Abstract
Modern oral nicotine products (ONPs; nontherapeutic nicotine pouches, gums, lozenges, and gummies) may be perceived in ways that could promote uptake in nonvapers, dual use with e-cigarettes, or use to quit vaping. In this cross-sectional digital remote survey of 1,460 respondents aged 21–24 from Southern California, we examined beliefs about ONPs among past-30-day e-cigarette nonusers, users unmotivated to quit vaping, and users motivated to quit vaping. Positive beliefs about ONPs were reported by 31.8% of the overall sample and higher in past-30-day e-cigarette users (with or without quit motivation) than nonusers. Perceiving ONPs to be easy to conceal, convenient, and able to be used where vaping/smoking is not allowed were the most common types of beliefs reported. Among e-cigarette users with quit motivation (n = 142), interest in using ONPs to quit/reduce vaping (44.4%) was higher than interest in using medicinal nicotine gum/lozenges (23.4%), nicotine patch (17.6%), or prescription medications (16.6%). Interest in using ONPs to reduce/quit vaping (vs. no interest) was greater among participants who reported vaping ≥20 (vs. <10) days in the past month, vaping ≥10 (vs. <10) times per day, low/moderate (vs. high) quit vaping self-efficacy, and low/moderate (vs. high) desire to quit vaping. These findings suggest that: (a) appreciable subsets of the young adult population may hold positive beliefs about ONPs that could promote ONP uptake, particularly e-cigarette users and (b) some young adult e-cigarette users may be interested in using ONPs to reduce/quit vaping, particularly frequent vapers with relatively lower self-efficacy and desire to quit vaping.
Keywords: e-cigarettes, non-tobacco oral nicotine products, beliefs, vaping cessation, young adults
There is a growing sector of modern flavored oral nicotine products (ONPs; i.e., nontherapeutic nicotine gums, lozenges, gummies, and nicotine pouches) that are federally regulated as nonmedicinal nicotine/tobacco products in the United States (O’Connor et al., 2022; Patwardhan & Fagerström, 2022; Robichaud et al., 2020). These products contain nicotine—sometimes derived from the tobacco plant. Some modern ONP manufacturers state that their products do not contain tobacco leaves and market their products as “nontobacco” (Robichaud et al., 2020). ONPs are increasingly marketed in the United States (O’Connor et al., 2022; Patwardhan & Fagerström, 2022; Robichaud et al., 2020), with an estimated 15-fold increase in sales from 2017 to 2019 (Delnevo et al., 2021). It is important to understand how priority populations, such as young adults, perceive ONPs in order to inform regulatory policies and other public health strategies.
Given the biopsychosocial context of the young adulthood (Gajofatto et al., 2019), this population is likely to be attracted to any product perceived as affordable, convenient to use, available in appealing flavors, socially acceptable to peers, and able to be used discreetly. Most ONP packs of 20 are one third to one half the cost of a pack of 20 combustible cigarettes or a disposable e-cigarette (e.g., Puff Bar). ONPs are available in various fruit, coffee, cinnamon, mint, and dessert flavors (Ling et al., 2022; Robichaud et al., 2020). ONP marketing highlights the ease of opening the package, popping it into the mouth, and parking it between the cheek and gum for “nicotine on demand” (Lucy Goods Inc, n.d., Lucy Chew+Park section; Rogue Holdings LLC, n.d.).
While ONP could appeal to the overall young adult population, ONPs may have features that are especially salient to young people who vape. ONPs are available in many of the same flavors that e-cigarettes have historically been marketed in that are widely used by young adults that vape (Robichaud et al., 2020). With increasing regulatory restrictions on flavored e-cigarettes (Posner et al., 2022), availability of ONPs in flavors may be particularly important and to vapers who are not motivated to quit vaping and still enjoy flavored nicotine products. Additionally, ONPs enable nicotine use indoors where vaping and smoking are not allowed, which could facilitate ONP-cigarette dual use.
ONPs could also be appealing to some young adult e-cigarette users who are motivated to quit vaping nicotine and might be interested in switching to using ONPs instead. While adoption of evidence-based Food and Drug Administration (FDA)-approved tobacco use cessation medications in young adults motivated to quit tobacco use is rare (Watkins et al., 2020), ONPs could be perceived as appealing means to quit vaping and switch to a potentially less harmful alternative. Industry-supported studies have reported that toxicity and addiction potential of these products are likely lower than inhaled tobacco products, including cigarettes, heated tobacco, and e-cigarettes (Azzopardi et al., 2021; Lunell et al., 2020; Rensch et al., 2021).
Understanding which characteristics among young adult vapers are associated with interest in using nonmedicinal ONPs to quit vaping can inform regulatory policies and clinical decision making. If research found that the subgroup of young adult vapers at the greatest risk for vaping-related harms are especially likely to adopt ONPs to quit vaping that would provide evidence suggesting that less stringent regulatory policies may benefit a subgroup of young adults. Those at greatest risk of long-term vaping trajectories and other harms include frequent and chronic vapers and poly-users of combustible cigarettes alongside e-cigarettes. Hence, it is important to understand whether combustible cigarette couse and vaping frequency and chronicity are associated with interest in using ONPs to quit vaping. Additionally, it is useful to determine whether young adult vapers who use specific flavors, e-cigarette device types, or vape higher nicotine concentrations are more likely to be interested in using ONPs to quit. Such evidence can inform regulatory policies that consider the possible effects of joint regulation of e-cigarette products and ONPs in tandem with one another. Obtaining evidence showing that young adults with a history of failed vaping cessation, weaker desire to quit vaping, and lower self-efficacy in their ability to maintain abstinence are especially likely to be interested in using ONPs to quit vaping would be useful to clinicians. Such evidence would alert clinicians that their patients who struggle most to quit vaping could be interested in switching to ONPs and might benefit if clinicians are to offer advice and information about these products.
