTHOR]

Objective: To examine the relation­ship between adolescents' cigarette smoking experiences and alternative tobacco product (ATP) use. Methods: Multiple indicators and multiple causes (MIMIC) models estimated simultane­ously the relationship between ciga­rette smoking experiences and ATP use among high school students (N=1827) completing the 2009 Virginia Youth To­bacco Survey. Results: Overall, ATP use was associated with adolescents' ever use of cigarettes, early onset of ciga­rette smoking, cigarettes smoked per day, and peer smoking; however, im­portant model differences between ra­cial/ethnic groups were observed. Con­clusions: Prevention and cessation pro­grams might reduce adolescent ATP use by targeting specific characteristics of cigarette smoking. [ABSTRACT FROM AUTHOR]

Objectives: To examine the prevalence and characteristics of dual users of cigarettes and waterpipes by comparing them with individuals who use either product exclusively. Participants: Cross-sections of undergraduate students at a public university recruited each spring semester from 2006 to 2011 (total N = 2,998). Methods: Participants completed an Internet survey that assessed demographics, tobacco use, perceptions, and norms concerning various tobacco products. Individuals who reported exclusive cigarette, exclusive waterpipe, and dual (waterpipe + cigarette) use were examined. Results: Across years, 22% reported exclusive cigarette, 6.1% exclusive waterpipe, and 9.3% dual cigarette and waterpipe use. Dual users differed in demographics and social influences from their exclusive counterparts. Conclusions: Findings suggest that dual waterpipe and cigarette use was more prevalent than exclusive waterpipe use, and dual users may differ from individuals who use either product alone. These results warrant the inclusion of waterpipe-specific content in state and national surveys as well as tobacco prevention and intervention efforts. [ABSTRACT FROM PUBLISHER]

ABSTRACT Aims To provide an initial abuse liability assessment of an electronic cigarette (EC) in current tobacco cigarette smokers. Design The first of four within-subject sessions was an EC sampling session that involved six, 10-puff bouts (30 seconds inter-puff interval), each bout separated by 30 minutes. In the remaining three sessions participants made choices between 10 EC puffs and varying amounts of money, 10 EC puffs and a varying number of own brand cigarette (OB) puffs, or 10 OB puffs and varying amounts of money using the multiple-choice procedure (MCP). The MCP was completed six times at 30-minute intervals, and one choice was reinforced randomly at each trial. Setting Clinical laboratory. Participants Twenty current tobacco cigarette smokers. Measurements Sampling session outcome measures included plasma nicotine, cardiovascular response and subjective effects. Choice session outcome was the cross-over value on the MCP. Findings EC use resulted in significant nicotine delivery, tobacco abstinence symptom suppression and increased product acceptability ratings. On the MCP, participants chose to receive 10 EC puffs over an average of $1.06 or three OB puffs and chose 10 OB puffs over an average of $1.50 ( P < 0.003). Conclusions Electronic cigarettes can deliver clinically significant amounts of nicotine and reduce cigarette abstinence symptoms and appear to have lower potential for abuse relative to traditional tobacco cigarettes, at least under certain laboratory conditions. [ABSTRACT FROM AUTHOR]

Background Waterpipe tobacco package labelling typically indicates "0.0% tar" and "0.05% or 0.5% nicotine". Objective To determine the extent to which nicotine labeling is related to nicotine delivery. Methods 110 waterpipe smokers engaged in a 45-minute waterpipe smoking session. Puff topography and plasma nicotine were measured. Three waterpipe tobacco brands were used: Nakhla (0.5% nicotine), Starbuzz (0.05% nicotine), and Al Fakher (0.05% nicotine). Data were analyzed by one-way ANOVA. Results Topography did not differ across brands. Peak plasma nicotine varied significantly across brands. Al Fakher had the highest nicotine delivery (11.4 ng/ml) followed by Nakhla (9.8 ng/ml) and Starbuzz (5.8 ng/ml). Conclusions Nicotine labelling on waterpipe tobacco products does not reflect delivery; smoking a brand with a "0.05% nicotine" label led to greater plasma nicotine levels than smoking a brand with a "0.5% nicotine" label. Waterpipe tobacco products should be labelled in a manner that does not mislead consumers. [ABSTRACT FROM AUTHOR]

Introduction: Researchers have suggested that adolescents' cigar use has increased beyond the rates being reported on tobacco use surveys. Differences in content knowledge and everyday colloquial expressions may be responsible for misreporting of cigar use. To determine whether cigar use is subject to systematic misreporting, we compared reports of general cigar use ("During the past 30 days, on how many days did you smoke cigars, little cigars, and cigarillos?") with reports of brand-specific use ("During the past 30 days, on how many days did you smoke Black & Milds?") among a statewide sample of adolescents in Virginia., Methods: We examined data from 3,093 youth who completed the 2009 Virginia Youth Tobacco Survey to determine differences in the rate of misreported cigar use (ie, those who reported Black & Mild use but did not report cigar, little cigar, or cigarillo use) for youth with varying demographic profiles and conditions., Results: More than one-half of Black & Mild users (57.3%) did not report general cigar use. Cigar use misreporting was most prevalent among older adolescents, blacks/African Americans, current users of cigarettes and hookah, and youth diagnosed with asthma., Conclusion: General cigar-use items on statewide surveys significantly underestimate the prevalence of youth cigar use. More comprehensive measures of cigar use may be beneficial in assessing tobacco use among groups most likely to misreport their tobacco use, such as African Americans and youth diagnosed with asthma.

