Authors: Yang J, Pacheco C, Mackey TK
Journal: Addictive Behavior Reports
Year Published: 2022
Type: Original Research
Abstract:
The effects of COVID-19 on tobacco and cannabis use have been variable, and it is unclear the extent to which factors affecting changes in tobacco and cannabis use differ. The purpose of this study was to identify the COVID-19-related factors that affect changes in tobacco and cannabis use during the pandemic. Focus groups with 114 young adults in California in April 2021 were held to discuss tobacco and cannabis use patterns, adverse events, and the effect of COVID-19 on tobacco and cannabis product use. Factors affecting changes in use were largely similar between tobacco products and cannabis products. Increases in product use were a result of changing social environment, coping with emotional and psychological distress, and product related factors. Decreases in product use were a result of social isolation, COVID-19-related health concerns, disruptions in daily patterns of living, and reduced access. Drivers of increased cannabis use distinct from tobacco or nicotine product use included feeling greater freedom to disengage and perceptions of less harm. Improved understanding of how the pandemic has affected tobacco and cannabis use can inform tailored interventions to both support those who have decreased or quit and assist those who have increased use during the pandemic to reduce or cease their consumption.

Authors: Yang J, Lim P, Ojeda K, Cuomo RE, Purushothoman V, Mackey TK
Journal: AJPM Focus
Year Published: 2022
Type: Original Research
Abstract:
Introduction
Previous studies have identified numerous adverse events experienced with the use of ENDS or E-cigarettes. However, much remains unknown about adverse event frequency, duration, and response experienced by users. The purpose of this study was to inductively characterize ENDS-attributed adverse events among young adults.

Methods
Sixteen focus groups were held with 114 young adults (aged 18–29 years) who have reported lifetime ENDS use in April 2021. Discussion topics included current and previous tobacco, nicotine, and cannabis use; specific symptoms and frequency and duration of and response to symptoms of ENDS-attributed adverse events; and the impact of other conditions such as COVID-19 on ENDS use. Data were inductively analyzed using a team-based approach.

Results
More than 40 ENDS-attributed adverse events were reported in focus groups among approximately three quarters of all study participants, with headache, coughing, lightheadedness, nausea, dry or sore throat, and dizziness the most common. In general, adverse events were transient, with most resolving in a few hours, although some tended to last for longer. The frequency of adverse events varied most between every time ENDS were used and when someone vaped excessively. Finally, behavioral responses varied by adverse events, with difficulty in breathing, chest pain, and lung discomfort more likely to result in quitting permanently.

Conclusions
Overall, the results of this study show that not only do adverse events vary greatly, but they also vary across multiple dimensions of user experience.

Authors: Shah N, Nali M, Bardier C, Li J, Cuomo RE, Mackey TK
Journal: Tobacco Control
Year Published: 2021
Type: Original Research
Abstract:
Background Increased public health and regulatory scrutiny concerning the youth vaping epidemic has led to greater attention to promotion and sales of vaping products on social media platforms.

Objectives We used unsupervised machine learning to identify and characterise sale offers of electronic nicotine delivery systems (ENDS) and associated products on Instagram. We examined types of sellers, geographic ENDS location and use of age verification.

Methods Our methodology was composed of three phases: data collection, topic modelling and content analysis. We used data mining approaches to query hashtags related to ENDS product use among young adults to collect Instagram posts. For topic modelling, we applied an unsupervised machine learning approach to thematically categorise and identify topic clusters associated with selling activity. Content analysis was then used to characterise offers for sale of ENDS products.

Results From 70 725 posts, we identified 3331 engaged in sale of ENDS products. Posts originated from 20 different countries and were roughly split between individual (46.3%) and retail sellers (43.4%), with linked online sellers (8.8%) representing a smaller volume. ENDS products most frequently offered for sale were flavoured e-liquids (53.0%) and vaping devices (20.5%). Online sellers offering flavoured e-liquids were less likely to use age verification at point of purchase (29% vs 64%) compared with other products.

Conclusions Instagram is a global venue for unregulated ENDS sales, including flavoured products, and access to websites lacking age verification. Such posts may violate Instagram’s policies and US federal and state law, necessitating more robust review and enforcement to prevent ENDS uptake and access.