In this exploratory secondary analysis of an ongoing cohort survey study, we conducted a cross-sectional investigation of young adults’ beliefs about ONPs and interest in using ONPs to reduce/quit vaping. First, we compared the prevalence of 11 different types of beliefs about ONPs across young adult e-cigarette nonusers, users not motivated to quit vaping, and users motivated to quit vaping. Then, among the subset of young adults motivated to quit vaping, we compared interest in using ONPs as a potential tool to reduce/quit vaping with their interest in using FDA-approved nicotine use cessation pharmacotherapies to reduce/quit vaping. Finally, we estimated associations of several e-cigarette user characteristics with interest in using ONPs to reduce/quit vaping.
Method
Participants
Data were drawn from the Happiness and Health Study (Leventhal et al., 2015), an ongoing cohort study of behavioral health that initially recruited 9th graders from 10 high schools in Los Angeles, California in 2013 and repeatedly surveyed them throughout high school and into young adulthood. This study used the most recent survey conducted in November 2021–December 2021 when the cohort members were young adults (aged 21–24 years). Details of the Happiness and Health Study can be found elsewhere (Leventhal et al., 2015).
Of 1,496 young adults who completed the assessment, the analytic sample for the analysis of beliefs about ONPs was restricted to 1,460 respondents with nonmissing data on past 30-day e-cigarette use status and motivation to quit vaping. In the analysis of interest in using ONPs to reduce/quit vaping, we further limited the sample to respondents who (a) used any electronic cigarettes with nicotine (e.g., e-cigarettes, vaporizer, JUUL, Puff Bar), e-hookahs, or hookah pens in the past 30 days, (b) reported seriously considering quitting vaping nicotine within the next 6 months, and (c) did not use ONPs, including nontherapeutic nicotine gums, lozenges, gummies, and nicotine pouches, in the past 30 days (n = 142; Supplemental Materials Figure S1). The University of Southern California institutional review board approved the study.
Measures
Outcome Measures
Positive Beliefs About ONPs.
Respondents were administered an 11-item author-constructed survey that listed various statements representing a different type of belief about ONPs, and were informed that the questions referred to a product category including nicotine gums, lozenges, candies, or pouches (statements depicted in Table 1). Based on previous measures of beliefs about other tobacco products (Sharma et al., 2021), the belief domains assessed spanned convenience, affordability, discreetness, perceived harm relative to smoking/vaping, cessation-promoting potential, and social accept-ability. Response options were “not agree,” “agree,” or “do not know”; for simplicity, prevalence of agree responses was the primary outcome. We also calculated total number of positive beliefs as an outcome (range: 0–11) and prevalence of having any positive beliefs (≥1 vs. 0).
Table 1.
Beliefs About Oral Nicotine Products, by E-Cigarette Use and Quit Vaping Motivation Status
| Variable | Overall sample (N = 1,460) | Stratified by past 30-day e-cigarette use and quit vaping motivation status |
||
|---|---|---|---|---|
| No use (n = 1,221) | Use without quit motivation (n = 88) | Use with quit motivation (n = 151) | ||
| At least one positive belief | 441 (31.8) | 340 (29.5)a | 38 (43.2)b | 63 (43.2)b |
| Total number of positive beliefs, M (SD) | 1.4 (2.6) | 1.2 (2.4)a | 2.2 (3.2)b | 2.2 (3.3)b |
| Specific beliefs | ||||
| Can be used in places where smoking/vaping isn’t allowed | 311 (22.1) | 230 (19.6)a | 31 (35.2)b | 50 (33.6)b |
| Is easier to hide or conceal than smoking/vaping | 291 (20.7) | 225 (19.2)a | 26 (29.5)b | 40 (26.8)b |
| Can be used without other people knowing | 275 (19.6) | 215 (18.4)a | 26 (29.5)b | 34 (22.8)ab |
| Convenient to use | 218 (15.5) | 160 (13.7)a | 24 (27.3)b | 34 (23.0)b |
| Available in appealing favors | 164 (11.7) | 115 (9.8)a | 16 (18.2)b | 33 (22.3)b |
| More socially acceptable than smoking/vaping | 158 (11.2) | 123 (10.5)a | 13 (14.8)a | 22 (14.8)a |
| Help people quit smoking/vaping | 147 (10.5) | 106 (9.1)a | 14 (15.9)ab | 27 (18.4)b |
| Helps people avoid going back to smoking/vaping | 133 (9.5) | 92 (7.9)a | 15 (17.0)b | 26 (17.4)b |
| A lot of people use oral nicotine products | 103 (7.3) | 74 (6.3)a | 13 (14.8)b | 16 (10.7)ab |
| Less harmful than smoking or vaping | 79 (5.6) | 50 (4.3)a | 10 (11.4)b | 19 (12.8)b |
| More affordable than other nicotine products | 59 (4.2) | 35 (3.0)a | 8 (9.1)b | 16 (10.7)b |
Note. Values represent n(%) who reporting agreeing with the respective belief unless otherwise specified. Frequencies may not sum to the total due to missing observations (see Table S2, for n[%] that selected disagree or don’t know responses). Groups not sharing superscript letters are significantly different in post hoc pairwise contrasts using an adjusted p value (correcting for false discovery rate of 0.05) across e-cigarette use and quit vaping motivation status.
Interest in Using ONPs and Tobacco Use Cessation Medications to Reduce/Quit Vaping.