Introduction: Cigarillo smoking likely exposes users to many of the same toxicants (e.g., nicotine, carbon monoxide [CO]) as cigarette smoking. Yet, few controlled clinical laboratory studies evaluating of the effects of cigarillos exist. This study evaluated the cardiovascular response, toxicant exposure, subjective effects, and puffing topography of a popular cigarillo brand, Black & Mild (B&M)., Methods: Sixteen B&M smokers (M ± SD = 1.9 ± 2.5 cigarillos/day for 3.4 ± 3.5 years) participated in 2 counterbalanced conditions: lit (ACTIVE) or unlit (SHAM) B&M in which they completed two 10-puff smoking bouts (30-s interpuff intervals)., Results: Plasma nicotine concentrations for ACTIVE increased significantly from pre-smoking (M ± SEM = 2.0 ± 0.0 ng/ml) to 5 min after Bouts 1 (5.3 ± 0.8 ng/ml) and 2 (4.9 ± 0.9 ng/ml) but did not increase above 2.0 ± 0.0 ng/ml at any timepoint for SHAM. Heart rate increased significantly from pre- to post-smoking for ACTIVE but not for SHAM. Average expired-air CO levels, collapsed across time, were 14.3 ± 0.8 ppm for ACTIVE and 4.5 ± 0.2 ppm for SHAM. Neither condition reduced symptoms of nicotine/tobacco abstinence reliably, although ratings for some measures were significantly lower for ACTIVE than for SHAM. ACTIVE, but not SHAM, produced a variety of positive effects related to product sensory characteristics (e.g., "satisfying," "pleasant"). Smoking topography did not differ across the two conditions., Conclusions: Ten puffs from a B&M cigarillo deliver active doses of nicotine and considerable amounts of CO but do not suppress abstinence-induced withdrawal symptoms reliably. The nicotine delivery profile suggests that cigarillo smoking may promote nicotine/tobacco dependence and the CO exposure likely poses significant health risks.

Background: Waterpipe (hookah, shisha) tobacco smoking has spread worldwide. Many waterpipe smokers believe that, relative to cigarettes, waterpipes are associated with lower smoke toxicant levels and fewer health risks. For physicians to address these beliefs credibly, waterpipe use and cigarette smoking must be compared directly., Purpose: The purpose of this study is to provide the first controlled, direct laboratory comparison of the toxicant exposure associated with waterpipe tobacco and cigarette smoking., Methods: Participants (N=31; M=21.4 years, SD=2.3) reporting monthly waterpipe use (M=5.2 uses/month, SD=4.0) and weekly cigarette smoking (M=9.9 cigarettes/day, SD=6.4) completed a crossover study in which they each smoked a waterpipe for a maximum of 45 minutes, or a single cigarette. Outcome measures included expired-air carbon monoxide (CO) 5 minutes after session's end, and blood carboxyhemoglobin (COHb), plasma nicotine, heart rate, and puff topography. Data were collected in 2008-2009 and analyzed in 2009., Results: On average, CO increased by 23.9 ppm for waterpipe use (SD=19.8) and 2.7 ppm for cigarette smoking (SD=1.8), while peak waterpipe COHb levels (M=3.9%, SD=2.5) were three times those observed for cigarette smoking (M=1.3%, SD=0.5; p's<0.001). Peak nicotine levels did not differ (waterpipe M=10.2 ng/mL, SD=7.0; cigarette M=10.6 ng/mL, SD=7.7). Significant heart rate increases relative to pre-smoking were observed at 5, 10, 15, 20, 25, and 35 minutes during the cigarette session and at 5-minute intervals during the waterpipe session (p's<0.001). Mean total puff volume was 48.6 L for waterpipe use as compared to 1.0 L for cigarette smoking (p<0.001)., Conclusions: Relative to cigarette smoking, waterpipe use is associated with greater CO, similar nicotine, and dramatically more smoke exposure. Physicians should consider advising their patients that waterpipe tobacco smoking exposes them to some of the same toxicants as cigarette smoking and therefore the two tobacco-smoking methods likely share some of the same health risks.

Waterpipe smoking, a traditional method of tobacco use, has experienced a resurgence in the Middle East and Indian subcontinent in recent years. Despite growing evidence of its dependence potential and health-damaging effects, waterpipe use has spread beyond these regions to many other countries, including the United States. Because little is known about waterpipe use in the United States, we surveyed convenience samples of users from two U.S. cities, Richmond, Virginia (n = 109), and Memphis, Tennessee (n = 34). Respondents in both cities were primarily young adults, a majority (75%) were men, and most were college students or had a college degree. Initial and current use usually occurred in a social context, with a group of friends in a cafe or restaurant or at home. Most respondents had smoked waterpipe for 2 or fewer years, and 67% currently smoked at least once a month (22% smoked at least once per week and 10% smoked daily). Most believed waterpipe use to be less addictive and harmful than cigarette smoking, believed they could quit use at any time, but had no plans or desire to quit. A majority of respondents used other tobacco products such as cigarettes, and 35% of those who did not smoke cigarettes said they would "probably" or "definitely" smoke one in the next year. Multivariate correlates of greater frequency of use included younger age at first use, ownership of a waterpipe, use occurring primarily with groups of friends, and the perception of being "hooked." Waterpipe users in these two convenience samples from the United States were young and educated, tended to experiment with multiple forms of tobacco, were unaware of the potentially harmful and addictive properties of waterpipe use, and planned to continue use in the future. Educational efforts are needed to increase awareness of the potential hazards of this increasingly popular form of tobacco use.