Authors: Nali M, Purushothaman V, Li J, Mackey TK
Journal: Preventive Medicine Reports
Year Published: 2022
Type: Original Research
Abstract:
Various tobacco vendors, including alternative tobacco product sellers, are listed on the popular crowdsourced business listing platform Yelp. Yelp is used to rate and choose tobacco, electronic nicotine delivery systems (ENDS) goods/services and includes self-reporting of user experiences with shops and products. We cross-referenced California Department of Tax and Fee Administration (CDTFA) licensed tobacco, vape, and head shop retail stores with publicly available Yelp business listings to identify licensed and unlicensed stores in California. We extracted metadata associated with store accounts and analyzed user comments and ratings for discussion of tobacco-related complaints and adverse events. We detected a total of 3,717 shops that were categorized as tobacco/vape/head shops on Yelp and by cross-referencing with CDTFA data, licensed businesses accounted for 49.5% (n = 1,841), licensed individual retailers 31.6% (n = 1,174), and suspected unlicensed storefronts 18.9% (n = 702). Businesses and individuals with a state tobacco retail license received a higher average rating from Yelp users (3.86 out of 5) compared to unlicensed shops (3.57) (p < 0.001). Additionally, 4,682 unique comments about licensed businesses, 1,535 unique comments about individual retailers, and 560 unique comments about unlicensed vendors were reviewed, with themes including discussion about defective and counterfeit products and adverse events including coughing, difficulty breathing and reports of hospitalization detected. In contrast, comments about licensed stores predominantly discussed customer service issues. Close to one-fifth of tobacco, vape and/or head shops reviewed on Yelp were not in CDTFA's licensure database. Overall self-reported tobacco user experiences appeared to differ in content and severity based on whether an establishment was licensed. These results have the potential to identify unauthorized stores and adverse events associated with their tobacco and vaping products or services.

Authors: Yang J, Sou A, Afsana, F, Mackey TK
Journal: Preventive Medicine Reports
Year Published: 2021
Type: Original Research
Abstract:
The 2019 outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) increased awareness of potential health risks associated with vaping among the general public. Little is known, however, about how unfolding information regarding EVALI affected knowledge, attitudes, and behaviors among e-cigarette users, particularly among young adults. This study describes attitudinal and behavioral responses to EVALI among young adult e-cigarette users. In October and November 2019, seven focus groups were held with college-going young adult tobacco users from two four-year public universities in California. Focus groups included questions regarding knowledge of and reaction to EVALI news, and how the news affected product use. Text from current e-cigarette users was extracted to develop individual phenomenological textural-structural descriptions of e-cigarette use for 38 individuals which were used to create a composite experience of e-cigarette use in light of EVALI. Experiences indicated that e-cigarette users were aware of information regarding EVALI and received information from numerous sources. Information was filtered for legitimacy of EVALI claims and causes of EVALI. Risk rationalizations were developed to assess potential harm of continued e-cigarette use and provided reasoning for behavioral responses to EVALI. The emerging harm associated with EVALI prompted e-cigarette users to engage in a cognitive process resulting in employment of a range of rationalities to justify continued use. These results suggest how environmental, cognitive, and behavioral factors may interact as young adults negotiate e-cigarette-related harms.

Authors: Bardier C, Yang J, Li J, Mackey TK
Journal: BMC Research Notes
Year Published: 2021
Type: Original Research
Abstract:
Objective
The objective of this study was to develop an inductive coding approach specific to characterizing user-generated social media conversations about transition of use of different tobacco and alternative and emerging tobacco products (ATPs).

Results
A total of 40,206 tweets were collected from the Twitter public API stream that were geocoded from 2018 to 2019. Using data mining approaches, these tweets were then filtered for keywords associated with tobacco and ATP use behavior. This resulted in a subset of 5718 tweets, with 657 manually annotated and identified as associated with user-generated conversations about tobacco and ATP use behavior. The 657 tweets were coded into 9 parent codes: inquiry, interaction, observation, opinion, promote, reply, share knowledge, use characteristics, and transition of use behavior. The highest number of observations occurred under transition of use (43.38%, n=285), followed by current use (39.27%, n=258), opinions about use (0.07%, n=46), and product promotion (0.06%, n=37). Other codes had less than ten tweets that discussed these themes. Results provide early insights into how social media users discuss topics related to transition of use and their experiences with different and emerging tobacco product use behavior.
Citation: Bardier C, Yang J, Li J, Mackey TK. Characterizing Alternative and Emerging Tobacco Product Transition of Use Behavior on Twitter. BMC Res Notes. 2021;14:303