We administered the following survey question: How interested would you be in using fruit- or mint-flavored nontobacco oral nicotine products, including nicotine gums, gummies, lozenges, tablets, or pouches, to help you cut down or quit using e-cigarettes or other nicotine vaping products? (we do not mean medicines like Nicorette or nicotine polacrilex). We also measured respondents’ interest in using the following tobacco pharmacotherapies to reduce/quit vaping: (a) medicinal nicotine gum or lozenges (e.g., Nicorette or nicotine polacrilex), (b) nicotine transdermal patch, and (c) prescription medications. For each product above, responses options were “not at all,” “slightly,” “somewhat,” or “very” interested. Raw response categories were reported for descriptive purposes. For regression analyses, we dichotomized the outcome variable as “interested” (i.e., response options “slightly,” “somewhat,” or “very”) versus “not interested” (i.e., response option “not at all”) due to the skewed distribution that may produce unstable parameter estimates.
ONP Use.
For descriptive purposes, we also assessed past 6-month and past 30-day use (yes/no) of these products.
E-Cigarette and Tobacco Use Characteristics
Using items derived from previous work (Leventhal et al., 2021, 2022; McCabe et al., 2017), we assessed past-30-day vaping characteristics including: (a) number of days used (infrequent [1–9 days], moderate [10–19 days], or frequent [20 days or more]); (b) number of times took out device to vape on a usual vaping day (<10 times vs. ≥10 times); (c) nicotine concentration typically used (<5% vs. ≥5%); (d) flavor used most often (sweet, mint/menthol, ice–fruit combination, or others [flavorless, tobacco, nonsweet, or mix of favors]); (e) device used most often (disposables, rechargeable pod [with prepackaged or refillable cartridges/pods], or mod/tank/vape pen [including mech-mod rechargeable device, box mod, tank style devices that use e-liquid solution, or vape pen including pen-like rechargeable device]). We also measured vaping duration (started vaping before/during vs. after high school), self-efficacy to quit vaping based on responses to “If you were to quit vaping, how successful do you think you would be?” (from lowest expectation to highest expectation of success, rated 0–100; dichotomized [due to a skewed distribution] into low/moderate [<80] versus high [≥80; Thrasher et al., 2016]), desire to quit vaping according to question that “How do you currently feel about quitting vaping” (with “no desire” and “full desire to quit vaping” as anchors, rated 0–100; dichotomized in the same manner), and past 30-day combustible tobacco use (yes/no; use of cigarettes, cigar, cigarillo, or hookah).
Sociodemographic Covariates
Sociodemographic variables included self-reported gender identity (female/feminine, male/masculine, transgender female, transgender male, gender variant/nonbinary, additional gender category/identity, or prefer not to disclose), race/ethnicity (Hispanic/Latino, American Indian/Alaska Native, Asian, Black/African American, Native Hawaiian/Pacific Islander, White, another race/ethnicity, or cannot choose one term), enrollment in posthigh school degree program (yes/no), current job/paid employment status (not working for pay vs. working for pay), personal financial situation (living comfortably vs. not living comfortably), and sexual identity (straight, asexual, bisexual, gay, lesbian, pansexual, queer, questioning/unsure, or prefer not to disclose) as covariates.
Statistical Analysis
After descriptive analyses of sample characteristics, we calculated prevalence of each of the 11 beliefs about ONPs, prevalence of having any positive beliefs, and mean number of positive beliefs by past 30-day e-cigarette use and quit motivation status. Then, among the subsample of past 30-day e-cigarette users motivated to quit vaping, we calculated the percentages of participants who reported interest in using ONPs and each of the three tobacco use cessation medications to reduce/quit vaping using McNemar’s paired samples chi-square tests. Next, using the same subsample, we fitted a series of logistic regression models to estimate associations of e-cigarette and tobacco use characteristic regressors with interest in using ONPs to reduce/quit vaping. Given the large number of regressors compared to sample size and their correlations with each other, separate models were tested for each e-cigarette/tobacco use variable regressor; each model simultaneously adjusted for all sociodemographic covariates listed above. Results are reported as adjusted odd ratios (ORs) with 95% confidence intervals (CIs). The generalized variance inflation factor (GVIF) index for all models indicated negligible multicollinearity (all GVIFs < 2). Due to different patterns of missing data across exposures and covariates, analytical Ns range from 109 to 125 for each regression analysis. We additionally conducted sensitivity analyses using imputed data on e-cigarette and tobacco use characteristics and sociodemographic covariates (5 imputed data sets, 40 iterations for each set using multiple imputation with chained equations method). Analyses were conducted in R Version 4.2.0 software and statistical significance was set to .05 (two tailed). We report how we determined our sample size, all data exclusions, all manipulations, and all measures in the study. Data and study materials are available from the authors upon reasonable request. This study was not preregistered.
Results
Sample Characteristics
Table 2 summarizes descriptive statistics in the analytic sample stratified by three groups: past 30-day e-cigarette users with quit motivation, those without quit motivation, and e-cigarette nonusers. Past 30-day ONP use was fairly low overall and more common among past 30-day e-cigarette users with (4.6%) or without (5.7%) quit motivation compared with e-cigarette nonusers (0.4%; p < .001).
Table 2.
Characteristics of Study Sample (N = 1,460)
| Variable | Overall sample (n = 1,460) | Past 30-day e-cigarette use and quit vaping motivation status |
|||
|---|---|---|---|---|---|
| No use (n = 1,221) | Use without quit motivation (n = 88) | Use with quit motivation (n = 151) | p value | ||
| ONPa use in the past 30 days | 17 (1.2) | 5 (0.4) | 5 (5.7) | 7 (4.6) | <.001 |
| Sociodemographics | |||||
| Age, years | 22.6 (0.4) | 22.6 (0.4) | 22.5 (0.4) | 22.6 (0.4) | .709 |
| Gender identity | .002 | ||||
| Female/feminine | 881 (61.5) | 764 (63.8) | 41 (47.1) | 76 (51.4) | |
| Male/masculine | 496 (34.6) | 338 (32.5) | 40 (46.0) | 68 (45.9) | |
| Transgender female | 2 (0.1) | 1 (0.1) | 1 (0.1) | 0 (0.0) | |
| Transgender male | 4 (0.3) | 4 (0.3) | 0 (0.0) | 0 (0.0) | |
| Gender variant/nonbinary | 35 (2.4) | 26 (2.2) | 5 (5.7) | 4 (2.7) | |
| Additional gender category/identity | 4 (0.3) | 4 (0.3) | 0 (0.0) | 0 (0.0) | |
| Prefer not to disclose | 11 (0.8) | 11 (0.7) | 0 (0.0) | 0 (0.0) | |
| Race/ethnicity | .122 | ||||
| Hispanic/Latino | 650 (45.6) | 559 (46.9) | 36 (42.9) | 55 (36.7) | |
| American Indian/Alaska Native | 7 (0.5) | 6 (0.5) | 1 (1.2) | 0 (0.0) | |
| Asian | 294 (20.6) | 240 (20.1) | 13 (15.5) | 41 (27.3) | |
| Black/African American | 70 (4.9) | 57 (4.8) | 7 (8.3) | 6 (4.0) | |
| Native Hawaiian/Pacific Islander | 47 (3.3) | 34 (2.8) | 6 (7.1) | 7 (4.7) | |
| White | 217 (15.2) | 182 (15.3) | 11 (13.1) | 24 (16.0) | |
| Another race/ethnicity | 70 (4.9) | 60 (5.0) | 4 (4.8) | 6 (4.0) | |
| Cannot choose one term | 72 (5.0) | 55 (4.6) | 6 (7.1) | 11 (7.3) | |
| Currently enrolled in a degree program | 587 (45.5) | 502 (46.7) | 25 (31.6) | 60 (44.1) | .033 |
| Current job/paid employment status | .325 | ||||
| Not working for pay | 272 (21.6) | 225 (21.5) | 13 (16.7) | 34 (25.4) | |
| Working for pay | 985 (78.4) | 820 (78.5) | 65 (83.3) | 100 (74.6) | |
| Personal financial situation | .115 | ||||
| Living comfortably | 511 (38.7) | 431 (39.1) | 23 (28.0) | 57 (41.0) | |
| Not living comfortably | 811 (61.3) | 670 (60.9) | 59 (72.0) | 82 (59.0) | |
| Sexual identity | .002 | ||||
| Straight | 1,010 (76.5) | 854 (77.6) | 53 (64.6) | 103 (74.1) | |
| Asexual | 24 (1.8) | 19 (1.7) | 1 (1.2) | 4 (2.9) | |
| Bisexual | 135 (10.2) | 105 (9.5) | 11 (13.4) | 19 (13.7) | |
| Gay | 31 (2.3) | 26 (2.4) | 5 (6.1) | 0 (0.0) | |
| Lesbian | 8 (0.6) | 7 (0.6) | 0 (0.0) | 1 (0.7) | |
| Pansexual | 24 (1.8) | 14 (1.3) | 7 (8.5) | 3 (2.2) | |
| Queer | 12 (0.9) | 9 (0.8) | 1 (1.2) | 2 (1.4) | |
| Questioning/unsure | 45 (3.4) | 36 (3.3) | 3 (3.7) | 6 (4.3) | |
| Another identity | 4 (0.3) | 4 (0.4) | 0 (0.0) | 0 (0.0) | |
| Prefer not to disclose | 28 (2.1) | 26 (2.4) | 1 (1.2) | 1 (0.7) | |
Note. ANOVA = analysis of variance; ONP = oral nicotine products. Values in the table are frequencies, and those in parenthesis are proportions. Pearson’s chi-squared test (for categorical variables) and one-way ANOVA (for continuous variables) were used to examine difference in responses for each question measuring attitude toward oral nicotine products by e-cigarette use and quit vaping motivation status. Frequencies may not sum to the total due to missing observations. CI = confidence interval.
Oral nicotine products including flavored nicotine gums, lozenges, tablets, and/or gummies (Lucy, Rogue, REVEL, Krave) or smokeless nicotine pouches (Zyn, Velo, On!).
Detailed characteristics of the subsample of 142 young adult past 30-day e-cigarette users who were motivated to quit vaping are depicted in Supplemental Materials Table S1. In this group, over 40% were frequent e-cigarette users (≥20 days in past month). More than half of participants (51.4%) reported vaping ≥10 times per typical vaping day, and 28.9% were dual users who also smoked combustible tobacco in the past month.
Beliefs About ONPs by E-Cigarette Use and Quit Motivation Status
Table 1 shows young adults’ beliefs about ONPs by e-cigarette use and quit vaping motivation status. Collapsed across groups, 31.8% of all respondents reported at least one positive belief about ONPs. Prevalence and total number of positive beliefs were higher in past 30-day e-cigarette users (with or without quit motivation). For each item, the most commonly reported ONP beliefs in the overall sample were “ability to be used in places where smoking/vaping isn’t allowed” (22.1%) and concealability (20.7%). The least commonly reported beliefs were affordability (4.2%) and lower harm than vaping/smoking (5.6%). E-cigarette users with or without quit vaping motivation were more likely than nonusers to perceive that ONPs are more affordable than other nicotine products, less harmful than smoking/vaping, available in appealing favors, convenient to use, and able to be used in places where smoking/vaping is not allowed; the two e-cigarette users groups did not significantly differ. Prevalence of believing that ONPs help people quit smoking/vaping was higher in e-cigarette users with quit motivation (18.4%) than it was in nonusers (9.1%) but not significantly different from e-cigarette users without quit motivation (15.9%). Respondents’ beliefs toward social acceptability of ONPs did not differ by e-cigarette use and quit vaping motivation status. Prevalence of disagree and don’t know responses are presented in Supplemental Materials Table S2; “don’t know” was more commonly reported for each item.