Authors: Bardier C, Purushothaman V, McMann T, Nali M, Li Z, Cuomo RE, Mackey TK
Journal: Journal of Medical Internet Research
Year Published: 2022
Type: Original Research
Abstract:
Background
TikTok is a micro-video social media platform experiencing exponential
growth with 60% of its monthly users between ages 16-24. Recent studies have found that increased exposure to e-cigarette content on social media may influence patterns of use. However, there is limited research assessing the characteristics of nicotine poisoning-related content posted on social media.

Objective
To assess the characteristics of nicotine-related content on TikTok.

Methods
The study collected TikTok posts associated with the #nicsick hashtag and
used inductive coding to conduct content analysis for video characteristics. Videos weremanually annotated to generate a codebook of nicotine sickness-related themes. Statistical analysis was used to compare continuous characteristics of videos with and without active nicotine sickness TikTok topics.

Results
A total of 132 TikTok videos with the hashtag #nicsick were manually coded,
with 52.3% (n=69) identified as discussing first-hand and second-hand reports of suspected nicotine poisoning symptoms. Among these videos were users who documented their experiences with adverse events and users actively vaping. Videos depicting adverse events and/or nicotine poisoning symptoms were longer in duration than those for other #nicsick-related topics (P=.08).

Conclusion
TikTok users openly discuss experiences, both firsthand and secondhand,
with nicotine adverse events via the #nicsick hashtag. Exposure to promotional e-cigarette social media content may facilitate overconsumption of nicotine, leading to nicotine poisoning. The appeal of “going viral” may encourage TikTok users to spread novel and potentially dangerous e-cigarette use patterns in addition to discussions and experiences with nicotine poisoning.

Authors: Purushothaman V, McMann T, Li Z, Cuomo RE, Mackey TK
Journal: Tobacco Induced Diseases
Year Published: 2022
Type: Original Research
Abstract:
Introduction
Exposure to pro-tobacco and electronic nicotine delivery system (ENDS) social media content can lead to overconsumption, increasing the likelihood of nicotine poisoning. This study aims to examine trends and characteristics of nicotine sickness content on Twitter between 2018–2020.

Methods
Tweets were collected retrospectively from the Twitter Academic Research Application Programming Interface (API) stream filtered for keywords: ‘nic sick’, ‘nicsick’, ‘vape sick’, ‘vapesick’ between 2018–2020. Collected tweets were manually annotated to identify suspected user-generated reports of nicotine sickness and related themes using an inductive coding approach. The Augmented Dickey-Fuller (ADF) test was used to assess stationarity in the monthly variation of the volume of tweets between 2018–2020.

Results
A total of 5651 tweets contained nicotine sickness-related keywords and 18.29% (n=1034) tweets reported one or more suspected nicotine sickness symptoms of varied severity. These tweets were also grouped into five related categories including firsthand and secondhand reports of symptoms, intentional overconsumption of nicotine products, users expressing intention to quit after ‘nic sick’ symptoms, mention of nicotine product type/brand name that they consumed while ‘nic sick’, and users discussing symptoms associated with nicotine withdrawal following cessation attempts. The volume of tweets reporting suspected nicotine sickness appeared to increase throughout the study period, except between February and April 2020. Stationarity in the volume of ‘nicsick’ tweets between 2018–2020 was not statistically significant (ADF= -0.32, p=0.98) indicating a change in the volume of tweets.

Conclusions
Results point to the need for alternative forms of adverse event surveillance and reporting, to appropriately capture the growing health burden of vaping. Infoveillance approaches on social media platforms can help to assess the volume and characteristics of user-generated content discussing suspected nicotine poisoning, which may not be reported to poison control centers. Increasing volume of user-reported nicotine sickness and intentional overconsumption of nicotine in twitter posts represent a concerning trend associated with ENDS-related adverse events and poisoning.