Interest in Using ONPs and Tobacco Use Cessation Medications to Reduce/Quit Vaping
Figure 1 reports the distribution of responses indicating level of interest in using four different products to reduce/quit vaping in past 30-day e-cigarette users who were motivated to quit vaping. The percentage of participants with any interest in using ONPs (44.4%; either slightly, somewhat, or very interested) was higher than the percentage indicating any interest in using medicinal nicotine gum/lozenges (23.4%; χ2 = 11.3, p < .001), nicotine transdermal patch (17.6%; χ2 = 15.6, p < .001), or prescription medications (15.6%; χ2 = 16.6, p < .001) to reduce/quit vaping.
Figure 1. Prevalence of Responses Indicating Level of Interest in Using Nontherapeutic Tobacco-Free Oral Nicotine or Medicinal Products to Reduce or Quit Vaping.
Note. “Not at all” responses for each question (not depicted in figure) are included in the denominator for percentage calculations. Using binary responses (not interested vs. interested), difference in interest between tobacco-free oral nicotine products and other three products were tested using McNemar’s paired samples chi-square tests (vs. medicinal nicotine gum/lozenges, χ2 = 11.3, p < .001; vs. nicotine transdermal patch, χ2 = 15.6, p < .001; vs. prescription medications, χ2 = 16.6, p < .001). X-axis = proportion of responses; Y-axis = product type.
Association of E-Cigarette and Cigarette Use Characteristics With Interest in Using ONPs
Table 3 shows the results of logistic regression models estimating associations of e-cigarette and tobacco use characteristics with any interest in using ONPs to reduce/quit vaping after adjustment for sociodemographic characteristics in the subsample of past-30-day e-cigarette users motivated to quit vaping. In comparison to infrequent past-30-day e-cigarette users (1–9 days), interest in using ONPs to reduce/quit vaping was significantly higher in frequent (≥20 days) users, adjusted OR = 3.56, 95% CI [1.49, 8.91], but not moderate (10–19 days) users. Higher number of e-cigarette use episodes per vaping day (≥10 vs. <10 times) was associated with higher odds of being interested in using ONPs to reduce/quit vaping, adjusted OR = 2.39, 95% CI [1.08, 5.42].
Table 3.
Associations of E-Cigarette and Tobacco Use Characteristics With Interest in Using Tobacco-Free Oral Nicotine Products to Reduce or Quit Vaping (N = 142)
| Regressors | Interest in using nontherapeutic tobacco-free oral nicotine products to quit vaping |
||
|---|---|---|---|
| n (row %) | OR (95% CI) | p value | |
| Past 30-day use frequency | |||
| Infrequent use (1–9 days) | 22 (32.8) | Reference | |
| Moderate use (10–19 days) | 7 (41.2) | 1.88 (0.54, 6.43) | .312 |
| Frequent use (20 days or more) | 34 (58.6) | 3.56 (1.49, 8.91) | .005 |
| Use frequency per day | |||
| <10 times | 24 (35.8) | Reference | |
| 1≥10 times | 39 (54.9) | 2.39 (1.08, 5.42) | .034 |
| Nicotine concentration used | |||
| <5% | 14 (35.9) | Reference | |
| ≥5% | 44 (51.8) | 1.97 (0.80, 5.03) | .145 |
| Past 30-day flavor used most often | |||
| Sweet | 20 (40.8) | Reference | |
| Mint/menthol | 11 (36.7) | 0.67 (0.22, 1.89) | .454 |
| Ice–fruit combination | 25 (52.1) | 2.12 (0.83, 5.61) | .123 |
| Other flavorsa | 7 (58.3) | 5.18 (1.09, 30.74) | .048 |
| Past 30-day device used most oftenb | |||
| Disposable | 42 (47.7) | Reference | |
| Rechargeable pod | 10 (71.4) | 2.77 (0.75, 11.91) | .140 |
| Mod/tank/vape pen | 10 (34.5) | 0.67 (0.22, 1.94) | .470 |
| Past 12-month quit attempt | |||
| No | 10 (35.7) | Reference | |
| Yes | 53 (46.5) | 1.74 (0.66, 4.90) | .271 |
| Vaping duration | |||
| Since young adulthood | 22 (44.0) | Reference | |
| Since adolescence | 40 (47.1) | 1.04 (0.46, 2.39) | .918 |
| Self-efficacy in ability to quit vapingc | |||
| High | 19 (30.2) | Reference | |
| Low/moderate | 40 (57.1) | 3.99 (1.70, 9.97) | .002 |
| Desire to quit vapingd | |||
| High | 18 (33.3) | Reference | |
| Low/moderate | 41 (53.9) | 2.78 (1.21, 6.66) | .018 |
| Past 30-day combustible tobacco usee | |||
| No | 40 (39.6) | Reference | |
| Yes | 23 (56.1) | 1.67 (0.70, 4.05) | .252 |
Note. Respondents were past 30-day e-cigarette users who had not used ONPs and were motivated to quit vaping within the next 6 months. Separate models were tested for each e-cigarette/tobacco use variable regressor; each model simultaneously adjusted for all sociodemographic covariates in Table 2. Outcome n indicates frequency of positive responses for the outcome variable. Ns range from 114 to 130 for each regression analysis. OR = odds ratio; CI = confidence interval; ONP = oral nicotine products.
Flavorless, tobacco, nonsweet (e.g., alcohol, clove, coffee, spice), or mix of favors.
Disposables = disposable device without separate cartridges or pods; rechargeable device = rechargeable device that uses prepackaged/refillable cartridges or pods; mod/tank/vape pen = mod, mech-mod rechargeable, box mod, tank style device that uses e-liquid solution, or vape pen or pen-like rechargeable device.
“If you were to quit vaping, how successful do you think you would be?” (0–100); high = 80 or above; low/moderate = below 80.
“How do you currently feel about quitting vaping?” (0–100). High = 80 or above; low/moderate = below 80.
Cigarettes, cigar, cigarillo, or hookah.
Interest in using ONPs to reduce/quit vaping was higher among those with low/moderate (vs. high) self-efficacy in quitting vaping, adjusted OR = 3.99, 95% CI [1.70, 9.97], and with low/moderate (vs. high) desire to quit vaping, adjusted OR = 2.78, 95% CI [1.21, 6.66]. Nicotine concentration used, device type used most often, flavor most used often (mint/menthol, ice–fruit combination), vaping duration, and combustible tobacco use in the past month were not associated with interest in using ONPs to reduce/quit vaping. The sensitivity analyses with imputed data on e-cigarette use characteristics and sociodemographic covariates produced similar findings with the main findings (Supplemental Materials Table S3). Estimates of sociodemographic covariates were all nonsignificant and are reported in Supplemental Materials Table S4.
Discussion
This cross-sectional secondary analysis of survey data collected in 2021 among young adults from Southern California provides new evidence about young people’s beliefs about ONPs and interest in using these products as vaping cessation tools. The main findings were that: (a) appreciable subsets of young adults held some positive beliefs about ONPs, particularly e-cigarette users, and (b) e-cigarette users were more interested in using ONPs than FDA-approved pharmacotherapies to reduce/quit vaping, especially frequent vapers with relatively lower self-efficacy and desire to quit vaping.
While prevalence of ONP use was low, approximately 32% of all young adults in this sample reported at least one positive belief about ONPs, including 29% of past 30-day e-cigarette nonusers. These new products have the appearance of food products (e.g., gum, candy) and do not require the exhalation of aerosol like e-cigarettes, potentially contributing to the finding that concealability and convenience were the most commonly reported types of positive beliefs about ONPs. Although ONP use was uncommon in this sample, ONPs are a new product sector, and it is plausible to expect increased marketing of ONPs and new product types emerging soon. Hence, the appreciable prevalence of positive ONP beliefs raises the possibility that more young adults could adopt ONP use in the future, including those who do not currently use noncombustible nicotine products and may be newly exposed to nicotine.
For current e-cigarette users without quit motivation, some of their positive beliefs about ONPs are problematic due to the risk of becoming a dual user of e-cigarettes and ONPs. A noticeable number of respondents in this group perceived that ONPs (a) can be used in places where smoking or vaping is not allowed, (b) are easier to hide or conceal than smoking or vaping, and (c) can be used without other people knowing. ONPs may be particularly appealing to this subgroup of e-cigarette users because vapers could use ONPs when they cannot vape nicotine due to a certain environment (e.g., socially unacceptable conditions).
A sizable fraction of e-cigarette users with quit motivation perceived that ONPs are less harmful than smoking/vaping and help people quit smoking/vaping, but many did not know about the relative harm and cessation potential. Although more data should be accumulated about the health effects of ONPs, an industry-supported analysis showed that ONPs may provide lower toxicant exposure than other commercial (nonmedicinal) nicotine/tobacco products (Azzopardi et al., 2021). Pending additional verification of the constituents, toxicology, and safety of ONPs, it is possible that the availability of novel ONPs products on the commercial market may expand the reach of oral nicotine to young adult e-cigarette users. Whether young adults who try ONPs consistently adopt use and ultimately quit vaping and whether e-cigarette users who are not motivated to quit vaping are also interested in using ONPs for “recreational purposes” are unknown and merit further study.
Approximately 45% of e-cigarette users with quit motivation in this sample indicated some interest in using ONPs to reduce or quit vaping. Interest in using these products was approximately twice as common than interest in using pharmacotherapies that are approved by the United States FDA for nicotine addiction and are proven to increase success in quitting tobacco use (Cahill et al., 2013). Despite apparent similarities, there are potential explanations for significant difference between respondents’ interest in using ONPs and pharmacotherapies to reduce/quit vaping. Recent ONPs are currently being marketed with a “nontobacco nicotine” claim. Perhaps such claim influenced product perception in a positive way, which could increase interest in using those products compared to conventional nicotine cessation tools. Indeed, a recent randomized experimental trial of young adults found that the nontobacco nicotine claim in e-cigarettes can decrease harm perception and negative expectancy towards the product use (Chen-Sankey et al., 2021). Additionally, a wider selection of flavors (e.g., berry, cool cider, mango) and product types (e.g., pouch, gummy) in ONPs (Ling et al., 2022; Robichaud et al., 2020) compared with pharmacotherapies may have contributed to the difference in use interest. Our findings suggest that e-cigarette users who are motivated to quit vaping but unwilling to use pharmacotherapies might be drawn into oral nicotine via ONPs, although evidence is not yet available on whether modern nonmedicinal ONPs improve vaping reduction/cessation. Also, given that rates of FDA-approved nicotine cessation aid use in young adults are still low (Patel et al., 2021) despite its proven efficacy (Cahill et al., 2013), our results imply a need for targeted strategies to more effectively promote evidence-based nicotine cessation products to young adults who are interested in quitting vaping or smoking.
Interest in using ONPs for vaping reduction or cessation was significantly higher among frequent (≥20 days per month and ≥10 times per day) compared to infrequent nicotine vapers, and those with a low expectation of vaping cessation success. Because frequent vapers are more likely than infrequent vapers to experience nicotine addiction symptoms, it may be difficult for them to quit vaping unassisted, which could explain their increased interest. The cigarette literature finds that low quit self-efficacy is a robust predictor of inability to maintain smoking abstinence during cessation attempts (Gwaltney et al., 2009; Lawrance, 1989). It therefore makes sense that young adults unconfident in their ability to quit vaping would be more inclined to seek out any form of cessation assistance, including ONPs. The particular e-cigarette product characteristics preferred by vapers, such as device type, flavor, and nicotine concentration were not associated with interest in quitting vaping.
This study has limitations. First, while interest in engaging in a behavior is often an antecedent of executing the behavior (Ajzen & Fishbein, 1977), there is not a perfect correspondence between the two, and the predictive validity of interest in adopting ONPs is unknown. Second, although young adult nicotine users generally tend to prefer product substitution (i.e., different nicotine product use) as a cessation strategy to using pharmacotherapies (Watkins et al., 2020), their significantly higher interest in using ONPs to reduce/quit vaping than interest in using FDA-approved pharmacotherapies could have been due to the previous failures of vaping cessation using the pharmacotherapies. Third, small cell sizes for e-cigarette use characteristics (e.g., flavor and device type used most often) may have produced insufficient statistical power as well as some unstable parameter estimates that require a cautious interpretation. Also, we were not able to investigate how each category in some sociodemographic characteristics (e.g., race/ethnicity, sexual identity) is associated with the study outcome due to very small cell sizes. Fourth, this was a regional sample; therefore, the representativeness of the sample and generalizability of the findings to other localities in the United States or other countries is unknown. The small sample size for examining the associations between e-cigarette use characteristics and interest in using ONPs to reduce/quit vaping may limit generalizability or power of those results. Fifth, causal interpretation cannot be made due to the cross-sectional study design. Lastly, interest in using nontherapeutic ONPs was measured in a single question to reduce participant burden. A multi–item measure that distinguishes curiosity, interest, and intent to use ONPs might be a more sensitive outcome. Relatedly, separate measures gauging interest in using specific subtypes of ONP formulations (gum vs. lozenge vs. pouch vs. gummy) or flavors (mint vs. fruit) could provide more detailed information for making regulatory decisions. While this study did not examine the association between risk perception and interest in using ONPs to reduce/quit vaping due to small cell sizes, further studies should examine the association in a larger sample (e.g., national sample) of young adult e-cigarette users. We also suggest that future research compares interest in using ONPs to reduce/quit vaping with interest in using other oral products that may be more harmful (e.g., smokeless tobacco).
In conclusion, this cross-sectional study of Southern California young adults in 2021 found that appreciable subsets of young adults held beliefs about ONPs that could promote ONP uptake. Additionally, among young adult e-cigarette users motivated to quit vaping, a sizable number was interested in using ONPs to quit, especially frequent vapers unconfident in their ability to quit. Further studies are needed that determine whether young adults with positive beliefs about ONPs ultimately take up ONP use, become dual e-cigarette and ONP users, or successfully reduce or stop vaping. Such information is needed to guide regulatory decisions about authorizing the sale of these products and how clinicians might advise patients interested in switching from vaping to ONPs. In the meantime, regulatory agencies and clinicians should be aware that an appreciable portion of young adults may have positive beliefs about ONPs and be interested in using nontherapeutic ONPs to reduce/quit vaping.
Supplementary Material
Public Health Significance.
Regulatory agencies and clinicians should be aware that an appreciable portion of young adults may have positive beliefs about ONPs and a sizeable fraction of young adult e-cigarette users may be interested in using nontherapeutic ONPs to reduce/quit vaping.
Acknowledgments
Research reported in this publication was supported by the National Cancer Institute and the Food and Drug Administration (FDA) Center for Tobacco Products (CTP) under Award Number U54CA180905, National Cancer Institute under award number R01CA229617, National Institute on Drug Abuse under award number K24DA048160 and K01DA042950, and the National Heart, Lung and Blood Institute (K01HL148907). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH) or the FDA. The authors have no conflicts of interest to disclose.
Footnotes
The work has not been published elsewhere. Data from this study were previously disseminated in poster presentations at the annual meetings of the Society for Research on Nicotine and Tobacco in March 2022 and the College on Problems of Drug Dependence in June 2022. This study was not preregistered. Data and study materials are available from the authors upon reasonable request.
Supplemental materials: https://doi.org/10.1037/pha0000595.supp
References
- Ajzen I, & Fishbein M (1977). Attitude-behavior relations: A theoretical analysis and review of empirical research. Psychological Bulletin, 84(5), 888–918. 10.1037/0033-2909.84.5.888 [DOI] [Google Scholar]
- Azzopardi D, Liu C, & Murphy J (2021). Chemical characterization of tobacco-free “modern” oral nicotine pouches and their position on the toxicant and risk continuums. Drug and Chemical Toxicology. Advance online publication. 10.1080/01480545.2021.1925691 [DOI] [PubMed] [Google Scholar]
- Cahill K, Stevens S, Perera R, & Lancaster T (2013). Pharmacological interventions for smoking cessation: An overview and network meta-analysis. The Cochrane Database of Systematic Reviews, 2015(5), Article CD009329. 10.1002/14651858.CD009329.pub2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Chen-Sankey J, Ganz O, Seidenberg A, & Choi K (2021). Effect of a ‘tobacco-free nicotine’ claim on intentions and perceptions of Puff Bar e-cigarette use among non-tobacco-using young adults. Tobacco Control. Advance online publication. 10.1136/tobaccocontrol-2021-056957 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Delnevo CD, Hrywna M, Miller Lo EJ, & Wackowski OA (2021). Examining market trends in smokeless tobacco sales in the United States: 2011–2019. Nicotine & Tobacco Research, 23(8), 1420–1424. 10.1093/ntr/ntaa239 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gajofatto A, Donisi V, Busch IM, Gobbin F, Butturini E, Calabrese M, Carcereri de Prati A, Cesari P, Del Piccolo L, Donadelli M, Fabene P, Fochi S, Gomez-Lira M, Magliozzi R, Malerba G, Mariotti R, Mariotto S, Milanese C, Romanelli MG, … Rimondini M (2019). Biopsychosocial model of resilience in young adults with multiple sclerosis (BPS-ARMS): An observational study protocol exploring psychological reactions early after diagnosis. BMJ Open, 9(8), Article e030469. 10.1136/bmjopen-2019-030469 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gwaltney CJ, Metrik J, Kahler CW, & Shiffman S (2009). Self-efficacy and smoking cessation: A meta-analysis. Psychology of Addictive Behaviors, 23(1), 56–66. 10.1037/a0013529 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lawrance L (1989). Validation of a self-efficacy scale to predict adolescent smoking. Health Education Research, 4(3), 351–360. 10.1093/her/4.3.351 [DOI] [Google Scholar]
- Leventhal A, Dai H, Barrington-Trimis J, & Sussman S (2021). ‘Ice’ flavoured e-cigarette use among young adults. Tobacco Control. Advance online publication. 10.1136/tobaccocontrol-2020-056416 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Leventhal AM, Dai H, Barrington-Trimis JL, Tackett AP, Pedersen ER, & Tran DD (2022). Disposable e-cigarette use prevalence, correlates, and associations with previous tobacco product use in young adults. Nicotine & Tobacco Research, 24(3), 372–379. 10.1093/ntr/ntab165 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Leventhal AM, Strong DR, Kirkpatrick MG, Unger JB, Sussman S, Riggs NR, Stone MD, Khoddam R, Samet JM, & Audrain-McGovern J (2015). Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. JAMA, 314(7), 700–707. 10.1001/jama.2015.8950 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Ling PM, Kim M, Egbe CO, Patanavanich R, Pinho M, & Hendlin Y (2022). Moving targets: How the rapidly changing tobacco and nicotine landscape creates advertising and promotion policy challenges. Tobacco Control, 31(2), 222–228. 10.1136/tobaccocontrol-2021-056552 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Lucy Goods Inc. (n.d.). Lucy chew+park. https://help.lucy.co/category/kdz9ywnz7g-lucygum
- Lunell E, Fagerström K, Hughes J, & Pendrill R (2020). Pharmacokinetic comparison of a novel non-tobacco-based nicotine pouch (ZYN) with conventional, tobacco-based Swedish snus and American moist snuff. Nicotine & Tobacco Research, 22(10), 1757–1763. 10.1093/ntr/ntaa068 [DOI] [PubMed] [Google Scholar]
- McCabe SE, West BT, Veliz P, & Boyd CJ (2017). E-cigarette use, cigarette smoking, dual use, and problem behaviors among US adolescents: Results from a national survey. The Journal of Adolescent Health, 61(2), 155–162. 10.1016/j.jadohealth.2017.02.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- O’Connor R, Schneller LM, Felicione NJ, Talhout R, Goniewicz ML, & Ashley DL (2022). Evolution of tobacco products: Recent history and future directions. Tobacco Control, 31(2), 175–182. 10.1136/tobaccocontrol-2021-056544 [DOI] [PubMed] [Google Scholar]
- Patel M, Cuccia AF, Zhou Y, Kierstead EC, Briggs J, & Schillo BA (2021). Smoking cessation among US adults: Use of e-cigarettes, including JUUL, and NRT use. Tobacco Control, 30(6), 693–695. 10.1136/tobaccocontrol-2020-056013 [DOI] [PubMed] [Google Scholar]
- Patwardhan S, & Fagerström K (2022). The new nicotine pouch category: A tobacco harm reduction tool? Nicotine & Tobacco Research, 24(4), 623–625 10.1093/ntr/ntab198 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Posner H, Romm KF, Henriksen L, Bernat D, & Berg CJ (2022). Reactions to sales restrictions on flavored vape products or all vape products among young adults in the United States. Nicotine & Tobacco Research, 24(3), 333–341. 10.1093/ntr/ntab154 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rensch J, Liu J, Wang J, Vansickel A, Edmiston J, & Sarkar M (2021). Nicotine pharmacokinetics and subjective response among adult smokers using different flavors of on!nicotine pouches compared to combustible cigarettes. Psychopharmacology, 238(11), 3325–3334. 10.1007/s00213-021-05948-y [DOI] [PubMed] [Google Scholar]
- Robichaud MO, Seidenberg AB, & Byron MJ (2020). Tobacco companies introduce ‘tobacco-free’ nicotine pouches. Tobacco Control, 29(e1), e145–e146. 10.1136/tobaccocontrol-2019-055321 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rogue Holdings LLC. (n.d.). Rogue nicotine on demand \ free shipping on nicotine products, 2021. https://www.roguenicotine.com
- Sharma A, McCausland K, & Jancey J (2021). Adolescent’s health perceptions of e-cigarettes: A systematic review. American Journal of Preventive Medicine, 60(5), 716–725. 10.1016/j.amepre.2020.12.013 [DOI] [PubMed] [Google Scholar]
- Thrasher JF, Swayampakala K, Borland R, Nagelhout G, Yong HH, Hammond D, Bansal-Travers M, Thompson M, & Hardin J (2016). Influences of self-efficacy, response efficacy, and reactance on responses to cigarette health warnings: A longitudinal study of adult smokers in Australia and Canada. Health Communication, 31(12), 1517–1526. 10.1080/10410236.2015.1089456 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Watkins SL, Thrul J, Max W, & Ling PM (2020). Cold Turkey and Hot Vapes? A national study of young adult cigarette cessation strategies. Nicotine & Tobacco Research, 22(5), 638–646. 10.1093/ntr/nty270 [DOI] [PMC free article] [PubMed] [Google Scholar]
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